Estimating the Short-term Clinical and Economic Benefits of Smoking Cessation: Do We Have it Right?

Joseph Menzin; Lisa M Lines; Jeno Marton

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(3):257-264. 

In This Article

Short-term Clinical Outcomes of Smoking Cessation

Smoking cessation is beneficial in primary prevention of disease (prevention before health problems occur), secondary prevention (prevention after diagnosis but before damage) and tertiary prevention (prevention after damage from disease), although most of the evidence of benefit comes from studies of smoking cessation as a secondary or tertiary intervention. Examples of each of these types of benefits are given in the sections that follow.

According to recent data from the Nurses' Health Study, the risk of mortality from all causes, vascular diseases, lung cancer or any smoking-related cancer is lower among female former smokers than among female continuing smokers within 5 years of quitting. Mortality risk from respiratory disease and other causes is higher among former smokers than continuing smokers for the first 5 years after quitting but decreases below the risk for continuing smokers by 10 years following quitting.[13]

Smoking is an important risk factor for cardiovascular disease. Many cardiovascular effects of smoking are moderated by mechanisms that respond in the short term. Within days of complete smoking cessation, improvements can be seen in coronary vasoconstriction, adverse changes to lipoprotein profiles, oxidative modification of lipoproteins, endothelial damage, activation of leukocytes and prothrombic effects.[14] Quitters also have a lower risk of death from acute myocardial infarction (AMI) than current smokers do, which the Surgeon General suggests may be related to decreased blood coagulability, increased tissue oxygenation and lower predisposition for cardiac arrhythmias after smoking cessation.[67]

While the cost to produce one successful quitter has been estimated to be approximately US$1000-1500, these costs are quickly recouped through reductions in AMI and stroke alone.[15] In a study analyzing incident coronary heart disease (CHD), nearly a third of the excess risk of CHD was eliminated within 2 years of quitting. Quitters' total risk of CHD approximates the risk of never smokers by 10-15 years following quitting.[16] Among men at high risk for CHD who quit within the past year, the adjusted relative risk of mortality from CHD for quitters compared with continuing smokers is 0.58 (95% confidence interval [CI]: 0.40-0.84). For men who quit 3 years previously, the adjusted relative risk (RR) of CHD mortality compared with continuing smokers is 0.35 (95% CI: 0.20-0.63).[17] Within 5 years of smoking cessation, quitters' relative risk for stroke is similar to that of never smokers.[18] However, hospitalized heart disease patients followed for 1 year did not have a significant reduction in the adjusted odds of a secondary cardiovascular disease event among quitters compared with continuing smokers.[19]

Smoking cessation has been shown to be as effective as other secondary preventive therapies, such as statins (for cholesterol control), aspirin, β-blockers and angiotensin-converting enzyme inhibitors, in reducing CHD-related mortality.[20] Smoking cessation has a comparable effect to the leading drug treatment in reducing morbidity and mortality in patients with left ventricular dysfunction.[21] In addition, quitters have a lower risk of hospitalizations related to myocardial infarction and stroke shortly after quitting smoking.[20]

In multiple studies, cigarette smoking has been shown to increase the risk of developing diabetes mellitus in a dose-dependent manner, even after controlling for confounding variables, such as age, diet, weight and activity levels. This increased risk is reduced to the level of never smokers within 5-10 years after quitting for women and after 10 years or more for men.[22] This may, in turn, reduce the risk of a host of diabetes-related complications.

The risk of mortality from any cancer is lower for quitters than for current smokers within 5 years after quitting.[13] In addition, the risk of cervical cancer begins to decline in the first few years of successful smoking cessation. Former smokers have a lower adjusted RR for cervical cancer than current smokers (1.3 vs 1.5), but the risk is dependent on time since quitting. People who quit within 2-4 years have a negligible adjusted RR compared with never smokers (1.1).[23] Smoking cessation does not have an observable effect on the mortality rate from lung cancer.[17]

Chronic obstructive pulmonary disease (COPD) is the umbrella term for emphysema and chronic bronchitis. Most COPD patients are current or former smokers; 40-73% of COPD mortality is related to smoking, and approximately half of all smokers will develop COPD.[24] Among patients with COPD, lung function improves within a year after quitting, and the annual rate of decline in lung function over 4 years, as measured by forced expiratory volume in 1 s (FEV1), is half the decline seen among continued smokers.[25]

Approximately a third of surgical patients are smokers.[26] Smoking increases the risk of pulmonary, circulatory and infectious complications and impairs wound healing. Smokers have a higher rate of postoperative admission to the intensive-care unit than nonsmokers.[26,27,28] The largest improvements among former smokers are seen in wound healing, although cardiovascular complications are also reduced. Recent quitters spend less time in the hospital and far less time in the intensive-care unit. Smoking cessation as few as 6 weeks before surgery can more than halve postoperative complications.[26] Short-term preoperative smoking cessation decreases perioperative and postoperative complications. The longer the elapsed time between smoking cessation and surgery, the better the outcomes for the surgical patient.[29]

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