a case study of tobacco use

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• Published: 21 January 2021

The effects of tobacco control policies on global smoking prevalence

• Luisa S. Flor   ORCID: orcid.org/0000-0002-6888-512X 1 ,
• Marissa B. Reitsma 1 ,
• Vinay Gupta 1 ,
• Marie Ng   ORCID: orcid.org/0000-0001-8243-4096 2 &
• Emmanuela Gakidou   ORCID: orcid.org/0000-0002-8992-591X 1  

Nature Medicine volume  27 ,  pages 239–243 ( 2021 ) Cite this article

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Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control 1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development 2 . Here we show that comprehensive tobacco control policies—including smoking bans, health warnings, advertising bans and tobacco taxes—are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

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Decades after its ill effects on human health were first documented, tobacco smoking remains one of the major global drivers of premature death and disability. In 2017, smoking was responsible for 7.1 (95% uncertainty interval (UI), 6.8–7.4) million deaths worldwide and 7.3% (95% UI, 6.8%–7.8%) of total disability-adjusted life years 3 . In addition to the health impacts, economic harms resulting from lost productivity and increased healthcare expenditures are also well-documented negative effects of tobacco use 4 , 5 . These consequences highlight the importance of strengthening tobacco control, a critical and timely step as countries work toward the 2030 Sustainable Development Goals 2 .

In 2003, the World Health Organization (WHO) led the development of the Framework Convention on Tobacco Control (FCTC), the first global health treaty intended to bolster tobacco use curtailment efforts among signatory member states 1 . Later, in 2008, to assist the implementation of tobacco control policies by countries, the WHO introduced the MPOWER package, an acronym representing six evidence-based control measures (Table 1 ) (ref. 6 ). While accelerated adoption of some of these demand reduction policies was observed among FCTC parties in the past decade 7 , many challenges remain to further decrease population-level tobacco use. Given the differing stages of the tobacco epidemic and tobacco control across countries, consolidating the evidence base on the effectiveness of policies in reducing smoking is necessary as countries plan on how to do better. In this study, we evaluated the association between varying levels of tobacco control measures and age- and sex-specific smoking prevalence using data from 175 countries and highlighted missed opportunities to decrease smoking rates by predicting the global smoking prevalence under alternative unrealized policy scenarios.

Despite the enhanced global commitment to control tobacco use, the pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, sex and age 8 ; in 2017, there were still 1.1 billion smokers across the 195 countries and territories assessed by the Global Burden of Diseases, Injuries, and Risk Factors Study. Global smoking prevalence in 2017 among men and women aged 15 and older, 15–29 years, 30–49 years and 50 years and older are shown in Extended Data Figs. 1 , 2 , 3 and 4 , respectively. We found that, between 2009 and 2017, current smoking prevalence declined by 7.7% for men (36.3% (95% UI, 35.9–36.6%) to 33.5% (95% UI, 32.9–34.1%)) and by 15.2% for women globally (7.9% (95% UI, 7.8–8.1%) to 6.7% (95% UI, 6.5–6.9%)). The highest relative decreases were observed among men and women aged 15–29 years, at 10% and 20%, respectively. Conversely, prevalence decreased less intensively for those aged over 50, at 2% for men and 9.5% for women. While some countries have shown an important reduction in smoking prevalence between 2009 and 2017, such as Brazil, suggesting sustained progress in tobacco control, a handful of countries and territories have shown considerable increases in smoking rates among men (for example, Albania) and women (for example, Portugal) over this time period.

In an effort to counteract the harmful lifelong consequences of smoking, countries have, overall, implemented stronger demand reduction measures after the FCTC ratification. To assess national-level legislation quality, the WHO attributes a score to each of the MPOWER measures that ranges from 1 to 4 for the monitoring component (M) and 1–5 for the other components. A score of 1 represents no known data, while scores 2–5 characterize the overall strength of each measure, from the lowest level of achievement (weakest policy) to the highest level of achievement (strongest policy) 6 . Between 2008 and 2016, although very little progress was made in treatment provision (O) 7 , 9 , the share of the total population covered by best practice (score = 5) P, W and E measures increased (Fig. 1 ). Notably, however, a massive portion of the global population is still not covered by comprehensive laws. As an example, less than 15% of the global population is protected by strongly regulated tobacco advertising (E) and the number of people (2.1 billion) living in countries where none or very limited smoke-free policies (P) are in place (score = 2) is still nearly twice as high as the population (1.1 billion) living in locations with national bans on smoking in all public places (score = 5).

To assess national-level legislation quality, the WHO attributes a score to each MPOWER component that ranges from 1 to 5 for smoke-free (P), health warning (W) and advertising (E) policies. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from 2 representing the lowest level of achievement (weakest policy), to 5 representing the highest level of achievement (strongest policy).

Source data

In terms of fiscal policies (R), the population-weighted average price, adjusted for inflation, of a pack of cigarettes across 175 countries with available data increased from I$3.10 (where I$ represents international dollars) in 2008 to I$5.38 in 2016. However, from an economic perspective, for prices to affect purchasing decisions, they need to be evaluated relative to income. The relative income price (RIP) of cigarettes is a measure of affordability that reflects, in this study, what proportion of the country-specific per capita gross domestic product (GDP) is needed to purchase half a pack of cigarettes a day for a year. Over time, cigarettes have become less affordable (RIP 2016 > RIP 2008) in about 75% of the analyzed countries, with relatively more affordable cigarettes concentrated across high-income countries.

Our adjusted analysis indicates that greater levels of achievement on key measures across the P, W and E policy categories and higher RIP values were significantly associated with reduced smoking prevalence from 2009 to 2017 (Table 2 ). Among men aged 15 and older, each 1-unit increment in achievement scores for smoking bans (P) was independently associated with a 1.1% (95% UI, −1.7 to −0.5, P  < 0.0001) decrease in smoking prevalence. Similarly, an increase of 1 point in W and E scores was associated with a decrease in prevalence of 2.1% (95% UI, −2.7 to −1.6, P  < 0.0001) and 1.9% (95% UI, −2.6 to −1.1, P  < 0.0001), respectively. Furthermore, a 10 percentage point increase in RIP was associated with a 9% (95% UI, −12.6 to −5.0, P  < 0.0001) decrease in overall smoking prevalence. Results were similar for men from other age ranges.

Among women, the magnitude of effect of different policy indicators varied across age groups. For those aged over 15, each 1-point increment in W and E scores was independently associated with an average reduction in prevalence of 3.6% (95% UI, −4.5 to −2.9, P  < 0.0001) and 1.9% (95% UI, −2.9 to −1.8, P  = 0.002), respectively, and these findings were similar across age groups. Smoking ban (P) scores were not associated with reduced prevalence among women aged 15–29 years or over 50 years. However, a 1-unit increase in P scores was associated with a 1.3% (95% UI, −2.3 to −0.2, P  = 0.016) decline in prevalence among women aged 30–49 years. Lastly, while a 10 percentage point increase in RIP lowered women smoking prevalence by 6% overall (95% UI, −10.0 to −2.0, P = 0.014), this finding was not statistically significant when examining reductions in prevalence among those aged 50 and older (Table 2 ).

If tobacco control had remained at the level it was in 2008 for all 155 countries (with non-missing policy indicators for both 2008 and 2016; Methods ) included in the counterfactual analysis, we estimate that smoking prevalence would have been even higher than the observed 2017 rates, with 23 million more male smokers and 8 million more female smokers (age ≥ 15) worldwide (Table 3 ). Out of the counterfactual scenarios explored, the greatest progress in reducing smoking prevalence would have been observed if a combination of higher prices—resulting in reduced affordability levels—and strictest P, W and E laws had been implemented by all countries, leading to lower smoking rates among men and women from all age groups and approximately 100 million fewer smokers across all countries (Table 3 ). Under this policy scenario, the greatest relative decrease in prevalence would have been seen among those aged 15–29 for both sexes, resulting in 26.6 and 6.5 million fewer young male and female smokers worldwide in 2017, respectively.

Our findings reaffirm that a wide spectrum of tobacco demand reduction policies has been effective in reducing smoking prevalence globally; however, it also indicates that even though much progress has been achieved, there is considerable room for improvement and efforts need to be strengthened and accelerated to achieve additional gains in global health. A growing body of research points to the effectiveness of tobacco control measures 10 , 11 , 12 ; however, this study covers the largest number of countries and years so far and reveals that the observed impact has varied by type of control policy and across sexes and age groups. In high-income countries, stronger tobacco control efforts are also associated with higher cessation ratios (that is, the ratio of former smokers divided by the number of ever-smokers (current and former smokers)) and decreases in cigarette consumption 13 , 14 .

Specifically, our results suggest that men are, in general, more responsive to tobacco control interventions compared to women. Notably, with prevalence rates for women being considerably low in many locations, variations over time are more difficult to detect; thus, attributing causes to changes in outcome can be challenging. Yet, there is already evidence that certain elements of tobacco control policies that play a role in reducing overall smoking can have limited impact among girls and women, particularly those of low socioeconomic status 15 . Possible explanations include the different value judgments attached to smoking among women with respect to maintaining social relationships, improving body image and hastening weight control 16 .

Tax and price increases are recognized as the most impactful tobacco control policy among the suite of options under the MPOWER framework 10 , 14 , 17 , particularly among adolescents and young adults 18 . Previous work has also demonstrated that women are less sensitive than men to cigarette tax increases in the USA 19 . Irrespective of these demographic differences, effective tax policy is underutilized and only six countries—Argentina, Chile, Cuba, Egypt, Palau and San Marino—had adopted cigarette taxes that corresponded to the WHO-prescribed level of 70% of the price of a full pack by 2017 (ref. 20 ). Cigarettes also remain highly affordable in many countries, particularly among high-income nations, an indication that affordability-based prescriptions to countries, instead of isolated taxes and prices reforms, are possibly more useful as a tobacco control target. In addition, banning sales of single cigarettes, restricting legal cross-border shopping and fighting illicit trade are required so that countries can fully experience the positive effect of strengthened fiscal policies.

Smoke-free policies, which restrict the opportunities to smoke and decrease the social acceptability of smoking 17 , also affect population groups differently. In general, women are less likely to smoke in public places, whereas men might be more frequently influenced by smoking bans in bars, restaurants, clubs and workplaces across the globe due to higher workforce participation rates 16 . In addition to leading to reduced overall smoking rates, as indicated in this study, implementing complete smoking bans (that is, all public places completely smoke-free) at a faster pace can also play an important role in minimizing the burden of smoking-attributable diseases and deaths among nonsmokers. In 2017 alone, 2.18% (95% UI, 1.8–2.7%) of all deaths were attributable to secondhand smoke globally, with the majority of the burden concentrated among women and children 21 .

Warning individuals about the harms of tobacco use increases knowledge about the health risks of smoking and promotes changes in smoking-related behaviors, while full advertising and promotion bans—implemented by less than 20% of countries in 2017 (ref. 20 )—are associated with decreased tobacco consumption and smoking initiation rates, particularly among youth 17 , 22 , 23 . Large and rotating pictorial graphic warnings are the most effective in attracting smokers’ attention but are lacking in countries with high numbers of smokers, such as China and the USA 20 . Adding best practice health warnings to unbranded packages seems to be an effective way of informing about the negative effects of smoking while also eliminating the tobacco industry’s marketing efforts of using cigarette packages to make these products more appealing, especially for women and young people who are now the prime targets of tobacco companies 24 , 25 .

While it is clear that strong implementation and enforcement are crucial to accelerating progress in reducing smoking and its burden globally, our heterogeneous results by type of policy and demographics highlight the challenges of a one-size-fits-all approach in terms of tobacco control. The differences identified illustrate the need to consider the stages 26 of the smoking epidemics among men and women and the state of tobacco control in each country to identify the most pressing needs and evaluate the way ahead. Smoking patterns are also influenced by economic, cultural and political determinants; thus, future efforts in assessing the effectiveness of tobacco control policies under these different circumstances are of value. As tobacco control measures have been more widely implemented, tobacco industry forces have expanded and threaten to delay or reverse global progress 27 . Therefore, closing loopholes through accelerated universal adoption of the comprehensive set of interventions included in MPOWER, guaranteeing that no one is left unprotected, is an urgent requirement as efforts toward achieving the Sustainable Development Goals by 2030 are intensified.

This was an ecological time series analysis that aimed to estimate the effect of four key demand reduction measures on smoking rates across 175 countries. Country-year-specific achievement scores for P, W and E measures and an affordability metric measured by RIP—to capture the impact of fiscal policy (R)—were included as predictors in the model. Although the WHO also calls for monitoring (M) and tobacco cessation (O) interventions, these were not evaluated. Monitoring tobacco use is not considered a demand reduction measure, while very little progress has been made in treatment provision over the last decade 7 , 9 . Further information on research design is available in the Life Sciences Reporting Summary linked to this paper.

Smoking outcome data

The dependent variable is represented by country-specific, age-standardized estimates of current tobacco smoking prevalence, defined as individuals who currently use any smoked tobacco product on a daily or occasional basis. Complete time series estimates of smoking prevalence from 2009 to 2017 for men and women aged 15–29, 30–49, 50 years and older and 15 years and older, were taken from the Global Burden of Disease (GBD) 2017 study.

The GBD is a scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries and risk factors by age, sex and geography for specific points in time. While full details on the estimation process for smoking prevalence have been published elsewhere, we briefly describe the main analytical steps in this article 3 . First, 2,870 nationally representative surveys meeting the inclusion criteria were systematically identified and extracted. Since case definitions vary between surveys, for example, some surveys only ask about daily smoking as opposed to current smoking that includes both daily and occasional smokers, the extracted data were adjusted to the reference case definition using a linear regression fit on surveys reporting multiple case definitions. Next, for surveys with only tabulated data available, nonstandard age groups and data reported as both sexes combined were split using observed age and sex patterns. These preprocessing steps ensured that all data used in the modeling were comparable. Finally, spatiotemporal Gaussian process regression, a three-step modeling process used extensively in the GBD to estimate risk factor exposure, was used to estimate a complete time series for every country, age and sex. In the first step, estimates of tobacco consumption from supply-side data are incorporated to guide general levels and trends in prevalence estimates. In the second step, patterns observed in locations, age groups and years with smoking prevalence data are synthesized to improve the first-step estimates. This step is particularly important for countries and time periods with limited or no available prevalence data. The third step incorporates and quantifies uncertainty from sampling error, non-sampling error and the preprocessing data adjustments. For this analysis, the final age-specific estimates were age-standardized using the standard population based on GBD population estimates. Age standardization, while less important for the narrower age groups, ensured that the estimated effects of policies were not due to differences in population structure, either within or between countries.

Using GBD-modeled data is a strength of the study since nearly 3,000 surveys inform estimates and countries are not required to have complete survey coverage between 2009 and 2017 to be included in the analysis. Yet, it is important to note that these estimates have limitations. For example, in countries where a prevalence survey was not conducted after the enactment of a policy, modeled estimates may not reflect changes in prevalence resulting from that policy. Nonetheless, the prevalence estimates from the GBD used in this study are similar to those presented in the latest WHO report 28 , indicating the validity and consistency of said estimates.

MPOWER data

Summary indicators of country-specific achievements for each MPOWER measure are released by the WHO every two years and date back to 2007. Data from different iterations of the WHO Report on the Global Tobacco Epidemic (2008 6 , 2009 29 , 2011 30 , 2013 31 , 2015 32 and 2017 20 ) were downloaded from the WHO Tobacco Free Initiative website ( https://www.who.int/tobacco/about/en/ ). To assess the quality of national-level legislation, the WHO attributes a score to each MPOWER component that ranges from 1 to 4 for the monitoring (M) dimension and 1–5 for the other dimensions. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from the lowest level of achievement (weakest policy) to the highest (strongest policy).

Specifically, smoke-free legislation (P) is assessed to determine whether smoke-free laws provide for a complete indoor smoke-free environment at all times in each of the respective places: healthcare facilities; educational facilities other than universities; universities; government facilities; indoor offices and workplaces not considered in any other category; restaurants or facilities that serve mostly food; cafes, pubs and bars or facilities that serve mostly beverages; and public transport. Achievement scores are then based on the number of places where indoor smoking is completely prohibited. Regarding health warning policies (W), the size of the warnings on both the front and back of the cigarette pack are averaged to calculate the percentage of the total pack surface area covered by the warning. This information is combined with seven best practice warning characteristics to construct policy scores for the W dimension. Finally, countries achievements in banning tobacco advertising, promotion and sponsorship (E) are assessed based on whether bans cover the following types of direct and indirect advertising: (1) direct: national television and radio; local magazines and newspapers; billboards and outdoor advertising; and point of sale (indoors); (2) indirect: free distribution of tobacco products in the mail or through other means; promotional discounts; nontobacco products identified with tobacco brand names; brand names of nontobacco products used or tobacco products; appearance of tobacco brands or products in television and/or films; and sponsorship.

P, W and E achievement scores, ranging from 2 to 5, were included as predictors into the model. The goal was to not only capture the effect of adopting policies at its highest levels but also assess the reduction in prevalence that could be achieved if countries moved into the expected direction in terms of implementing stronger measures over time. Additionally, having P, W and E scores separately, and not combined into a composite score, enabled us to capture the independent effect of different types of policies.

Although compliance is a critical factor in understanding policy effectiveness, the achievement scores incorporated in our main analysis reflect the adoption of legislation rather than degree of enforcement, representing a limitation of these indicators.

Prices in I$ for a 20-cigarette pack of the most sold brand in each of the 175 countries were also sourced from the WHO Tobacco Free Initiative website for all available years (2008, 2010, 2012, 2014 and 2016). I$ standardize prices across countries and also adjust for inflation across time. This information was used to construct an affordability metric that captures the impact of cigarette prices on smoking prevalence, considering the income level of each country.

More specifically, the RIP, calculated as the percentage of per capita GDP required to purchase one half pack of cigarettes a day over the course of a year, was computed for each available country and year. Per capita GDP estimates were drawn from the Institute for Health Metrics and Evaluation; the estimation process is detailed elsewhere 33 .

Given that the price data used in the analysis refer to the most sold brand of cigarettes only, it does not reflect the full range of prices of different types of tobacco products available in each location. This might particularly affect our power in detecting a strong effect in countries where other forms of tobacco are more popular.

Statistical analysis

Sex- and age-specific logit-transformed prevalence estimates from 2009 to 2017 were matched to one-year lagged achievement scores and RIP values using country and year identifiers 34 . The final sample consisted of 175 countries and was constrained to locations and years with non-missing indicators. A multiple linear mixed effects model fitted by restricted maximum likelihood was used to assess the independent effect of P, W and E scores and RIP values on the rates of current smoking. Specifically, a country random intercept and a country random slope on RIP were included to account for geographical heterogeneity and within-country correlation. The regression model takes the following general form:

where y c,t is the prevalence of current smoking in each country ( c ) and year ( t ), β 0 is the intercept for the model and β p , β w , β e and β r are the fixed effects for each of the policy predictors. \(\mathrm{P}_{c,\,t - 1},\,\mathrm{W}_{c,\,t - 1},\,\mathrm{E}_{c,\,t - 1}\) are the P, W and E scores and R c , t −1 is the RIP value for country c in year t  − 1. Finally, α c is the random intercept for country ( c ), while δ c represent the random slope for the country ( c ) to which the RIP value (R t − 1 ) belongs. Variance inflation factor values were calculated for all the predictor parameters to check for multicollinearity; the values found were low (<2) 35 . Bivariate models were also run and are shown in Extended Data Fig. 5 . The one-year lag introduced into the model may have led to an underestimation of effect sizes, particularly as many MPOWER policies require a greater period of time to be implemented effectively. However, due to the limited time range of our data (spanning eight years in total), introducing a longer lag period would have resulted in the loss of additional data points, thus further limiting our statistical power in detecting relevant associations between policies and smoking prevalence.

In addition to a joint model for smokers from both sexes, separate regressions were fitted for men and women and the four age groups (15–29, 30–49, ≥50 and ≥15 years old). To assess the validity of the mixed effects analyses, likelihood ratio tests comparing the models with random effects to the null models with only fixed effects were performed. Linear mixed models were fitted by maximum likelihood and t -tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if <0.05. All analyses were executed with RStudio v.1.1.383 using the lmer function in the R package lme4 v.1.1-21 (ref. 36 ).

A series of additional models to examine the impact of tobacco control policies were developed as part of this study. In each model, cigarette affordability (RIP) and a different set of policy metrics was used to capture the implementation, quality and compliance of tobacco control legislation. In models 1 and 2, we replaced the achievements scores by the proportion of P, W and E measures adopted by each country out of all possible measures reported by the WHO. In model 3, we used P and E (direct and indirect measures separately) compliance scores provided by the WHO to represent actual legislation implementation. Finally, an interaction term for compliance and achievement to capture the combined effect of legislation quality and performance was added to model 4. Results for men and women by age group for each of the additional models are presented in the Supplemental Information (Supplementary Tables 1–4 ).

The main model described in this study was chosen because it includes a larger number of country-year observations ( n  = 823) when compared to models including compliance scores and because it is more directly interpretable.

Counterfactual analysis

To further explore and quantify the impact of tobacco control policies on current smoking prevalence, we simulated what smoking prevalence across all countries would have been achieved in 2017 under 4 alternative policy scenarios: (1) if achievement scores and RIP remained at the level they were at in 2008; (2) if all countries had implemented each of P, W and E component at the highest level (score = 5); (3) if the price of a cigarette pack was I$7.73 or higher, a price that represents the 90th percentile of observed prices across all countries and years; and (4) if countries had implemented the P, W and E components at the highest level and higher cigarette prices. To keep our results consistent across scenarios, we restricted our analysis to 155 countries with non-missing policy-related indicators for both 2008 and 2016.

Random effects were used in model fitting but not in this prediction. Simulated prevalence rates were calculated by multiplying the estimated marginal effect of each policy by the alternative values proposed in each of the counterfactual scenarios for each country-year. The global population-weighted average was computed for status quo and counterfactual scenarios using population data sourced from the Institute for Health Metrics and Evaluation. Using the predicted prevalence rates and population data, the additional reduction in the number of current smokers in 2017 was also computed. Since models were ran using age-standardized prevalence, the number of smokers was proportionally redistributed across age groups using the sex-specific numbers from the age group 15 and older as an envelope.

The UIs for predicted estimates were based on a computation of the results of each of the 1,000 draws (unbiased random samples) taken from the uncertainty distribution of each of the estimated coefficients; the lower bound of the 95% UI for the final quantity of interest is the 2.5 percentile of the distribution and the upper bound is the 97.5 percentile of the distribution.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

The dataset generated and analyzed during the current study is publicly available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 ( https://doi.org/10.6069/QAZ7-6505 ). The dataset contains all data necessary to interpret, replicate and build on the methods or findings reported in the article. Tobacco control policy data that support the findings of this study are released every two years as part of the WHO’s Global Report on Tobacco Control; these data are also directly accessible at https://www.who.int/tobacco/global_report/en/ . Source data are provided with this paper.

Code availability

All code used for these analyses is available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 and https://github.com/ihmeuw/team/tree/effects_tobacco_policies .

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Acknowledgements

The study was funded by Bloomberg Philanthropies (grant 47386, Initiative to Reduce Tobacco Use). We thank the support of the Tobacco Metrics Team Advisory Group, which provided valuable comments and suggestions over several iterations of this manuscript. We also thank the Tobacco Free Initiative team at the WHO and the Campaign for Tobacco-Free Kids for making the tobacco control legislation data available and providing clarifications when necessary. We thank A. Tapp, E. Mullany and J. Whisnant for assisting in the management and execution of this study. We thank the team who worked in a previous iteration of this project, especially A. Reynolds, C. Margono, E. Dansereau, K. Bolt, M. Subart and X. Dai. Lastly, we thank all GBD 2017 Tobacco collaborators for their valuable work in providing feedback to our smoking prevalence estimates throughout the GBD 2017 cycle.

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Luisa S. Flor, Marissa B. Reitsma, Vinay Gupta & Emmanuela Gakidou

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L.S.F., M.N. and E.G. conceptualized the study and designed the analytical framework. M.B.R. and V.G. provided input on data, results and interpretation. L.S.F. and E.G. wrote the first draft of the manuscript. All authors read and approved the final version of the manuscript.

