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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.

— Barbara Boughton

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adj.

1. Engaging in the smoking of tobacco: smoking passengers.
2. Designated or reserved for smokers: the smoking section of a restaurant.
3. Of or relating to the use of tobacco: corporate smoking policies.

Tobacco is believed to have been grown in the Americas for many thousands of years, and native Americans are thought to have discovered ways of using the plant, including smoking the leaves, a thousand years before Christ. A pottery vessel, found in Guatemala, dated earlier than the eleventh century, depicts a Mayan smoking a roll of tobacco leaves tied with string. Landing at San Salvador in 1492, Columbus was presented with dried fragrant leaves, but threw them away, not realizing the value placed on them by the natives. Rodrigo de Jerez was probably the first European smoker, learning of the practice from Cubans in the 1490s and taking the habit back to Spain. He was imprisoned by the Holy Inquisitors for seven years, but the practice was common by the time he was released. By the middle of the sixteenth century, smoking of tobacco was known in Mexico, Santa Domingo, Cuba, Brazil, Canada (in Montreal), France, Holland, Portugal, Spain, Germany, and Britain. It spread eastwards to Turkey and Poland by the 1580s, and in 1586 the first cautionary remarks about its use were made in Germany, where it was described as the ‘violent herb’. The smoking habit was spread largely by sailors, who both experienced it on their journeys and brought back supplies for continuing use at home. Certainly the naval explorers Sir John Hawkins and Sir Francis Drake, or at least their crews, brought back supplies and made use of the leaves. It was Sir Francis Drake who introduced tobacco to Sir Walter Raleigh in 1585, and, as the story goes, a servant finding Raleigh smoking thought he was on fire and drenched him with beer. Tobacco was smoked in various ways — rolled into a cigar, as cigarettes made with reed stems, and in pipes. Raleigh, while not the originator of smoking in England, did much to improve the method of curing the leaf, and popularized it amongst the courtiers of his day. The rich would smoke the leaf in silver pipes, while in the taverns clay pipes filled with smouldering tobacco would be passed from hand to hand. The poor man made do with a walnut shell and a straw stem. The price of tobacco was high, the purchaser getting enough leaf to balance the silver coins placed on the other pan of the scales. Numerous claims were made for the benefits of tobacco, such as prevention of toothache, falling fingernails, worms, hallitosis, lockjaw, and cancer. In 1566, Catherine de Medici, Queen of France, received snuff (powdered tobacco) to treat her migraine, and later decreed it Herba Regina.

The impact of tobacco, particularly in Europe, was considerable, and often contradictory. For example, importation of tobacco from the colonies prompted governments to impose a heavy duty, which in turn encouraged smuggling, bootlegging, and attempts to grow tobacco at home. In 1604, James I published a ‘counterblaste’ against tobacco, concluding that smoking was

‘a custom lothsome to the eye, hateful to the nose, harmefull to the braine, daungerous to the lungs, and in the blacke stinking fume thereof, nearest resembling the horrible Stigian smoke of the pit that is bottomelesse’.

In the colonies it was realized that the Spanish leaf (Nicotiana tabacum) was superior to the indifferent leaf found in the colonies (Nicotiana rustic), and English colonials were very influential in setting up the tobacco growing industry in Virginia and Maryland, to the obvious advantage to trade. Indeed, an article in the Washington Post in 1997, by Susan de Ford, was entitled ‘Tobacco: the noxious weed that built a nation’ — referring here, of course, to the US. In the Americas a special tax levied in 1693 helped establish the college of William and Mary at Williamsburg, and in the nineteenth century Duke University in North Carolina was founded on tobacco. Spenser's Fairy Queen, published in 1590, contains the earliest poetical allusion to tobacco. Six years later Ben Jonson's Every Man is his humor has a scene in which an argument about tobacco is played out. By 1614 there were 7000 tobacconists' shops in London alone. Cigarettes became the most popular form of tobacco, use by the 1880s, made by huge corporations, particularly in the US, supplying the worlds' smoking needs: pipes were in decline. The taking of snuff and the use of chewing tobacco are now almost extinct, although dedicated pipe smokers and cigar devotees are still to be found.

