...at least half of the people who do smoke will die from their tobacco use ten years before never smokers The health risks of tobacco use are well established with cigarette smoking identified as the most significant contributor to the leading causes of death in the United States (U.S.). Although the cigarette smoking prevalence has fallen from a peak of 45%, in 1964, to 13.7% prevalence in 2018 (U.S. Department of Health and Human Services [DHHS], 2020), 34 million people continue to smoke cigarettes (DHHS, 2020). This substantial smoking prevalence represents volumes of lives saved from quitting smoking or having never started. Still, at least half of the people who do smoke will die from their tobacco use ten years before never smokers (American Cancer Society [ACS], 2018; Jha et al., 2013). Cigarette smoking is seemingly the most dangerous of tobacco products and is attributable to 90% of all tobacco related illnesses and deaths (ACS, 2018), accounting for 480,000 deaths annually (DHHS, 2014).

With the continued shift toward bundled care and value-based reimbursement models, an emphasis on prioritizing the provision of high-impact healthcare that produces high-quality outcomes is pronounced. The current direct healthcare costs of smoking in the United States amount to $170 billion (DHHS, 2020); these costs are directly shouldered by taxpayers, employers, and consumers. Additionally, $151 billion is spent on indirect costs of such illnesses, and include lost wages and decreased productivity (Ekpu & Brown, 2015).

Tobacco related illnesses may be avoided by preventing the initiation of ever smoking, and early intervention...Tobacco related illnesses may be avoided by preventing the initiation of ever smoking, and early intervention in the successful cessation of tobacco products. Nursing, represented by 4 million highly capable professionals practicing across the care continuum (Smiley, 2018), constitutes critical resources toward this effort. Nursing expertise, combined with the sheer number of nurses available to patients who are dependent on tobacco, yields a striking opportunity to profoundly affect tobacco cessation quit rates, positively influence public health, and prevent human suffering and premature death.

This article will examine who is at high risk for and contributors to tobacco use disorder, including newer nicotine delivery systems (vapes), the evidence-based approaches to helping people quit, and how nurses may respond and take action.

History of Tobacco and Nicotine

Awareness of the native North and South American tobacco plants, Nicotiana tabacum, and Nicotiana rustica dates back to 5000 to 3000 BC (Gately, 2001; Musk & de Klerk, 2003). Worldwide transport and introduction of the tobacco plant occurred in the late 1400s with early explorers like Christopher Columbus and through widespread colonization (Gately, 2001; Proctor, 2011). Early on, the medicinal and stimulating properties of the tobacco plant were identified with its activating substance, nicotine, later named after the French explorer, Jean Nicot, hence the name “nicotine” (Proctor, 2011).

The tobacco plant has long been recognized and customarily utilized by the Native Americans and others for its hallucinogenic properties, especially in spiritual and ritualistic ceremonies (Burns, 2007; Godlaski, 2013). The potent properties of the tobacco plant have leveraged it over time as a popular and valuable bartering and trading commodity by early colonists and Native Americans in the 1600s to present day (U.S. History.org, 2020).

Tobacco manufacturing continues as a lucrative business with a long history...Cultivation of tobacco remains a critical mainstay for many farmers in the United States and around the world. This plant is the basis of livelihood and survival for these farmers, and because of this and its pleasurable properties, successful tobacco control has been challenging (ACS, 2018). Tobacco manufacturing launched in the late 19^th century with the invention of the cigarette rolling machine, with mass cigarette production and a resulting tobacco boom beginning in the early part of the 20^th century and extending to the 1960s (Proctor, 2011). Tobacco manufacturing continues as a lucrative business with a long history, laden with what many say are unethical and unconscionable practices, including directed marketing to teens that successfully influences the premature uptake of cigarettes and other tobacco products and the continued use by those who are addicted to nicotine, no matter the delivery system (Proctor, 2011).

