Chronic Conditions/ Diseases

Forty-five percent of Americans have at least one chronic condition.1 Tobacco users often come into contact with healthcare professionals—including physicians, nurses, medical staff, dentists, and pharmacists—during diagnosis and treatment of chronic conditions. In particular, diagnosis of a tobacco-related disease has been associated with an increase in quit attempts, use of cessation resources, and cessation, as it provides a teachable moment for patients when they are motivated to make and sustain a quit attempt. Optimal treatment of these chronic conditions must address tobacco use by encouraging and supporting quitting.2

The Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions.3

  • Smoking is associated with poor therapeutic outcomes in patients with comorbid disease
  • Continued smoking increases the risk for developing additional adverse health conditions after diagnosis and/or treatment of a comorbid condition
  • Tobacco assessment and cessation support is not well incorporated into clinical care and research for comorbid disease
  • People with comorbid conditions appear to have similar or improved motivation to quit. The “teachable moment” may be useful to improve motivation to quit
  • Multiple comorbid conditions (psychiatric, cancer, etc.) may occur within a patient who uses tobacco and may be important components of developing individualized care
  • Smoking cessation medications may interact with medications used to treat comorbid conditions
  • Evidence-based approaches to tobacco cessation (counseling and pharmacotherapy) can be used across comorbid conditions
  • All people who use tobacco, with or without a comorbid condition, should receive evidence-based tobacco cessation support
 

In addition to these common themes, specific chronic diseases are addressed below, including:

  • Cancer
  • Diabetes
  • Heart Disease/Cardiovascular Disease
  • People living with HIV/AIDSRespiratory Disease

Chronic Disease: Cancer

Why it Matters

  • A study that assessed smoking behaviors among U.S. adult cancer survivors using the 2017 NHIS data found the prevalence of cigarette smoking in this high-risk group (13.16%) to be similar to that of the U.S. general adult population (13.7%) despite the compelling evidence supporting the adverse consequences of smoking on health and survival after cancer diagnosis.
    • Current smoking prevalence was substantially higher among smoking related cancer (SRC) survivors (19.78%) compared with non-smoking related cancer (NSRC) survivors (10.63%) and individuals without cancer (14.2%).5
    • Compared with NSRC survivors, SRC survivors may be at higher risk of being
      cigarette smokers at cancer diagnosis and of continuing smoking afterward.6
  • Evidence is suggestive but not sufficient to infer a causal relationship between smoking cessation and improved all-cause mortality in patients with cancer who are current smokers at the time of a cancer diagnosis.7
  • Patients with cancer who have recently quit smoking have an approximately two-fold increase in the five-year overall likelihood of survival from cancer.8

What We Know About What Works

  • People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Cancer-specific talking points would include:9
    • Fewer and less serious side effects from cancer treatment, including surgery, chemotherapy, and radiation therapy
    • Faster recovery from treatment
    • Lower risk of secondary cancers
    • Decreased risk for many other serious illnesses, including secondary infections, heart attacks and pneumonia10

What’s Relevant in Pennsylvania

  • The long-term goal of the NCI Cancer Center Cessation Initiative (C3I) is to help cancer centers build and implement sustainable tobacco cessation programs to routinely address tobacco cessation with cancer patients. Pennsylvania participants include the Abramson Cancer Center University of Pennsylvania and the UPMC Hillman Cancer Center.

What Other States Are Doing

  • The University of Wisconsin-Madison Center for Tobacco Research and Intervention provides training videos illustrating clinical cessation encounters with specific talking points tailored to cancer.

References and Resources

  • The American Lung Association is committed to defeating lung cancer and supporting those affected by this disease. We offer a variety of resources and information about lung cancer.
  • Saved By The Scan is a lung cancer screening campaign by the American Lung Association’s LUNG FORCE initiative and the Ad Council that aims to raise awareness of the benefits of early detection through lung cancer screening and drive high-risk individuals to take an online lung cancer screening eligibility quiz.
    • The American Cancer Society offers tools including a smoking habits quiz and a fact sheet on the health risks of tobacco.

