Electronic cigarettes (also known as e-cigarettes) are
battery-operated devices that often are designed to look, feel, and
taste like tobacco cigarettes. These devices, which may be marketed to
young people and sold as a safer alternative to smoking, contain
nicotine, flavors, and other substances that are turned into a vapor and
are then inhaled. In July 2009, several public health organizations,
including the U.S. Food and Drug Administration (FDA), the U.S.
Department of Health and Human Services, and the Centers for Disease
Control and Prevention (CDC), determined that e-cigarettes contain toxic
chemicals and cancer-causing agents (carcinogens) and that health
claims made by manufacturers of these devices are unproven.
In the mid-twentieth century smoking in the
United States
was often associated with romance, relaxation, and adventure; movie
stars oozed glamour on screen while smoking, and movie tough guys were
never more masculine than when lighting up. Songs such as "Smoke Gets in
Your Eyes" topped the hit parade. Smoking became a rite of passage for
many young males and a sign of increasing independence for women.
Since the 1990s, however, there has been an increase of opposition to
tobacco use. Health authorities warn of the dangers of smoking and
chewing tobacco, and nonsmokers object to secondhand smoke
—because
of both the smell and the health dangers of breathing smoke from other
people's cigarettes. Today, a smoker is more likely to ask for
permission before lighting up, and the answer is often "no." Because of
health concerns, smoking has been banned on airplanes, in hospitals, and
in many workplaces, restaurants, and bars.
PHYSICAL PROPERTIES OF NICOTINE
Tobacco is a plant native to the Western Hemisphere. It contains
nicotine, a drug classified as a stimulant, although it has some
depressive effects as well. Nicotine is a poisonous alkaloid that is the
major psychoactive (mood-altering) ingredient in tobacco. (Alkaloids
are carbon- and nitrogen-containing compounds that are found in some
families of plants. They have both poisonous and medicinal properties.)
Nicotine's effects on the body are complex. The drug affects the
brain and central nervous system as well as the hypothalamus and
pituitary glands of the endocrine (hormone) system. Nicotine easily
crosses the blood-brain barrier (a series of capillaries and cells that
controls the flow of substances from the blood to the brain), and it
accumulates in the brain
—faster
than caffeine or heroin, but slower than diazepam (a sedative medicine
used to treat anxiety). In the brain nicotine imitates the actions of
the hormone epinephrine (adrenaline) and the neurotransmitter
acetylcholine, both of which heighten awareness. Nicotine also triggers
the release of dopamine, which enhances feelings of pleasure, and
endorphins, "the brain's natural opiates," which have a calming effect.
As noted earlier, nicotine acts as both a stimulant and a depressant.
By stimulating certain nerve cells in the spinal cord, nicotine relaxes
the nerves and slows some reactions, such as the knee-jerk reflex.
Small amounts of nicotine stimulate some nerve cells, but these cells
are depressed by large amounts. In addition, nicotine stimulates the
brain cortex (the outer layer of the brain) and affects the functions of
the heart and lungs.
TRENDS IN TOBACCO USE
Cigarettes
CONSUMPTION DATA
According to the Centers for Disease Control and Prevention (CDC),
the consumption of cigarettes, the most widely used tobacco product, has
decreased over the past generation among adults. After increasing
rather consistently for sixty years, the per capita (per person)
consumption of cigarettes peaked in the 1960s at well over four thousand
cigarettes per year ("Chronic Disease Notes and Reports," Fall 2001,
http://www.cdc.gov/nccdphp/publications/cdnr/pdf/CDNRfall2001.pdf). The
steady decline in smoking came shortly after 1964, when the
Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service
(January 1964, http://www.cdc.gov/Tobacco/sgr/sgr_1964/sgr64.htm)
concluded that cigarette smoking is a cause of lung and laryngeal cancer
in men, a probable cause of lung cancer in women, and the most
important cause of chronic bronchitis in both genders. By 2006 the
annual per capita consumption of cigarettes for those aged eighteen and
over was 1,691. (See Table 3.1.)
| TABLE 3.1 |
| Per capita consumption of tobacco products, 1996–2006 |
| Year |
Per capita 16 years and over |
Per capita 18 years and over |
Per male 18 years and over |
| Cigarettesa |
Snuffb |
All tobacco products |
Large cigars & cigarillos |
Smoking tobaccob |
Chewing tobaccob |
|
Number |
Number |
Pounds |
Number |
Pounds |
| aUnstemmed processing weight. |
| bFinished product weight. |
| cPreliminary. |
| Source: Tom Capehart, "Table 2. Per Capita
Consumption of Tobacco Products in the United States (including Overseas
Forces), 1996–2006," in Tobacco Outlook,
U.S. Department of Agriculture, Economic Research Service, September
26, 2006,
http://usda.mannlib.cornell.edu/usda/ers/TBS//2000s/2006/TBS-09-26-2006.pdf
(accessed October 10, 2006) |
| 1996 |
2,355 |
2,445 |
4.1 |
0.31 |
4.83 |
31.9 |
0.52 |
0.12 |
0.63 |
| 1997 |
2,290 |
2,422 |
4.1 |
0.31 |
4.85 |
37.3 |
0.61 |
0.11 |
0.60 |
| 1998 |
2,190 |
2,275 |
3.6 |
0.31 |
4.32 |
37.1 |
0.61 |
0.12 |
0.53 |
| 1999 |
2,022 |
2,101 |
3.5 |
0.32 |
4.23 |
38.5 |
0.63 |
0.13 |
0.51 |
| 2000 |
1,974 |
2,049 |
3.4 |
0.33 |
4.10 |
38.0 |
0.62 |
0.13 |
0.48 |
| 2001 |
1,976 |
2,051 |
3.5 |
0.34 |
4.30 |
41.2 |
0.68 |
0.15 |
0.47 |
| 2002 |
1,909 |
1,982 |
3.4 |
0.34 |
4.16 |
41.8 |
0.68 |
0.16 |
0.43 |
| 2003 |
1,820 |
1,890 |
3.2 |
0.35 |
3.97 |
44.5 |
0.73 |
0.16 |
0.40 |
| 2004 |
1,747 |
1,814 |
3.1 |
0.36 |
3.87 |
47.9 |
0.79 |
0.15 |
0.37 |
| 2005 |
1,675 |
1,716 |
2.9 |
0.36 |
3.69 |
46.9 |
0.77 |
0.16 |
0.36 |
| 2006c |
1,650 |
1,691 |
2.9 |
0.38 |
3.69 |
47.8 |
0.78 |
0.15 |
0.37 |
| TABLE 3.2 |
| Percentage of lifetime, past-year, and past-month cigarette users, by age group, gender, and ethnicity, 2004 and 2005 |
| Demographic characteristic |
