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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 changesit 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 smokethe 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 4684% 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 blooda 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 doseabout 10 drops per dayshould 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 rootthe 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 difficultiesthe 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): 13381340.

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): 224230.

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): 4854.

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): 607618.

Richmomd, R., and N. Zwar. "Review of Bupropion for Smoking Cessation." Drug and Alcohol Review 22 (June 2003): 203220.

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): 487493.

"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): 9439.

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

views updated

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 changesit 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.

Symptoms That Occur After Quitting Smoking
Symptom Cause Duration Relief
Craving for cigarette nicotine craving first week can linger for months distract yourself with other activity
Irritability, impatience nicotine craving 2 to 4 weeks Exercise, relaxation techniques, avoid caffeine
Insomnia nicotine craving temporarily reduces deep sleep 2 to 4 weeks Avoid caffeine after 6 PM relaxation techniques; exercise
Fatigue lack of nicotine stimulation 2 to 4 weeks Nap
Lack of concentration lack of nicotine stimulation A few weeks Reduce workload; avoid stress
Hunger cigarettes craving confused hunger pangs Up to several weeks Drink water or low calorie drinks; eat low-calorie snacks
Coughing, dry throat, nasal drip Body ridding itself of mucus in lungs and airways Several weeks Drink plenty of fluids; use cough drops
Constipation, gas Intestinal movement decreases with lack of nicotine 1 to 2 weeks Drink plenty of fluids; add fiber to diet; exercise

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 blooda 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 difficultiesthe 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 doseabout 10 drops per dayshould 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 rootthe 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.

views updated

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

Percentage of adults in the United States age 45 and over who are current cigarette smokers, by selected characteristics, selected years, 2000–2007‡
 Total White Black or African American
Year 45–64 65 and over 45–64 65 and over 45–64 65 and over
†The value for all women includes other races which have a very low rate of cigarette smoking. Thus, the weighted average for all women is slightly lower than that
for white women.
‡The 2007 estimates are based on Early Release National Health Interview Survey (NHIS) data collected January?June 2007, using preliminary weights.
source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey
(Illustration by GGS Information Services. Cengage Learning, Gale)
Men Percent
200026.4%10.2%25.8%9.8%32.2%14.2%
200126.4%11.5%25.1%10.7%34.3%21.1%
200224.5%10.1%24.4%9.3%29.8%19.4%
200323.9%10.1%23.3%9.6%30.1%18.0%
200425.0%9.8%24.4%9.4%29.2%14.1%
200525.2%8.9%24.5%7.9%32.4%16.8%
200624.5%12.6%23.4%12.6%32.6%16.0%
2007‡22.6%8.6%21.5%8.6%30.5%12.8%
Women
200021.7%9.3%21.4%9.1%25.6%10.2%
200121.4%†9.1%21.6%9.4%22.6%9.3%
200221.1%8.6%21.5%8.5%22.2%9.4%
200320.2%8.3%20.1%8.4%23.3%8.0%
200419.8%8.1%20.1%8.2%20.9%6.7%
200518.8%8.3%18.9%8.4%21.0%10.0%
200619.3%8.3%18.8%8.4%25.5%9.3%
2007‡20.0%8.1%21.2%8.6%21.0%8.2%

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

views updated

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

Bothwell, P. W. 1959 The Epidemiology of Cigarette Smoking in Rural School Children. Medical Officer 102:125–132.

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.

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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

American Academy of Pediatrics. 1994. "Tobacco-Free Environment: An Imperative for the Health of Children and Adolescents." Pediatrics 93: 866–868.

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.

Thomas Cipollone, Individually and as Executor of the Estate of Rose D. Cipollone, Petitioner v. Liggett Group, Inc., et al. No. 90–1038. Supreme Court of the United States. Argued October 8, 1991. Decided June 24, 1992.

U.S. Department of Health, Education and Welfare. 1964. Smoking and Health. Washington, D.C.: U.S. Government Printing Office.

U.S. Department of Health and Human Services. 1986. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General. Publication CDC 87–8398. Washington, D.C.: U.S. Government Printing Office.

U.S. Department of Health and Human Services. 1992. Smoking and Health in the Americas. Publication CDC 92–8419. Washington, D.C.: U.S. Government Printing Office.

U.S. Department of Health and Human Services. 1994. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, D.C.: U.S. Government Printing Office.

U.S. Department of Health and Human Services. 2000a. Healthy People 2010, Vols. 1 and 2. Washington, D.C.: U.S. Government Printing Office.

U.S. Department of Health and Human Services. 2000b. Reducing Tobacco Use: A Report of the Surgeon General—Executive Summary. Washington, D.C.: U.S. Government Printing Office.

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>.

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SMOKING

In some industrialized communities smoking prevalence in elderly people is as high as 30 percent, and smoking prevalence is highest in low socioeconomic groups so that those older people with smoking-related diseases may also have other poverty-related social and medical problems. In the United Kingdom the smoking-related disease epidemic has probably passed its peak in men but is reaching its peak in womenin whom the maximum smoking uptake began with those born in the 1920s and 1930s.

Almost all smoking-related diseases are more common in old age. Furthermore, the beneficial effects of quitting smoking are for the most part maintained into old age. The reduction in risk of myocardial infarction (heart attack) is certainly not affected by aging, so that an older smoker who quits reduces his or her heart attack risk almost to normal after about three years. Quitting smoking can reduce the complications of peripheral vascular disease (hardening of the arteries to the legs and feet) in both young and elderly sufferers. Quitting produces a reduced risk of lung cancer (and probably many other cancers) in old people as well as in the middle-aged. Though only about one-quarter of heavy smokers will develop smoking-related airways obstruction (chronic obstructive pulmonary disease) resulting in chronic respiratory disability, quitting smoking will stop the accelerated decline of lung function in sufferers from this condition independent of the age at which they quit, at least up to the age of eighty.

