Smoking

Definition

Smoking is the inhalation of the smoke of burning tobacco encased in cigarettes, pipes, and cigars. Casual smoking is the act of smoking only occasionally, usually in a social situation or to relieve stress . A smoking habit is a physical addiction to tobacco products. Many health experts now regard habitual smoking as a psychological addiction, too, and one with serious health consequences.

Description

The U.S. Food and Drug Administration (FDA) has asserted that cigarettes and smokeless tobacco should be considered nicotine delivery devices. Nicotine, the active ingredient in tobacco, is inhaled into the lungs, where most of it stays. The rest passes into the bloodstream, reaching the brain in about ten seconds and dispersing throughout the body in about 20 seconds.

Depending on the circumstances and the amount consumed, nicotine can act as either a stimulant or tranquilizer. This can explain why some people report that smoking gives them energy and stimulates their mental activity, while others note that smoking relieves anxiety and relaxes them. The initial "kick" results in part from the drug's stimulation of the adrenal glands and resulting release of epinephrine into the blood. Epinephrine causes several physiological changes—it temporarily narrows the arteries, raises the blood pressure, raises the levels of fat in the blood, and increases the heart rate and flow of blood from the heart. Some researchers think epinephrine contributes to smokers' increased risk of high blood pressure.

Nicotine by itself increases the risk of heart disease . However, when a person smokes, he or she is ingesting a lot more than nicotine. Smoke from a cigarette, pipe, or cigar is made up of many additional toxic chemicals, including tar and carbon monoxide. Tar is a sticky substance that forms into deposits in the lungs, causing lung cancer and respiratory distress. Carbon monoxide limits the amount of oxygen that the red blood cells can convey throughout the body. Also, it may damage the inner walls of the arteries, which allows fat to build up in them.

Besides tar, nicotine, and carbon monoxide, tobacco smoke contains 4,000 different chemicals. More than 200 of these chemicals are known be toxic. Nonsmokers who are exposed to tobacco smoke also take in these toxic chemicals. They inhale the smoke exhaled by the smoker as well as the more toxic sidestream smoke—the smoke from the end of the burning cigarette, cigar, or pipe.

Here's why sidestream smoke is more toxic than exhaled smoke: When a person smokes, the smoke he or she inhales and then breathes out leaves harmful deposits inside the body. But because lungs partially cleanse the smoke, exhaled smoke contains fewer poisonous chemicals. That's why exposure to tobacco smoke is dangerous even for a nonsmoker.

Causes & symptoms

No one starts smoking to become addicted to nicotine. It isn't known how much nicotine may be consumed before the body becomes addicted. However, once smoking becomes a habit, the smoker faces a lifetime of health risks associated with an addiction that has been shown to be stronger than alcohol addiction and at least as strong as narcotics addiction.

About 70% of smokers in the United States would like to quit; in any given year, however, only about 3.6% of the country's 47 million smokers quit successfully.

Although specific genes have not yet been identified as of 2003, researchers think that genetic factors contribute substantially to developing a smoking habit. Several twin studies have led to estimates of 46–84% heritability for smoking. It is thought that some genetic variations affect the speed of nicotine metabolism in the body and the activity level of nicotinic receptors in the brain.

Smoking risks

Smoking is recognized as the leading preventable cause of death, causing or contributing to the deaths of approximately 430,700 Americans each year. Anyone with a smoking habit has an increased chance of lung, cervical, and other types of cancer; respiratory diseases such as emphysema, asthma , and chronic bronchitis ; and cardiovascular disease, such as heart attack , high blood pressure, stroke , and atherosclerosis (narrowing and hardening of the arteries). The risk of stroke is especially high in women who take birth control pills.

Smoking can damage fertility, making it harder to conceive, and it can interfere with the growth of the fetus during pregnancy . It accounts for an estimated 14% of premature births and 10% of infant deaths. There is some evidence that smoking may cause impotence in some men.

Because smoking affects so many of the body's systems, smokers often have vitamin deficiencies and suffer oxidative damage caused by free radicals. Free radicals are molecules that steal electrons from other molecules, turning the other molecules into free radicals and destabilizing the molecules in the body's cells.

Smoking is recognized as one of several factors that might be related to a higher risk of hip fractures in older adults.

Studies reveal that the more a person smokes, the more likely he is to sustain illnesses such as cancer, chronic bronchitis, and emphysema. But even smokers who indulge in the habit only occasionally are more prone to these diseases.

Some brands of cigarettes are advertised as "low tar," but no cigarette is truly safe. If a smoker switches to a low-tar cigarette, he is likely to inhale longer and more deeply to get the chemicals his body craves. A smoker has to quit the habit entirely in order to improve his health and decrease the chance of disease.

Though some people believe chewing tobacco is safer, it also carries health risks. People who chew tobacco have an increased risk of heart disease and mouth and throat cancer. Pipe and cigar smokers have increased health risks as well, even though these smokers generally do not inhale as deeply as cigarette smokers do. These groups haven't been studied as extensively as cigarette smokers, but there is evidence that they may be at a slightly lower risk of cardiovascular problems but a higher risk of cancer and various types of circulatory conditions.

Recent research reveals that passive smokers, or those who unavoidably breathe in secondhand tobacco smoke, have an increased chance of many health problems such as lung cancer , ischemic heart disease, and asthma; and in children, sudden infant death syndrome. A Swedish study published in 2001 found that people who were exposed to environmental tobacco smoke (ETS) as children were both more likely to develop asthma as adults, and to become smokers themselves. In the fall of 2001 the Environmental Protection Agency (EPA) partnered with the American Academy of Allergy, Asthma, and Immunology (AAAAI) to educate parents about the risks to their children of secondhand smoke, and to persuade parents to sign a Smoke Free Home Pledge. The AAAAI reported that many parents cut down on or gave up smoking when they recognized the damage that smoking was causing to their children's lungs. A study of secondhand smoke in the workplace done by the European Union found that it can affect workers as severely as smoke in the home can affect children. The study noted that workers exposed to secondhand smoke from their colleagues had significantly higher rates of asthma and upper respiratory infections than those who were employed in smoke-free workplaces.

Smokers' symptoms

Smokers are likely to exhibit a variety of symptoms that reveal the damage caused by smoking. A nagging morning cough may be one sign of a tobacco habit. Other symptoms include shortness of breath, wheezing , and frequent occurrences of respiratory illness, such as bronchitis. Smoking also increases fatigue and decreases the smoker's sense of smell and taste. Smokers are more likely to develop poor circulation, with cold hands and feet and premature wrinkles.

Sometimes the illnesses that result from smoking come on silently with little warning. For instance, coronary artery disease may exhibit few or no symptoms. At other times, there will be warning signs, such as bloody discharge from a woman's vagina, a sign of cancer of the cervix. Another warning sign is a hacking cough, worse than the usual smoker's cough, that brings up phlegm or blood—a sign of lung cancer.

Withdrawal symptoms

A smoker who tries to quit may expect one or more of these withdrawal symptoms: nausea, constipation or diarrhea , drowsiness, loss of concentration, insomnia, headache , nausea, and irritability.

Diagnosis

It's not easy to quit smoking. That's why it may be wise for a smoker to turn to his physician for help. For the greatest success in quitting and to help with the withdrawal symptoms, the smoker should talk over a treatment plan with his doctor or alternative practitioner. He should have a general physical examination to gauge his general health and uncover any deficiencies. He should also have a thorough evaluation for some of the serious diseases that smoking can cause.

Treatment

There are a wide range of alternative treatments that can help a smoker quit the habit, including hypnotherapy , herbs, acupuncture, and meditation . For example, a controlled trial demonstrated that self-massage can help smokers crave less intensely, smoke fewer cigarettes, and in some cases give them up completely.

Hypnotherapy

Hypnotherapy helps the smoker achieve a trance-like state, during which the deepest levels of the mind are accessed. A session with a hypnotherapist may begin with a discussion of whether the smoker really wants to and truly has the motivation to stop smoking. The therapist will explain how hypnosis can reduce the stress-related symptoms that sometimes come with kicking the habit.

Often the therapist will discuss the dangers of smoking with the patient and begin to "reframe" the patient's thinking about smoking. Many smokers are convinced they can't quit, and the therapist can help persuade them that they can change this behavior. These suggestions are then repeated while the smoker is under hypnosis. The therapist may also suggest while the smoker is under hypnosis that his feelings of worry, anxiety, and irritability will decrease.

In a review of 17 studies of the effectiveness of hypnotherapy, the percentage of people treated by hypnosis who still were not smoking after six months ranged from 4% to 8%. In programs that included several hours of treatment, intense interpersonal interaction, individualized suggestions, and follow-up treatment, success rates were above 50%.

Aromatherapy

One study demonstrated that inhaling the vapor from black pepper extract can reduce symptoms associated with smoking withdrawal. Other essential oils can be used for relieving the anxiety a smoker often experiences while quitting.

Herbs

A variety of herbs can help smokers reduce their cravings for nicotine, calm their irritability, and even reverse the oxidative cellular damage done by smoking. Lobelia, sometimes called Indian tobacco, has historically been used as a substitute for tobacco. It contains a substance called lobeline, which decreases the craving for nicotine by bolstering the nervous system and calming the smoker. In high doses, lobelia can cause vomiting , but the average dose—about 10 drops per day—should pose no problems.

Herbs that can help relax a smoker during withdrawal include wild oats and kava kava .

To reduce the oral fixation supplied by a nicotine habit, a smoker can chew on licorice root—the plant, not the candy. Licorice is good for the liver, which is a major player in the body's detoxification process. Licorice also acts as a tonic for the adrenal system, which helps reduce stress. And there's an added benefit: If a smoker tries to light up after chewing on licorice root, the cigarette tastes like burned cardboard.

Other botanicals that can help repair free-radical damage to the lungs and cardiovascular system are those high in flavonoids, such as hawthorn, gingko biloba, and bilberry , as well as antioxidants such as vitamin A, vitamin C, zinc , and selenium .

Acupuncture

This ancient Chinese method of healing is used commonly to help beat addictions, including smoking. The acupuncturist will use hair-thin needles to stimulate the body's qi, or healthy energy. Acupuncture is a sophisticated treatment system based on revitalizing qi, which supposedly flows through the body in defined pathways called meridians. During an addiction like smoking, qi isn't flowing smoothly or gets stuck, the theory goes.

Points in the ear and feet are stimulated to help the smoker overcome his addiction. Often the acupuncturist will recommend keeping the needles in for five to seven days to calm the smoker and keep him balanced.

Vitamins

Smoking seriously depletes vitamin C in the body and leaves it more susceptible to infections. Vitamin C can prevent or reduce free-radical damage by acting as an antioxidant in the lungs. Smokers need additional C, in higher dosage than nonsmokers. Fish in the diet supplies Omega-3 fatty acids , which are associated with a reduced risk of chronic obstructive pulmonary disease (emphysema or chronic bronchitis) in smokers. Omega-3 fats also provide cardiovascular benefits as well as an anti-depressive effect. Vitamin therapy doesn't reduce craving but it can help beat some of the damage created by smoking. Vitamin B₁₂ and folic acid may help protect against smoking-induced cancer.

Allopathic treatment

Research shows that most smokers who want to quit benefit from the support of other people. It helps to quit with a friend or to join a group such as those organized by the American Cancer Society. These groups provide support and teach behavior modification methods that can help the smoker quit. The smoker's physician can often refer him to such groups.

Other alternatives to help with the withdrawal symptoms of kicking the habit include nicotine replacement therapy (NRT) in the form of gum, patches, nasal sprays, and oral inhalers. These are available by prescription or over the counter. A physician can provide advice on how to use them. They slowly release a small amount of nicotine into the bloodstream, satisfying the smoker's physical craving. Over time, the amount of gum the smoker chews is decreased and the amount of time between applying the patches is increased. This tapering helps wean the smoker from nicotine slowly, eventually beating his addiction to the drug. But there's one important caution: If the smoker lights up while taking a nicotine replacement, a nicotine overdose may cause serious health problems.