Time period |
| Lifetime |
Past year |
Past month |
| 2004 |
2005 |
2004 |
2005 |
2004 |
2005 |
| Source: "Table 2.31B. Cigarette Use in
Lifetime, Past Year, and Past Month among Persons Aged 12 or Older, by
Demographic Characteristics: Percentages, 2004 and 2005," in Results from the 2005 National Survey on Drug Use and Health: Detailed Tables,
U.S. Department of Health and Human Services, Substance Abuse and
Mental Health Services Administration, Office of Applied Studies, 2006,
http://www.drugabusestatistics.samhsa.gov/NSDUH/2k5NSDUH/Tabs/Sect2peTabs31to36.pdf
(accessed October 10, 2006) |
| Total |
67.3 |
66.6 |
29.1 |
29.1 |
24.9 |
24.9 |
| Age |
|
|
|
|
|
|
| 12-17 |
29.2 |
26.7 |
18.4 |
17.3 |
11.9 |
10.8 |
| 18-25 |
68.7 |
67.3 |
47.5 |
47.2 |
39.5 |
39.0 |
| or 26 older |
72.3 |
71.9 |
27.3 |
27.6 |
24.1 |
24.3 |
| Gender |
|
|
|
|
|
|
| Male |
72.4 |
71.3 |
32.5 |
31.9 |
27.7 |
27.4 |
| Female |
62.4 |
62.1 |
25.9 |
26.5 |
22.3 |
22.5 |
| Hispanic origin and race |
|
|
|
|
|
|
| Not Hispanic or Latino |
69.4 |
68.3 |
29.4 |
29.3 |
25.4 |
25.3 |
| White |
73.0 |
72.2 |
30.4 |
30.1 |
26.4 |
26.0 |
| Black or African American |
56.6 |
55.7 |
27.4 |
27.4 |
23.5 |
24.5 |
| American Indian or Alaska Native |
77.2 |
69.2 |
37.1 |
42.0 |
31.0 |
36.0 |
| Native Hawaiian or other Pacific Islander |
* |
64.4 |
* |
35.0 |
* |
28.8 |
| Asian |
43.5 |
41.1 |
13.4 |
17.4 |
10.3 |
13.4 |
| Two or more races |
74.1 |
61.7 |
43.0 |
35.2 |
38.3 |
30.9 |
| Hispanic or Latino |
52.9 |
55.3 |
26.8 |
27.9 |
21.3 |
22.1 |
Each year the Substance Abuse and Mental Health Services
Administration surveys U.S. households on drug use for the National
Survey on Drug Use and Health (NSDUH). The 2005 NSDUH reports that 66.6%
of the U.S. population had smoked cigarettes at some time in their
lives and that 24.9% were current smokers (meaning that they had smoked
within the month prior to the survey). (See Table 3.2.)
In 2005 men (27.4%) were more likely than women (22.5%) to be current
smokers. Additionally, whites (26%) were more likely to be current
smokers than African-Americans
(24.5%), Hispanics (22.1%), or Asian-Americans (13.4%). Those aged
eighteen to twenty-five had the highest rates of current smoking at 39%,
compared with 10.8% for twelve- to seventeen-year-olds and 24.3% for
those aged twenty-six and older. (See Table 3.2.) In general, rates of
cigarette smoking remained the same or declined from 2004 to 2005 for
most groups. A notable increase in smoking occurred, however, in the
American Indian and Alaskan Native group.
The National Health Interview Survey (NHIS), which is conducted
annually by the National Center for Health Statistics, reports findings
similar to those of the NSDUH. Preliminary findings from the
January-March 2006 NHIS show that 21.5% of adults in the United States
were current smokers in early 2006, down from 24.7% in 1997. Like the
NSDUH, the NHIS finds that men are more likely than women to smoke. Just
over 24% of adult men and 19.1% of adult women were current smokers.
Women were more likely than men to have never smoked. (See Figure 3.1.)
Although the NHIS uses different age groups than the NHSDA, results
of both surveys show that younger people smoke at a higher rate than
older people. Figure 3.2 shows that those aged eighteen to forty-four
are slightly
more likely than those aged forty-five to sixty-four to smoke. The rate
of smoking in the sixty-five and over age group was dramatically lower
than in either of the two younger groups. Men in all age categories were
more likely than women in the same age group to smoke.
Also, like the NHSDA, the NHIS finds that the prevalence of current
smoking among various races and ethnicities is highest for non-Hispanic
whites (23.5%). Non-Hispanic African-Americans (23.1%) were slightly
less likely to smoke, whereas Hispanics (13.8%) were the least likely to
smoke. (See Figure 3.3.)
Cigars, Pipes, and Other Forms of Tobacco
According to the NSDUH, 3.2% of those aged twelve and older were
current users of smokeless tobacco (chewing tobacco and/or snuff), and
5.6% were current users of cigars. Only 0.9% smoked pipes. These
percentages remained relatively constant from 2002 to 2005. (See Figure
3.4.)
According to the U.S. Department of Agriculture, in 2006 the per
capita consumption by males aged eighteen and over was 47.8 large cigars
and small, narrow cigars called cigarillos. (See Table 3.1.) This
figure is much higher than in 1996 when the per capita consumption
among this group was 31.9 cigars and cigarillos. The use of snuff has
increased as well, although not as much as cigars. In 2006 the per
capita consumption of snuff was 0.38 of a pound. In 1996 the per capita
consumption of this tobacco product was 0.31 of a pound. Snuff is
powdered tobacco that is inhaled through the nose.
ADDICTIVE NATURE OF NICOTINE
Is tobacco addictive? In
The Health Consequences of Smoking—Nicotine Addiction: A Report of the Surgeon General
(1988, http://www.cdc.gov/tobacco/sgr/sgr_1988/index.htm), researchers
examined this question. They determined that the pharmacological
(chemical and physical) effects and behavioral processes that contribute
to tobacco addiction are similar to those that contribute in the
addiction to drugs such as heroin and cocaine. Many researchers consider
nicotine to be as potentially addictive as cocaine and heroin and note
that it can create dependence quickly in some users.
Researchers have also discovered that some cigarettes have a "kick,"
in that they contain thirty-five times more freebase nicotine than other
cigarettes. According to the article "'Crack' Nicotine in Cigarettes" (
Journal of Chemical Research in Toxicology, July 28, 2003), the danger of this freebase nicotine is that it is in a volatile,
uncombined form that is absorbed by the lungs and brain at a faster
rate than standard forms of nicotine. Researchers sometimes refer to
this raw form of nicotine as "crack nicotine," because it potentially
has the same addictive quality as crack cocaine. (A drug's addictiveness
is measured by the speed at which it reaches the brain.)
