Laryngeal cancer is one of various smoking-related cancers. It has long been assumed that antismoking campaigns are effective for primary prevention, because the ratio of non-smoker patients with laryngeal cancer is extremely low, at only 2.7 percent. In Japan, the percentage of male smokers was over 80 percent in the 1960s, but as of 2016 it has fallen to 29.7 percent. The ratio of female smokers has also fallen within the same time frame, from 18 percent to 9.7 percent. The age-standardized incidence rate of laryngeal cancer was 2.8 per 100,000 in the 1960s, higher than the aggregated rate of oral cancer and pharyngeal cancer, but the rate has subsequently declined to 2.1. By contrast, the rates of oral cancer, oropharyngeal cancer and hypopharyngeal cancer have risen from 1.2, 0.1, and 0.2 respectively to 3.8, 1.7, and 1.6. It is only laryngeal cancer that has been directly influenced by the declines in the smoking rates. To achieve success in primary prevention of laryngeal cancer, it is important that antismoking campaigns are continued aggressively.

Non-malignant diseases induced by smoking are, like malignant diseases, a serious issue. Chronic obstructive pulmonary disease (COPD) is a representative respiratory disease induced, like lung cancer, by tobacco usage. It shows slow progressive development with irreversible airway obstruction, leading to respiratory failure. Not to smoke is the only way to prevent COPD. If a patient with COPD quits smoking, progression of the disease will slow but inflammation is presumed to continue. In the case of asthma, smoking is known to be a factor that causes the disease to worsen. Also, passive smoking attributed to parents smoking has a significant influence on the incidence of asthma in children. Because of nicotine addiction, many patients keep smoking even knowing that it is harmful to the lungs. Many non-malignant diseases such as interstitial pneumonia and respiratory infection, and not only malignant diseases, are closely related to smoking.

The International Agency for Research on Cancer (IARC) has reported that tobacco smoking is the single largest cause of cancer of various organs. More than 70 carcinogens have been identified in tobacco smoke, the strongest being nitrosamines and polycyclic aromatic hydrocarbons. There is convincing evidence that smoking tobacco strongly increases the risk of lung cancer in the Japanese population, with the relative risk, compared to nonsmokers, 4.4 times higher in men and 2.8 times higher in women. As to the danger accompanying passive smoking, the hazard ratio (HR) for adenocarcinoma incidence is reported to be 2.03 times higher in women who live with a smoking husband than in women married to nonsmokers.

Among histological types of lung cancer, smoking is known to be closely associated not only with squamous cell carcinoma and small cell carcinoma but also with adenocarcinoma and LCNEC. Tobacco smoking is strongly associated with mutation of the K-ras gene in patients with primary adenocarcinoma of the lung. Metabolic genetic factors, for example polymorphisms in CYP1A1, play a role in lung cancer developing at young ages.

Patients with COPD are 3-4 times more likely to develop lung cancer than smokers with normal lung function. Meta-analyses have revealed that the presence of COPD in patients with lung cancer results in worse OS than those without COPD. Lung cancer patients with interstitial lung diseases who have undergone pulmonary resection often develop acute exacerbation (AE) of interstitial pneumonia in the post-operative period. Risk scores can be used in routine clinical practice to identify high-risk individuals. Smokers with lung cancer tend to have advanced lung cancer, impaired pulmonary function, and high morbidity after surgery. Non-smokers have significantly better OS, even patients with stage IA lung cancers. People who stop smoking, even well into middle age, avoid most subsequent risk of lung cancer, and stopping before middle age avoids more than 90% of the risk attributable to tobacco.

Smoking-related disorders such as pulmonary/cardiovascular diseases are known to increase perioperative risk, and smoking itself can increase the risk of morbidity. However, the significance of perioperative smoking cessation is not fully understood, and patients in many hospitals are still not guided to quit smoking before surgery. In 2015 the Japan Society of Anesthesiologists formulated “perioperative smoking-cessation guidelines.” During the perioperative period, cigarette smokers have significantly higher risks of cardiopulmonary complications, including death and infectious complications, compared to non-smokers. With regard to the duration of the preoperative smoke-free period, it was recently reported that each week of cessation can increase the magnitude of effect. In addition, it has been indicated that short-term smoking cessation starting at least 2 days before surgery will eliminate problems in tissue oxygen uptake by CO, starting 3 weeks before will reduce wound infection complications, and starting 4 weeks before will reduce respiratory complications. Thus, it is important to advise patients to quit smoking some time before surgery. We also present a possible solution to the problem of managing anesthesia in smokers during surgery.

Smoking and smoking cessation are both important from the perspective of health economics because the social costs of smoking are enormous while smoking cessation is a cost-effective intervention. The social costs of smoking are generally divided into the excess healthcare costs incurred with smoking-related diseases, which are calculated based on risk attributable to smoking, and productivity loss representing loss of the value of time lost due to treatment or death. It has been argued that reduction of the healthcare costs of smoking-related diseases is offset by the increase of healthcare costs, including for unrelated diseases, when the period of evaluation is extended over a longer period of time. Generally, however, unrelated healthcare costs are not considered when making economic evaluations of healthcare. Accordingly, smoking cessation most often yields a “cost-reducing” result, i.e. improved health and lower costs compared to subjects who do not cease smoking. Future collaborations between clinicians and health economists are necessary in order to analyze the economic impacts of both smoking and smoking cessation on society based on evidence of social costs and economic evaluations.

Smoking is a chronic general disease that is a combination of addiction and smoking-related diseases rather than a personal habit or pastime; i.e. smokers are patients who are suffering from nicotine dependence and who require active treatment. The most important clinical issues in treating nicotine dependence are difficulty in starting to quit smoking and a high rate of recurrence. The Agency for Healthcare Research and Quality (AHRQ) recommends motivational interviewing (MI) or the 5R approach for patients who show no interest or readiness to quit smoking. In smoking cessation clinics, patients are typically prescribed nicotine products as nicotine replacement therapy or the oral medication varenicline, which contains no nicotine. Although usage of medicine improves the success rate of attempts to quit smoking, the recurrence rate reminds high. Today, psychotherapy, including cognitive behavioral therapy, is being conducted as well as experiments in novel forms of psycho-education based on brain science (hypersensitization theory, Paradise Lost theory, etc.).