National data from 2011 to 2014 indicate that in the first year of implementation, penalized smokers were less likely to be insured and the penalty did not encourage cessation . Charging smokers higher insurance premiums could discourage getting health insurance or lead to concealment of one’s smoking status; either would reduce opportunities for treatment. Tobacco cessation treatments are cost effective. In Massachusetts, for every $1 spent on cessation services for state Medicaid program beneficiaries, more than $3 was saved .The Community Preventive Services Task Force deemed smoke free air policies to have strong evidence for reducing youth initiation of tobacco use, increasing quitting among smokers, reducing exposure to secondhand smoke, reducing tobacco-related morbidity and mortality, and reducing healthcare costs . Furthermore, smoke-free policies do not adversely affect businesses. Smoke-free air policies in the home similarly reduce harmful secondhand smoke exposure, increase quit attempts and abstinence, and decrease cigarette consumption in adult smokers . A U.S. study found that statewide smoking bans in restaurants and bars were associated with reduced smoking among those with psychiatric conditions . Psychiatric facilities are increasingly adopting smoking bans, although still not mandated nationally.Given that few people start smoking after age 20 and that brain development continues through the mid-20s, with early drug exposure predictive of greater likelihood of chronic, addictive use,pollen trim tray legislation has sought to raise the minimum tobacco sales age to 21 . The Institute of Medicine concluded, based on simulation models, that Tobacco 21 laws would reduce smoking and related mortality .
Lacking a federal Tobacco 21 law, states and local jurisdictions have passed legislation, with regional differences in coverage. As of January 2019, most U.S. residents aged 18 to 20 were not covered by a Tobacco 21 policy, with the largest gaps in coverage in the South . As of 1 June 2019, 14 states and >400 local jurisdictions have passed Tobacco 21 legislation; 16 of the non-adopting states preempt lower levels of government from implementing these regulations. Analyzing national data, a recent study found that Tobacco 21 policies were associated with a significant absolute 3% reduction in the prevalence of smoking among 18 to 20 year olds . Surveys indicate that two-thirds to three quarters of U.S. adults are in favor of raising the minimum age of tobacco sales to 21 .Tobacco products are readily accessible for open sale in retail outlets throughout the United States and globally. In the United States, there are an estimated 375,000 tobacco retailers ; this equates to 27 tobacco retail locations for every McDonald’s restaurant. The tobacco retail environment contributes to tobacco-related disparities. Tobacco retailers concentrate disproportionately in disadvantaged areas . Even after adjusting for the density of retailers, cigarettes and little cigars/cigarillos cost less in these areas. The same is true for areas with a higher proportion of African American residents . In its blueprint to end the U.S. tobacco epidemic, the Institute of Medicine recommended that governments develop, implement, and evaluate legal mechanisms for restructuring retail tobacco sales and restricting the number of tobacco outlets . In response, there has been a rapid rise in planning and implementation of retail interventions by states and communities . For example, at least two states and >200 localities restrict the sale of flavored tobacco ; dozens have set a minimum price and pack size for little cigars/cigarillos, and at least three prohibit price discounts and coupon redemption .
By restricting the sales and distribution of tobacco, the long term goal of these interventions is to reduce tobacco use and inequities in the retail environment. With a focus on youth, a global study of bans on tobacco point-of-sale ads in retail environments reported lower odds of ever smoking, lower smoking prevalence, and less daily smoking . A growing evidence base is informing best practices for state and local programs aimed at countering tobacco industry influence at the point of sale.Tobacco use remains the leading preventable cause of death in the United States and worldwide. While important public health gains have been achieved in reducing the prevalence of cigarette smoking, because of population growth and diversification of product, the absolute number of tobacco users in the United States has stayed relatively constant over the last 50 years, at about 40 million. Furthermore, dual use of tobacco products is on the rise , and declines in smoking have not been equitable for all groups. Disproportionately affected by tobacco-related morbidity and mortality are people of certain racial/ethnic groups , individuals of lower income and lower education, and people with mental illness and substance use disorders. Among adolescents, cigarette smoking has declined to under 10%; however, the use of e-cigarettes has increased markedly, with 27.5% of high school students reporting past 30-day use. Today, more young people in the United States are exposing their brains to nicotine than in recent years. Although free of the toxins from combustion, e-cigarettes typically still contain nicotine, the main psychoactive and addictive component in tobacco. Our review covered evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product use in youth. The smoking cessation treatments with evidence in adults include seven FDA-approved cessation medications , individual and group counseling, quitlines and other mobile technologies, and monetary incentives.
