Guidelines for Smoking Cessation (JCS 2010) -

Circulation Journal Vol.76, April 2012

Circulation JournalOfficial Journal of the Japanese Circulation Societyhttp://www.j-circ.or.jp

This document is a minor revision of the Guidelines for Smok-ing Cessation published in 2005 as one of the Guidelines for the Diagnosis and Treatment of Cardiovascular Diseases reported by the Japanese Circulation Society (JCS). During the more than five years since the release by chairman: Hisayoshi Fujiwara, there have been many changes among JCS members in terms of smoking rate, consciousness of smoking, non-smoking policies in hospitals, and establishment of smoking cessation clinics. Moreover, the oral smoking-cessation drug, varenicline, was launched and listed in the National Health Insurance (NHI) price list, and has been widely used in smok-ing cessation clinics. In order to reflect these changes, the guidelines were revised in cooperation with many JCS mem-bers and collaborators. We express our gratitude to all indi-viduals who cooperated in revising the guidelines.

Since the release of the previous guidelines, many academic societies and groups adopted declarations on tobacco control. The guidelines of 2005 listed the full texts of anti-smoking declarations published by all academic societies since only a small number of academic societies had adopted it at that time. However, the present guidelines include the anti-smoking

declaration only by the JCS, since so many societies now declare similarly.

Recently the tobacco prices and tax in Japan were slightly increased. However, the tobacco prices in Japan is still lower than those in other developed countries, and we must continue to encourage the government to “increase the tobacco tax” further. On February 22, 2010, the Tobacco Control Medical-Dental Research Network (chairman: Hisayoshi Fujiwara, http://tobacco-controlresearch-net.jp/), a group of 17 academic societies in Japan, established the 22th day of each month as “the smoking cessation day” to promote nation-wide smoking cessation campaigns (http://www.kinennohi.jp/). The Network has regularly presented petitions for making all lines com-pletely non-smoking to Japan Railroad (JR) companies on the basis of the international clinical study data that the prevention of passive as well as active smoking decreases the prevalence of cardiovascular diseases. In Japan, Kanagawa Prefecture introduced the non-smoking ordinance in public places. A survey is planned to assess whether the prevalence of cardio-vascular diseases changes before and after enforcement of the ordinance.

Introduction to the Revised Guidelines

Released online February 11, 2012Mailing address: Scientific Committee of the Japanese Circulation Society, 8th Floor CUBE OIKE Bldg., 599 Bano-cho, Karasuma

Aneyakoji, Nakagyo-ku, Kyoto 604-8172, Japan. E-mail: [email protected] English language document is a revised digest version of Guidelines for Smoking Cessation reported at the Japanese Circulation Soci-

ety Joint Working Groups performed in 2009. (website: http://www.j-circ.or.jp/guideline/pdf/JCS2010 murohara.d.pdf)Joint Working Groups: The Japanese Society for Oral Health, The Japanese Society of Oral and Maxillofacial Surgeons, The Japanese

Society of Public Health, The Japanese Respiratory Society, The Japan Society of Obstetrics and Gynecology, The Japanese Circulation Society, The Japan Pediatric Society, The Japanese College of Cardiology, The Japan Lung Cancer Society

ISSN-1346-9843 doi: 10.1253/circj.CJ-88-0021All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected]

Guidelines for Smoking Cessation (JCS 2010)– Digest Version –JCS Joint Working Group

Table of Contents Introduction to the Revised Guidelines ············· 1024I Overview ·································································· 1025 1. Introduction and Methodology ································ 1025 2. Simple Smoking Cessation Treatment

(Smoking Cessation Support in the General Practice Setting) ··································································· 1026

3. Intensive Smoking Cessation Treatment················ 1028 4. Active Invovement in the Government’s Anti-Smoking

Measures ································································ 1030 5. Creating Non-Smoking Environment to Promote

Smoking Cessation ················································· 1032II Smoking Cessation Treatment for Various

Subgroups ······························································ 1033 1. Cardiovascular Diseases ········································ 1033 2. Respiratory Diseases ············································· 1035

3. Women ··································································· 1036 4. Children and Adolescents ······································ 1037 5. Dental and Oral Cavity Disorders ··························· 1038 6. Status Before Surgery and Surgical Diseases ······· 1039III Immediate Problems ·········································· 1040 1. Prevention of Underage Smoking and Promotion of

Smoking Cessation ················································· 1040 2. Sufficient Protection of Non-Smokers From Passive

Smoking ·································································· 1040 3. Education on the Harms of Smoking and Widespread

Implementation of Smoking Cessation Treatment ··· 1040 4. Implementation of Social Systems and Policies to

Promote a Smoke-Free Society ····························· 1041References ·································································· 1041

(Circ J 2012; 76: 1024 – 1043)

JCS GUIDELINES


1025JCS Guidelines for Smoking Cessation

We strongly hope that the present guidelines will help pro-mote a non-smoking environment in Japan, where the smok-ing rate is still high.

Introduction to the First EditionThe Guidelines for Smoking Cessation were completed as a result of cooperative activities by nine academic societies since 2003. Although the tentative title was the “Guidelines for Smoking Cessation Instruction”, the title was finally decided as the “Guidelines for Smoking Cessation” to include guid-ance to encourage smokers to stop smoking and prevent indi-viduals from starting smoking. We express our gratitude to all physicians of nine societies participating in the project.

The Guidelines for Smoking Cessation are characterized by the following three features.

The first is that they are Japan’s practice guidelines prepared by nine academic societies directly involved in smoking-related problems, i.e., the Japanese Society for Oral Health, the Japanese Society of Oral and Maxillofacial Surgeons, the Japanese Society of Public Health, the Japanese Respiratory Society, the Japan Society of Obstetrics and Gynecology, the JCS, the Japan Pediatric Society, the Japanese College of Car-diology, and the Japan Lung Cancer Society. The representa-tives of these societies gathered several times and exchanged e-mails to prepare the present guidelines. The success in pre-paring the guidelines through complex processes reflects regret and sense of danger concerning the slow progress in producing a non-smoking environment in Japan.

Smoking adversely affects the health of adult as well as ado-lescent. Smoking also affects the health of surrounding people including infants who are exposed to secondhand smoke and fetus whose mother smoke. Smoking causes cardiovascular diseases, respiratory diseases and oral tissue diseases as well as various troubles in many organs. Accordingly, various aca-demic societies, physicians and dentists should be involved in smoking cessation programs through cross-sectional collabora-tion, and the expertise of the above nine societies is necessary to prepare unified guidelines. Smoking is actually a systemic disease (nicotine dependence and smoking-related diseases), and the present guidelines are prepared for the treatment of patients requiring intensive smoking cessation treatment.

The second is that smoking cessation methods for otherwise healthy smokers and those with various disorders or character-istics are described separately. Methods for otherwise healthy smokers are described in the first chapter, the Overview, which includes the subsections “Introduction and Methodology”, “Simple Smoking Cessation Treatment (Smoking Cessation Support in the General Practice Setting)”, “Intensive Smoking Cessation Treatment”, “Active Involvement in the Govern-ment’s Anti-Smoking Measures” and “Creating Non-Smoking Environment to Promote Smoking Cessation”. In addition to smoking cessation treatment for current smokers, how to ensuring non-smoking environment to prevent people from starting smoking are also described. The second chapter describes in detail smoking cessation methods for patients with cardiovascular diseases, respiratory diseases, women and preg-

nant/lactating women, children and adolescents, patients with dental/oral cavity disorders, preoperative patients and patients with surgical diseases.

The third is that immediate problems are described in the third chapter. In Japan, measures to prevent underage smok-ing, protect non-smokers, and treat smokers are quite insuffi-cient. This chapter describes social systems and political mea-sures to promote a non-smoking environment.

There have been no comprehensive guidelines like these on smoking cessation in Japan. Smoking is the most preventable cause of diseases, and smoking cessation is the most reliable method of significantly decreasing the prevalence of a wide variety of serious diseases. Promoting a non-smoking environ-ment is one of the biggest steps to contribute to good health in the society by helping both smokers and non-smokers main-tain well-being and by enabling the government to decrease healthcare cost significantly. It is time that individual physi-cians and dentists as healthcare specialists begin advocating non-smoking environment in cooperation with academic soci-eties. We hope the present guidelines will help ensure success-ful smoking cessation treatment and protect non-smokers.

Finally, the Smoking Cessation Guideline Committee of the nine academic societies would like to encourage individuals to act to prevent passive smoking. In Japan, rules to prohibit smoking or to limit smoking areas in public spaces such as workplaces, hospitals, schools, department stores, restaurants, movie theaters, and Shinkansen trains have not been fully im-plemented compared to other developed countries. Things have improved rapidly in one or two years, but Japan is still under-developed in terms of the prevention of passive smoking, and smokers can smoke relatively freely. It is difficult to suggest stop smoking to the elders. However, many academic societies in Japan finally started to advocate quitting smoking, and in May 2003, article 25 of the Health Promotion Law stipulating that “it is the right of non-smokers and the responsibility of the administrators to avoid passive smoking in places where many people come” was enforced. On February 27, 2005, the World Health Organization Framework Convention on Tobacco Con-trol (WHO FCTC) was enforced. Tobacco package labeling was changed from “For the good of your health, be careful not to smoke too much”, which was totally useless, to a more direct message “Smoking is a cause of lung cancer” in 2005, but the current message is still problematic and lenient as compared with those in Europe and in the United States.

The Smoking Cessation Guideline Committee of the nine academic societies discussed the social situation in Japan and decided to advocate the prevention of passive smoking in public areas without hesitation. The Committee sent petitions four times for a total smoking ban in Shinkansen trains and other limited express trains to the six JR companies in Japan. Please visit the Tobacco Control Medical-Dental Research Network (consisting of Japanese twelve academic societies) website (http://tobacco-control-research-net.jp/) or the JCS website (http://www.j-circ.or.jp/) for the contents of and JR’s responses to the petitions.

I Overview

1. Introduction and Methodology

Smoking is the most preventable cause of diseases, and smok-

ing cessation is the most reliable method of decreasing the prevalence of diseases. Promoting a non-smoking environ-ment will be the biggest factor to promote the well-being of the society. There is an international movement towards a non-


1026 JCS Joint Working Group

smoking environment. In May 2003, the WHO FCTC was adopted, and the Health Promotion Law was enforced in Japan. There are also social movements to promote non-smoking environment in public places. Hospitals have separated smok-ing areas, and banned smoking in particular or all areas of the hospital. This is the time when physicians, dentists and other healthcare professionals must address the problem of smoking seriously. As healthcare specialists, we should promote a non-smoking environment as a social custom rather than restricting smoking areas.

There are three important steps in preventing or stopping smoking.(1) Many smokers started his/her smoking during adolescence

and established as smokers before adulthood. Prevention of smoking should mainly be targeted to adolescents.