Recent research shows that stopping smoking in middle age may extend the life of men by over seven years and in particular reduces deaths from heart disease. Even in those with preexisting smoking related lung disease, quitting smoking may extend life by up to six years.

We thus know that quitting smoking gives health gains for elderly people, but are they able to quit? The simple answer is that they are probably overall just as likely to be able to stop as younger smokers, however the situation is complex. Nicotine is an extremely addictive substance and quitting is difficult. Simply being told to quit by a medical professional produces a quit rate of about two to three percent. The most important predictor of whether a smoker is able to quit is their motivation (often judged by previous failed attempts to quit). In motivated elderly people without drug help (nicotine replacement) quit rates can be as high as 15 percentslightly higher perhaps than in the young. However, there has been little research work into the value and acceptability of nicotine replacement or other newer drug therapies in old people. Furthermore, at least in the United States older smokers are, overall, probably less likely to want to quit than to accept advice that smoking is bad for them, however among those who do recognize the dangers there is greater motivation and urgency to quit and a higher success rate.

Martin J. Connolly

See also Heart Disease; Lung, Aging; Vascular Disease.

BIBLIOGRAPHY

Burchfiel, C. M.; Marcus, E. B.; Curb, D.; et al. Effects of Smoking and Smoking Cessation on Longitudinal Decline in Pulmonary Function. American Journal of Respiratory and Critical Care Medicine 151 (1995): 17781785.

Raw, M.; McNeill, A.; and WEST, R. Smoking Cessation Guidelines for Health Professionals. Thorax 53, supp. 5 (1998): S1S38.

Rosenberg, L.; Palmer, J. R.; and Shapiro, S. Decline in Risk of Myocardial Infarction Among Women Who Stopped Smoking. New England Journal of Medicine 332 (1990): 213217.

Ruchlin, H. S. An Analysis of Smoking Patterns Among Older Adults. Medical Care 37 (1999): 615619.

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Smoking


Tobacco use and cultivation originated in South America and spread northward through the Americas, reaching the upper Mississippi Valley by 160 c.e. An important part of the Columbian exchange, tobacco took root in western Europe in the late sixteenth century, and then in Africa and the Asian mainland in the seventeenth century. Though Europeans first regarded tobacco as a medicinal herb, they discovered that the real demand was of a recreational nature. By the mid-1600s tobacco had joined alcohol and caffeine as one of the world's three great social drugs and had become an important source of revenue for colonial planters, merchants, and tax collectors.

Early Modern and Modern Tobacco Use

Early modern tobacco rituals varied by geography, class, and local custom. Some users preferred pipes, others chewing tobacco, others snuff. Though governments imposed different regulations and levels of taxation, a few generalizations hold across nations and cultures. Men used tobacco more often than women. Tobacco use typically began in childhood or adolescence. The more abundant the local supply, the larger the crop of neophytes and the sooner they started. Children as young as seven smoked in Britain's Chesapeake colonies, where tobacco pipes were nearly as ubiquitous as tobacco plants.

Tobacco initiation was a social process. It signified coming of age, that a boy was taking on the attributes of a man. Tobacco enhanced standing among male peers. It provided an occasion for relaxation and conviviality. Only later, as tobacco users became dependent on nicotine and suffered withdrawal symptoms in its absence, did the motive for consuming tobacco change. This reversal of effects is the single most consistent pattern running through the history of smoking. Children and adolescents began smoking for social reasons. They continued to smoke, often after they wished they could quit, because they had become addicted.

Knowing that youthful indulgence in tobacco led to a lifelong habit, and knowing that the habit was dirty, dangerous, and unhealthful, many parents, especially those of middle-class standing or pious temperament, discouraged children from using tobacco. Girls' use was considered particularly unseemly, though boys courted a whipping as well. The writer Samuel Clemens (18351910), better known as Mark Twain, admitted to smoking at age nineprivately at first, then in public only after his father died two years later. To acquire a supply, he and his friends traded old newspapers to the local tobacconist for cheap cigars.

That Clemens smoked, rather than chewed or sniffed, tobacco symbolized a broader nineteenth-century trend. Oral use remained popular in a few places, such as Iceland or Sweden, but elsewhere children's initiation into tobacco use increasingly meant initiation into smoking. Cigarette smoking was especially dangerous and addictive, because smoke could be inhaled into the lungs, where it delivered a powerful dose of nicotine directly to the bloodstream. At first store-bought cigarettes, hand-rolled specialty products aimed at the carriage trade, were too expensive for most children to afford. Then, in the 1880s, James B. Duke (18561925) transformed the industry with machine-production techniques. Prices dropped and use expanded. The United States, where per capita cigarette consumption increased tenfold between 1900 and 1917, was the epicenter of the first global cigarette revolution.

City boys were among the most avid consumers of Duke's products, and their insouciant smoking proved a powerful affront to bourgeois morality. Evangelical and progressive reformers attacked cigarettes on moral and health grounds, blaming "the little white slaver" for ruining children's health, encouraging intemperance, and poisoning the race. But such legislative barriers as they managed to erect (fifteen states outlawed some aspect of cigarette manufacture, distribution, or promotion) were soon swept aside. Widespread military use during World War I, Hollywood valorization, and mass advertising, including a successful campaign to recruit female smokersthe fastest growing segment of the market during the 1920s, 1930s, and 1940sall helped legitimate cigarettes. Smoking's ordinariness became its best defense. Laws banning sale to minors persisted, though vending machines and mothers' purses provided easy means of circumvention. Youthful smoking became unremarkable, even de rigueur. Those who didn't smoke, the writer John Updike remembered, got nowhere in the Pennsylvania high-school society of the late 1940s. Updike's Irish contemporary and fellow writer Frank McCourt recalled his friends asking him, incredulously, how he could possibly go out with girls if he didn't smoke.