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Extended data

Extended data fig. 1 prevalence of current smoking for men (a) and women (b) aged 15 years and older (age-standardized) in 2017..

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 2 Prevalence of current smoking for men (a) and women (b) aged 15 to 29 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15–29 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 3 Prevalence of current smoking for men (a) and women (b) aged 30 to 49 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 30–49 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 4 Prevalence of current smoking for men (a) and women (b) aged 50 years and older (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 50 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 5 Percentage changes in current smoking prevalence based on fixed effect coefficients from bivariate mixed effect linear regression models, by policy component, sex and age group.

Bivariate models examined the unadjusted association between smoke-free (P), health warnings (W), and advertising (E) achievement scores, and cigarette’s affordability (RIP) and current smoking prevalence, from 2009 to 2017, across 175 countries (n = 823 country-years). Linear mixed models were fit by maximum likelihood and t-tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if lower than 0.05.

Supplementary information

Supplementary information.

Supplementary Tables 1–4: additional models results.

Source Data Fig. 1

Input data for Fig. 1 replication.

Source Data Extended Data Fig. 1

Input data for Extended Data 1 replication.

Source Data Extended Data Fig. 2

Input data for Extended Data 2 replication.

Source Data Extended Data Fig. 3

Input data for Extended Data 3 replication.

Source Data Extended Data Fig. 4

Input data for Extended Data 4 replication.

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Flor, L.S., Reitsma, M.B., Gupta, V. et al. The effects of tobacco control policies on global smoking prevalence. Nat Med 27 , 239–243 (2021). https://doi.org/10.1038/s41591-020-01210-8

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See the Figure for a more detailed summary of the recommendations for clinicians. See the Practice Considerations section for more information on recommended behavioral interventions and pharmacotherapy and for suggestions for practice regarding the I statements. USPSTF indicates US Preventive Services Task Force.

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eFigure. US Preventive Services Task Force (USPSTF) Grades and Levels of Evidence

• USPSTF Review: Interventions for Tobacco Cessation in Adults, Including Pregnant Persons JAMA US Preventive Services Task Force January 19, 2021 This systematic review to support the 2021 US Preventive Services Task Force Recommendation Statement on interventions for tobacco cessation in adults summarizes published evidence on the benefits and harms of interventions for tobacco cessation in adults, including pregnant persons. Carrie D. Patnode, PhD, MPH; Jillian T. Henderson, PhD, MPH; Erin L. Coppola, MPH; Joy Melnikow, MD, MPH; Shauna Durbin, MPH; Rachel G. Thomas, MPH
• A Comprehensive Approach to Increase Adult Tobacco Cessation JAMA Editorial January 19, 2021 Brenna VanFrank, MD, MSPH; Letitia Presley-Cantrell, PhD
• Initiating Pharmacologic Treatment in Tobacco-Dependent Adults JAMA JAMA Clinical Guidelines Synopsis January 19, 2021 This JAMA Clinical Guidelines Synopsis summarizes the American Thoracic Society’s 2020 recommendations for treating tobacco dependence with pharmacologic therapy in adults. Atul Jain, MD, MS; Andrew M. Davis, MD, MPH
• USPSTF Recommendation: Interventions to Promote Tobacco Cessation JAMA JAMA Patient Page January 19, 2021 This JAMA Patient Page summarizes the USPSTF 2020 guideline recommending that physicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and drugs shown effective for stopping cigarette and other tobacco use. Jill Jin, MD, MPH
• COVID-19 and the “Lost Year” for Smokers Trying to Quit JAMA Medical News & Perspectives May 18, 2021 This Medical News article describes a reduction in smoking cessation attempts during the COVID-19 pandemic. Mary Chris Jaklevic, MSJ
• Considerations of Sex and Gender in FDA Tobacco Regulation JAMA Viewpoint June 20, 2023 This Viewpoint discusses how sex and gender subpopulations may be differentially affected by tobacco products and suggests that the FDA formulate regulations in clinically meaningful ways. Danielle R. Davis, PhD; Suchitra Krishnan-Sarin, PhD; Carolyn M. Mazure, PhD
• Varenicline or Nicotine Replacement After Initial Treatment Failure JAMA Original Investigation May 28, 2024 This sequential, multiple assignment randomized trial compares treatment strategies and dosages after abstinence from smoking was not achieved after 6 weeks of first-line therapies. Paul M. Cinciripini, PhD; Charles E. Green, PhD; Sanjay Shete, PhD; Jennifer A. Minnix, PhD; Jason D. Robinson, PhD; Yong Cui, PhD; Seokhun Kim, PhD; George Kypriotakis, PhD; Diane Beneventi, PhD; Janice A. Blalock, PhD; Francesco Versace, PhD; Maher Karam-Hage, MD

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US Preventive Services Task Force. Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons : US Preventive Services Task Force Recommendation Statement . JAMA. 2021;325(3):265–279. doi:10.1001/jama.2020.25019

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Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons : US Preventive Services Task Force Recommendation Statement

• Editorial A Comprehensive Approach to Increase Adult Tobacco Cessation Brenna VanFrank, MD, MSPH; Letitia Presley-Cantrell, PhD JAMA
• US Preventive Services Task Force USPSTF Review: Interventions for Tobacco Cessation in Adults, Including Pregnant Persons Carrie D. Patnode, PhD, MPH; Jillian T. Henderson, PhD, MPH; Erin L. Coppola, MPH; Joy Melnikow, MD, MPH; Shauna Durbin, MPH; Rachel G. Thomas, MPH JAMA
• JAMA Clinical Guidelines Synopsis Initiating Pharmacologic Treatment in Tobacco-Dependent Adults Atul Jain, MD, MS; Andrew M. Davis, MD, MPH JAMA
• JAMA Patient Page USPSTF Recommendation: Interventions to Promote Tobacco Cessation Jill Jin, MD, MPH JAMA
• Medical News & Perspectives COVID-19 and the “Lost Year” for Smokers Trying to Quit Mary Chris Jaklevic, MSJ JAMA
• Viewpoint Considerations of Sex and Gender in FDA Tobacco Regulation Danielle R. Davis, PhD; Suchitra Krishnan-Sarin, PhD; Carolyn M. Mazure, PhD JAMA
• Original Investigation Varenicline or Nicotine Replacement After Initial Treatment Failure Paul M. Cinciripini, PhD; Charles E. Green, PhD; Sanjay Shete, PhD; Jennifer A. Minnix, PhD; Jason D. Robinson, PhD; Yong Cui, PhD; Seokhun Kim, PhD; George Kypriotakis, PhD; Diane Beneventi, PhD; Janice A. Blalock, PhD; Francesco Versace, PhD; Maher Karam-Hage, MD JAMA

Importance   Tobacco use is the leading preventable cause of disease, disability, and death in the US. In 2014, it was estimated that 480 000 deaths annually are attributed to cigarette smoking, including second hand smoke exposure. Smoking during pregnancy can increase the risk of numerous adverse pregnancy outcomes (eg, miscarriage and congenital anomalies) and complications in the offspring (including sudden infant death syndrome and impaired lung function in childhood). In 2019, an estimated 50.6 million US adults (20.8% of the adult population) used tobacco; 14.0% of the US adult population currently smoked cigarettes and 4.5% of the adult population used electronic cigarettes (e-cigarettes). Among pregnant US women who gave birth in 2016, 7.2% reported smoking cigarettes while pregnant.

Objective   To update its 2015 recommendation, the USPSTF commissioned a review to evaluate the benefits and harms of primary care interventions on tobacco use cessation in adults, including pregnant persons.

Population   This recommendation statement applies to adults 18 years or older, including pregnant persons.

Evidence Assessment   The USPSTF concludes with high certainty that the net benefit of behavioral interventions and US Food and Drug Associated (FDA)–approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial. The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial. The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence.

Recommendations   The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. (A recommendation) The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. (A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant persons. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety. (I statement)

Tobacco use is the leading preventable cause of disease, disability, and death in the US. In 2014, it was estimated that 480 000 deaths annually are attributed to cigarette smoking, including second hand smoke. 1 Smoking during pregnancy can increase the risk for miscarriage, congenital anomalies, stillbirth, fetal growth restriction, preterm birth, placental abruption, and complications in the offspring, including sudden infant death syndrome and impaired lung function in childhood. 1 - 4 In 2019 (the most recent data currently available), an estimated 50.6 million US adults (20.8% of the adult population) used tobacco; 14.0% of the US adult population currently smoked cigarettes; and 4.5% of the US adult population used electronic cigarettes (e-cigarettes). 5 According to data from the National Vital Statistics System, in 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy. 6 There are disparities in smoking behaviors associated with certain sociodemographic factors: smoking rates are particularly high in non-Hispanic American Indian/Alaska Native persons; lesbian, gay, or bisexual adults; adults whose highest level of educational attainment is a General Educational Development certificate; persons who are uninsured and those with Medicaid; adults with a disability; and persons with mild, moderate, or severe generalized anxiety symptoms. 5 According to the 2015 National Health Interview Survey, which reported responses from 33,672 adults, 68% of adults who smoked reported that they wanted to stop smoking and 55% attempted quitting in the past year 7 ; only 7% reported having recently quit smoking and 31% reported having used cessation counseling, medication, or both when trying to quit. 7

Quiz Ref ID The USPSTF concludes with high certainty that the net benefit of behavioral interventions and US Food and Drug Administration (FDA)–approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial .

Quiz Ref ID The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial .

Quiz Ref ID The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined.

Quiz Ref ID The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient , and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials (RCTs) on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence.

See the Figure , Table 1 , and the eFigure in the Supplement for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine net benefit, see the USPSTF Procedure Manual. 8

This recommendation applies to adults 18 years or older, including pregnant persons. The USPSTF has issued a separate recommendation statement on primary care interventions for the prevention and cessation of tobacco use in children and adolescents. 9

Key definitions related to tobacco use are reported in the Box . Although tobacco use refers broadly to the use of any tobacco product, cigarette smoking has historically been the most prevalent form of tobacco use in the US, and most of the evidence surrounding cessation of tobacco products relates to quitting combustible cigarette smoking. Thus, the current USPSTF recommendations focus on interventions for tobacco smoking cessation. Additionally, although e-cigarettes are considered a tobacco product that should also be the focus of tobacco prevention and cessation efforts, for this recommendation statement, the evidence on e-cigarettes as a potential cessation aid for cigarette smoking was also evaluated.

Key Definitions Related to Tobacco Use

Tobacco use.

Tobacco use refers to use of any tobacco product. As defined by the US Food and Drug Administration, tobacco products include any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems. 10

Smoking generally refers to the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes.

Vaping refers to the inhaling and exhaling of aerosols produced by e-cigarettes. 11 Vaping products (ie, e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape. While the 2015 USPSTF recommendation statement used the term “electronic nicotine delivery systems” or “ENDS,” the USPSTF recognizes that the field has shifted to using the term “e-cigarettes” (or “e-cigs”) and uses the term e-cigarettes in the current recommendation statement. e-Cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or “vapor”) that is inhaled (“vaped”) by users. 11

USPSTF indicates US preventive Services Task Force.

All patients should be asked about their tobacco use, whether or not risk factors for use are present, and encouraged to stop using tobacco. When smoking is identified, all patients should be provided interventions to quit smoking. Higher smoking prevalence has been observed in men; persons younger than 65 years; non-Hispanic American Indian/Alaska Native persons; persons who are lesbian, gay, or bisexual; persons whose highest level of educational attainment is a General Educational Development certificate; persons with an annual household income less than $35 000; persons with a disability; and persons with mild, moderate, or severe anxiety symptoms. 5

Common approaches for clinicians to assess patients’ tobacco use include the following.

The 5 As: (1) Ask about tobacco use; (2) Advise to quit through clear, personalized messages; (3) Assess willingness to quit; (4) Assist in quitting; and (5) Arrange follow-up and support. 12

“Ask, Advise, Refer,” which encourages clinicians to ask patients about tobacco use, advise them to quit, and refer them to telephone quit lines, other evidence-based cessation interventions, or both. 12

Vital Sign: Treating smoking status as a vital sign and recording smoking status at every health visit are also frequently used to assess smoking status. 12

Because many pregnant women who smoke do not report it, using multiple choice questions to assess smoking status in this group may improve disclosure. 12

Effective tobacco smoking cessation interventions for nonpregnant adults include behavioral counseling and pharmacotherapy, either individually or in combination. 13 , 14

Combining behavioral and pharmacotherapy interventions has been shown to increase tobacco smoking cessation rates compared with either usual care/brief cessation interventions alone or pharmacotherapy alone. 13 Most combination interventions include behavioral counseling involving several sessions (≥4), with planned total contact time usually ranging from 90 to 300 minutes. 13 The largest effect was found in interventions that provided 8 or more sessions, although the difference in effect among the number of sessions was not significant. 13

Many behavioral counseling interventions are available to increase tobacco smoking cessation in adults. These interventions can be delivered in the primary care setting or can be referred to community settings with feedback to the primary care clinician. Effective behavioral interventions include physician advice, nurse advice, individual counseling with a cessation specialist, group behavioral interventions, telephone counseling, and mobile phone–based interventions. 13 Behavioral counseling interventions used in studies typically targeted individuals who were motivated to quit tobacco smoking. 13 For additional information about behavioral counseling interventions in nonpregnant adults, see Table 2 .

Quiz Ref ID The current pharmacotherapy interventions approved by the FDA for the treatment of tobacco smoking dependence in adults are nicotine replacement therapy (NRT) (including nicotine transdermal patches, lozenges, gum, inhalers, or nasal spray), bupropion hydrochloride sustained-release (SR), and varenicline. 46 All 3 types of pharmacotherapy increase tobacco smoking cessation rates. Using a combination of NRT products (in particular, combining short-acting plus long-acting forms of NRT) has been found to be more effective than using a single form of NRT. 13 Based on a smaller number of studies, varenicline appears to be more effective than NRT or bupropion SR. 13 Information on dosing regimens is available in the package inserts of individual medications or in the 2020 Surgeon General Report on Smoking Cessation. 47

Providing any psychosocial intervention to pregnant persons who smoke tobacco can increase smoking cessation. The behavioral counseling intervention type most often studied in pregnant persons who smoke was counseling. Behavioral interventions were more effective when they provided more intensive counseling, were augmented with messages and self-help materials tailored for pregnant persons, and included messages about the effects of smoking on both maternal and fetal health and strong advice to quit as soon as possible. 12 , 13 Although smoking cessation at any point during pregnancy yields substantial health benefits for the expectant mother and infant, quitting early in pregnancy provides the greatest benefit to the fetus. 12 , 13 Other interventions included feedback, incentives, health education, and social support, although provision of health education alone, without counseling, was not found to be effective. For additional information about behavioral counseling interventions in pregnant persons, see Table 2 .

Primary care clinicians may find the following resources useful in talking with adults and pregnant persons about tobacco smoking cessation.

Centers for Disease Control and Prevention

Health care clinician resources for treatment of tobacco use and dependence https://www.cdc.gov/tobaccoHCP

Tips From Former Smokers https://www.cdc.gov/tobacco/campaign/tips/partners/health/index.html

US Department of Health and Human Services

SmokeFree.Gov Health Professionals Page https://smokefree.gov/help-others-quit/health-professionals

SmokeFreeWomen http://women.smokefree.gov/pregnancy-motherhood

In addition, the following resources may be useful to primary care clinicians and practices trying to implement interventions for tobacco smoking cessation.

Million Hearts tools for clinicians for tobacco cessation https://millionhearts.hhs.gov/tools-protocols/tools/tobacco-use.html

Centers for Disease Control and Prevention state and community resources for tobacco control programs https://www.cdc.gov/tobacco/stateandcommunity/index.htm

The US Department of Veterans Affairs (VA) Primary Care & Tobacco Cessation Handbook https://www.mentalhealth.va.gov/quit-tobacco/docs/IB_10-565-Primary-Care-Smoking-Handbook-PROVIDERS-508.pdf

World Health Organization’s toolkit for delivering brief smoking interventions in primary care http://www.who.int/tobacco/publications/smoking_cessation/9789241506953/en/

In 2020, the Surgeon General issued a Report on Smoking Cessation. 47 The report’s findings were largely similar to that of the USPSTF. The Surgeon General’s report issued some additional findings regarding internet-based interventions for cessation and describes some suggestive but not sufficient evidence about specific e-cigarette use behaviors and increased cessation. Overall, the Surgeon General’s report found that there is inadequate evidence to conclude that e-cigarettes increase smoking cessation. More information on the Surgeon General’s Report on Smoking Cessation is available at https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/#fact-sheets .

According to data from the National Vital Statistics System, in 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy, 6 and among 1071 pregnant women aged 18 to 44 years, 3.6% reported using e-cigarettes. 48 Smoking during pregnancy reduces fetal growth, increases the risk of preterm birth, and doubles the risk for delivering an infant with low birth weight. It also increases the relative risk for stillbirth death by 25% to 50%. 1 , 2 Quitting smoking early in pregnancy can reduce or eliminate the adverse effects of smoking on fetal growth. 47 For pregnant persons for whom behavioral counseling alone does not work, evidence to support other options to increase smoking cessation during pregnancy are limited. Few clinical trials have evaluated the effectiveness of NRT for smoking cessation in pregnant women. Although most studies were in the direction of benefit, no statistically significant increase in cessation was seen. 13 There is limited evidence on harms of NRT from trials in pregnant persons. Potential adverse maternal events reported in studies of NRT include slightly increased diastolic blood pressure and skin reactions to the patch. 13 Potential adverse events reported in nonpregnant adults include higher rates of low-risk cardiovascular events, such as tachycardia. 13 It has been suggested that NRT may be safer than smoking during pregnancy given that cigarette smoke contains harmful substances in addition to nicotine. The USPSTF identified no studies on bupropion SR or varenicline pharmacotherapy for tobacco smoking cessation during pregnancy.

In the absence of clear evidence on the balance of benefits and harms of pharmacotherapy in pregnant women, clinicians are encouraged to consider the severity of tobacco dependence in each patient and engage in shared decision-making to determine the best individual treatment course.

No tobacco product use is risk-free, including the use of e-cigarettes. Tobacco smoking cessation can be difficult for many individuals; thus, having a variety of tools available to help persons quit smoking would potentially be helpful. Findings from small surveys and qualitative data report mixed findings on whether physicians are recommending e-cigarettes to patients to help them quit smoking. 13 , 49 - 51 Few randomized trials have evaluated the effectiveness of e-cigarettes to increase tobacco smoking cessation in nonpregnant adults, and no trials have evaluated e-cigarettes for tobacco smoking cessation in pregnant persons. 13 Overall, results were mixed on whether smoking cessation increased with e-cigarettes; however, continued e-cigarette use after the intervention phase of trials remained high, indicating continued nicotine dependence. Trial evidence on harms of e-cigarettes used for smoking cessation is also limited. The most commonly reported adverse effects from e-cigarette use reported in trials included coughing, nausea, throat irritation, and sleep disruption. 13 Generally, no significant difference in short-term serious adverse events associated with e-cigarette use was reported. 13 Evidence on potential harms of e-cigarette use in general (whether for tobacco smoking cessation or not) has been reviewed in the National Academies of Science, Engineering, and Medicine report Public Health Consequences of E-Cigarettes. 52 For example, the report found conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances. Additionally, an outbreak of e-cigarette, or vaping product, use–associated lung injury (EVALI) that occurred in the US in late 2019 also suggests potential harms of e-cigarette use. The vast majority of cases have been associated with tetrahydrocannabinol (THC)–containing e-cigarettes. 53

Given the high rates of e-cigarette use in children and adolescents currently in the US, 54 the USPSTF recognizes that an overall public health question remains on whether the potential use of e-cigarettes as a tobacco smoking cessation aid (if ever proven effective) could be balanced with the high rates of e-cigarette use in youth as a driver for increasing overall tobacco use. The USPSTF has issued a separate recommendation statement on the prevention of tobacco use, including e-cigarettes, in children and adolescents. 9 The current USPSTF recommendation statement for adults evaluated the evidence on the benefits and harms of e-cigarettes to increase tobacco cessation; the USPSTF found this evidence to be insufficient. Given the proven effectiveness of behavioral counseling interventions in both nonpregnant and pregnant adults, and of pharmacotherapy in nonpregnant adults, the USPSTF recommends that clinicians focus on offering behavioral counseling and pharmacotherapy to increase smoking cessation in nonpregnant adults, and behavioral counseling to increase smoking cessation in pregnant persons.

In 2020, the USPSTF recommended that primary care clinicians provide interventions, including education or brief counseling, to prevent the initiation of tobacco use (including e-cigarettes) in school-aged children and adolescents. 9 The USPSTF found the evidence on primary care interventions for the cessation of tobacco use in youth to be insufficient.

This recommendation statement replaces the 2015 USPSTF recommendation statement on behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women. 55 The current recommendation statement has been updated to reflect newer evidence and language in the field of tobacco cessation and includes a description of the 2019 EVALI outbreak in the US. However, the recommendations on the services primary care clinicians should provide for tobacco cessation are the same as in 2015.

The USPSTF commissioned a systematic review to evaluate the benefits and harms of primary care interventions on tobacco use cessation in adults, including pregnant persons. 13 , 14 The USPSTF considered evidence on the benefits and harms of behavioral counseling interventions, pharmacotherapy interventions, and e-cigarettes in nonpregnant adults and pregnant persons. The vast majority of evidence identified focused on cigarette smoking cessation.

The USPSTF reviewed evidence on the benefits of behavioral counseling interventions on tobacco use cessation in general adults primarily from 20 systematic reviews that covered approximately 830 RCTs and more than 500 000 participants. 13 The evidence almost exclusively evaluated interventions for cessation of cigarette smoking. Physician advice, nurse advice, individual counseling with a cessation specialist, group behavioral interventions, telephone counseling, and mobile phone–based interventions have all been found to be effective to increase cessation of cigarette smoking. 13

Based on a 2013 systematic review that pooled 26 trials (n = 22 239), rates of smoking cessation at 6 months or more were an average of 8.0% in groups that received physician advice compared with 4.8% in groups that received no advice or usual care (risk ratio [RR], 1.76 [95% CI, 1.58-1.96]). 13 , 56 When stratified by intensity level, both minimal advice (defined as a single session lasting <20 minutes with ≤1 follow-up sessions) and intensive advice (defined as a single session lasting ≥20 minutes or >1 follow-up session) from a physician was associated with significantly increased cessation rates compared with no advice. Although not definitive, some subgroup analyses suggest that more intensive physician counseling (>20 minutes for initial consult, use of additional materials, or >1 follow-up visit) may be associated with an increase in cessation rates, particularly in patients who have smoking-related disease. 13 , 56

Based on a 2017 systematic review that pooled 44 trials evaluating nurse advice, 14.2% of participants who received interventions from nurses achieved smoking cessation at 6 months or more compared with 12.2% of those who received usual care or minimal intervention (RR, 1.29 [95% CI, 1.21-1.38]). 13 , 57 No evidence of effect modification was found when comparing higher- or lower-intensity counseling provided by nurses.

A systematic review from 2017 that pooled 33 trials (n = 13 762) found that an average of 11.4% of participants who received individual counseling with a cessation specialist achieved smoking cessation, compared with 7.7% of those who received minimal contact of less than 15 minutes of advice (RR, 1.48 [95% CI, 1.34-1.64]). 13 , 58 The review found some evidence suggesting that more intensive counseling was associated with higher cessation rates. Another systematic review published in 2017 that pooled 13 trials (n = 4395) also found that participants receiving group behavioral interventions had higher cessation rates compared with those who received a self-help program (10.4% cessation rate in intervention group vs 5.8% cessation rate in control group; RR, 1.88 [95% CI, 1.52-2.33]). 13 , 59

A 2019 review on telephone counseling interventions found that proactive telephone counseling (where telephone counselors called participants directly either to initiate counseling or in response to a participant calling a quitline) was associated with increased cessation rates. 13 , 60 If the telephone counseling was a “cold call” from telephone counselors to initiate counseling, smoking cessation rates were 11.0% in control participants and 13.9% in telephone counseling recipients (RR, 1.25 [95% CI, 1.15-1.35]; 65 trials; n = 41 233). 13 , 60 If telephone counseling occurred in response to a participant contacting a quitline, cessation rates were 7.8% in control participants and 10.8% in intervention recipients (RR, 1.38 [95% CI, 1.19-1.61]; 14 trials; n = 32 484). 13 , 60

A 2019 review that pooled 13 trials (n = 14 133) found higher cessation rates associated with mobile phone–based interventions. 13 , 61 All studies primarily used text messaging as the main intervention component, although a limited number of studies looked at individual mobile phone applications. Smoking cessation rates were an average of 5.6% in participants receiving usual or minimal care and 9.5% in those receiving mobile phone–based interventions (RR, 1.54 [95% CI, 1.19-2.00]).