(2) Many smokers want to quit smoking, but a large number of smokers have given up trying to quit smoking. We should develop effective measures to motivate them to try smoking cessation.

(3) After successful smoking cessation, many past smokers start smoking again. It is often difficult for past smokers to quit smoking for the rest of their life. Physicians and den-tists are encouraged to support past smokers to keep quit-ting smoking.

Increasing the tobacco tax, restricting tobacco advertise-ments, and tobacco packaging warning messages are useful in increasing momentum towards a smoke-free society. Remov-ing tobacco vending machines and restricting smoking on the street are also helpful. We also should pay full attention to the media which affect smoking problems significantly. Activities of anti-smoking groups and individuals promoting a non-smoking society through lectures and publications have strong impacts. Smoking cessation support systems using informa-tion technology (IT) are producing good results. Physicians and dentists may lead such movements by providing appropri-ate instructions. Anti-smoking education for school children and students is also important. It is essential to ensure total smoking ban in school buildings and grounds and decrease the smoking rate among teachers.

Recently, several associations of physicians and other health-care professionals such as the Japan Medical Association and the Japanese Nursing Association have adopted declarations on tobacco control. Further expansion and implementation of such activities are expected. The roles of nurses and pharma-cists who closely communicate with patients should be also emphasized. Cooperative measures with nurses and pharma-cists should be considered. It is also expected that to promote individual or small-group treatment of smoking cessation such as instruction in the general practice setting at medical institu-tion or smoking cessation clinics, various type of smoking cessation classes.

Since health is one of the most important factors affecting the life of adults, it is beneficial to emphasize the adverse effects of tobacco on health to motivate them to quit smoking. Special measures are required to motivate adolescents, who often have little concern about their health, to quit smoking for example by relating the adverse effects of tobacco to things attracting young people. Healthcare professionals should be aware of the specific risk of smoking among women as it affects pregnancy and child-bearing.

Healthcare professionals, especially physicians and dentists, are in a position to help patients with smoking-related prob-lems. It is preferable that all physicians and dentists, regardless of their specialty, assess the smoking status of all patients and instruct smoking patients to quit it, regardless of their diseases.

Physicians and dentists are expected to be role models in terms of health, and their attitudes toward smoking greatly affect other people. Of course physicians and dentists should be nonsmokers. Medical and dental students should be educated on smoking in detail, and should be encouraged not to smoke as well. Physicians and dentists in educational institutions are expected to instruct students appropriately.

It is useful to establish guidelines for smoking cessation which describe the importance of smoking cessation treatment and details of treatment procedures. Smoking affects adults, adolescents, young children, infants and fetuses through direct or passive exposure as well as maternal exposure to tobacco smoke. Smoking affects direct smokers, passive smokers, and infants of mothers exposed to smoke. Since smoking has a variety of effects on many organs, it is important for medical and dental associations to prepare cross-sectional, unified guidelines for smoking cessation.

The “Strength of Evidence” in the efficacy evaluation in the present guidelines is defined as follows according to the “Treating Tobacco Use and Dependence: 2008 Update”1 in the United States:A: Multiple well-designed randomized clinical trials, directly

relevant to the recommendation, yielded a consistent pat-tern of findings.

B: Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the tri-als were not directly relevant to the recommendation.

C: Reserved for important clinical situations in which the Committee achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

2. Simple Smoking Cessation Treatment (Smoking Cessation Support

in the General Practice Setting)

Since clinicians can make a difference with even minimal (less than 3 minutes) intervention1 (Strength of Evidence: A), the treatment of smoking cessation (smoking cessation support) in the general practice setting is important. If physicians and den-tists who talk with smokers during their practice begin inter-vention routinely, a significant number of patients may be able to quit smoking even if the abstinence rate is not high, since the number of patients encouraged smoking cessation is huge.2

The 5 A’s approach (Ask, Advise, Assess, Assist, and Arrange)1 is used in many countries as a simple smoking ces-sation treatment available in the general practice setting (Table 1). It is important that physicians perform Step 1 (Ask) routinely, i.e., asking their patients about smoking status: Phy-sicians should interview their patients about current smoking status and willingness to quit smoking (Strength of Evidence: A). With these questions, patients may be categorized into (1) smokers who are not willing to quit, (2) smokers who are will-ing to quit, (3) past smokers who are not smoking currently, and (4) lifelong non-smokers, and physicians may instruct their patients accordingly.

1. How to Instruct Patients Who Are Not Willing to Quit (Strengthen Motivation to Quit Smoking)

The first goal of intervention to patients who are not willing to quit should be placed to motivate them to quit smoking. This should be done with Step 2 (Advise) (Strength of Evidence: A) and Step 3 (Assess) (Strength of Evidence: C) of the 5 A’s



approach. For patients in whom repetitive instructions are feasible such as those visiting the clinic regularly, the “5 R’s” i.e., Relevance, Risks, Rewards, Roadblocks, and Repetition are effective1 (See the unabbreviated guidelines for detail). In order to explain the Risks of tobacco use, physicians may determine expiratory carbon monoxide (CO) concentration and urinary cotinine concentration (a metabolite of nicotine; test strips are available), and show the results to patients to motivate them to quit smoking.3

2. How to Instruct Patients Who Are Willing to Quit Smoking

Patients who are willing to quit smoking should be instructed

as follows using Step 4 (Assist) of the 5 A’s approach.(1) Help the patient to prepare his/her own quitting plan: Set

the quit date as a day within 2 weeks whenever possible, explain types of nicotine withdrawal symptoms and how to control the tobacco cravings, and encourage the patient to start smoking cessation with confidence.

(2) Provide smoking cessation counseling (Strength of Evi-dence: A): Emphasize that stopping smoking completely but not decreasing the number of cigarettes smoked is a good way to achieve smoking cessation. Instruct the patient to refrain from alcohol immediately after starting a quit attempt, and to consult with physicians and dentists without hesitation for support regarding smoking cessation.

Table 1. Simple Procedures for Smoking Cessation Treatment Suitable for Outpatient Clinics: 5 A’s Approach

Step Strategies for implementation

Step 1: Ask Systematically identify all tobacco users at every visit

• Implement an office-wide system that ensures that, for every patient at every clinic visit, tobacco use status is queried and documented.

• Expand the vital signs (e.g., blood pressure, pulse, body temperature, body weight) to include tobacco use (current smoker, past smoker, or non-smoker), or put a sticker indicating tobacco use status on all patient charts.

Step 2: Advise In a clear, strong, and personal-ized manner, urge every tobacco user to quit

Advice should be:

• Clear: “It is important that you quit smoking now, and I can help you.” “Cutting down while you are ill is not enough.”

• Strong: “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.”

• Personalized: Tie tobacco use to current symptoms and health concerns, and/or its social and economic costs, and/or the impact of tobacco use on children and others in the household.

Step 3: Assess Assess every tobacco user’s willingness to make a quit attempt at the time

• Assess patient’s willingness to quit. If the patient is willing to make a quit attempt at the time, provide assistance. If the patient clearly states that he or she is unwilling to make a quit attempt at the time, provide an intervention shown to increase future quit attempts.

Step 4: Assist Aid the patient in quitting • Help the patient with a quit plan

• Set a quit date. Ideally, the quit date should be within 2 weeks.

• Tell family, friends, and coworkers about quitting, and request understanding and support.

• Anticipate challenges to the upcoming quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.

• Remove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car).

• Recommend the use of approved medication

• Recommend the use of medications found to be effective. Explain how these medications increase quit-ting success and reduce withdrawal symptoms. The first-line medications include nicotine replacement therapy and varenicline*.

• Provide practical counseling (problemsolving/skills training)

• Abstinence: Striving for total abstinence is essential. Not even a single puff after the quit date.

• Past quit experience: Identify what helped and what hurt in previous quit attempts.

• Alcohol: Because alcohol is associated with relapse, the patient should consider limiting/abstaining from alcohol while quitting.

• Other smokers in the household: Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates to quit with them or to not smoke in their presence.

• Provide intratreatment social support

• Provide a supportive clinical environment while encouraging the patient in his or her quit attempt. “My office staff and I are available to assist you.”

• Provide supplementary mate-rials

• Provide appropriate materials published by the government or nonprofit organizations*.

Step 5: Arrange Arrange for follow-up contacts

• Timing: Follow-up contact should begin soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.

• Actions during follow-up contact: For all patients, identify problems already encountered and anticipate challenges in the immediate future. Assess medication use and problems. Remind patients of quitline support.

• For patients who are abstinent, congratulate them on their success. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Consider use of or link to more intensive treatment.

Adapted from U.S. Department of Health and Human Services, Public Health Service. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline, 2008.1*Modified to fit the circumstances in Japan.



(3) Use of medications (Varenicline and nicotine replacement therapy) (Strength of Evidence: A) and supplementary ma-terials: Varenicline and nicotine replacement therapy may reduce nicotine withdrawal symptoms and improve patient self-efficacy.

As Step 5 (Arrange), the patient should be followed- up to ensure the progress of his/her quitting plan (Strength of Evi-dence: C).

3. Instruction During Smoking Cessation Treatment (Relapse Prevention)

In most cases, smoking relapse occurs within 3 months after starting smoking cessation. It is essential to prevent relapse during this period (Strength of Evidence: C). Patients in the early phase of smoking cessation often feel difficulty in coping with nicotine withdrawal symptoms, but physicians/dentists should remind the patients the benefits of smoking cessation and appreciate them for their efforts to quit smoking. Relapse is often triggered by a small incident such as social pressure (e.g., a cigarette offered at a party) and work-related stress. In order to continue smoking cessation, physicians/dentists should encourage patients to be aware of the situations where the risk of relapse is increased and learn about how to keep smoking cessation during clinical visits or telephone interviews.

4. Example of Simple Smoking Cessation ProgramsSimple smoking cessation programs include (1) individual instruction (e.g., individual support at clinical visits), (2) group instruction (e.g., smoking cessation class at workplace), and (3) self-help methods (e.g., smoking cessation contests).

(*See the unabbreviated guidelines for examples of pro-grams and contents of commonly used manuals.)

3. Intensive Smoking Cessation Treatment

The following results have been achieved in studies of inten-sive smoking cessation treatment.(1) Increasing the length or intensity of each session, increas-

ing the number of sessions, and prolonging the duration of program may achieve better results (Strength of Evidence: A).

(2) Multidisciplinary approaches involving various healthcare professionals have been demonstrated effective (Strength of Evidence: A). Clinicians should be involved in smoking cessation treatment. It has been proven effective for clini-cians to inform patients of the risks of tobacco use to health and benefits of smoking cessation and prescribe drug ther-apy while other healthcare professionals provide psycho-social and behavioral therapies.

(3) Varenicline and nicotine replacement therapy are always effective in improving abstinence rates (Strength of Evi-dence: A), and should be administered to all patients unless they are contraindicated.4 In Japan, varenicline, nicotine gums and nicotine patches are available.