Chronic Disease: Diabetes

Why it Matters

  • We now know that smoking causes type 2 diabetes. In fact, people who smoke are 30%-40% more likely to develop type 2 diabetes than nonsmokers. And people with diabetes who smoke are more likely than nonsmokers to have trouble with insulin dosing and with controlling their disease. The more cigarettes smoked, the higher the risk for type 2 diabetes.11
  • Smoking makes diabetes harder to control. People with diabetes who smoke are more likely to have serious health problems from diabetes. People who smoke and have diabetes have higher risks for serious complications, including:
    • Heart and kidney disease
    • Poor blood flow in the legs and feet that can lead to infections, ulcers, and possible amputation (removal of a body part by surgery, such as toes or feet)
    • Retinopathy (an eye disease that can cause blindness)
    • Peripheral neuropathy (damaged nerves to the arms and legs that causes
      numbness, pain, weakness, and poor coordination)12
  • For smokers with diabetes, quitting smoking will benefit health immediately. People with diabetes who quit have better control of their blood sugar levels.13
  • Older men who were relapsed smokers had a higher risk of type 2 diabetes-related emergency department visits. Future research and clinical practice should focus on these patients and create more effective interventions for smoking cessation and diabetes management.14

What We Know About What Works

  • When patients with diabetes have multiple chronic conditions, screening, counseling, and treatment needs can far exceed the time available for patient-provider visits.15 Thus, scheduling longer provider visits should be considered to ensure time to address tobacco cessation.
  • Smoking cessation without subsequent weight gain is associated with a reduced risk of cardiovascular disease and mortality among smokers with type 2 diabetes. Weight gain after smoking cessation attenuates the reduction in risk of developing cardiovascular disease but does not attenuate the beneficial effect of smoking cessation with respect to mortality. These findings confirm the overall health benefits of quitting smoking among people with type 2 diabetes, but also emphasize the importance of weight management after smoking cessation to maximize its health benefits.16
  • People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Talking points specific to people with diabetes would include:17
    • Increase their control over their diabetic symptoms, including improved blood sugar levels
    • Decrease complications such as blindness as well as reducing the chances of amputation, through improved blood flow
    • Decreasing risk of developing neuropathy18

What’s Relevant in Pennsylvania

  • Approximately 1,455,813 people in Pennsylvania, or 12.8% of the adult population, have diabetes.19
  • Since 2014, Health Promotion Council (HPC) has been committed to increasing access to the National Diabetes Prevention Program (National DPP) for the millions of Pennsylvanians at risk for type 2 diabetes and living with prediabetes.
    • HPC supports organizations in delivering the National DPP through funding and technical assistance.
    • HPC supports learning and success among National DPP Lifestyle Coaches in Pennsylvania through virtual and face to face gatherings to share best practices and resources to promote program sustainability.
    • HPC fosters community-clinical integration among health plans, healthcare systems and providers, DPP lifestyle coaches, and community partners to increase referrals and enrollment.
  • Links to other Diabetes Prevention Programs can be found on the National CDC program website.

What Other States Are Doing

  • Diabetes educators throughout California have joined forces with the California Diabetes Program, California Tobacco Control Program and the California Smokers’ Helpline to assist their patients with diabetes to quit smoking. “Do you cAARd?” (Ask, Advise, Refer) challenges diabetes educators to give patients who smoke or chew the California Gold Card, a marketing piece that urges smokers to call the Helpline at 1-800-NO-BUTTS.20
  • In Washington, the state tobacco program has developed a strong linkage with the diabetes program through their joint work with the Washington State Diabetes Collaborative. Not only does the tobacco program provide funds to the Collaborative, additionally one of the performance measures for Collaborative participants is intervening with patients and referring to the state quitline. Quitline promotion materials and information are available at all Diabetes
    Collaborative learning sessions and these materials are routinely distributed to the participating clinics.21
  • The University of Wisconsin-Madison Center for Tobacco research and Intervention provides training videos illustrating clinical cessation encounters with specific talking points tailored to people with diabetes.