Cigarette smoking results in rapid distribution of nicotine
throughout the body, reaching the brain within ten seconds of
inhalation. However, the intense effects of nicotine disappear in a few
minutes, causing smokers to continue smoking frequently throughout the
day to maintain its pleasurable effects and to prevent withdrawal.
Tolerance develops after repeated exposure to nicotine, and higher doses
are required to produce the same initial stimulation. Because nicotine
is metabolized fairly quickly, disappearing from the body in a few
hours, some tolerance is lost overnight. Smokers often report that the
first cigarette of the day is the most satisfying. The more cigarettes
smoked during the day, the more tolerance develops, and the less effect
subsequent cigarettes have.
Is There a Genetic Basis for Nicotine Addiction?
Smoking is influenced by both environment and genetics. The results
of many scientific studies, such as Viba Malaiyandi, Edward M. Sellers,
and Rachel F. Tyndale's "Implications of
CYP2A6 Genetic Variation for Smoking Behaviors and Nicotine Dependence" (
Perspectives in Clinical Pharmacology,
March 2005), show that about 60% of the initiation of nicotine
dependence and about 70% of the maintenance of dependent smoking
behavior is genetically influenced.
The Collaborative Study on the Genetics of Alcoholism, in
"Co-occurring Risk Factors for Alcohol Dependence and Habitual Smoking" (
Alcohol Research and Health,
Winter 2000), reports the results that support the hypothesis that some
common genetic factors are involved in the susceptibility for
developing both alcohol and nicotine addiction. Moreover, studies of
twins support the role of common genetic factors in the development of
both disorders.
Nicotine May Not Be the Only Addictive Substance in Cigarettes
Research results suggest that nicotine may not be the only
psychoactive ingredient in tobacco. Some as-yet-unknown compound in
cigarette smoke decreases the levels of monoamine oxidase (MAO), an
enzyme responsible for breaking down the brain chemical dopamine. The
decrease in MAO results in higher dopamine levels and may be another
reason that smokers continue to smoke
—to sustain the high dopamine levels that result in pleasurable effects and the desire for repeated cigarette use.
One issue that complicates any efforts by a longtime smoker to quit
is nicotine withdrawal, which is often referred to as craving. This urge
for nicotine is not well understood by researchers. Withdrawal may
begin within a few hours after the last cigarette. According to the
National Institute on Drug Abuse, high levels of craving may persist six
months or longer. Besides craving, withdrawal can include irritability,
attention deficits, interruption of thought processes, sleep
disturbances, and increased appetite.
Some researchers also point out the behavioral aspects involved in
smoking. The purchasing, handling, and lighting of cigarettes may be
just as pleasing psychologically to the user as the chemical properties
of tobacco itself.
HEALTH CONSEQUENCES OF TOBACCO USE
Respiratory System Effects
Cigarette smoke contains almost four thousand different chemical
compounds, many of which are toxic, mutagenic (capable of increasing the
frequency of mutation), and carcinogenic (cancer-causing). At least
forty-three carcinogens have been identified in tobacco smoke. Besides
nicotine, the most damaging substances are tar and carbon monoxide (CO).
Smoke also contains hydrogen cyanide and other chemicals that can
damage the respiratory system. These substances and nicotine are
absorbed into the body through the linings of the mouth, nose, throat,
and lungs. About ten seconds later they are delivered by the bloodstream
to the brain.
Tar, which adds to the flavor of cigarettes, is released by the
burning of tobacco. As it is inhaled, it enters the alveoli (air cells)
of the lungs. There, the tar hampers the action of cilia
—small, hairlike extensions of cells that clean foreign substances from the lungs
—allowing the substances in cigarette smoke to accumulate.
CO affects the blood's ability to distribute oxygen throughout the body. CO is chemically similar to carbon dioxide (CO
2), which bonds with the hemoglobin in blood so that the CO
2
can be carried to the lungs for elimination. Hemoglobin has two primary
functions: to carry oxygen to all parts of the body and to remove
excess CO
2 from the body's tissues. CO bonds to hemoglobin more tightly than CO
2
and leaves the body more slowly, which allows CO to build up in the
hemoglobin, in turn reducing the amount of oxygen the blood can carry.
Lack of adequate oxygen is damaging to most of the body's organs,
including the heart and brain.
Diseases and Conditions Linked to Tobacco Use
Results of medical research show an association between smoking and
cancer, as well as heart and circulatory disease, fetal growth
retardation, and low birth weight babies. The 1983
Health Consequences of Smoking—Cardiovascular Disease: Report of the Surgeon General
(http://profiles.nlm.nih.gov/NN/B/B/T/D/_/nnbbtd.pdf) linked cigarette
smoking to
cerebrovascular disease (stroke) and associated it with cancer of the
uterine cervix. Two 1992 studies showed that people who smoke double
their risk of forming cataracts, the leading cause of blindness. Recent
research links smoking to unsuccessful pregnancies, increased infant
mortality, and peptic ulcer disease. In 2004 U.S. Surgeon General
Richard H. Carmona released a comprehensive report on smoking and
health,
The Health Consequences of Smoking: A Report of the Surgeon General
(http://www.cdc.gov/Tobacco/sgr/sgr_2004/index.htm), revealing for the
first time that cigarette smoking causes diseases in nearly every organ
of the body. Table 3.3 lists diseases
—including cancers
—and other adverse health effects for which cigarette smoking is identified as a cause.
The National Cancer Institute, in "Questions and Answers about Cigar
Smoking and Cancer" (2000,
http://www.cancer.gov/cancertopics/factsheet/Tobacco/cigars), notes that
cigar smoking is associated with cancers of the lip, tongue, mouth,
throat, larynx (voice box), lungs, and esophagus (food tube). Those who
smoke cigars daily and inhale the smoke are at increased risk for
developing heart and lung disease.
Smokeless tobacco, which includes chewing tobacco and snuff, also creates health hazards for its users. The 1979
Smoking and Health: A Report of the Surgeon General
(http://profiles.nlm.nih.gov/NN/B/C/M/D/_/nnbcmd.pdf) noted that
smokeless tobacco was associated with oral cancers; and the 1986
Health Consequences of Involuntary Smoking: A Report of the Surgeon General
concluded that it was a cause of these diseases. The nicotine in
smokeless tobacco is absorbed into the bloodstream through the lining of
the mouth and has been linked to periodontal (gum) disease and, more
important, to cancers of the lip, gum, and mouth. The CDC, in "Smokeless
Tobacco: Fact Sheet" (November 2005,
http://www.cdc.gov/Tobacco/factsheets/smoke lesstobacco.htm), reminds
the public that smokeless tobacco can lead to nicotine addiction. Thus,
people who use smokeless tobacco are more likely than nontobacco users
to become smokers.