(4) Telephone counseling, and individual or group counseling are effective (Strength of Evidence: A).

(5) Individual counseling and behavioral therapy are especially effective, and it has been proved that supports in hospital or clinic as well as supports in home, workplace and schools also improve abstinence rates (Strength of Evidence: B).

Smoking cessation clinics play a central role in intensive smoking cessation treatment in Japan through several sessions during drug therapy using varenicline, nicotine replacement therapy or other appropriate drugs with behavioral therapy to

control psychosocial factors are performed. Intensive smoking cessation treatment for hospitalized smokers is also effective: Instructions to quit smoking by attending physicians and other co-medical staffs are quite important. Since smoking is not feasible in hospital wards, patients may successfully quit smok-ing when appropriate intensive treatment is made during the period of hospitalization (Strength of Evidence: B).

1. Drug TherapyAlthough smoking status differs from person to person, “nico-tine dependence” plays a central role in continuing smoking. In ridding patients of their smoking, treatment with vareni-cline and nicotine replacement therapy are effective (Strength of Evidence: A) and are recommended for smokers who want to quit smoking unless these drugs are not contraindicated. Table 2 lists guidelines for drug therapy for smokers available in Japan that were made according to the recommendations for drug therapy for smokers in the “Treating Tobacco Use and Dependence: 2008 Update”.1

1. Oral Non-Nicotine DrugsVarenicline is Japan’s first oral drug for smoking cessation approved in January 2008. Varenicline does not contain nico-tine but it binds to and acts as a partial agonist of α4β2 nico-tinic receptors in the brain and thereby subsides nicotine with-drawal symptoms and tobacco cravings. Varenicline also acts as an antagonist of α4β2 nicotinic receptors when the patient restarts smoking during treatment: It prevents nicotine from binding to the receptors to suppress a feeling of satisfaction due to smoking. Treatment with varenicline should be started one week prior to smoking cessation, and continued for 12 weeks. During the first week of the treatment, the dose is gradually increased over time. Since a starter pack for the first 2 weeks of treatment is available, the dose escalation during the first week can easily be made. According to data obtained in Japan, 65.4% of patients receiving varenicline could abstain from tobacco for 4 consecutive weeks at the end of a 12-week treatment. According to the “Treating Tobacco Use and De-pendence: 2008 Update”,1 varenicline increases the likelihood of abstinence from tobacco use by 3.1 fold as compared to placebo treatment. Careful administration should be exercised for patients with psychiatric disorders such as schizophrenia, bipolar disorders and depression, patients with severe renal dysfunction, and patients on hemodialysis.

Healthcare professionals and patients should be aware of the possible effects of varenicline on driving. Caution should be exercised for patients not to involve in driving or operating machinery as there has been the report that dizziness, somno-lence or disturbances in consciousness occurred and it resulted in a traffic accident.

2. Nicotine Replacement TherapyIn Europe and in the United States, nicotine replacement ther-apy has been performed using several pharmaceutical forms of nicotine such as gums, patches, sublingual tablets, inhalers, and nasal sprays. Meta-analyses have demonstrated that these nicotine replacement products improve abstinence rates sig-nificantly4 (Strength of Evidence A), and these products have been recommended to use during smoking cessation. The products available in Japan are nicotine gums (NICORETTE® and Nicotinell® Mint [OTC drug]), nicotine patches (Nicotinell® TTS [prescription legend drug], Nicotinell® Patch, NICORETTE® Patch, and Ciganon® CQ [OTC drug]). Although tobacco smoke includes more than 200 different toxic substances, nic-otine replacement products contain only nicotine which is ab-



sorbed gradually by the body through the oral mucosa and skin to alleviate nicotine withdrawal symptoms and help patients quit smoking. Nicotine replacement products may be used safely because they do not cause an abrupt increase in blood nicotine concentration and the amount of nicotine absorbed from nicotine replacement products are generally smaller than those achieved during smoking.5–8 In the nicotine replacement therapy, nicotine intake via tobacco smoke is completely re-placed by that via nicotine gums or patches, and then nicotine

intake is decreased gradually.Table 3 lists the benefits, drawbacks, and common adverse

drug reactions and countermeasures to prevent or treat such events for varenicline, nicotine gums and nicotine patches.

3. Drug Therapy Other Than Nicotine Replacement Therapy

In addition to varenicline and nicotine replacement therapy, bupropion hydrochloride SR is listed as a first-line medication

Table 2. Clinical Guidelines for Prescribing Medication for Treating Tobacco Use and Dependence

Who should receive medication for tobacco use?

All smokers trying to quit should be offered medication, except when contraindicated or for specific populations for which there is insufficient evidence of effectiveness (e.g., pregnant women, smokeless tobacco users, light smokers, and adolescents).

What are the first-line medications recom-mended in this guideline?

Varenicline, nicotine patches and nicotine gums

What should be considered when select-ing smoking cessation medications?

Physicians should consider the contraindications, warnings, precautions, and adverse drug reactions of the drugs, coverage by NHI, and characteristics of patients (such as artificial tooth and skin diseases).

Are cessation medications appropriate for light smokers (e.g., <10 cigarettes/ day)?

Physicians should consider nicotine replacement therapy at low doses for light smokers.

Which medications should be considered with patients particularly concerned about weight gain?

Data show that nicotine replacement therapies, in particular nicotine gum, delay but do not prevent weight gain. In a study, the change in body weight before and after cessation treat-ment did not differ between varenicline and nicotine replacement therapy.

Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease?

No. The nicotine patch in particular has been demonstrated as safe for cardiovascular patients and believed not to cause cardiovascular adverse events. However, the safety of nicotine replacement therapy has not been established in patients with acute myocardial infarction and those with serious or unstable angina.

May tobacco dependence medications be used long-term (e.g., up to 6 months)?

Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms during the course of medications, who have relapsed in the past after stopping medication, or who desire long-term therapy. A minority of individuals who successfully quit smoking use nic-otine replacement products long-term.

May medications ever be combined? Although data from Japan are not available, evidence exists that combining the nicotine patch with nicotine gum increases long-term abstinence rates relative to mono-therapy of either product. Combining varenicline with nicotine replacement products has been associated with higher rates of adverse effects (e.g., nausea, headaches).

NHI, National Health Insurance.Adapted from U.S. Department of Health and Human Services, Public Health Service. Treating Tobacco Use and Dependence: 2008 Update.Clinical Practice Guideline, 2008,1 with modifications to fit the circumstances in Japan.

Table 3. A Comparison of Varenicline, Nicotine Gums and Nicotine Patches

Varenicline Nicotine gums Nicotine patches

Benefits 1. An oral drug easy to take2. Nicotine-free drug3. Alleviates withdrawal symptoms

and inhibits satisfaction after smoking

4. Useful for patients with cardio-vascular diseases

5. Covered by the NHI

1. Can be used at any time to control craving

2. Provides nicotine and satisfies the need to put something in the mouth

1. Supplies nicotine stably2. Effective with once-daily applica-

tion3. Unnoticeable by others4. Covered by the NHI (for some

products)

Drawbacks, common ADRs and counter-measures

1. Nausea may occur • Most common in the first 1 to

2 weeks • Take with a glass of cold or

warm water • Use with antiemetics when

appropriate, or reduce the dose

2. Headache, constipation, insom-nia, abnormal dreams, flatu-lence

• Use with commonly used an-algesics, laxatives, or hypnot-ics, or reduce the dose

1. Nausea, throat irritation • Avoid swallowing the nico-

tine-rich saliva • Cut the gum in half2. Some techniques such as chew-

ing are required, and efficacy varies depending on the usage

• Use nicotine patch3. Some patients cannot chew the

gum • Effective when licking gum in

the mouth4. Poorly absorbed in the acidic

condition • Do not take with carbonated

drinks, coffee, or alcoholic beverages

1. Itching and contact dermatitis may develop

• Change the site of application each day

• Remove the patch early • Consult a physician when

symptoms are severe2. Insomnia and abnormal dreams • Remove the patch at night3. Signs of too much nicotine includ-

ing headache may develop • Use a smaller size patch • Mask a part of adhesive sur-

face with cellophane tape to decrease the contact area

ADR, adverse drug reaction; NHI, National Health Insurance.



for smoking cessation in the “Treating Tobacco Use and De-pendence: 2008 Update”1 (Strength of Evidence: A). It has been reported that bupropion hydrochloride SR as monother-apy or in combination with nicotine replacement therapy im-proves abstinence rate compared with those in patients with-out drug therapy, though this drug is currently not available in Japan.

2. Behavioral TherapySince employment of multiple strategies for behavioral ther-apy are known to improve abstinence rates, drug therapy

should be combined with behavioral therapy. Healthcare pro-fessionals should assess patients for factors, environments and behaviors that are known to be associated with lower absti-nence rates (e.g., stress and sleep deprivation), discuss with the patients how to cope with such problems, and encourage them to perform appropriate measures. Table 4 lists effective behav-ioral therapies.9 Patients should understand that even a single cigarette can ruin efforts taken toward cessation and cause them to restart smoking, and that they must overcome nicotine dependence. Since changes in physical condition associated with smoking cessation such as weight gain and depressed feeling may hinder successful smoking cessation, patients receiving intensive smoking cessation treatment should be explained in detail and be encouraged to perform appropriate measures to cope with them.

4. Active Involvement in the Government’s Anti-Smoking Measures

On February 27, 2005, the WHO FCTC10 was enforced. The Member States including Japan must formulate and imple-ment comprehensive tobacco control regulations that are required under the WHO FCTC.

This chapter describes major tobacco control measures listed in the WHO FCTC, current situation and problems in terms of implementation of such measures in Japan, and per-spectives and methods necessary for physicians, dentists and academic societies to be actively involved to support the gov-ernment to change its policy and implement controls on tobacco use.

1. Price PolicyIncreasing tobacco price is the most effective measure to reduce tobacco use especially by adolescents, juveniles and economically challenged people (who do not have enough opportunities to control of their health) and thereby contrib-utes to the prevention of diseases and decreases health care cost in the future.

The price of tobacco products available in Japan is among the lowest in developed countries11 (Figure 1). Appropriate price policy is a good public-interest policy in terms of both public health and economy since it contributes to maintenance or increase of tax revenue while decreasing consumption of tobacco by the public.

In Japan,12 the tax rate for tobacco products should be increased gradually (however the initial rise should be more than 100 yen per package) to the level in developed countries where successful tobacco control has been made.

2. Advertising RegulationTobacco advertising not only increases the demands for to-bacco products and smoking rate but also tends indirectly to keep mass media receiving advertising fees from reporting the effects of tobacco on human health.13 Tobacco advertising should be banned without exception since partial regulation of tobacco advertising will allow the tobacco industry to exert its indirect effect on the mass media.