References and Resources

  • The CDC launched the Tips from Former Smokers campaign. This initiative profiles real people who are living with serious long-term health effects from smoking and secondhand smoke exposure. It features compelling stories of former smokers living with smoking-related diseases and disabilities including diabetes and the toll these conditions have taken on them.
  • Win the Fight to Quit Smoking is an American Diabetes Association web page with high level information about benefits of quitting, preparation for quitting, and choosing a quitting strategy.
  • The ADA’s Treatment for Kidney Disease page mentions avoiding tobacco under “Self-Care,” and may be an important message for tobacco users with diabetes who are worried about kidney failure, dialysis or the need for transplant.

Chronic Disease:
Heart Disease/ Cardiovascular Disease

Why it Matters

  • Smoking is a major cause of cardiovascular disease (CVD) and causes one of every four deaths from CVD. Smoking can:
    • Raise triglycerides (a type of fat in your blood)
    • Lower “good” cholesterol (HDL)
    • Make blood sticky and more likely to clot, which can block blood flow to the heart and brain
    • Damage cells that line the blood vessels
    • Increase the buildup of plaque (fat, cholesterol, calcium, and other substances) in blood vessels
    • Cause thickening and narrowing of blood vessels22
  • In patients who are current smokers when diagnosed with coronary heart disease, the evidence is sufficient to infer a causal relationship between:
    • Smoking cessation and a reduction in all-cause mortality
    • Smoking cessation and reductions in deaths due to cardiac causes and sudden deaths
    • Smoking cessation and reduced risk of new and recurrent cardiac events23
  • Quitting smoking can lower the risk of heart disease as much as, or more than, common medicines used to lower heart disease risk, including aspirin, statins, beta blockers, and ACE inhibitors.24
  • Each cigarette smoked per day elevated the odds of circulatory disease by 5% to 23% (seven diseases, including atherosclerosis, myocardial infarction, congestive heart failure, arterial embolisms).25

What We Know About What Works

  • People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Talking points specific to people with cardiovascular disease would include:26
    • Decrease their risk of heart attack and stroke
    • Decrease their chance of long-term disability
    • Make it easier to manage both blood pressure and cholesterol levels27

What’s Relevant in Pennsylvania

  • The leading cause of death in Pennsylvania is heart disease.28
  • In 2017, Pennsylvania ranked 14th among the states with 32,312 deaths caused by heart disease.29
  • Stroke is the fourth leading cause of death in Pennsylvania.30

What’s Other States Are Doing

References and Resources

Chronic Disease:
People Living With HIV/AIDS (PLWHA)

Why it Matters

  • Smoking rates among persons living with HIV, which is the virus that can cause AIDS, are much higher than among persons without HIV.
    • In 2014, among adults with HIV, 37.9% were current cigarette smokers.
    • People living with HIV are also less likely to quit smoking than the general population.31
  • Compared to the general population, the HIV-positive population is two to three times more likely to smoke.32
  • Smoking while HIV-positive increases the risk of developing infections and long-term side
    effects of HIV disease and treatment. It is also linked with a higher rate of death.33
  • There are many challenges to the implementation of smoking cessation among PLWHA. The overlap between HIV/AIDS, substance use, and mental illness makes smoking cessation among PLWHA a more difficult proposition than it has been for the general population.34
  • Age and education were the strongest predictors of current and past tobacco use among people living with AIDS (PLWHA); however, even college graduates reported current use
    rates twice the national average.35
  • Depressive symptoms were highly prevalent in this representative population of HIV-infected patients.36

What We Know About What Works

  • Encourage health care providers serving people with HIV to screen for tobacco use among and promote cessation.37
  • Because non-medically based HIV/AIDS service providers must also address the health-related needs of their clients through on-site and referral mechanisms, most if not all HIV/AIDS direct service providers are viable conduits for smoking cessation interventions.38
  • A Zolle Cochran review showed very low-quality evidence that combined tobacco cessation interventions were effective in helping PLWHA achieve short-term abstinence. Despite this, tobacco cessation interventions should be offered to PLWHA, since even non-sustained periods of abstinence have proven benefits.39
  • People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Talking points specific for PLWHA would include:40
    • Allows therapies to work as intended
    • Provide a better quality of life with fewer HIV-related symptoms
    • Decrease their risk for many serious illnesses, including heart attacks and pneumonia41

