Tobacco use, which includes cigarettes, cigars, pipes and smokeless (chewing) tobacco, remains the most preventable cause of death in the United States, leading to over 400,000 deaths each year and costing billions of dollars in medical expenses.² The Centers for Disease Control and Prevention (CDC) recommends that all health care providers ask patients whether they smoke or chew tobacco, and then to advise all smokers to try to quit. The stakes are high, and the health benefits of changed behavior are beyond dispute.³

A Vital Sign
Smoking and tobacco use are such an important part of an individual’s health status that some have called it a fifth vital sign, suggesting that it be tagged as a major factor for overall health similar to high blood pressure or high temperature.⁴ Tobacco use can lead to various cancers, heart and cardiovascular disease and chronic spine pain.^5-10

Perhaps no other health risk factor has been the subject of so much health science research. Peto and Doll first discovered that physicians in Great Britain who smoked had higher incidence rates of lung cancer¹¹ and that those who smoked the most were at the greatest risk for developing cancer. A major breakthrough in public awareness of the problem came in 1964, when U.S. Surgeon General Luther Terry produced the first report warning that smoking was a key risk factor for developing lung cancer and other diseases.¹² Today, numerous studies not only confirm this but indicate smokers have a greater risk of overall poor health and disability and have much higher health insurance costs, lost days from work and lowered productivity.^{13, 14}

In 1998 several state Attorneys General settled a suit against large tobacco companies to recover costs paid by state Medicaid agencies for tobacco-related illness in what is referred to as the Master Tobacco Settlement.¹⁵ Money from this billion dollar windfall to those states was to be used to start schools of public health and generate advertising against smoking.¹⁶ The verdict is still out as to how much good has come from the Master Tobacco Settlement.

How Your Health Care Provider Can Help
Unfortunately, only about 40% of smokers report that their primary care physician has advised them to quit smoking or using tobacco.¹⁷ A study at 9 chiropractic colleges found similar rates of patients who stated that their interns had advised them on cessation. Of these, even fewer were given information on cessation beyond being advised to quit.¹⁸

However, health care providers have consistently been found to be powerful “cues to action” when it comes to getting patients to make a quit attempt.¹⁹ The CDC report by Fiore and others states that all health care providers should urge patients to quit.³ In addition, it doesn’t seem to matter what kind of provider conveys the message. For example, orthopedic surgeons are not usually thought of as being on the front lines of anti-smoking programs, but some have admirably risen to the call. Responding to the fact that 90% of their failed surgeries and post-surgical infections occurred in smokers, Rechtine and colleagues at an orthopedic spine clinic were able to significantly increase the number of quit attempts in their patients by prioritizing tobacco cessation with patients.²⁰ Along the same lines, a study at one chiropractic college increased the amount of information given to patients by 25% in one month when an education campaign was delivered aimed at interns and clinic staff.²¹

It’s important to remember that stopping smoking is helpful not only to the person who stops but to those around them as well. Researchers at the University of Missouri–Kansas City found that adolescents who had a significant other who smoked were much more likely to smoke. When at least four significant others smoked, adolescents were 161 times more likely to smoke themselves.²² Therefore, when your doctor urges you to quit, it’s important to remember that this is not only for your own health but also for the potential preventive effect on your family. In addition, there are now numerous studies indicating that second-hand smoke is a significant factor for increased risk of disease.

How to Get Started
The CDC recommends a 5-step approach developed by the U.S. Surgeon General’s Office called “The 5-A’s.” Your doctor’s job is to “Ask” about your smoking (or tobacco use) status; “Advise” you to try to quit; “Assess” your willingness to try; “Assist” you in any way he or she can; and then “Arrange to follow up” so that you stay focused on the importance of quitting.³

Your job is to do everything in your power to work in partnership with your doctor to make this effort a lasting success. Your doctor, friends and family can all help you, but when all is said and done, the power is in your own hands.

If there are special circumstances in your case, such as other addictions or conditions that cause you ongoing pain, your doctor is likely to make recommendations for helping these problems as well, because they can complicate efforts to quit smoking.

Understanding How Change Works
Both you and your doctor can benefit from understanding the ways that people make major changes in their lives, and then applying these ideas to your efforts to stop using tobacco. The most common model used in smoking cessation programs is called “Stages of Change.” Developed by Drs. Prochaska and DiClemente,²³ this model is based on their finding that people with addictive behaviors (as you know, nicotine is quite addictive) are at one of the following five stages of the journey toward quitting:

1. Pre-contemplation. In this phase the smoker has no intention of quitting in the near future but is willing to receive information about quitting. If you are in this phase, your doctor might give you a brochure (or open a conversation) about why it would be good for you to consider stopping. In some cases, this information helps people move toward the next stage.

2. Contemplation. In this stage, you may have the intention to quit, but aren’t yet ready to do so. Sensing this, your doctor might try to motivate you to consider an action such as setting a specific date for quitting sometime in the next six months.

3. Preparation. In this stage you are actively making an effort to take action within 30 days. This might include some behavioral changes like reading more about cessation or nicotine replacement therapy (NRT). Your doctor may help you develop a solid action plan that could include setting gradual goals.

4. Action. In this stage, you have already changed your behavior. This might involve putting away all the ashtrays in your home or eliminating all purchases of tobacco. During this time, your doctor or his/her staff will do their best to help you with any problems that may arise, offering support to help you stay on track.

5. Maintenance. In this final stage, you have “maintained” the changed behavior for at least six months. During this time, you and your doctor need to do everything possible to reinforce your commitment and avoid a relapse. For example, smokers tend to smoke more when consuming alcohol or when their spouse is also a smoker. If you are in such a situation, it’s good to think in advance about ways to handle these situations.

Treatment Options: Smoking Cessation Programs and Medication
Paths to success in quitting tobacco vary widely, depending on the individual makeup of the person doing the quitting. Some people can make a decision to quit, apply all of their willpower, and then never again use tobacco for the rest of their lives. Others need assistance of various types.

The key point is to find an approach that works for you. Because nicotine patches and other forms of nicotine replacement therapy require a prescription, it’s usually a good idea for your medical physician to be involved. If you can quit without using the patch, that’s fine. But the most important question is not how you quit, but that you actually succeed at quitting and then maintain your commitment to a tobacco-free life.

Studies show that medications and cessation counseling, along with NRT, offer the greatest chance for success.^25-27 A list of area smoking cessation programs (some are free, others charge a fee) can usually be obtained from the local chapter of the American Lung Association or American Cancer Society. Many successful quit attempts are made at the beginning of a new year as a resolution or as part of the Great American Smoke-Out held in November of each year. Taking action at these times may increase your chances for success because you can draw strength from others when you realize you are not alone.

Will Evans, DC, PhD, CHES, is director of Health Promotion Programs for Cleveland Chiropractic College.

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