The prescription drug Zyban (bupropion hydrochloride) has shown some success in helping smokers quit. This drug contains no nicotine, and was originally developed as an antidepressant. It isn't known exactly how bupropion works to suppress the desire for nicotine. A five-year study of bupropion reported in 2003 that the drug has a very good record for safety and effectiveness in treating tobacco dependence. Its most common side effect is insomnia, which can also result from nicotine withdrawal.

Researchers are investigating two new types of drugs as possible treatments for tobacco dependence as of 2003. The first is an alkaloid known as 18-methoxy-coronaridine (18-MC), which selectively blocks the nicotinic receptors in brain tissue. Another approach involves developing drugs that inhibit the activity of cytochrome P450 2A6 (CYP2A6), which controls the metabolism of nicotine.

Expected results

Research on smoking shows that most smokers desire to quit. But smoking is so addictive that fewer than 20% of the people who try ever successfully kick the habit. Still, many people attempt to quit smoking over and over again, despite the difficulties—the cravings and withdrawal symptoms, such as irritability and restlessness.

For those who do quit, the rewards of better health are well worth the effort. The good news is that once a smoker quits the health effects are immediate and dramatic. After the first day, oxygen and carbon monoxide levels in the blood return to normal. At two days, nerve endings begin to grow back and the senses of taste and smell revive. Within two weeks to three months, circulation and breathing improve. After one year of not smoking, the risk of heart disease is reduced by 50%. After 15 years of abstinence, the risks of health problems from smoking virtually vanish. A smoker who quits for good often feels a lot better too, with less fatigue and fewer respiratory illnesses.

Prevention

How do you give up your cigarettes for good and never go back to them again?

Here are a few tips from the experts:

• Have a plan and set a definite quit date.
• Get rid of all the cigarettes and ashtrays at home or in your desk at work.
• Don't allow others to smoke in your house.
• Tell your friends and neighbors that you're quitting. Doing so helps make quitting a matter of pride.
• Chew sugarless gum or eat sugar-free hard candy to redirect the oral fixation that comes with smoking. This will prevent weight gain, too.
• Eat as much as you want, but only low-calorie foods and drinks. Drink plenty of water. This may help with the feelings of tension and restlessness that quitting can bring. After eight weeks, you'll lose your craving for tobacco, so it's safe then to return to your usual eating habits.
• Stay away from social situations that prompt you to smoke. Dine in the nonsmoking section of restaurants.
• Spend the money you save by not smoking on an occasional treat for yourself.

Resources

BOOKS

"Acupuncture." In The American Medical Association Encyclopedia of Medicine, edited by Charles B. Clayman. New York: Random House, 1989.

Molony, David, and Ming Ming Pan. The American Association of Oriental Medicine's Complete Guide to Herbal Medicine. New York: Berkley Books, 1998.

"Tobacco Addiction." Section 21, Chapter 290 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Tyler, Varro E. The Honest Herbal: a Sensible Guide to the Use of Herbs and Related Remedies. New York: Haworth Press, 1993.

PERIODICALS

"AAAAI, EPA Mount Effort to Raise Awareness to Dangers of Secondhand Smoke." Immunotherapy Weekly (November 30, 2001): 30.

Batra, V., A. A. Patkar, W. H. Berrettini, et al. "The Genetic Determinants of Smoking." Chest 123 (May 2003): 1338–1340.

Ferry, L., and J. A. Johnston. "Efficacy and Safety of Bupropion SR for Smoking Cessation: Data from Clinical Trials and Five Years of Postmarketing Experience." International Journal of Clinical Practice 57 (April 2003): 224–230.

Janson, Christer, Susan Chinn, Deborah Jarvis, et al. "Effect of Passive Smoking on Respiratory Symptoms, Bronchial Responsiveness, Lung Function, and Total Serum IgE in the European Community Respiratory Health Survey: A Cross-Sectional Study." Lancet 358 (December 22, 2001): 2103.

Lerman, C., and W. Berrettini. "Elucidating the Role of Genetic Factors in Smoking Behavior and Nicotine Dependence." American Journal of Medical Genetics 118-B (April 1, 2003): 48–54.

Maisonneuve, I. M., and S. D. Glick. "Anti-Addictive Actions of an Iboga Alkaloid Congener: A Novel Mechanism for a Novel Treatment." Pharmacology, Biochemistry, and Behavior 75 (June 2003): 607–618.

Richmomd, R., and N. Zwar. "Review of Bupropion for Smoking Cessation." Drug and Alcohol Review 22 (June 2003): 203–220.

Sellers, E. M., R. F. Tyndale, and L. C. Fernandes. "Decreasing Smoking Behaviour and Risk through CYP2A6 Inhibition." Drug Discovery Today 8 (June 1, 2003): 487–493.

"Study Shows Link Between Asthma and Childhood Exposure to Smoking." Immunotherapy Weekly (October 10, 2001): np.

Yochum, L., L. H. Kushi, and A. R. Folsom. "Dietary Flavonoid Intake and Risk of Cardiovascular Disease in Postmenopausal Women." American Journal of Epidemiology 149, no. 10 (May 1999): 943–9.

ORGANIZATIONS

American Association of Oriental Medicine. 909 22nd Street, Sacramento, CA 95816, (916) 451-6950 <http://www.aaom.org>.

American Cancer Society. Contact the local organization or call (800) 227-2345. <http://www.cancer.org>.

American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872 or (212) 315-8700. <http://www.lungusa.org>.

Herb Research Foundation. 1007 Pearl St., Suite 200, Boulder CO 80302. (303) 449-2265. <http://www.herbs.org>.

National Heart, Lung, and Blood Institute (NHLBI). Building 31, Room 5A52, 31 Center Drive, MSC 2486, Bethesda, MD 20892. (301) 592-8573. <http://www.nhlbi.nih.gov>.

Smoking, Tobacco, and Health Information Line; Centers for Disease Control and Prevention. Mailstop K-50, 4770 Bu-ford Highway NE, Atlanta, GA 30341-3724. (800) 232-1311. <http://www.cdc.gov/tobacco>.

OTHER

Virtual Office of the Surgeon General: Tobacco Cessation Guideline. <http://www.surgeongeneral.gov/tobacco>.

Barbara Boughton

Rebecca J. Frey, PhD

Smoking

Definition

Smoking is the inhalation of the smoke of burning tobacco encased in cigarettes, pipes, and cigars. Casual smoking is the act of smoking only occasionally, usually in a social situation or to relieve stress. A smoking habit is a physical addiction to tobacco products. Many health experts now regard habitual smoking as a psychological addiction, too, and one with serious health consequences.

Description

The U.S. Food and Drug Administration has asserted that cigarettes and smokeless tobacco should be considered nicotine delivery devices. Nicotine, the active ingredient in tobacco, is inhaled into the lungs, where most of it stays. The rest passes into the bloodstream, reaching the brain in about 10 seconds and dispersing throughout the body in about 20 seconds.

Depending on the circumstances and the amount consumed, nicotine can act as either a stimulant or tranquilizer. This can explain why some people report that smoking gives them energy and stimulates their mental activity, while others note that smoking relieves anxiety and relaxes them. The initial "kick" results in part from the drug's stimulation of the adrenal glands and resulting release of epinephrine into the blood. Epinephrine causes several physiological changes—it temporarily narrows the arteries, raises the blood pressure, raises the levels of fat in the blood, and increases the heart rate and flow of blood from the heart. Some researchers think epinephrine contributes to smokers' increased risk of high blood pressure.

Nicotine, by itself, increases the risk of heart disease. However, when a person smokes, he or she is ingesting a lot more than nicotine. Smoke from a cigarette, pipe, or cigar is made up of many additional toxic chemicals, including tar and carbon monoxide. Tar is a sticky substance that forms into deposits in the lungs, causing lung cancer and respiratory distress. Carbon monoxide limits the amount of oxygen that the red blood cells can convey throughout your body. Also, it may damage the inner walls of the arteries, which allows fat to build up in them.

Besides tar, nicotine, and carbon monoxide, tobacco smoke contains 4,000 different chemicals. More than 200 of these chemicals are known be toxic. Nonsmokers who are exposed to tobacco smoke also take in these toxic chemicals. They inhale the smoke exhaled by the smoker as well as the more toxic sidestream smoke —the smoke from the end of the burning cigarette, cigar, or pipe.

Here's why sidestream smoke is more toxic than exhaled smoke: When a person smokes, the smoke he or she inhales and then breathes out leaves harmful deposits inside the body. But because lungs partially cleanse the smoke, exhaled smoke contains fewer poisonous chemicals. That's why exposure to tobacco smoke is dangerous even for a nonsmoker.

Causes and symptoms

No one starts smoking to become addicted to nicotine. It isn't known how much nicotine may be consumed before the body becomes addicted. However, once smoking becomes a habit, the smoker faces a lifetime of health risks associated with one of the strongest addictions known to man.

About 70% of smokers in the United States would like to quit; in any given year, however, only about 3.6% of the country's 47 million smokers quit successfully.

Although specific genes have not yet been identified as of 2003, researchers think that genetic factors contribute substantially to developing a smoking habit. Several twin studies have led to estimates of 46-84% heritability for smoking. It is thought that some genetic variations affect the speed of nicotine metabolism in the body and the activity level of nicotinic receptors in the brain.

Smoking risks

Smoking is recognized as the leading preventable cause of death, causing or contributing to the deaths of approximately 430,700 Americans each year. Anyone with a smoking habit has an increased chance of lung, cervical, and other types of cancer; respiratory diseases such as emphysema, asthma, and chronic bronchitis ; and cardiovascular disease, such as heart attack, high blood pressure, stroke, and atherosclerosis (narrowing and hardening of the arteries). The risk of stroke is especially high in women who take birth control pills.

Smoking can damage fertility, making it harder to conceive, and it can interfere with the growth of the fetus during pregnancy. It accounts for an estimated 14% of premature births and 10% of infant deaths. There is some evidence that smoking may cause impotence in some men.

Because smoking affects so many of the body's systems, smokers often have vitamin deficiencies and suffer oxidative damage caused by free radicals. Free radicals are molecules that steal electrons from other molecules, turning the other molecules into free radicals and destabilizing the molecules in the body's cells.

Smoking is recognized as one of several factors that might be related to a higher risk of hip fractures in older adults.

Studies reveal that the more a person smokes, the more likely he is to sustain illnesses such as cancer, chronic bronchitis, and emphysema. But even smokers who indulge in the habit only occasionally are more prone to these diseases.

Some brands of cigarettes are advertised as "low tar," but no cigarette is truly safe. If a smoker switches to a low-tar cigarette, he is likely to inhale longer and more deeply to get the chemicals his body craves. A smoker has to quit the habit entirely in order to improve his health and decrease the chance of disease.

Though some people believe chewing tobacco is safer, it also carries health risks. People who chew tobacco have an increased risk of heart disease and mouth and throat cancer. Pipe and cigar smokers have increased health risks as well, even though these smokers generally do not inhale as deeply as cigarette smokers do. These groups haven't been studied as extensively as cigarette smokers, but there is evidence that they may be at a slightly lower risk of cardiovascular problems but a higher risk of cancer and various types of circulatory conditions.

Recent research reveals that passive smokers, or those who unavoidably breathe in second-hand tobacco smoke, have an increased chance of many health problems such as lung cancer and asthma, and in children, sudden infant death syndrome.

Smokers' symptoms

Smokers are likely to exhibit a variety of symptoms that reveal the damage caused by smoking. A nagging morning cough may be one sign of a tobacco habit. Other symptoms include shortness of breath, wheezing, and frequent occurrences of respiratory illness, such as bronchitis. Smoking also increases fatigue and decreases the smoker's sense of smell and taste. Smokers are more likely to develop poor circulation, with cold hands and feet and premature wrinkles.

Sometimes the illnesses that result from smoking come on silently with little warning. For instance, coronary artery disease may exhibit few or no symptoms. At other times, there will be warning signs, such as bloody discharge from a woman's vagina, a sign of cancer of the cervix. Another warning sign is a hacking cough, worse than the usual smoker's cough, that brings up phlegm or blood—a sign of lung cancer.