The WHO FCTC requests that Member States to prohibit any tobacco advertising, marketing activities and supports of tobacco products. However, the Japanese government granted special exemptions considering the freedom of expression en-sured in the Constitution, and has continued asking the tobacco industry to make voluntary control on tobacco advertising even after enforcement of the WHO FCTC. The effects of voluntary

Table 4. Behavioral Therapies Effective in Supporting Smoking Cessation Treatment

Change behavior patterns

Change behavior patterns associated with smoking to control craving

• Change the order of your morning routine such as face washing, tooth brushing and breakfast

• Eat lunch in places different from the usual

• Leave the table immediately after meals

• Refrain from coffee and alcohol

• Do not eat too much

• Avoid overwork

• Do not stay up late

• Hold a phone with the hand you usually have a cigarette, etc.

Improve the environment

Improve the environment triggering smoking to control craving

• Remove your tobacco products, lighters and ash trays from your environment

• Avoid places triggering smoking (e.g., coffee shops, pachinko parlors, and pubs)

• Stay away from smokers

• Have a seat next to non-smokers

• Keep away from places where you can buy tobacco

• Tell family, friends, and coworkers about quitting

• Wear a badge or place a notice saying that “I am trying to quit”

• Ask smokers not to offer you cigarettes and not to smoke around you, etc.

Behavioral compensation

Use coping skills to cope with an urge to smoke

• Irritation and nervousness

• Deep breathing and drinking water or tea

• Malaise, sleepiness

• Do light exercise such as walking and calisthenics

• Take a shower

• The urge to put something in the mouth

• Chew low-sugar chewing gum, mint candy or dried kombu seaweed

• Brush your teeth

• Boredom

• Organize your desk drawers

• Do delicate work such as building a plastic model

• Clean your garden or room

• Others

• Listen to music

• Count the number of seconds until a craving passes

• Find stress coping techniques other than smoking, etc.

Adapted from Nakamura M, Oshima A. You can quit smoking tomorrow: Smoking cessation self-help book, newly revised edn. Tokyo: HOUKEN CORP., 1999: 78 – 79.9



control are questionable, and we should continuously request the national and local governments to ban all tobacco advertis-ing including image advertising on good smoking manners and events named after tobacco brands.

3. Prevention of Passive SmokingArticle 25 of the Health Promotion Law enacted in 2002 indi-cates that it is the responsibility of “the administrators of places where many people come such as schools, gyms, hos-pitals, stations, ...... and restaurants” to endeavor to prevent passive smoking in such places. After enforcement of the law began in May 2003, an increasing number of public and pri-vate entities have “prohibited smoking” rather providing “sep-arate smoking areas in public places”.

Physicians and dentists should take initiative to achieve smoke-free environment in hospitals and clinics as well as public places and workplaces to prevent passive smoking based on the Health Promotion Law.

4. WarningsThe Ministry of Finance revised the “Regulations for Enforce-ment of the Tobacco Industries Act” in November 2003, and decided to print “warnings” on tobacco packages to replace

the vague “precautions” used in the past (the new warnings were fully enforced on July 1, 2005).

However, Japan uses text-only health warnings that are not “large, clear, visible and legible” as described by the WHO FCTC. The warnings in Japan are not impressive compared to those in many other countries, and use only 30% (minimum required percentage) of the principal display area. We should propose more effective warnings by referring to those used in Canada and Brazil (texts and highly impressive pictures using 100% of the principal display area) and other developed coun-tries including Australia.14

5. Prevention of Underage Smoking: Including Access Control

Although Japan is the first nation to enforce the “Underage Smoking Prevention Act” in 1900, many adolescents are still smoking. Tobacco vending machines are the most common and worst route to buy tobacco products by adolescents.

In order to make tobacco products less available to adoles-cents, tobacco vending machines should be totally removed, and tobacco products should be sold behind the counter after confirming the age of customers.

It is also essential to educate adolescents about health (and

Figure 1. Average price of 20 cigarettes in major developed countries. Source: Non-Smokers’ Rights Association, Canada (as of June 17, 2002)11 for the prices in foreign countries. The price of the most popular product in each nation/area was converted to yen based on the exchange rates as of May 31, 2002. [Note] As of October 2010, the tobacco price in Japan is higher than that in the graph.



education of smoking prevention) both in the community and school. However, education of adolescents is not sufficient as a single measure and should be combined with other national measures such as price control, advertising regulation, access control, education of adult smokers (especially smoking ces-sation treatment) and encouraging a smoke-free environment (e.g., tobacco ban in public spaces and prevention of passive smoking). In Japan, tobacco vending machines that require so called “taspo” cards to buy tobacco products were introduced in July 2008 to limit the use of tobacco vending machines to adults only, but this measure has not been effective in reducing underage smoking since they often buy tobacco from shops such as convenience stores by telling a lie about their age.

6. Dissemination and Institutionalization of Smoking Cessation Treatment

An increasing number of countries are providing smoking ces-sation treatment for free or at low cost as national programs. In 1999, the UK became the first country in the world to intro-

duce smoking cessation treatment as a program covered by the National Health Service (NHS).15 The institutionalization of smoking cessation program in the UK was promoted signifi-cantly by a review of the clinical efficacy and cost-effective-ness of smoking cessation treatment (e.g. Table 5) on the basis of published evidence16 and the smoking cessation guidelines for healthcare professionals17 prepared according to the re-view. Japan also must institutionalize smoking cessation treat-ment. Before achieving this goal, the clinical efficacy and cost-effectiveness of smoking cessation treatment should be evaluated on the basis of the results of interventional studies in Japan, and appropriate guidelines considering the health insurance system and other situations in Japan should be pre-pared. Healthcare professionals and academic societies should actively be involved in such efforts.

5. Creating Non-Smoking Environment to Promote Smoking Cessation

In order to quit smoking, smokers must acquire knowledge and attitudes that motivate smoking cessation, be supported by favorable conditions promoting the initiation and continuation of their efforts, and be encouraged in an appropriate condition to achieve continuous smoking cessation. This section describes the importance of total abstinence from smoking by physicians, dentists and other healthcare professionals who should become a role model in the community and of promoting to a smoke-free (non-smoking) environment by medical institutions.

1. Smoking Cessation in Healthcare Professionals1. Smoking Status of Healthcare Professionals in JapanThe smoking rate among male and female physicians in Japan (data evaluated by the Japan Medical Association in 2004)18 is lower than that of in the general population of Japan. But con-siderably higher than those in physicians in countries where

Table 5. Cost-Effectiveness of Smoking Cessation Treatment

Costs per life year saved (£)

Brief advice 212

Brief advice + self-help programs 259

Brief advice + self-help programs + NRT 696

Brief advice + self-help programs + NRT + specialist cessation service 873

NRT, nicotine replacement therapy.[Note]- The cost per life year saved ranges from 4,000 to 13,000 £ for treatment of hyperlipidemia with statins.

- A cost per life year saved of ≤800 £ is considered cost-effective.Adapted from Thorax 1998; 53(Suppl 5 Pt 2): S1 – S38,16 with per-mission from BMJ Publishing Group Ltd.

Figure 2. Smoking rate among physicians (comparison between Japan and other countries where anti-smoking measures have been highly successful). FP, family physician. Created mainly based on data of the third report of smoking status and attitudes toward smoking among the members of the Japan Medical Association in 200819 and Tobacco control country profiles 2003, 2nd edn. American Cancer Society, 2003.20



tobacco control is more strict (Figure 2). According to data on the smoking rate in female nursing staffs evaluated by the Japanese Nursing Association in 2001, the smoking rate is low in health nurses, while those in midwifes, nurses and assistant nurses are higher than that in the general female population.

2. Smoking-Related Problems and Promotion of Smoking Cessation in Physicians and Dentists

Smoking in healthcare professionals, especially smoking in physicians and dentists, are quite problematic in terms of the following points:21

(1) Smoking in physicians is the biggest promoter of smok-ing.

(2) Physicians who smoke tend to deny or underestimate the risk of smoking in order to justify their behavior due to the adjustment mechanism that smokers use to ignore the con-sequences of smoking, and become the biggest resistance force in hospitals against smoke-free policy.

In order to establish an environment that supports patient attempts at smoking cessation treatment, medical institutions should promote smoking cessation in their staff members as a first step. Smoking cessation treatment (support) for physi-cians should be prioritized.

2. Tobacco Ban and Restrictions on Sale of Tobacco Products in Medical Institutions

1. Complete Tobacco Ban in Medical Institutions (Non-Smoking)

A complete tobacco ban rather than limitation to smoking areas should be aimed at all medical institutions including hospitals and clinics, for the following reasons.22

(1) Medical institutions play an important role in preventing and treating diseases and protect the health of the com-munity residents.

(2) Medical institutions are places visited by many patients, and passive smoking must be completely avoided.

(3) Medical institutions are workplaces for healthcare profes-sionals who are aware of the adverse effects of tobacco on the health. When healthcare professionals act as role mod-els for smoke-free lifestyles, smoke-free environments in other public institutions, schools and workplaces will be promoted further.

In the current hospital evaluation system (Version 6.0; used

for hospitals evaluated in February 2009 and thereafter created by the Japan Council for Quality Health Care to perform third-party evaluation and support improvement of the quality of healthcare), the presence/absence of measures to prevent passive smoking in the hospital is a key evaluation item in the “health promotion and environment” domain. This item is rated on the basis of “(1) whether complete smoking ban is introduced in the hospital” and “(2) whether patients and healthcare staff members are actively encouraged to abstain from smoking”. Hospitals where smoking is prohibited in all buildings and spaces are highly acknowledged. This hospital evaluation system is expected to promote smoke-free environ-ments in hospitals.

2. Restrictions on Sale of Tobacco Products in Medical Institutions

In Japan, there are tobacco vending machines in public facili-ties and hospitals and even outside the front entrance of phar-macies and drug stores. The current law (Tobacco Industries Act) encourages the sale of tobacco products in order to “ensure sound development of tobacco industries and steady income”, and does not restrict the sale of tobacco products in hospitals and other public facilities. However, medical institu-tions should take initiative of restricting the sale of tobacco products in order to protect the health of the community resi-dents. Tobacco ban policy in a hospital, including the removal of tobacco vending machines and face-to-face selling in shops in the hospital, will not only promote the smoke-free environ-ment in the hospital but also affect nearby public facilities to introduce non-smoking policy.

3. On-Site Inspection and Support by Public Health Institutes

According to article 25 of the Medical Service Act, each pre-fectural governors send staffs of public health institutes to hospitals in the prefecture for on-site inspection at least once a year. We expect that the public health institutes will inspect hospitals for smoking cessation status and sale of tobacco products (hopefully report the results) in addition to the con-ventional items of inspection such as measures to avoid med-ical accidents and prevent nosocomial infections in order to promote nonsmoking policy in hospitals.