The accumulation of evidence that smoking caused cancer and other deadly diseases, which reached a critical mass in the early 1950s, threatened the prosperity of cigarette companies. They tried to defuse the crisis through public relations, suggesting that the jury was still out on the health question. This was, at best, a delaying tactic. The growing medical data eventually led to declining adult domestic consumption, heavier taxation, and increased regulationthe broad pattern in Western societies during the last third of the twentieth century.

Confronted with decreasing demand in North America and Europe, multinational companies like Philip Morris and British-American Tobacco adopted a two-pronged strategy. First, they recruited teenage smokers to replace the adults who died or quit, using advertising to suggest that smokers were independent, sexually potent, and disdainful of authorityin a word, cool. A social fact, that cigarettes served as accessories of teenage identity (and, for girls, of thinness), became a means of recruiting those who would ultimately come to depend on cigarettes as nicotine-delivery vehicles. Where advertisements were banned, companies devised alternative promotions, such as colorful logo tee shirts, or company-sponsored sporting events aimed at getting brand names and package colors before a youthful audience.

Smoking in the Developing World

Overseas expansion was the second means of acquiring new customers. In the 1970s, cigarette companies began to move more aggressively into developing nations. By the decade's end, smoking was up 33 percent in Africa, 24 percent in Latin American, and 23 percent in Asia. By 2001, of the approximately 1.1 billion people who smoked worldwide, 80 percent lived in the developing world. As in the industrialized nations, these smokers had started young. Most were male, although in a few cultures, such as the Maorirelative newcomers to cigaretteswomen outnumbered men among smokers under the age of twenty-four. In China, where smoking remained a largely male pastime, advertisers targeted young women, hoping to enlarge the market, just as their predecessors had in the United States after World War I.

Western cigarettes also displaced traditional means of tobacco consumption. During the 1970s, Bangladeshi smokers put aside their hookahs and bidis (cheap, hand-rolled cigarettes) for manufactured brands. The change was particularly noticeable among young people, who saw cigarettes as a way to differentiate themselves from older generations. Advertisers encouraged the impulse, pitching brands like Diplomat (Ghana) or High Society (Nigeria) that connoted worldly success and Western values. Brand consciousness developed at an early age. By century's end 29 percent of South African five-year-olds could recognize specific brands of cigarettes. In Jordan 25 percent of adolescent children aged thirteen to fifteen said company representatives had offered them free cigarettes.

The result was a growing public-health crisis. According to the World Bank, by 1996 developing nations were losing $66 billion a year to smoking-related illnesses. Because the most serious effects of cigarettes did not begin to appear until twenty years or thirty years later, epidemiologists forecast worse to come. The World Health Organization (WHO) predicted 10 million tobacco-related deaths annually by 2030. Fully 50 percent of those in developing countries who began smoking would die of smoking-related diseases. Half again of that 50 percent would die in middle age, losing years of productive life and wasting the social resources that had been invested in their upbringing and education. In essence, tobacco companies' globalized drive for profit and survival had lured another, even larger generation into the pulmonary minefield. In 2001 alone, between 64,000 and 84,000 young people in the developing world began smoking every day.

Despite the health threat and economic consequences, governments in developing nations did little to challenge the cigarette's spread, typically imposing fewer restrictions on advertising and marketing than did their Western equivalents. As of 2001, forty nations required no warnings on cigarettes. Others permitted warnings in English, rather than the native language. Restrictions on advertising, where enacted, were often indifferently enforced. Few regulations governed the levels of tar in cigarettes, which were often higher than those sold in Western nations.

Alarm over this regulatory vacuum and the lethal, mounting consequences of smoking in developing nations has provoked an increasingly vocal public health response, a situation reminiscent of attempts to negotiate controls on the international narcotic traffic in the early twentieth century (a historical parallel that the industry's critics have not been shy about developing). Several international organizations, including the WHO, have proposed global treaties aimed at curtailing, or at least slowing, sales of cigarettes and other tobacco products. The highest profile effort has been the Framework Convention on Tobacco Control (FCTC), a comprehensive regulatory scheme that includes such provisions as restrictions on tobacco advertising, promotion, and sponsorship that target minors. In May 2003 the World Health Assembly adopted the FCTC; at this writing the treaty awaits ratification by member nations.

bibliography

Courtwright, David T. 2001. Forces of Habit: Drugs and the Making of the Modern World. Cambridge, MA: Harvard University Press.

Kiernan, V. G. 1991. Tobacco: A History. London: Hutchinson Radius.

Nath, Uma R. 1986. Smoking: Third World Alert. Oxford, UK: Oxford University Press.

Tate, Cassandra. 1999. Cigarette Wars: The Triumph of "The Little White Slaver." Oxford, UK: Oxford University Press.

Winter, Joseph C., ed. 2000. Tobacco Use by Native North Americans: Sacred Smoke and Silent Killer. Norman: University of Oklahoma Press.

internet resources

Action on Smoking and Health. 2001. "Tobacco in the Developing World." Available at <www.ash.org.uk/html/factsheets/html/fact21.html/>.

World Bank. 2002. "Economics of Tobacco Control." Available at <www1.worldbank.org/tobacco/about.asp>.