Withdrawal symptoms

A smoker who tries to quit may expect one or more of these withdrawal symptoms: nausea, constipation or diarrhea, drowsiness, loss of concentration, insomnia, headache, nausea, and irritability.

Diagnosis

It's not easy to quit smoking. That's why it may be wise for a smoker to turn to his physician for help. For the greatest success in quitting and to help with the withdrawal symptoms, the smoker should talk over a treatment plan with his doctor or alternative practitioner. He should have a general physical examination to gauge his general health and uncover any deficiencies. He should also have a thorough evaluation for some of the serious diseases that smoking can cause.

Treatment

Research shows that most smokers who want to quit benefit from the support of other people. It helps to quit with a friend or to join a group such as those organized by the American Cancer Society. These groups provide support and teach behavior modification methods that can help the smoker quit. The smoker's physician can often refer him to such groups.

Other alternatives to help with the withdrawal symptoms of kicking the habit include nicotine replacement therapy in the form of gum, patches, nasal sprays, and oral inhalers. These are available by prescription or over the counter. A physician can provide advice on how to use them. They slowly release a small amount of nicotine into the bloodstream, satisfying the smoker's physical craving. Over time, the amount of gum the smoker chews is decreased and the amount of time between applying the patches is increased. This helps wean the smoker from nicotine slowly, eventually beating his addiction to the drug. But there's one important caution: If the smoker lights up while taking a nicotine replacement, a nicotine overdose may cause serious health problems.

The prescription drug Zyban (bupropion hydrochloride) has shown some success in helping smokers quit. This drug contains no nicotine, and was originally developed as an antidepressant. It isn't known exactly how bupropion works to suppress the desire for nicotine. A five-year study of bupropion reported in 2003 that the drug has a very good record for safety and effectiveness in treating tobacco dependence. Its most common side effect is insomnia, which can also result from nicotine withdrawal.

Researchers are investigating two new types of drugs as possible treatments for tobacco dependence as of 2003. The first is an alkaloid known as 18-methoxycoronaridine (18-MC), which selectively blocks the nicotinic receptors in brain tissue. Another approach involves developing drugs that inhibit the activity of cytochrome P450 2A6 (CYP2A6), which controls the metabolism of nicotine.

Expected results

Research on smoking shows that most smokers desire to quit. But smoking is so addictive that fewer than 20% of the people who try ever successfully kick the habit. Still, many people attempt to quit smoking over and over again, despite the difficulties—the cravings and withdrawal symptoms, such as irritability and restlessness.

For those who do quit, the benefits to health are well worth the effort. The good news is that once a smoker quits the health effects are immediate and dramatic. After the first day, oxygen and carbon monoxide levels in the blood return to normal. At two days, nerve endings begin to grow back and the senses of taste and smell revive. Within two weeks to three months, circulation and breathing improve. After one year of not smoking, the risk of heart disease is reduced by 50%. After 15 years of abstinence, the risks of health problems from smoking virtually vanish. A smoker who quits for good often feels a lot better too, with less fatigue and fewer respiratory illnesses.

Alternative treatment

There are a wide range of alternative treatments that can help a smoker quit the habit, including hypnotherapy, herbs, acupuncture, and meditation. For example, a controlled trial demonstrated that self-massage can help smokers crave less intensely, smoke fewer cigarettes, and in some cases completely give them up.

Hypnotherapy

Hypnotherapy helps the smoker achieve a trance-like state, during which the deepest levels of the mind are accessed. A session with a hypnotherapist may begin with a discussion of whether the smoker really wants to and truly has the motivation to stop smoking. The therapist will explain how hypnosis can reduce the stress-related symptoms that sometimes come with kicking the habit.

Often the therapist will discuss the dangers of smoking with the patient and begin to "reframe" the patient's thinking about smoking. Many smokers are convinced they can't quit, and the therapist can help persuade them that they can change this behavior. These suggestions are then repeated while the smoker is under hypnosis. The therapist may also suggest while the smoker is under hypnosis that his feelings of worry, anxiety, and irritability will decrease.

In a review of 17 studies of the effectiveness of hypnotherapy, the percentage of people treated by hypnosis who still were not smoking after six months ranged from 4-8%. In programs that included several hours of treatment, intense interpersonal interaction, individualized suggestions, and follow-up treatment, success rates were above 50%.

Aromatherapy

One study demonstrated that inhaling the vapor from black pepper extract can reduce symptoms associated with smoking withdrawal. Other essential oils can be used for relieving the anxiety a smoker often experiences while quitting.

Herbs

A variety of herbs can help smokers reduce their cravings for nicotine, calm their irritability, and even reverse the oxidative cellular damage done by smoking. Lobelia, sometimes called Indian tobacco, has historically been used as a substitute for tobacco. It contains a substance called lobeline, which decreases the craving for nicotine by bolstering the nervous system and calming the smoker. In high doses, lobelia can cause vomiting, but the average dose—about 10 drops per day—should pose no problems.

Herbs that can help relax a smoker during withdrawal include wild oats and kava kava.

To reduce the oral fixation supplied by a nicotine habit, a smoker can chew on licorice root—the plant, not the candy. Licorice is good for the liver, which is a major player in the body's detoxification process. Licorice also acts as a tonic for the adrenal system, which helps reduce stress. And there's an added benefit: If a smoker tries to light up after chewing on licorice root, the cigarette tastes like burned cardboard.

Other botanicals that can help repair free-radical damage to the lungs and cardiovascular system are those high in flavonoids, such as hawthorn, gingko biloba, and bilberry, as well as antioxidants such as vitamin A, vitamin C, zinc, and selenium.

Acupuncture

This ancient Chinese method of healing is used commonly to help beat addictions, including smoking. The acupuncturist will use hair-thin needles to stimulate the body's qi, or healthy energy. Acupuncture is a sophisticated treatment system based on revitalizing qi, which supposedly flows through the body in defined pathways called meridians. During an addiction like smoking, qi isn't flowing smoothly or gets stuck, the theory goes.

Points in the ear and feet are stimulated to help the smoker overcome his addiction. Often the acupuncturist will recommend keeping the needles in for five to seven days to calm the smoker and keep him balanced.

Vitamins

Smoking seriously depletes vitamin C in the body and leaves it more susceptible to infections. Vitamin C can prevent or reduce free-radical damage by acting as an antioxidant in the lungs. Smokers need additional C, in higher dosage than nonsmokers. Fish in the diet supplies Omega-3 fatty acids, which are associated with a reduced risk of chronic obstructive pulmonary disease (emphysema or chronic bronchitis) in smokers. Omega-3 fats also provide cardiovascular benefits as well as an anti-depressive effect. Vitamin therapy doesn't reduce craving but it can help beat some of the damage created by smoking. Vitamin B₁₂ and folic acid may help protect against smoking-induced cancer.

Prevention

How do you give up your cigarettes for good and never go back to them again?

KEY TERMS

Antioxidant— Any substance that reduces the damage caused by oxidation, such as the harm caused by free radicals.

Chronic bronchitis— A smoking-related respiratory illness in which the membranes that line the bronchi, or the lung's air passages, narrow over time. Symptoms include a morning cough that brings up phlegm, breathlessness, and wheezing.

Cytochrome— A substance that contains iron and acts as a hydrogen carrier for the eventual release of energy in aerobic respiration.

Emphysema— An incurable, smoking-related disease, in which the air sacs at the end of the lung's bronchi become weak and inefficient. People with emphysema often first notice shortness of breath, repeated wheezing and coughing that brings up phlegm.

Epinephrine— A nervous system hormone stimulated by the nicotine in tobacco. It increases heart rate and may raise smokers' blood pressure.

Flavonoid— A food chemical that helps to limit oxidative damage to the body's cells, and protects against heart disease and cancer.

Free radical— An unstable molecule that causes oxidative damage by stealing electrons from surrounding molecules, thereby disrupting activity in the body's cells.

Nicotine— The addictive ingredient of tobacco, it acts on the nervous system and is both stimulating and calming.

Nicotine replacement therapy— A method of weaning a smoker away from both nicotine and the oral fixation that accompanies a smoking habit by giving the smoker smaller and smaller doses of nicotine in the form of a patch or gum.

Sidestream smoke— The smoke that is emitted from the burning end of a cigarette or cigar, or that comes from the end of a pipe. Along with exhaled smoke, it is a constituent of second-hand smoke.

Here are a few tips from the experts:

• Have a plan and set a definite quit date.
• Get rid of all the cigarettes and ashtrays at home or in your desk at work.
• Don't allow others to smoke in your house.
• Tell your friends and neighbors that you're quitting. Doing so helps make quitting a matter of pride.
• Chew sugarless gum or eat sugar-free hard candy to redirect the oral fixation that comes with smoking. This will prevent weight gain, too.
• Eat as much as you want, but only low-calorie foods and drinks. Drink plenty of water. This may help with the feelings of tension and restlessness that quitting can bring. After eight weeks, you'll lose your craving for tobacco, so it's safe then to return to your usual eating habits.
• Stay away from social situations that prompt you to smoke. Dine in the nonsmoking section of restaurants.
• Spend the money you save not smoking on an occasional treat for yourself.

Resources

PERIODICALS

"AAAAI, EPA Mount Effort to Raise Awareness to Dangers of Secondhand Smoke." Immunotherapy Weekly November 30, 2001: 30.

Batra, V., A. A. Patkar, W. H. Berrettini, et al. "The Genetic Determinants of Smoking." Chest 123 (May 2003): 1338-1340.

Ferry, L., and J. A. Johnston. "Efficacy and Safety of Bupropion SR for Smoking Cessation: Data from Clinical Trials and Five Years of Postmarketing Experience." International Journal of Clinical Practice 57 (April 2003): 224-230.

Janson, Christer, Susan Chinn, Deborah Jarvis, et al. "Effect of Passive Smoking on Respiratory Symptoms, Bronchial Responsiveness, Lung Function, and Total Serum IgE in the European Community Respiratory Health Survey: A Cross-Sectional Study." Lancet 358 (December 22, 2001): 2103.

Lerman, C., and W. Berrettini. "Elucidating the Role of Genetic Factors in Smoking Behavior and Nicotine Dependence." American Journal of Medical Genetics 118-B (April 1, 2003): 48-54.

Maisonneuve, I. M., and S. D. Glick. "Anti-Addictive Actions of an Iboga Alkaloid Congener: A Novel Mechanism for a Novel Treatment." Pharmacology, Biochemistry, and Behavior 75 (June 2003): 607-618.

Richmomd, R., and N. Zwar. "Review of Bupropion for Smoking Cessation." Drug and Alcohol Review 22 (June 2003): 203-220.

Sellers, E. M., R. F. Tyndale, and L. C. Fernandes. "Decreasing Smoking Behaviour and Risk through CYP2A6 Inhibition." Drug Discovery Today 8 (June 1, 2003): 487-493.

"Study Shows Link Between Asthma and Childhood Exposure to Smoking." Immunotherapy Weekly October 10, 2001: np.

Yochum, L., L. H. Kushi, and A. R. Folsom. "Dietary Flavonoid Intake and Risk of Cardiovascular Disease in Postmenopausal Women." American Journal of Epidemiology 149, no. 10 (May 1999): 943-9.

ORGANIZATIONS

American Association of Oriental Medicine. 5530 Wisconsin Avenue, Suite 1210, Chevy Chase, MD 20815. (301) 941-1064 or (888) 500-7999. 〈http://www.aaom.org〉.

American Cancer Society. Contact the local organization or call (800) 227-2345. 〈http://www.cancer.org〉.

American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872 or (212) 315-8700. 〈http://www.lungusa.org〉.

Herb Research Foundation. 1007 Pearl St., Suite 200, Boulder CO 80302. (303) 449-2265. 〈http://www.herbs.org〉.

