CONSUMPTION

Industrial production of cigarettes exploded after the second world war, to reach by now about 95% of all consumed tobacco products. In France, cigarette sales reached their peak in 1991.
From 1991 to 1997, tobacco sales among the adult population of 15+ declined by 11%. In the most recent period, however, the decline has seemed to plateau, with even a slight increase (+1% on one year) observed.
Women's consumption is progressively matching men's consumption, and in  younger people, women's consumption   now exceeds  men's .
The smoking rate in the French population has stabilised around 34% (42% in men, among whom consumption is slightly declining, and 31% in women, a percentage still increasing).
Three phenomena  can  be observed:
1) A still high proportion, even if in slightly reducing , of young smokers, with a steep increase starting at age 15 , the average starting age being 14.
2) A still high proportion of smoking pregnant women (15% in 1981, raised to 25% in 1995).
3) A smoking rate among physicians close to that observed in the general population.

Recommendations:
1) The best way to reduce the number of smokers in the population being to avoid   people ever starting to smoke,  special attention should be directed towards actions (education, taxes, regulation) that aim at the reduction of tobacco smoking in youth.
2) It is important to reinforce our capacity to describe the different profiles of tobacco consumption in the population through large epidemiological and sociological studies.
 

IMPACT ON HEALTH

Impact on health is considerable. In France, tobacco causes 60,000 premature deaths each year, one out of 9 deaths. Half of regular smokers who started smoking during adolescence will die from tobacco smoking. Among these smokers, 50% will die before the age of 69.
Because tobacco smoking was primarily a male fashion, deleterious effects of tobacco smoking are predominant in men. An estimated 56,000 deaths are presently observed in men, while more than 3,000 are observed in women. The mortality is higher in the age range 45-64, representing around 30% of male deaths (4% of female deaths). The effects on morbidity are not only considerable in terms of reduction of life expectancy, but also in terms of disability, suffering, dependency and loss in quality of life. In pregnant women, tobacco smoking  affects the foetus, the new-born, the infant and the child. The impact of tobacco smoking on health is observable at both the middle- and long-term.

Taking into account   tobacco consumption during the last decades, particularly in women, the peak of the epidemic of tobacco-related diseases is still to come : in 2025, it is estimated that more than 165,000 premature deaths   will be directly attributable to tobacco each year, with a two-fold increase in men and a ten-fold increase in women.
The impact of tobacco consumption is mainly related to the duration of daily smoking. Thus, for lung cancer, the most studied, a two-fold increase in consumption   leads to a two-fold increase in cancer risk, but a two-fold increase in duration of smoking  leads to a twenty-fold increase in cancer risk. In regard of this observation, the main goal should be smoking cessation and long-term abstinence.

BENEFITS OF SMOKING CESSATION

Smoking cessation reduces the mortality and morbidity of all tobacco-related diseases, particularly for cardiovascular diseases and lung cancer.
The younger people quit smoking  , the greater the tobacco-related risk reduction. However, it is never too late to stop smoking.
Smoking cessation before 44 leads to a progressive risk reduction of premature death towards the non-smoker  level for cardiovascular diseases and lung cancer. If smoking cessation is beneficial for the individual, it is also beneficial for his/her family. Studies on passive smoking (involuntary inhalation by a non-smoker of tobacco smoke due to one or more surrounding smokers) have shown that :
- A child exposed to passive smoking has a 60% increase in risk of respiratory airways infection;
- Lung cancer risk is increased by about 25%, and is proportional to the duration of passive exposure;
- Risk for ischaemic events is increased by30% in non-smokers living with smokers.

Recommendations:
Smoking cessation must happen as soon as possible in life. Long term abstinence must be the goal. However, independently of the age of the smoker,   stopping smoking  always leads  to measurable health benefits.
 

OPINIONS AND EXPERIENCES OF HEALTH PROFESSIONALS ON SMOKING CESSATION

The physician and the smoking patients : missed opportunities. One third of the population is smoking, and one smoker out of three has tried to quit smoking during the past year, without support in many case. If physicians desire to play a role in the smoking cessation attempts of their patients, less than one out of two declare having seen a patient for that purpose during the last week.

Why these differences between intentions and facts ? Proffered reasons are : lack of time, patients' resistance to talk about their smoking status, lack of  education on smoking cessation and the desire to obtain a decent and distinct remuneration for prevention work. Moreover, physicians are still sceptical about their own efficacy on the smoking status of their patients.

The smoking physicians : example and credibility of the professional. More than one third of   physicians are smokers. Their ability to heal their patients is not questionable, but their credibility in terms of smoking cessation is affected. More than their non-smokers counterparts, they are reluctant to ask questions about their patients' smoking status.

Other health professionals. The success of smoking cessation programmes needs the participation of numerous actors. Integration of actors such as dentists, nurses, pharmacists, etc. has been shown in different countries to bring real efficacy in the sensitisation of  smoking patients.

Recommendations:
The 1994 objectives of the High Committee on Public Health (Haut Comité de la Santé Public) concerning the smoking status of  health professionals, is still justified ; however, its application has been delayed. Specific actions should be organised to reduce smoking rate in this population to less than 10%. Health professionals must then gain in efficacy in terms of example for the general population.