World Health Organization. 2002. "Tobacco Free Initiative." Available at <www5.who.int/tobacco/>.

David T. Courtwright

Andrew M. Courtwright

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Smoking

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 smokethe 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 1215 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 1825 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 difficultiesthe 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): 31023.

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): 1620.

"Reports: Fewer U.S., Canadian Youth are Lighting Up." Tobacco Retailer (August 2004): 78.

"Tobacco Use among Middle and High School StudentsUnited States, 2002." Morbidity and Mortality Weekly Report (November 14, 2003): 109698.

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).

Barbara Boughton, Ph.D.

Ken R. Wells

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.

Emphysema A chronic respiratory disease that involves the destruction of air sac walls to form abnormally large air sacs that have reduced gas exchange ability and that tend to retain air within the lungs. Symptoms include labored breathing, the inability to forcefully blow air out of the lungs, and an increased susceptibility to respiratory tract infections. Emphysema is usually caused by smoking.

Epinephrine A hormone produced by the adrenal medulla. It is important in the response to stress and partially regulates heart rate and metabolism. It is also called adrenaline.

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 A colorless, oily chemical found in tobacco that makes people physically dependent on smoking. It is poisonous in large doses.

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.

Secondhand smoke A mixture of the smoke given off by the burning end of a cigarette, pipe, or cigar and the smoke exhaled from the lungs of smokers.

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.

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Smoking

BIOLOGICAL ASPECTS OF NICOTINE ADDICTION

BEHAVIORAL ASPECTS AND ENVIRONMENTAL INFLUENCE

SMOKING CESSATION AND PREVENTION

GLOBAL ECONOMICS OF SMOKING

BIBLIOGRAPHY

Cigarette smoking has great societal and clinical significance. It is a major cause of several diseases, including a variety of cancers. The practice of cigarette smoking is pervasive; about a quarter of all adult Americans smoke cigarettes, and smoking rates are even higher in many other countries. Despite the high personal cost associated with cigarette smoking, it is a prototypical addictive disorder manifesting such features as tolerance, withdrawal, and chronic use. The peak age for smoking prevalence is between eighteen and twenty-five years. Retrospective data from the National Household Survey on Drug Abuse suggests that the average age of first use of tobacco products in 1999 among all persons who ever used in their lifetime was 15.4 for cigarettes, 20.5 for cigars, and 16.7 for smokeless tobacco across all age groups (Kopstein 2001). Data from the National Comorbidity Survey suggests that the onset of nicotine dependence is delayed for at least one year after the onset of daily smoking. Smoking rates decline among people who have reached their mid-twenties, but these declines are modest in comparison to other forms of substance use. This may be due to the fact that cigarette smoking is highly addictive, legal, and not immediately performance-impairing.

BIOLOGICAL ASPECTS OF NICOTINE ADDICTION

Nicotine, independently, yields the trademark effects of an addictive drug. It produces tolerance and physical dependence, and heightened doses produce euphoria and satisfaction (Corrigall 1999; USDHHS 1998). Smokers will not self-administer tobacco on a chronic basis if it does not contain nicotine. Nicotine is essential for the development and maintenance of a smoking habit. However, once nicotine dependence is established, cues related to nicotine release become greatly influential in controlling self-administration behaviors. When a cigarette is smoked, about 80 percent of the inhaled nicotine is absorbed in the lungs (Armitage et al. 1975). Absorption is both efficient and extremely rapid. Despite the overall recognition that the rapid onset of drug action promotes addictive drug use, it remains unclear why this is so. Researchers do not fully understand which characteristics of drug pharmacokinetics are most determinant of addictiveness.

BEHAVIORAL ASPECTS AND ENVIRONMENTAL INFLUENCE

Data published in 2002 suggest that smoking among American adolescents is fairly common, with 27 percent of twelfth graders, 18 percent of tenth graders, and 11 percent of eighth graders reporting that they had smoked in the past month (Johnston et al. 2002). This level of smoking prevalence represents a decline from peaks in the mid-1990s. Much less is known about the epidemiology of tobacco dependence in adolescents. Dependence is a term often correlated with addiction, and adolescent smokers are less likely to be diagnosed with tobacco dependence than are adult smokers (Colby et al. 2000), although many adolescent smokers consider themselves addicted. Adolescents who are dependent report the same symptoms as do dependent adults, including cravings, withdrawal, tolerance, and a desire to reduce smoking (Colby et al. 2000). Compared to adults at the same level of self-reported intake, adolescents who smoke are more likely to be diagnosed as dependent, which suggests that adolescents may be especially vulnerable to dependence or sensitive to the effects of nicotine (Kandel and Chen 2000).

Before they experiment with cigarettes, adolescents form beliefs and attitudes about the effects of smoking. These attitudes and beliefs prospectively predict both the onset and escalation of smoking. Many adolescents believe that there are no health risks related to smoking in the first few years, and they believe that they will stop smoking before any damage is done. Existing evidence suggests that adolescents and adults exhibit unrealistic optimism about the personalized risks of smoking (Arnett 2000; Weinstein 1999). Whether adolescents are any more likely than adults to underestimate the personalized risks of smoking is unclear.

Evidence indicates that as smokers become more dependent, there is a shift in the motivational basis for their tobacco use. Social motives and contextual factors are rated as influential to beginner smokers, while heavy smokers emphasize the importance of control over negative moods and urges, and the fact that smoking has become involuntary (Piper et al. 2004). When smoking becomes less linked to external cues and more linked to internal stimuli, smokers are classified as dependent. There is also evidence suggesting that smoking cigarettes may lead to the use of illicit drugs. Cigarette smoking is endemic among substance abusers, with rates as high as 74 percent to 88 percent (Kalman 1998), compared to 23 percent of the general population (CDC 2002).