National Heart, Lung, and Blood Institute (NHLBI). Building 31, Room 5A52, 31 Center Drive, MSC 2486, Bethesda, MD 20892. (301) 592-8573. 〈http://www.nhlbi.nih.gov〉.

Smoking, Tobacco, and Health Information Line. Centers for Disease Control and Prevention. Mailstop K-50, 4770 Buford Highway NE, Atlanta, GA 30341-3724. (800) 232-1311. 〈http://www.cdc.gov/tobacco〉.

OTHER

Virtual Office of the Surgeon General: Tobacco Cessation Guideline. 〈http://www.surgeongeneral.gov/tobacco〉.

Smoking

Definition

Smoking is the inhalation of the smoke of burning tobacco encased in cigarettes, pipes, and cigars. Casual smoking is the act of smoking only occasionally, usually in a social situation or to relieve stress . A smoking habit is a physical addiction to tobacco products. Many health experts now regard habitual smoking as a psychological addiction, too, and one with serious health consequences.

Description

The U.S. Food and Drug Administration has asserted that cigarettes and smokeless tobacco should be considered nicotine delivery devices. Nicotine, the active ingredient in tobacco, is inhaled into the lungs, where most of it stays. The rest passes into the bloodstream, reaching the brain in about 10 seconds and dispersing throughout the body in about 20 seconds.

Depending on the circumstances and the amount consumed, nicotine can act as either a stimulant or tranquilizer. This can explain why some people report that smoking gives them energy and stimulates their mental activity, while others note that smoking relieves anxiety and relaxes them. The initial “kick” results in part from the drug's stimulation of the adrenal glands and resulting release of epinephrine into the blood. Epinephrine causes several physiological changes—it temporarily narrows the arteries, raises the blood pressure , raises the levels of fat in the blood, and increases the heart rate and flow of blood from the heart. Some researchers think epinephrine contributes to smokers' increased risk of high blood pressure.

Nicotine, by itself, increases the risk of heart disease . However, when a person smokes, he or she is

ingesting a lot more than nicotine. Smoke from a cigarette, pipe, or cigar is made up of many additional toxic chemicals, including tar and carbon monoxide. Tar is a sticky substance that forms into deposits in the lungs, causing lung cancer and respiratory distress. Carbon monoxide limits the amount of oxygen that the red blood cells can convey throughout your body. Also, it may damage the inner walls of the arteries, which allows fat to build up in them.

Besides tar, nicotine, and carbon monoxide, tobacco smoke contains 4,000 different chemicals. More than 200 of these chemicals are known be toxic. Nonsmokers who are exposed to tobacco smoke also take in these toxic chemicals. They inhale the smoke exhaled by the smoker as well as the more toxic sidestream smoke—the smoke from the end of the burning cigarette, cigar, or pipe.

Here's why sidestream smoke is more toxic than exhaled smoke: When a person smokes, the smoke he or she inhales and then breathes out leaves harmful deposits inside the body. But because lungs partially cleanse the smoke, exhaled smoke contains fewer poisonous chemicals. That's why exposure to tobacco smoke is dangerous even for a nonsmoker.

Causes and symptoms

No one starts smoking to become addicted to nicotine. It isn't known how much nicotine may be consumed before the body becomes addicted. However, once smoking becomes a habit, the smoker faces a lifetime of health risks associated with one of the strongest addictions known to man.

About 70% of smokers in the United States would like to quit; in any given year, however, only about 3.6% of the country's 47 million smokers quit successfully.

Although specific genes have not yet been identified as of 2003, researchers think that genetic factors contribute substantially to developing a smoking habit. Several twin studies have led to estimates of 46–84% heritability for smoking. It is thought that some genetic variations affect the speed of nicotine metabolism in the body and the activity level of nicotinic receptors in the brain.

Smoking risks

Smoking is recognized as the leading preventable cause of death , causing or contributing to the deaths of approximately 430,700 Americans each year. Anyone with a smoking habit has an increased chance of lung, cervical, and other types of cancer ; respiratory diseases such as emphysema, asthma , and chronic bronchitis ; and cardiovascular disease, such as heart attack , high blood pressure, stroke , and atherosclerosis (narrowing and hardening of the arteries). The risk of stroke is especially high in women who take birth control pills.

Smoking can damage fertility, making it harder to conceive, and it can interfere with the growth of the fetus during pregnancy. It accounts for an estimated 14% of premature births and 10% of infant deaths. There is some evidence that smoking may cause impotence in some men.

Because smoking affects so many of the body's systems, smokers often have vitamin deficiencies and suffer oxidative damage caused by free radicals. Free radicals are molecules that steal electrons from other molecules, turning the other molecules into free radicals and destabilizing the molecules in the body's cells.

Smoking is recognized as one of several factors that might be related to a higher risk of hip fractures in older adults.

Studies reveal that the more a person smokes, the more likely he is to sustain illnesses such as cancer, chronic bronchitis, and emphysema. But even smokers who indulge in the habit only occasionally are more prone to these diseases.

Some brands of cigarettes are advertised as “low tar,” but no cigarette is truly safe. If a smoker switches to a low-tar cigarette, he is likely to inhale longer and more deeply to get the chemicals his body craves. A smoker has to quit the habit entirely in order to improve his health and decrease the chance of disease.

Though some people believe chewing tobacco is safer, it also carries health risks. People who chew tobacco have an increased risk of heart disease and mouth and throat cancer. Pipe and cigar smokers have increased health risks as well, even though these smokers generally do not inhale as deeply as cigarette smokers do. These groups haven't been studied as extensively as cigarette smokers, but there is evidence that they may be at a slightly lower risk of cardiovascular problems but a higher risk of cancer and various types of circulatory conditions.

Recent research reveals that passive smokers, or those who unavoidably breathe in second-hand tobacco smoke, have an increased chance of many health problems such as lung cancer and asthma, and in children, sudden infant death syndrome.

Smokers' symptoms

Smokers are likely to exhibit a variety of symptoms that reveal the damage caused by smoking. A nagging morning cough may be one sign of a tobacco habit. Other symptoms include shortness of breath, wheezing, and frequent occurrences of respiratory illness, such as bronchitis. Smoking also increases fatigue and decreases the smoker's sense of smell and taste. Smokers are more likely to develop poor circulation, with cold hands and feet and premature wrinkles .

Sometimes the illnesses that result from smoking come on silently with little warning. For instance, coronary artery disease may exhibit few or no symptoms. At other times, there will be warning signs, such as bloody discharge from a woman's vagina, a sign of cancer of the cervix. Another warning sign is a hacking cough, worse than the usual smoker's cough, that brings up phlegm or blood—a sign of lung cancer.

Withdrawal symptoms

A smoker who tries to quit may expect one or more of these withdrawal symptoms: nausea, constipation or diarrhea , drowsiness, loss of concentration, insomnia , headache, nausea, and irritability.

Diagnosis

It's not easy to quit smoking. That's why it may be wise for a smoker to turn to his physician for help. For the greatest success in quitting and to help with the withdrawal symptoms, the smoker should talk over a treatment plan with his doctor or alternative practitioner. He should have a general physical examination to gauge his general health and uncover any deficiencies. He should also have a thorough evaluation for some of the serious diseases that smoking can cause.

Treatment

Research shows that most smokers who want to quit benefit from the support of other people. It helps to quit with a friend or to join a group such as those organized by the American Cancer Society. These groups provide support and teach behavior modification methods that can help the smoker quit. The smoker's physician can often refer him to such groups.

Other alternatives to help with the withdrawal symptoms of kicking the habit include nicotine replacement therapy in the form of gum, patches, nasal sprays, and oral inhalers. These are available by prescription or over the counter. A physician can provide advice on how to use them. They slowly release a small amount of nicotine into the bloodstream, satisfying the smoker's physical craving. Over time, the amount of gum the smoker chews is decreased and the amount of time between applying the patches is increased. This helps wean the smoker from nicotine slowly, eventually beating his addiction to the drug. But there's one important caution: If the smoker lights up while taking a nicotine replacement, a nicotine overdose may cause serious health problems.

The prescription drug Zyban (bupropion hydrochloride) has shown some success in helping smokers quit. This drug contains no nicotine, and was originally developed as an antidepressant. It isn't known exactly how bupropion works to suppress the desire for nicotine. A five-year study of bupropion reported in 2003 that the drug has a very good record for safety and effectiveness in treating tobacco dependence. Its most common side effect is insomnia, which can also result from nicotine withdrawal.

Researchers are investigating two new types of drugs as possible treatments for tobacco dependence as of 2003. The first is an alkaloid known as 18 methoxycoronaridine (18-MC), which selectively blocks the nicotinic receptors in brain tissue. Another approach involves developing drugs that inhibit the activity of cytochrome P450 2A6 (CYP2A6), which controls the metabolism of nicotine.

Results

Research on smoking shows that most smokers desire to quit. But smoking is so addictive that fewer than 20% of the people who try ever successfully kick the habit. Still, many people attempt to quit smoking over and over again, despite the difficulties—the cravings and withdrawal symptoms, such as irritability and restlessness.

For those who do quit, the benefits to health are well worth the effort. The good news is that once a smoker quits the health effects are immediate and dramatic. After the first day, oxygen and carbon monoxide levels in the blood return to normal. At two days, nerve endings begin to grow back and the senses of taste and smell revive. Within two weeks to three months, circulation and breathing improve. After one year of not smoking, the risk of heart disease is reduced by 50%. After 15 years of abstinence, the risks of health problems from smoking virtually vanish. A smoker who quits for good often feels a lot better too, with less fatigue and fewer respiratory illnesses.

Alternative treatment

There are a wide range of alternative treatments that can help a smoker quit the habit, including hypnotherapy, herbs, acupuncture , and meditation. For example, a controlled trial demonstrated that self-massage can help smokers crave less intensely, smoke fewer cigarettes, and in some cases completely give them up.

Hypnotherapy helps the smoker achieve a trancelike state, during which the deepest levels of the mind are accessed. A session with a hypnotherapist may begin with a discussion of whether the smoker really wants to and truly has the motivation to stop smoking. The therapist will explain how hypnosis can reduce the stress-related symptoms that sometimes come with kicking the habit.

Often the therapist will discuss the dangers of smoking with the patient and begin to “reframe” the patient's thinking about smoking. Many smokers are convinced they can't quit, and the therapist can help persuade them that they can change this behavior. These suggestions are then repeated while the smoker is under hypnosis. The therapist may also suggest while the smoker is under hypnosis that his feelings of worry, anxiety, and irritability will decrease.

In a review of 17 studies of the effectiveness of hypnotherapy, the percentage of people treated by hypnosis who still were not smoking after six months ranged from 4–8%. In programs that included several hours of treatment, intense interpersonal interaction, individualized suggestions, and follow-up treatment, success rates were above 50%.

One study demonstrated that inhaling the vapor from black pepper extract can reduce symptoms associated with smoking withdrawal. Other essential oils can be used for relieving the anxiety a smoker often experiences while quitting.

A variety of herbs can help smokers reduce their cravings for nicotine, calm their irritability, and even reverse the oxidative cellular damage done by smoking. Lobelia, sometimes called Indian tobacco, has historically been used as a substitute for tobacco. It contains a substance called lobeline, which decreases the craving for nicotine by bolstering the nervous system and calming the smoker. In high doses, lobelia can cause vomiting, but the average dose—about 10 drops per day—should pose no problems.

Herbs that can help relax a smoker during withdrawal include wild oats and kava kava.

To reduce the oral fixation supplied by a nicotine habit, a smoker can chew on licorice root—the plant, not the candy. Licorice is good for the liver, which is a major player in the body's detoxification process. Licorice also acts as a tonic for the adrenal system, which helps reduce stress. And there's an added benefit: If a smoker tries to light up after chewing on licorice root, the cigarette tastes like burned cardboard.

Other botanicals that can help repair free-radical damage to the lungs and cardiovascular system are those high in flavonoids, such as hawthorn, gingko biloba, and bilberry, as well as antioxidants such as vitamin A, vitamin C , zinc , and selenium.