Over the years increasing statistical evidence related smoking to cardiovascular and lung disease, especially bronchitis, emphysema, and cancer. It is undoubtedly true that the pleasures of smoking are derived from the actions of nicotine on the central nervous system. Nicotine is rapidly absorbed from the mucosal membrane of the mouth and from the lungs, and readily penetrates the nervous system. It also has peripheral actions, tending to increase blood pressure and heart rate. The Surgeon-General's Report in the US in 1964 was the real start of the campaign to prevent or abolish smoking. Vested interests in the tobacco companies promoted ideas to reduce the harmful effects by the introduction of filters and creation of low tar cigarettes. It is the carcinogenic compounds in the tar which are the serious hazard to health, and some, but not all, of these compounds are removed by the filters. People changing to cigarettes with low nicotine content tend to smoke more and draw more deeply. Artificial smoking materials have been developed, consisting of pure cellulose-based material impregnated with nicotine. However, combustion of all plant material, and of pure cellulose, seems to produce some carcinogenic agents. The ultimate in the safe cigarette consists of a hollow tube which is not ignited but releases nicotine as the ‘smoker’ draws air through. Nicotine chewing gum and nicotine patches, which release the alkaloid when applied to the skin, have also been produced as substitutes, largely for those who are breaking the habit.

The taking of nicotine is habit forming, indeed it can be described as addictive. The balance of psychological to physical dependence is generally more towards the former, as physical withdrawal symptoms are less severe than with drugs such as heroin. However, individual tobacco addicts vary enormously in their level of dependence. Some of the pleasures of smoking are due to ritual — particularly so in pipe smokers, who carry a variety of equipment for preparing for a satisfying smoke. Many smokers never do so in the dark, for the curl of the smoke from the pipe or cigarette end is part of the ritualistic satisfaction. Many psychological tests have shown that mental activity and performance is enhanced by smoking, particularly when fatigued — but the young often take up smoking to imitate their peers or idols. Serious programmes to stop people smoking or to prevent the young from starting are now being offered, particularly in the Western world, and the number of public places in which smoking is acceptable has greatly reduced.

To understand why smoking is still so common, despite all that is known about its effects, it is necessary to appeal to experiments made in model systems. In the brain a tract of nerve fibres run from the ventral tegmental area (VTA) of the mesolimbic dopamine system to the nucleus accumbens (NA). When this tract of nerve fibres is activated, dopamine is released in the NA. Application of nicotine to the VTA also causes dopamine release in the NA. Experimental animals which have been trained to self-administer nicotine by lever pressing fail to do so if the mesolimbic pathway from the VTA to the NA is cut. Thus, in this experimental paradigm, release of dopamine in the NA seems to be part of a reward response which reinforces administration. More importantly, other addictive drugs, such as amphetamine, cocaine, or morphine, also cause dopamine release in the NA. Most drugs when administered repeatedly result in desensitization — the cell membrane receptors upon which the drug acts fail to respond or they ‘down regulate’, meaning that the number of receptors decreases, thus limiting the response. This is the basis of tolerance. In the case of nicotine receptors in the brain, the numbers increase with continued and repeated administration of the drug, though not uniformly in all areas of the brain. How this increased number of receptors is related to tolerance is unknown. Tolerance to nicotine does exist, for obviously smokers are used to low levels of nicotine for much of their waking hours and have increased numbers of nicotinic receptors. Yet the non-smoker who for one reason or another takes a cigarette or cigar often shows profound effects not only in the psyche but in the periphery as well, often vomiting and feeling very unwell. Stories of fathers making their children smoke a cigar if caught trying to smoke have claimed lifelong cures by this ruse. Finally, nicotinic receptors are so called because they can be activated by nicotine, as well as by the natural transmitter acetylcholine. Activation of the dopaminergic mesolimbic system by release of acetylcholine in the VTA is presumably involved with pleasurable feelings, even in non smokers.

— Alan W. Cuthbert

See also addiction.

The process of flavouring and preserving meat or fish by drying slowly in the smoke from a wood fire; the type of wood used affects the flavour of the final smoked product.

Many smokers claim that their habit helps them to relax, but there is no doubt that smoking is harmful to health and has a detrimental effect on athletic performance. Tobacco smoking is a major, preventable factor leading to death. Almost 20 per cent of deaths in the USA have been attributed to diseases associated with inhaling the products of combustion from the tobacco plant, Nicotiana tobacum. These products include nicotine, carbon monoxide, and tars.