Greater parental education is associated with less likelihood of smoking in offspring. Additionally, girls appear to be more influenced by peer smoking than boys (Mermelstein 1999). In the United States, the highest smoking rates are among American Indian and Alaska Native adolescents, followed by whites and then Hispanics, with lowers rates among Asian Americans and African Americans. While studies that sample multiethnic groups are sparse, research has suggested that African American and Asian American adolescents report stronger antismoking socialization messages from parents and that African American parents report feeling particularly empowered to influence their childrens smoking (for reviews, see Mermelstein 1999; USDHHS 1998). Peer smoking is a relatively weak predictor of smoking for African American adolescents compared to white adolescents.

Adolescents sometimes start smoking as a result of self-image. The social image of an adolescent smoker is an ambivalent one, with negative aspects but also images of toughness, sociability, and precocity that may be particularly valued by deviance-prone adolescents who are at risk to smoke (Barton et al. 1982). Additionally, adolescents may start smoking and continue smoking because of their perception of the effect that smoking has on weight control and dieting. The belief that smoking can control body weight has been shown to predict smoking initiation among adolescent girls, but not boys (Austin and Gortmaker 2001). In addition, this belief is held more widely by white girls than by African American girls (Klesges et al. 1997). Despite the above-mentioned indicators, peer smoking is the most consistently identified predictor of adolescent smoking (Derzon and Lipsey 1999). In addition to cigarette smoking by peers, affiliation with peers who engage in high levels of other problem behaviors also prospectively predicts smoking initiation, as does self-identification with a high-risk social group (Sussman et al. 1994).

SMOKING CESSATION AND PREVENTION

The tobacco industry spends millions of dollars per day on advertising and promotional materials to keep their products in the public eye. Beyond such reminders of the availability of tobacco products, smoking is not an easy habit to break. Smokers must not only break the physical addiction to nicotine, but also the habit of lighting up at certain times of the day. Successful quitters confess that quitting is often a lengthy process that involves several unsuccessful attempts. Although one-third of smokers attempt to quit each year, 90 percent or more of those who attempt to quit will fail.

Nicotine replacement therapies (NRTs) have been used to help some people quit smoking. The two most common forms of NRTs are chewing gum and the nicotine patch, both of which are available over the counter. Nicorette, a prescription chewing gum containing nicotine, is often used to help reduce the consumption of nicotine over time. Users have reported experiencing fewer cravings for nicotine as the dosage is reduced, until they are completely weaned. The nicotine patch was first marketed in 1991 for smokers with a desire to quit. Generally, the nicotine patch is used in conjunction with a comprehensive smoking-behavior cessation program. Additionally, a nicotine nasal spray, nicotine inhaler, and nicotine pill have been approved by the FDA to help cigarette smokers quit smoking. In order to prevent the initiation and maintenance of smoking, there has been an increase since the mid-1980s in the development and implementation of smoking cessation and prevention programs, especially for young people and adolescents.

GLOBAL ECONOMICS OF SMOKING

Approximately 80 percent of the worlds 1.1 billion smokers live in low- and middle-income countries. In 1998 about four million people died of tobacco-related disease worldwide (WHO 1999). This number is projected to increase to ten million annually by 2030, with 70 percent of these deaths occurring in low-income countries. Death counts of this magnitude could be prevented if current smokers quit, but it is rare for smokers living in low- to middle-income countries to attempt to quit smoking (Jha and Chaloupka 2000). Although few dispute that smoking is damaging to human health on a global scale (Peto and Lopez 2000), governments have avoided taking action to control smoking. This is mainly due to concerns that such interventions might have harmful economic consequences, such as permanent job losses. Despite these concerns, several common measures aimed at the control of smoking, such as higher tobacco taxes, consumer information, bans on advertising and promotion, and regulatory policies, have had a significant impact. Each will be discussed below.

An increase in tobacco taxes is the single most effective intervention to reduce the demand for tobacco. A review by Prabhat Jha and Frank Chaloupka (2000) suggests that a price increase of 10 percent would reduce smoking by 4 percent in high-income countries and by about 8 percent in low- and middle-income countries. This evidence also implies that young people, individuals on low incomes, and those with less education are more responsive to price changes (Chaloupka et al. 2000). Policies to improve the quality and extent of tobacco information can also reduce smoking, particularly in lowand middle-income countries. For example, in the 1960s and 1970s, the promulgation in the United States and Britain of new evidence on the health risks of smoking helped reduce consumption between 4 and 9 percent. In addition, warning labels on cigarette packages were also found to reduce consumption during that era (Kenkel and Chen 2000). In a review of 102 countries and econometric analyses of income, Henry Saffer and Chaloupka (2000) revealed that bans on advertising and promotion led to considerable reductions in tobacco consumption.

Enforcing regulatory policies designed to prevent smoking in public places, worksites, and other facilities can also significantly reduce cigarette consumption worldwide (Yurekli and Zhang 2000). Attempts to impose restrictions on the sale of cigarettes to young people in high-income countries have mostly been unsuccessful (Siegel et al. 1999). Furthermore, it may be difficult to implement and enforce such restrictions in low-income countries. Evidence indicates that freer trade in tobacco products has led to an increase in smoking and other types of tobacco use. One solution is for countries to adopt measures that effectively reduce demand and apply those measures to both imported and domestically produced cigarettes (Taylor et al. 2000).

