Quit Smoking

Overview of Smoking & Health Effects of Smoking:

Tobacco has a negative effect on almost every organ of the body. According to the U.S. Department of Health & Human Services, tobacco use is the leading preventable cause of death in the United States, resulting in more than 443,000 deaths each year. Worldwide, recent studies have shown that tobacco is responsible for about 6 million deaths each year.

Cigar smokers and smokeless tobacco (chew or spit tobacco) users have similar health risks as cigarette smokers.

Secondhand Smoke

Environmental tobacco smoke (ETS)—or secondhand smoke—results in approximately 3,000 lung cancer deaths per year in non-smokers. Secondhand smoke is what is given off by the end of the burning cigarette and by the smoker's exhalations.

Short-term Effecs of Smoking

Short-term effects of smoking include more frequent respiratory illnesses such as coughs, colds, bronchitis, and pneumonia. Among children and adolescents exposed to secondhand smoke, rates of asthma, ear infection and lower respiratory infections are higher.

Long-term Effects of Smoking

The long-term effects of smoking are extensive. There are numerous diseases linked to smoking. Smoking can cause cancer of the mouth and throat and lung cancer, and can increase the risk for stomach (gastric) cancer, kidney cancer, bladder cancer, cervical cancer, and pancreatic cancer. About one third of all cancers are linked to tobacco use—and 90 percent of lung cancer cases are linked to smoking.

Smoking also causes chronic obstructive pulmonary disease, or COPD, (e.g., emphysema, chronic bronchitis), which is severe lung damage. Smoking reduces blood circulation and narrows blood vessels, depriving the body of oxygen and increasing the risk for heart disease. Non-smokers who are exposed to secondhand smoke are 25 percent more likely to develop heart disease. Smoking also doubles the risk for stroke and increases the risk for developing cataracts.

Smoking poses additional health risks for women. It increases the risk for rheumatoid arthritis (RA) and leads to loss of bone density (osteoporosis), increasing the chances of hip and spine fractures in postmenopausal women.

Women of childbearing age who smoke face higher rates of infertility and greater risks for complications during pregnancy. Smoking during pregnancy also increases the unborn baby's health risks (e.g., premature birth, respiratory illnesses, low birth weight). After birth, the risk for sudden infant death syndrome (SIDS) doubles for babies exposed to secondhand smoke.

Children and teens are especially vulnerable to the hazards of smoking. Because their bodies are not fully mature, smoking interferes with normal lung development in those who begin smoking as children or adolescents. Young people who smoke may become more strongly addicted to cigarettes and face an even greater risk for developing lung cancer than those who start smoking later in life. Every day, approximately 4,000 children under the age of 18 try a cigarette for the first time and 1,000 become regular smokers.

Teenagers who smoke are more likely to have depression or other psychological problems. They are also more likely to engage in other dangerous behaviors, such as using alcohol and other drugs.

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.

Tobacco

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 (CO₂), which bonds with the hemoglobin in blood so that the CO₂ 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 CO₂ from the body's tissues. CO bonds to hemoglobin more tightly than CO₂ 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:

1. Secondhand smoke causes premature death and disease in children and in adults who do not smoke.

1. 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.
2. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer.
3. The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.
4. 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.
5. 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. Miniño 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.