This ancient Chinese method of healing is used commonly to help beat addictions, including smoking. The acupuncturist will use hair-thin needles to stimulate the body's qi, or healthy energy. Acupuncture is a sophisticated treatment system based on revitalizing qi, which supposedly flows through the body in defined pathways called meridians. During an addiction like smoking, qi isn't flowing smoothly or gets stuck, the theory goes.

Points in the ear and feet are stimulated to help the smoker overcome his addiction. Often the acupuncturist will recommend keeping the needles in for five to seven days to calm the smoker and keep him balanced.

Nutrition/Dietetic concerns

Smoking seriously depletes vitamin C in the body and leaves it more susceptible to infections. Vitamin C can prevent or reduce free-radical damage by acting as an antioxidant in the lungs. Smokers need additional C, in higher dosage than nonsmokers. Fish in the diet supplies Omega-3 fatty acids, which are associated with a reduced risk of chronic obstructive pulmonary disease (emphysema or chronic bronchitis) in smokers. Omega-3 fats also provide cardiovascular benefits as well as an anti-depressive effect. Vitamin therapy doesn't reduce craving but it can help beat some of the damage created by smoking. Vitamin B₁₂ and folic acid may help protect against smoking-induced cancer.

Prevention

How do you give up your cigarettes for good and never go back to them again?

Here are a few tips from the experts:

• Have a plan and set a definite quit date.
• Get rid of all the cigarettes and ashtrays at home or in your desk at work.
• Don't allow others to smoke in your house.
• Tell your friends and neighbors that you're quitting. Doing so helps make quitting a matter of pride.
• Chew sugarless gum or eat sugar-free hard candy to redirect the oral fixation that comes with smoking. This will prevent weight gain, too.
• Eat as much as you want, but only low-calorie foods and drinks. Drink plenty of water. This may help with the feelings of tension and restlessness that quitting can bring. After eight weeks, you'll lose your craving for tobacco, so it's safe then to return to your usual eating habits.
• Stay away from social situations that prompt you to smoke. Dine in the nonsmoking section of restaurants.
• Spend the money you save not smoking on an occasional treat for yourself.

KEY TERMS

Antioxidant —Any substance that reduces the damage caused by oxidation, such as the harm caused by free radicals.

Chronic bronchitis —A smoking-related respiratory illness in which the membranes that line the bronchi, or the lung's air passages, narrow over time. Symptoms include a morning cough that brings up phlegm, breathlessness, and wheezing.

Cytochrome —A substance that contains iron and acts as a hydrogen carrier for the eventual release of energy in aerobic respiration.

Emphysema —An incurable, smoking-related disease, in which the air sacs at the end of the lung's bronchi become weak and inefficient. People with emphysema often first notice shortness of breath, repeated wheezing and coughing that brings up phlegm.

Epinephrine —A nervous system hormone stimulated by the nicotine in tobacco. It increases heart rate and may raise smokers' blood pressure.

Flavonoid —A food chemical that helps to limit oxidative damage to the body's cells, and protects against heart disease and cancer.

Free radical —An unstable molecule that causes oxidative damage by stealing electrons from surrounding molecules, thereby disrupting activity in the body's cells.

Nicotine —The addictive ingredient of tobacco, it acts on the nervous system and is both stimulating and calming.

Nicotine replacement therapy —A method of weaning a smoker away from both nicotine and the oral fixation that accompanies a smoking habit by giving the smoker smaller and smaller doses of nicotine in the form of a patch or gum.

Sidestream smoke —The smoke that is emitted from the burning end of a cigarette or cigar, or that comes from the end of a pipe. Along with exhaled smoke, it is a constituent of second-hand smoke.

Resources

PERIODICALS

“AAAAI, EPA Mount Effort to Raise Awareness to Dangers of Secondhand Smoke.” Immunotherapy Weekly November 30, 2001: 30.

Batra, V., A. A. Patkar, W. H. Berrettini, et al. “The Genetic Determinants of Smoking.” Chest 123 (May 2003): 1338–1340.

Ferry, L., and J. A. Johnston. “Efficacy and Safety of Bupropion SR for Smoking Cessation: Data from Clinical Trials and Five Years of Postmarketing Experience.” International Journal of Clinical Practice 57 (April 2003): 224–230.

Janson, Christer, Susan Chinn, Deborah Jarvis, et al. “Effect of Passive Smoking on Respiratory Symptoms, Bronchial Responsiveness, Lung Function, and Total Serum IgE in the European Community Respiratory Health Survey: A Cross-Sectional Study.” Lancet 358 (December 22, 2001): 2103.

Lerman, C., and W. Berrettini. “Elucidating the Role of Genetic Factors in Smoking Behavior and Nicotine Dependence.” American Journal of Medical Genetics 118-B (April 1, 2003): 48–54.

Maisonneuve, I. M., and S. D. Glick. “Anti-Addictive Actions of an Iboga Alkaloid Congener: A Novel Mechanism for a Novel Treatment.” Pharmacology, Biochemistry, and Behavior 75 (June 2003): 607–618.

Richmomd, R., and N. Zwar. “Review of Bupropion for Smoking Cessation.” Drug and Alcohol Review 22 (June 2003): 203–220.

Sellers, E. M., R. F. Tyndale, and L. C. Fernandes. “Decreasing Smoking Behaviour and Risk through CYP2A6 Inhibition.” Drug Discovery Today 8 (June 1, 2003): 487–493.

“Study Shows Link Between Asthma and Childhood Exposure to Smoking.” Immunotherapy Weekly October 10, 2001: np.

Yochum, L., L. H. Kushi, and A. R. Folsom. “Dietary Flavonoid Intake and Risk of Cardiovascular Disease in Postmenopausal Women.” American Journal of Epidemiology 149, no. 10 (May 1999): 943–9.

ORGANIZATIONS

American Association of Oriental Medicine. 5530 Wisconsin Avenue, Suite 1210, Chevy Chase, MD 20815. (301) 941-1064 or (888) 500-7999. http://www.aaom.org.

American Cancer Society. Contact the local organization or call (800) 227-2345. http://www.cancer.org.

American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872 or (212) 315-8700. http://www.lungusa.org.

Herb Research Foundation. 1007 Pearl St., Suite 200, Boulder CO 80302. (303) 449-2265. http://www.herbs.org.

National Heart, Lung, and Blood Institute (NHLBI). Building 31, Room 5A52, 31 Center Drive, MSC 2486, Bethesda, MD 20892. (301) 592-8573. http://www.nhlbi.nih.gov.

Smoking, Tobacco, and Health Information Line. Centers for Disease Control and Prevention. Mailstop K-50, 4770 Buford Highway NE, Atlanta, GA 30341-3724. (800) 232-1311. http://www.cdc.gov/tobacco.

OTHER

Virtual Office of the Surgeon General: Tobacco Cessation Guideline. http://www.surgeongeneral.gov/tobacco.

Barbara Boughton

Smoking

BIBLIOGRAPHY

Tobacco was introduced to Europe by Columbus upon his return from the New World. As the habit of smoking spread throughout Europe, Russia, Africa, and the Orient, it met with formidable opposition from rulers, who instigated periodic attacks upon it. In 1604, King James i of England issued a proclamation called “A Counterblast to Tobacco.” He and others, however, were unsuccessful in eradicating the use of tobacco, which soon became an export of considerable economic importance to the new American colonies. In the United States tobacco remains economically important; it contributes to national income, and its yield of tax revenue plays a significant role in the budget of the federal government.

Although social and religious controversies occasionally have flared between those segments of society which found smoking pleasurable and those which believed it to be a foul-smelling, unnatural, and loathsome habit, scientists showed little interest in the effects of smoking for some five centuries after its introduction to Europe.

In 1900 vital statisticians reported an increase in the incidence of cancer of the lung. Beginning in 1930, scientists from various parts of the world have reported vital statistics suggesting a relationship between certain populations’ increasing consumption of cigarettes and an increased incidence of lung cancer, heart disease, and other illnesses in the same populations. Since the mid–1950s these results have become sufficiently convincing to cause the following health agencies to declare that smoking is a significant health hazard: the British Medical Research Council; the cancer societies of Denmark, Norway, Sweden, Finland, and the Netherlands; the American Cancer Society; the American Heart Association; the Joint Tuberculosis Council of Great Britain; and the Canadian National Department of Health and Welfare. However, cigarette manufacturers have steadfastly maintained that the evidence linking cigarettes and disease is not conclusive.

In any study of smoking, an initial problem arises with regard to the definition of who is a cigarette smoker and, even more problematic, who is an ex-smoker, light smoker, medium smoker, or heavy smoker. There is no precise definition as to what are the actual behavioral (motions), physiological, or psychological referents of smoking. For example, do all individuals who “smoke heavily” inhale to the same extent? One individual might light 40 cigarettes a day but puff only one-eighth of each, whereas another individual, claiming to smoke only 12 cigarettes a day, could inhale each of these down to the last quarter inch. We also do not know the relationship between reported smoking (through verbal self-report or responses to a questionnaire) and actual smoking. Data relevant to these preliminary questions would contribute greatly to the precision of subsequent research on smoking.

Within the past decade social scientists have become interested in the smoker, as evidenced by the appearance of numerous surveys and other research reports on the psychosocial characteristics of smokers. The vast majority of these have focused only on cigarette smokers, and the findings reported below will relate primarily to them.

The reader interested in a detailed review of this subject may consult five reviews that include comprehensive bibliographies of the original literature. Two of the reviews appeared in 1960—one in the United States (Matarazzo & Saslow 1960), and one in Scotland (Kissen 1960). A third review was published by Lawton (1962) and a fourth by Horn (1963). The most recent review (Hochbaum 1964) was prepared as part of the highly publicized report of the advisory committee to the surgeon general of the United States Public Health Service.

Several individual studies are of especial significance because of their scope, sampling, or over-all design. Haenszel, Shimkin, and Miller (1956) surveyed the smoking habits of a cross section (40,000) of the total population of American men and women 18 years of age and older. Sackrin and Conover (1957) followed this by further study of 18,000 of the same 40,000 individuals. Kallner (1958) studied the entire population of Israel. Lilienfeld (1959) studied 4,400 adults in Buffalo, New York. Horn and his associates (1959) polled the total population of high school students (22,000) in Portland, Oregon, while Salber and her associates (see Salber & MacMahon 1961; Salber et al. 1962; Salber, Welsh, & Taylor 1963; Salber & Worcester 1964; Salber et al. 1961; 1963) have published a series of related studies of 6,810 high school students in Newton, Massachusetts. In England, Both well (1959) conducted a study of the smoking habits of 8,314 Oxfordshire schoolchildren, while Chave and Schilling and their associates (1959) studied another group of 3,500 London youngsters. Also, Eysenck and his co-workers (1960) attempted to measure some personality characteristics of a stratified sample of 2,360 smoking and nonsmoking adult British males and followed this with a more detailed study of 3,194 additional males (Eysenck 1963).

Demographic variables. Although social scientists have only recently begun to study the cigarette smoker, there already seem to be a number of variables whch are consistently found to be associated with smoking. These variables are reviewed below, although, because of space limitations, no attempt has been made to review the findings of every study on each variable. Rather, the more significant or better-established findings of a particular study have been presented, and the original articles can be referred to for more detail. The reader interested in the attempts of health educators and social scientists to understand why people smoke and in some of the methods currently being explored in the United States to help smokers give up their habit should consult the report by Mausner and Platt (1966).

Age, sex, and marital status. With respect to age, data from both sides of the Atlantic are similar and indicate that regular smoking usually begins in mid-adolescence to late adolescence, although a small percentage of youngsters start cigarette smoking earlier. Boys are inclined to smoke somewhat earlier and more heavily than girls (Bothwell 1959; Cartwright et al. 1959; Haenszel et al. 1956; Hochbaum 1964; Horn et al. 1959; Horn 1963; Kissen 1960, p. 368; Matarazzo & Saslow 1960; and Salber et al. 1961). Among women, the incidence of smoking is increasing. In their study in Newton, Massachusetts, Salber and Worcester (1964) report that the number of women, particularly Jewish women, who smoke may soon exceed the number of men who smoke.