At the population level, mass media education campaigns, product regulations, health insurance coverage of cessation treatments, and enactment of tobacco control policies are promising interventions. Most efficacious are combinations of medication and behavioral treatments leveraged in an environment with strong tobacco control policies. Notably absent are evidence-based treatments for stopping e-cigarette use, particularly in adolescents, an area of public health interest. The changing marketplace and the challenges of treating addiction necessitate the sustained efforts of clinical providers, policymakers, and researchers. Investment in comprehensive tobacco cessation treatment at the state and federal levels and continued research in the development of novel behavioral and medication treatments, diagnostics for personalized medicine, technological innovations for broader reach, and evidence-based policies are warranted. Here, we briefly highlight some areas for further investigation.The potential harms to health from various harm reduction products could not be extensively discussed here, but assessment of harm is a critical component of a reasoned benefit versus risk analysis. On the basis of current evidence, it is believed that e-cigarettes and heated tobacco will be very much less harmful than cigarette smoking, but how much less harmful is unknown. Heated tobacco products have been successfully marketed in Japan where 4.7% of the population used the products in 2017,grow tent although 72% of heated tobacco users also continued to smoke cigarettes . The prevalence of cigarette smoking has declined substantially in recent years in Japan, and although speculated that heated tobacco use is responsible for that decline, this is unproven. Heated tobacco products are marketed in many other countries and are approved for use in the United States, but so far, uptake has been limited. As yet, there are no data on abuse liability and no trials of heated tobacco for combustible cigarette cessation, and we are unaware of any data on youth uptake of IQOS. Considerable national and international debate has also occurred regarding the use of smokeless tobacco for harm reduction . While the use of some forms of smokeless tobacco is associated with oral, esophageal, and pancreatic cancer and other adverse health effects, low nitrosamine smokeless tobacco is associated with much lower risk . In Sweden, snus is manufactured and marketed under strict quality standards, resulting in low levels of nitrosamines . In Sweden, 20% of men and 8% of women use snus, while the smoking prevalence is lower than in other countries. The incidence and mortality from smoking related diseases is significantly lower in Sweden than in other European countries . Epidemiologic studies indicate that the health risks of Swedish snus use are low, including a small, if any, increase in cancer and cardiovascular disease risk and no increased risk of lung disease. On the basis of these observations, some public health experts advocate that smokeless tobacco be encouraged as an alter native to cigarette smoking.In Sweden, there is a long tradition of smokeless tobacco use, and most men use snus without a transition to cigarette smoking.
However, in the United States, where smokeless tobacco use is much less widely accepted, there is concern that smokeless tobacco use is a gateway to smoking among youth . There is also concern that smokeless tobacco could reduce smoking cessation in dual users, because smokeless tobacco could be used in circumstances where smoking is prohibited. Controlled clinical trials of smokeless tobacco as an approach to aid smoking cessation or in switching from cigarettes to smokeless tobacco have shown modest benefits, similar to NRT . Further mechanistic and epidemiologic studies are needed to help inform harm reduction public policy. In addition, likely an area of research development and interest in the very near future are study of cessation treatments for those users who want to quit their e-cigarette, heated tobacco, or snus use. Given the mechanism of nicotine addiction, it would seem reasonable that medications helpful in quitting smoking would prove efficacious; however, no randomized controlled trial to address these questions has been conducted to date.As mentioned at the start, dual use of tobacco products is on the rise , and rates of dual use are threefold greater for high school students than adults , with smoking cigarettes and vaping e-cigarettes the most common combination. Analysis of survey data from the United States, United Kingdom, Canada, and Australia concluded that adults who smoke cigarettes and e-cigarettes concurrently should be considered a distinct group given higher levels of nicotine dependence and generally more pro-attitudes toward both smoking and vaping . Dual use may represent greater dependence and compulsion to dose nicotine in settings where smoking is prohibited or may reflect motivation to quit combustible cigarettes . In a nationally representative study, interest in quitting and attempts to quit were comparable among dual tobacco–using adults and cigarette-only users . The re search on dual tobacco use is still nascent. Greater and more detailed study is needed to understand use patterns of two or more tobacco products; the implication of different types of combinations; and the relationship of dual use to addiction, biomarkers of harm, and success with quitting.Treatment studies of cannabis use disorder in adults suggest that about half of participants also currently smoke tobacco. Among adolescents and adults , persistent tobacco use is associated with poorer treatment outcomes for cannabis use disorders, and individuals who use both cannabis and tobacco in combi nation have higher rates of psychiatric and psychosocial problems as compared to individuals who smoke cannabis only . Blunt smoking is associated with greater difficulty controlling cannabis use and high levels of toxicant exposures , as compared to joint smoking. Despite decades of research on cannabis and tobacco use separately, there is little treatment research addressing the co-use of cannabis and tobacco. In addition, although currently the co-use of cannabis and nicotine by vaping is relatively rare and primarily occurs among established tobacco or cannabis users, given the growth in popularity of both cannabis and nicotine vaping, it is likely to increase and expand to tobacco/ cannabis naïve individuals. Study of the behavioral co-use patterns and pharmacologic effects, with an understanding of addiction potential and quantified toxicant exposures, and the potential for pulmonary injury is needed. There is a high concordance of tobacco use with virtually all other drugs of abuse, including cannabis, alcohol, opiates, and stimulants. Neurobiology research has found interacting neural circuits between nicotine and other abused substances. Such research may lead to discovery of medications that simultaneously treat multiple drugs of abuse. Likewise, studies of the genetics of addiction to nicotine and other substances of abuse, as well as genetic signals of concor dance of nicotine addiction with other addictions and mental illnesses, may lead to the discovery of similar therapeutic targets.Smoking cessation treatment has been particularly challenging in some populations, including among people with mental illness, those with other substance use disorders, adolescents, pregnant smokers, and light and nondaily smokers. In addition, cessation success varies by race and ethnicity, as seen with lower quit rates in African American and American Indian/Alaska Native smokers.