The USPSTF considered evidence on other behavioral counseling interventions such as print-based, nontailored self-help materials, internet-based interventions, motivational interviewing, biofeedback, exercise, acupuncture, and hypnotherapy 13 ; however, limited evidence was available on these interventions.

The USPSTF reviewed evidence from 4 systematic reviews on pharmacotherapy that reported smoking cessation at 6 months or more. 13

A 2018 review on NRT (133 studies; n = 64 640) 62 found that 16.9% of participants taking any form of NRT achieved smoking abstinence at 6 months or more compared with 10.5% of participants receiving placebo or taking no NRT (RR, 1.55 [95% CI, 1.49-1.61]). All forms of NRT (patch, gum, inhaler, intranasal, and tablets) were found to be effective. Another review found that using combination NRT (patch plus a fast-acting form) was associated with higher smoking cessation rates than using a single form of NRT (16.9% vs 13.9%; RR, 1.25 [95% CI, 1.15-1.36]). 63

A 2020 systematic review on the use of antidepressants for smoking cessation (46 studies; n = 17 866) found that bupropion SR was associated with a significantly higher rate of smoking abstinence at 6 months or more than placebo or no bupropion SR (19.0% vs 11.0%; RR, 1.64 [95% CI, 1.52-1.77]). 64

Based on pooled analyses of 27 studies (n = 12 625), a 2016 systematic review found that varenicline was associated with higher rates of smoking cessation over placebo (25.6% vs 11.1%; RR, 2.24 [95% CI, 2.06-2.43]). 65

Smaller subsets of studies from these reviews directly compared types of pharmacotherapy for smoking cessation. Eight studies (n = 6264) compared varenicline and NRT and found that varenicline was associated with a greater smoking cessation rate over any form of NRT. 65 Six studies (n = 6286) evaluated varenicline vs bupropion SR and found that varenicline was associated with a higher cessation rate. 64 , 65 Smoking cessation rates among participants using NRT vs bupropion SR at 6 months or more did not significantly differ (10 studies; n = 9230). 64

Combinations of behavioral counseling and pharmacotherapy for smoking cessation were also effective, and potentially more effective than behavioral counseling or pharmacotherapy alone. 13 A 2016 systematic review (52 studies; n = 19 488) 66 found that participants who received combination pharmacotherapy and intensive behavioral counseling had a higher abstinence rate at 6 months or more compared with control participants who received usual care, self-help materials, or brief advice on quitting (which was less intensive than the counseling or support given to the intervention groups) (15.2% vs 8.6%; RR, 1.83 [95% CI, 1.68-1.98]). These combination interventions often have behavioral components delivered by specialized smoking cessation counselors or trained staff; however, no difference in effectiveness was seen in studies in which a nonspecialist provided the counseling. 13 Most studies used NRT as the pharmacotherapy. The intensity and format of the behavioral counseling component of the intervention varied greatly, with the majority of studies offering at least 4 behavioral counseling sessions, with a total planned contact time generally ranging from 90 to 300 minutes. Most of the behavioral counseling was delivered by a specialized smoking cessation counselor or trained trial staff.

Another systematic review, 67 which pooled analyses of 65 studies (n = 23 331), found that cessation rates at 6 months or more were modestly higher in participants who received behavioral support as an adjunct to pharmacotherapy than in those who received pharmacotherapy alone. Most studies offered NRT as the pharmacotherapy. Participants in the control group may have also received some counseling or support, but it was less intensive than in the intervention group. The addition of behavioral support to pharmacotherapy was associated with significantly higher cessation rates, approximately 17% in persons using pharmacotherapy alone vs 20% in those using a combination of pharmacotherapy and behavioral support (RR, 1.15 [95% CI, 1.08-1.22]). 13

For benefits of tobacco use cessation interventions in pregnant persons, the USPSTF reviewed evidence from an existing systematic review on behavioral counseling interventions 68 and from primary studies of pharmacotherapy. As with the evidence base in nonpregnant adults, the available evidence primarily addressed smoking cessation.

Based on a systematic review from 2017, 68 the USPSTF found that behavioral counseling interventions in pregnant women were effective at improving rates of smoking cessation as well as some perinatal health outcomes. Pooled analyses from 97 studies (n = 26 637) found that use of any psychosocial intervention was associated with higher smoking cessation rates in late pregnancy relative to control groups (an average quit rate of 12.2% in control groups and 16.4% in intervention groups) (RR, 1.35 [95% CI, 1.23-1.48]). The majority of studies used counseling interventions, and analyses of only counseling interventions (51 studies; n = 18 276) found a significant increase in smoking cessation rates late in pregnancy, from 10.8% in control groups to 14.5% in intervention groups (RR, 1.31 [95% CI, 1.16-1.47]). Studies of other intervention types (health education, feedback, incentives, social support, and exercise) were much fewer, with fewer total participants. Findings of smoking cessation effectiveness by intervention type were all in the direction of benefit, although not all were statistically significant. No subgroup differences by intervention type were found. The same systematic review also assessed the association of behavioral counseling interventions with perinatal outcomes and found lower rates of low birth weight (RR, 0.83 [95% CI, 0.72-0.94]; 18 trials; n = 9402) and increased mean birth weight (mean difference, 55.6 g [95% CI, 29.82-81.38]; 26 trials; n = 11 338). No statistically significant difference in rates of preterm births or stillbirths was found.

The USPSTF identified 5 placebo-controlled trials on NRT during pregnancy. 13 All 5 trials included behavioral counseling or support in addition to NRT. One trial used NRT gum as the intervention, one used an inhaler, while the other 3 trials used a NRT patch. Adherence to NRT in studies was low (<10% in 1 study). Findings of the 5 trials were all generally in the direction of benefit with NRT; however, none of the studies, either individually or when pooled, found a statistically significant difference in smoking cessation (11.9% in NRT intervention groups vs 10.1% in control groups; RR, 1.11 [95% CI, 0.79-1.56]; 5 trials; n = 2033). 13 Seven trials (the 5 placebo-controlled trials previously mentioned plus 2 additional non–placebo-controlled trials) reported on perinatal and health outcomes with NRT during pregnancy 13 ; findings were inconsistent and imprecise. No studies on bupropion SR or varenicline for smoking cessation during pregnancy were identified.

The FDA classifies e-cigarettes as a tobacco product and to date, no e-cigarettes have been approved as a smoking cessation aid. Approximately 4.5% of adults 5 , 69 and 3.6% of pregnant women 48 report using e-cigarettes. Higher e-cigarette use is reported among young adults aged 18 to 24 years (7.6%) 70 and has been increasing in recent years. 70 In addition to young adults, e-cigarette use among adults is higher in men; non-Hispanic White adults and other non-Hispanic adults; lesbian, gay, or bisexual 5 persons; and persons with chronic illnesses (such as cardiovascular disease, diabetes, cancer, asthma, chronic obstructive pulmonary disease, chronic kidney disease, and depression). 13 , 71 Most adult e-cigarette users report that quitting smoking and health improvement are major reasons why they started using e-cigarettes. 72 , 73 This is in contrast to youth, where it has been found that e-cigarette use increases risk of ever smoking cigarettes. 52 Nineteen percent of tobacco users use 2 or more tobacco products, the most common combination being cigarettes and e-cigarettes. 74

The USPSTF identified 5 RCTs (n = 3117) on e-cigarettes for smoking cessation in nonpregnant adults 13 , 75 - 80 and no studies in pregnant persons. 13 All 5 studies were conducted outside of the US (2 in New Zealand, 1 in Italy, 1 in Korea, and 1 in the UK). Four of the studies included participants who either wanted to stop smoking or were attending a stop smoking service. The type of e-cigarette interventions (nicotine content, whether NRT was also given, nicotine cartridge vs e-liquid, and whether behavioral support was also provided) and control interventions (NRT vs nonnicotine e-cigarette) varied across studies, making comparisons difficult. Only 3 of the e-cigarettes used in the studies are currently available in the US. Study size ranged from 150 to 1124 participants.

Reported trial findings were mixed. The 2 largest and most recent trials reported a statistically significant increase in smoking cessation at 6 months; 1 study reported smoking cessation rates of 4% in control groups vs 7% 79 in intervention groups; the second trial reported smoking cessation rates of 25% in control groups vs 35% 78 in intervention groups. The 3 remaining trials reported no statistically significant differences in smoking cessation rates. Three of the studies reported on continued e-cigarette use after achievement of smoking cessation in intervention groups at 6 months to 1 year, with continued e-cigarette use ranging from 38% to 80%. One study reported that 26.9% of all study participants were using e-cigarettes at 1 year. 77

The USPSTF identified limited evidence on harms from behavioral counseling interventions for tobacco cessation. Three systematic reviews (1 on internet-based interventions, another on incentives, and 1 on hypnotherapy) did not find evidence of serious adverse events associated with interventions. 13

The USPSTF identified 4 systematic reviews on NRT that reported on harms 13 : 3 reviews compared harms of NRT vs placebo 62 , 81 , 82 and 1 compared harms from various types of NRT. 63 Twelve to 21 studies (n = 10 234 to 11 647) reported on cardiovascular harms. Statistically significantly more cardiovascular adverse events (in particular, heart palpitations and chest pain) were found for participants randomized to NRT vs placebo (RR, 1.81 [95% CI, 1.35-2.43]; 21 trials; n = 11 647). 82 However, when analyses focused on major cardiovascular adverse events (combined outcome of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke), findings were no longer statistically significant (RR, 1.38 [95% CI, 0.58-3.26]; 21 trials; n = 11 647). 82 Other reported harms associated with NRT included nausea, vomiting, gastrointestinal symptoms, and insomnia. Localized increased skin irritation at the NRT patch site has also been reported. No statistically significant increase in headaches, dizziness, anxiety, or depression were found. Cardiac adverse events and other serious adverse events did not differ by type of NRT. 63

The USPSTF considered evidence on harms from bupropion SR for tobacco smoking cessation from 4 systematic reviews. 13 No difference in serious adverse events (RR, 1.30 [95% CI, 1.00-1.69]; 33 trials; n = 9631), 83 cardiovascular adverse events (RR, 1.03 [95% CI, 0.71-1.50]; 27 trials; n = 10 402), 82 or major cardiovascular events (RR, 0.57 [95% CI, 0.31-1.04]; 27 trials; n = 10 402) 82 were found with bupropion SR (compared with placebo or no bupropion SR). No difference in moderate and severe neuropsychiatric events, including rates of suicidal behavior and ideation, were found with bupropion SR (compared with varenicline or NRT) in the recent Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES) trial. 84 , 85

Evidence on harms of varenicline for tobacco cessation are available from 3 systematic reviews on varenicline in unselected smokers, 4 systematic reviews of varenicline among persons with severe mental illness, and 1 review on varenicline for cessation of smokeless tobacco. 13 Common adverse effects reported with varenicline include nausea, insomnia, abnormal dreams, headache, and fatigue. 13 One review found an increase in serious adverse events with varenicline in unselected smokers (RR, 1.25 [95% CI, 1.04-1.49]; 29 trials; n = 15 370); however, many of these events included comorbidities that were mostly considered by the study authors to be unrelated to the treatments. 65 Across 3 systematic reviews (encompassing 18 to 38 studies; n = 8587 to 12 706), no statistically significant difference in cardiovascular adverse events or cardiovascular severe adverse events was found. 13 Additionally, no statistically significant increase in neuropsychiatric adverse events (including depression, suicidal ideation, and suicide attempt) was found across several systematic reviews. 13

The USPSTF did not identify any reports of adverse events related to combinations of behavioral counseling interventions and pharmacotherapy. Any harms of combined therapy are assumed to be similar to those of the pharmacotherapy being used.

The primary review that informed the USPSTF on the benefits of behavioral counseling interventions for smoking cessation during pregnancy also summarized evidence on harms of behavioral counseling interventions. 68 Based on analyses of 13 trials (n = 5831), no increase in adverse effects from psychosocial interventions was seen.

Nicotine in general has been shown in animal studies to cause fetal harms. However, NRT does not contain many harmful substances, such as hydrogen cyanide and carbon monoxide, that are present in cigarette smoke. 86 Evidence on harms of NRT during pregnancy is limited; the USPSTF identified 5 placebo-controlled trials (n = 3117), 2 non–placebo-controlled trials (n = 233), and 3 cohort studies (n = 306 721). 13 Findings on potential harms of NRT on birth outcomes from trial evidence is mixed, although most studies reported findings in the direction of benefit rather than harm. Observational evidence from cohort studies generally did not indicate an increase in stillbirth or low birth weight with NRT. Based on observational evidence, there was no evidence of increased risk of premature delivery, small for gestational age, stillbirth, or congenital anomalies associated with the use of NRT, bupropion, and varenicline vs smoking. According to FDA labeling, some fetal harms with bupropion were noted in animal studies, but currently, no adequate, well-controlled studies of bupropion SR use during pregnancy (for any indication) in humans are available. 87 Labeling for varenicline states that available studies cannot definitively establish or exclude varenicline-associated risk during pregnancy. 88

The USPSTF identified 9 RCTs (n = 3942) that reported on harms of e-cigarette interventions for tobacco smoking cessation in nonpregnant adults 13 (the 5 trials previously described that reported cessation rates at 6 months or more, as well as an additional 4 trials that reported on cessation rates at less than 6 months). No trials on harms of e-cigarettes for smoking cessation in pregnant persons was identified. The most commonly reported adverse effects from e-cigarette use reported in trials include coughing, nausea, throat irritation, and sleep disruption. 13 Generally, no significant difference in short-term serious adverse events associated with e-cigarette use was reported. 13 Data on potential long-term harms of e-cigarette use are currently lacking.

Additional evidence on harms from e-cigarette use (whether used for tobacco cessation or not) considered by the USPSTF included data of the 2019 EVALI outbreak in the US 53 and the 2018 report Public Health Consequences of E-Cigarettes by the National Academies of Sciences, Engineering, and Medicine. 52 In late 2019, an outbreak of EVALI occurred in the US. Symptoms of EVALI include cough, shortness of breath, chest pain, nausea, vomiting, stomach pain, diarrhea, fever, chills, and weight loss. As of February 2020, more than 2800 cases of EVALI were reported, with 68 deaths. 53 Based on testing of bronchoalveolar lavage fluid samples of patients with EVALI 89 and testing of products used by patients with EVALI, 53 vitamin E acetate (an additive in some THC-containing e-cigarettes) was found to be strongly linked to EVALI. 53 However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non–THC–containing products, in some reported EVALI cases. 53

The National Academies of Sciences, Engineering, and Medicine report found that in youth and young adults, there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco and moderate evidence that e-cigarette use increases the frequency and intensity of subsequent cigarette smoking. 52 The report also found conclusive evidence that e-cigarettes contain and emit potentially toxic substances, although substantial evidence shows that other than nicotine, there is significantly lower exposure to potentially toxic substances from e-cigarettes compared with combustible tobacco cigarettes. 52

A draft version of this recommendation statement was posted for public comment on the USPSTF website from June 2, 2020, to June 29, 2020. Several comments expressed concern about the insufficient evidence statement on e-cigarettes for cessation. Some respondents wanted the USPSTF to recommend against e-cigarettes for tobacco cessation, while others wanted the USPSTF to recommend in favor of e-cigarettes. Based on the evidence reviewed, the USPSTF could not determine whether e-cigarettes are effective in helping persons to quit smoking cigarettes, nor could it determine what the potential long-term harms of e-cigarette use are; thus, it cannot recommend for or against their use. Some comments were also received requesting that the USPSTF recommend NRT for smoking cessation during pregnancy. Too few trials were identified for the USPSTF to determine whether NRT during pregnancy provides overall more benefits or harms, and the USPSTF calls for more research on NRT and other pharmacotherapy to help pregnant persons quit using tobacco. Last, edits to clarify language, as well as additional information from the recent 2020 Surgeon General’s Report on Smoking Cessation, have been provided in response to comments.

Because of the well-established health benefits of smoking cessation, 1 , 12 , 47 most of the research on interventions for smoking cessation focuses on cessation (rather than health outcomes) as a primary outcome. The current review identified 1 study 90 of middle-aged men at high risk for cardiorespiratory disease that found lower (although not statistically significant) total mortality, fatal coronary disease, and lung cancer death at 20 years of follow-up in participants who received advice from medical practitioners. 91 The study also found some reduction in all-cause mortality, coronary disease mortality, and lung cancer incidence and mortality at 20 years of follow-up, although these outcomes were not significant. 91

Although not zero, less toxins have been found to be released by e-cigarettes than by cigarettes. It is hypothesized that health outcomes may be improved in adults who completely switch from cigarette smoking to e-cigarette use, although long-term data are not available yet to support this. Evidence on long-term harms of e-cigarette use in general is lacking and is needed. Additionally, emerging evidence suggests that toxicant levels in dual users of e-cigarettes and cigarettes may be higher than in conventional cigarette–only users. 92

The greatest research needs are to gain a better understanding of the effectiveness of e-cigarettes for smoking cessation, as well as potential short- and long-term harms of e-cigarette use, and to understand whether there are effective pharmacotherapy options for pregnant persons.

e-Cigarettes: Given the potential negative effect that increasing e-cigarette use in youth is having on overall tobacco control efforts, there is an urgent need for research that provides both a clearer understanding of whether e-cigarettes may increase adult tobacco smoking cessation, as well as the potential harms of e-cigarette use as a tobacco product. Future research on e-cigarettes for smoking cessation in adults should address the following:

Studies must be well-designed RCTs that compare e-cigarette interventions with placebo, as well as established, effective combinations of pharmacotherapy and behavioral support.

Studies should be adequately powered to detect differences in continued smoking abstinence rates at 6 months or more.

Given the high rate of continued e-cigarette use after smoking cessation, research on both the short- and long-term harms of e-cigarette use is needed, as well as the harms in dual users of e-cigarettes and conventional cigarettes. More research is needed on smoking relapse rates in adults who have used e-cigarettes for smoking cessation and how to help with cessation of e-cigarette use once smoking abstinence has been achieved.

Given the rapidly evolving landscape of e-cigarettes, trials should include current generations of e-cigarettes. Additionally, to successfully conduct these types of studies, standardization of how to quantify e-cigarette use and levels of nicotine exposure from e-cigarettes is needed.

More research is needed to understand the patterns of e-cigarette use in youth and the risk factors for their transition from e-cigarette use to conventional cigarette smoking.

More research is also needed to better understand patterns of e-cigarette use in pregnant persons and potential harms of e-cigarette use to both pregnant persons and their offspring.

More research is needed on understanding how to help adults quit e-cigarettes.

Pharmacotherapy in pregnant persons: Although behavioral counseling interventions have been found to be effective in improving smoking cessation during pregnancy, additional research is needed on pharmacotherapy options, in particular NRT, for pregnant persons for whom behavioral counseling interventions alone are not effective.

Larger studies adequately powered to detect an effect on both smoking cessation rates (during pregnancy and postpartum) and changes in perinatal and child health outcomes are needed.

A better understanding of why adherence rates to NRT during pregnancy is so low would also be helpful.

Although the benefits of behavioral counseling interventions and pharmacotherapy in nonpregnant adults and the benefits of behavioral counseling interventions in pregnant adults are well established, additional research on effective components of behavioral counseling and who to target specific interventions to would be informative. More research on newer modalities and remotely delivered interventions (mobile phone apps, internet-based interventions) would also be helpful. Additionally, the effectiveness of interventions for cessation of other forms of tobacco and whether interventions need to be tailored to individual tobacco product types are also needed. Last, more research is needed on interventions to prevent relapse of tobacco use.

Numerous professional societies and health organizations, including the American Academy of Family Physicians, 93 American College of Physicians, 94 and American College of Obstetricians and Gynecologists (ACOG), 95 recommend that clinicians screen for tobacco use and provide interventions to patients who smoke.

For pregnant persons, ACOG recommends brief behavioral counseling and the use of evidence-based smoking cessation aids as effective strategies for achieving smoking cessation, even for very heavy smokers. 96 ACOG also recommends that NRT should be considered only after a detailed discussion with the patient of the known risks of continued smoking, the possible risks of NRT, and need for close supervision. 95

The American Academy of Pediatrics also has a policy statement recommending that pediatricians screen for the tobacco exposure of children during pediatric care visits and recommend nicotine dependence treatment, including behavioral interventions and pharmacotherapy, to tobacco-dependent parents. 97

More recently some organizations have addressed e-cigarette use in their tobacco use guidelines. The American Academy of Family Physicians, 98 the American College of Preventive Medicine, 99 and the American Heart Association 100 recommend that clinicians screen for e-cigarette use. Organizations vary somewhat in terms of whether they recommend e-cigarettes for smoking cessation. ACOG recommends against use of e-cigarettes in pregnant and postpartum individuals. 95 , 101 The American Cancer Society does not recommend e-cigarettes as a smoking cessation method, 102 and the American Heart Association 100 states that there is not enough evidence for clinicians to counsel patients on using e-cigarettes as a primary smoking cessation aid.

Corresponding Author: Alex H. Krist, MD, MPH, Virginia Commonwealth University, One Capitol Square, 6th Flr, 830 E Main St, Richmond, Virginia 23219 ( [email protected] )).

Accepted for Publication: December 4, 2020.

The US Preventive Services Task Force (USPSTF) members: Alex H. Krist, MD, MPH; Karina W. Davidson, PhD, MAS; Carol M. Mangione, MD, MSPH; Michael J. Barry, MD; Michael Cabana, MD, MA, MPH; Aaron B. Caughey, MD, PhD; Katrina Donahue, MD, MPH; Chyke A. Doubeni, MD, MPH; John W. Epling Jr, MD, MSEd; Martha Kubik, PhD, RN; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; Michael Silverstein, MD, MPH; Melissa A. Simon, MD, MPH; Chien-Wen Tseng, MD, MPH, MSEE; John B. Wong, MD.

Affiliations of The US Preventive Services Task Force (USPSTF) members: Fairfax Family Practice Residency, Fairfax, Virginia (Krist); Virginia Commonwealth University, Richmond (Krist); Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York (Davidson); University of California, Los Angeles (Mangione); Harvard Medical School, Boston, Massachusetts (Barry); University of California, San Francisco (Cabana); Oregon Health & Science University, Portland (Caughey); University of North Carolina at Chapel Hill (Donahue); Mayo Clinic, Rochester, Minnesota (Doubeni); Virginia Tech Carilion School of Medicine, Roanoke (Epling Jr); George Mason University, Fairfax, Virginia (Kubik); New York University, New York, New York (Ogedegbe); University of Massachusetts Medical School, Worcester (Pbert); Boston University, Boston, Massachusetts (Silverstein); Northwestern University, Evanston, Illinois (Simon); University of Hawaii, Honolulu (Tseng); Pacific Health Research and Education Institute, Honolulu, Hawaii (Tseng); Tufts University School of Medicine, Boston, Massachusetts (Wong).

Author Contributions: Dr Krist had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The USPSTF members contributed equally to the recommendation statement.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Authors followed the policy regarding conflicts of interest described at https://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures . All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. Dr Barry reported receiving grants and personal fees from Healthwise.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank Tina Fan, MD, MPH (AHRQ), who contributed to the writing of the manuscript, and Lisa Nicolella, MA (AHRQ), who assisted with coordination and editing.

Additional Information: The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

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Youth and Tobacco Use

Youth use of tobacco products in any form is unsafe .

Preventing tobacco product use among youth is critical to reducing tobacco use among the nation’s youth.

• Tobacco product use is started and established primarily during adolescence. 1,2
• Nearly 9 out of 10 adults who smoke cigarettes daily first try smoking by age 18.
• In 2021, 80.2% of high school students and 74.6% of middle school students who used tobacco products in the past 30 days reported using a flavored tobacco product during that time. 6
• In 2023, 90.3% of high school students and 87.1% of middle school students who used e-cigarettes in the past 30 days reported using a flavored e-cigarette during that time. 7

Estimates of Current Tobacco Use Among Youth

Factors associated with youth tobacco product use, reducing youth tobacco product use.

