Treating tobacco dependence

As we proceed through the twenty-first century, cigarette smoking continues to exact an enormous worldwide health toll. One in five deaths in the United States—approximately 430,000—are related to tobacco exposure each year. Tobacco exposure has been directly related not only to chronic obstructive pulmonary disease and lung cancer but also to heart disease, stroke, and many other significant causes of morbidity and mortality. There is also a cadre of information now available on the toxicity of secondhand smoke exposure, indisputably placing it as the third leading cause of preventable premature death in the United States. As primary care providers, we are given a great opportunity to positively impact the health of individuals who use tobacco by providing them with the advice to quit and the tools they will require for successful tobacco cessation. The purpose of this issue of the Medical Clinics of North America is to: (1) review the pathophysiology of tobacco-related illness; (2) explain its impact on specific organ systems and disease processes; and (3) provide evidence-based guidance for treating tobacco dependence.

The first section of this book focuses on the most prevalent aspects of the ramifications of tobacco use. Kamholz, Bradley, Martinez, and Guntupalli, in their respective articles, have comprehensively reviewed the most current information available for primary care physicians. The article by Prezant addresses a clinically relevant but often ignored aspect of patient health care: the persistent exposure to secondhand tobacco smoke. The basic physiology of nicotine, reviewed by Metz and Gregersen, lays the foundation for further practical treatment discussions in the articles by Swan and Swartz.

The remainder of this issue focuses on populations that are especially vulnerable to tobacco, particularly adolescents, pregnant women, and individuals with psychiatric comorbidities. The articles by Levin and Sunday address some of the difficult problems that arise because of a lack of a consensus on how to best treat these specific populations. Women as a group have a difficult time dealing with tobacco addiction; Reichert's article focuses on the groundbreaking information that is available today with regard to this topic. Hopefully the information in these articles will provide additional guidance to practicing physicians who deal with these complex situations and populations.

It is important for physicians to realize that comprehensive care of the patient who uses tobacco encompasses more than just nicotine replacement therapy. The article by Talwar reviews the pharmacologic components of treating tobacco dependence, and Villano and White do a comprehensive review of the evidence that addresses the efficacy of alternative treatments such as acupuncture and hypnosis. The article by Kenford and Fiore provides credence to the point of treating tobacco dependence as we would any other chronic disease, one that requires long-term management with pharmacotherapy in combination with behavior modification.

Spit tobacco usage has been increasing in this country; the article by Ebbert and Dale addresses the most current information available with regard to this topic. Also new to this issue is the groundbreaking information regarding nicotine addiction and sleep disorders.

Where do we go from here? With such a large population to treat and so few comprehensive programs available throughout the country, we believe the gauntlet of treating this massive problem currently lies with primary care physicians. Future endeavors in tobacco addiction should focus on further randomized studies on target populations such and teenagers, pregnant women, HIV populations, and patients with malignancies. Safety and efficacy of long-term use of pharmacotherapy also needs to be explored.