Premature Aging
Smoking cigarettes contributes to premature aging in a variety of
ways. Results of research over two decades, such as Marysia Placzek et
al.'s "Tobacco Smoke Is Phototoxic" (
British Journal of Dermatology,
May 2004), show that smoking enhances facial aging and skin wrinkling.
Additionally, smoking has been associated with a decline in overall
fitness in women.
Interactions with Other Drugs
Smoking can have adverse effects when combined with over-the-counter
(without a prescription) and prescription medications that a smoker may
be taking. In many cases tobacco smoking reduces the effectiveness of
medications, such as pain relievers (acetaminophen), antidepressants,
tranquilizers, sedatives, ulcer medications, and insulin. With estrogen
and oral contraceptives, tobacco smoking may increase the risk of heart
and blood vessel disease and can cause strokes and blood clots.
SMOKING AND PUBLIC HEALTH
A study in the 1920s found that men who smoked two or more packs of
cigarettes per day were twenty-two times more likely than nonsmokers to
die of lung cancer. At the time, these results surprised researchers and
medical authorities alike. Some forty years ago, the U.S. government
first officially recognized the negative health consequences of smoking.
In 1964 the Advisory Committee to the Surgeon General released a
groundbreaking survey of studies on tobacco use. In
Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service,
U.S. Surgeon General Luther L. Terry reported that cigarette smoking
increased overall mortality in men and caused lung and laryngeal cancer,
as well as chronic bronchitis. The report concluded, "Cigarette smoking
is a health hazard of sufficient importance in the United States to
warrant appropriate remedial action," but what action should be taken
was left unspecified at that time.
Later surgeons general issued additional reports on the health
effects of smoking and the dangers to nonsmokers of passive or
secondhand smoke. Besides general health concerns, the reports have
addressed specific health consequences and populations. Table 3.4 shows a
listing of reports of the surgeon general and the years in which they
were published. The later reports concluded that smoking increased the
morbidity (proportion of diseased people in a particular population) and
mortality (proportion of deaths in a particular population) of both men
and women.
In 1965 Congress passed the Federal Cigarette Labeling and
Advertising Act (PL 89-92), which required the following health warning
on all cigarette packages: "Caution: Cigarette smoking may be hazardous
to your health." The Public Health Cigarette Smoking Act of 1969 (PL
91-222) strengthened the warning to read: "Warning: The Surgeon General
has determined that cigarette smoking is dangerous to your health."
Still later acts resulted in four different health warnings to be used
in rotation.
The April 2, 1999,
Morbidity and Mortality Weekly Report
(http://www.cdc.gov/mmwr/PDF/wk/mm4812.pdf) included "recognition of
tobacco use as a health hazard" as one of the country's ten greatest
public health achievements of the twentieth century, along with
vaccination, control of infectious diseases, safer and healthier food,
healthier mothers and babies, family planning, safer workplaces,
motor-vehicle
| TABLE 3.3 |
| Diseases and other adverse health effects caused by cigarette smoking, according to the U.S. Surgeon General, 2004 |
| Disease |
Highest level conclusion from previous Surgeon General's reports (year) |
Conclusion from the 2004 Surgeon General's report |
| Cancer |
|
|
| Bladder cancer |
"Smoking is a cause of bladder cancer;
cessation reduces risk by about 50 percent after only a few years, in
comparison with continued smoking." (1990) |
"The evidence is sufficient to infer a causal relationship between smoking and … bladder cancer." |
| Cervical cancer |
"Smoking has been consistently associated with an increased risk for cervical cancer." (2001) |
"The evidence is sufficient to infer a causal relationship between smoking and cervical cancer." |
| Esophageal cancer |
"Cigarette smoking is a major cause of esophageal cancer in the United States." (1982) |
"The evidence is sufficient to infer a causal relationship between smoking and cancers of the esophagus." |
| Kidney cancer |
"Cigarette smoking is a contributory factor
in the development of kidney cancer in the United States. The term
'contributory factor' by no means excludes the possibility of a causal
role for smoking in cancers of this site." (1982) |
"The evidence is sufficient to infer a causal relationship between smoking and renal cell, [and] renal pelvis … cancers." |
| Laryngeal cancer |
"Cigarette smoking is causally associated with cancer of the lung, larynx, oral cavity, and esophagus in women as well as in men…." (1980) |
"The evidence is sufficient to infer a causal relationship between smoking and cancer of the larynx." |
| Leukemia |
"Leukemia has recently been implicated as a smoking-related disease … but this observation has not been consistent." (1990) |
"The evidence is sufficient to infer a causal relationship between smoking and acute myeloid leukemia." |
| Lung cancer |
"Additional epidemiological, pathological,
and experimental data not only confirm the conclusion of the Surgeon
General's 1964 report regarding lung cancer in men but strengthen the
causal relationship of smoking to lung cancer in women." (1967) |
"The evidence is sufficient to infer a causal relationship between smoking and lung cancer." |
| Oral cancer |
"Cigarette smoking is a major cause of cancers of the oral cavity in the United States." (1982) |
"The evidence is sufficient to infer a causal relationship between smoking and cancers of the oral cavity and pharynx." |
| Pancreatic cancer |
"Smoking cessation reduces the risk of
pancreatic cancer, compared with continued smoking, although this
reduction in risk may only be measurable after 10 years of abstinence."
(1990) |
"The evidence is sufficient to infer a causal relationship between smoking and pancreatic cancer." |
| Stomach cancer |
"Data on smoking and cancer of the stomach … are unclear." (2001) |
"The evidence is sufficient to infer a causal relationship between smoking and gastric cancers." |
| Cardiovascular diseases |
|
|
| Abdominal aortic aneurysm |
"Death from rupture of an atherosclerotic abdominal aneurysm is more common in cigarette smokers than in nonsmokers." (1983) |
"The evidence is sufficient to infer a causal relationship between smoking and abdominal aortic aneurysm." |
| Atherosclerosis |
"Cigarette smoking is the most powerful risk factor predisposing to atherosclerotic peripheral vascular disease." (1983) |
"The evidence is sufficient to infer a causal relationship between smoking and subclinical atherosclerosis." |
| Cerebrovascular disease |
"Cigarette smoking is a major cause of
cerebrovascular disease (stroke), the third leading cause of death in
the United States." (1989) |
"The evidence is sufficient to infer a causal relationship between smoking and stroke." |
| Coronary heart disease |
"In summary, for the purposes of preventive
medicine, it can be concluded that smoking is causally related to
coronary heart disease for both men and women in the United States."