Electronic cigarettes (E-cigarettes)

• E-cigarettes have been the most commonly used tobacco product among youth since 2014.
• In 2023, about 1 out of every 22 middle school students (4.6%) reported that they had used electronic cigarettes in the past 30 days. 7
• In 2023, 1 of every 10 high school students (10.0%) reported that they had used electronic cigarettes in the past 30 days. 7
• In 2023, about 1 of every 100 middle school students (1.1%) reported that they had smoked cigarettes in the past 30 days. 7
• In 2023, nearly 2 of every 100 high school students (1.9%) reported that they had smoked cigarettes in the past 30 days. 7
• In 2023, nearly 1 of every 100 middle school students (1.1%) reported that they had smoked cigars in the past 30 days. 7
• In 2023, nearly 2 of every 100 high school students (1.8%) reported that they had smoked cigars in the past 30 days. 7

Smokeless Tobacco

• In 2023, nearly 1 of every 100 middle school students (0.7%) reported that they had had used smokeless tobacco in the past 30 days. 7
• In 2023, nearly 2 of every 100 high school students (1.5%) reported that they had had used smokeless tobacco in the past 30 days. 7
• In 2023, less than 1 of every 100 middle school students (1.0%) reported that they had smoked hookah in the past 30 days. 7
• In 2023, about 1 of every 100 high school students (1.1%) reported that they had smoked hookah in the past 30 days. 7

Heated Tobacco Products

• In 2023, less than 1 of every 100 middle school students (0.8%) and about 1 of every 100 high school students (1.0%) reported using heated tobacco products in the past 30 days. 7
• Heated tobacco products, also known as “heat-not-burn” products, deliver nicotine to the user by heating tobacco leaves rather than a nicotine-containing liquid like e-cigarettes.

Nicotine Pouches

• In 2023, about 1 of every 100 high school students (1.7%) reported using nicotine pouches in the past 30 days. 7
• Nicotine pouches are microfiber pouches with flavored nicotine powder that users dissolve in the mouth without spitting. Sales of nicotine pouches have increased rapidly in the U.S. 8

All Tobacco Product Use

• In 2023, more than 6 of every 100 middle school students (6.6%) and about 1 of every 8 high school students (12.6%) reported current use of a tobacco product. 7
• In 2023, nearly 15 of every 100 middle school students (14.7%) and nearly 28 of every 100 high school students (27.9%) said they had ever tried a tobacco product. 7

Many young people use multiple tobacco products.

• In 2023, more than 2 of every 100 middle school students (2.5%) and about 1 of every 30 high school students (3.9%) reported current use of multiple tobacco products in the past 30 days. 7
• In 2023, about 6 of every 100 middle school students (6.1%) and more than 12 of every 100 high school students (12.7%) reported they had ever tried multiple tobacco products. 7

Youth who use multiple tobacco products are at higher risk for developing nicotine dependence and might be more likely to continue using tobacco into adulthood. 1, 2

Notes: * “Current use” is determined by respondents indicating that they have used a tobacco product on at least 1 day during the past 30 days.

† In 2023, any tobacco product includes e-cigarettes, cigarettes, cigars, smokeless tobacco (composite), pipe tobacco, bidis (small brown cigarettes wrapped in a leaf), hookahs, heated tobacco products, nicotine pouches, and other oral nicotine products.

Factors associated with youth tobacco product use include the following:

• The way mass media show tobacco product use as a normal activity can make young people want to try these products.
• Youth are more likely to use tobacco products if they see people their age using these products.
• High school athletes are more likely to use smokeless tobacco than those of the same age who are not athletes. 11
• Young people may be more likely to use tobacco products if a parent uses these products.
• There is evidence that youth may be sensitive to nicotine and that teens can feel dependent on nicotine sooner than adults.
• Genetic factors may make quitting smoking harder for young people.
• Smoking during pregnancy may increase the likelihood that the child will smoke cigarettes regularly in the future.
• Mental health: There is a strong relationship between youth smoking and depression, anxiety, and stress. 2
• Personal views: When young people expect positive things from smoking, such as coping with stress better or losing weight, they are more likely to smoke. 2,10
• Lower socioeconomic status, including lower income or education
• Not knowing how to say “no” to tobacco product use
• Lack of support or involvement from parents
• Accessibility, availability, and price of tobacco products
• Doing poorly in school
• Low self-image or self-esteem
• Seeing tobacco product advertising in stores, on television, the Internet, in movies, or in magazines and newspapers

National, state, and local program activities have been shown to reduce and prevent youth tobacco product use when implemented together. 2,12,13  These activities include:

• Higher costs for tobacco products (for example, through increased taxes) 2,13
• Prohibiting smoking in indoor areas of workplaces and public places 2,13
• Raising the minimum age of sale for tobacco products to 21 years 2,12
• TV and radio commercials, posters, and other media messages aimed at kids and teens in order to counter tobacco product ads 2,13
• Community programs and school and college policies that encourage tobacco-free places and lifestyles 2,12
• Community programs that lower tobacco advertising, promotions, and help make tobacco products less easily available 2,13  

Some social and environmental factors are related to lower smoking levels among youth. Among these are: 2

• Being part of a religious group or tradition
• Racial/ethnic pride and strong racial identity
• Higher academic achievement

It is important to keep working to prevent and reduce the use of all forms of tobacco product use among youth.

• Flavored Tobacco Product Use Among Middle and High School Students—United States, 2014 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2019 Feb 28].
• U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012 [accessed 2019 Feb 28].
• Substance Abuse and Mental Health Services Administration. 2018 National Survey on Drug Use And Health: Detailed Tables . Substance Abuse and Mental Health Data Archive [accessed 4 Dec 2019].
• Centers for Disease Control and Prevention.  Flavored Tobacco Product Use Among Middle and High School Students—United States, 2014 . Morbidity and Mortality Weekly Report, 2015;64(38):1066–70 [accessed 2019 Feb 28].
• Wang TW, Gentzke AS, Neff LJ, et al. Characteristics of e-Cigarette Use Behaviors Among US Youth, 2020 . JAMA Netw Open. 2021;4(6):e2111336. doi:10.1001/jamanetworkopen.2021.11336
• Gentzke AS, Wang TW, Cornelius M, Park-Lee E, Ren C, Sawdey MD, Cullen KA, Loretan C, Jamal A, Homa DM. Tobacco Product Use and Associated Factors Among Middle and High School Students – National Youth Tobacco Survey, United States, 2021 . Morbidity and Mortality Weekly Report, 2022; 71(No. SS-5):1–29.
• Birdsey J, Cornelius M, Jamal A, et al. Tobacco Product Use Among U.S. Middle and High School Students — National Youth Tobacco Survey, 2023.  MMWR Morb Mortal Wkly Rep 2023; 72(44);1173–1182.
• Gentzke AS, Wang TW, Jamal A, Park-Lee E, Ren C et al.  Tobacco Product Use Among Middle and High School Students, United States, 2020 . Morbidity and Mortality Weekly Report 2020;69(50);1881–1888 [accessed 2020 Dec 17].
• Marynak KL, Wang X, Borowiecki M, et al. Nicotine Pouch Unit Sales in the US, 2016-2020. JAMA . 2021;326(6):566–568. doi:10.1001/jama.2021.10366
• U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000 [accessed 2019 Feb 28].
• Centers for Disease Control and Prevention.  Combustible and Smokeless Tobacco Use Among High School Athletes—United States, 2001–2013 . Morbidity and Mortality Weekly Report, 2015;64(34):935–9 [accessed 2019 Feb 28].
• Gentzke AS, Glover-Kudon R, Tynan M, Jamal A. Adults’ attitudes toward raising the minimum age of sale for tobacco products to 21 years, United States, 2014-2017 . Prev Med. 2020 Feb 3;133:106012. doi: 10.1016/j.ypmed.2020.106012. Epub ahead of print. PMID: 32027916.
• Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014 . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2019 Feb 28].

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Tobacco, Nicotine, and E-Cigarettes Research Report What research is being done on tobacco use?

New scientific developments can improve our understanding of nicotine addiction and spur the development of better prevention and treatment strategies.

Genetics and Epigenetics

An estimated 50-75 percent of the risk for nicotine addiction is attributable to genetic factors. 221  A cluster of genes (CHRNA5-CHRNA3-CHRNB4) on chromosome 15 that encode the α5, α3, and β4 protein subunits that make up the brain receptor for nicotine 221–223 are particularly implicated in nicotine dependence and smoking among people of European descent. Variation in the CHRNA5 gene influences the effectiveness of combination NRT, but not varenicline. 224 Other research has identified genes that influence nicotine metabolism and therefore, the number of cigarettes smoked, 225 responsiveness to medication, 204,205 and chances of successfully quitting. 226 For example, the therapeutic response to varenicline is associated with variants for the CHRNB2, CHRNA5, and CHRNA4 genes, while bupropion-related cessation is linked with variation in genes that affect nicotine metabolism. 227

Smoking can also lead to persistent changes in gene expression (epigenetic changes), which may contribute to associated medical consequences over the long term, even following cessation. 228 Epigenetic changes may serve as a potential biomarker for prenatal tobacco smoke exposure. Researchers found tobacco-specific changes at 26 sites on the epigenome, and this pattern predicted prenatal exposure with 81 percent accuracy. 229 A large scale meta-analysis of data on epigenetic changes associated with prenatal exposure to cigarette smoke also identified many epigenetic changes that persisted into later childhood. 230 More research is needed to understand the long-term health impacts of these changes.

Neuroimaging

Cutting-edge neuroimaging technologies have identified brain changes associated with nicotine dependence and smoking. Using functional magnetic resonance imaging (fMRI), scientists can visualize smokers’ brains as they respond to cigarette-associated cues that can trigger craving and relapse. 231 Such research may lead to a biomarker for relapse risk and for monitoring treatment progress, as well as point to regions of the brain involved in the development of nicotine addiction. 29

A neuroimaging technology called default-mode or resting-state fMRI (rs-fMRI) reveals intrinsic brain activity when people are alert but not performing a particular task. Using this technique, researchers are examining the neurobiological profile associated with withdrawal and how nicotine impacts cognition. 232 Comparisons between smokers and nonsmokers suggest that chronic nicotine may weaken connectivity within brain circuits involved in planning, paying attention, and behavioral control—possibly contributing to difficulty with quitting. 233 fMRI studies also reveal the impact of smoking cessation medications on the brain—particularly how they modulate the activity of different brain regions to alleviate withdrawal symptoms and reduce smoking. A review of these studies suggested that NRT enhances cognition during withdrawal by modulating activity in default-network regions, but may not affect neural circuits associated with nicotine addiction. 234

Some imaging techniques allow researchers to visualize neurotransmitters and their receptors, further informing our understanding of nicotine addiction and its treatment. 27 Using these techniques, researchers have established that smoking increases the number of brain receptors for nicotine. Individuals who show greater receptor upregulation are less likely to stop smoking. 28 Combining neuroimaging and genetics may yield particularly useful information for improving and tailoring treatment. For example, nonsmoking adolescents with a particular variant in the CHRNA5-CHRNA3-CHRNB4 gene cluster (which is associated with nicotine dependence and smoking) showed reduced brain activity in response to reward in the striatum as well as the orbitofrontal and anterior cingulate cortex. This finding suggests that genetics can influence how the brain processes rewards which may influence vulnerability to nicotine dependence. 235 Neuroimaging genetics also shows that other genes, including ones that influence dopamine neurotransmission, influence reward sensitivity and risk for addiction to nicotine. 236

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AAP Youth Tobacco Cessation Case Studies

Pediatricians and other health care providers can utilize these case studies to understand the use of the Ask-Counsel-Treat (A.C.T.) model in assisting youth cessation attempts from smoking, vaping and/or other tobacco products.

A.C.T. Summary

• Pediatric health clinicians have a collective responsibility to identify youth who use tobacco and connect them with the resources they need to quit successfully.
• The A.C.T. model is used to facilitate conversations with youth about tobacco cessation.
• The A.C.T. model is designed to minimize time and burden on the pediatric health clinician and maximize the patient’s chances of a successful quit.
• The A.C.T. model can be used universally with all pediatric patients ages 11+.
• This resource  does not serve as official policy of the AAP, or as a clinical guideline. Rather, this resource is designed to provide practical advice and considerations for addressing tobacco cessation in youth.
• More information on youth tobacco cessation can be found at  aap.org/cessation.

Inpatient Case Study 1

This case explores a patient who is inpatient for asthma exacerbation.

Inpatient Case Study 2

This case explores an inpatient with generalized tonic clonic seizures. This case demonstrates how to prescribe Nicotine Replacement Therapy in the form of gum to a patient under 18 years of age.

School-Based Health Center Case Study 1

This case study explores a patient who is unsure of quitting.

School-based Health Center Case Study 2

This case explores a patient in for a general visit. This case demonstrates how to prescribe Nicotine Replacement Therapy in the form of nicotine path to a patient under 18.

Substance Use Treatment Center Case Study 1

This case study explores a patient in intensive outpatient program for alcohol use disorder and vaping.

Substance Use Treatment Center Case Study 2

This case explores a patient for substance use, cannabis & tobacco use. This case demonstrates how to prescribe Nicotine Replacement Therapy in the form of gum and patch to a patient under 18.

Federally Qualified Health Center Case Study 1

This case explores a patient visiting a federally qualified health center for a sports physical.

Federally Qualified Health Center Case Study 2

This case explores a patient who is visiting a federally qualified health center for an annual visit. This case demonstrates how to prescribe Varenicline to a patient.

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The Epidemiology of Tobacco Use

Dr. Erika Trapl  uses a classical epidemiological approach to study what is both a health and social issue: the use of cigars, cigarillos, and little cigars (CCLC) by adolescents and young adults. Using quantitative data from the Cleveland-Cuyahoga County Youth Risk Behavior Survey (YRBS) and qualitative data of from youth and young adults, she aims to understand the characteristics, correlates, and associated risk factors of CCLC users in a local context.

The result of this research is a deeper understanding of the why, where, and how of CCLC use among young adults that can inform interventions at all levels. Dr. Trapl has provided invited testimony to Cleveland City Council regarding adolescent use of CCLC products, including flavored tobacco, and the location of retail outlets selling CCLC in relation to Cleveland public schools. Her research was instrumental in the passage of legislation banning the sale of tobacco products to anyone under age 21 in the city of Cleveland.

Dr. Trapl was the 2016 recipient of the Ohio Public Health Association’s Public Health Policy Award.

• Open access
• Published: 14 February 2024

Implementing a tobacco-free workplace program at a substance use treatment center: a case study

• Anastasia Rogova 1 , 2 ,
• Isabel Martinez Leal 1 , 2 ,
• Maggie Britton 1 , 2 ,
• Tzuan A. Chen 2 ,
• Lisa M. Lowenstein 1 ,
• Bryce Kyburz 3 ,
• Kathleen Casey 3 ,
• Kim Skeene 3 ,
• Teresa Williams 3 &
• Lorraine R. Reitzel 1 , 2  

BMC Health Services Research volume  24 , Article number:  201 ( 2024 ) Cite this article

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People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center.

This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff ( n  = 6) and clients ( n  = 16) at the substance use treatment center and site visits ( n  = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice.

Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center.

Conclusions

Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Peer Review reports

According to data from the Centers for Disease Control and Prevention, 12.5% of the US adults aged ≥ 18 years reported current use of cigarettes in 2020 [ 1 ]. While this figure represents a substantial decrease from over 40% of the adult population smoking in the 1960s, tobacco use is still the leading preventable cause of death in the US [ 2 ] with annual deaths directly attributable to tobacco use estimated to be at least 480,000 [ 3 ]. However, these devastating effects of tobacco use do not equally impact all population groups. The proportion of people who use tobacco products is dramatically elevated among the often intersecting groups of people experiencing socioeconomic disadvantage, who are medically underserved, and/or people living with comorbid mental health and non-nicotine substance use disorders [ 4 ]. These health disparity populations have disproportionately high smoking rates; for example, over 65% of adults with substance use disorders (and up to 90% according to some sources) are active smokers [ 5 , 6 , 7 ]. As a result, adults with substance use disorders are disproportionately affected by tobacco-related disease compared to the general population [ 7 , 8 ].

There is an overwhelming body of evidence that adults with substance use disorders are interested in and capable of quitting with appropriate support [ 9 , 10 ]. Current clinical guidelines recommend that all clients be provided with evidence-based cessation care, which includes behavioral interventions such as tobacco use assessment, brief cessation advice, individual or group counseling, and pharmacotherapy such as nicotine replacement therapy or non-nicotine medication (bupropion and varenicline) [ 11 , 12 ]. Moreover, the adoption of system-level policies, including comprehensive tobacco-free workplace policies, which prohibit the use of any form of tobacco inside buildings and on the grounds of behavioral health treatment centers, are also shown to be effective in improving quit rates [ 13 ]. Despite their proven effectiveness, however, evidence-based practices and policies remain underutilized, and tobacco use treatment is given a low priority in substance use treatment centers. For example, according to a 2016 nationwide study, only 64.0% of substance use treatment centers reported screening clients for tobacco use, 47.4% offered tobacco cessation counseling, 26.2% offered nicotine replacement therapy, and 34.5% had tobacco-free policies [ 4 ]. Furthermore, although not reported, it is possible that some proportion of these centers had tobacco-free workplace policies that may have been non-comprehensive in product coverage (e.g., not extending to e-cigarettes/vaping) or workplace area coverage (e.g., allowing smoking areas), which are known to be less effective than their comprehensive policy counterparts [ 14 , 15 , 16 ]. Consequently, there is a missed opportunity for substance use treatment centers to comply with clinical care guidelines [ 11 , 12 ] and to intervene to reduce tobacco use and related health disparities among their clients.

There are several previously identified barriers to providing tobacco cessation treatment at substance use treatment centers, including limited training, limited resources, time restraints, and cultural norms [ 9 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]. Additionally, available treatment opportunities that take little time or training, such as referral to a state tobacco cessation quitline, are often unknown by staff at substance use treatment centers [ 23 ]. Our use of “staff” here refers to both clinical employees, those providing direct services to clients, and nonclinical employees. Moreover, despite evidence to the contrary, staff may believe that treating tobacco use and substance use disorders simultaneously will jeopardize substance use treatment and recovery [ 25 ]. Together, these barriers and others may contribute to the known translational lag whereby any type of evidence-based practice takes a long time (e.g., up to 17 years) to be implemented into practice to reach the intended population and ensure the improvement of clients’ health [ 26 , 27 ]. While this translational lag is detrimental for all clients and communities, the negative consequences of these delays are even worse for populations who experience health disparities, such as individuals living with substance use disorders.

Together, the previously described evidence-based tobacco cessation practices and policies, such as tobacco use assessment, brief cessation advice, individual or group counseling, pharmacotherapy, tobacco-free policies, form the core components of a comprehensive tobacco-free workplace program [ 28 , 29 ]. Academic-community partnerships can assist substance use treatment centers in implementing comprehensive tobacco-free programs and reducing the translational gap that affects health disparities among their clients [ 29 , 30 , 31 , 32 ]. This study describes the implementation of a tobacco-free workplace program at a substance use treatment center in Houston, Texas, which included a comprehensive tobacco-free workplace policy implementation, education and specialized training support, and the provision of resources to support tobacco cessation care. The goal of the study was to identify barriers and facilitators to successful integration of tobacco-free workplace policy and cessation practices into a substance use treatment center. The current study was based on an ethnographic approach and uses a case study design, which is considered an efficient way to present qualitative ethnographic findings [ 33 , 34 ]. Case study design has been found to be particularly useful in implementation research, as it allows for an in-depth analysis of complex interventions in combination with a participatory approach in a real-life context [ 35 , 36 , 37 , 38 ]. Prior research has shown the importance of studying interventions in close connection with the context of dynamic environments that can have an extensive influence on the implementation process [ 37 ]. In the case of complex interventions, such as comprehensive tobacco-free programs, this is particularly relevant, given their dependence on contextual elements for their effectiveness [ 39 ]. Intervention and context cannot be easily separated in this situation, and there is an urgent need to better understand the relationship between these two core elements of implementation to ensure that research evidence can meaningfully impact policy and healthcare organizational culture [ 38 ]. By applying a case study design, this work contributes to the existing research on implementing tobacco-free workplace programs at substance use treatment centers [ 32 ] by providing an in-depth qualitative description of program implementation in the setting of a nonprofit outpatient substance use treatment center serving diverse clients, most of whom belong to socioeconomically disadvantaged and medically underserved groups. Additionally, this study represents both staff, clinical and nonclinical alike, including leadership, and clients’ perspectives on this program, the latter of which were not included in prior work [ 32 ]. The findings presented in this study can be used by other substance use treatment centers that serve similar populations and seek to implement a comprehensive tobacco-free program in the most sustainable way.

Case description

This initiative was undertaken as a part of the Taking Texas Tobacco Free (TTTF) program, which is a multicomponent, evidence-based comprehensive tobacco-free workplace program that was designed to address tobacco dependence within healthcare treatment settings, including substance use treatment settings [ 30 , 32 ]. TTTF includes (1) tobacco-free policy development and implementation and/or refreshment for comprehensiveness or quality assurance; (2) education and specialized training for staff on tobacco use and cessation, screening practices, and treatment provision; and (3) resource provision, including free nicotine replacement therapy, signage, and passive dissemination materials. Throughout the implementation process, TTTF team members, comprising an academic-community collaboration, provide ongoing technical assistance and support (for more information on the TTTF program, see previously published studies [ 28 , 30 , 31 , 32 , 40 , 41 , 42 , 43 , 44 ]).

To ensure the privacy of the research participants, we refer to the field research location as the “Center” herein. The Center is located in a Houston, Texas, zip code that is among the Centers for Medicare and Medicaid Services-designated low-income and health professional shortage areas. It is a small Center that employs 7 staff (including clinical and nonclinical staff) and serves approximately 1,000 unique clients each year. One of these staff members was designated the TTTF program champion to serve as the main point of contact for all aspects of the tobacco-free workplace program implementation process. This staff member was not financially compensated for accepting this role, but they received additional week-long full-time training to become a Tobacco Treatment Specialist. The financial compensation for this role was not a part of the current program, and the expectation was that the Center’s leadership incorporates this role in the regular scope of work for their staff to ensure the sustainability of the program.

The Center serves a diverse group of clients, with 90% of their clients having histories of incarceration or another form of engagement in the criminal justice system, many of whom come from low socioeconomic backgrounds and/or have been diagnosed with comorbid behavioral health (i.e., mental health or substance use disorders) and physical health conditions. The Center estimated that approximately 80% of their clients smoked conventional cigarettes and 30% used other tobacco products, including e-cigarettes (there is an overlap, as some clients might be dual or multiple product users). Most clients participate in the Center’s substance use treatment program for 90 days. The Center introduced a tobacco-free policy in 2000, which prohibited the use of tobacco products of any type both indoors and outdoors; however, they had not provided any tobacco cessation services to their clients beyond the requirement not to use tobacco on their property prior to their enrollment in the TTTF program. The tobacco-free workplace program implementation components and the Center’s timeline are presented in Table  1 .

This project was approved by the Internal Review Board of the University of Houston and the Quality Improvement Assessment Board at the University of Texas MD Anderson Cancer Center. Oral informed consent was received from all participants prior to participation in qualitative study procedures. The aims of the project and interviews were discussed with participants who were given an opportunity to ask any questions about the interview process and the nature of the study. Additionally, all participants gave oral permission to audio-record the interview; they were given the option to remain anonymous and not use their names or other identifying information in any written summary of the collected data. Participants were informed that their participation was voluntary, that they could decline to answer any questions and stop participating in the interview at any time.