II Smoking Cessation Treatment for Various Subgroups

1. Cardiovascular Diseases

1. Special Considerations Regarding Patients With Cardiovascular Diseases During Smoking Cessation Treatment

Special considerations should be made for smokers with car-diovascular diseases because (1) they should be strongly rec-ommended to quit smoking as an evidence-based medicine; (2) they should discontinue smoking during the acute phase of cardiovascular disease and continue abstinence thereafter; and (3) they are contraindicated for nicotine replacement therapy during the acute phase of cardiovascular disease.

Epidemiological studies have demonstrated that smoking is a strong risk factor for cardiovascular diseases such as coro-nary artery disease, stroke and peripheral artery diseases that are common in adults.23–28 Accordingly, patients receiving

treatment to prevent cardiovascular diseases or treat acute or chronic phase of cardiovascular diseases should be strongly motivated to quit smoking according to medical evidence and encouraged to receive smoking cessation treatment.

Smoking cessation treatment for patients with cardiovascu-lar diseases differs from those for other patients in that patients are often forced to quit smoking after an unexpected cardio-vascular event that suddenly occurs and to continue abstinence for life. Since the onset of cardiovascular disease is the biggest reason that motivates smokers to quit smoking, and advise to quit smoking from healthcare professionals will be a strong trigger for abstinence and may lead abstinence for life, physi-cians must provide appropriate smoking cessation programs for patients with cardiovascular diseases.



2. Significance of Smoking Cessation Treatment for Patients With Cardiovascular Diseases

Smoking cessation treatment is important for patients with cardiovascular diseases since tobacco use has acute and chron-ic effects on the cardiovascular diseases and significantly af-fects the prognosis of patients.

The nicotine in tobacco smoke is absorbed into the blood-stream through the lungs, and stimulates the adrenal cortex to release catecholamines that stimulates the sympathetic ner-vous system to cause peripheral vasoconstriction, and in-creases in blood pressure and heart rate.29,30 Nicotine also en-hances the release of thromboxane A2,31 which is known to cause vasoconstriction and bronchoconstriction more potently than does nicotine. CO in tobacco smoke binds strongly to hemoglobin in red blood cells, causing chronic oxygen deficit of arterial blood. Smoking also enhances the production of extrinsic reactive oxygen species and free radicals to increase oxidative stress.32

Smoking is known to increase the risk of ischemic heart disease, stroke (cerebral infarction and subarachnoid hemor-rhage) and hypertension, great vessel diseases (development of abdominal aortic aneurysm, increase in aneurysm diameter, rupture of aneurysm, and death), peripheral artery diseases (e.g., arteriosclerosis obliterans, development and aggravation of Buerger’s disease, and microvascular lesion secondary to diabetes), among other cardiovascular diseases.

The prevalence of ischemic heart diseases begins to de-crease relatively soon after smoking cessation.24 In addition, the incidences of recurrent myocardial infarction and death are lower among patients who quit smoking after onset of acute myocardial infarction than those who did not. It has been demonstrated that the risks for repeat coronary artery bypass grafting (CABG) and postoperative angina significantly de-crease when patients quit smoking after their first CABG, but do increase when they restart smoking. It is believed that the risks for myocardial infarction, repeat CABG and angina in patients who had quit smoking do not differ from those in non-smokers.33 Studies have demonstrated that the anti-ischemic effects of β-blockers and calcium channel blockers are weak in smokers with angina, and improve after they quit smok-ing.34 The risk of stroke decreases rapidly within 2 years after smoking cessation and reaches a level similar to that in non-smokers within 5 years.35

3. Smoking Cessation Treatment in Patients With Cardiovascular Diseases

1. Smoking Cessation Instruction to Prevent Cardiovascular Diseases

All smokers should be instructed repeatedly to quit smoking in every opportunity such as clinic visits and discussions after regular health check-ups no matter how short the instruction is1 (See section I-2 “Simple Smoking Cessation Treatment” for basic methods).

All patients with other risk factors for cardiovascular dis-eases should be instructed to quit smoking.

Varenicline and/or nicotine replacement therapy should be considered.

2. Smoking Cessation Instruction for Patients in the Acute Phase of Cardiovascular Disease

Introduction to quit smoking (almost compulsory tobacco abstinence): Healthcare professionals should provide accurate information on the relationship between smoking and diseases on the basis of their medical expertise. A clear strong person-alized message should be provided to urge every patient to

quit smoking.Continuation of smoking cessation: Healthcare profession-

als should encourage patients to continue not to smoke during the sub-acute and chronic stable phase of cardiovascular dis-eases. It is important to encourage not only the patients but also their families.

Nicotine replacement therapy should not be used.

3. Smoking Cessation Instruction for Patients in the Chronic Phase of Cardiovascular Disease

Ensure instruction at regular outpatient visits:(1) Describe smoking status in the medical record in such a

way that is easy to determine changes over time in the pa-tient smoking status.

(2) When the patient is still smoking, the physicians should try to motivate him/her to quit smoking by giving clear and concrete messages about the disease and health hazards of smoking repeatedly.

(3) Varenicline and/or nicotine replacement therapy should be recommended.

(4) When the patient does not quit smoking despite the above measures, he/she should be recommended to visit a smok-ing cessation clinic.

(5) Smoking status should be followed at each visit.(6) When the patient has restarted smoking, he/she should not

be blamed but encouraged to retry cessation.

4. Available Materials(1) Smoking cessation guidebook: Three steps to quit smok-

ing. “PASSPORT to STOP SMOKING”, edited by the JCS36

(2) Educational DVD for prevention of smoking: “STOP SMOKING”, planned, produced by the JCS

The prevention of active and passive smoking is recommend-ed in several guideline documents reported by the JCS. In the Guidelines for the Primary Prevention of Ischemic Heart Dis-ease in 2001,37 “complete smoking cessation” and prevention of passive smoking are recommended. Smoking cessation is also recommended in many other JCS guideline documents including the Guidelines for Secondary Prevention of Myocar-dial Infarction,38 the Guidelines on Indications for Coronary Intervention for the Treatment of Coronary Artery Disease,39 and the Guidelines for Treatment of Chronic Heart Failure.40 The AHA Guidelines for Primary Prevention of Cardiovascu-lar Disease and Stroke: 2002 Update also listed complete smoking cessation and no exposure to environmental tobacco smoke as a goal.41

4. Targets of Tobacco Control by Healthcare Professionals Involved in the Treatment of Cardiovascular Diseases

In April 2002, the JCS adopted on anti-smoking declaration,42 saying “as the leading professional association for cardiovas-cular specialists in Japan, hereby declares that we will vigor-ously fight against smoking by working to ban smoking, en-couraging smoking cessation, and preventing passive smoking exposure. ......The JCS will promote the importance of these countermeasures to the public.” With the three basic principles of (1) beginning within our own membership, (2) calling for hospitals and medical schools to be engaged in tobacco con-trol, and (3) calling for patients, general public, and society to be engaged in tobacco control, the JCS has proposed 10 spe-cific targets to promote smoke-free environments.



2. Respiratory Diseases

1. Smoking and Respiratory DiseasesSmoking affects many organs in the body, but most signifi-cantly affects the respiratory organs that are exposed directly to tobacco smoke. The effects of smoking on the airways and lungs include morphological changes and changes of lung function such as respiratory function (gas exchange) and non-respiratory functions (defensive function and metabolism).

Smoking cause both morphological and functional changes in the respiratory system, which may result in various symp-toms and diseases. Table 6 lists respiratory diseases for which smoking is a strong risk factor. Lung cancer and chronic ob-structive pulmonary disease (COPD) are the two major respi-ratory diseases associated with smoking.13

A causal relationship between smoking and lung cancer has now been well established in many epidemiological studies and experimental research. The risk of lung cancer in smokers is several to over 10- fold that in nonsmokers. Many epide-miological studies have shown a dose-response relationship between cigarette consumption and lung cancer mortality. It is known that the risk of lung cancer death is higher in indi-viduals who smoke higher numbers of cigarettes per day, those who have smoked for a longer period of time, those with a higher Brinkman index, and the risk of lung cancer is higher in individuals who began to smoking at a younger age. Smok-ers are at a high risk of developing not only lung squamous cell carcinoma and small cell lung carcinoma but also large cell lung carcinoma and lung adenocarcinoma when it comes to the risk of different tissue types of lung cancer.

COPD is characterized by obstructive ventilator disturbance caused by pulmonary emphysema and/or chronic bronchitis. However, COPD is not a diagnostic term widely used in the general practice setting in Japan. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline43 that was introduced recently in Japan indicates that “Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.” Although it is believed that smoking accounts for 80 to 90% of the risk of COPD, not all

smokers develop COPD: The risk of clinically significant COPD is high in 15 to 20% of smokers who are susceptible to tobacco smoke.

2. Effects of Smoking Cessation in Patients With Respiratory Diseases (Benefits)

A dose-response relationship has been observed between the incidence of lung cancer and COPD and smoking, and many studies have demonstrated that smoking cessation is effective in preventing and treating these diseases.

According to the results of studies in and outside of Japan, the risk of lung cancer decreases by 30 to 50% in the first 10 years after smoking cessation, and gradually decreases there-after. Studies in the UK and in the United States have reported that lung cancer mortality began to decline in association with a significant decrease in smoking rate. It is known that smok-ing promotes pulmonary dysfunction over time and is a major risk factor for COPD, and studies have demonstrated that smoking cessation reduces the changes in pulmonary function over time and improves life expectancy.

3. Smoking Cessation Treatment in Patients With Respiratory Diseases

Smoking cessation treatment includes education and instruc-tion for smokers. It is important to treat them as patients through appropriate education and instruction to encourage them to quit smoking.44 Table 7 lists the smoking cessation programs described in the COPD Guideline by the Japanese Respiratory Society (1st edition).45

Table 6. Respiratory Diseases for Which Smoking Is a Strong Risk Factor

1. Lung cancer

2. Chronic obstructive pulmonary disease (COPD)

3. Bronchial asthma

4. Spontaneous pneumothorax

5. Interstitial lung disease

1) Pulmonary eosinophilic granuloma (Langerhans cell histio-cytosis)

2) Idiopathic interstitial pneumonia (pulmonary fibrosis)

3) Respiratory bronchiolitis-associated interstitial lung disease (RBILD)

6. Respiratory disorders during sleep (e.g., sleep apnea syndrome)

7. Respiratory tract infection

8. Acute eosinophilic pneumonia

9. Others

Adapted from Respiratory Diseases. Smoking and health: a report by the Study Group on Smoking and Health Issues, new edn. Tokyo: HOKENDOHJINSHA Inc., 2002: 137.13

Table 7. Smoking Cessation Programs

1. Patient evaluation

1) Ask about smoking history and past cessation attempts

2) Evaluate the severity of nicotine dependence

3) Evaluate health conditions and smoking-related dis eases

4) Assess the patient’s interest in smoking cessation and stages of change toward smoking cessation

2. Smoking cessation education and instruction

1) Smoking cessation education

(1) Inform patient of the harms of smoking and the benefits of smoking cessation

(2) Explain the process of smoking cessation

(3) Explain nicotine dependence

2) Smoking cessation instruction

(1) Advise on smoking cessation/provide self-help materials

(2) Set a quit date/cold turkey

(3) Behavioral therapy

(4) Varenicline*/nicotine replacement therapy

3. Follow-up

1) Set follow-up visits soon after the quit date to follow-up the patient. Confirm abstinence by measuring expiratory carbon monoxide concentration.