SEE ALSO Addiction; Adolescent Psychology; Disease; Peer Effects; Tobacco Industry; Tolerance, Drug

BIBLIOGRAPHY

Armitage, A. K., C. T. Dollery, C. F. George, et al. 1975. Absorption and Metabolism of Nicotine from Cigarettes. British Medical Journal 4: 313-316.

Arnett, Jeffrey Jensen. 2000. Optimistic Bias in Adolescent and Adult Smokers and Nonsmokers. Addictive Behavior 25: 625-632.

Austin, S. Bryn, and Steven L. Gortmaker. 2001. Dieting and Smoking Initiation in Early Adolescent Girls and Boys: A Prospective Study. American Journal of Public Health 91: 446-450.

Barton, John, Laurie Chassin, Clark Presson, and Steven J. Sherman. 1982. Social Image Factors as Motivators of Smoking Initiation in Early and Middle Adolescence. Child Development 53 (6): 1499-1511.

Centers for Disease Control and Prevention (CDC). 2002. Cigarette Smoking among AdultsUnited States, 2000. Morbidity and Mortality Weekly Report 51: 642-645.

Chaloupka, Frank J., Teh-Wei Hu, Kenneth E. Warner, et al. 2000. The Taxation of Tobacco Products. In Tobacco Control in Developing Countries, eds. Prabhat Jha and Frank Chaloupka, 237-272. Oxford: Oxford University Press.

Colby, Suzanne, Stephen T. Tiffany, Saul Shiffman, and Raymond S. Niaura. 2000. Are Adolescent Smokers Dependent on Nicotine? A Review of the Evidence. Drug Alcohol Dependence 59 (suppl.): 83-95.

Corrigall, William A. 1999. Nicotine Self-Administration in Animals as a Dependence Model. Nicotine Tobacco Resistance 1: 11-20.

Derzon, James H., and Mark W. Lipsey. 1999. Predicting Tobacco Use to Age 18: A Synthesis of Longitudinal Research. Addiction 94: 995-1006.

Jha, Prabhat, and Frank J. Chaloupka. 2000. The Economics of Global Tobacco Control. British Medical Journal 321: 358-361.

Johnston, Lloyd D., Patrick M. OMalley, Jerold Bachman, and John E. Schulenberg. 2002. National Survey Results on Drug Use from the Monitoring the Future Study, 1975-2002. Vol. 1: Secondary School Students. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, and National Institutes of Health.

Kalman, David. 1998. Smoking Cessation Treatment for Substance Misusers in Early Recovery: A Review of the Literature and Recommendations for Practice. Substance Use and Misuse 33: 2021-2047.

Kandel, Denise B., and Kevin Chen. 2000. Extent of Smoking and Nicotine Dependence in the United States, 1991-1993. Nicotine and Tobacco Research 2: 263-275.

Kenkel, Donald, and Lisa Chen. 2000. Consumer Information and Tobacco Use. In Tobacco Control in Developing Countries, eds. Prabhat Jha and Frank Chaloupka, 177-214. Oxford: Oxford University Press.

Klesges, Robert C., Vanessa E. Elliot, and Leslie A. Robinson. 1997. Chronic Dieting and the Belief that Smoking Controls Body Weight in a Biracial Population-based Adolescent Sample. Tobacco Control 6: 89-94.

Kopstein, Andrea. 2001. Tobacco Use in America: Findings from the 1999 National Household Survey on Drug Abuse. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

Mermelstein, Robin. 1999. Ethnicity, Gender, and Risk Factors for Smoking Initiation: An Overview. Nicotine and Tobacco Research 1 (suppl.): 45-51.

Peto, Richard, and Alan D. Lopez. 2000. The Future Worldwide Health Effects of Current Smoking Patterns. In Critical Issues in Global Health, eds. C. Everett Koop, Clarence E. Pearson, and M. Roy Schwartz, 154-161. San Francisco: Jossey-Bass.

Piper, Megan E., Thomas M. Piasecki, E. Belle Federman, et al. 2004. A Multiple Motives Approach to Tobacco Dependence: The Wisconsin Inventory of Smoking Dependence Motives (WISDM). Journal of Consulting in Clinical Psychology 72 (2): 139-154.

Saffer, Henry, and Frank J. Chaloupka. 2000. Tobacco Advertising: Economic Theory and International Evidence. Journal of Health Economics 19: 1117-1137.

Siegel, Michael, Lois Biener, and Nancy A. Rigotti. 1999. The Effect of Local Tobacco Sales Laws on Adolescent Smoking Initiation. Prevention Medicine 29: 334-342.

Sussman, Steve, Clyde W. Dent, Lou Anne McAdams, et al. 1994. Group Self-identification and Adolescent Cigarette Smoking: A 1-year Prospective Study. Journal of Abnormal Psychology 103: 576-580.

Taylor, Allyn L., Frank J. Chaloupka, Emmanuel Guindon, and Michaelyn Corbett. 2000. The Impact of Trade Liberation on Tobacco Consumption. In Tobacco Control in Developing Countries, eds. Prabhat Jha and Frank Chaloupka, 343-364. Oxford: Oxford University Press.

U.S. Department of Health and Human Services (USDHHS). 1998. Tobacco Use among US Racial/Ethnic Minority Groups: African Americans, American Indians, and Alaska Natives, Asian Americans and Pacific Islanders, Hispanics, Report of the Surgeon General. Atlanta, GA: USDHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Weinstein, Neil D. 1999. Accuracy of Smokers Risk Perceptions. Nicotine and Tobacco Research 1 (suppl.): 123-130.

World Health Organization (WHO). 1999. Making a Difference, World Health Report 1999. Geneva, Switzerland: Author.