What’s Relevant in Pennsylvania

  • In 2016, the Bureau of Epidemiology examined the trend in new HIV diagnoses among young adults in Pennsylvania. The results showed that, while other age groups have experienced continuous declines in new HIV diagnoses, young adults age 20 to 29 years old predominated among new HIV diagnoses over the preceding 10 years.
  • The number of new diagnoses peaked in the early to mid-1990s when almost 3,000 new diagnoses were reported annually. In 2018, fewer than 1,000 new diagnoses were reported.
    • Approximately three times as many males have been diagnosed with HIV disease than females.
    • People who are Black/African American or Hispanic make up 11% and 6.6% of the population of Pennsylvania, but account for 4% and 18%, respectively, of all new diagnoses of HIV among Pennsylvania residents.
    • Although a person can be infected at any age, the majority of new diagnoses occur in persons who are between the ages of 20 and 49.
  • Large disparities remain in terms of race, risk and county of residence. There is a continuing need for HIV prevention efforts targeted at specific demographic, risk and geographic areas, as well as integrating pre-exposure prophylaxis and prompt linkage of new cases to HIV care services.

References and Resources

Chronic Disease:
Respiratory Diseases
(Asthma, Bronchitis, COPD, Lung Cancer)

Why it Matters

  • Diseases caused by smoking kill more than 480,000 people in the U.S. each year. Smoking is directly responsible for almost 90% of lung cancer and COPD deaths.45
  • Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation.  Despite increasing numbers of randomized controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases, many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.46
  • The evidence is suggestive but not sufficient to infer that smoking cessation improves lung function among persons with asthma who smoke.47
  • Each cigarette smoked per day elevated the odds of respiratory diseases by 5% to 33% (nine distinct diseases, including pneumonia, emphysema, obstructive chronic bronchitis,
    pleurisy, pulmonary collapse, respiratory failure).48

What We Know About What Works

  • Smoking cessation is the only proven way of modifying the progression of COPD.49
  • A research team compared two ways to help people with COPD quit cigarette smoking.
    • Long-term nicotine replacement therapy (LT-NRT)
    • Standard smoking cessation (SSC)
  • The team wanted to see if LT-NRT was better than SSC at helping patients with COPD quit smoking. After one year, the research team did not find a difference between the two groups in the number of people who had stopped smoking, the number of cigarettes smoked per day, the number of times patients tried to quit smoking, the amount of unhealthy chemicals they breathed in, how well their lungs worked or in how many times they had to go to the hospital or emergency room. However, the research team found that patients in the SSC group took less time to complete the program and had fewer side effects than those in the LT-NRT group.50
  • High-quality evidence in a meta-analysis demonstrated that a combination of behavioral treatment and pharmacotherapy is effective in helping people who smoke and have COPD to quit smoking. There was no convincing evidence for preferring any particular form of behavioral or pharmacological treatment.51
  • People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Talking points for people with respiratory diseases would include:52
    • Reduce irritation in airways and lessen the possibility of triggering an asthma attack
    • Enhance the effectiveness of asthma medications
    • Decrease asthma symptoms
    • Decrease serious COPD flare ups
    • Allow the person to be more active
    • Slow the progression of COPD
    • Help make breathing easier53

What’s Relevant in Pennsylvania

  • Asthma Prevalence among Pennsylvania’s adults in 2018 was 10.0%.54
  • 11.2 percent of children (17 and younger) in Pennsylvania have asthma.55
  • As of 2017, the BRFSS estimates that seven percent of Pennsylvania adults reported ever being told they have COPD. That is more than half a million people.56
  • The rate of new lung cancer cases in Pennsylvania is 64.4 and significantly higher than the national rate of 59.6.  It ranks 31st among all states, placing it in the average tier.57
  • The American Lung Association sponsors 23 active Better Breathers clubs in Pennsylvania. These clubs provide social and educational support to patients with COPD, asthma, and other lung diseases, and their caregivers.
  • Breathe Pennsylvania offers an eight session group Smoke-Free for Life cessation program and trains facilitators in motivational interviewing and counseling. Also available:

What Other States Are Doing

References and Resources

  1. Ann Tinker, “How to Improve Patient Outcomes for Chronic Diseases and Comorbidities,” Health Catalyst, 2017.
  2. Jeffrey Drope et al., “Comorbidities.” The Tobacco Atlas 6th ed. (Atlanta: American Cancer Society and Vital Strategies, 2018). https://tobaccoatlas.org/topic/comorbidities/#:~:text=Tobacco%20use%20significantly%20worsens%20other,HIV%20infection%20and%20mental%20illness.&text=We%20now%20know%20that%20tobacco,HIV%20infection%20and%20alcohol%20abuse.
  3. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke,” Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco 18, no. 8 (2016): 1684–96, https://doi.org/10.1093/ntr/ntw016.
  4. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke.”
  5. Ellen R. Gritz et al., “Smoking Behaviors in Survivors of Smoking-Related and Non–Smoking-Related Cancers,” JAMA Network Open 3, no. 7 (July 1, 2020): e209072–e209072. https://doi.org/10.1001/jamanetworkopen.2020.9072.
  6. Ibid.
  7. “Smoking Cessation: A Report of the Surgeon General.” US Department of Health and Human Services. 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.
  8. “How to Make the Case for Tobacco,” American Lung Association. https://www.lung.org/policyadvocacy/tobacco/cessation/technicalassistance/hospital-community-benefits/make-the-case.
  9. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke.”
  10. “Quit Don’t Switch Training” American Lung Association. https://quitdontswitchtraining.lung.org.
  11. “Smoking and Diabetes,” Centers for Disease Control and Prevention, March 31, 2020. https://www.cdc.gov/tobacco/campaign/tips/diseases/diabetes.html.
  12. Ibid.
  13. Ibid.
  14. Yu-Hsiang Kao, “Smoking Relapse and Type 2 Diabetes Mellitus–Related Emergency Department Visits Among Senior Patients with Diabetes,” Preventing Chronic Disease. 2019. https://doi.org/10.5888/pcd16.190027.
  15. John D. Piette et al., “The Impact of Comorbid Chronic Conditions on Diabetes Care,” Diabetes Care. March 1, 2006. https://doi.org/10.2337/diacare.29.03.06.dc05-2078.
  16. Gang Liu et al., “Smoking Cessation and Weight Change in Relation to Cardiovascular Disease Incidence and Mortality in People with Type 2 Diabetes: A Population-Based Cohort Study,” The Lancet Diabetes & Endocrinology. February 1, 2020. https://doi.org/10.1016/S2213-8587(19)30413-9.
  17. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke.”
  18. “Quit Don’t Switch Training”.
  19. “The Burden of Diabetes in Pennsylvania,” American Diabetes Association. http://main.diabetes.org/dorg/PDFs/Advocacy/burden-of-diabetes/pennsylvania.pdf.
  20. “The Growing Link Between Quitlines and Chronic Disease Programs,” North American Quitline Consortium. https://cdn.ymaws.com/www.naquitline.org/resource/resmgr/docs/factsheet-chronicdisease_200.pdf.
  21. Ibid.
  22. “Heart Disease and Stroke,” Centers for Disease Control and Prevention, June 25, 2019. https://www.cdc.gov/tobacco/basic_information/health_effects/heart_disease/index.htm.
  23. “Smoking Cessation: A Report of the Surgeon General.”
  24. “How to Make the Case for Tobacco.”
  25. Catherine King et al., “Mendelian Randomization Case-Control PheWAS in UK Biobank Shows Evidence of Causality for Smoking Intensity in 28 Distinct Clinical Conditions,” EClinicalMedicine. July 31, 2020. https://doi.org/10.1016/j.eclinm.2020.100488.
  26. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke.”
  27. “Quit Don’t Switch Training”.
  28. “National Center for Health Statistics Pennsylvania Key Health Indicators,” Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/pressroom/states/pennsylvania/pa.htm.
  29. “National Center for Health Statistics Stats of the State of Pennsylvania 2017,” Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/pressroom/states/pennsylvania/pennsylvania.htm