2) Continue smoking cessation support

3) Assist patients who have relapsed

4) Consider other smoking cessation treatments

Adapted from Smoking Cessation. The guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease (COPD). Tokyo: Medical Review, 1999: 42.45

*Added to this table.



4. Approaches to Smoking Cessation by Respiratory Disease Specialists and Academic Societies in the Field of Respiratory Medicine

Smoking by respiratory disease specialists who treat patients with smoking-related diseases such as lung cancer and COPD is extremely problematic. They must be role models for a smoke-free, healthy lifestyle and encourage patients and gen-eral public to quit smoking. Academic societies in the field of respiratory medicine have actively committed to anti-smoking education, and the Japanese Respiratory Society (former name: the Japan Society of Chest Diseases) was the first academic society in Japan to publish the “Recommendations Concerning Smoking” in 1997.46 Following this, other academic societies published recommendations and declarations concerning anti-smoking measures and smoking cessation. Those published by academic societies in the field of respiratory medicine in-clude the “Tokyo Declaration on Tobacco” by the Interna-tional Association for the Study of Lung Cancer, the “Anti-Smoking Declaration” by the Japan Lung Cancer Society,47 and the “Anti-Smoking Declaration” by the Japan Society for Respiratory Endoscopy (former name: the Japan Society for Bronchology).48 The Japanese Respiratory Society adopted the “Anti-Smoking Declaration” at the 43rd annual meeting in March 2003. The declaration describes that “the eligible members must be non-smokers.”

3. Women

1. Smoking Status Among WomenThe smoking rate among women in Japan has been nearly stable since 1965. However, changes in prevalence by age group indicate that smokers are decreasing among women in their 40 s and older, but are clearly increasing in younger women, which reflects an increasing tendency in smoking rate among pregnant women.

Since the smoking rate among women in Japan has been lower than those in other countries, appropriate anti-smoking measures may decrease smoking rate and mortality without increasing female smokers further.

2. Special Considerations for Smoking Cessation Treatment in Women

Women are more susceptible to smoking than men. Nicotine dependence tends to be more severe in women than in men.

Smoking during pregnancy causes adverse effects beyond the mother. Smoking during pregnancy means that chemicals contained in tobacco smoke affect child during the most im-portant periods of development and growth in the uterus and after birth. Smoking cessation during pregnancy is difficult since pregnant women cannot use varenicline and nicotine replacement therapy (these drugs are basically contraindicated during pregnancy), and pregnant women may have a sense of guilt when they cannot quit smoking.

3. Significance of Smoking Cessation Treatment for WomenOvarian endocrine function plays an important role in the life cycle of women. Tobacco smoke affects ovarian function. Smoking cessation is important in (1) improving ovarian func-tion affected by smoking, (2) avoiding adverse effects on the next generation, and (3) eliminating adverse cosmetic effects. Of course, smoking cessation is important in preventing and treating smoking-related diseases and preventing recurrence of diseases, and especially the effects of smoking cessation on infectious diseases are significant. Also, smoking cessation

decreases the risk of thrombosis, the most important adverse effect of oral contraceptives.

1. Ovarian FunctionSmoking cessation may improve menstrual pain, abnormal menstrual cycles, and secondary amenorrhoea, prevent prema-ture menopause due to smoking, and decrease the incidence of infertility.

2. Effects on the Fetus and Complications of PregnancyRelationships of the following with smoking have been dem-onstrated: Fetal growth retardation, premature birth, placen-tal complications (placenta praevia and premature separation of a normally implanted placenta), early/premature rupture of membranes, and perinatal death. Smoking cessation may lower the incidence of these complications.

Relationship with smoking is apparent based on a lot of reli-able study results: Abortion,49 ectopic pregnancy,50 and re-duced milk volume.51

Relationship has been pointed out but no clear causal rela-tionship was demonstrated: Cleft lip and palate,52 absent limbs,53 urogenital malformation,54 and neural tube defect,55 etc. Women should quit smoking before they become preg-nant to ensure preventing these complications.

Recently, fetal programming studies have been performed, and studies on the relationship between smoking during preg-nancy and disorders of children after reaching adulthood have been reported. There are reports suggesting relationships of smoking during pregnancy with development of such as neu-rodevelopmental disorders and diabetes mellitus.56,57

3. Cosmetic AspectsAdverse cosmetic effects of smoking: Decreased skin elastic-ity increase in skin wrinkles, disorders of the hair (poliosis and alopecia), chapped lips, discoloration of the teeth and gum, halitosis, voice alteration, and hirsutism

4. Other DisordersIt is believed that exposure to tobacco smoke may affect the incidence of breast cancer, cervical cancer, and bacterial vag-inosis.

The risk of COPD is higher in female smokers than in male smokers.

5. Use of Oral ContraceptivesUse of oral contraceptives increases the incidence of cardio-vascular disorders (angina attacks) in smoking women 12-fold than in non-smoking women.58,59

4. Smoking Cessation Treatment in WomenWomen of all ages should be urged to quit smoking regardless of whether they are nonpregnant, pregnant, or lactating. As a first step, physicians should ask all female patients regarding their smoking status.

1. Steps in Smoking Cessation TreatmentFirst, patients should be assessed for smoking status and sever-ity of nicotine dependence, and asked concerning their will-ingness to quit smoking (stages of change toward smoking cessation).

Patients in the precontemplation stage should receive clear and substantial messages on “why smoking cessation is neces-sary” to motivate them by explaining the most relevant risk factor among those described in the section 3.

Patients in the contemplation stage should further motivated



by providing information and methods for smoking cessation, encouraging and giving assurance of support.

For patients in the preparation stage, smoking cessation treatment should be scheduled and implemented.

Patients in the action and maintenance stages should be praised for continued abstinence, and remotivated to continue and prevent a smoking relapse.

After treatment begins, patients should visit the clinic at week 1, and then at month 1 of treatment.

2. Precautions for WomenWomen should quit smoking before pregnancy. In particular, smoking cessation is a precondition for women undergoing treatment for infertility.

It is never too late to quit smoking even during pregnancy. Smoking cessation is effective at any time.

Smoking women often hesitate to quit due to fear of weight gain after smoking cessation. Weight gain is a major reason for such hesitation. It may be prevented with drug therapy (the degree of weight gain is relatively small when using nicotine replacement therapy), behavioral therapy (patients should be encouraged to brush their teeth and drink cold water but not eat snacks to cope with nicotine withdrawal symptoms, and perform exercise and deep breathing), and dietary therapy (patients should be instructed to eat more vegetables and have the right diet).

Since unemployed women may have problems such as isolation, poor communication, and boredom, at a loose end that may hinder successful smoking cessation, they should be instructed to improve their lifestyle as well. A strong support system should also be established to follow them frequently.

When treating pregnant women, both patients and their family members should be encouraged to quit smoking. Smok-ing cessation for all family members is necessary and may be more effective than instructing the pregnant women only.

Since smoking cessation treatment during pregnancy is challenging as varenicline and nicotine replacement therapy cannot be used during pregnancy, healthcare professionals should not pursue short-term effects, and should instruct them patiently to achieve successful smoking cessation over a long span of time. Pregnancy is a good opportunity to quit smoking because patients visit the clinic regularly and may be moti-vated effectively.

Care should be taken to minimize the risk of smoking re-lapse after childbirth when patients visit the clinic less fre-quently. Mothers have many factors such as childcare stress that may lead to smoking relapse. Patients should receive suf-ficient instruction regarding the risks of smoking to both moth-er and child during pregnancy and thereafter.

4. Children and Adolescents

1. Underage Smoking and Importance of Smoking Cessation Treatment

In Japan, underage smoking has become increasingly preva-lent, especially among junior and senior high school girls.

The effects of harmful chemicals in tobacco smoke are significantly greater in growing children than in adults. A seri-ous problem of smoking in youths is that nicotine dependence develops in a shorter period of time in children than in adults. For example, it has been reported that children 12 to 13 years of age who smoke only for several weeks or months have nicotine dependence and feel difficult to quit.60 Children with “nicotine dependence” cannot quit smoking of their own will,

and need treatment for nicotine dependence.

2. Smoking Cessation Treatment for Children1. Basic Methods of Smoking Cessation Clinics for

ChildrenSince children who smoke generally do not have sufficient ability to solve problems by themselves, tend to lack positive feelings about themselves, and may have social problems either at home or in school, it is important to accept their feelings and carefully listen to them. Healthcare professionals should not blame them without giving them a chance to explain why they smoke. Rather, they should talk with children at ease in asking them for their reasons for starting to smoke and smoking sta-tus, and about their daily life, school life, and friendship, and assess the severity of their nicotine dependence.

Smoking cessation treatment for children should include provision of correct information on the adverse effects of to-bacco, and treatment mainly using nicotine patches under care-ful supervision.61 Photos, figures, and videos are useful tools to explain the effects of direct and passive smoking and effects of smoking during pregnancy on the fetus, among others.

2. Nicotine Dependence and TreatmentChildren should be instructed that nicotine dependence, a disease of the brain which cannot work properly without nico-tine, is the cause of difficulty in quitting smoking, and that appropriate treatment may help smoking cessation. Children should be instructed how to use nicotine patches. If they are willing to use them, nicotine patches for 1 to 2 weeks (7 to 14 patches) should be prescribed. Nicotine patches are available as large, medium- and small-sized patches. Medium-sized patches are often sufficient for junior and senior high school students, but the required dose may vary among individuals. Usually a nicotine patch should be applied daily to the upper arm or lower back after wake-up, and kept the patch on by bedtime. When the children use nicotine patches 1 to 2 weeks to control tobacco craving and can be free from tobacco for 1 to 2 weeks, they can often overcome physical nicotine depen-dence. However, the number of patches required to achieve it may significantly vary among individuals.

For example, instructions for children may include “Try these patches for 3 days (or within a week). Apply one patch in the morning, and remove it before bed. You will not want to smoke when you use the patches. When you feel it would be OK without the patches, try without a patch next day. You may not want to smoke during the day. But if you crave a cigarette, use a patch immediately. For a while, nicotine patch deliver nicotine, the craving will be reduced soon. Keep the patch before bed, and try again without a patch next morning. The time without the patch will be longer and longer, and finally you will not need any patches or cigarettes.”

3. Follow-up After Smoking Cessation TreatmentChildren should be followed-up after outpatient sessions to ensure abstinence. When they or their parents wish follow-up, physicians should follow-up the children for abstinence by requesting that they visit the clinic regularly or contacting them via phone.

