Current Cardiovascular Risk Reports

, Volume 4, Issue 6, pp 413–420

Smoking as a Chronic Disease

  • Michael B. Steinberg
  • Amy C. Schmelzer
  • Patrick N. Lin
  • Gadiz Garcia


Despite remaining the leading cause of preventable death in the United States, tobacco smoking does not garner the attention it deserves in the medical and public health communities. Smoking is often referred to merely as a “bad habit” that simply requires adequate willpower to conquer effectively. Fortunately, recent attitudes regarding smoking, as illustrated by the latest US Public Health Service Clinical Practice Guidelines, call for a “chronic disease model” for treating tobacco dependence. This article underscores the importance of viewing smoking as a chronic disease by illustrating the effects on morbidity and mortality, discussing the relapsing nature of addiction, outlining the need for continuum of care for different “severities” of illness, and describing the latest research regarding effective treatment components. Tobacco dependence treatments are safe, effective, and cost-saving, and their use should be encouraged and covered by health insurance analogous to other chronic conditions.


Smoking cessation Tobacco dependence Nicotine replacement Cessation pharmacotherapy Chronic disease model Cardiovascular risk factor 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Fiore MC, Bailey WC, Cohen SJ, et al.: Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service; 2000.Google Scholar
  2. 2.
    Heron MP, Hoyert DL, Murphy SL, et al.: Deaths: Final data for 2006. National vital statistics reports; vol 57 no 14. Hyattsville, MD: National Center for Health Statistics; 2009.Google Scholar
  3. 3.
    US Department of Health and Human Services: The Consequences of Smoking: A Report of the Surgeon General. Washington DC: US 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; 2004.Google Scholar
  4. 4.
    Benowitz NL: The role of nicotine in smoking-related cardiovascular disease. Prev Med 1997, 26:412.PubMedCrossRefGoogle Scholar
  5. 5.
    Chobanian AV, Bakris GL, Black HR, et al.: National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. JAMA 2003, 289:2560–2572.PubMedCrossRefGoogle Scholar
  6. 6.
    Hayward RA, Manning WG, Kaplan SH, et al.: Starting insulin therapy in patients with type 2 diabetes: effectiveness, complications, and resource utilization. JAMA 1997, 278:1663–1669.PubMedCrossRefGoogle Scholar
  7. 7.
    National Heart, Lung, and Blood Institute and Boston University: Framingham Heart Study. Available at Accessed May 7, 2010.
  8. 8.
    National Heart, Lung, and Blood Institute: Healthy People 2010 Gateway. Available at Accessed May 7, 2010.
  9. 9.
    • Steinberg MB, Schmelzer AC, Richardson DL, Foulds J: The case for treating tobacco dependence as a chronic disease. Ann Int Med 2008, 148:554–557. This case study and review demonstrates the benefit of long-term nicotine inhaler use and suggests that tobacco dependence treatment compares favorably to treatment for diabetes across many characteristics. It suggests that tobacco treatments should be reimbursed to the same degree as diabetes.PubMedGoogle Scholar
  10. 10.
    Plans-Rubio P: Cost-effectiveness of cardiovascular prevention programs in Spain. Int J Technol Assess Health Care 1998, 14:320–330.PubMedCrossRefGoogle Scholar
  11. 11.
    Cromwell J, Bartosch WJ, Fiore MC, et al.: Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA 1997, 278:1759–1766.PubMedCrossRefGoogle Scholar
  12. 12.
    Gaspoz JM, Coxson PG, Goldman PA, et al.: Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease. N Engl J Med 2002, 346:1800–1806.PubMedCrossRefGoogle Scholar
  13. 13.
