Cigarette smoking is a chronic and relapsing addictive trait harmful to public health.
According to statistics from the World Health Organization (WHO 2013), smoking
kills approximately six million people worldwide each year, with more than five
million of those deaths resulting from direct cigarette smoking and more than
600,000 from secondary or passive smoke exposure. The number of smokingrelated deaths is expected to increase to more than eight million annually by 2030 if
the current pattern of smoking continues unabated (Eriksen et al. 2013).
The main deadly effect of smoking is a variety of severe diseases, such as cancers and psychiatric disorders. More than 25% of all cancer deaths can be attributed to smoking, especially those from lung cancer, for which about 80% are caused by tobacco smoking (CDC 2010). Moreover, multiple lines of evidence show that a large amount of the morbidity and premature deaths in schizophrenia patients can be attributed to smoking-related diseases (Brady et al. 1993; Crump et al. 2013). Extremely high healthcare expenditures are associated with smoking-related illnesses worldwide. It is estimated that globally, more than US$500 billion in economic damage is caused annually by tobacco smoking. In the United States, the total of public and private healthcare costs related to tobacco smoking were estimated to be about US$170 billion each year (Ekpu and Brown 2015), and in the United Kingdom, the direct expenditures of the British National Health Service (NHS) attributable to smoking have been estimated at between £2.7 billion and £5.2 billion, about 5% of the total annual NHS budget (Allender et al. 2009; Callum et al. 2011; Ekpu and Brown 2015).
Furthermore, in some developing countries, the economic damage from smoking has substantially increased in the past decade. For
example, in China, about USD 6.2 billion was spent for direct smoking-attributed
healthcare costs and USD 22.7 billion for indirect economic costs in 2008, the direct
and indirect costs were rose by 154% and 376%, respectively, compared with the
costs in 2000 (Yang et al. 2011).
Prevention of smoking initiation and promotion of smoking cessation, coupled
with regulations and legislation, remain to be effective ways to control tobacco use
(Koplan and Eriksen 2015; Yang et al. 2015; Zhu et al. 2012). Although abundant
benefits accrue from smoking cessation, the cessation rate is still low in many countries.
A variety of factors have been proposed as causes of the difficulties of obtaining and maintaining smoking cessation, including psychological, genetic,
pharmacologic, and social factors (Li and Burmeister 2009). One of the most important factors is nicotine dependence (ND), which is the main contributor to the persistence of smoking (Gunby 1988). Growing evidence (Baker et al. 2007; Branstetter
et al. 2015; Branstetter and Muscat 2013; Mercincavage et al. 2013) has shown that
time to the first cigarette of the day, one of the best indicators of ND (Fagerstrom
2003), is associated with the likelihood of smoking relapse and with withdrawal
symptoms, nicotine intake, tobacco-related carcinogen exposure, and cancer risk.
Furthermore, many twin and family studies have shown consistently that the risk of
ND is heritable, with an average heritability of 0.59 in male and 0.46 in female
smokers (see Chap. 3 for details).
In light of the severe impact of smoking on the individual and society, many studies have examined the epidemic pattern of smoking and its associated diseases. To
help control the trend to more smoking, a battery of effective systemic and scientific
measures should be implemented with the hope of assisting in the implementation
of current cessation methods and accommodating the specific conditions of particular countries in order to reduce the demand for tobacco. In the following sections,
we briefly review the prevalence of smoking in the world and summarize the harmful influence of smoking on people’s health.
The Global Prevalence of Smoking
There are about one billion cigarette smokers worldwide (Mackay et al. 2013),
amounting to approximately 30% of men and 7% of women (Gowing et al. 2015).
Smoking rates differ widely between populations across the world (Fig. 1.1). A
series of factors impact the prevalence of smoking and trends in prevalence, such as
individuals’ educational level, national economic development, and tobacco control
policies. In developed countries, such as the United States and the United Kingdom, the prevalence of smoking increased sharply in the earlier twentieth century, partly
as a result of the low prices of cigarettes. The prevalence of smoking has been estimated to have been 37% among men and 25% among women. However, because of
better public awareness of smoking as a hazard and the implementation of stringent
legislation against smoking in the Western European countries and the United
States, smoking prevalence has been greatly reduced. From 1990 to 2009, tobacco
consumption in Western Europe declined by about 26% (Brathwaite et al. 2015). In
the United States, the proportion of smokers declined from 20.9% in 2005 to 15.1%
in 2015 (Jamal 2016).
In contrast, the prevalence of smoking has increased remarkably in low- and
middle-income countries (Benowitz 2008).
During the years 1990 to 2009, tobacco
consumption increased by 57% in Africa and some Middle Eastern countries
(Brathwaite et al. 2015). Throughout the world, more than 80% of smokers now
reside in poor countries, especially in Eastern and Southeastern Asia and Africa
(Stewart 2014). For example, in China, cigarette consumption in 2016 is approximately twofold higher than it was in 1998 (Gilmore et al. 2015). As the largest user
of tobacco worldwide, the smoking rate in China remains high. The nation consumes more than 30% of the world’s cigarettes, and two-thirds of men smoke (Chen
et al. 2015; Li et al. 2011; Yang 2014). In China, many smokers do not fully understand the damaging consequences of smoking, and social conventions have linked
smoking with a positive image (Yang et al. 2015; Zhang et al. 2011), which plays an
important role in preventing smoking cessation.