The psychological and addictive effects of smoking cigarettes are attributed to nicotine, a drug that stimulates the central nervous system and enhances arousal. Nicotine affects blood pressure and heart rate directly, increasing the risk to smokers of coronary heart disease. It also affects hormone production. For example, cigarette smoking lowers blood oestrogen levels and therefore reduces bone mineralization. When inhaled, the carbon monoxide passes into the bloodstream where it combines with haemoglobin, reducing the ability of blood to transport oxygen. Among heavy, chronic smokers the reduction may be as much as 10 per cent, reducing their ability to take part in strenuous exercise, and accounting for the breathlessness experienced by most smokers. Tars inhaled during smoking are microscopic, organic substances which can stick onto cells in the lungs. Some tars release free radicals that may be carcinogenic and increase the risk of lung cancer. The high production of free radicals in smokers may explain why they break down vitamin C faster than non-smokers (vitamin C is one of the antioxidants that mops up free radicals). It is estimated that the vitamin C requirements of smokers may be twice as much as non-smokers. In the UK, the RNI for adult non-smokers is 40 mg but smokers require more vitamin C (possibly as much as an extra 80 mg); in the USA, the RDAs are 60 mg for non-smokers and 100 mg for smokers.

Smoking is highly addictive. Smokers who try to give up may suffer withdrawal symptoms including a persistent craving for tobacco, irritability, poor concentration, and weight gain. The weight gain is popularly attributed to eating more to compensate for the lack of oral gratification provided by smoking. However, the gain may also be due to metabolic changes because nicotine increases metabolic rate, particularly during exercise. It is sensible for ex-smokers to moderate the effects of weight gain by increasing their aerobic activity. They should also control their feeding habits carefully. For example, snacks should consist of nutritious, low calorie foods such as raw vegetables and fruit.

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.

THERAPIES FOR TREATING SYMPTOMS OF SMOKING CESSATION
Treatment	Description	Symptom treated
Lobelia	Used as a nicotine substitute, it can bolster the nervous system	Withdrawal and craving
Wild oats or kava kava	Relaxant	Withdrawal
Licorice	Can be chewed to help withdrawal	Oral fixation
Hawthorn, gingko biloba, and bilberry	All contain bioflavonoids that can help repair free radical damage	Damage to lungs and cardiovascular system
Acupuncture	Stimulation of points in ears and feet helps cessation	Addiction and withdrawal
Vitamin C	Antioxidant that helps fight infection	Boosts immune system
Vitamin B12	Helps protect body from disease	Smoking-induced cancers
Omega-3 fatty acids	Helps protect body from disease	Smoking-related illness, such as emphysema, and depression

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 .

American Cancer Society. Contact the local organization or call (800) 227-2345. .

American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872 or (212) 315-8700. .

Herb Research Foundation. 1007 Pearl St., Suite 200, Boulder CO 80302. (303) 449-2265. .

National Heart, Lung, and Blood Institute (NHLBI). Building 31, Room 5A52, 31 Center Drive, MSC 2486, Bethesda, MD 20892. (301) 592-8573. .

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. .

Other

Virtual Office of the Surgeon General: Tobacco Cessation Guideline. .

[Article by: Barbara Boughton; Rebecca J. Frey, PhD]

Definition

Smoking is the inhalation of the smoke of burning tobacco that is used mostly in three forms: cigarettes, pipes, and cigars.

Description

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 as of 2004 regarded habitual smoking as a psychological addiction, one with serious health consequences. 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 dual role explains 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 effect 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 as 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. Nicotine may also 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 to 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.

The harmful effects of teenage smoking are both short-term and long-term. During adolescence, smoking interferes with ongoing lung growth and development, preventing the attainment of full lung function. Teenagers who smoke are less fit than their nonsmoking peers and more apt to experience shortness of breath, dizziness, coughing, and excess phlegm in their lungs. They are also more vulnerable to colds, flu, pneumonia, and other respiratory problems. Smoking for even a short time can produce a chronic smoker's cough. In addition to respiratory problems and a diminished level of overall well-being in adolescence, teenage smoking is also responsible for health problems in adulthood.

It is estimated that one third of the teenagers who start smoking each year eventually die of diseases related to tobacco use, diseases that will shorten their lives by an average of 12–15 years. Cigarette smoking is a major risk factor for cardiovascular disease, including coronary heart disease, atherosclerosis (hardening of the arteries), and stroke. Reports by the surgeon general link teenage smoking to cardiovascular disease in both adolescents and adults. The same reports cite evidence that the length of time a person has smoked has a greater impact on the risk of developing lung cancer and other smoking-related cancers than the number of cigarettes smoked; in other words, starting to smoke at an early age is an even greater health risk than being a heavy smoker.