Among both sexes and all ages, there is a greater percentage of smoking among divorced and widowed individuals than among those either married or never married. Although this has been established for the United States, comparable data for other countries are not available.

Income, occupation, and education. The five reviews suggest that yearly income is not related in any consistent manner to smoking. However, socioeconomic class, when defined only in terms of occupational and educational level, does appear to bear a consistent relationship to smoking; individuals at the lowest occupational levels start to smoke earlier and in greater numbers than those in all other groups. For example, white-collar groups (professional workers, managers, and so forth) typically contain fewer smokers than are found among craftsmen, foremen, salespersons, and similar groups. Possibly it is because some individuals in the latter groups have higher yearly incomes than do some white-collar workers that the relationship between smoking and socioeconomic class, more broadly defined to include income and place of residence as well, is not clearly established.

Apparently there is no clear linear relationship between the highest educational level attained by maturity and smoking (see especially Lilienfeld 1959). However, among high school students those with highest achievement and those in college preparatory courses are considerably less likely to smoke than those in business and technical courses. An interesting twenty-year longitudinal study of a group of Harvard undergraduates indicates that individuals who major in the arts and letters, education, and social sciences later become smokers in greater numbers than do students whose career choice is in the physical sciences (Heath 1958; McArthur et al. 1958).

Urban—rural differences. In all studies examining urban—rural differences, rural farm populations, including both sexes and all ages, were found to contain a smaller percentage of smokers than either the rural nonfarm or the city populations. Rural nonfarm persons closely resemble urban dwellers in their smoking habits. Women and girls in large cities in the northeastern United States (e.g., New York City and Boston) smoke more than do women and girls in cities in other areas of the United States. It is unknown whether a similar pattern prevails when cosmopolitan centers such as London, Paris, and Rome are used as a basis for comparison.

Race and religion. In the English-speaking countries which have been studied, there appears to be no relationship between race and smoking, the proportion of smokers being approximately equal between the Caucasian and Negro sub-samples.

It is well known that devout followers of some religions do not smoke at all (e.g., Hindus, Muslims, Mormons). Studies of young men and women of high school and college age in the United States (Horn et al. 1959; Salber & Worcester 1964; Straits & Sechrest 1963) have reported that significantly more followers of the Roman Catholic and Jewish faiths were found to smoke than Protestants in these age groups. In the Newton, Massachusetts, study, Salber and Worcester (1964, p. 36) found that Catholic men and boys smoked more than other males, while Jewish women and girls smoked more than other females.

Psychological variables. In addition to sociological and demographic variables, some psychological variables have also been explored.

Intelligence and achievement. Present available evidence suggests that there is no direct relationship between intelligence, as measured by tests of IQ, and smoking (Matarazzo & Saslow I960; Hochbaum 1964).

The same is not true for academic achievement during adolescence, however. The previously mentioned studies in Portland, Oregon; Buffalo, New York; Newton, Massachusetts; and a study in London, England (Davis, as reported in Kissen 1960, p. 369) indicate that those students who are academically inferior to their age mates or classmates have a significantly greater tendency to be smokers. This relationship between achievement and smoking, of course, does not establish that one of the two factors is a cause of the other. It can be stated, however, on the basis of consistent evidence, that groups of young men and women who are academically less successful than theirpeers contain a higher proportion of smokers than is found among their more successful classmates. Also, smokers are found to take the scholastically less demanding academic programs (vocational preparation in contrast to a college preparatory curriculum). Smokers date more but engage in fewer extracurricular activities, including sports of some types, than do nonsmokers. No interpretation of these disparate facts has yet achieved wide acceptance.

Personality. Studies attempting to relate personality variables to smoking suffer from the serious handicap that there exists today no highly valid, universally accepted measure either of global personality or of any specific personality dimension. (This assertion quite probably will find support among serious students of personality.) One result is that seldom do any two studies, even those allegedly measuring the same trait (e.g., neuroti-cism), utilize the same methods of assessment; therefore they cannot be compared meaningfully.

Matarazzo and Saslow (1960), Kissen (1960), Lawton (1962), Horn (1963), and Hochbaum (1964) have presented reviews of the few published studies in this area. The results, meager and poorly supported as they are, suggest the following. In most English-speaking countries roughly half of the population are smokers. Studies using stratified as well as nonstratified samples (some small, some large) reveal the presence of a slightly higher number of “extraverts” and “neurotic,” “anxious,” and “tense” individuals among the smokers as compared to the nonsmokers. However, although the differences in the mean scores of smokers and nonsmokers are statistically significant, they typically reflect a difference in response to only one or two questionnaire items. Two of the most extensive (3,194 individual subjects) and best-designed studies on this subject (Eysenck et al. I960; Eysenck 1963) utilized stratified samples of individuals in the British Isles. In the second one Eysenck (1963, pp. 114–115) concludes : “Degree and type of smoking are ... related to extraversion, in the sense that pipe smokers are introverted, as are non-smokers; light, medium and heavy smokers are extraverted, increasingly so in that order.” The degree of extraversion among ex-smokers is found to be indistinguishable from that among light smokers. Such a strong conclusion may not be justified, however, since the mean extraversion scores, on the 31–item extra-version measure used by Eysenck, were as follows for the groups studied (in the order in which they are mentioned above): 17.07, 17.63, 17.60, 18.70, 18.95, and 17.71. Although several of the groups differed significantly from each other because of the large number of subjects, the mean difference between the highest and lowest groups was only 1.88 items on the 31–item personality measure. Similar small but statistically significant differences between smokers and nonsmokers have been found on the “anxiety” scale used by Matarazzo and Saslow (1960, p. 499) and on the “tension,” “psychosomatic,” and “neuroticism” measures used by other workers.

Referring to the research described above in their 1960 review, Matarazzo and Saslow concluded

. . . while smokers do differ from non-smokers in a variety of characteristics, none of the studies has shown a single variable which is found exclusively in one group and is completely absent in the other . . . [this] is especially true for the variables measuring personality characteristics. . . . Examination of the means, standard deviations, ranges, percentages, etc. . . . makes clear that while group trends suggest the smoker to be more “neurotic,” on the average, there are still many individual smokers with neuroticism, or anxiety . . . scores lower than those of many non-smokers. . . . Thus, a clear-cut smoker’s personality has not emerged from the results so far published in the literature. ... It is hard to believe that they [the half of a country’s population who smoke] would share in common one personality “type.” This is not to imply, however, that the various psychological dimensions along which smokers have been shown, as a group, to differ from non-smokers may not suggest an important single process, or processes, underlying these various demonstrated (but small) differences. Further research may indeed so systematize the disparate findings. (1960, pp. 508–510)

Thus, a number of studies report small differences in mean scores, suggesting that compared to the nonsmoker the average smoker has a slight tendency to be more extraverted, outgoing, adventurous, tense, anxious, inclined to drink more alcohol and coffee, date earlier, watch more television, see more movies, drive an automobile earlier, read fewer books per month, play fewer sports, and belong to fewer clubs and school organizations. However, a large number of individual smokers may show few or none of these characteristics. In addition, no unifying theme, trait, or personality dimension has been abstracted from these separate characteristics. For the present it seems best to conclude that any psychological dynamics that may differentiate the smoker from the nonsmoker have not yet been isolated.

Initiation of smoking. Phanishayi (1951), in India, was one of the first to study variables associated with the initiation of smoking. His researchwas followed by that of McArthur and his associates (1958) with Harvard College undergraduates in Boston; Bothwell (1959) in Oxfordshire, England; Chave, Schilling and their associates (1959) in London; Horn and his associates (1959) in Portland, Oregon; Cartwright et al. (1959) in Edinburgh, Scotland; Morison and Medovy (1961) in Winnipeg, Canada; and Salber and MacMahon (1961) in Newton, Massachusetts.

These studies consistently have identified parental smoking as one of the most important predisposing factors in smoking among school-age children. As mentioned above, most smokers appear to have begun smoking between the ages of 10 and 18. If both parents smoke, the probability that their children will begin to smoke is several times that of children with nonsmoking parents. When only one parent smokes, the incidence of smoking among the offspring falls midway between that of the other two groups. Published data also suggest a higher frequency of smoking among children with older siblings who smoke.

The relationship of some other sociopersonal factors to initiation of the smoking habit is less clear-cut. In general, the studies suggest that youngsters’ beginning to smoke is related to: (a) curiosity about smoking; (b) conformity pressures among adolescents; (c) need for status among peers, including self-perceived failure to achieve peer-group status or satisfaction; (d) the need for self-assurance; and (e) striving for adult status (see the reviews by Hochbaum 1964; Horn 1963). However, it is difficult to measure the strength of such needs, as well as their relative influence, and therefore these relationships should be considered tentative.

There is no convincing evidence that beginning to smoke in childhood or young adulthood is a sign of rebellion against parents or other authority figures, although such a hypothesis has been suggested by several writers.

Most writers have suggested that once the smoking habit has been established the factors associated with its continuation very likely are different from those associated with its initiation. Although the evidence is far from conclusive, it appears that sit-uational tension-reduction is an important motivational factor in perpetuating the smoking habit. Also, a small group of smokers attest that they continue to smoke because it is pleasurable.

Many smokers report considerable dissatisfaction with smoking but, despite repeated attempts, have found themselves unable to break the habit. In fact, Horn (1963, p. 364), who sampled the adult population of the entire United States, reports that only 14 per cent of regular cigarette smokers state that they consider the habit pleasurable, safe, and worth the cost.

Discontinuation of smoking. Why do smokers not give up the habit that so many state they would like to shed? Despite pronouncements from health authorities in all parts of the world, the proportion of smokers reporting successful discontinuation of smoking is from 10 to 20 per cent in males and 3 to 10 per cent in females (Haenszel et al. 1956, p. 24; Hammond & Percy 1958, p. 2,956; Cart-wright et al. 1959, p. 726; and Horn 1963, p. 391).

Immediately following the 1964 report of the surgeon general of the United States, 8.6 per cent of the smoking students at two U.S. colleges reported that they stopped smoking as a result of the health hazard identified in this report (Katahn et al. 1964). Again, a greater percentage of male smokers (10.3 per cent) than female smokers (5.9 per cent) reported quitting. In addition, more natural science majors (18.2 per cent) quit smoking than did liberal arts majors (6.7 per cent). The same students took a story-completion test requiring them to create both an imaginary story and an estimate of the amount of time which in reality would have transpired during the occurrence of the sequence of events in the story. Ex-smokers tended to respond with a longer time perspective than did students who continued to smoke, and the authors suggest that these individuals might be more likely to worry about long-term health hazards.

Immediately before and following the surgeon general’s report, several researchers attempted to find effective means for discouraging initiation and encouraging cessation of– the smoking habit. Horn (1960) used a variety of educational approaches with high school students in Portland, Oregon, but he reported only minimal success in preventing the initiation of smoking. Both Horn (1964, personal communication) and Lawton (1964, personal communication) have attempted to help adult smokers discontinue smoking through the use of weekly educational meetings (Horn in Washington) and weekly “group therapy” sessions (Lawton in Philadelphia). With both techniques, success rates were not much higher than the 10 to 20 per cent “spontaneous” successes reported by other writers. The Horn and Lawton studies raise an important question for all cessation studies: who is an ex-smoker? Is he an individual who quits for a week, a month, a year, or forever? It is both a common observation and an established statistical fact thatmany ex-smokers resume the habit after varyinglengths of time.

Comment. After reviewing the above literature, the present authors have concluded that, in all probability, people begin to smoke for essentially the same reasons that they adopt other habits, such as eating certain foods, using certain brands of soap, wearing lipstick, going to see the Beatles, and so forth. That is, initiation of smoking appears to be a result of the millions of dollars spent yearly by (cigarette) manufacturers to influence people to do so; the standards and fads extant in youthful and adult social circles; the examples provided by parents and families; the depth of commitment to personal religious codes; and, finally, some psychological and personality characteristics (e.g., extra-version, tension, neuroticism, etc.) of the individual himself. In our opinion, the last category (personality characteristics) is the least influential in determining whether a given individual will begin to smoke, whereas the other factors (especially the amount spent on world-wide advertising) have considerable influence. Once started, however, continuation or discontinuation appears to be, in large part, a function of the sociopsychological characteristics of the individual.