Data collection instruments

Data for this qualitative case study were collected via group and individual interviews with staff and clients at the Center, as well as site visits and participant observations. Data include interview transcripts and fieldnotes. We conducted one pre- and one post-implementation focus group with clients ( n  = 16), two pre-implementation semi-structured interviews with staff ( n  = 2), two individual interviews with staff during the implementation process ( n  = 2), and one post-implementation group interview with staff ( n  = 2). Interview guides were used for interviews and focus groups, which lasted 60–90 min (see Additional file 1 : Interview Guides). Pre-implementation interview questions for staff focused on any Center-specific needs for the program rollout, populations they served, their personal experience with tobacco use, their knowledge of and attitudes toward tobacco use and cessation among their clients, and implementation barriers and facilitators they anticipated. Staff post-implementation interview questions addressed experiences with implementing the program, interventions that were successful and less successful, changes in their practices addressing tobacco dependence, and any challenges they experienced. Focus groups with clients addressed their experiences with tobacco use and cessation, their knowledge of the tobacco-free program at the Center, their attitudes toward and interest in this program, and their experiences with and results of receiving any tobacco cessation support at the Center. In addition, we undertook several site visits ( n  = 8), when A.R. (the 1st author) and I.M.L. (the 2nd author), both cultural anthropologists who worked as qualitative research specialists on the project, conducted observations and made fieldnotes using a free-form approach. The site visits (1 to 2 h long) incorporated both direct and indirect observations. The collected observational data were not subjected to standalone analysis but served to inform the interview questions, gain a more nuanced understanding of how the Center was implementing various parts of the program, and provide further details about the study’s context and setting.

Two authors (A.R. and I.M.L.) moderated the focus groups and completed the interviews. Audio-recordings of focus groups and interviews were transcribed verbatim by a professional transcription service and analyzed using thematic analysis to initially inductively code and identify themes within the dataset. Data analysis was conducted iteratively using constant comparison, and themes were drawn directly from the data. The process of constant comparison provided analytic rigor and ensured accurate accounting of all the data, identifying appropriate selection of categories and themes [ 45 ]. At the next stage of the analysis, the concepts of the extended Normalization Process Theory (discussed in detail below) were applied to these themes to more effectively analyze and evaluate the implementation process.

Approach: extended normalization process theory

When exploring the implementation process, the application of a theoretical framework enhances understanding of the process and highlights barriers to and facilitators of the implementation. Implementation scientists have developed several major frameworks and theories to describe and evaluate the implementation process [ 26 , 46 , 47 , 48 , 49 ]. For this analysis, we followed the extended Normalization Process Theory (eNPT) [ 46 , 47 ], which is a sociological theory that informs the implementation of innovations in healthcare practice, focusing on bridging the translational gap between evidence-based practices and their implementation [ 50 ]. This theory approaches the implementation process as a series of interactions between people’s actions (their ‘agency’) and the context within which the intervention is implemented [ 46 , 50 ].

The eNPT identifies and explains key elements that contribute to or impede normalization of complex interventions within a social system, including four core constructs, two of which are focused on context (potential and capacity) and two of which address agency (capability and contribution, see Fig.  1 for details) [ 46 ]. The identification of these major constructs helps researchers guide and understand the implementation process and provide a systematic description [ 46 ]. The eNPT has been effectively utilized at all stages of research projects, both during the planning stages and the post-implementation analysis, as in this case, where this theory helps to frame emergent themes and consider their implications for further research and implementation practice [ 51 ]. The application of the eNPT as a theoretical framework enhances stakeholders’ ability to improve design for more successful implementation in the future and to enhance the application and normalization of interventions within organizations by community adopters and researchers [ 50 ].

Concepts and Constructs of the Extended Normalization Process Theory (eNPT, adapted from May 2013 [ 46 ])

The two constructs of the eNPT that characterize the context of implementation are potential and capacity . Participants’ potential is expressed through individual intentions and collective commitment to participate in the intervention [ 52 ]. Capacity, which is another crucial element of context, is defined as the availability of material and cognitive resources, as well as existing social norms and social roles. Attention to these contextual elements ensures a better understanding of the implementation process and its outcomes, as they shape agents’ ability to effectively cooperate with each other to bring about change [ 46 ]. Capability and contribution are two constructs that characterize the agency of the participants involved in the implementation process. Capability refers to how workable the complex intervention is, as well as to the possibility of integrating it in everyday practice. Contribution refers to the actions of the agents who are involved in the implementation process [ 46 ]. This construct focuses on how the agents, including individuals and groups, enact potential and capacity by undertaking actions to make things happen and ensure that new processes and practices become “the way we do things here.” [ 46 ] Each of these constructs is further divided into categories used to understand and evaluate the implementation process (see Table  2 ).

After conducting the initial coding, the emerged themes were systematized and organized in relation to the major concepts and constructs of the eNPT theory. Table  2 shows the identified themes from the case study data and how they are related to the eNPT constructs and dimensions. In the section below, we present our results in relation to these theoretical constructs.

Context: potential

The Center’s CEO initiated the Center’s participation in the tobacco-free workplace program and continuously expressed their personal support and commitment to implement and maintain the program. The Center’s staff were also enthusiastic about the tobacco-free program and expressed commitment to its implementation. Most participants welcomed this forthcoming change and expansion of tobacco cessation services and agreed that it was necessary and beneficial for the Center’s working environment and for their clients’ needs and well-being. This collective commitment was supported and reinforced during the preparation phase of the implementation process, when all staff received training provided by the TTTF program:

I think one of the biggest things in preparation for implementing the program was when we had our staff retreat. Bryce [B.K.] actually flew in, and he participated in the retreat and helped train our staff prior to us actually implementing the program. So, he did a workshop with us, and that gave us an opportunity to ask him questions […] So, everybody was ready. Everybody was pumped and ready because we knew what to do. We knew what the problem was about . (Staff post-implementation interview)

The number of staff who used tobacco products themselves was very low at the Center. The only staff member who said that she smoked cigarettes participated in the program herself and, at the time of the interview, reported a successful quit attempt and being tobacco-free. In the pre- and post-implementation interviews, staff members shared their negative attitudes towards smoking related to health concerns and their readiness to facilitate tobacco cessation efforts at their center:

I grew up as an athlete, and so smoking is something that was not encouraged in my field. I didn’t partake when I was around people that did such as my mom who later on in life actually stopped smoking. (Staff pre-implementation interview)

Context: capacity

One of the major barriers to the implementation of the tobacco-free workplace program at the Center was associated with the widespread practice of tobacco use among the Center’s clients and within their immediate environment. There are two closely interrelated aspects of this problem: clients’ lived experiences with tobacco being an innate part of their everyday life and staff attitudes and expectations of their clients’ interest in and ability to quit tobacco, both of which are discussed below.

Most of the Center’s clients grew up in an environment where smoking had been normalized for years. They shared their experiences of having parents, older siblings, grandparents, neighbors, and friends who had smoked on a regular basis for most of their lives:

Kind of like I think started smoking from– because I would light cigarettes for my daddy or whatever, so he was smoking. (Client focus group, pre-implementation) Me growing up around my grandfather and stuff, he smokes. […] Mine started just with social. Got out of high school, my own place. All my friends, they bring over rum […] and cigarettes and everything. (Client focus group, pre-implementation)

Some of the clients reported a lack of interest in quitting or their perceived inability to quit:

So officially, once I turned 18 or the age to buy a pack of cigarettes, I bought a pack of cigarettes and since then it’s been– I never had the urge to quit, never tried to quit. Just always adapted to it. (Client focus group, pre-implementation) They [clients] point-blank told me that they feel that if they stop smoking, that they’ll latch back onto something else that is not as legal. (Staff post-implementation interview)

However, these experiences do not mean that none of the clients problematized tobacco use practices and were interested in quitting tobacco. Some clients reported varied attitudes toward quitting. For example, one of the clients who participated in a focus group shared her motivation to quit smoking:

I didn’t want him [her son] to - when he’s picking up pieces of paper towel and putting it to his mouth like a cigarette, it bothers me. I don’t want him to […] also, my baby’s father wasn’t a smoker. It’s a shame thing. I was ashamed. (Client focus group, post-implementation)

In the interviews with the Center’s staff members, they generally revealed that tobacco cessation treatment was a low-priority problem, related partly to a perceived lack of interest in quitting among their clients. Staff shared expectations that clients must be proactive in expressing their interest in quitting and seeking support. Staff at the Center repeatedly expressed the idea that if their clients were interested in quitting tobacco use, they had to ask for help to proactively demonstrate that they were interested in and committed to quitting. As the Center’s program champion said during a conversation with one of the researchers:

I see some of the guys who signed up for the program, but they go out and smoke with other guys outside. I walk by, I see him, but I am not going to say anything to him. It must be his decision, he is an adult, and he must take responsibility. I cannot do it for them. (fieldnotes, conversation with program champion, May 2022)

In a similar way, one of the clinicians at the Center shared during the interview:

I guess if they ask me, if they would like the patches, if they want to participate, I guess that’s when I’ll bring it up […] I think it’s ultimately really up to the client if they really want to make that change. That’s what I love. Some of the clients really want to commit strongly about making the change to stop smoking. (Staff post-implementation interview)

Tobacco education trainings were offered to all Center staff at the beginning of implementation, which were designed to mitigate these barriers (e.g., by providing information about how to proactively address tobacco use with clients) and enhance the implementation capacity by ensuring that they had the knowledge and skills required to implement the program. One of the staff evaluated this training as being very important to help them to be able to deliver tobacco cessation services:

Teaching us about pharmacology, motivational interviewing […]. That thing that was really helpful for us to learn and to be able to explain it to the clients if questions were to come up. (Staff post-implementation interview)

The capacity to implement the program also depends on the availability of material resources. One of most important and expensive resources, nicotine replacement therapy products, were provided to the Center free of charge as a part of the active implementation process. The availability of the nicotine replacement products was widely discussed by the Center’s staff and evaluated as one of the central elements of the program implementation at the Center:

We actually not only have “No Smoking” sign posted up, but we’re able to say, “Here, we have products, nicotine replacement products, that we could give you to help you stop smoking.” (Staff post-implementation interview).

Agency: capability

The Center’s capability to implement the program was evaluated by assessing the implementation’s workability and integration with the everyday workflow and preexisting work processes, following the eNPT framework concepts.

The Center already had a standard tobacco-free policy in place prior to the involvement in the project, and while the TTTF presented them with a much more comprehensive program, the initial buy-in was facilitated by the level of familiarity with the intervention by both staff and clients:

We weren’t really implementing anything. It [tobacco-free policy] was there. It was understood, but this gave us a fuller picture of a way to implement, how to introduce it, a guideline to follow . (Staff post-implementation interview)

One element of the program that contributed to the increased workability was the introduction of the program champion role into the program:

I think the best thing is to have a point person. Because we have a point person, that point person stays on top of all the policy procedures, regulation, inventory, whatever we have going on. (Staff pre-implementation interview)

The Center’s CEO and staff also emphasized that the support they received from the TTTF program increased the workability of the intervention. In addition to regular practical and informational support, they were able to contact program staff with any ongoing questions and requests for assistance. They shared that the focus groups that were conducted with clients also contributed to the program implementation success by increasing clients’ interest in the program:

You guys come in here and working with those guys, because you legitimize the process as a third-party source, and the guys come in to see and you do the surveys [focus group] with them. I think that’s very helpful. (Staff post-implementation interview)

New aspects of the program were reported to be well integrated into the everyday workflow, and while their implementation needed certain changes in practices and attitudes among staff and clients, these changes were not particularly disruptive or time consuming, according to staff who participated in post-implementation interviews:

It’s good to have it embedded into the program that you already have, immerse into what you have going and make it a part of the process, not as something separate, but just this is our program. This is included in the program. I think it’s welcomed a little bit more. (Staff post-implementation interview)

Agency: contribution

Most staff members shared a clear understanding of the purpose of the intervention and its potential benefits. They evaluated the program as important, saw the value of this program for their clients, and shared positive experiences of being involved in its implementation:

I love the program because it gives the clients an opportunity to work on solving that problem of addiction in a positive manner. (Staff post-implementation interview) I felt like it was a great idea to come into play here at the facility. (Staff post-implementation interview)

All staff were well aware of the program being implemented and what new practices and routines were introduced at the Center. They reported very little disagreement about a shared understanding of the need to implement this program:

Everybody was clear on what the mission was, how we would present it, and the way it would be implemented . (Staff post-implementation interview)

One example of effective engagement with the program was one of the staff members quitting smoking herself:

When I came in, he was doing a class and I sat in on it and I’m like, “Hey, I want to do this.” […] we talked about it and I signed up to do it. It’s worked very good for me. (Staff post-implementation interview)

In the interviews, staff at the Center discussed how their engagement in the program and enacting it in their everyday practices contributed to their deeper sense of belonging:

I have the feeling like you can’t disrespect the facility [ by smoking ]. This is our facility and we need to respect her. (Staff post-implementation interview)

Staff members shared a commitment to serving their clients and supporting each other, which was further reinforced by their increased capacity to provide tobacco cessation support to their clients:

That sign right there says we are community, and that’s what we promote, that we are a community center, and this community center has many different programs in it that can provide assistance and this is one of the additional programs that we have that can provide assistance. (Staff post-implementation interview)

Various program components were implemented with different degrees of commitment. The tobacco-free policy was the component that staff reported to be implemented most consistently. The tobacco-free policy has been routinely maintained and reinforced by both the Center’s staff and clients themselves:

They are not allowed to smoke within the facility area. So, that’s worked pretty good. (Staff post-implementation interview) We were always like, “You can’t smoke in here. You got to walk outside.” I think that they just pretty much are just like, “Okay, we got to do the right thing.” […] So yes, they respect it, I think . (Staff post-implementation interview)

However, as A.R. and I.M.L. observed when they visited the Center, clients were often smoking outside. While they were not violating the policy as they were technically outside the property and were smoking while on a public road, they remained physically close to the building, and whoever was leaving or entering the property had to go past a group of clients smoking to enter through the only door to the Center. The Center’s leadership has not found a solution to this problem, as they said they did not have control over the territory and could not prohibit tobacco use beyond their property. This location-specific issue led to a situation in which the tobacco-free policy was technically enforced; however, clients were still able to smoke in the vicinity of the Center, visitors were exposed to secondhand smoke, and this practice was not challenged by leadership or staff, either pre-implementation or after.

Tobacco screenings were reported to be implemented on a regular basis, although there were some discrepancies in the participants’ accounts of screening practices and their regularity. All clients were reportedly screened for all forms of tobacco use during intake, but the follow-up screenings of those clients who reported using tobacco were less consistent. There seemed to be a lack of clear understanding and agreement among staff who was responsible for these screenings, which resulted in a lack of consistency and depended on a specific staff member’s practice rather than established and clearly understood guidelines:

Each time we do an intake on a form, there is an assessment that asks the client if they do smoke, and if they do smoke, do they smoke cigarettes, or do they smoke e-cigarettes? We do offer the NRT [nicotine replacement therapy, and if they want to participate, they would need to say yes or no. Let the counsellor know. […] The individual counsellors, after 30 days in their sessions, ask them again. (Staff post-implementation interview)

However, in individual interviews with staff, at least one of them said that they did not conduct any follow-up screenings unless their clients brought this up and asked about the tobacco cessation program themselves.

As one of the central elements of the program implementation, the program champion provided regular information sessions to inform their clients on the Center’s participation in the program and available support and resources for clients who were interested in quitting tobacco. All clients were expected to attend at least one of these sessions, as these presentations were performed during their mandatory group counseling sessions. Clients were made aware of the resources and support available to them at the Center if they decided to make a quit attempt, as well as given a brief educational presentation on the harms of smoking and the benefits of quitting. These presentations were seen as an effective tool to get clients interested in the program, provide them an opportunity to ask for more information, and engage in conversations about quitting:

People have changed their minds, actually. They initially said no, but then once they heard [the program champion] and people talk about it, they come back and say, well, yes, they would like to. There’s been a couple of guys that have done it, that I know personally, that have done that. (Staff post-implementation interview)

The actual engagement of clients and motivating them to make a quit attempt was the most challenging part of the implementation process for the Center. The overall number of participants who made a quit attempt was 17 clients and two staff members by the end of the implementation period. While the reach of the program is larger than immediate client participation in cessation treatment, there were also some clients’ accounts of inconsistency in support they received during their time at the Center regarding their tobacco use:

Nobody has ever asked me anything [about tobacco use], except you. (Client focus group, post-implementation)

While staff supported the implementation of the program from the beginning, there were some concerns about how well this program might be accepted by their clients. In the post-implementation interview, a counselor shared an observation that their clients were more interested in quitting than they anticipated:

I guess I’m just surprised that I feel like I’m getting some yes’s now instead of a whole bunch of no’s. So, I think that’s actually a good thing because I feel like now that the program has been implemented here, that we’re getting quite a few yes’s. So, that’s definitely something to feel good about, that makes me feel good. (Staff post-implementation interview)

While we observed a variation in the degree to which tobacco cessation intervention services were provided in practice, there was a shared understanding that some of the services needed to be improved:

To be honest, it’s a question [tobacco use and interest in quitting] I feel like I need to ask them more. I haven’t been asking them about it, but I feel like I do need to ask them . […]So, that’s something I could work on. (Staff post-implementation interview)

In the quote above, the counsellor acknowledges that they should ask their clients about their smoking habits and interest in quitting more proactively, which is a positive example of reflexive monitoring of their own actions and practices and could ultimately lead to better outcomes of the intervention.

Staff also demonstrated their involvement by critically evaluating the program delivery and expressing suggestions for improvement:

[We say] “We’re going to have smoking cessation group today and this is going to be the only one for the month.” Well, why can’t we bring it up every meeting? Look, we have three meetings a week, let’s bring it up every time. […] I think there should be a smoking class […] for the whole group at least once a month. (Staff post-implementation interview)

Staff reflected on how this program changed their Center, and they reported a positive change, creating an opportunity to provide more meaningful and involved support and services to their clients:

It’s positively changed or impacted our facility because it gives us some legitimacy behind not only just having a no smoking sign just posted like every public place you see, but actually giving some type of support, nicotine replacement therapy. […] (Staff post-implementation interview).

This case study discusses the implementation of a tobacco-free workplace program at a substance use treatment center serving a diverse group of clients, including many from low socioeconomic backgrounds. This analysis and consideration of the interplay between context and emergent agency, facilitated by the application of the eNPT framework, contribute to the existing knowledge on implementing similar programs in substance use treatment settings that serve marginalized and medically underserved populations facing socioeconomic and health challenges. The findings from this study offer insights that can guide other substance use treatment centers with similar populations in implementing sustainable tobacco-free programs effectively.

A key barrier associated with the context of the implementation, as defined by the eNPT framework, was the widespread tobacco use among clients and within their immediate environment. Prior research has indicated that individuals with substance use disorders are often interested in quitting smoking [ 16 ], but they tend to have lower success rates [ 53 , 54 ]. These contextual barriers to achieving success in tobacco cessation efforts among this population require an exceptionally high level of commitment from the staff working at substance use treatment centers to provide continuous, robust support to their clients [ 55 , 56 ]. As our findings suggest, it is essential to acknowledge and consider the difficulties faced by these individuals when they are trying to quit smoking. While these challenges should not deter clinicians from motivating their clients to quit smoking, it is crucial that they are prepared to approach the situation with sensitivity and awareness of the contextual factors and lived experiences of the clients, which is also emphasized in the principles of trauma-informed care.

Other contextual categories, defined by the eNPT, which we addressed in our study to evaluate the Center’s potential to implement the program, include individual intentions and collective commitment shared by staff and leadership. Most of the staff expressed a strong commitment to participate in the program and provide cessation services to the clients. However, we also encountered attitudes indicating that staff, including clinicians, were doubtful about their clients’ interest in quitting and ability to do so. Given their expertise and supportive roles as addiction treatment specialists, clinicians’ attitudes can greatly affect those of their clients; moreover, clinicians’ beliefs and attitudes are often cited as one of the major barriers to effectively implementing tobacco-free programs within substance use treatment settings [ 4 , 22 , 25 , 57 ]. Training given as a part of the program implementation provided staff with information on evidence-based tobacco cessation practices and addressed some of these attitudes to better prepare staff to provide cessation care to their clients. Such training programs are particularly important for successful implementation and can be further enhanced by placing a stronger emphasis on motivational interviewing techniques, providing practitioners with a better understanding of the nature of ambivalence toward behavior change and the diverse factors influencing clients’ readiness to quit tobacco use.

The capacity to successfully implement and maintain the tobacco-free workplace program is also dependent on access to material resources and, specifically, nicotine replacement therapy products. While two shipments of nicotine replacement products were provided free of charge by the TTTF program, ensuring a continuous supply of these products is anticipated to be challenging for the Center. While individual clients can access free nicotine replacement products through services such as the Texas Tobacco Quitline [ 58 ], the availability of these products on-site and the ability to distribute them immediately and at no cost has been emphasized by the Center’s staff as a crucial component of the program. To address this challenge, the TTTF staff provided informational resources to the Center’s leadership and program champion, highlighting the support available in the community to secure additional funding for the ongoing purchase of nicotine replacement products. However, it remains uncertain at this stage whether the Center will be able to secure the necessary funding to sustain the provision of free nicotine replacement products to their clients and how the availability of these products will impact the long-term sustainability of the tobacco-free program. This is a limitation of this study, as it was conducted during the active phase of implementation and shortly after its completion, lacking data on the program’s long-term maintenance and outcomes. Therefore, further investigation specifically focusing on the long-term sustainability of tobacco-free programs at substance-use treatment centers would be valuable to address this gap and provide insights into ensuring ongoing access to nicotine replacement therapy products for patients. We suggest, however, that it is important to maintain communication with centers after the program implementation is completed, highlighting specific local funding opportunities, as well as sharing examples of successful programs maintained by other centers as a mechanism to support collaboration and pursue additional resources.

Analysis of the themes reflecting the expressions of agency, another major eNPT concept, showed a gradual positive change in tobacco treatment practices at the Center following the implementation of the program, including the enforcement of policies and staff quitting smoking. However, the findings also show that these changes did not immediately affect the provision of smoking cessation care to clients at the Center. Tobacco cessation treatment remained a problem of a lower priority, even for staff who had negative experiences with smoking associated with health concerns, did not use tobacco themselves and were overall very supportive of the program and excited about helping their clients to quit. Rather, this seemed closely related to a persistent perception that their clients were not genuinely interested in or capable of quitting, which was also revealed in the expectations shared by staff that clients had to be proactive in expressing their interest in quitting and seeking support.

We suggest that the expectation of clients proactively seeking support shared by the Center’s staff is associated, at least partially, with their understanding of the existing standards of client-clinician communication, which emphasizes the importance of “sharing power” equally with clients and involving them in the decision-making process [ 59 ]. The concept of patient-centered care, designed to improve healthcare provision and outcomes, is often regarded as a matter of ethical and moral healthcare practice, and it assumes patients’ involvement in their care [ 60 , 61 ]. It is important to consider, however, that these expectations might not work as planned with vulnerable populations, including clients who experience socioeconomic disadvantage, limited access to healthcare services, lower literacy levels and/or limited English proficiency [ 62 ]. These individuals’ ability to take a proactive stance and advocate for their health and well-being may be further hindered by systemic inequalities and structural racism disproportionately experienced by minoritized and underserved groups, and these factors have to be considered to improve the delivery of patient-centered care to these clients and ensure that the care they receive is tailored to their specific needs. Taking Texas Tobacco Free program has developed multiple training videos on smoking cessation support to special population groups [ 63 ], which can be used to provide continuing education on working with diverse groups to ensure that healthcare professionals are equipped with knowledge and skills needed to provide such care.

It is important to acknowledge that concerns about promoting smoking cessation are not entirely unfounded, as clinicians’ advice can have various consequences beyond the client simply following or not following it [ 64 ], and prior research has shown that avoidance of hearing specific recommendations to change behavior, including smoking, is reported as one of the reasons why people avoid seeking medical care [ 65 ]. However, these findings should not discourage health care providers from asking their clients about tobacco use, as this practice is associated with increased quit attempts and is recommended by The US Public Health Service Clinical Practice Guideline [ 66 ]. The potential risk of inadvertently stigmatizing clients who may already feel shame and guilt regarding their tobacco use and inability to quit might be avoided if clinicians use non-stigmatizing approaches identified in prior research [ 67 , 68 , 69 , 70 , 71 ]. It is particularly important to address these concerns in tobacco cessation trainings and educate staff on non-stigmatizing approaches. It is important to incorporate motivational interviewing in these trainings as this approach highlights the importance of displaying unconditional positive regard toward clients, which may increase client resilience in the face of behavioral change advice offered and minimize perceived stigma. It is crucial to find a balance between being sensitive to clients’ choices and priorities and providing the healthcare necessary to alleviate the consequences of systemic health inequities among minoritized and medically underserved groups.