    Franco OH, Peeters A, Looman CW, Bonneux L: Cost effectiveness of statins in coronary heart disease. J Epidemiol Community Health 2005, 59:927–933.PubMedCrossRefGoogle Scholar
  14. 14.
    • Kahn R, Robertson RM, Smith R, Eddy D: The impact of prevention on reducing the burden of cardiovascular disease. Circulation 2008, 118:576–585. This study evaluated various prevention strategies and concludes that smoking cessation is the only strategy that is cost-saving over 30 years.PubMedCrossRefGoogle Scholar
  15. 15.
    •• Fiore MC, Jaén CR, Baker TB, et al.: Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2008. This clinical practice guideline summarizes the available evidence for several aspects of tobacco dependence treatment including pharmacotherapy, behavioral interventions, and follow-up treatment in various settings.Google Scholar
  16. 16.
    Steinberg MB, Nanavati K, Delnevo CD, Abatemarco DJ: Predictors of self-reported discussion of cessation medications by physicians in New Jersey. Addict Behav 2007, 32:3045–3053.PubMedCrossRefGoogle Scholar
  17. 17.
    Linder JA, Rigotti NA, Schneider LI, et al.: An electronic health record-based intervention to improve tobacco treatment in primary care: a cluster-randomized controlled trial. Arch Intern Med 2009, 169:781–787.PubMedCrossRefGoogle Scholar
  18. 18.
    Rigotti NA, Munafo MR, Stead LF: Smoking cessation interventions for hospitalized smokers. Arch Intern Med 2008, 168:1950–1960.PubMedCrossRefGoogle Scholar
  19. 19.
    Koplan KE, Regan S, Goldszer RC, et al.: A computerized aid to support smoking cessation treatment for hospital patients. J Gen Intern Med 2008, 23:1214–1217.PubMedCrossRefGoogle Scholar
  20. 20.
    Thomsen T, Tonnesen H, Moller AM: Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg 2009, 96:451–461.PubMedCrossRefGoogle Scholar
  21. 21.
    The Joint Commission. Screening and Treating Tobacco and Alcohol Use. 2009. Available at Accessed May 8, 2010.
  22. 22.
    Stead LF, Perera R, Bullen C, et al.: Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, 1:CD000146.Google Scholar
  23. 23.
    Foulds J, Hughes J, Hyland A, et al.: Barriers to use of FDA-approved smoking cessation medications: implications for policy action. Society for Research on Nicotine and Tobacco and ATTUD. Available at Accessed May 8, 2010.
  24. 24.
    Murray RP, Bailey WC, Daniels K, et al.: Safety of nicotine polacrilex gum used by 3,094 participants in the Lung Health Study. Chest 1996, 109:438–445.PubMedCrossRefGoogle Scholar
  25. 25.
    • Schnoll RA, Patterson F, Wileyto EP, et al.: Effectiveness of extended-duration transdermal nicotine therapy. Ann Intern Med 2010, 152:144–151. This randomized trial demonstrates the benefit of longer-term use of the nicotine patch beyond the recommended duration found on the package label. This suggests a need to reconsider the utility of the current labeling for cessation pharmacotherapy, as it appears to be in disagreement with evidence-based data.PubMedGoogle Scholar
  26. 26.
    Cummings KM, Hyland A, Giovino GA, et al.: Are smokers adequately informed about the health risks of smoking and medicinal nicotine? Nicotine Tob Res 2004, Suppl 3:S333–340.Google Scholar
  27. 27.
    Hyland A: Perceptions of NRT safety and efficacy: results from the International Tobacco Control (ITC) Four C Country Survey. Presented at Society for Research on Nicotine and Tobacco (SRNT) Preconference Symposium, Increasing Access to Effective Treatments: The Case for More Flexible Regulatory Policy. Austin, TX; February 21, 2007. Available at
  28. 28.
    Benowitz NL: Smoking-induced coronary vasoconstriction: implications for therapeutic use of nicotine. J Am Coll Cardiol 1993, 22:648–649.PubMedCrossRefGoogle Scholar