Prevalence of Tobacco Use

...the United States witnessed its peak prevalence of cigarette use in 1964...At the height of the tobacco boom, the United States witnessed its peak prevalence of cigarette use in 1964, with 42.5% (51% men and 34% women) of all Americans smoking (ACS, 2019). The Surgeon General released the seminal Report on Smoking and Health, in 1964 (U.S. Public Health Service), which revealed and broadly disseminated concrete scientific evidence that smoking has a significantly negative impact on health, and that subsequent smoking related illnesses lead to higher rates of associated morbidity and premature mortality compared to never smokers. This report spurred a consistent downward trend in smoking, with only 13.7% of people currently smoking in the United States (DHHS, 2020). Although traditional cigarette smoking rates are favorably falling, nearly 20% (49.1 million) of U.S. adults still report using tobacco products (Creamer et al., 2019).

Pathogenesis of Tobacco (Nicotine) Dependence

The health risks that result from the use of tobacco products, and the benefits from quitting, would seem to the never tobacco user to be a strong impetus not to start using tobacco products, and appear to be a logical and simple reason to stop. If it were this easy, the prevalence of tobacco product use would be much lower, including that of traditional cigarettes. Each year 70% of smokers express an interest in quitting smoking, with half making a significant attempt that lasts 24 hours or more. Still, only 4% to 7% of these attempts succeed (Glynn, 2018), mainly because people try to quit without evidence-based treatment and much needed behavioral counseling.

Nicotine is one of the most addictive known substancesNicotine is one of the most addictive known substances (Institute of Medicine [IOM], 2001; U.S. Food and Drug Administration [FDA], 2020). Its potency is due to its mechanism of action in the human body, particularly in the brain, with systemic secondary effects on the body. The alpha-4-beta-2-nicotinic acetylcholine receptors (α4β2nAChR) in the brain are high-affinity nicotine binding sites specifically responsive to the presence of nicotine (Brody et al., 2006; Gotti et al., 2009; Tiwari et al., 2020). When nicotine is introduced into the body by any modality (inhalation through smoking; absorption in the mouth; or other routes), it readily attaches to the α4β2nAChR and in turn triggers a chemical reaction that results in expression of higher levels of neurotransmitters "(dopamine, norepinephrine, acetylcholine, serotonin, γ-aminobutyric acid, glutamate, and endorphins)" in the brain (IOM U.S. Committee, 2007, p. 79; Tiwari et al., 2020).

The greater the nicotine consumption and the higher blood nicotine concentration, the more neurotransmitters circulating. These neurotransmitters induce pleasurable psychopharmacologic effects (mood elevation or mild euphoria, increased energy, enhanced concentration, stress reduction, and calming effects) for the tobacco user (Benowitz, 2010; Dani, 2019; IOM U.S. Committee, 2007; Tiwari et al., 2020). The release of these neurotransmitters, particularly dopamine, also stimulate the brain’s reward system and reinforce repetitive use (IOM U.S. Committee, 2007; Tiwari et al., 2020).

These neurotransmitters induce pleasurable psychopharmacologic effects...for the tobacco user.In the setting of routine nicotine use, acute and unpleasant symptoms of withdrawal occur with abrupt discontinuation of nicotine, leading to a subsequent drop in blood concentration levels of nicotine. This quickly negates the beneficial experience of nicotine if not replenished. The symptoms of withdrawal (e.g., irritability, drop in mood, depression, anxiety, restlessness, difficulties concentrating, intense cravings) are quite unpleasant and even severe (Dani, 2019; IOM U.S. Committee, 2007). The symptomatic swings in nicotine blood concentration directly correlate with regular use and daily dosing of nicotine and the intolerability of nicotine withdrawal symptoms, which often lead to the resumption of nicotine use or relapse (Dani, 2019).

There is a strong behavioral and conditioning component to any habitual activities, including substance use.There is a strong behavioral and conditioning component to any habitual activities, including substance use. With regular tobacco use, environmental associations, and the anticipated effects of indulging in the substance cause conditioning that reinforces a strong desire to access the substance (Kahler, 2014). In essence, the brain develops a response to these environmental associations that trigger the urge to engage in the behavior/substance use. These associations and cues are a potent stimulus to use tobacco (Benowitz, 2010; IOM U.S. Committee, 2007).