Follow-up with visits to the clinic should be performed every 1 or 2 weeks, while those with telephone calls from the clinic should be performed several days after the last visit and then every 1 or 2 weeks thereafter. Physicians should not blame children even if they have restarted smoking, and should listen to them sympathetically and encourage them to retry.

When children and their parents agree, physicians will con-



tact their teachers or nurses in their schools to ask them to support the children in school. They will be highly motivated when they feel support from adults close to them.

3. Measures to Prevent Underage Smoking and Avoid Smoking Relapse

Nicotine replacement therapy is effective in underage smokers as in adults,62 and many children can quit smoking after using nicotine patches for a relatively short period of time. However, it is difficult to continue abstinence from tobacco for a long period of time, and many children restart smoking. There are many reasons why children restart smoking, including a social environment that still accepts smoking as well as easy access to tobacco products via vending machines.

Not only education and instruction for children, but also strict measures, such as removal of tobacco vending machines and a ban on smoking scenes on TV drama, and cartoon are needed to prevent underage smoking in our society as a whole.63

5. Dental and Oral Cavity Disorders

1. Smoking and Dental DisordersThe oral cavity is the first part of the body to be exposed to tobacco smoke. Tobacco smoke is involved in the develop-ment and progression of oral cavity disorders and reduces the efficacy of dental treatment. Active smoking is related to abnormalities of the oral mucosa, periodontal tissues, teeth, salivary gland, tongue, lips, dental restorative materials, and prosthetic appliances, as well as halitosis and abnormalities of saliva. Smoking during pregnancy is related to anomalies of the lips and palate of the fetus. Passive smoking is related to periodontal diseases, dental caries in children, and abnormal deposition of melanin in gingiva. Smoking cessation reduces the risk of oral cavity disorders and thus ensures more effec-tive dental treatment. According to the latest, 2004 Surgeon General’s Report on the health consequences of smoking, scientific evidence for causal relationships of active smoking with cancer of the mouth and periodontal disease have been established.64

2. Chewing TobaccoThe use of chewing tobacco (betel quid), which is common in South Asia, especially India and Southeast Asia, is important in explaining the effects of nitroso compounds found in to-bacco products on the oral mucosa. Betel quid is a combina-tion of areca nut (fruit of thebetel palm), betel leaf (leaf of piper betle), slaked lime, and tobacco leaf. During chewing betel quid containing tobacco leaf, alkaloids such as arecoline

contained in areca nut are nitrosated to form carcinogenic N-nitrosamines which interact with DNA and proteins. Slaked lime, a strong alkaline, causes inflammation of submucosal tissues, and produces reactive oxygen species that damage DNA in cells of the oral mucosa.65,66 These stimuli induce leukoplakia, verrucous tumor, and squamous cell carcinoma in the mouth. It has been reported that anemic changes and submucus fibrosis in the mouth caused by the chewing of betel quid leads to cancer of the mouth. In countries where the use of betel quid is common, patients with cancer of the mouth account for as many as 30% of all cancer patients. These find-ings in Southeast Asia suggest the risk of smoking as well as nitroso compounds contained in tobacco gums, the chewing of which is becoming common in Japan (See photo in Table 9). Careful consideration is thus needed concerning the long-term use of nicotine-containing products in the mouth.

3. Smoking Cessation Treatment for Dental PatientsBased on the experience in developed countries where smok-ing cessation treatment has achieved favorable results, the benefits of smoking cessation treatment in dental clinics (e.g., department of dentistry and oral surgery in hospitals, dental offices, and public dental health activities including dental check-ups) have been specified67,68 (Table 8). Dental clinics may motivate patients to quit smoking and support them if they are willing to quit smoking. In a recent report in the United States, smoking cessation treatment by dental health-care professionals, the effects of which are evaluated compre-hensively as treatment by healthcare professionals other than physicians, is effective in the delivery of smoking cessation treatment and should be performed. As of 2002, there are 65,073 dental offices and 1,265 dental hospitals in Japan. It is estimated that 1.15 million people per day, accounting for 17% of all patients visiting an outpatient clinic, visited their dentist in 1999. The number of patients visiting a dentist for the treat-ment of dental caries exceeded 40 per 1,000 people in almost all age groups between 5 and 74 years in 2001. When smoking cessation treatment for dental patients becomes common, and if one patient per month quits smoking in each clinic, a total of 0.8 million people in the various age groups will quit smok-ing each year.

4. Organizational MeasuresPrefectural dental associations have begun or are planning to provide smoking cessation treatment. This commitment is ex-pected to increase the number of people who quit smoking under the instruction of dentists. However, dentists in Japan are not formally allowed to prescribe nicotine patches, though they are in other developed countries in which successful to-bacco control has been obtained. The unavailability of nico-tine patches in many dental clinics has hindered dentists from promoting smoking cessation more successfully. The Japanese Society for Oral Health, the Japanese Society of Oral and Maxillofacial Surgeons, the Japanese Society of Periodontol-ogy, and the Japanese Association for Dental Science have adopted declaration on tobacco control. In 1996, the World Dental Federation (FDI) established the Section on World Dentistry Against Tobacco and adopted the FDI position state-ment on tobacco. The International Association for Dental Research and the International Federation of Dental Educators and Associations have performed activities in accordance with the FDI. The Japan Dental Association adopted an anti-smok-ing declaration in 2005.

Since dental clinics are important in performing antismok-ing activities and smoking cessation treatment, the current

Table 8. Benefits of Smoking Cessation Treatment in Dental Clinics

1. Since the incidence and prevalence of oral cavity disorders are high, dentists see many patients of various age groups re-peatedly.

2. Dentists may support and instruct smoking cessation regularly during periodic dental check-ups.

3. Oral health care instructions by dentists or dental hygienists may include smoking cessation support.

4. Patients may be strongly motivated since they can observe their oral lesions by themselves.

5. Smoking cessation education may be provided for smokers who have not experienced systemic effects of smoking.



laws and regulations should be promptly revised to promote smoking cessation treatment by dentists and include smoking cessation treatment in the list of practices covered by social insurance, determine fees for smoking cessation treatment, and secure financing for it. In 2001, the American Dental Association included descriptions of smoking cessation treat-ment in its clinical recommendations. It is also important to create a forum to share information on smoking cessation treatment in dentistry.

Dental healthcare professionals should be actively encour-aged to quit smoking as well. Smoking by dental healthcare professionals decreases the motivation of patients to quit, and dental healthcare professionals with nicotine dependence may deny the importance of antismoking activities and rationalize their smoking habit. Environmental changes such as total smoking bans in healthcare facility that are currently under-way are important not only in preventing passive smoking but also in prompting dental healthcare professionals who smoke to attempt to quit smoking.

6. Status Before Surgery and Surgical Diseases

1. Effects of Smoking on Physical Function Before SurgeryNicotine, a major component of tobacco smoke that affects circulatory function, increases heart rate and systolic and dia-stolic blood pressure.13 Smoking causes coronary and systemic microcirculation disorders as a result of decreasing vasodilator reserve over time.69 The level of carboxyhemoglobin (COHb) in the blood is significantly higher in smokers than in non-smokers.70 Since CO causes a left shift of the oxyhemoglobin dissociation curve,71 and binds to cytochromes to inhibit aero-bic metabolism,72 smokers have chronic tissue hypoxia.

Circulatory dysfunction and tissue hypoxia start to improve after 2 to 3 days of abstinence. Ciliary movement starts to recover in 4 to 6 days, and sputum volume is normalized in 2 to 6 weeks. However, more than 3 months of abstinence is required to normalization of clearance, and at least 4 weeks are required to improve peripheral airway disorders.73,74

Smoking also impairs immune function.75 It has been re-ported that the prevalences of chronic bronchitis in patients planned to undergo surgery are about 5% and 25% among non-smokers and smokers, respectively.74

2. Effects of Smoking on the Results of Surgery1. Intraoperative ComplicationsSchwilk et al76 reported that the incidence of intraoperative respiratory complications (reintubation, laryngospasm, bron-chospasm, aspiration, hypoventilation, and hypoxemia) was 3.1% among non-smokers and 5.5% among smokers. The relative risk of intraoperative respiratory complications was 1.8 in all smokers, 2.3 in young smokers, and 6.3 in young obese patients. The incidence of bronchospasm was especially high in smokers.

2. Postoperative ComplicationsImpaired pulmonary function due to smoking may cause post-operative respiratory complications. Wellman et al77 have re-ported that the incidence of respiratory complications after abdominal or chest surgery is twice as high in smokers as in non-smokers, and Bluman et al78 have reported a correspond-ing ratio of 4. Relationships of smoking with adult respiratory distress syndrome (ARDS), acute myocardial infarction, devel-opment of atrial fibrillation, and perioperative death have been reported.

3. Smoking Cessation Support as Pre- and Postoperative Management

1. Effects of Smoking Cessation Before Surgery on Postoperative Complications

Warner et al79 reported that the incidence of postoperative respiratory complications was significantly lower in patients who quit smoking for ≥8 weeks before coronary surgery (14.5%) than in those who quit smoking for less than 8 weeks (57.1%), and that the incidence of such complications did not differ between patients who quit smoking for ≥6 months before coronary surgery and non-smoking patients. Nakagawa et al80 reported that the incidence of postoperative respiratory complications following pulmonary surgery was significantly lower in non-smokers (23.9%) than in smokers (43.2%), and lower in smokers who quit smoking for ≥4 weeks (34.7%) than in those who continued smoking. These findings indicate that patients should quit smoking for 4 to 8 weeks before sur-gery to prevent postoperative respiratory complications. Kuri et al81 reported that the incidence of delayed wound healing following head and neck reconstructive surgery was 85.7% in smokers, 67.6%, 55.0%, and 59.1% in smokers who had quit smoking for ≤3 weeks, ≤6 weeks, and ≥7 weeks before sur-gery, respectively, and 47.5% in non-smokers, and that smok-ing cessation for at least 3 weeks before surgery improves wound healing in such surgery.

2. Effects of Preoperative Smoking Cessation TreatmentIn a randomized comparative study by Møller et al82 in pa-tients who did or did not receive preoperative smoking inter-vention before surgery, the incidence of postoperative compli-cations was significantly lower in the smoking intervention group (18%) than in the control group (52%). The incidence of postoperative complications did not decrease in smokers who decreased the number of cigarettes smoked before sur-gery. These findings suggested that smoking cessation treat-ment but not a simple reduction of the number of cigarette use was effective in preventing postoperative complications. The authors also conducted a study in which the incidence of post-operative complications was significantly decreased in pa-tients who received smoking cessation treatment for ≥4 hours/week and in patients with higher educational status.83

Detailed explanation of the risks of postoperative complica-tions and delayed wound healing in smokers may motivate patients to quit smoking before surgery and continue absti-nence thereafter. It has been found that smokers planned to undergo surgery are more highly motivated to quit smoking than other smokers, and that simple instructions and treatment for smoking cessation may be highly effective.84 In particular, patients with lung cancer are highly motivated, and it has been reported that abstinence rate is improved when varenicline and nicotine replacement therapy are introduced immediately after the diagnosis of lung cancer.