One of the limitation of the study is the limited data on clients’ quit attempts and their outcomes. While the Center attempted to collect these data, they had difficulties following up with their clients after they left the program (most of the clients attended a 90-day program), which created difficulties in evaluating outcomes of those clients who initiated a quit attempt while being treated at the Center. While a more detailed analysis of client outcomes would enhance the evaluation of the intervention, the focus of this study has been on the implementation outcomes, including changes in provider behavior regarding assessing and treating tobacco dependence rather than assessing its direct impact on clients’ tobacco use and cessation [ 72 ]. Future research is needed to delve into evaluating the effects of the intervention on clients’ outcomes, which would provide valuable insights for further refining and optimizing the program.

While the Center’s staff exhibited strong potential and capacity to implement the program, our findings indicate that the actual change in practice has been less successful than anticipated based on the overall support of the program, high potential, and capability. Tobacco cessation treatment had not yet become a routine practice for all staff members by the end of the implementation process. However, despite encountering significant barriers, there is evidence that the program has led to a change in attitudes, including a better understanding of the need and improved ability to provide evidence-based tobacco cessation treatment to their patients. The staff at the Center have started to integrate tobacco treatment into their routine practices, informing clients about the available support, including nicotine replacement therapy products, providing personalized assistance, and assessing patients who may not be ready to quit. Although there are areas for improvement, the program has effectively initiated change in practices, normalizing tobacco cessation treatment and incorporating it as a routine practice at the Center.

The results of this study suggest that substance use treatment centers can maintain tobacco-free workplace policies and integrate evidence-based tobacco cessation practices in their daily operations, but they face extreme challenges due to the complex behavioral health needs and socioeconomic needs of their clients. Understanding the complex interplay between social norms, social roles, and limited resources within such settings is paramount for the success of tobacco cessation efforts. These organizations need extensive support, including a longer implementation period, as well as additional material resources, informational and educational support, and assistance in preparing and maintaining local policies. Regular training of staff, including implementing a train-the-trainer program, would allow to promote and sustain local expertise on evidence-based tobacco cessation interventions for minoritized and medically underserved populations. With proper support, substance use treatment settings have the potential to play a crucial role in addressing tobacco use and provide much needed cessation services to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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This project was supported by funding from the Cancer Prevention & Research Institute of Texas (grant #PP210003 to L.R.R.). A.R.’s time and effort for manuscript drafting was supported in part by MD Anderson’s Tobacco Settlement Funds and by Halliburton Employees Fellowship in Cancer Prevention Fund from The University of Texas MD Anderson Cancer Center. Publication was supported by start-up funds provided by MD Anderson to L.R.R. The funders had no role in the design of the study, the collection, analyses or interpretation of the data, the writing of the manuscript or the decision to publish the results.

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AR, LRR, IML conceptualized the research question and design of the case study; AR and IML completed the collection, analysis, and interpretation of qualitative data; TC completed the analysis of survey data; AR drafted the manuscript text; IML, LRR, MB, LML substantively revised it; MB, BK, KS, KC, TW administered the project and contributed to data collection. All authors reviewed and approved the manuscript.

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This project was approved by the Internal Review Board of the University of Houston (STUDY00002885, initial approval 4/20/2021) and the Quality Improvement Assessment Board at the University of Texas MD Anderson Cancer Center (initial approval 11/21/2022). All parts of the study were performed in accordance with the relevant guidelines and regulations as outlined in the approved research protocol. Oral informed consent was received from all participants prior to participation in qualitative study procedures. The aims of the project and interviews were discussed with participants who were given an opportunity to ask any questions about the interview process and the nature of the study. Additionally, all participants gave oral permission to audio-record the interview. Participants were informed that their participation was voluntary and that they could decline to answer any questions and stop participating in the interview at any time. Clients who participated in the interviews each received a $25.00 Amazon e-gift card as compensation for their time. Staff members did not receive remuneration.

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Rogova, A., Leal, I.M., Britton, M. et al. Implementing a tobacco-free workplace program at a substance use treatment center: a case study. BMC Health Serv Res 24 , 201 (2024). https://doi.org/10.1186/s12913-024-10629-5

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Addressing Tobacco Use Through Organizational Change: A Case Study of an Addiction Treatment Organization †

Douglas m. ziedonis.

* Professor and Chair, Department of Psychiatry, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester MA

Lucy Zammarelli

** Director of Adolescent and Research Programs Willamette Family, Inc., Eugene, OR

Gregory Seward

*** Director, Tobacco-Free Initiative, Coordinator, Tobacco Research, Departments of Psychiatry and Administration, University of Mass Memorial Medical Center, Worcester, MA

Karen Oliver

**** Research and Evaluation Assistant/ATTOC Project Coordinator, Willamette Family, Inc., Eugene, OR

Joseph Guydish

***** Professor of Medicine, Institute for Health Policy Studies, University of California, San Francisco (UCSF)

Marie Hobart

****** Assistant Professor of Psychiatry, University of Massachusetts Medical School; Chief Medical Officer, Community Health Link, Worcester, Ma

Bruce Meltzer

******* Assistant Professor, Departments of Psychiatry, University of Massachusetts Medical School, Worcester, MA; Medical Director, University of Massachusetts Memorial, Adolescent Continuing Care Units, Westborough State Hospital, Westboro, Ma

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-Step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting. Other treatment programs may use the experience and lessons learned from using the ATTOC organizational change model to better address tobacco use in the context of drug abuse treatment.

Tobacco dependence is the leading cause of death among individuals in recovery and yet most addiction treatment programs don’t include it in their treatment planning or treatment interventions ( American Psychiatric Association 2006 ). This is not because addiction treatment specialists don’t treat multiple addictions concurrently, aren’t wellness oriented, or don’t change to address new clinical problems. Tobacco use has been accepted in the culture of addiction treatment programs over the past seventy-five years—clients smoke, staff members smoke, and they often smoke together. The founders of Alcoholics Anonymous, Bill W. and Dr. Bob, were both smokers and died of tobacco-caused diseases (emphysema and cancer, respectively) before the health consequences and addictive nature of tobacco use were fully recognized. Myths and misperceptions persist about why tobacco use should be tolerated in addiction treatment programs. Cigarettes have been accepted and even promoted as part of the norm in the recovery community. The smoking break is sometimes viewed as a reward. But the tipping point may be approaching in drug abuse treatment settings so that, as has happened in the general population, it is no longer acceptable to use tobacco products within addiction treatment programs.

There are barriers within addiction treatment programs that contribute to the limited focus on tobacco use and addiction. These include staff and patient attitudes about tobacco use, limited staff training, fears about the negative impact that would result from limiting tobacco use, belief that quitting tobacco is a major life change versus another addiction, resistance from staff and patient smokers, and limited financial resources to support tobacco dependence treatment ( Ziedonis et al. 2006 ; Williams et al. 2005 ; Asher et al. 2003 ; Hurt et al. 1995 ; Bobo & Davis 1993 ). With regard to adolescents, little is known about the longitudinal course of nicotine dependence following interventions designed to affect smoking, particularly among high-risk samples ( Strong et al. 2007 ). Another barrier to cultural change has been the reality that addiction treatment staff in community-based programs are about two to three times more likely to be tobacco dependent ( Bernstein & Stoduto 1999 ) compared with the general population ( Richter, Choi & Alford 2005 ; Lasser et al. 2000 ). Smoking prevalence among community-based drug abuse treatment staff (40% to 60%) is much higher than the 5% prevalence observed among other healthcare providers such as physicians, dentists, and dental hygienists ( American Psychiatric Association 2006 ; Goldstein et al. 1998 ). From our experience, staff members who smoke are less likely to try to help a patient quit smoking, sometimes due to guilt and shame about their own smoking, and they may smoke with patients in the name of “better therapeutic alliance.” However, staff members who make the quit attempt may also become the most supportive of others who are trying to quit.

Incorporating tobacco dependence treatment into addiction treatment settings must change the current culture and address training needs. Specific approaches to organizational change have been developed ( Simpson 2002 ; Rosenheck 2001 ; DeSmet 1998 ; Backer 1995 ; Backer, David & Saucy 1995 ), and factors supporting organizational change have been identified. Factors influencing the adoption of new approaches in addiction treatment settings include providing staff with the new information, providing evidence that the intervention will make a difference, having support to make the changes, and the staff/organization level of readiness for change ( Backer 1995 , 1991 ; Backer, David & Saucy 1995 ; Rogers 1995 ).

Organizational change models have been developed and adapted specifically to address tobacco in addiction treatment settings ( Bowman & Walsh 2003 ; Sharp et al. 2003 ; Stuyt, Order-Connors & Ziedonis 2003 ; Ziedonis & Williams 2003 ; Campbell, Krumenacker & Stark 1998 ; Rustin 1998 ; Bobo, Anderson & Bowman 1997 ; Hoffman et al. 1997 ; Campbell et al. 1995 ; Hoffman & Slade 1993 ). Research has shown that minimal interventions (such as the traditional “half-day skills-building workshop”) are not powerful enough to change nicotine-related counseling practices of outpatient staff, and there is a need for more intensive and multidimensional interventions to affect attitudes and increase skills and knowledge ( Bobo, Anderson & Bowman 1997 ). Tobacco use should be addressed in both adult and adolescent addiction treatment programs. Nicotine dependence usually begins in adolescence, and addressing tobacco in adolescent addiction treatment should include both treatment and prevention efforts. Hymowitz and colleagues (2001) instituted organizational change in a pediatrics residency program that led to increased youth tobacco interventions; these approaches may also be helpful in adolescent addiction treatment programs.

This article describes a specific organizational change intervention, Addressing Tobacco Through Organizational Change (ATTOC), in terms of its history and development, core implementation components, and the 12-Step approach guiding the model. In addition, it includes a description of one addiction treatment program that implemented the ATTOC intervention.

HISTORY AND DEVELOPMENT OF THE ATTOC MODEL

There have been reports from several different groups describing organizational change interventions that include some combination of staff training, providing staff with nicotine dependence treatment, providing nicotine dependence treatment for clients, changing program structure and clinical chart templates, and implementing local program policy changes. For example, Sharp and colleagues (2003) reported on three programs that successfully incorporated nicotine dependence treatment into clinical practice. All of the programs followed an organizational change model, and all instituted nicotine dependence treatment and a “zero-tolerance” tobacco-free policy. Sharp contrasts this finding with those of Rustin (1998) who reported that programs not following an organizational change model failed in attempts to integrate nicotine dependence treatment. Campbell and colleagues (1995) implemented a demonstration organizational change effort in a multisite treatment center which included staff education, training to conduct nicotine dependence treatment groups, voluntary nicotine dependence treatment for staff, and nicotine dependence treatment for clients. In this study, efforts to treat nicotine dependence were most successful in the site that agreed to integrated program features, such as incorporating smoking cessation into individual treatment plans and incorporating cessation groups into the treatment schedule.

The ATTOC intervention model has been developed, modified, and implemented in many addiction and mental health treatment programs. Hoffman and Slade (1993) first identified steps necessary for addressing tobacco use in addiction treatment settings, and these were developed into a manual titled Drug Free is Nicotine Free , which helped addiction treatment programs better address tobacco use and included a focus on developing smoke-free grounds ( Hoffman et al. 1997 ; Slade & Hoffman 1992 ). Dr. Slade was a great mentor for Dr. Ziedonis when they teamed up in 1998 at the Robert Wood Johnson Medical School. Their team further implemented and developed the model in both addiction and mental health treatment settings. The approach was further described in other articles ( Williams et al. 2005 ; Ziedonis, Williams & Smelson 2003 ), but basically stays focused on staff development, basic and advanced training, offering staff members and clients assistance to quit smoking, developing a change plan for the organization, helping the leadership team to organize for the changes that they want to achieve, considering organizational structure and process changes, and also policy development. The model developed from the premise that staff training was not enough and that these treatment settings had a culture where it was normal not to address tobacco.

The current version of this organizational change intervention is the Addressing Tobacco Through Organizational Change (ATTOC) model. This approach emphasizes and recommends a tobacco dependence treatment model that includes multiple interventions for different states of motivation on the clinical level ( Ziedonis et al. 2006 ; Ziedonis & Trudeau 1997 ) and offers a menu of options for organizational change goals on the organizational level. Part of the intervention includes assessing the agency’s motivation to change; the agency then determines its major goals. For example, some organizations just want the intervention to focus on increasing staff knowledge and skills through training. Other agencies might want to also include treating staff nicotine dependence and want the setting to be smoke-free for staff only. Other agencies want sweeping changes that include smoke-free grounds for all, including staff and patients.

The ATTOC model described in this article is currently being implemented and evaluated in a National Institute of Drug Abuse (NIDA) study, using a multiple baseline design with each of three residential addiction treatment programs. The six month ATTOC intervention is designed to support organizational change, including developing a leadership team, goals, change plan, communication effort, staff training, treatment for staff and patients, and policies on tobacco use restrictions. These clinical, program, and system level interventions ( Ziedonis et al. 2006 ) include a focus on both the process of change and the content specific to tobacco use and dependence.

This article includes a more detailed description of the ATTOC intervention at one clinical agency, Willamette Family Treatment Services (WFTS), which decided to have smoke-free grounds for staff but allow only adult patients (not adolescents) to smoke in designated places. In a “motivation-based” treatment model the approach varies based on the motivational level of the patient, including having different strategies for lower and higher motivated patients. All patients who are tobacco dependent are screened, assessed, and offered some type of nicotine dependence treatment.

The ATTOC intervention is driven by six core implementation strategies that define the implementation process, and by 12 steps in the organizational change process. The use of a 12-Step organizational change model, in addition to laying out a clear approach to addressing tobacco within an organization, can also defuse staff resistance through its familiarity in the addiction treatment and recovery community. The sections below describe the six core implementation strategies and the guiding 12 steps of the ATTOC model.

SIX CORE STRATEGIES USED TO IMPLEMENT THE ATTOC MODEL

The ATTOC intervention is delivered through a combination of phone consultations and on-site consultations and trainings. The six core strategies include: (1) preparation activities for the start of the intervention, (2) on-site consultation, (3) formation of the agency’s Addressing Tobacco Leadership Group, (4) formation of work groups to address the specific areas of the ATTOC 12-Step approach, (5) development of tobacco treatment specialists at the agency, and (6) phone consultations to provide ongoing technical assistance.

Preparation for the ATTOC Intervention

Prior to the six month intervention, there is a one month planning period in which the site champion(s) anticipate the intervention and begin to work with the intervention team. The champion(s) are the leader(s) of the event and serve a vital role for facilitating the organizational change plan. Having leaders with authority in the agency is important, as is a passion for the issues of addressing tobacco, wellness, and recovery. A first step is planning for the development of the leadership team and anticipating the intervention team’s on-site consultation. The membership of the Addressing Tobacco Leadership Committee (or whatever local name might be selected) reflects a broad stakeholder involvement. During the preparation period, the leadership committee reviews the existing policies and the manner in which the clinical chart reflects documentation for tobacco use, dependence, and treatment. Other preparation work includes planning for the on-site staff training (such as arranging for Continuing Medical Education units and logistics for staff attendance) and selection of the three on-site staff members to attend the off-site advanced training. Carbon monoxide (CO) meters are purchased for the agency to provide routine screening and assessment for tobacco use and exposure. The CO meter is also a great teaching tool to help patients to see the personal advantages of tobacco dependence treatment ( Steinberg et al. 2004 ).

On-Site Three Day Consultation

During the first month, the ATTOC intervention team does an on-site consultation which includes four primary activities: providing organizational change consultation to the leadership committee, meeting the agency’s leadership and staff, training staff, and doing an on-site assessment of the organization’s capabilities to address tobacco use. The intervention team meets with the leadership committee to review current policies and practices, consider past efforts at organizational change, acknowledge the challenges tobacco creates for the agency, and begin development of the change plan.

During the three day on-site consultation there is a one-day tobacco training for all staff. The on-site training, entitled “Integrating Tobacco Dependence Treatment into Your Professional Practice,” trains staff to: (1) communicate the importance of addressing nicotine in their clinic, (2) identify nicotine resources, treatment, and training options, (3) incorporate tobacco screening, assessment treatment planning, and treatment of nicotine dependence into practice, and (4) inform clients of evidence-based nicotine dependence treatments, including psychosocial and pharmacological treatments. Medical staff members (nurses and physicians) are provided with intensive training on prescribing FDA-approved medications for nicotine dependence treatment.

Addressing Tobacco Leadership Committee

Throughout the ATTOC intervention, the champions and the leadership committee meet at least monthly to provide clinical, training, human resources, and policy leadership. The leadership committee maintains a written change plan and monitors and supports its implementation over time. Communication from the leadership committee is critical for staff, patients, families, and other community agencies.

Formation of Tobacco Work Groups

The leadership committee is encouraged to develop work groups to implement the goals developed from the 12 steps of the ATTOC model. The agency has flexibility in how to organize these tasks, but typical workgroups are concerned with assessment/documentation, staff training, communication, staff recovery, medication management, policy development, and program development. Ultimately the goal is to have these tasks become integrated into existing agency committees and structure.

Training Tobacco Treatment Specialists

Staff members across various disciplines may have received little training in nicotine dependence, but they do have the necessary tools to adapt existing knowledge and skills. The ATTOC intervention includes the further development of two or three staff members to increase their ability and identity as the organization’s tobacco treatment specialists. These individuals receive an extensive three-day off-site training focused on motivation-based treatment approaches including motivational enhancement therapy, specific lesson plans for use in group treatment or for individual treatment with lower motivated clients, cognitive behavioral therapy for smoking cessation with adaptations for substance abusers, cultural competence, and case discussions/role plays.

Weekly Phone Check-ins

The ATTOC intervention includes weekly phone check-ins conducted by the intervention team with the program champion(s) and the leadership committee. These calls provide additional technical assistance on the 12 step change process, and support the agency in maintaining the gains achieved through the intervention.

Nicotine Dependence Treatment Medications

As it was applied in the NIDA study, the ATTOC intervention provided $ 11,000 to each agency to purchase nicotine dependence treatment medications. The agency had flexibility to choose from among the seven FDA-approved medications (five types of nicotine replacement therapy (NRT), varenicline, and bupropion). Providing medication in the NIDA study supported the goals of increasing access to treatment for staff and patients, and facilitating training on medication treatment.

THE ATTOC 12 STEP APPROACH

Table 1 outlines the 12 steps of the ATTOC model that are used to guide the intervention. A manual was developed that describes these 12 key issues, and includes a description of the motivation-based orientation to organizational change.

The Addressing Tobacco Through Organizational Change 12 Step Approach

Step One: Acknowledge the Challenge

The intervention consultant helps the champion(s) and the agency to develop a sense of urgency in addressing the issue of tobacco use and dependence, including creating a vision and addressing the common barriers for addiction treatment programs.

Step Two: Establish a Leadership Committee

The champion(s) cannot facilitate cultural change without the help of others at the agency. The leadership committee needs to represents all staff at the organization (i.e., administration, medical, nursing, counselor and social work staffs, union members, housekeeping, security and grounds staff, etc.) and have members who are leaders within the agency and are able to make decisions with financial support.

Step Three: Create a Written Change Plan and Implementation Timeline

What are the short, medium, and long-term goals and plans? Who will be affected? When will goals be achieved? In this step the leadership committee establishes a timeline with measurable goals and objectives. This intervention process includes planning, collecting data to measure change, evaluating outcomes, and making further improvements ( Ziedonis & Williams 2003 ).

Step Four: Start with Easier System Changes

Many clinicians and program directors initially get overwhelmed when they consider addressing tobacco use, so there is a need for early victories in the effort. Breaking the task into smaller steps can also help. Commonly perceived “easier things to do” are listed in the Table 2 .

Easy Policy Changes to Better Address Tobacco Use

Step Five: Conduct Staff Training

All staff should be trained to screen, assess, and develop treatment plans for tobacco dependence. Staff training includes a motivation-based treatment approach with specific interventions for lower and higher motivated patients, including both psychosocial and pharmacologic treatment options. This training includes increasing knowledge of local resources, regional and national web-based interventions and educational sites, and community support groups (e.g., Nicotine Anonymous).

Step Six: Provide Treatment Assistance for Interested Nicotine-Dependent Staff

Staff who smoke are often resistant to organizational change to better address tobacco use among patients. Some of this is their own ambivalence about their tobacco use, but there is also concern that they will be forced to be tobacco-free while at work. Staff members deserve the same sensitivity and compassion provided to the clients on this issue, including education and access to medication, psychosocial treatment, and social support. Sensitivity to staff’s nicotine dependence is important in training—especially the counter-transference issues that arise, and the staff’s resistance to intervening with their patients on smoking. Such resistance is often due to their own guilt or shame about smoking, or a sense of hypocrisy in helping others to quit smoking while they continue.

Step Seven: Document Assessment and Treatment Planning for Nicotine Dependence

Changing intake/assessment, treatment and discharge planning forms to include tobacco items will prompt staff to assess tobacco use comprehensively. Modifications can be made to these tools to include nicotine, to have questions that are more detailed (e.g., progression of use, CO meter score, history of prior quit attempts, motivational level, support system), and to assess its relationship to alcohol and other drugs and its impact on functioning. All tobacco-dependent clients should have this problem listed on their treatment plan.

Step Eight: Incorporate Tobacco Issues into Patient Education Curriculum

Information for all smokers and tobacco users should include the health consequences of tobacco, interactions between medications and tobacco, what medications and other treatments are available for nicotine dependence treatment, fact sheets on common patient concerns, strategies to address cravings, information personalizing risks, and nicotine dependence measurement tools. Educational information on how tobacco impacts the family and what the family can do is also important.

Step Nine: Provide Medications for Nicotine Dependence Treatment and Required Abstinence Periods

Medication usage in treating nicotine dependence parallels its use for other addictions in treating acute withdrawal (detoxification), protracted withdrawal, and even maintenance as harm reduction. Primary medications are NRT (patch, gum, spray, inhaler, lozenge), bupropion, and varenicline. Utilizing these treatments to help manage required abstinence periods and as part of nicotine dependence treatment is routine. Some agencies cannot afford to integrate these medications into their agency and must rely on behavioral interventions.

Step Ten: Integrate Tobacco Dependence Treatment Groups into the Program and Include the Development of Onsite Nicotine Anonymous Meetings

The ATTOC model encourages the use of evidence-based tobacco dependence treatments that integrate medications and psychosocial interventions (motivation based treatments, education, relapse prevention, and support). Staff are trained in core psychosocial treatments (cognitive behavioral therapy and motivational enhancement therapy) for the “quitters” group treatment, which is for smokers ready to quit and emphasizes techniques for quitting. It is recommended that staff provide the quitters group treatment for 10 weeks. For lower motivated patients, the staff are trained in motivational enhancement therapy and also delivering a more educational model that allows for interaction with the clients. The approach has more of a “wellness” orientation and describes the importance of addressing tobacco at some time in the individual’s recovery process. A useful resource for these two types of groups is the Learning about Healthy Living manuals ( Williams et al. 2005 ). These manuals were designed for individuals with serious mental illness and are adapted in the NIDA study for the substance abuse treatment population. The manual is readily available via the internet site: http://ubhc.umdnj.edu/nav/LearningAboutHealthyLiv-ing.pdf . The group treatment approach for lower motivated clients includes information regarding the risks associated with smoking, what is in cigarettes, the benefits of quitting and ways to quit smoking, and healthy lifestyle behaviors that can assist them in quitting smoking. Education and other motivational interventions can help less-motivated patients to incrementally increase their commitment to quit.

For individuals with other addictions that utilize the 12-Step approach of Alcoholics Anonymous, Nicotine Anonymous (Nic-A) and “working a program” for addressing tobacco dependence can be familiar and helpful. In most communities in the United States there are few Nic-A meetings whose members meet on a regular basis, so some individuals benefit from just reading the Nic-A materials and sharing these concepts with their sponsor or therapist. Addiction treatment programs are a good place to have Nic-A meetings, and one goal for programs in the ATTOC model is to develop Nic-A meetings at their site.

Step Eleven: Communicate with 12-Step Groups, Colleagues, and Referral Sources about System Changes

Communication is needed, throughout the intervention, with staff, patients, families, local Alcoholics Anonymous and other support groups, colleagues, insurance companies, and referral sources. Often agencies are concerned about negative fall-out that may accompany an aggressive change in smoking policies. For example, providers may worry that making their program smoke free, including smoke-free grounds, may result in a loss of business.