Repetitive exposure to nicotine also effectively alters the brain in a way that remodeling and permanent changes occur...Brain development is a critical factor in tobacco (nicotine) dependence and an essential consideration within the grand scheme of lifelong dependency. Research clearly demonstrates the continuum of brain development across the life span, particularly during adolescence, and the higher risk of addiction to all substances, including nicotine, during this formative and developmental period (Smith et al., 2015). Nicotine changes the neurochemistry and neurohormonal function of the brain and its drive for reinforcement of reward in response to enhanced levels of neurohormones in the presence of nicotine (Esch & Stefano, 2004). Repetitive exposure to nicotine also effectively alters the brain in a way that remodeling and permanent changes occur to the motivational substrates and its neurobehavior, including in impulsivity and decision-making (Chambers et al., 2003). These integral changes and altered neuroplasticity of the brain are primary drivers of addictive behaviors, including nicotine, with a strong correlation between the earlier onset of smoking and increased difficulty in quitting (Chen & Millar, 1998; Kendler et al., 2013; Klein et al., 2013).

Tobacco Concerns

Risk of Tobacco Products
The risk of developing disease and related death from smoking has increased, despite the precipitous drop in smoking over the last 40 yearsThe development and manufacturing of cigarettes have become more complex, and subsequently, cigarettes are more dangerous than ever before. The risk of developing disease and related death from smoking has increased, despite the precipitous drop in smoking over the last 40 years (DHHS, 2014). This continued health burden is due to the ongoing and more toxic changes in the composition of cigarettes undertaken by tobacco companies and manufacturers. Most recent cigarette analyses revealed many more chemicals (7,000) and carcinogens (69) than previously known (DHHS, 2010). These toxic chemicals are varied and voluminous with predictable, measurable harmful effects on most organs in the human body, and culpability for most cancers (ACS, 2018).

...some people concurrently use more than one tobacco product, which is of great concern.Sixteen million people are suffering from disabling diseases related to tobacco use (DHHS, 2020), with 480,000 cigarette smokers dying annually, ten years before their never-smoking peers (Jha et al., 2013). Furthermore, some people concurrently use more than one tobacco product, which is of great concern. According to the National Health and Nutrition Examination Survey, (Choi et al., 2019) cigarette smokers who also regularly use one or more other tobacco products smoke an equal number of cigarettes or more, compared to exclusive cigarette smokers, and carry an increased smoking related morbidity and mortality risk (Choi et al., 2019).

Disparities in Tobacco Use and Health
...certain vulnerable populations and minority groups suffer disproportionate rates of tobacco dependence and morbidity and mortality...While overall cigarette smoking rates are at an all-time low, certain vulnerable populations and minority groups suffer disproportionate rates of tobacco dependence and morbidity and mortality related to their tobacco use disorder and nicotine dependence (DHHS & Centers for Disease Control and Prevention [CDC], 2020; IOM U.S.Committee, 2007). People who experience disproportionate rates of tobacco dependence and disease include but are not limited to 1) Adults aged 25-44 who possess a high school education or less, 2) People who are living at or below the poverty level, 3) People who are uninsured or on state Medicaid health plans, 4) Members of ethnic and racial minority groups, 5) Persons with disabilities or mental health illness, and 6) Men and women who identify as gay, lesbian, or bisexual (American Lung Association, 2020; Creamer et al., 2019; Jamal et al., 2016; Siahpush et al., 2010).

These disparities also translate to barriers in quitting with decreased access to and opportunities for cessation services...The significantly higher risk of tobacco dependence and health consequences across the lifespan in these groups cannot be overstated. This risk begins in utero for an unborn child of a parent who is using tobacco, and is present for children with second-hand smoke exposure in the home, and early access to tobacco products as a youth. These disparities also translate to barriers in quitting with decreased access to and opportunities for cessation services as well as delayed diagnosis and care when they develop tobacco related illnesses (DHHS, 2020; 2014).

Electronic Nicotine Delivery Systems
There are over 900 million people smoking cigarettes worldwideDespite the downward trend of U.S. cigarette consumption, globally 6 trillion cigarettes are consumed annually (ACS, 2020) with an upward trend in certain countries. There are over 900 million people smoking cigarettes worldwide (ACS, 2020; Morris et al., 2015). Tobacco companies and manufacturers are concurrently innovating novel devices to perpetuate the worldwide nicotine addiction pandemic. The resulting income from sales of the devices funds these giant companies, who beheld an $11.73 billion value in the global e-cigarette market in 2019 (Businesswire, 2020).