3. Prevention of Smoking RelapseAlthough many patients quit smoking when cancer is diag-nosed, 14 to 58% of patients continue smoking, and patients who quit smoking before surgery often restart smoking after the surgical treatment. Further studies should be performed to investigate how to approach patients who restart smoking after discharge or treatment and how to use effective measures in-cluding varenicline and nicotine replacement therapy.



On February 27, 2005, the WHO FCTC was enforced. In com-memoration of this enforcement, which is important in the promotion of a smoke-free society in Japan, the nine academic societies pointed out problems that should be solved promptly.

Current problems regarding smoking in Japan are summa-rized as follows:

1 Insufficient “Measures to Prevent Underage Smoking”1-1 There are many underage smokers.1-2 Educational methods to prevent underage smoking

have not been fully established.1-3 Social systems including school education to prevent

underage smoking have not been established.

2 Insufficient “Measures to Protect Non-Smokers From Tobacco Smoke”2-1 The harms of passive smoking have not been fully

recognized.2-2 Sufficient measures to protect non-smokers from pas-

sive smoking have not been implemented.

3 Insufficient “Recognition of the Harms of Smoking and Implementation of Smoking Cessation Treatment”3-1 Healthcare professionals and educators who must be

role models in society are not fully aware of the harms of smoking, and many of them are smokers.

3-2 Low prevalence of smoking cessation treatment.3-3 Methods of smoking cessation treatment have not been

established, and anti-smoking drugs confirmed effec-tive in foreign countries have not been approved in Japan.

4 Insufficient “Social Systems and Policies for Promotion of a Smoke-Free Society”4-1 Tobacco products are relatively cheap, and there are

problems in terms of distribution routes, advertisements, and new tobacco products development.

4-2 There is no government organization dedicated to smok-ing-related problems.

4-3 No study organizations for continuous research on smoking-related problems have been established.

For the above-listed immediate problems, the following measures are proposed.

1. Prevention of Underage Smoking and Promotion of Smoking Cessation

Education should be widely given to the society on the harms of underage smoking. Educational organization should be established in the national and local governments as well as other suitable levels. The number of healthcare professionals who may educate on the prevention of underage smoking and provide smoking cessation treatment for underage smokers when requested by school should be increased. Cooperation between healthcare professionals, schools, and social support systems such as local child counseling centers should be estab-lished. In accordance with the WHO FCTC, tobacco vending machines should be removed.

2. Sufficient Protection of Non-Smokers From Passive Smoking

2-1 Increase in Recognition of the Harms of Passive Smoking

Information on the harms of passive smoking should be pro-vided at every possible opportunity, and anti-passive smoking campaigns should be deployed. Since passive smoking is a significant health concern, healthcare organizations and healthcare professionals should provide information and pro-mote campaigns elsewhere.

2-2 Implementation of Prevention of Passive Smoking in Accordance With the Health Promotion Law

In order to ensure the prevention of passive smoking in accor-dance with the Health Promotion Law, information on effec-tive preventive measures should be provided. Total smoking ban is the only way to avoid passive smoking in public spaces. Since it is particularly important to avoid passive smoking in school, we strongly request a total smoking ban on school grounds throughout Japan. We also request that the govern-ment enact laws to protect non-smokers from passive smoking and revise relevant laws and regulations (e.g., the Industrial Safety and Health Act, notifications) to ensure the avoidance of passive smoking.

3. Education on the Harms of Smoking and Widespread Implementation of Smoking

Cessation Treatment

3-1 Implementation of Campaigns and Education on the Harms of Smoking

Education on the harms of smoking may motivate smokers to quit smoking. All healthcare professionals and the national and local governments must provide opportunities for both smokers and non-smokers to learn about the harms of smoking and methods to quit smoking.

3-2 Development of Human Resources to Provide Smoking Cessation Treatment and Support for Smokers

Currently, only a limited number of healthcare professionals are capable of providing smoking cessation treatment and sup-port for smokers to quit smoking. Specialists in smoking ces-sation treatment and patient support must be fostered.

3-3 Establishment of Smoking Cessation Treatment and Institutionalization to Promote the Widespread Use of Effective Methods for Such Treatment

More feasible methods should be developed and institutional-ized to promote the widespread use of effective measures to quit smoking. Smoking cessation treatment should be covered by the NHI, and anti-smoking drugs should be listed the NHI drug price list. Moreover, anti-smoking drugs that have been confirmed effective and safe in foreign countries should be approved and launched promptly in Japan.

Problems With Tobacco GumIn October 2003, the world’s first chewing gum-type tobacco product was launched in the Tokyo metropolitan area. Tobacco gum is classified as a “tobacco product” (smokeless chewing

III Immediate Problems



tobacco) in the Tobacco Industries Act. This product is a chewing gum containing tobacco leaf, and appears similar to conventional chewing gums (Table 9). This product was test-marketed in kiosks in stations of private railroads by empha-sizing its “usefulness for smokers who cannot smoke” when smoking ban to prevent passive smoking extended to cover more areas according to the Health Promotion Law.

Chewing tobacco products have been demonstrated in many countries to increase the risk of development of oral cavity disorders including cancer and decrease the QOL signifi -cantly.

Anti-smoking civilian groups opposed the release of to-bacco gum. In November 2003, the Japanese Society of Oral and Maxillofacial Surgeons and the Japanese Society for Oral Health jointly submitted a petition to the Ministry of Finance to request that the government release precautions for the product or withdraw approval of it. In 2004, the Offi ce for Lifestyle-Related Disease Control, General Affairs Division, Health Service Bureau of the Ministry of Health, Labour, and Welfare (MHLW) published “Information on health-related issues of tobacco gum” on the MHLW website to describe its health-related risks and the risk of misuse of it by children. A member of the Diet asked questions concerning the risk of confusing tobacco gum with nicotine gum in smoking cessa-tion treatment and the risk for underage use of such gum. In April 2004, the Japan Medical-Dental Association for Tobacco Control held an impromptu symposium entitled “Smokeless Tobacco or Health” to discuss the effects of smokeless tobacco on the health and measures for smoke-free society and share reports by specialists and citizens on the risk of smokeless to-bacco products (Table 9), and issued a warning to the society that “if we make a bad judgement now, we will have serious problems in the future”.

In some foreign countries, products containing tobacco leaf such as tobacco candies and tobacco toothpastes are available. Tobacco gum is a dangerous step for nextgeneration tobacco products. The WHO recommended that prohibition of promo-tion, advertising, and labeling of nicotine-containing products be promptly performed.85

4. Implementation of Social Systems and Policies to Promote a Smoke-Free Society

4-1 Solve Problems Concerning Tobacco Price, Distribution, Advertisements, and New Tobacco Products

The WHO FCTC requests strict regulation of the price, distri-bution, and advertisement of tobacco products. We request that the government implement laws and regulations conform-ing to the WHO FCTC.

4-2 Establish Government and Private Organizations Dedicated to Smoking-Related Problems

There are no national, public or private organizations dedi-cated to tobacco control in Japan, and there are no specialists dedicate to smoking-related problems, which may delay im-plementation of measures to promote smoke-free society. We strongly request the government to establish an administrative organization which can dedicate to tobacco control and pro-mote tobacco control measures actively and include medical professionals in it.

4-3 Establish an Organization for Continuous Research on Smoking-Related Problems

Japan urgently needs to perform long-term epidemiological studies, large-scale interventional studies of effective smoking cessation procedures, long-term investigations of the effi cacy of educational programs to prevent underage smoking, inter-ventional studies on smoking cessation support for women and adolescents, and studies based on comparisons of policies be-tween Japan and other countries.

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AppendixChair: • Toyoaki Murohara, Department of Cardiology, Nagoya University

Graduate School of Medicine

Members: • Tadayuki Ahiko, Health and Welfare Department, Yamagata Prefec-

ture/Yamagata Prefectural Institute of Public Health • Yoshinori Doi, Department of Medicine and Geriatrics, Kochi Medical

School • Takashi Hanioka, Department of Preventive and Public Health Den-

tistry, Fukuoka Dental Colledge • Jitsuo Higaki, Department of Integrated Medicine and Infomatics,

Ehime University Graduate School of Medicine • Takashi Hirano, Toda Chuo General Hospital • Mami Iida, Department of Internal Medicine, Gifu Prefectural General

Medical Center • Masahiro Ishii, Department of Pediatrics, Kitasato University, School

of Medicine • Masayuki Kaji, Shizuoka City Public Health Center • Katsuyuki Kinoshita, Seijo Kinoshita Hospital • Yumiko Mochizuki-Kobayashi, Division of Tobacco Policy and Edu-

cation, National Cancer Center Research Institute • Atsushi Nagai, First Department of Medicine, Tokyo Women’s Medi-

cal University School of Medicine • Keijiro Saku, Department of Cardiology, Fukuoka University School

of Medicine • Yuko Takahashi, Health Administration Center, Nara Women’s Uni-

versity • Teruo Takano, Nippon Medical School • Masanobu Yanase, Department of Organ Transplantation, National

Cerebral and Cardiovascular Center • Nobuo Yosizawa, Yamagata University

Collaborators: • Yukari Kamiyama, Divisions of Thoracic Diseases, Tochigi Cancer

Center • Masahiko Kawakami, Ryokufuso Hospital • Hiroshi Kawane, Japanese Red Cross Hiroshima College of Nursing • Yoshihisa Matsumura, Department of Medicine and Geriatrics, Kochi

Medical School • Masakazu Nakamura, Department of Health Promotion and Education,

Osaka Medical Center for Health Science and Promotion • Yasushi Nakamura, Department of Fetal Medicine, Chigasaki Tokush-

ukai General Hospital • Yuri Nakata, Department of Health Development, Institute of Indus-

trial Ecological Science, University of Occupational and Environ-mental Health

• Toshiyuki Shibata, Department of Oral and Maxillofacial Sciences, Division of Organ Pathobiology, Gifu University School of Medi-cine

• Jun Sono, Nishinomiya City Public Health Center • Masahiro Tsuboi, Department of Thoracic Surgery, Kanagawa Cancer

Center Hospital • Hiroshi Yamato, Department of Health Development, Institute of In-

dustrial Ecological Science, University of Occupational and Envi-ronmental Health

Independent Assessment Committee: • Hiroyuki Daida, Division of Cardiology, Department of Internal Med-

icine, Juntendo University School of Medicine • Takayuki Ito, Department of Internal Medicine, Division of Cardiology,

Aichi Medical University School of Medicine • Hisao Ogawa, Department of Cardiovascular Medicine, Graduate

School of Medical Sciences, Kumamoto University • Kazuaki Shimamoto, Sapporo Medical University

(The affiliations of the members are as of September 2011)

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