(1979) |
"The evidence is sufficient to infer a causal relationship between smoking and coronary heart disease." |
| Respiratory diseases |
|
|
| Chronic obstructive pulmonary disease |
"Cigarette smoking is the most important of
the causes of chronic bronchitis in the United states, and increases the
risk of dying from chronic bronchitis." (1964) |
"The evidence is sufficient to infer a
causal relationship between active smoking and chronic obstructive
pulmonary disease morbidity and mortality." |
| Pneumonia |
"Smoking cessation reduces rates of
respiratory symptoms such as cough, sputum production, and wheezing, and
respiratory infections such as bronchitis and pneumonia, compared with
continued smoking." (1990) |
"The evidence is sufficient to infer a
causal relationship between smoking and acute respiratory illnesses,
including pneumonia, in persons without underlying smoking-related
chronic obstructive lung disease." |
| Respiratory effects in utero |
"In utero exposure to maternal smoking is associated with reduced lung function among infants…." (2001) |
"The evidence is sufficient to infer a
causal relationship between maternal smoking during pregnancy and a
reduction of lung function in infants." |
| Respiratory effects in childhood and adolescence |
"Cigarette smoking during childhood and
adolescence produces significant health problems among young people,
including cough and phlegm production, an increased number and severity
of respiratory illnesses, decreased physical fitness, an unfavorable
lipid profile, and potential retardation in the rate of lung growth and
the level of maximum lung function." (1994) |
"The evidence is sufficient to infer a
causal relationship between active smoking and impaired lung growth
during childhood and adolescence."
"The evidence is sufficient to
infer a causal relationship between active smoking and the early onset
of lung function decline during late adolescence and early adulthood."
"The
evidence is sufficient to infer a causal relationship between active
smoking and respiratory symptoms in children and adolescents, including
coughing, phlegm, wheezing, and dyspnea."
"The evidence is sufficient
to infer a causal relationship between active smoking and
asthma-related symptoms (i.e., wheezing) in childhood and adolescence." |
| Respiratory effects in adulthood |
"Cigarette smoking accelerates the
age-related decline in lung function that occurs among never smokers.
With sustained abstinence from smoking, the rate of decline in pulmonary
function among former smokers returns to that of never smokers." (1990) |
"The evidence is sufficient to infer a
causal relationship between active smoking in adulthood and a premature
onset of and an accelerated age-related decline in lung function."
"The
evidence is sufficient to infer a causal relationship between active
sustained cessation from smoking and a return of the rate of decline in
pulmonary function to that of persons who had never smoked." |
| Other respiratory effects |
"Smoking cessation reduces rates of
respiratory symptoms such as cough, sputum production, and wheezing, and
respiratory infections such as bronchitis and pneumonia, compared with
continued smoking." (1990) |
"The evidence is sufficient to infer a
causal relationship between active smoking and all major respiratory
symptoms among adults, including coughing, phlegm, wheezing, and
dyspnea."
The evidence is sufficient to infer a causal relationship between active smoking and poor asthma control." |
| TABLE 3.3 |
| Diseases and other adverse health effects caused by cigarette smoking, according to the U.S. Surgeon General, 2004 [contiuned] |
| Disease |
Highest level conclusion from previous Surgeon General's reports (year) |
Conclusion from the 2004 Surgeon General's report |
| Source: "Table 1.1. Diseases and Other
Adverse Health Effects for Which Smoking Is Identified as a Cause in the
Current Surgeon General's Report," in The Health Consequences of Smoking: A Report of the Surgeon General,
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,
http://www.cdc.gov/tobacco/sgr/sgr_2004/pdf/chapter1.pdf (accessed
October 10, 2006) |
| Reproductive effects |
|
|
| Fetal death and stillbirths |
"The risk for perinatal mortality—both stillbirth and neonatal deaths—and
the risk for sudden infant death syndrome (SIDS) are increased among
the offspring of women who smoke during pregnancy." (2001) |
"The evidence is sufficient to infer a
causal relationship between sudden infant death syndrome and maternal
smoking during and after pregnancy." |
| Fertility |
"Women who smoke have increased risks for conception delay and for both primary and secondary infertility." (2001) |
"The evidence is sufficient to infer a causal relationship between smoking and reduced fertility in women." |
| Low birth weight |
"Infants born to women who smoke during pregnancy have a lower average birth weight … than … infants born to women who do not smoke." (2001) |
"The evidence is sufficient to infer a
causal relationship between maternal active smoking and fetal growth
restriction and low birth weight." |
| Pregnancy complications |
"Smoking during pregnancy is associated with
increased risks for preterm premature rupture of membranes, abruptio
placentae, and placenta previa, and with a modest increase in risk for
preterm delivery." (2001) |
"The evidence is sufficient to infer a
casual relationship between maternal active smoking and premature
rupture of the membranes, placenta previa, and placental abruption."
"The
evidence is sufficient to infer a causal relationship between maternal
active smoking and preterm delivery and shortened gestation." |
| Other effects |
|
|
| Cataract |
"Women who smoke have an increased risk for cataract." (2001) |
"The evidence is sufficient to infer a causal relationship between smoking and nuclear cataract." |
| Diminished health status/morbidity |
"Relationships between smoking and cough or
phlegm are strong and consistent; they have been amply documented and
are judged to be causal…." (1984)
"Consideration
of evidence from many different studies has led to the conclusion that
cigarette smoking is the overwhelmingly most important cause of cough,
sputum, chronic bronchitis, and mucus hypersecretion." (1984) |
"The evidence is sufficient to infer a
causal relationship between smoking and diminished health status that
may be manifest as increased absenteeism from work and increased use of
medical care services."
"The evidence is sufficient to infer a causal
relationship between smoking and increased risks for adverse surgical
outcomes related to wound healing and respiratory complications." |
| Hip fractures |
"Women who currently smoke have an increased risk for hip fracture compared with women who do not smoke." (2001) |
"The evidence is sufficient to infer a causal relationship between smoking and hip fractures." |
| Low bone density |
"Postmenopausal women who currently smoke have lower bone density than do women who do not smoke." (2001) |
"In postmenopausal women, the evidence is sufficient to infer a causal relationship between smoking and low bone density." |
| Peptic ulcer disease |
"The relationship between cigarette smoking
and death rates from peptic ulcer, especially gastric ulcer, is
confirmed. In addition, morbidity data suggest a similar relationship
exists with the prevalence of reported disease from this cause." (1967) |
"The evidence is sufficient to infer a
causal relationship between smoking and peptic ulcer disease in persons
who are helicobacter pylori positive." |
safety, decline in deaths from coronary heart disease and stroke, and
fluoridation of drinking water. These ten accomplishments were chosen
based on their contributions to prevention and their impact on illness,
disability, and death in the United States.