Joseph D. Matarazzoand Ruth G. Matarazzo

[Directly related are the entriesDrinking and Alco– Holism; Drugs.]

BIBLIOGRAPHY

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Caktwright, Ann; Martin, F. M.; and THOMSON, J. G. 1959 Distribution and Development of Smoking Habits. Lancet (1959) no. 2:725–727.

Chave, S. P. W.; and Schilling, R. S. F. et al. 1959 The Smoking Habits of School Children. British Journal of Preventive and Social Medicine 13:1–4.

Eysenck, H. J. 1963 Smoking, Personality and Psychosomatic Disorders. Journal of Psychosomatic Research 7:107–130.

Eysenck, H. J. et al. 1960 Smoking and Personality. British Medical Journal [1960], no. 5184:1456–1460.

From Epidemiology to Ecology—Smoking and Health in Transition. 1966 American Journal of Public Health 56, no. 12.

Haenszel, William; Shimkin, Michael B.; and Miller, Herman P. 1956 Tobacco Smoking Patterns in the United States. U.S. Public Health Monograph No. 45; Public Health Service Publication No. 463. Washington: Government Printing Office.

Hammond, E. Cuyler; and Percy, Constance 1958 Ex-smokers. New York State Journal of Medicine 58:2956–2959.

Heath, Clark W. 1958 Differences Between Smokers and Non-smokers. AMA Archives of Internal Medicine 101:377–388. [Hochbaum, G. M.] 1964 Psycho-Social Aspects of Smoking. Pages 359–379 in U.S. Surgeon General’s Advisory Committee on Smoking and Health, Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Public Health Service Publication No. 1103. Washington: Government Printing Office.

Horn, Daniel 1960 Modifying Smoking Habits in High School Students. Children 7:63–65.

Hobn, Daniel 1963 Behavioral Aspects of Cigarette Smoking. Journal of Chronic Diseases 16:383–395.

Horn, Daniel et al. 1959 Cigarette Smoking Among High School Students. American Journal of Public Health 49:1497–1511.

Kallner, Gertrude 1958 Smoking Habits of the Population. Unpublished manuscript, Israel, Central Bureau of Statistics.

Katahn, Martin; Spielberger, Charles D.; and JUDSON, ABE J. 1964 Smokers and Ex-smokers: Reactions of College Students to the Surgeon General’s Cancer Report. Psychonomic Science 1:323–324.

Kissen, David M. 1960 Psycho-Social Factors in Cigarette Smoking Motivation: A Review. Medical Officer 104:365–372.

Lawton, M. P. 1962 Psychosocial Aspects of Cigarette Smoking. Journal of Health and Human Behavior 3: 163–170.

Lihenfeld, Abraham M. 1959 Emotional and Other Selected Characteristics of Cigarette Smokers and Non-smokers as Related to Epidemiological Studies of Lung Cancer and Other Diseases. Journal of the National Cancer Institute 22:259–282.

Mcarthur, Charles; Waldran, Ellen; and Dickinson, John 1958 The Psychology of Smoking. Journal of Abnormal and Social Psychology 56:267–275.

Matarazzo, Joseph D.; and Saslow, George 1960 Psychological and Related Characteristics of Smokers and Nonsmokers. Psychological Bulletin 57:493–513.

Mausneb, Bernard; and Platt, Ellen S. 1966 Behavioral Aspects of Smoking: A Conference Report. Health Education Monographs Supplement, No. 2. → Presents the highlights of a three-day conference held at Beaver College (Glenside, Pennsylvania) attended by 39 scientists and health educators.

Morison, JamesB.; and Medovy, H. 1961 Smoking Habits of Winnipeg School Children. Canadian Medical Association Journal 84:1006–1012.

Phanishayi, R. A. 1951 Causes of Smoking Habit in College Students: An Investigation. Journal of Education and Psychology 9:29–37.

Sackrin, Seymour M.; and Conover, Arthur G. 1957 Tobacco Smoking in the United States in Relation to Income. U.S. Department of Agriculture, Market Research Report, No. 189. Washington: The Department.

Salber, Eva J.; and Macmahon, Brian 1961 Cigarette Smoking Among High School Students Related to Social Class and Parental Smoking Habits. American Journal of Public Health 51:1780–1789.

Salber, Eva J.; Macmahon, Brian; and Welsh, Barbara

1962 Smoking Habits of High School Students Re– lated to Intelligence and Achievement. Pediatrics 29:780–787.

Salber, Eva J.; Welsh, Barbara; and Taylor, S. V.

1963 Reasons for Smoking Given by SecondarySchool Children. Journal of Health and Human Be– havior 4: 118–129.Salber, Eva J.; and Worcester, Jane 1964 Change in Women’s Smoking Patterns. Cancer 17:32–36.

Salbeh, Eva J. et al. 1961 Smoking Habits of High School Students in Newton, Massachusetts. New England Journal of Medicine 265:969–974.

Salber, Eva J. et al. 1963 Smoking Behavior, Recreational Activities and Attitudes Toward Smoking Among Newton Secondary School Children. Pediatrics 32: 911–918.

Stbaits, Bruce C.; and SECHHEST, LEE 1963 Further Support of Some Findings About the Characteristics of Smokers and Non-smokers. Journal of Consulting Psychology 27:282.

U. S. Surgeon General’s Advisory Committee on Smoking and Health 1964 Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Public Health Service Publication No. 1103. Washington: Government Printing Office.

SMOKING

From the time when the native peoples of the Americas introduced Europeans to tobacco until the second decade of the twentieth century smoking and other forms of tobacco use focused on questions of production, commerce, and morality rather than on questions of medicine (U.S. Department of Health and Human Services, 1992). The first public policy issues concerning tobacco centered on its role as an important cash crop and a potential source of tax revenue. Medical questions about tobacco use did not materialize because until the 1920s there were no scientific grounds for supposing that smoking endangers the health of smokers. Half a century passed before epidemiologists began to make a case for the dangers of environmental tobacco smoke (ETS) to nonsmokers. Smoking and other forms of tobacco use provide a vivid illustration of how ethical considerations can change over time as scientific evidence and the social, political, and economic dimensions of an issue change.

Scientists began to build the case for the dangers of smoking when A. C. Broders (1920) published an article correlating tobacco use with lip cancer. Subsequent studies repeatedly linked tobacco use, in particular smoking, with a variety of diseases, primarily lung cancer and respiratory diseases. Evidence was derived from epidemiological studies, typically retrospective laboratory studies, and findings at autopsy. In 1957 based on the findings of a federally sponsored study group on smoking and health the U.S. Public Health Service (USPHS) concluded that there was a causal link between smoking and lung cancer (U.S. Department of Health, Education, and Welfare). The USPHS also affirmed a causal link between smoking and numerous other cancers, as well as other diseases in 1964, when Surgeon General Luther Terry issued an advisory report titled Smoking and Health (U.S. Department of Health, Education and Welfare).

Since 1964 a wealth of research has demonstrated the deleterious effects of tobacco use on health. Both government and private agencies have been instrumental in publicizing and documenting research findings and their implications, most efficiently through their websites. For example, the Centers for Disease Control and Prevention (CDC) lists all the surgeon general's reports on tobacco and health from 1964 to 2001. These reports summarize the state of research and education on tobacco use at the time of each report. Research articles, tobacco industry documents, tobacco control guideline programs, and educational materials can be accessed through the CDC's site. Other websites—the Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Health and Human Services (USDHHS), the National Library of Medicine, and the National Institutes of Health (including the National Cancer Institute), as well as private foundations such as the American Cancer Society and the American Lung Association—all provide access to research and educational materials for laypersons and professionals. The importance of tobacco use and exposure as a health risk is demonstrated further in the USDHHS document Healthy People 2010 (2000a), which cites morbidity and mortality related to tobacco use and ETS as one of the leading indicators of the health of the American people for the next ten years.

Reflection on some of the facts gives one a sense of the ethical and policy problems posed by smoking. Approximately 440,000 deaths in the United States are due to smoking and diseases related to tobacco use (American Lung Association, 2002). Exposure to ETS (also known as passive smoking) increases the risk of cancer in people who have never smoked (Hackshaw et al.). Tobacco use has become a serious pediatric health issue, but in spite of regulation, children and adolescents continue to be able to obtain tobacco products (U.S. Department of Health and Human Services, 2000b). Control of the risks and diseases related to tobacco use has been hampered by continuing efforts by the tobacco industry to promote and market its products without constraints (U.S. Department of Health and Human Services, 2000b; Ong and Glatz).

The negative health effects of tobacco use are widely known and may be widely acknowledged even though individuals may not change their behavior on the basis of that knowledge. The reasons for the lack of behavioral change are many and complex (U.S. Department of Health and Human Services, 2000b). The ethical issues are also complex and have evolved over time and as a result of political and legal factors. Major ethical issues related to smoking and other tobacco use are: (1) the protection of nonsmokers from the effects of ETS; (2) the protection of children from an addictive product; (3) the scientific integrity of tobacco industry research; and (4) corporate integrity in marketing tobacco products.

In the past ethical arguments about smoking focused on issues of autonomy, paternalism, and societal harm. Smoking as an individual choice was juxtaposed against the restriction of individual smoking behavior as a consideration in protecting the individual from himself or herself and protecting society from smokers. Today the moral issues associated with tobacco use have moved away from individual autonomy and individual values because of the recognition of the significant public health implications of smoking. However, the earlier ethical arguments regarding smoking and tobacco use will be reviewed here to gain a historical perspective.

Ethics and Restrictive Policies: Autonomy, Paternalism, and Societal Harm

Before the harmful effects of ETS were demonstrated, the health risks of smoking suggested that at least some restrictive policies designed to protect smokers from themselves could be ethically justified. Knowledge of the risks that smokers impose on nonsmokers could support public policies designed to keep smokers from exposing nonsmokers to ETS or imposing on nonsmokers the medical costs of smoking. In addition to these two considerations the promotion of health has served as a third impetus for a restrictive policy. For example, in 1992 the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), the chief hospital accreditation agency in the United States, required hospitals to forbid smoking within their premises by 1994 as a condition of accreditation (Center for Disease Control Chronology of Significant Developments). Robert Goodin (1989) used these considerations to develop a vigorous case for a public policy aimed at a total ban on smoking. Today bans on smoking in public places are common and often complement state tobacco control programs that have been shown to be effective, at least in one instance, in reducing the mortality from heart disease attributed to smoking (Fichtenberg and Glantz).

Restrictive social policies that attempt to protect an individual from harming himself or herself have been viewed as paternalistic. At least since John Stuart Mill's (1859) On Liberty antipaternalistic sentiment has been widespread in the English-speaking philosophical community, with Joel Feinberg being one of its leading contemporary voices. Feinberg has emphatically rejected legal paternalism, the doctrine that "[i]t is always a good reason in support of a prohibition that it is necessary to prevent harm (physical, psychological, or economic) to the actor himself" (Feinberg, p. xvii). Despite an absence of consensus on what constitutes a competent choice, factors such as coercion, ignorance, mental impairment, and addiction serve as grounds for challenging the competence of a choice. The rejection of restrictive smoking policies on the basis of their paternalistic nature and curtailment of individual autonomy thus was considered a viable moral argument until the addictive properties of nicotine and the extent of children's tobacco use became known. The case for smoking as simply another autonomous value choice became difficult to make for an addictive substance whose use often began in childhood or adolescence.