Demographics

The National Survey on Drug Use and Health (NSDUH) is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. The study found that an estimated 70.8 million Americans reported current (past month) use of a tobacco product in 2003. This is 29.8 percent of the population aged 12 or older, similar to the rate in 2002 (30.4%). Young adults aged 18–25 reported the highest rate of past month cigarette use (40.2%), similar to the rate among young adults in 2002. An estimated 35.7 million Americans aged twelve or older in 2003 were classified as nicotine dependent in the past month because of their cigarette use (15% of the total population), about the same as for 2002.

Young adults aged 18 to 25 had the highest rate of current use of cigarettes (40.2%), similar to the rate in 2002. Past month cigarette use rates among youths in 2002 and 2003 were 13 percent and 12.2 percent, respectively, not a statistically significant change. However, there were significant declines in past year (from 20.3% to 19%) and lifetime (from 33.3% to 31%) cigarette use among youths aged 12 to 17 between 2002 and 2003. Among persons aged twelve or older, a higher proportion of males than females smoked cigarettes in the past month in 2003 (28.1% versus 23%). Among youths aged 12 to 17, however, girls (12.5%) were as likely as boys (11.9%) to smoke in the past month. There was no change in cigarette use among boys aged 12 to 17 between 2002 and 2003. However, among girls, cigarette use decreased from 13.6 percent in 2002 to 12.5 percent in 2003.

Causes and Symptoms

No one starts smoking to become addicted to nicotine. It is not 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 humans.

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 cancer (lung, cervical, and other types); respiratory diseases (emphysema, asthma, and chronic bronchitis); and cardiovascular disease (heart attack, high blood pressure, stroke, and atherosclerosis). 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 percent of premature births and 10 percent of infant deaths. There is some evidence that smoking may cause impotence in 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.

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 have not 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. Some 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, asthma, and sudden infant death syndrome in babies.

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 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.

When to Call the Doctor

Smokers should seek medical help if they want to quit smoking but are unable to do so, or if they exhibit signs of any of the illnesses associated with long-term tobacco use. Persons who are frequently around smokers should seek medical advice if they show any of the symptoms associated with illnesses caused by smoking since second-hand smoke can be more damaging to health than first-hand smoke.

Diagnosis

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

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 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 process helps wean the smoker from nicotine slowly. However, if the smoker smokes while taking a nicotine replacement, a nicotine overdose may occur.

The drug buproprion hydrochloride has shown some success in helping smokers quit. This drug contains no nicotine and was originally developed as an antidepressant. It is not known exactly how buproprion works to suppress the desire for nicotine.

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.

Prognosis

Research on smoking shows that 80 percent of all smokers desire to quit. But smoking is so addictive that fewer than 20 percent of the people who try ever successfully break 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, it is 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 percent. 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 smokers give up their cigarettes for good and never go back to them again? Here are a few tips from the experts:

• People should tell their friends and neighbors that they are quitting. Doing so helps make quitting a matter of pride.
• They should chew sugarless gum or eat sugar-free hard candy to redirect the oral fixation that comes with smoking and to prevent weight gain.
• They should eat as much as they want, but only low-calorie foods and drinks. They should drink plenty of water, which may help with the feelings of tension and restlessness that quitting can bring. After eight weeks, they will lose their craving for tobacco, so it is safe then to return to their usual eating habits.
• They should stay away from situations that prompt smoking, avoiding other people who smoke and dining in the nonsmoking section of restaurants.

Parental Concerns

Parents and guardians need to be aware of the power they have to influence the development of their kids throughout the pre-teen and teenage years. Adolescence brings a new and dramatic stage to family life. The changes that are required are not just the teen's to make; parents need to change their relationship with their teenager. It is best if parents are proactive about the challenges of this life cycle stage, particularly those that pertain to the possibility of experimenting with and using tobacco. Parents should not be afraid to talk directly to their kids about smoking, even if they have had problems with smoking themselves. Parents should give clear, nouse messages about smoking and its negative consequences on health. It is important for kids and teens to understand that the rules and expectations set by parents are based on parental love and concern for their wellbeing. Parents should also be actively involved and demonstrate interest in their teen's friends and social activities. Spending quality time with teens and setting good examples are essential. Even if tobacco use already exists in the teen's life, parents and families can still have a positive influence on their teen's behavior.

