Why Won't Our Patients Stop Smoking?

The power of nicotine addiction

Health risks related to tobacco use have been well established for >50 years, with diseases including lung cancer, other malignancies, and cardiovascular diseases linked to smoking and causing early mortality in current and former smokers (1–4). Yet cigarette smoking remains highly prevalent in both the developing and developed worlds (5). Smoking uptake typically occurs in the teenage years, when risk-taking behavior is the norm and peer pressure is a powerful predictor of behavior. The prevalence of chronic diseases, such as hypertension, diabetes, respiratory disease, arthritis, and cardiovascular disease, is low in teenagers and young adults but increases into middle-age and older adulthood (6–9). Conversely, in developed countries like the U.S., smoking prevalence peaks in young adults and decreases as the population ages, because people stop smoking or die (with current smokers dying at a faster rate than former or never smokers) (10). Most of the adult population in the developed world who are current smokers grew up in an environment where the risks of smoking were well established and well known to the public. So why do our adult patients, many of whom have diseases either related to tobacco smoking or complicated by smoking, find it difficult to quit?

This question has been a vexing one to both clinicians and public health practitioners since the adverse affects of smoking became known to us. There are divergent truths. On one hand, in most developed countries, the majority of people who have ever smoked in their lifetime have successfully quit (11). On the other hand, many people with chronic diseases that are clearly worsened by cigarette smoking are unable to quit. So why can some patients quit quickly and easily while other patients smoke right …