Yurekli, Ayda A., and Ping Zhang. 2000. The Impact of Clean Indoor-Air Laws and Cigarette Smuggling on Demand for Cigarettes: An Empirical Model. Health Economics 9: 159-170.

Daphne C. Watkins

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SMOKING

SMOKING . Plants whose properties when consumed place the user in an unusual state have always been looked upon as being endowed with supernatural power. Such plants play an important part in both religious ceremonies and in healing. In such a context, these plants have been either used as symbols or consumed in different forms, including smoking. The one plant that has consistently maintained such religious association is tobacco, a New World contribution to the world's flora. Other plant products that can be smoked, such as hashish and opium, both of which originated in the Near East, have never had significant functions in religious ritual, although most recently some midwestern sects in the United States claim hashish smoking as part of their religious rituals.

The genus Nicotiana (tobacco) consists of seventy-four species, all but two of which are native to the North American continent. The latter two, N. fragrans and N. suaveolens, grow wild in Australia but were not used for smoking before the arrival of the white people. The most popular species are N. rustica and N. tabacum. Several others, such as N. bigelovii and N. attenuata, grow wild in the western Unites States. Indian tribes of California, the northern Plains, and the Northwest Coast are known to have planted these as their only agricultural effort.

Ancient Native American and European reports describe tobacco as a strong and addictive herb smoked with apparent hallucinogenic effects. Tobacco as it is known today produces no such effects. The indigenous people of the American continent may have been using more potent admixtures, or tobacco may have only induced a state that allowed its user to ease into altered states of consciousness.

It is possible that the use of tobacco was at first confined to shamans, priests, and medicine men. Data indicate that the tobacco plant and products derived from it were held in high esteem and those who grew or could obtain the plant used it as a precious offering to both worldly and supernatural rulers. Later, due to the interchange of ritual customs, the abundance of tobacco in some areas, and European influence, tobacco smoking became a worldwide custom; but its sacrosanct character among the natives of the Americas survived.

North America

Tobacco initially grew wild. Gathered as a cultivated plant, it made its appearance with maize in North America. The two primary modes of tobacco consumption were smoking pipes and cigarettes and chewing. Tobacco pipes have been found in archaeological excavations of basket making culture sites (some as early as 2500 bce) in the Southwest.

The Plains Indians developed considerable skill and ingenuity, as well as aesthetic sensitivity and care in making pipes. As Peter T. Furst points out,

No object, no matter how splendidly proportioned or complex in iconography, can convey the enormous depth of feeling, ritual and belief, the very conception of the universe and how it came to be, the mutuality and interdependence of the sexes, and, indeed the whole relationship of human beings to the holy earth and sky, which are embodied in these traditional Native American smoking instruments. (Furst, 1982)

The famous Plains pipes are made of catlinite, thought to represent the flesh and blood of dead ancestors and dead buffalo, poured together and turned to stone. Catlinite had been mined in southwestern Minnesota by the Oto and Iowa tribes, who were replaced in the seventeenth century by Siouan-speaking groups, who became sole owners of the sacred material and compelled all other tribes to buy the stone from them.

Bowl and stem of the ritual pipe were carried separately when not in use. Apart, the instruments had no supernatural power. In many tribes women carved or decorated the stems, which had male attributes, and men fashioned the bowls, which were considered to have female attributes. The Plains Indians undertook no ceremony or ritual act without smoking pipes, which were kept in their medicine bundles. When an Indian died, his tobacco and pipe were placed with him in his burial place.

Kinnikinnick was the native name for the smoked material. This term means "mixture" to the Algonquin. They mixed their tobacco with different plant materials, such as sumac, bearberry, manzanilla, and dogwood bark. Though they used plants other than tobacco for smoking, none had the sacred nature attributed to tobacco.

The Indians of the Northwest Coast were introduced to smoking by Western explorers, who found them chewing their tobacco with lime. These tribes limited tobacco to important rituals, especially to commemorative feasts for the dead. Their pipes were carved out of wood or ivory and decorated with pictures of animals or mythological scenes. The shamans smoked pipes primarily to communicate with their guardian spirits and also during healing ceremonies. For them, tobacco was the symbol of the equilibrium of the universe and of divine benevolence from generation to generation.

South America

Both N. tabacum and N. rustica were modified by selection or by hybridization in South America, probably in Peru, Ecuador, Bolivia, and northern Argentina. Even today, tobacco is used by many native tribes, but is rarely smoked by them. The preferable form of consumption is chewing or drinking in the form of a syrupy juice. Tobacco juice is taken either by mouth or through the nostrils, or administered as an enema. The last method has been documented for the Inca and Tihuanaco of the pre-Conquest periods.

Smoking tobacco for the purpose of divination was practiced by Venezuelan tribes, who also offered tobacco as a gift to their gods. The Guajiro of Colombia, the Kumaná of the Orinoco River, and the Warao and the Shipibo-Conibo on the Ucayali River also celebrate healing ceremonies by smoking, or smoke in preparation for other drug use. The Piro and the Machiganga of Peru inhale tobacco snuff through tubes made of bird bones as medicine against colds. This old remedy was adopted by Europeans in the sixteenth century.

Mesoamerica

The most extensive depictions of smoking and the oldest and most abundant data on the pre-Columbian use of tobacco (mostly in the form of cigars) are found in Maya art. The word cigar is Maya in origin; the word tobacco might be derived from an Arawak word for "cigar." The Maya also depicted cigarette smoking, for which there are no early records elsewhere. Pipe smoking did not appear in Maya art, and it is doubtful that it was a custom. Early Spanish reports describe the coating of cigars with a varnish of clay, which was then decorated, and the stuffing of small tubes of cane, clay, and other materials with shredded tobacco, which was either smoked or used to blow smoke.