Step Twelve: Develop Policies Addressing Tobacco Use

Addiction treatment programs routinely use policy manuals for clinical and nonclinical issues, and this is one way to assess prior tobacco dependence policies. Tobacco policies often include rules about the boundaries on specific behaviors and consequences for violation, including if smoking and use of other forms of tobacco are allowed and at what locations if allowed. Policies need to include how to manage violations, and should apply to both staff and patients. In some cases, programs will require that staff members not be identifiable in any way as tobacco users, in order to prevent the sight or smell of tobacco from triggering the relapse of clients, staff, or visitors. Some system changes may necessitate modifying standard intake forms to better assess tobacco use, include tobacco on the treatment plan, and require discharge planning on tobacco dependence. Signage such as pro-wellness posters and no-smoking signs reminding people of these new policies can be helpful. In some cases the treatment program will want to have tobacco-free grounds for staff and/or patients, recognizing that environmental tobacco smoke is a substantial health risk ( US DHHS 2006 ).

WILLAMETTE FAMILY TREATMENT SERVICES (WFTS) CASE STUDY

This article now offers the perspective of an addiction treatment program that participated in the NIDA ATTOC study (October 2006 to March 2007). WFTS is the largest substance abuse treatment agency in Lane County, Oregon, with an operating budget of over $4 million per year, and includes both adolescent and adult treatment programs. The three core facilities within the WFTS adult treatment program are Women’s Rehabilitation, Men’s Rehabilitation and Detoxification. The Women’s Treatment Facility offers a full spectrum of care including outpatient, residential and aftercare services, and annually serves 400 women in outpatient and 200 women in residential services. The residential (35 beds) and outpatient programs serve both women and teens, including those who are pregnant and parenting. A licensed Child Development Center provides care for infants and children while their mothers are in treatment. The Men’s Treatment Facility provides the same continuum of care, serving nearly 200 clients in residential and 160 in outpatient treatment. The Buckley Detoxification Center, serving over 500 men and women annually, offers short sobering stays (less than 10 days) for those in need of acute withdrawal management.

For over 10 years, WFTS policy as stated in the Employee Handbook prohibited tobacco use on site at any program facility. However, this policy had largely been ignored. All the WFTS facilities had designated smoking areas for clients and staff, and supervisors overlooked frequent staff smoking breaks and the use of break areas as social meeting places. Although most WFTS programs ignored written smoking policies, two programs (the Adolescent Program and the Child Development Center) maintained strict policies against tobacco use. The Adolescent Program prohibited tobacco use by all clients. Staff members were prohibited from smoking during the workday, and staff members who were addicted to tobacco were encouraged to quit. New staff hires were informed of this policy and were generally not tobacco users.

Prior to beginning the ATTOC intervention, there was consensus determined by the WFTS top administrative staff that WFTS needed to do more about addressing tobacco. The period before the intervention began induced anxiety in staff members, as it was unclear whether WFTS would have tobacco-free grounds as the goal of the intervention. Staff who smoked were fearful that they would have to quit smoking, or that their “right to smoke” would be curtailed. Many nonsmokers expected a complete ban on tobacco, including tobacco-free grounds. Before the intervention there were two smoking areas at the Women’s Program facility, at opposite ends of the building. The clients smoked in a large covered shelter located just off the facility grounds, while the staff members smoked in a covered outdoor spot in the maintenance area. Both spots had seating conducive to socializing. Staff members with heavy tobacco addictions often used their area hourly, with little restriction by supervisors (some of whom also smoked). The ATTOC intervention helped many staff quit smoking; however, some relapsed while others remained abstinent. Initially the tobacco awareness efforts of nonsmoking staff were met with resistance by smoking staff and clients. In the men’s residential setting (20 beds), residents arrive from jails, prisons, and other treatment centers, and nearly all clients are tobacco users, either smokers or chewers. Before the intervention, staff and clients shared a smoking area at this facility, and there were few restrictions on shared tobacco use, with staff smoking with clients during individual counseling sessions, and staff chewing of tobacco common. At that time clients would pool their money, augment it with recreation funds earned through fundraising events, and buy bulk tobacco for rolling or inexpensive cigarettes. When new clients entered treatment, they were provided with tobacco and invited into the pool. These practices were ended in the course of the ATTOC intervention.

Two WFTS opinion leaders worked in partnership to lead the ATTOC intervention, the Adolescent Program Director and the Women’s Treatment Director. Because this leadership team included both a smoker and a nonsmoker, both of whom were committed to the organizational change process, WFTS was able to reach all clinical staff and most other staff to present the goals of the project. These two champions represented the agency as a whole, and had years of experience and a grassroots connection to both clients and staff. Other staff provided leadership support, notably by developing Nicotine Anonymous meetings on site, and publicizing local Nicotine Anonymous meetings to staff.

Shortly before the start of the intervention, a Tobacco Leadership Committee was developed with representation from every clinical program as well as support and maintenance staff. A mission statement regarding tobacco use and nicotine cessation was developed, presented to the board of directors, and endorsed by the president of the board and the executive director. The statement outlined that, in addition to health concerns related to the use of tobacco by employees, tobacco-related organizational costs (lost productivity, absenteeism, health care costs, and insurance) were $178,500 per year. The Leadership Committee met monthly, and subgroups were formed to mirror key steps in the ATTOC model (e.g., supervision and training, program implementation, policies and procedures, assessment and documentation, patient education, patient medications/NRT, Nicotine Anonymous Meetings, treatment and recovery resources for staff).

In the course of the ATTOC intervention, Leadership Committee members estimated that 150 patients and staff benefited from NRT and other nicotine dependence medications provided by the study. Having NRT available during the NIDA-funded ATTOC intervention was important in expanding nicotine dependence treatment on-site, since not having access to NRT or other medications for nicotine dependence is a barrier. WFTS staff commented that clients were often receptive to smoking-related interventions. Clinical staff benefited from the general staff training offered during the on-site consultation in October 2006. The key tobacco treatment specialists were identified and received advanced training off-site about one month later.

After several months of collaborative effort, a new agency tobacco policy was finalized by the Leadership Committee and proposed to staff on January 1, 2007. At this time the staff smoking area at the Women’s Facility was closed, and smoking staff were asked to smoke off site. After some additional changes, the final WFTS Tobacco Policy was implemented on February 1, 2007. A short staff satisfaction survey taken soon after the policy was implemented showed a generally positive response to the tobacco policy. At the time of this writing, one year after the ATTOC intervention was initiated, there continues to be maintenance of the progress, including the desire to be a tobacco-free agency, with strong incentive for staff to quit smoking, and a focus on cessation efforts for all clients.

The new agency policy required staff to use tobacco products off-site and restricts break times to one ten-minute morning and afternoon break, along with a lunch break. This restriction curtailed excessive use of work time for smoking breaks. Many employees have found it inconvenient to go off grounds to smoke and have chosen to either quit smoking or to use NRT during the workday. Several people have reported that they couldn’t have quit smoking without the NRT, as well as the emotional and behavioral support offered as a result of the intervention.

Staff members found it was helpful to have both a quitters group treatment approach and a lower motivated group treatment approach. Continued trainings for clinical staff were provided through in-service trainings and by distributing the ATTOC binders and manuals again. Tobacco education videos and tobacco cessation posters were placed throughout the agency’s three facilities. One limitation was that nicotine-related training and education was offered only to counselors and supervisors; other staff, and particularly support staff, may have benefited from the education and should have had the opportunity to participate. Another potential limitation of the study is that all clients at the agency aren’t evaluated — only a sampling of the clients. The NIDA-funded study will assess whether WFTS clients were more likely to receive nicotine dependence services (e.g., assessment, counseling, referral) after the intervention was completed; however, those data are not available at this writing. In addition, as the focus of the study was on organizational change and not on client-level change, the NIDA study will not directly measure whether clients are more likely to quit smoking after the intervention. Whether changes in organizational practices to better address smoking among clients may affect client smoking behavior (e.g., quit attempts, quit rates), and how much change in client smoking behavior may occur, are questions for future research.

A key issue for the success of the intervention was effective communication, and the Leadership Committee took the lead in this. Nicotine Anonymous meetings and the incorporation of CO meters in smoking cessation groups were well received by the clients and motivated several clients to attempt smoking cessation. A tobacco cessation support group was offered to staff as well. Although the staff support group was small and only met weekly for a few months, those who attended said they found it to be helpful. Members of the WFTS Tobacco Leadership Committee report that, through education and encouragement, a gradual shift in the WFTS tobacco culture has occurred. As an example, some residential clients complain that they are “having trouble finding someone to smoke with.”

Tobacco use and dependence is the leading cause of morbidity and mortality to clients in addiction treatment programs. The ATTOC model can be helpful to addiction treatment programs making the organizational change effort toward controlling and eliminating tobacco use. Today it continues to be normal to smoke in most addiction treatment programs; however, the tipping point is near and broad cultural change is likely to occur in coming years. Addressing tobacco use requires clinical, program, and system level change. The 12 steps of the ATTOC model provide a prescriptive approach to helping organizations change so that they can support clients in their recovery from tobacco addiction as well as other addictions. The ATTOC model provides a general structure and guidance for organizational change, but programs must adapt it to the unique features of their treatment population, including culture, co-occurring disorders, and other factors that are unique to their needs and social context.

Acknowledgments

† This work was supported by the National Institute on Drug Abuse (R01 DA020705), by the California-Arizona research node of the NIDA Clinical Trials Network (U10 DA015815), and by the NIDA San Francisco Treatment Research Center (P50 DA009253).

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Certification of Health IT

Health information technology advisory committee (hitac), health equity, hti-1 final rule, hti-2 proposed rule, information blocking, interoperability, patient access to health records, clinical quality and safety, health it and health information exchange basics, health it in health care settings, health it resources, laws, regulation, and policy, onc funding opportunities, onc hitech programs, privacy, security, and hipaa, scientific initiatives, standards & technology, usability and provider burden.

Improving Tobacco Use Screening and Smoking Cessation in a Primary Care Practice

Miramont Family Medicine is a 17-provider primary care practice serving 4 locations, including a small rural clinic, across northern Colorado. The practice attested for MU Stage 1 years 1 and 2.

Improve both tobacco screening and cessation intervention rates in appropriate patients to 90% or above for all practice providers.

Improvement Target

Target selection.

Tobacco screening quickly became an area of focus for Miramont after implementing its EHR in 2007 (see below).  Interest was driven by Miramont’s participation in the National Committee of Quality Assurance (NCQA) PPC-PCMH (Physician Practice Connections - Patient Centered Medical Home) pilot and coaching from their Quality Improvement Organization (QIO), the Colorado Foundation for Medical Care. Finally, Pay for Performance (P4P) bonuses were made available as part of a three year multi-payer patient centered medical home pilot.

Target Measure

The P4P tobacco goal was to assess and document tobacco use status in 80% of all patients between the ages of 18 and 75 and to have 80% of all identified all smokers and other tobacco users ages 18 to 75 receive a tobacco cessation intervention. Although the P4P target was 80%, Miramont wanted to be more ambitious and set an organizational goal of 90%.

Improvement Goal

Because the P4P under the pilot project was only to be paid in the last of the 3 year projects (2009-2011), the objective was to reach goal by the beginning of year three (2011) and sustain it for one year.

QI Setup and Approach

Miramont elected to focus on quality beginning in 2008 with the pursuit of NCQA level 3 PCMH recognition under the 2008 standard.  They believed that by having this recognition and the associated policies and procedures they would gain market share, lower costs, improve outcomes, and improve patient and staff satisfaction.

The QI/Quality Assurance (QA) program team is headed by the Director of Quality and the Medical Director, with the full support of the practice’s partners and CEO.

Ongoing engagement of staff played a key role in Miramont’s ability to improve clinical measures. A standing weekly patient medical home meeting enabled providers and staff to present QI-related problems (such as gaps in needed data) and troubleshoot them. Select staff members also participated in off-site learning collaborative and medical education activities related to QI/QA.

Miramont’s Quality Improvement (QI) approach to identifying and decreasing tobacco use in its patient population was underpinned by a collaborative network of providers and staff working together to ensure comprehensive patient care.

They analyzed and improved workflows, including automating many care process and population management activities.

For example, their workflow included using an embedded clinical decision support tool, Clinical Integration Networks of America (CINA) sheet, at the time of huddle. CINA is a clinical summary that they used for every patient to identify gaps in tobacco use documentation and intervention.

In addition, they used EHR templates that standardize data capture and recording among teams and detailed monthly reporting by individual teams with data trending, including posting graphs in the nurse’s station area as a daily reminder of tobacco metrics.

QI Tools and Partners

In 2006, Miramont recognized the need for an EHR with an integrated practice management system that would allow the organization to better serve its patient population. After careful deliberation, the practice chose and implemented a single EHR for all its practice sites. Realizing the additional benefits that advanced reporting functionality could provide, Miramont later integrated a separate quality metrics reporting tool into its quality improvement efforts (see Health IT Tools, below). In 2008, Miramont joined Colorado Primary Care Collaborative convened by HealthTeamWorks (a non-profit QI facilitator) and began participating in their PCMH pilot.

Miramont has also engaged with other regional and national QI initiatives. For example, they received coaching and support from their quality improvement organization (QIO), the Colorado Foundation for Medical Care; Bridges to Excellence; the Colorado Academy of Family Physicians and the Colorado Children’s Healthcare Access Program. In addition, they have worked with the Colorado regional extension center (REC) to exchange clinical information, and participated in the CMS Comprehensive Primary Care Initiative (CPCI).

• Miramont has substantially optimized its workflow using a combination of redesign methods including lean processing, Toyota Production Model, Value Stream Mapping, 5 S, root cause analysis, PDSA (Plan, Do, Study, Act) cycles and cycle time analysis.

QI Approach to Target

An initial step was to have MAs begin to work at the top of their license by empowering them to ask patients about smoking status, and record this information in an EHR flowsheet along with BP and height. Involvement of MAs, active flowsheet management (e.g., keeping them up-to-date, using them in patient discussions), and weekly staff meetings contributed to improvement. The quality team looks at data every month and gives provider teams a report that helps the team to see performance gaps. Poor performance would result in lower P4P payments and a consequent reduction in individual monthly production bonuses. They noticed that results started to slip when they skipped meetings. Over time, MAs and health coaches started to practice at the top of their scope.

Central to the approach are integrated ancillary services, such as an embedded psychologist, and a pharmacy technician who offers low cost generic bupropion (a medication to support smoking cessation), electronic cigarettes and hypnotherapy CDs.  These services have facilitated patient-specific and patient-centered choices for patients desiring to stop smoking.

• Using simple value stream process mapping, the staff identified opportunities for all care team members to work together in providing care more effectively and efficiently at several key points in care flow — including before, during and after patient encounters. For example, it was determined that some patients might benefit from seeing the asthma coach as part of their decision making process, and that these coaching sessions could be offered on the spot with open communication across teams. (Not every team has an asthma coach, but work could be redistributed quickly to allow one coach to perform an intervention for another team with little notice.)
• Prior to patient visits, teams take part in daily morning patient huddles to discuss interventions. Using patient summary sheets (CINA sheets) that are generated daily, the MAs can address most clinical deficiencies prior to each patient/provider encounter.  The CINA sheet is a patient summary form produced by the tool that outlines key metric-related patient information, including medications and follow-up action items. Patients without documentation of tobacco status were highlighted and queried by the MA. At the end of the visit, the patient summary sheet is provided to the patient, and any remaining gaps in care, such as no tobacco cessation plan, are identified so the patient can consider addressing this in the future.
• Finally, the visit summary details the tobacco cessation plan (including community resources) when such a plan is in place, and prescription names that have been sent electronically to nearby pharmacies. In addition, the plan might include referrals to Colorado quit line (smoking cessation program) that offers smoking cessation counseling, to nurse-level education (performed by an advanced practice nurse with prescriptive authority) or to behavioral health (performed by a licensed psychologist who can do hypnotherapy and offers a CD with guidance on self-help).
• Miramont’s protocol-driven team-based management approach empowered medical assistants (MAs) to assess for tobacco use and to document the assessment in the patient chart.
• Nursing staff used a pocket checklist as a reminder to cover all the steps they need to take, such as taking vitals, blood test, etc.
• Electronic cigarettes with instructions for use by a pharmacy technician, access to a psychologist, and group classes led by a nurse educator were provided in-house to clinic patients.

Overview of Specific CDS Interventions

Protocols & customized order sets.

After the MA asks about smoking status, he then does a readiness to quit assessment . If the patient scores high enough, the physician can select prescriptions to support smoking cessation that are built into the order sets. The prescriptions include nicotine patches, varenicline, bupropion and electronic cigarettes available through an in-house dispensary.

The flowsheet is filled out at each visit with smoking status, and with a result of a readiness to quit assessment if completed. See above QI Approach to Target section .

Advanced Reporting

The quality reporting tool (CINA sheet) supports population management by highlighting individual and aggregate data pertinent to quality metrics. See above QI Approach to Target section . 

Patient Empowerment & Education

Together, Miramont’s collaborative framework and reporting capabilities have helped foster a culture of patient accountability and care plan ownership. See above QI Approach to Target section for information about patient summary sheets.

2008 baseline data showed a 70% rate for assessing weight, BP, height, smoking status. It took approximately six months after QI approaches began to see improvement. From April 2011 to February 2012, average tobacco screening rates for the practice increased from 80% to 90% and smoking cessation rates over this time increased from 80% to 87%. As of spring 2013, 13 of the practice’s 17 providers have achieved a 90% rate for smoking assessment and intervention.

Miramont will participate in an All Payers Claims Database . They will publically report metrics to make healthcare cost and outcomes data available to the public. They are also interested in developing a Medical Neighborhood for improved integration and health information exchange for patients requiring specialty care.

Key Lessons

• Use your EHR to its fullest capacity.
• Participate in pre-planning team sessions. Holding recurring sessions such as patient “huddles” before visits can help identify gaps in care. A pre-determined schedule for these meetings helps ensure that providers have dedicated time to address these issues.
• Provide ongoing feedback on clinical performance. Feedback will provide practitioners with a solid understanding of where they stand regarding clinical measures. Feedback reports reveal deficiencies, allowing providers to effectively address them.

Open Survey

• Open access
• Published: 11 September 2024

Tobacco and COPD: presenting the World Health Organization (WHO) Tobacco Knowledge Summary

• Wenying Lu 1 ,
• Rebekka Aarsand 2 ,
• Kerstin Schotte 3 ,
• Jing Han 2 ,
• Elizaveta Lebedeva 4 ,
• Elena Tsoy 5 ,
• Nino Maglakelidze 6 ,
• Joan B Soriano 5 , 7 ,
• Werner Bill 8 ,
• David M G Halpin 9 , 10 ,
• M. Patricia Rivera 11 ,
• Kwun M Fong 12 ,
• Hasmeena Kathuria 13 , 14 ,
• Arzu Yorgancıoğlu 15 ,
• Monika Gappa 16 ,
• David CL Lam 17 ,
• Sarah Rylance 2 &
• Sukhwinder Singh Sohal 1  

Respiratory Research volume  25 , Article number:  338 ( 2024 ) Cite this article

Metrics details

The WHO recently published a Tobacco Knowledge Summary (TKS) synthesizing current evidence on tobacco and COPD, aiming to raise awareness among a broad audience of health care professionals. Furthermore, it can be used as an advocacy tool in the fight for tobacco control and prevention of tobacco-related disease. This article builds on the evidence presented in the TKS, with a greater level of detail intended for a lung-specialist audience. Pulmonologists have a vital role to play in advocating for the health of their patients and the wider population by sharing five key messages: (1) Smoking is the leading cause of COPD in high-income countries, contributing to approximately 70% of cases. Quitting tobacco is an essential step toward better lung health. (2) People with COPD face a significantly higher risk of developing lung cancer. Smoking cessation is a powerful measure to reduce cancer risk. (3) Cardiovascular disease, lung cancer and type-2 diabetes are common comorbidities in people with COPD. Quitting smoking not only improves COPD management, but also reduces the risk of developing these coexisting conditions. (4) Tobacco smoke also significantly impacts children’s lung growth and development, increasing the risk of respiratory infections, asthma and up to ten other conditions, and COPD later in life. Governments should implement effective tobacco control measures to protect vulnerable populations. (5) The tobacco industry’s aggressive strategies in the marketing of nicotine delivery systems and all tobacco products specifically target children, adolescents, and young adults. Protecting our youth from these harmful tactics is a top priority.

What is COPD?

Chronic obstructive pulmonary disease (COPD) is a progressive and largely irreversible respiratory condition that causes poorly reversible airflow obstruction and an abnormal inflammatory response in the lungs, associated with overall poor lung health [ 1 , 2 , 3 ]. It affects the airways, lung parenchyma, and pulmonary vasculature as well as having extra-pulmonary effects. COPD mechanisms include mucus hypersecretion (chronic bronchitis), tissue destruction (emphysema), and small airway inflammation with fibrosis. Emphysema usually develops later, and chronic bronchitis is diagnosed if a productive cough persists for at least three months in at least two consecutive years. The main pathological changes are found in the small airways with epithelial remodeling including goblet cell metaplasia, basal cell hyperplasia, leading to thickening of small airway walls and obliteration [ 4 ]. The large airways are also affected with remodeling changes, inflammation, squamous metaplasia, and there can be associated bronchiectasis (Fig.  1 ). Emphysema of the peri-bronchial lung parenchyma can occur more than 10 years after small airway obstruction can be detected, and predominantly in the areas initially affected by air trapping. The pathological changes in the small airways lead to increased airflow resistance, and air trapping [ 3 , 5 ]. People with COPD are at risk of developing both infections and lung cancer [ 6 , 7 ]. The 5-year mortality rate for COPD is estimated at 25% [ 8 , 9 ].

Tobacco smoking and development of Chronic Obstructive Pulmonary Disease (COPD). There were 329 million cases of COPD globally in 2019, with high rates of mortality and morbidity. The leading risk factor for developing COPD is smoking, including early life exposure. The pathogenesis of COPD involves various factors such as airway inflammation, oxidative stress, genetic factors, epithelial-mesenchymal transition (EMT) mediated airway remodeling, and endothelial-mesenchymal transition (EndMT) mediated vascular remodeling. COPD often coexists with other conditions such as lung cancer, cardiovascular diseases, and pulmonary hypertension as common comorbidities

Development of COPD

COPD is considered a preventable and manageable disease, and it is possible to prevent or reduce its individual and population burden by dealing, among other, with social determinants of health. These social determinants are tobacco and tobacco products, indoor and outdoor pollution, occupational exposures, infections, low education and socioeconomic status, and poverty. COPD is a major global health problem and the third leading cause of death worldwide. In 2019, there were 392 million cases of COPD globally [ 10 ], associated with 3.23 million deaths [ 1 ] and 74.4 million disability-adjusted life years [ 11 ]. Three-quarters of people with COPD live in low- and middle-income countries [ 1 , 10 , 11 ]. Smoking is still the primary, causal risk factor leading to COPD, but environmental exposures, such as exposure to biomass fuel combustion, air pollution, and occupational exposures, and poor lung development (both pre- and post-natal) are increasingly recognized as important causes of COPD [ 3 , 12 ]. Children’s exposure to tobacco constituents during fetal development, and environmental tobacco smoke exposure are also risk factors associated with poor lung development. Second- and third-hand tobacco smoke exposure are also risk factors for ill-health during childhood, including asthma, respiratory infections, otitis media, sudden infant death syndrome (SIDS), low birth weight and premature birth, cognitive and behavioral problems, and likely an increased cancer risk. It is estimated that approximately 70% of COPD cases in high income countries are caused by tobacco smoking [ 1 ], and the burden is growing in low- and middle-income countries. When burned, cigarette smoke contains over seven thousand chemicals, some with toxic and carcinogenic effects [ 13 , 14 ]. The inhaled complex cigarette smoke particles can adhere to and affect the respiratory tract, and the deposition varies depending on their particles size. Larger particles tend to settle in the upper airways (large airways), while smaller particles are deposited in the lower airways (small airways < 2 mm) and alveoli, leading to chronic inflammation, oxidative stress and damage to the airways and lung parenchymal structures [ 15 ]. Substantial evidence indicates that exposure to household air pollution, particularly from indoor sources such as biomass cooking fuel, firewood heating, and candles [ 16 ], is also associated with an increased risk of developing COPD [ 17 ], especially in low- and middle-income countries [ 18 ] where children and women are predominantly exposed [ 19 ]. Household air pollution is recognized as a major risk factor for COPD, with chronic respiratory diseases in women being associated with the use of solid fuel for cooking [ 20 ]. Moreover, the detrimental effects of household air pollution exposure on lung development during early life are also evident [ 19 , 20 ].