Efficiency and effectiveness is the driving mechanism for the development and distribution of ENDS. The efficiency and effectiveness of nicotine delivery in electronic nicotine delivery systems (ENDS) is similar to traditional cigarettes, via rapid absorption by inhalation into the lungs, direct transport to the heart, and delivery to the brain’s α4β2nAChRs (IOM U.S. Committee, 2007). Efficiency and effectiveness is the driving mechanism for the development and distribution of ENDS. The devices are often referred to as vapes, vaporizers, vape pens, electronic cigarettes, or e-cigs or by their manufacturer names like “JUUL.” These devices heat nicotine and other toxicants in a suspension (often propylene glycol, glycerin, and vitamin e-acetate) that aerosolizes nicotine for inhalation rather than delivery by combustible smoke in a traditional cigarette (Blount et al., 2020; Dinakar & O'Connor, 2016).

Adults and Youth at Risk for ENDS use
Of greater concern is that youth are the prime target for ENDS through directed advertising and alluring packagingAdult (over 18 years old) uptake of ENDS is growing, with current use at 3.2% (Creamer et al., 2019). Of greater concern is that youth are the prime target for ENDS through directed advertising and alluring packaging (ACS, 2020; Dinakar & O'Connor, 2016). These recruitment strategies work, as evidenced by the recent surreptitious rise in use among youth (Singh et al., 2016). In 2017, 11.7% of teens under 18 years old were using ENDS. This figure jumped to 27.5% in 2019, reflecting a 135% increase in just two years. This change represents over 6 million middle school (1 in 20) and high school (1 in 5) youth regularly using ENDS (CDC, 2020; Cullen et al., 2019). If the uptake of ENDS continues on this trajectory, the prevalence of use in the United States and beyond will reach similar levels in the next several years, as seen in the peak tobacco boom in 1964. As 90% of lifelong smokers of traditional cigarettes initiated smoking before they turned 18 years old (DHHS, 2014), the statistical chance of lifelong addiction and the allure of ENDS to teens is not lost on tobacco manufacturers.

ENDS and Harm Reduction Strategies in Smoking Cessation
Recent and exponential consumer uptake of ENDS has revealed the actual addiction potential and health risks in routine utilization of such devices. While ENDS are advertised as a safe and alternative approach to harm reduction over smoking traditional cigarettes, emerging evidence continues to reveal quite the contrary. Ongoing debates and research address the potential for ENDS to be safer options for smokers and an effective means for “harm reduction” in those who are established smokers with the pretense that smoking ENDS may be less harmful than smoking traditional, combustible cigarettes.

Evidence has shown mixed findings in the value of using ENDS for cessation purposes.Evidence has shown mixed findings in the value of using ENDS for cessation purposes. While studies have demonstrated some benefit in the use of ENDS as a cessation aid to help people reduce cigarette intake and even quit smoking compared to nicotine replacement therapy (Bullen et al., 2013), some research has shown that users replace cigarette smoking with long-term use of ENDS (Hajek et al., 2019). Currently, studies are limited with no evidence that overwhelmingly supports the use of ENDS in smoking cessation. Further research is needed to clarify if there is more benefit than harm in use of ENDS as smoking cessation aids (Lindson-Hawley, 2016; Wallace & Foronjy, 2019) and to explore the long-term health effects of using ENDS.

Perhaps equally important in this harm reduction discussion is the critical distinction between the use of such devices to help people dependent on cigarettes to quit, versus the uptake and initiation of regular use by a never smoker. We should take great care to protect youth from gaining access to ENDS, ever using ENDS and other tobacco products, and subsequently developing lifelong nicotine dependence (FDA, 2018).

E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI)
We should take great care to protect youth from gaining access to ENDS...Concurrent with the disconcerting and expeditious uptake in ENDS, case reports and other evidence of harm have emerged, spurring significant concern by the medical community; health related organizations, including the CDC, the U.S. FDA; and federal officials. Such findings have demonstrated a direct link between the use of ENDS that contain nicotine and acute lung injury that surged in 2019, this injury led to countless cases of illness and death, predominately in persons younger than 35 years old (Blount et al., 2020).