Resources

Books

Gosselin, Kim, and Thom Buttner. Smoking Stinks! Plainview, NY: Jayjo Books, 2002.

Haugen, Hayley Mitchell. Teen Smoking. San Diego, CA: Greenhaven Press, 2004.

Shipley, Robert H. Stop Smoking Kit: Quit Smart Stop Smoking Guide, Hypnosis Quit Smoking CD, and Cigarette Substitute. Durham, NC: QuitSmart Stop Smoking Resources, Inc., 2004.

Periodicals

Brook, Judith S., et al. "Tobacco Use and Health in Young Adulthood." Journal of Genetic Psychology (September 2004): 310–23.

Frieden, Joyce. "Peer Pressure Likely to Prompt Tobacco Use: Behavior Predictors Studied." Family Practice News (June 15, 2004): 66.

McCollum, Sean. "Up in Smoke: Smoking Harms Your Health and Empties Your Wallet. How Much Does This Lethal Habit Cost? Do the Math and Find Out." Scholastic Choices (February-March 2004): 16–20.

"Reports: Fewer U.S., Canadian Youth are Lighting Up." Tobacco Retailer (August 2004): 7–8.

"Tobacco Use among Middle and High School Students—United States, 2002." Morbidity and Mortality Weekly Report (November 14, 2003): 1096–98.

Organizations

Campaign for Tobacco-Free Kids. 1400 Eye Street, Suite 1200, Washington DC 20005. Web site: www.tobaccofreekids.org.

Youth Anti-Tobacco Collaborative. 1469 Park Ave., San Jose, CA 95128. Web site: www.notbuyinit.org.

Web Sites

"Kids against Tobacco Smoke." Roy Castle Lung Cancer Foundation. Available online at www.roycastle.org/kats/about.htm (accessed November 3, 2004).

"Stand Up. Speak Out against Tobacco." Available online at www.standonline.org (accessed November 3, 2004).

"Tobacco vs. Kids." Campaign for Tobacco-Free Kids. Available online at www.tobaccofreekids.org (accessed November 3, 2004).

[Article by: Barbara Boughton, Ph.D.; Ken R. Wells]

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The act of smoking has been the object of extensive research, especially since the 1950s. It remains difficult, however, to know the historical influences that prompted the early use of tobacco. It is known that smoking developed social significance through tribal ceremonies and customs of the indigenous populations of North America. As industrial societies became established, mass production and corporate marketing took advantage of the stimulative and addictive properties of nicotine. The use of tobacco also took on a new social meanings as it was marketed to fulfill psychosocial needs such as a attaining independence or being part of a "cool" trend. The result was widespread and frequent usage, particularly through the smoking of cigarettes. High consumption has since produced devastating health effects. Although early opponents had to rely primarily on moral and emotional persuasion, epidemiological evidence of tobacco's impact on morbidity and mortality now provides the principal impetus to develop policies to prevent smoking.

The abundance of information that now exists on smoking necessitates the use of various frameworks, theories, and models in order to achieve a comprehensive and coherent perspective. A frame work, such as PRECEDE-PROCEED, helps depict the broad context of smoking and encourages the analysis of a comprehensive range of variables; a theoretical approach facilitates explanations as well as predictions; and modeling enhances visual representation or mathematical relations. Most of the major public health models and theories have been applied to smoking, and the literature contains support for many of these theories. This is partly due to the generality of the theoretical concepts.

Figure 1 is a graph of the prevalence of smoking across age groups in Canada. This graph shows that daily smoking largely begins and expands during the teenage years, and then peaks among young adults before decreasing. The behavior follows a sequence of experimentation, initiation, maintenance, and cessation. While the major behavioral change occurs during the teenage years, many of the predisposing factors develop at an earlier age. Beliefs, attitudes, and values begin to develop very early in life, and these influence later behavioral patterns.

Development of Behavior Patterns

Human beings have a long period of infant and child development, which allows children to adapt and acquire coping skills that help them survive in their environments. Due to the increasingly complex nature of society, the early socialization process needs to build capacities for communication, learning, and making decisions for healthful behavior. The initiation of smoking tends to exist among young people who report having a home environment that includes difficulty communicating with parents, lack of parental understanding, low levels of trust, and a generally unhappy home life. This type of family setting creates conditions conducive to a lifestyle that includes smoking. Such predisposing factors are also evident as social networks expand during the teenage years.