Up to late-20th century, COPD was considered solely a smoking-related disease [ 21 ], and most research focused on the pathological and physiological changes in the airways and lungs caused by smoking. As discussed above, it is now recognized that many patients with COPD are people who never smoked, but there is relatively little data on the pathological changes seen in these patients. There is some evidence that the deposition of the particles produced by cigarette smoking is different to that due to biomass or occupational exposures as these are mostly inhaled nasally where the filtration efficiency is higher, whereas tobacco smoke is inhaled through the mouth at a high flow rate leading to greater deposition in the lower airways and alveoli [ 22 ]. In susceptible subjects, cigarette smoke triggers a complex cascade of inflammation, with oxidative stress, accelerated cellular senescence and aberrant repair processes. There is evidence that women, especially after menopause, are more susceptible to the effects of tobacco smoke and develop a different pattern of disease with more severe small airway obstruction and less emphysema [ 23 , 24 , 25 , 26 , 27 ].

Tobacco smoke

Tobacco products and tobacco smoke contain a complex mixture of over 9500 compounds, such as nicotine, tar, and chemicals, many of which have been recognized as hazardous to human health by regulatory agencies [ 28 ]. Tobacco smoke is a complex aerosol which includes condensed liquid droplets (the particulate matter (PM) or tar) suspended in a mixture of volatile and semi-volatile compounds and combustion gases (the gas fraction). The gas phase of cigarette smoke include traces of acetaldehyde, methane, hydrogen cyanide, nitric acid, acetone, acrolein, ammonia, methanol, hydrogen sulfide, hydrocarbons, gas phase nitrosamines, carbonyl compounds and toxic metals including sodium, mercury, iron, arsenic, cadmium, and cobalt [ 29 ]. Constituents in the particulate phase include carboxylic acids, phenols, water, nicotine, terpenoids, tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons, and catechol. Some toxic effects induced by tobacco smoke, result from direct genetic or epigenetic effects resulting in altered gene functions (for example, cell cycle, DNA repair, and tumor suppressor genes). Many components of tobacco smoke also have the potential to drive the inflammatory response and impaired healing. Depending on the size of the inhaled complex smoke particles, they can be deposited throughout the airway. Larger particles favor the larger and more central airways, while smaller particles are deposited in the smaller peripheral airways and sacs, leading to chronic inflammation, infections, oxidative stress and damage to the airways and gas exchange areas of the lung [ 15 ]. Combustion also produces reactive oxidative substances such as superoxide anion (O2−), hypochlorite (ClO−), peroxynitrite (ONOO−), and hydroxyl (•OH) [ 30 ] that are not present in the leaf. Nicotine levels vary in different types of tobacco leaves [ 31 ]. Additives, chemicals, and flavorings are usually added to increase the palatability, attractiveness, and addictiveness of tobacco products [ 32 , 33 ]. Combined with other substances, such additives can become toxic during combustion of these products [ 33 , 34 ]. These contribute to oxidative stress and damage epithelial cells by inducing peroxidation of lipids and other cell membrane constituents, activate oxidative-sensitive cellular pathways, and induce DNA damage [ 35 ]. Other forms of smoked tobacco products, for example, hookah or water-pipe, burn tobacco leaves with other additives [ 36 , 37 ]. These forms of smoking are at least as detrimental to lung health as smoking cigarettes and should not be considered as a safe alternatives of cigarette smoking [ 38 ]. Moreover, nicotine, a highly addictive substance, is deposited in the lung and rapidly absorbed, stimulating the central nervous system, and causing increase in heart rate and blood pressure [ 39 , 40 ].

Airway inflammation

The immune response to inhaled tobacco smoke leads to the recruitment of inflammatory cells, such as neutrophils, lymphocytes and alveolar macrophages [ 41 ]. COPD is a heterogeneous condition, with between-individual variation in the nature and severity of airway inflammation [ 42 ] and the inflammatory cell profile also varies in large and small airways and with severity of COPD, hence careful appraisal is needed [ 43 ]. Both neutrophil-associated COPD with T1 and T17 type immune responses and eosinophil-associated T2-mediated immunity are found in different patients, as well as autoimmunity in more severe disease [ 42 ]. Studies have also shown increase in M1/M2 macrophages and mast cells in people who smoke and patients with COPD [ 44 , 45 , 46 ].

Genetic factors

Genetic factors also play a role in the development of COPD and may accelerate a decline in lung function. The well-known genetic factor related to COPD is the deficiency of serine protease α1-antitrypsin (AATD), a hereditary disorder, which increases the risk of 1–3% of individuals developing COPD, especially in those who smoke [ 47 ]. Genetic variants could strongly predict COPD in independent populations, and these variants are higher in those who smoke [ 48 ]. In addition, the enrichment of lung developmental pathways was observed in lung function-associated genetic variants, which altered lung gene expression [ 49 ]. The study also showed that although the heritability of lung function and COPD was estimated to be between 38 and 50%, individual genetic variants only account for a small fraction of the overall risk associated with COPD [ 50 ].

Tobacco smoking, COPD and multimorbidity

People with COPD also have a higher risk for other health problems, both because of shared risk factors and due to the systemic effects of COPD [ 3 , 51 ]. Multimorbidity can impact negatively on symptoms, quality of life, complication rates, disease management and life expectancy [ 2 ]. The most common multi-morbid conditions include coronary artery disease, atrial fibrillation, congestive heart failure, skeletal muscle wasting, metabolic syndromes including diabetes mellitus, osteoporosis, depression, anxiety, gastro-esophageal reflux disease (GERD) and lung cancer [ 3 ]. Nearly half of all COPD patients have three or more other long-term conditions, underscoring the importance of a holistic person-centered approach to the overall management of COPD [ 51 ]. (Fig.  2 )

Chronic obstructive pulmonary disease (COPD) and multimorbidity, and the management strategies. The most common comorbidities in COPD include cardiovascular diseases, lung cancer, gastro-oesophageal reflux disease (GERD), skeletal muscle wasting, osteoporosis, depression and anxiety, which normally affect COPD progression and management. Most COPD patients have three or more comorbidities. Multidisciplinary management strategies, including smoking cessation, weight management, dietary changes, exercise training, medication and psychological counselling, are essential for COPD patients with multimorbidity

Cardiovascular diseases

Individuals with COPD often share cardiovascular risk factors, such as smoking, sedentary lifestyle, and hypertension [ 52 ]. Chronic inflammation in COPD can also contribute to atherosclerosis and vascular thrombosis [ 51 ]. Impaired lung function or oxygen exchange can increase strain on the heart in people with COPD. Cardiovascular diseases can have a negative impact on individuals with COPD, causing pulmonary hypertension (PH) [ 53 ]. In addition, coronary artery disease or heart failure can compromise lung function by reducing oxygen supply to the lungs [ 54 ]. The co-existence of COPD and cardiovascular diseases is associated with worse outcomes, increased hospitalization, higher death rates and reduced quality of life. PH has also been associated with COPD and cardiovascular abnormalities. Patients with COPD showed noticeable alteration in the pulmonary vasculature, characterized by vascular remodeling primarily affecting small size vessels, such as muscular walls of arteries and arterioles [ 55 , 56 ]. The process of endothelial to mesenchymal transition might be central to this pathology [ 57 ]. Severe COPD can contribute to the development of PH due to several factors. These include chronic inflammation, loss of lung tissue elasticity, destruction of small blood vessels in the lungs, and hypoxemia [ 58 ]. Similarly, PH can also worsen COPD symptoms and prognosis. The increased pressure in the pulmonary arteries puts additional strain on the right side of the heart, leading to right heart failure [ 59 ]. This can further compromise lung function and exacerbate COPD symptoms.

Skeletal muscle wasting

Inactivity is common among COPD patients and significantly contributes to many systemic issues of COPD [ 60 ], especially during exacerbations [ 61 ]. Research indicate that inactivity independently increases the risk of skeletal muscle wasting, osteoporosis [ 62 ], type 2 diabetes, cardiovascular disease and depression [ 63 ]. Among these, skeletal muscle wasting is a critical consequence of inactivity and around 20% of COPD patients suffer from severe skeletal muscle wasting, which leads to considerable morbidity and mortality [ 61 ]. Skeletal muscle wasting can initiate a “downward disease spiral”, where muscle weakness and inefficient metabolism at low exercise intensity further decrease exercise capacity [ 64 ].

Osteoporosis

Osteoporosis is one of the most prevalent comorbidities in COPD, especially the severe airflow obstruction had the greatest risk of osteoporosis [ 65 , 66 ]. Smoking is a common risk factor for both COPD and osteoporosis. Long-term smoking can result in reduction of bone density [ 67 ], degeneration of bone microstructure, and increased bone fragility [ 66 ]. Inactivity is another main risk factor osteoporosis in COPD. Due to respiratory failure and shortness of breath after activity in patients with COPD, reduced physical exercise ability becomes an important cause of bone mass loss [ 68 ]. Other factors, such as low body composition measures, pulmonary dysfunction, and inflammation, are associated with osteoporosis and COPD [ 69 , 70 ]. Effective treatments with COPD-associated osteoporosis are unknown, and a specific treatment guideline is needed for better management of these patients [ 71 ].

Depression and anxiety

Patients with COPD are commonly experienced mental health conditions, such as depression and anxiety, more than the general population [ 72 , 73 ]. Depression and anxiety have a significant negative impact on COPD prognosis by reducing physical activity, worsening dyspnea, increasing the frequency of exacerbations, and increase the burden of healthcare services [ 74 ]. Depression and anxiety also further interfere with other risk factors such as smoking and worsen patients’ quality of life [ 75 ]. In particular, anxiety is linked to poor quality of life regarding mental and physical health outcomes in COPD patients [ 76 ]. Routine assessment for depression and anxiety are crucial and should become a standard practice in managing COPD [ 77 ]. Early detection and comprehensive treatment of depression and anxiety in COPD patients are essential for improving their overall quality of life and health outcomes.

Gastro-oesophageal reflux disease (GERD)

GERD is another commonly observed comorbidity in patients with COPD and can significantly impact the disease’s progression and management [ 78 ]. Smoking is a known risk factor for GERD in general population [ 79 ] and COPD [ 80 ]. GERD is associated with an increase frequency of COPD exacerbations [ 81 ]. The reflux of stomach contents can irritate the airways and lungs, and further worsen respiratory symptoms such as coughing and shortness of breath and diminishing the quality of life for COPD patients [ 80 ]. Modification of lifestyle, including dietary changes [ 82 ], weight management, smoking cessation and appropriate medications to reduce stomach acid production can alleviate GERD symptoms [ 78 , 83 ], improving quality of life in COPD patients.

Lung cancer

Individuals with COPD have a four-to-six-fold higher risk of developing lung cancer compared with the general population [ 84 ]. COPD and lung cancer share the same risk factors, such as exposure to tobacco smoke and indoor/outdoor air pollution [ 85 , 86 ]. COPD and lung cancer often have overlapping symptoms, such as chronic cough, shortness of breath and chest discomfort. This can make it challenging to differentiate between the two conditions based on symptoms alone. Along with inflammation, epithelial to mesenchymal transition have been reported in people who smoke and patients with COPD, which may be one of the shared mechanisms leading to lung cancer in these patients [ 87 , 88 , 89 , 90 , 91 ]. High dose inhaled corticosteroids ameliorate epithelial to mesenchymal transition and improve vascular changes [ 92 , 93 ]. Inhaled corticosteroids have been shown to reduce risk of lung cancer [ 94 , 95 , 96 ]. However, effects of inhaled corticosteroids against lung cancer in COPD remains controversial [ 97 , 98 ].

Second-hand smoke and COPD

Exposure to second-hand smoke is a significant risk factor for the onset and progression of COPD. Exposure to second-hand smoke in both childhood and adulthood have been linked to an increased risk for COPD-related mortality [ 99 ]. Inhalation of second-hand smoke can adversely affect the respiratory system, particularly for individuals already affected by asthma, infections, or allergies. Prolonged exposure to second-hand smoke can cause airway inflammation, broncho-constriction, airway obstruction and lung tissue damage, increase the likelihood of developing COPD, worsen existing COPD symptoms and accelerate lung function decline [ 100 , 101 ]. Second-hand smoke also increases the risk of developing lung cancer. Tobacco smoke exposure in utero may lead to preterm birth and increase the risk of respiratory diseases such as asthma and COPD in the offspring.

Smokeless tobacco and COPD

There is no direct evidence to date that smokeless tobacco (such as chewing tobacco or snuff) can lead to the development of COPD. Although smokeless tobacco does not involve inhaling smoke into the lungs, it still exposes users to high level of nicotine and harmful chemicals and toxins that can cause oropharyngeal cancer, which could affect the lungs [ 102 ]. The use of smokeless tobacco can lead to chronic irritation and inflammation in the airways [ 103 ], contributing to the development of respiratory conditions such as large airway inflammation or bronchitis. We have defined different tobacco products in Table  1 .

New and emerging nicotine-delivery systems and other tobacco products and COPD

Electronic nicotine delivery systems (ends).

Serious health concerns regarding the use of electronic cigarettes (e-cigarettes) have been raised, particularly related to their use by adolescents and young adults [ 104 , 105 ]. Early studies have shown a correlation between the use of e-cigarettes and lung injury [ 12 , 106 ], with e-cigarette users showing increased respiratory symptoms, an elevated risk of developing airway disease and a decline in lung function [ 107 ]. However, to date, there is no direct evidence that use of electronic smoking devices leads to the development of COPD. However, based on the literature review, it is postulated that use of e-cigarettes could lead to lung health issues and be a risk factor for development of COPD among those who have never smoked. Osei et al. reported that current e-cigarette users have a 75% higher risk of developing COPD compared with those who have never used e-cigarettes [ 108 ]. Daily e-cigarette users and former tobacco cigarette users who currently use e-cigarettes are at a higher risk of developing COPD compared with individuals who have never smoked conventional cigarettes or never used e-cigarettes [ 109 ]. In addition, individuals who smoke conventional cigarettes and use e-cigarettes (“dual use”) showed the highest likelihood of developing COPD compared with those who have never smoked conventional cigarettes or used e-cigarettes [ 108 , 110 , 111 , 112 ]. These findings suggested that the use of e-cigarettes may potentially promote pathophysiological processes similar to those seen in COPD. Hence e-cigarettes should not be promoted as a tool for smoking cessation [ 110 , 111 ]. Additional research is needed to examine the long-term risk of developing COPD among users of e-cigarette products, considering the heterogenous composition of e-cigarette products.

Heated tobacco products

Heated tobacco products (HTPs) emit toxic chemicals, including nicotine, when tobacco is heated or when a device containing tobacco is heated, and these are inhaled by the user. The tobacco industry markets these products as a “less harmful alternative” to conventional cigarettes [ 113 , 114 ]. Currently, the existing evidence is insufficient to support the reduced exposure claims for HTPs, and existing evidence is also insufficient to support either the reduced risk or reduced harm claims for HTPs [ 115 ]. HTPs have recently gained popularity and are available in about 70 countries [ 114 ]. Research studies have shown that exposure to HTP emissions can be just as harmful to human lung cells as exposure to smoke from conventional cigarettes. It can cause a persistent allergic response, smoke- or environmental-triggered inflammation that leads to airway scarring, which are the principal causes of airflow limitation in COPD [ 116 , 117 ]. There was a high prevalence of dual use of HTPs with conventional cigarettes among COPD patients (up to 33%), which did not reduce the harm for these patients [ 118 ] or the prevalence of smoking-related chronic diseases [ 119 ].

Impact of selected tobacco control interventions on COPD

There is no safe way to use tobacco. Tobacco control plays an important role in public health and chronic disease management. People should be supported to stop using tobacco in all forms, including e-cigarettes and HTPs. Smoking cessation has a great impact on reducing the health risks associated with smoking. It is a crucial intervention for all people who smoke and have COPD, as it can slow the decline in lung function and the progression of COPD [ 3 ], improve respiratory symptoms and reduce mortality in patients with COPD compared with those who continue to smoke [ 120 ]. Smoking cessation also benefits COPD patients who have nocturnal sleep disorders [ 121 ]. Health-care professionals should increase patients’ awareness of the hazards of smoking and provide smoking cessation advice to enhance their self-efficacy in quitting [ 122 , 123 ]. The WHO urges governments to include smoking cessation and treatment services as part of tobacco control programmes [ 124 ], also recommended in the United States Surgeon General’s 2020 report on smoking cessation [ 125 ].

Population-level interventions to address tobacco use

Population-level interventions to combat tobacco-linked COPD morbidity and mortality are essential. WHO has well-established tools for implementing tobacco control measures. To support countries in implementing the WHO Framework Convention on Tobacco Control (FCTC), WHO introduced the MPOWER package in 2008 and reported on progress in a biennial report on the global tobacco epidemic [ 123 ]. MPOWER contained a set of six tobacco control demand reduction measures corresponding to one or more articles in the WHO FCTC. These are, (1) Monitoring tobacco use and prevention policies; (2) Protecting people from tobacco smoke; (3) Offering help to quit tobacco use; (4) Warning about the dangers of tobacco; (5) Enforcing bans on tobacco advertising, promotion, and sponsorship; (6) Raising taxes on tobacco (MPOWER). The WHO Package of Essential Noncommunicable (PEN) Disease Interventions for primary health care includes a module on the management of COPD. PEN emphasizes the need to inform people with COPD about the risks of smoking and indoor air pollution and the need to stop smoking [ 122 ]. The updated “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases were adopted by the 76th World Health Assembly in 2023. These include six cost-effective interventions to reduce tobacco exposure and two on the management of COPD. The WHO recommends the following population-level and pharmacological interventions to ensure access to comprehensive cessation support (Table  2 ).

Emerging concerns and future directions

The primary strategy to reduce the burden of COPD is to address all risk factors, especially exposure to all forms of tobacco smoke throughout life, to promote respiratory health and overall well-being [ 126 ]. Lungs have not evolved to safely inhale tobacco smoke. Bold action is required by individuals, health practitioners and policymakers to create a tobacco-free world. In particular, the Tobacco Endgame targets to have a generation free of tobacco by 2030, banning sales in those born from 2012 and later [ 127 ]. Although smoking rates have fallen globally but still smoking is likely to remain a leading cause of preventable death throughout this century unless smoking cessation efforts can significantly and rapidly reduce the number of people who smoke, particularly in the developing countries [ 128 ]. The risk of developing COPD is present throughout life, and exposure to risk factors can be particularly harmful during lung growth and development (in utero, in childhood and in adolescence). Tobacco use among children, adolescents and young people is of particular concern. It is important to note in this context that worldwide, at least 37 million young people aged 13–15 years (9.7%) use some form of tobacco product [ 129 ]. In fact, it is now well known, that COPD may start in childhood, when genetic and environmental factors may lead to reduced lung growth; and repeated insults/exposures may add to the negative effects [ 130 ]. These vulnerable groups are being actively targeted by the tobacco industry with campaigns promoting nicotine and tobacco products, including e-cigarettes, HTPs and nicotine pouches. The emergence of a tobacco epidemic among populations already vulnerable to COPD through adverse early life events and exposure to indoor and outdoor air pollution is catastrophic for already overstretched health systems, which are ill-equipped to manage chronic conditions. Protecting these groups from the dangers of tobacco use through effective tobacco control legislation, including total product ban, it is not just a matter of public health, but also an ethical obligation. It is also crucial to expose the tobacco industry’s tactics and equip the general public with knowledge and tools to combat the influence of the tobacco industry. Moreover, it is imperative that all tobacco users, particularly those living in low-to-middle income countries, have access to comprehensive cessation support aligned with WHO recommendations. This support should encompass brief advice from healthcare professionals, availability of toll-free quit lines, access to treatment for tobacco dependence, and digital cessation tools. Table  3 summarizes the five key messages from the WHO Tobacco Knowledge Summary [ 131 ] shared with the wider population.

Data availability

No datasets were generated or analysed during the current study.

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WL, RA, RS, SR, SSS conceived, designed the structure of the article, revised, and edited. WL wrote the first draft, made figures, and made revisions. KS, JH, EL, ET, NM, JBS, WB, DMGH, MPR, KMF, HK, AY, MG and DCLL reviewed and edited the manuscript. All authors read and approved the final manuscript.

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Lu, W., Aarsand, R., Schotte, K. et al. Tobacco and COPD: presenting the World Health Organization (WHO) Tobacco Knowledge Summary. Respir Res 25 , 338 (2024). https://doi.org/10.1186/s12931-024-02961-5

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Associations of tobacco and alcohol use with sexual behaviors among adolescents in 59 countries: a population-based study

Affiliations.

• 1 Department of Preventive Medicine, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China.
• 2 Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Medical University, No.1 Xincheng Road, Dongguan, 523808, Guangdong, China.
• 3 Clinical Research Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
• 4 Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Medical University, No.1 Xincheng Road, Dongguan, 523808, Guangdong, China. [email protected].
• PMID: 39261836
• DOI: 10.1186/s12889-024-19939-z

Background: Sexual behaviors, particularly risky sexual behavior, has become a serious public health concern among adolescents worldwide, presenting a substantial obstacle to the prevention of sexually transmitted infections, including human immunodeficiency virus (HIV). However, there is limited research using consistent and standardized methodology to examine associations between tobacco and alcohol use frequency and both total and risky sexual behaviors among adolescents. We aimed to examine the association between tobacco and/or alcohol use with both total and risky sexual behaviors among adolescents worldwide.

Methods: Data were collected from the Global School-based Student Health Survey, which comprised 211,847 adolescents aged 12-17 years from 59 countries. The frequency of tobacco or alcohol use during the past 30 days was categorized as 0, 1-2, 3-5, 6-9, or ≥ 10 days. Tobacco and alcohol use were also categorized as non-use, tobacco use alone, alcohol use alone, and combined use. Multi-variable logistic regression analysis was used to examine both the independent and combined associations of tobacco and alcohol use with total and risky sexual behaviors.

Results: Compared with no tobacco use, the odds ratio of engaging in sexual intercourse increased with the frequency of tobacco use from 1 to 2 days to ≥ 10 days (total: 2.03 [95% confidence interval 1.47-2.81] to 3.98[2.63-6.03]; risky: 2.43[1.75-3.38] to 4.21[3.26-5.42]), as well as with the frequency of alcohol use. Overall, combined users had greater likelihood of both total and risky sexual behaviors than tobacco users alone, alcohol users alone, and non-users. Similarly, the association between risky sexual behaviors and tobacco use alone was more pronounced among adolescent girls (vs. adolescent boys), as were those of risky sexual behaviors with alcohol use alone among younger adolescents aged 12-14 years (vs. aged 15-17 years) and with tobacco and/or alcohol use among adolescents in the Western Pacific region (vs. Regions of Africa and Americas).

Conclusions: Our findings suggest independent and combined associations between tobacco and/or alcohol use with sexual behaviors among adolescents, with variations across age, sex, and WHO region.

Keywords: Adolescents; Alcohol use; Sexual behaviors; Tobacco use.

© 2024. The Author(s).

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• Jing Z, Li J, Wang Y, Zhou C. Prevalence and trends of sexual behaviors among young adolescents aged 12 years to 15 years in Low and Middle-Income countries: Population-based study. JMIR Public Health Surveillance. 2023;9:e45236. - DOI - PubMed - PMC
• Smith L, Jackson SE, Vancampfort D, Jacob L, Firth J, Grabovac I, McDermott D, Yang L, Lopez-Sanchez GF, Niederkrotenthaler T, Veronese N, Koyanagi A. Sexual behavior and suicide attempts among adolescents aged 12–15 years from 38 countries: a global perspective. Psych Res. 2020;287:112564.
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• Buve A, Bishikwabo-Nsarhaza K, Mutangadura G. The spread and effect of HIV-1 infection in sub-Saharan Africa. Lancet. 2002;359:2011–17.
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