Benefit of Quitting Tobacco Use

...there are always health benefits to quitting and many opportunities to help people quit.While 90% of lifelong smokers of traditional cigarettes initiate smoking before age 18 (DHHS, 2014), the longitudinal effects of smoking commence with the first cigarette. Health risks from smoking accumulate over time with the intensity (i.e., number of cigarettes consumed) and duration (i.e., length of time). The good news is that evidence has demonstrated that if a person stops smoking before they turn 40 years old, the mortality risk of smoking related illness drops by 90% (Jha et al., 2013). No matter how much or how long someone has engaged in the use of tobacco products, including smoking, there are always health benefits to quitting and many opportunities to help people quit.

...there are direct economic benefits.Benefits of quitting smoking include health-related quality of life, where former smokers experience health improvements as well as “significant improvement in self-control, vitality, cessation-targeted anxiety and overall mental component profile” (Hays et al., 2012, p. 228). Similar findings (e.g., quality of general and mental health and vitality) have been observed in former smokers when compared to current smokers (Heikkinen et al., 2008), including a positive correlation in health benefits with more extended periods of successful cessation (Mulder et al., 2001). Additionally, there are direct economic benefits. For a 1 pack-per-day smoker, these benefits include a $50K savings in spending on cigarettes over ten years (Smokefree.gov, 2020). Economic benefits can also be realized in the direct healthcare savings of lowered healthcare expenditures and improved quality-adjusted life years (less disease burden) in former smokers over current smokers (DHHS, 2020).

Tobacco Use Cessation Treatments
Combined interventions... is the standard of care for tobacco use disorder.Nicotine dependence can be effectively combatted through many modalities, including pharmacotherapy (medications) and behavioral counseling. The U.S. Preventive Services Task Force (2015) has issued a Grade A recommendation for tobacco smoking cessation in adults to include FDA approved medication(s) combined with behavioral counseling for optimal cessation outcomes. This recommendation is evidence-based. When used individually, medication treatments or counseling have demonstrated enhanced success in quitting. When combined, these modalities yield as much as a 70% to 100% increased chance of quitting smoking compared to brief advice to quit (Stead et al., 2016). Combined interventions (i.e., medication and behavioral counseling) is the standard of care for tobacco use disorder.

Patients are vital partners in the process of choosing cessation medications and developing a treatment plan.There are a variety of approaches and forms of behavioral counseling, including individual and group counseling and seven FDA approved medications for cessation. These medications (extended and short-acting nicotine replacement therapy [NRT], varenicline, and bupropion) all target the α4β2nAChR’s in the brain and the neurohormonal interplay that is so crucial in nicotine dependence to any tobacco product (Fiore, 2008). Patients are vital partners in the process of choosing cessation medications and developing a treatment plan. Approaching this conversation with patients and supporting them throughout the cessation journey can be facilitated by the steps in the 5A’s (Ask, Advise, Assess, Assist, Arrange) (Siu & USPST, 2015).

Using the 5A’s to Help Patients Quit Smoking
Asking all patients about tobacco use enhances the chance of capturing opportunities to initiate cessation and launches this essential and potentially life-saving conversation. Advising patients about the benefits of quitting can be quite effective, especially when patients are accessing healthcare in a time of need. Assessing the patients’ willingness and readiness to quit, as well as their history with tobacco use, is perhaps one of the most important steps in making a cessation treatment plan. This opens the opportunity to understand what the cessation journey has looked like in the past for the patient, and what has and has not worked. It is also an opportunity to educate patients about treatment options and to dispel any myths or misconceptions they may have about any particular approach. Assisting patients to secure medications, plan counseling, and follow through with the treatment plan in their quit attempt is key. Finally, arranging for clinical follow-up is a very helpful, crucial element of successfully quitting. (Fiore, 2008; Kahler, 2014; La Torre, 2013) Nurses and other healthcare providers may leverage touch-points with patients, using the 5A’s as a tool for support in successfully navigating the complexities of the cessation journey.