The prevalence of smoking in men and women differs greatly in different regions
of the world (Gowing et al. 2015).
Globally, smoking prevalence in men is more than four times that in women (West 2017). In developing countries, the prevalence
of smoking in men is much higher than that in women. For example, there was an
estimated prevalence ratio of 22 to 1 for men to women in China (Li et al. 2011). In
Eastern, Southeastern, and Western Asia, the prevalence is estimated to be approximately 40% in men, whereas only approximately 4% of women smoke (West 2017).
One reason for this phenomenon is that female smoking is considered socially unacceptable (Giovino et al. 2012; Jung-Choi et al. 2012). The difference is much less in
most developed countries (West 2017). For example, the prevalence of tobacco
smoking among women in the United States is estimated to be 13.6%, which is
close to the prevalence of 16.7% among men (Jamal 2016). Moreover, the total
number of male smokers in the leading three tobacco-using countries, e.g., China,
India, and Indonesia, accounted for 51.4% of the world’s male smokers in 2015,
whereas the United States, China, and India were the leading three countries in the
total number of female smokers, yet they accounted for only 27.3% of the world’s
female smokers (Ali and Hay 2017), suggesting that the epidemic of smoking is less
geographically concentrated for women than for men.
The Stages of Change
You can't make a change until you are ready to change.
Sometimes, the ''getting ready" takes a long time.
Let's look at this process of changing.
A year after you started smoking, you probably didn't think you needed to quit.
Young smokers often say:
"Cancer and emphysema are a long way off."
"Most of my friends smoke."
"Smoking makes me feel older and more mature."
"My parents smoke and they don't care if I do."
"My parents don't smoke and they don't want me to."
"Smoking is a cheap buzz."
"Who cares?"
Were some of these your reasons for smoking when you were young?
As the years passed and you matured, quitting became more important.
You became more responsible. You didn't have the endurance you once had. Many of your friends quit smoking. Your doctor advised you to quit. And gradually, you began to consider quitting smoking. Consider, yes; quit, no.
You were thinking about it, wondering about it, maybe even asking for information about itbut you weren't ready to quit just yet.
That first stage, where smokers refuse to quit or don't see any need to quit, is called the "Precontemplation Stage."
The second stage, where they think about quitting but aren't quite ready, is called the "Contemplation Stage."
About 40 percent of all smokers are in each of these two stages at any time.
The other 20 percent have decided to quit; they are in the "Preparation Stage."
Which stage are you in today? If you are in the Precontemplation Stage but know you need to quit "some day," Quit and Stay Quit or the first Clean and Free workbook ("Get Ready") can help you make progress.
Few people in Precontemplation will read this far, so you probably aren't in that stage. People in Contemplation are ambivalent; they want to quit, and they don't want to quit. They know they'd be better off if they quit, but they don't feel ready.
They anticipate failing and expect to suffer, so they hesitate. They want to be convinced (sort of), but they also wish people would leave them alone.
Are you in the Contemplation Stage?
If you are barely past Precontemplation, Quit and Stay Quit or the second Clean and Free workbook ("Get Set") will help you make faster progress.
If you are further along than that, the information in the next section, "Getting Ready to Get Ready," will help you move ahead. People in the Preparation Stage have resolved their ambivalence about quitting.
They are ready to quit; they want suggestions and solutions to their problems. They're ready to go. Are you in the Preparation Stage?
If you are, you can find helpful information in Quit and Stay Quit, in the third Clean and Free workbook ("Go"), or in the Countdown to Quit Cards.
Getting Ready to Get Ready People have probably been telling you that you need to quit smoking for some time.
In your life, how many different people have advised you or told you to quit smoking?
Most smokers say "hundreds," and name their relatives and family members, their friends, their co-workers, their doctor, and the surgeon general.
Who are some of the people that come to your mind?
Over the years, each of these people (and many others) have given you their reasons for quitting smoking. These reasons may or may not have also been your reasons.
You might quit for someone else's reasons for a little while, but the chances are good that you would start smoking again if they were not your reasons too.
Why did those people want you to quit smoking?
Were any of these reasons your reasons to quit smoking too?
The problem is that since you have heard these reasons over and over again, you have begun to think that they are your reasons.
Some of them make perfect sense; we call these reasons logical reasonssuch as "To avoid getting lung cancer" or "To save money."
These are excellent reasons to quit smoking, but you have known for years that smoking causes lung cancer and that it costs you money. These logical reasons were not enough to get you to quit smoking, because they were not personal reasons.
You will only be able to quit smoking and recover from your dependence on nicotine and tobacco when you are doing it for your own, very personal reasons. Take a few moments to answer these questions:
1. How would you be better off if you quit smoking?
2. If you quit smoking, you might live an extra ten years; what would you want to do with those years? 3. What sort of impression do you want to make on the people you love?
4.What kind of person are you? 5. What kind of person do you want to become?
5. What would you be able to accomplish as a nonsmoker that you cannot accomplish as a smoker?
6. Would you like yourself better if you could quit smoking?
7. Besides quitting smoking, what other changes do you want to make in your life?
8. Are you willing to ask yourself these questions?
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