  30. “Heart Disease and Stroke Prevention Program,” Pennsylvania Department of Health. https://www.health.pa.gov/topics/programs/Heart-Disease/Pages/Heart%20Disease-Stroke.aspx
  31. “People Living With HIV – Tips From Former Smokers,” Centers for Disease Control and Prevention, May 28, 2020. https://www.cdc.gov/tobacco/campaign/tips/groups/hiv.html.
  32. “Smoking Cessation: Primary Care of Veterans with HIV.” US Department of Veterans Affairs. 2009. https://www.hiv.va.gov/pdf/pcm-manual.pdf
  33. “HIV and smoking.” AIDS.gov website. August 12, 2014 https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-ofyourself/smokingtobacco-use/.
  34. James Tesoriero et al., “Smoking Among HIV Positive New Yorkers: Prevalence, Frequency, and Opportunities for Cessation.”Aids and Behavior. October 2008. https://www.researchgate.net/publication/23243019_Smoking_Among_HIV_Positive_New_Yorkers_Prevalence_Frequency_and_Opportunities_for_Cessation.
  35. Ibid.
  36. Antoine Benard et al., “Tobacco Addiction and HIV Infection: Toward the Implementation of Cessation Programs. ANRS CO3 Aquitaine Cohort,” AIDS Patient Care and STDs 21. July 1, 2007. https://doi.org/10.1089/apc.2006.0142.
  37. “Best Practices User Guide: Health Equity in Tobacco Prevention and Control.” Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2015. https://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-healthequity.pdf.
  38. James Tesoriero et al., “Smoking Among HIV Positive New Yorkers: Prevalence, Frequency, and Opportunities for Cessation.”
  39. Erica RM Pool et al., “Interventions for Tobacco Use Cessation in People Living with HIV and AIDS,” Cochrane Database of Systematic Reviews, no. 6 (2016). https://doi.org/10.1002/14651858.CD011120.pub2.
  40. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke.”
  41. “Quit Don’t Switch Training”.
  42. “2018 Annual HIV Surveillance Summary Report,” Bureau of Epidemiology, July 2019. https://www.health.pa.gov/topics/Documents/Programs/HIV/2018%20Annual%20HIV%20Surveillance%20Report.pdf
  43. Ibid.
  44. Ibid.
  45. “Smoking and Respiratory Diseases,” Johns Hopkins Medicine.
    https://www.hopkinsmedicine.org/health/conditions-and-diseases/smokingand-respiratory-diseases.
  46. Carlos A. Jiménez-Ruiz et al., “Statement on Smoking Cessation in COPD and Other Pulmonary Diseases and in Smokers with Comorbidities Who Find It Difficult to Quit,” The European Respiratory Journal 46, no. 1 (July 2015): 61–79.
    https://doi.org/10.1183/09031936.00092614.
  47. “Smoking Cessation: A Report of the Surgeon General.”
  48. Catherine King et al., “Mendelian Randomization Case-Control PheWAS in UK Biobank Shows Evidence of Causality for Smoking Intensity in 28 Distinct Clinical Conditions.”
  49. “How to Make the Case for Tobacco.”
  50. Eva AM van Eerd et al., “Smoking Cessation for People with Chronic Obstructive Pulmonary Disease,” Cochrane Database of Systematic Reviews. 2016. https://doi.org/10.1002/14651858.CD010744.pub2.
  51. Ibid.
  52. Alana M. Rojewski et al., “Exploring Issues of Comorbid Conditions in People Who Smoke.”
  53. “Quit Don’t Switch Training”.
  54. “Most Recent State or Territory Asthma Data,” Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/most_recent_data_states.htm
  55. “Percentage of Children with Current Asthma by State/Territory,” Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/asthmadata/Child_prevalence_state.html
  56. “COPD,” Pennsylvania Department of Health. https://www.health.pa.gov/topics/Documents/Environmental%20Health/COPD.pdf
  57. “Pennsylvania Lung Cancer Rates,” American Lung Association,
    https://www.lung.org/research/state-of-lung-cancer/states/pennsylvania

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