The teenage years are a time of transition. They form a bridge between the relatively sheltered environment of childhood and the roles of adulthood. Teenagers begin to confirm their own identities and emulate adult roles. There is a heightened awareness of role models and a tendency to establish boundaries through experimentation and experiencing new risks. School is obviously an important environment for teenagers and students who smoke at this age are more likely to experience difficulties in the academic setting. They experience lower grades, poor student-teacher interactions, minimal academic aspirations for the future, and often complain of unfair school rules. Teenage smokers also tend to have lower self-esteem—they are more likely to report feelings of unhappiness and loneliness, a lack of confidence, and a sense of being unhealthy.

Young people who smoke generally have a reduced capacity to implement practices that promote advancement at home and at school, and in other important settings. This can affect their ability to maintain a healthy sense of identity that includes belonging, worthiness, and hope for the future. Tobacco advertisements prey on these needs by offering an image of suave independence. The insinuation is that smoking will help an individual to achieve desirable qualities. Data are not readily available to quantify the behavioral impact of this practice. It has been shown, however, that young people are readily able to identify images and brands promoted by the tobacco industry.

Other aspects of the social environment have promoted the acceptability of smoking, such as smoking by role models in the movie industry and the widespread visibility of smoking. Studies indicate that smokers tend to overestimate the prevalence of smoking and underestimate the health hazards. All these processes and conditions are set in place during the early years of socialization, and they contribute toward a predisposition that smoking is acceptable and even desirable. Once individuals are predisposed toward the possibility of smoking, enabling factors facilitate the actual behavior.

Enabling Factors

Two obvious requirements are necessary for someone to smoke: being able to acquire cigarettes and having a setting that is conductive to lighting up. Increased access to a supply of cigarettes is closely related to the expansion of a person's boundaries and social networks. Peer groups create an important source and setting for the uptake and maintenance of smoking. During their midteens, smokers tend to have a larger number of friends and spend a great deal of time with them outside of school activities. Friends and relatives often supply cigarettes to begin smoking, but commercial outlets quickly become the main source. Studies have found that young people do not have difficulty obtaining tobacco, even with recent legislation to prevent the sale of tobacco to minors.

When prices are increased, largely through taxation, additional sources become important. These include roll-your-own tobacco, illegal smuggling, tax-free sales on Indian reservations, and mail order. The inverse relationship between price and consumption may be because smoking is more prevalent among persons with a lower socioeconomic status who have a limited amount of money to spend on tobacco products. However, once smoking has begun there is a tendency toward continuance and an integration of smoking into one's lifestyle. The predisposing and enabling factors develop into patterns that reinforce the behavior, as do the addictive properties of nicotine.

Reinforcing Behavior Patterns

Reinforcing patterns begin with having friends who are smokers. Spending time with such friends provides ample opportunities to reinforce smoking behavior. Patterns develop to have a cigarette during breaks at work, with food and beverages, and during social events such as parties. Strong correlations exist between smoking and the consumption of caffeine, alcohol, and marijuana. These patterns move smokers away from healthy and productive lifestyles. There are thus a host of illness symptoms and premature deaths attributable directly to smoking as well as indirectly to the broader pattern of unhealthful behavior.

In 1999, The World Health Organization reported that "the joint probability of trying smoking, becoming addicted, and dying prematurely is higher than for any other addiction." Although smokers downplay the consequences of smoking, they do recognize that a risk exists, though they find it difficult to quit. Many teenagers believe they will only smoke for a short duration. Others state they can "quit anytime." Unfortunately, a significant number are in for a long struggle, and perhaps a lifetime addiction to tobacco. Most of the decline in the proportion of smokers does not occur until past the age of forty. This is partially related to successful quitters and premature deaths of smokers. More than two out of three adult smokers report a desire to quit smoking. The most common reason for successful quitting is a concern about future health. The influence of these health concerns is enhanced by a continual decline in the proportion of adult smokers subsequent to the publication of the 1964 Surgeon General's report outlining the consequences of smoking. However, during the 1990s there was a slightly upward trend in the proportion of high school students who are smoking. For young people, the subjective meaning of smoking extends beyond the concern about future health consequences.