DEATHS ATTRIBUTED TO TOBACCO USE
According to the
Health Consequences of Smoking: A Report of the Surgeon General,
cigarette smoking is the leading cause of preventable death in the
United States and produces substantial health-related economic costs to
society. The report notes that smoking caused an estimated 440,100
deaths in the United States each year from 1995 to 1999. Nationwide,
smoking kills more people each year than alcohol, drug abuse, car
crashes, murders, suicides, fires, and acquired immune deficiency
syndrome combined.
In 2004 diseases linked to smoking accounted for four of the top five
leading causes of death in the United States. (See Table 3.5.)
According to the CDC, about 655,000 people died of various heart
diseases in 2004 (down from about 761,000 in 1980). Approximately
550,000 died of cancer, and cerebrovascular disease (stroke) claimed
about 150,000 lives. Chronic lower respiratory diseases, including
chronic bronchitis, asthma, and emphysema, claimed nearly 124,000 lives.
In
Cancer Facts and Figures, 2006 (2006,
http://www.cancer.org/downloads/STT/CAFF2006PWSecured.pdf), the American
Cancer Society estimated that 162,460 Americans died of lung and
bronchus cancer in 2006. While not all lung and bronchus cancer deaths
are directly attributable to smoking, a large proportion of them are.
Lung cancer is the leading cause of cancer mortality in both men and
women in the United States. It has been the leading cause of cancer
deaths among men since the early 1950s and, in 1987, surpassed breast
cancer to become the leading cause of cancer deaths in women.
SECONDHAND SMOKE
Secondhand smoke, also known as environmental tobacco smoke (ETS) or
passive smoke, is a health hazard for nonsmokers who live or work with
smokers. The
National Cancer Institute (2006,
http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=46431) defines
secondhand smoke as "smoke that comes from the burning of a tobacco
product and smoke that is exhaled by smokers
…. Inhaling ETS is called involuntary or passive smoking."
| TABLE 3.4 |
| Twenty-nine Surgeon General's reports on smoking and health, selected years 1964–2006 |
| Note: Smoking remains the leading cause of
preventable death and has negative health impacts on people at all
stages of life. It harms unborn babies, infants, children, adolescents,
adults, and seniors. |
| Source: Adapted from "28 Surgeon General's Reports on Smoking and Health, 1964–2004,"
U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Tobacco Information and Prevention Source (TIPS),
http://www.cdc.gov/tobacco/sgr/sgr_2004/Factsheets/11.htm (accessed
October 30, 2006), and "The Health Consequences of Involuntary Exposure
to Tobacco Smoke: A Report of the Surgeon General," 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,
http://www.surgeongeneral.gov/library/secondhandsmoke/report/executivesummary.pdf
(accessed November 24, 2006) |
| 1964 |
Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service |
| 1967 |
The Health Consequences of Smoking: A Public Health Service Review |
| 1968 |
The Health Consequences of Smoking: 1968 Supplement to the 1967 Public Health Service Review |
| 1969 |
The Health Consequences of Smoking: 1969 Supplement to the 1967 Public Health Service Review |
| 1971 |
The Health Consequences of Smoking |
| 1972 |
The Health Consequences of Smoking |
| 1973 |
The Health Consequences of Smoking |
| 1974 |
The Health Consequences of Smoking |
| 1975 |
The Health Consequences of Smoking |
| 1976 |
The Health Consequences of Smoking |
| 1978 |
The Health Consequences of Smoking, 1977–1978 |
| 1979 |
Smoking and Health |
| 1980 |
The Health Consequences of Smoking for Women |
| 1981 |
The Health Consequences of Smoking—The Changing Cigarette |
| 1982 |
The Health Consequences of Smoking—Cancer |
| 1983 |
The Health Consequences of Smoking—Cardiovascular Disease |
| 1984 |
The Health Consequences of Smoking—Chronic Obstructive Lung Disease |
| 1985 |
The Health Consequences of Smoking—Cancer and Chronic Lung Disease in the Workplace |
| 1986 |
The Health Consequences of Involuntary Smoking |
| 1988 |
The Health Consequences of Smoking—Nicotine Addiction |
| 1989 |
Reducing the Health Consequences of Smoking—25 Years of Progress |
| 1990 |
The Health Benefits of Smoking Cessation |
| 1992 |
Smoking and Health in the Americas |
| 1994 |
Preventing Tobacco Use among Young People |
| 1998 |
Tobacco Use among U.S. Racial/Ethnic Minority Groups |
| 2000 |
Reducing Tobacco Use |
| 2001 |
Women and Smoking |
| 2004 |
The Health Consequences of Smoking |
| 2006 |
The Health Consequences of Involuntary Exposure to Tobacco Smoke |
The first scientific paper on the harmful effects of secondhand smoke
was Takeshi Hirayama's "Non-smoking Wives of Heavy Smokers Have a
Higher Risk of Lung Cancer: A Study from
Japan" (
British Medical Journal,
1981). Hirayama studied 92,000 nonsmoking wives of smoking husbands and
a similarly sized group of women married to nonsmokers. He discovered
that nonsmoking wives of husbands who smoked faced a 40% to 90% elevated
risk of lung cancer (depending on how frequently their husbands smoked)
compared with the wives of nonsmoking husbands.
Other studies have followed. The U.S. Environmental Protection Agency (EPA), in
Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders
(December 1992,
http://cfpub2.epa.gov/ncea/cfm/recordisplay.cfm?deid=2835), concluded
that the "widespread exposure to environmental tobacco smoke (ETS) in
the United States presents a serious and substantial public health
impact." In Elizabeth T. H. Fon-tham et al.'s "Environmental Tobacco
Smoke and Lung Cancer in Nonsmoking Women: A Multicenter Study" (
Journal of the American Medical Association,
June 1994), a large case-control study on secondhand smoke, compelling
links were found between passive smoke and lung cancer. In 2000 the
Environmental Health Information Service's
Ninth Report on Carcinogens classified secondhand smoke as a Group A (Human) Carcinogen
—a substance known to cause cancer in humans. According to the EPA, there is no safe level of exposure to such Group A toxins.
In 2005 more evidence accumulated on the risks of passive smoking. In
"Environmental Tobacco Smoke and Risk of Respiratory Cancer and Chronic
Obstructive Pulmonary Disease in Former Smokers and Never Smokers in
the EPIC Prospective Study" (
British Medical Journal, 2005),
the European Prospective Investigation into Cancer and Nutrition reveals
that those who had been exposed to secondhand smoke during childhood
for many hours each day had more than triple the risk of developing lung
cancer compared with people who were not exposed. In addition, Sarah M.
McGhee et al., in "Mortality Associated with Passive Smoking in
Hong Kong" (
British Medical Journal, January
2005), show that there is a correlation between an increased risk of
dying from various causes (including lung cancer and other lung
diseases, heart disease, and stroke) and the number of smokers in the
home. Risk increased by 24% when one smoker lived in the home and by 74%
with two smokers in the household.