Ethics and the Public's Health: Protecting Children and Nonsmokers

Although a moral argument based on the freedom to exercise individual autonomy could be made for not restricting competent adults from engaging in tobacco-related behaviors that are detrimental to their health, that argument fails because of the propensity of adult smokers to begin smoking in childhood or adolescence and the known effects of active and passive smoke on nonsmokers, children, and fetuses. According to a 1994 surgeon general's report, most first-time smoking occurs before graduation from high school, and the younger a child is when he or she begins smoking, the greater are the negative health effects (U.S. Department of Health and Human Services, 1994). Smoking and ETS are associated with decreased fetal growth during pregnancy and respiratory problems in school-age children who were exposed to smoke during early development (American Academy of Pediatrics). Children exposed to passive smoke are more likely to develop respiratory and middle-ear problems (Cook and Strachan).

Maternal smoking has been associated with sudden infant death syndrome, and passive smoke has been associated with an increase in hospital admissions among children with cystic fibrosis (Cook and Strachan). Because of these and other significant health risks to children and adolescents, the American Academy of Pediatrics has identified the reduction of children's exposure to both active and passive smoke as a primary goal of preventive health (American Academy of Pediatrics Committee on Substance Abuse).

The moral obligation to protect a vulnerable population is heightened by the dangers of tobacco to children in all stages of development and the fact that those risks are preventable. Although children potentially may be harmed by actively smoking or by their parents' smoking, children are also at risk from ETS outside the home.

The harm from ETS in all age groups is well established. The increased risks of respiratory and heart diseases and the role of passive smoke as an irritant were summarized in a 1986 surgeon general's report (U.S. Department of Health and Human Services, 1986). More recent meta-analyses of epidemiological studies have continued to affirm ETS as a cause of lung cancer (Hackshaw et al.) and have provided further evidence of the negative cardiac effects associated with ETS (He et al.). The continuing confirmation through scientific evidence of the detrimental health effects of passive smoking and the recognition of nicotine as addicting have moved smoking from the realm of personal value choice to the realm of public health.

The ethics involved in public health issues may differ in some respects from those involved in clinical medicine in that obligations to society as a whole may be different from or conflict with obligations to an individual patient. Although some conflicts between the rights of society and the rights of individuals may entail controversy, the overwhelming scientific evidence for the detrimental effects of tobacco has effectively eliminated controversy and promoted consensus among health professionals. The evidence justifies the imposition of restrictions such as workplace bans and restrictions on smoking in public places, whereas the lack of a total ban allows adult individuals to make the choice to smoke. Rather than being viewed as restrictions on personal liberty or intolerance of diverse values, those restrictions can be seen as analogous to the imposition of speed limits to protect the public's safety on highways. Occasional challenges to the scientific evidence still appear, but it is recognized increasingly that one reason for the public's (and some health professionals') delay in accepting the scientific evidence regarding the negative effects of smoking was an active campaign by the tobacco industry to market tobacco use aggressively and discredit scientific evidence about its negative health effects (Ong and Glantz).

Scientific Integrity and Corporate Morality

Since the 1990s confidential tobacco industry documents have become public as a result of litigation and increased public knowledge about the health effects of active tobacco use and ETS. Those documents demonstrate the efforts of the tobacco industry to publicly deny its own research results confirming the dangers of ETS, alter data to support its desired conclusions, and discredit legitimate scientists whose work demonstrated negative effects of ETS (Barnes et al.). Elisa K. Ong and Stanton A. Glantz describe how between 1993 and 1998 lawyers and marketing firms employed by Philip Morris directed a campaign to distort epidemiological standards with contrived concepts of sound science in order to attack legitimate scientific evidence on the negative health effects of tobacco use. Because further regulation of the tobacco industry appeared inevitable, the industry's goal was to raise the standards for scientific proof of harm so that legitimate studies demonstrating harm could never reach those standards and thus could be dismissed as junk science (Ong and Glantz).

The campaign was insidious but lost its force when epidemiological organizations refused to agree to some of the statistical standards being pushed by the tobacco industry (Ong and Glantz). This example of the tobacco industry's unethical attempts to manipulate public opinion is only one of many. Policies related to the sale of tobacco to foreign countries also raise difficult issues, including the promotion of cigarettes to children or to people who lack adequate information about the risks of smoking. Vigorous opposition by tobacco companies to efforts to inform Third World consumers about the effects of smoking and attempts to manipulate those efforts have exacerbated the problem (Emri, Bagci, Karakoca, Baris). Corporate morality leading to conflicts of interest and potential harm to individuals remains an unresolved problem.

Legal Regulation of the Tobacco Industry

All defensible theories of just laws recognize the harmfulness of a conduct to others as a good reason for regulating that conduct (Feinberg). In the environment of recognized health risks and the deceptive marketing practices of the tobacco industry lawsuits and regulations have become increasingly common.

Historically, legal decisions and regulations have been decided for and against both the tobacco industry and consumers. For example, the Federal Cigarette Labeling and Advertising Act of 1965 required the warning label that is familiar today but at the same time prohibited warning labels on cigarette advertisements for a period of three years (Center for Disease Control). The Controlled Substance Act of 1970, regulating addictive substances; the Consumer Product Safety Act of 1972, regulating hazardous substances; and the Toxic Substances Control Act of 1976, regulating injurious chemicals, specifically excluded tobacco from their lists of hazardous or addictive substances (Center for Disease Control). Other notable regulations include policies and laws in 1973, 1987, and 1989 to segregate and then ban smoking on domestic airline flights and bans on smoking in government workplaces in 1987, 1994, and 1997 (Center for Disease Control). The CDC website provides a summary of the numerous government regulations pertaining to tobacco since the early twentieth century (Center for Disease Control).

Over the years legal battles by individuals against the tobacco industry were fought with varying degrees of success, but eventually more consumers began to prevail in the courts. Although most disputes were heard in lower courts, two cases involving state laws, cigarette advertising, and injury or potential injury reached the U.S. Supreme Court and resulted in rulings that were partially favorable to each side (Thomas Cipollone; Lorillard Tobacco Company). In a third case, a victory for the tobacco industry, the U.S. Supreme Court ruled that the U.S. Food and Drug Administration did not have the authority to regulate tobacco products as it did other drugs.

By the mid-1990s four individual states had sued the tobacco industry to obtain reimbursement for healthcare costs related to tobacco use. In an effort to avoid more lawsuits the six major tobacco companies entered into an agreement with the attorney generals and representatives of the remaining forty-six states, along with U.S. territories and the District of Columbia. This so-called Master Settlement provides billions of dollars in payments to states from the tobacco industry beginning in June 2000 and extending over the following twenty-five years (Wilson). In addition to settlement payments, provisions of the Master Settlement include the prevention of industry targeting of children and adolescents in advertising, the regulation of tobacco industry lobbying, and public access to industry records and research (Wilson).

Since the last two decades of the twentieth century the changes in the ways in which the public thinks about and uses tobacco have been sweeping. The moral considerations of individual personal choice and freedom in smoking have become issues of public health, the protection of children, the integrity of science and scientists, and the morality of corporations. On January 27, 2003, Philip Morris changed its name to Altria Group, Inc., to demonstrate, it claimed, "To better clarify its identity as the owner of both food and tobacco companies that manage some of the world's most successful brands" (according to <http://www.philipmorris.com>). However, the moral tensions between the industry and the public continue. What the industry changes will mean in the long term remains to be seen.

michael lavin (1995)

revised by jacquelyn slomka

SEE ALSO: Addiction and Dependence; Advertising; Alcohol and Other Drugs in a Public Health Context; Alcoholism; Behavior Modification Therapies; Freedom and Free Will; Genetics and Human Behavior; Harm; Harmful Substances, Legal Control of; Hazardous Wastes and Toxic Substances; Human Dignity; Life, Quality of; Maternal-Fetal Relationship; Patients' Responsibilities; Race and Racism; Responsibility

BIBLIOGRAPHY

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American Academy of Pediatrics Committee on Substance Abuse. 2001. "Tobacco's Toll: Implications for the Pediatrician." Pediatrics 107: 794–798.

Barnes, Deborah E.; Hanauer, Peter; Slade, John; et al. 1995. "Environmental Tobacco Smoke: The Brown and Williamson Documents." Journal of the American Medical Association 274: 248–253.

Broders, A. C. 1920. "Squamous-Cell Epithelioma of the Lip: A Study of 537 Cases." Journal of the American Medical Association 74(10): 656–664.

Cook, Derek G., and Strachan, David P. 1999. "Health Effects of Passive Smoking: 10. Summary of Effects of Parental Smoking on the Respiratory Health of Children and Implications for Research." Thorax 54(4): 357–366.

Emri, Salih; Bagci, Tulay; Karakoca, Yalcin; et al. 1998. "Recognition of Cigarette Brand Names and Logos by Primary Schoolchildren in Ankara, Turkey." Tobacco Control 7: 386–392.

Feinberg, Joel. 1986. Harm to Self: Moral Limits of the Criminal Law, Vol. 3. Oxford, Eng.: Oxford University Press.

Fichtenberg Caroline M., and Glantz, Stanton A. 2000. "Association of the California Tobacco Control Program with Declines in Cigarette Consumption and Mortality from Heart Disease." New England Journal of Medicine 343: 1772–1777.

Food and Drug Administration, et al. v. Brown and Williamson Tobacco Corporation, et al. 98–1152. Supreme Court of the United States. Argued December 1, 1999. Decided March 21, 2000.

Goodin, Robert E. 1989. No Smoking: The Ethical Issues. Chicago: University of Chicago Press.

Hackshaw, A. K.; Law, M. R.; and Wald, N. J. 1997. "The Accumulated Evidence on Lung Cancer and Environmental Tobacco Smoke." British Medical Journal 315: 980–988.

He, Jiang; Vupputuri, Suma; Allen, Krista; et al. 1999. "Passive Smoking and the Risk of Coronary Heart Disease: A Meta-Analysis of Epidemiologic Studies." New England Journal of Medicine 340: 920–926.

Lorillard Tobacco Company, et al. v. Thomas F. Reilly. Attorney General of Massachusetts, et al.; Altadis U.S.A. Inc., etc., et al. v. Thomas F. Reilly, Attorney General of Massachusetts, et al. Nos. 00–596 and 00–597. Supreme Court of the United States. Argued April 25, 2001 Decided June 28, 2001.

Mill, John Stuart. 1975 (1859). On Liberty. New York: Norton.

Ong Elisa K., and Glantz, Stanton A. 2001. "Constructing 'Sound Science' and 'Good Epidemiology': Tobacco, Lawyers, and Public Relations Firms." American Journal of Public Health 91: 1749–1757.

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INTERNET RESOURCES

Agency for Healthcare Research and Quality. 2003. Available from <http://www.ahrq.gov>.

American Cancer Society. Available from <http://www.cancer.org>.

American Lung Association. 2002. "Trends in Tobacco Use." American Lung Association. Best Practices and Program Services Epidemiology and Statistics Unit. Available from <http://www.nicpp.org/files/ALA_Trends_in_Tobacco_Use_2002.pdf>.

Centers for Disease Control and Prevention. Available from <http://www.cdc.gov/tobacco/>.

Chronology of Significant Developments Related to Smoking and Health. Centers for Disease Control (a). Updated April 14,2003. Available from <http://www.cdc.gov/tobacco/overview/chron96.htm#1992>.

Fact Sheet—Smoking. 2003. New York, NY: American Lung Association. Available from <http://www.lungusa.org/tobacco/smoking_factsheet99.html>.

National Institutes of Health. 2003. Available from <http://www.nih.gov>.

National Library of Medicine. 2003. Availbale from <http://www.nlm.nih.gov>.

Philip Morris. 2003. Available from <http://www.philipmorris.com>.

Selected Actions of the U.S. Government Regarding the Regulation of Tobacco Sales, Marketing and Use. Centers for Disease Control(b). Updated March 31, 2003. Available from <http://www.cdc.gov/tobacco/overview/regulate.htm>.

U.S. Department of Health and Human Services. 2003. Available from <http://www.os.dhhs.gov>.

Wilson, Joy J. 1999. Summary of the Attorneys General Master Tobacco Settlement. Washington, D.C.: National Conference of State Legislatures. Available from <www.ncsl.org/statefed/tmsasumm.htm>.