The principal predisposing and enabling factors for smoking occur during the socialization process. Personal insecurities, problems at home, and difficulties in academic environment are all preyed upon by a tobacco industry driven by profits, and smoking cigarettes and intake of nicotine become entrenched into behavioral patterns that create a high-risk trajectory and bleak outlook for the health of individuals and the population. The underlying causes of smoking are complex and deeply rooted, and the necessary research on smoking continues to expand. Public health advocates recognize the need for comprehensive tobacco control strategies, but also admonish individuals that: If you don't smoke, don't start, and if you do smoke, quit. Social changes and changes in individual behavior are required to achieve a significant reduction in tobacco use.

(SEE ALSO: Addiction and Habituation; Adolescent Smoking; Advertising of Unhealthy Products; Behavior, Health-Related; Counter-Marketing of Tobacco; Enforcement of Retail Sales of Tobacco; Smoking Cessation)

Bibliography

Green, L. W., and Kreuter, M. W. (1999). Health Promotion Planning: An Educational and Ecological Approach. Mountain View, CA: Mayfield.

Health Canada. Tobacco Use Monitoring Survey, Wave 1 Fact Sheets. Available at http://www.hc-sc-.gc.ca/hpb/lcdc/bc/ctums/pdf/ctums99.pdf.

Lalonde, M. (1974). A New Perspective on the Health of Canadians: A Working Document. Ottawa: Canadian Department of National Health and Welfare.

National Association of County and City Health Officials (2000). Programming and Funding Guidelines for Comprehensive Local Tobacco Control Programs. Available at http://www.naccho.org/downloadfile2.cfm/General185.pdf.

Pollay, R. W. (2000). "Targeting Youth and Concerned Smokers: Evidence from Canadian Tobacco Industry Documents." Tobacco Control 9:136–147.

World Health Organization (1999). "Combating the Tobacco Epidemic." In The World Health Report 1999—Making a Difference. Available at http://www.who.int/whr/1999/.

— RONALD A. DOVELL

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For more information on smoking, visit Britannica.com.

The act of inhaling the products of combustion from tobacco that contains carbon monoxide and nicotine. Smoking is harmful to health and athletic performance. It can cause lung cancer. Smoking is the main risk factor for heart disease and peripheral vascular disease.

Tobacco, as it is most often smoked today, is largely derived from the Nicotiana tabacum plant, a broad-leafed herb native to the Americas and a member of the nightshade family, to which potatoes and sweet peppers also belong. The indigenous peoples of the Americas used the plant in many different kinds of religious and medical rituals, though no one knows what kinds of health hazards may have been recognized. A Mayan pottery vessel from about the ninth century A.D. shows a man smoking a roll of tobacco leaves tied with a string; Columbus found natives puffing away on tobacco pipes when he arrived in the West Indies in the fifteenth century. Tobacco later became an important staple in the American export economy, with many Southern slave states earning much of their income from tobacco sales and exports.

Pipes, snuff, and chewing tobacco were the most common forms of ingestion prior to the twentieth century. Cigarette smoking did not become popular until the end of the nineteenth century, following the invention of the Bonsack rolling machine in 1884 and flue curing, which gave a milder taste to tobacco smoke, making it easier to inhale. Cigarette smoking was also promoted by the development of mass tobacco advertising and the encouragement of national governments, which recognized tobacco as an easy source of tax revenues. Cigarettes were included with the rations of soldiers fighting in World War I; hundreds of thousands of men returned from combat hooked on the new and fashionable drug. The net effect was a spectacular rise in smoking in the first six decades of the twentieth century. So whereas Americans in 1900 smoked only about fifty cigarettes per adult per year; this would grow by a factor of about eighty over the next sixty years. U.S. smoking rates peaked in 1964, when men and women were smoking an average of 4,300 cigarettes per person per year. Some people smoked more than 20,000 cigarettes per year.

Between 1893 and 1927, fifteen American states banned the sale of cigarettes. Anti-tobacco sentiments were often linked to campaigns to prohibit the sale of alcohol, and although both movements stressed the "moral dangers" accompanying such indulgences, health concerns were also beginning to come into play. Tobacco had been shown to be a health threat in the eighteenth century, when cancers of the nasal passages and lips were linked to smoking. In the nineteenth century, French scientists found that the overwhelming majority of people suffering from cancer of the mouth were pipe smokers. German scholars in the 1920s and 1930s established the lung cancer link, and by the 1950s in both Europe and America, a broad medical consensus had been established that cigarettes were responsible for many serious ailments, including cancer and heart attacks. Many national governments were slow to admit the hazard, however, having become dependent on tobacco taxation as a source of national income. Germany in the 1930s, for example, earned nearly one-twelfth of its total revenue from tobacco taxes, and England in the 1950s earned about 14 percent of its tax revenue from tobacco.