In June 2006 the twenty-ninth report of the surgeon general on smoking
—The Health Consequences of Involuntary Exposure to Tobacco Smoke (http://www.surgeongeneral.gov/library/secondhandsmoke/report/)
—was published. The report notes that:
With regard to the involuntary exposure of nonsmokers to tobacco
smoke, the scientific evidence now supports the following major
conclusions:
- Secondhand smoke causes premature death and disease in children and in adults who do not smoke.
- Children exposed to secondhand smoke are at an increased risk for
sudden infant death syndrome (SIDS), acute respiratory infections, ear
problems, and more severe asthma. Smoking by parents causes respiratory
symptoms and slows lung growth in their children.
- Exposure of adults to secondhand smoke has immediate adverse effects
on the cardiovascular system and causes coronary heart disease and lung
cancer.
- The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.
- Many millions of Americans, both children and adults, are still
exposed to secondhand smoke in their homes and workplaces despite
substantial progress in tobacco control.
- Eliminating smoking in indoor spaces fully protects nonsmokers from
exposure to secondhand smoke. Separating smokers from nonsmokers,
cleaning the air, and ventilating buildings cannot eliminate exposures
of nonsmokers to secondhand smoke.
| TABLE 3.5 |
| Leading causes of death, 1980 and 2004 |
| Rank order |
1980 |
2004 |
| Cause of death |
Cause of death |
| Source: Adapted from "Table 32. Leading
Causes of Death and Numbers of Deaths, according to Sex, Race, and
Hispanic Origin: United States, 1980 and 2000," in Health, United States, 2002,
U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Health Statistics, September
2002, and Arialdi M. Minino, Melonie P. Heron, and Betty L. Smith,
"Table 7. Deaths and Death Rates for the 10 Leading Causes of Death in
Specified Age Groups: United States, Preliminary 2004," in "Deaths:
Preliminary Data for 2004," in National Vital Statistics Reports,
vol. 54, no. 19, U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for Health
Statistics, June 28, 2006,
http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_19.pdf (accessed October
10, 2006) |
|
All causes |
|
All causes |
| 1 |
Diseases of heart |
1 |
Diseases of heart |
| 2 |
Malignant neoplasmas |
2 |
Malignant neoplasmas |
| 3 |
Cerebrovascular diseases |
3 |
Cerebrovascular diseases |
| 4 |
Unintentional injuries |
4 |
Chronic lower respiratory diseases |
| 5 |
Chronic obstructive pulmonary diseases |
5 |
Accidents (unintentional injuries) |
| 6 |
Pneumonia and influenza |
6 |
Diabetes mellitus |
| 7 |
Diabetes mellitus |
7 |
Alzheimer's disease |
| 8 |
Chronic liver disease and cirrhosis |
8 |
Influenza and pneumonia |
| 9 |
Atherosclerosis |
9 |
Nephritis, nephrotic syndrome and nephrosis |
| 10 |
Suicide |
10 |
Septicemia |
A MOVEMENT TO BAN SMOKING
Many efforts have been initiated over the years to control public
smoking or to separate smokers and nonsmokers. In 1975 the Clean Indoor
Air Act in
Minnesota
became the nation's first statewide law to require the separation of
smokers and nonsmokers. The purpose of the law was to protect public
health, public comfort, and the environment by banning smoking in public
places and at public meetings, except in designated smoking areas.
Other states soon followed Minnesota. In 1977 Berkeley became the first community in
California
to limit smoking in restaurants and other public places. In 1990 San
Luis Obispo, California, became the first city to ban smoking in all
public buildings, bars, and restaurants. In 1994 smoking was restricted
in many government buildings in California. In that same year the
fast-food giant McDonald's banned smoking in all of its establishments.
In 1995 New York City banned smoking in the dining areas of all
restaurants with more than thirty-five seats. As of July 2003, all
public and workplaces in New York City became smoke-free, including bars
and restaurants. Laws vary from state to state and from city to city,
but by 2005 smoking was banned in most workplaces, hospitals, government
buildings, museums, schools, theaters, and many restaurants throughout
the United States.
Gallup conducted a poll regarding secondhand smoke after the 2006
surgeon general's report on the subject was published. Gallup notes that
the document had "little immediate impact on public attitudes about the
risks" of passive smoking. The 2006 poll revealed that 56% of those
surveyed perceived the risk of secondhand smoke to be very harmful.
Twenty-nine percent believed that secondhand smoke was somewhat harmful,
and 12% thought it was not too harmful or not at all harmful in the
2006 survey. (See Figure 3.5.)
STOPPING SMOKING
The CDC, in "Cigarette Smoking among Adults
—United
States, 2005" (October 27, 2006,
http://www.cdc.gov/mmwr/PDF/wk/mm5542.pdf), estimates that in 2005 there
were 45.1 million current smokers. Furthermore, the CDC reports in
"Smoking Prevalence among U.S. Adults" (October 2006,
http://www.cdc.gov/tobacco/research_data/adults_prev/prevali.htm) that
there continues to be a decline in adult smokers. In 1965, 42.4% of
adults smoked; by 2005, 20.9% of adults smoked.
Many cigarette smokers are trying to stop smoking
—or
would at least like to. In the 2006 Gallup poll "Tobacco and Smoking,"
smokers were asked if they would like to give up smoking. Seventy-five
percent answered yes. This figure is down from 82% in 2004 and 76% in
1999 but up from 66% in 1977.
According to the article "U.S. Has New Plan against Smoking" (
New York Times,
October 5, 1991), the federal government began a massive antismoking
campaign in 1991 that was intended to prevent 1.2 million
smoking-related deaths. The goal of the multiyear program was to help
4.5 million adults stop smoking, prevent two million
youths from starting, and reduce the number of smokers to 15% of the
population.
The government reports
Reducing Tobacco Use (2000, http://www.cdc.gov/Tobacco/sgr/sgr_2000/FullReport.pdf) and
Investment in Tobacco Control State Highlights
(2002, http://www.cdc.gov/tobacco/statehi/statehi_2002.htm) say that
drug treatment for nicotine addiction, combined with other treatment
methods, will enable 20-25% of users to refrain from smoking one year
after treatment. Even physicians who simply advise their patients to
quit smoking can produce a cessation increase of 5-10%.
Global Efforts to Reduce Tobacco Use
According to the World Health Organization (WHO), in
Tobacco: Deadly in Any Form or Disguise
(2006,
http://www.who.int/tobacco/communications/events/wntd/2006/Tfi_Rapport.pdf),
an estimated 1.3 billion adults around the world use tobacco. In
addition, the WHO notes that tobacco causes five million deaths per
year.