Relapse Prevention and Chronic Disease Management
Tobacco (nicotine) dependence is a chronic relapsing condition (Steinberg et al., 2008). The road to successful cessation from any tobacco product is often a long one that calls on immense resources for all involved. Given the complex neurochemistry and neurohormonal alterations in the brain with long-term, established tobacco use, and the associated behavioral changes and environmental cues that reinforce use, tobacco users are at high risk for relapse (Steinberg et al., 2008). Evidence shows that it may take an average of 30 quit attempts for successful smoking cessation (Chaiton et al., 2016).

Successful cessation is a process; nurses and other healthcare professionals must not give up on patients in the cessation journey. The characteristics of tobacco dependence and the chronic relapsing nature of this disease call for ongoing management and monitoring similar to any other chronic disease (Steinberg et al., 2008). This includes routine screening for the use of any tobacco product with all healthcare visits, and nursing preparedness to provide ongoing treatment and counseling or refer for services as necessary.

The War Against Tobacco and Nursing Action
Although the United States has experienced a slow and steady decline in cigarette smoking, the recent flattening curve of other tobacco product use, coupled with the significant increase by youth in ENDS use, has effectively dissolved any progress made in the overall drop in cigarette smoking in this country (Gentzke et al., 2019). This is cause for alarm and necessitates an urgent call to nurses and all healthcare professionals to take action. More attention to proactive measures to avoid an explosive rise in ENDS and other tobacco product use and related harm.

...we must continue to safeguard the public from the dangers of second-hand smoke...Comprehensive tobacco control strategies to protect youth from initiating the use of any tobacco product during their most vulnerable period of development and risk for addiction is critical, and has been shown to be effective (Yeh et al., 2017). Such strategies would start with an emphasis on avoiding the use of ENDS, currently posing the highest risk for tobacco use disorder in teens, and protecting all people from ever-initiating tobacco use. Additionally, we must continue to safeguard the public from the dangers of second-hand smoke, and proactively help those who currently depend on tobacco products to quit, with the overarching goal to preserve and restore health.

...nurses and other healthcare professionals must not give up on patients in the cessation journey.Much of this action is underway, including increased regulatory jurisdiction over ENDS by the U.S. FDA (2018), including steps to restrict sales of flavored ENDS and banning other flavored tobacco products (e.g., menthol cigarettes). Other approaches have also demonstrated effectiveness, such as increased pricing and taxation of tobacco products (Yeh et al., 2017) and limiting youth access by raising the minimum age of purchase for tobacco products to 21 (Winickoff et al., 2014). Directly counteracting tobacco manufacturers' efforts with public service announcements, launching anti-tobacco media campaigns, and imposing restrictions on advertising and promotion of tobacco sales may all be helpful (ACS, 2020). Nurses may also collaborate at a local and national level in advocacy efforts, including directed prevention efforts and public awareness; educating youth; development of health policy; and providing personal and professional testimony that supports passing and enacting appropriate legislation.

Conclusion

Each nurse must be prepared to support efforts to decrease tobacco use in the United States and worldwide.The potency of nicotine in tobacco products takes control of the brain. This leads millions of people to lifelong dependence, and exponential risk for developing a plethora of diseases that result in significant suffering and too often, premature death. Minority groups and other at-risk populations suffer some of the highest rates of tobacco use and the subsequent sequelae. Young people are at particular risk for exposure to tobacco products, including ENDS, which positions them for the high potential of developing lifelong dependence. In the war against tobacco, nurses are poised to address the concerns of dependence discussed in this article through prevention measures and successful evidence-based treatment. Each nurse must be prepared to support efforts to decrease tobacco use in the United States and worldwide.

Author

Joelle T. Fathi, DNP, RN, ARNP, ANP-BC, CTTS, NCTTP
Email: thirsk@uw.edu

Joelle T. Fathi is an adult nurse practitioner who has over 20 years of experience working in both primary and acute care settings. She holds national certifications as a tobacco treatment specialist and has been dedicated to helping people with tobacco use disorder, quit tobacco for more than two decades. She serves as the Vice-Chair to the Tobacco Treatment Task Group for the American Cancer Society, Atlanta, GA. She also serves on the Tobacco Treatment Guidelines Committee for the American Thoracic Society and the Tobacco Control and Smoking Cessation Committee for the International Association for the Study of Lung Cancer. She has multiple publications and presentations focused on educating patients, nurses, and other healthcare professionals about how to take charge of tobacco.