In 1964, the United States Surgeon General's Report on Smoking declared cigarettes a major source of health hazards, prompting a decline in U.S. cigarette consumption. By 1994 only about one in four Americans over the age of sixteen was a smoker, and per capita consumption had declined as well—to about 2,500 cigarettes per adult per year. Warning labels had been put on tobacco packaging in the 1960s, though tobacco companies had managed to soften the blow somewhat by camouflaging the labels. New forms of advertising were also sought to compensate for the 1970 ban on television advertising. Tobacco companies became major sponsors of many sporting events (such as race-car driving and tennis) and began to pay actors to smoke in Hollywood movies. Brown and Williamson, for example, in 1983 agreed to pay Sylvester Stallone $500,000 to use that company's tobacco products in each of his next five films.

Tobacco companies won all of the lawsuits filed against them in the 1960s, '70s, and '80s, arguing either that smoking had not been proven hazardous or that smokers themselves were to blame for their illnesses. Tobacco companies spent hundreds of millions of dollars challenging the medical link between smoking and disease. Front organizations such as the Council for Tobacco Research and the Tobacco Institute were established in the 1950s to "balance" the anti-smoking message with "no evidence of harm" propaganda. The industry abruptly changed its legal strategy in the 1990s, however, by conceding that the dangers of smoking had been well known for many decades. Companies began to hire historians to argue that smokers made an informed choice when they decided to take up smoking, and that blame for whatever risks this may have entailed must reside with the smoker.

Tobacco ads were banned on American television in 1970. The U.S. Congress banned smoking on airline flights of less than two hours in 1988, and in 1990 this was extended to all domestic flights. Anti-smoking policies were strengthened in the 1990s. Lawsuits were filed against manufacturers by states seeking to recover medical costs from smoking, and in 1998 the attorneys general of forty-six states agreed to accept a settlement of $206 billion from the five major tobacco companies to offset the public-health costs of smoking. Critics have charged that the increased costs can simply be passed on to consumers and that the settlement, to be paid out over twenty-five years, amounts to only about thirty or forty cents per pack in any event. The U.S. tobacco industry has also responded by shifting the focus of its sales overseas. Today the U.S. market is a shrinking component of U.S. tobacco sales, and more than one-third of the cigarettes manufactured in this country are now being smoked abroad. Philip Morris now sells three cigarettes abroad for every one sold in the United States.

Smoking today is generally regarded as the cause of a global cancer epidemic. While smoking still kills about half a million Americans every year—mainly from heart attacks and cancer—the figure is much higher in places like China, which has become the world's leading consumer of tobacco products. Lung cancer was an extremely rare disease at the beginning of the twentieth century, with only 142 cases recorded in the medical literature worldwide. By the end of the century it was the world's most common cause of cancer death. The World Health Organization has estimated that China is soon going to have a million lung cancer fatalities every year, the majority of these being caused by smoking. The number of Americans dying from lung cancer began to decline in the 1990s as a result of many people quitting, though teen smoking rates actually rose for most of that decade.

Smoking is growing rapidly worldwide, which is why we can expect the global lung cancer epidemic to continue. Global cigarette production in the year 2000 was more than 5.5 trillion cigarettes per annum, and growing. Since one lung cancer death is generated for every 2 to 4 million cigarettes smoked in any given society, we can expect more than 2 million lung cancer deaths per year, worldwide, in the not-too-distant future. Total deaths from other kinds of cigarette-related illnesses (and fires) will of course be greater than this, approaching 10 million per year by the 2020s according to World Health Organization estimates. Cigarettes must already have caused more than 100 million deaths since their invention, and the twenty-first-century toll could be as high as one billion. Anthropologists estimate that approximately 80 billion people have lived since the evolution of Homo sapiens, which means that by the end of the twenty-first century cigarettes may have killed more than 1 percent of everyone who has ever lived.

Bibliography

Kluger, Richard. Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York: Knopf, 1996.

Parker-Pope, Tara. Cigarettes: Anatomy of an Industry from Seed to Smoke. New York: New Press, 2001.

Proctor, Robert N. Cancer Wars: How Politics Shapes What We Know and Don't Know about Cancer. New York: Basic Books, 1995.