  29. 29.
    Cooke JP, Bitterman H: Nicotine and angiogenesis: a new paradigm for tobacco-related diseases. Ann Med 2004, 36:33–40.PubMedCrossRefGoogle Scholar
  30. 30.
    Catassi A, Servent D, Paleari L, et al.: Multiple roles of nicotine on cell proliferation and inhibition of apoptosis : implications on lung carcinogenesis. Mutat Res 2008, 659:221–231.PubMedCrossRefGoogle Scholar
  31. 31.
    Brick J: Handbook of the Medical Consequences of Alcohol and Drug Abuse. New York: The Howarth Press; 2008.Google Scholar
  32. 32.
    Joseph H, Stancliff S, Langrod J: Methadone maintenance treatment (MMT): a review of historical and clinical issues. Mt Sinai J Med 2000, 67:347–364.PubMedGoogle Scholar
  33. 33.
    Benowitz NL: Clinical pharmacology of nicotine: implications for understanding, preventing, and treating tobacco addiction. Clin Pharmacol Ther 2008, 83:531–541.PubMedCrossRefGoogle Scholar
  34. 34.
    • Shiffman S, Brockwell SE, Pillitteri JL, Gitchell JG: Use of smoking-cessation treatments in the United States. Am J Prev Med 2008, 34:102–111. This population-level study demonstrated that the majority of smokers who report making a quit attempt do so without any behavioral or pharmacologic support.PubMedCrossRefGoogle Scholar
  35. 35.
    • Smith SS, Mccarthy DE, Japuntich SJ, et al.: Comparative effectiveness of 5 smoking cessation pharmacotherapies in primary care clinics. Arch Intern Med 2009, 169:2148–2155. This randomized trial adds to the data demonstrating the benefit of combination pharmacotherapy for tobacco treatment.PubMedCrossRefGoogle Scholar
  36. 36.
    • Steinberg MB, Greenhaus S, Schmelzer AC, et al.: Triple Combination pharmacotherapy for medically ill smokers. A randomized trial. Ann Intern Med 2009, 150:447–454. This randomized trial is the first to demonstrate the benefit of a three-medication combination for treating tobacco dependence in medically ill smokers.PubMedGoogle Scholar
  37. 37.
    Ebbert JO, Burke MV, Hays JT, Hurt RD: Combination treatment with varenicline and nicotine replacement therapy. Nicotine Tob Res 2009, 11:572–576.PubMedCrossRefGoogle Scholar
  38. 38.
    Ebbert JO, Croghan IT, Sood A, et al.: Varenicline and bupropion sustained release combination therapy for smoking cessation. Nicotine Tob Res 2009, 11:234–239.PubMedCrossRefGoogle Scholar
  39. 39.
    • Apelberg BJ, Onicescu G, Avila-Tang E, Samet JM: Estimating the risks and benefits of nicotine replacement therapy for smoking cessation in the United States. Am J Public Health 2010, 100:341–348. This economic model suggests that increased utilization of nicotine replacement medications would significantly reduce premature deaths over a 20-year period.PubMedCrossRefGoogle Scholar
  40. 40.
    Moore D, Aveyard P, Connock M, et al.: Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ 2009, 338:b1024.PubMedCrossRefGoogle Scholar
  41. 41.
    Rose JE, Herskovic JE, Behm FM, Westman EC: Precessation treatment with nicotine patch significantly increases abstinence rates relative to conventional treatment. Nicotine Tob Res 2009, 11:1067–1075.PubMedCrossRefGoogle Scholar
  42. 42.
    Etter JF, Huguelet P, Perneger TV, Cornuz J: Nicotine gum treatment before smoking cessation: a randomized trial. Arch Intern Med 2009, 169:1028–1034.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Michael B. Steinberg
    • 1
  • Amy C. Schmelzer
    • 1
  • Patrick N. Lin
    • 1
  • Gadiz Garcia
    • 1
  1. 1.Tobacco Dependence Program, Robert Wood Johnson Medical School, Division of General Internal MedicineUniversity of Medicine and Dentistry of New JerseyNew BrunswickUSA

Personalised recommendations