In May 2003 member states of the WHO adopted the world's first
international public health treaty for global cooperation in reducing
the negative health consequences of tobacco use. The WHO Framework
Convention on Tobacco Control is designed to reduce tobacco-related
deaths and disease worldwide. In February 2005 the treaty came into
force after being ratified by member countries. Each of the 168
countries that signed the treaty must now pass it into law. Although the
United States signed the treaty in May 2004, indicating its general
acceptance, by the end of 2006 it had not yet ratified (become bound by)
the treaty. The treaty has many measures, which include requiring
countries to impose restrictions on tobacco advertising, sponsorship,
and promotion; establishing new packaging and labeling of tobacco
products; establishing clean indoor air controls; and promoting taxation
as a way to cut consumption and fight smuggling.
Benefits of Stopping
The Health Benefits of Smoking Cessation: A Report of the Surgeon General
(1990, http://profiles.nlm.nih.gov/NN/B/B/C/T/_/nnbbct.pdf) notes that
quitting offers major and immediate health benefits for both sexes and
for all ages. This first comprehensive report on the benefits of
quitting showed that many of the ill effects of smoking can be reversed.
The surgeon general's report
Health Consequences of Smoking reveals that deaths attributable to smoking can be reduced dramatically if the prevalence of smoking is cut.
According to Arialdi M. Mini
ño et al. in
Deaths: Preliminary Data for 2004
(June 28, 2006,
http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_19.pdf), heart disease
was the number-one killer of Americans in 2004 and cancer was the
number-two killer. Of all cancers, lung cancer is the number-one killer
of both men and women. People who quit smoking in middle age or before
middle age avoid more than 90% of the lung cancer risk attributable to
tobacco. Results of Richard Peto et al.'s "Smoking, Smoking Cessation,
and Lung Cancer in the UK since 1950: Combination of National Statistics
with Two Case-Control Studies" (
British Medical Journal,
August 5, 2000) reveal the extent to which smoking cessation lowers lung
cancer risk. For men who stopped smoking at aged sixty, fifty, forty,
and thirty, the cumulative risks of lung cancer by the age of
seventy-five were 10%, 6%, 3%, and 2%, respectively. These results were
supported by the findings of Anna Crispo et al., in "The Cumulative Risk
of Lung Cancer among Current, Ex- and Never-Smokers in European Men" (
British Journal of Cancer,
October 2004), that led to the conclusion that, for long-term smokers,
giving up smoking in middle age allows people to avoid most of the
subsequent risk of lung cancer.
For smokers who quit, the risk of heart disease drops rapidly after
smoking cessation. After one year's abstinence from smoking, the risk of
heart disease is reduced by about 50% and continues to decline
gradually. After
five to ten years of smoking cessation, the risk has declined to that of
a person who has never smoked. In addition, Gay Sutherland reports in
"Smoking: Can We Really Make a Difference?" (
Heart, May 2003) that stopping smoking reduces the risk of stroke to that of a nonsmoker after five years of smoking cessation.
The study "Effects of Multiple Attempts to Quit Smoking and Relapses to Smoking on Pulmonary Function" (
Journal of Clinical Epidemiology,
December 1998) by Robert P. Murray et al. investigated whether short
periods of quitting were beneficial to smokers' health. Results revealed
that those who made several attempts to quit smoking had less loss of
lung function than those who continued to smoke. Therefore, even
intermittent lapses in smoking are beneficial.
Quitting and Pregnancy
The 2005 NSDUH finds that from 10.4% to 26.4% of pregnant women
smoked cigarettes in the month prior to the survey. Those aged eighteen
to twenty-five had the highest percentage of smokers. Nonetheless, in
the fifteen- to seventeen-year-old group a higher percentage of pregnant
girls smoked than nonpregnant girls, 22.3% versus 18.5%, respectively.
(See Figure 3.6.)
Smoking during pregnancy can compromise the health of the developing fetus. The 2004 surgeon general's report
Health Consequences of Smoking
notes that evidence suggests the possibility of a causal relationship
between maternal smoking and ectopic pregnancy, a situation in which the
fertilized egg implants in the fallopian tube rather than in the
uterus. This situation is quite serious and is life-threatening to the
mother. Smoking by pregnant women is also linked to an increased risk of
miscarriage, stillbirth, premature delivery, and sudden infant death
syndrome, and is a cause of low birth weight in infants. A woman who
stops smoking before pregnancy or during her first trimester (three
months) of pregnancy significantly reduces her chances of having a low
birth weight baby. Research finds that it takes smokers longer to get
pregnant than nonsmokers, but that women who quit are as likely to get
pregnant as those who have never smoked.
Complaints about Quitting
A major side effect of smoking cessation is nicotine withdrawal. The
short-term consequences of nicotine withdrawal may include anxiety,
irritability, frustration, anger, difficulty concentrating, and
restlessness. Possible long-term consequences are urges to smoke and
increased appetite. Nicotine withdrawal symptoms peak in the first few
days after quitting and subside during the following weeks. Improved
self-esteem and an increased sense of control often accompany long-term
abstinence.
One of the most common complaints among former smokers is that they
gain weight when they stop smoking. Many reasons explain this weight
gain, but two primary reasons are the metabolism changes when nicotine
is withdrawn from the body and many former smokers use food in an
attempt to manage their withdrawal cravings. To combat weight gain, some
former smokers start exercise programs.
Ways to Stop Smoking
Nicotine replacement treatments can be effective for many smokers.
Nicotine patches and gum are two types of nicotine replacement therapy
(NRT). The nicotine in a patch is absorbed through the skin, and the
nicotine in gum is absorbed through the mouth and throat. NRT helps a
smoker cope with nicotine withdrawal symptoms that discourage many
smokers trying to stop. Nicotine patches and gum are available over the
counter. Other NRT products are the nicotine nasal spray and the
nicotine inhaler, which are available by prescription.
The nonnicotine therapy bupropion (an antidepressant drug such as
Zyban and Wellbutrin) is also available by prescription for the relief
of nicotine withdrawal symptoms. In addition, behavioral treatments,
such as smoking-cessation programs, are useful for some smokers who want
to quit. Behavioral methods are designed to create an aversion to
smoking, develop self-monitoring of smoking behavior, and establish
alternative coping responses.
Quitting smoking is not easy. Sutherland notes that the expected
one-year success rates of quitting smoking vary among stop-smoking
interventions. Only 1-2% of smokers trying to quit will remain
smoke-free for a year with no advice or support from a doctor or other
health care professional and no treatment (NRT or bupropion). Five
percent of those who receive three minutes' advice from a health care
professional to help them quit will remain smoke-free for a year. Advice
plus treatment raises the percentage of those who remain smoke free to
10%. Intensive behavioral support from a specialist plus treatment can
lead to a 25% success rate.
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