Besides smoking, the Maya also chewed, licked, ate, and drank tobacco, social customs reported frequently from Conquest times to the present day. Tobacco as a form of incense, however, had an exclusive and important role in ceremonial healing. The Maya attributed most diseases to supernatural intervention, and native healing was, and still is, a predominantly religious act of communication with supernatural forces in which religion and medicine remain inseparable.

The pre-Columbian Maya often depicted their divine rulers, nobles, and gods smoking. Among the deities, god L appears to be a heavy smoker; the death god, the rain god, god D of the creation, and the ancestral god N could be characterized as only occasional indulgers. God K not only smokes on occasion but he is shown with a smoking cigar stuck through his forehead. Some of the mythological animals, usually representing gods, are also shown smoking: Monkeys have a strong lead, with jaguars second, and frogs or toads third. All of these animals are also patron deities of days or months.

Noble Maya lords were also frequently shown smoking or handling cigars or cigarettes either alone or in the company of others. Apparently no women participated in these rituals, although they are sometimes shown on ancient paintings and monuments in proximity to smokers. The context of these scenes is varied and not always clear. There are processional scenes with supernaturals and their impersonators, and there are scenes with offerings of human victims or other sacrifices. Other smoking scenes commemorate ancestors and still others show smoking to be one of several ways to achieve a state of trance.

The Lacandon, a few hundred Maya Indians still living in the Chiapas rain forest, continue to cultivate tobacco in the ancient ways. They believe that the Nohoch Yum Chacob, the white-haired, bearded servants of the god of rain and thunder, live in the second highest level of the heavens and smoke cigars. Comets or meteorites are thought to be the glowing butts they throw away. Until recently the Lacandon placed cigars as offering to their gods in the holy area. There is a special ceremony of thanksgiving during their tobacco harvest: Thanksgiving is offered to the deity depicted on a "god pot," who is usually smoking, seated on the hieroglyph for "earth."

The Maya of Yucatán believe that the Balams, the gods of wind and the four directions, are heavy cigar smokers. When the gods light the cigars by pounding heavy rocks together to create a spark, there is thunder and lightning on earth. Tobacco smoking also has an important role in a number of milpa (corn patch) ceremonies.

The Tzeltal Maya of Oxchuc offer thirteen calabashes of tobacco in their celebration of the New Year. The Tzotzil tribe attributes magical power to tobacco and uses it as a defense against evil forces, such as Pucuh, the demon of death. Tobacco in all its forms is considered by most Maya tribes as the most effective agent against the numerous underworld threats, evil spirits, demons, and any form of witchcraft that may cause illness or death. The healing shaman uses tobacco to divine the exact cause of the illness and to find out how to help the patient. Maya travelers protect themselves from evil influences by chewing tobacco and by carrying gourds filled with tobacco. In many of the Mesoamerican areas, tobacco and smoking paraphernalia are placed in graves to accompany the spirit of the dead as a protection during the journey to the underworld and as a gift the dead can offer to the gods.

The main body of data on tobacco use among the Aztec comes from observations and reports by Europeans. Torquemada (1615) wrote that the old earth goddess, Cihuacoatl, female warrior and creator of humankind, had a body composed of tobacco, and she was the incarnation of the plant. Hernando Ruiz de Alarcón (1629) described rites to honor the war god, Huitzilopochtli, to whom an offering of tobacco is as pleasing as one composed of other drugs. Fray Diego Durán (c. 1581) reported that the fire god, Xiuhtecuhtli, received tobacco, incense, and pulque daily, sprinkled onto the fire in his temple. The priests who prepared victims for sacrifice to the goddess Toci (old earth or moon goddess, patron of the day named Jaguar) wore small tobacco gourds on their backs, as did the priests serving Tezcatlipoca, the counterpart to the Maya god K. Both in the Codex Mendoza and in the Codex Florentine several of the figures participating in sacrificial rites are pictured carrying tobacco gourds (yetecomatl) and pouches (yequachtli ) or incense ladles (tlemaitl), the insignia of Aztec priesthood. Tobacco was carried in powder form or shaped into balls and used as a form of incense. When actually smoked it was mixed with other herbs, among them jimsonweed (Datura stramonium ). During a beautiful ceremony called Dance of Flowers, the vegetation goddess Xochiquetzal invited other gods to sit with her; they smoked together and were entertained by her court.

Among the Mexicans tobacco was a protection against witchcraft or wild animals, but it could also be used to cast spells. Fray Bernardino de Sahagún (15691582) described a hunt for snakes, which were enfeebled and stunned when powdered tobacco was hurled at them.

The Totonac of Papantla de Olarte believed that tobacco protected them not only against snakes but also against the dead, and they offered it to the supernatural rulers of the forest. The Cuicatec used wild tobacco in rituals conducted on hilltops or in caves. Among the Mazatec the healer used a paste of powdered tobacco and lime to render pregnant women invulnerable to witchcraft. The Tlaxcalan offered tobacco to their war god Camaxtli. Bowls of tobacco, eagle feathers, and two bloodstained arrows were sent to the enemy camp by the cacique of Michoacán to announce the outbreak of war. The Huichol regarded tobacco as a prized possession of Grandfather Fire. They made small tobacco balls, touched them with feathers, and wrapped them in corn husks. During pilgrimages, these "cigarettes" were carried in small gourds tied to their quivers to symbolize the birth of tobacco. After completion of the pilgrimage, they burned and smoked tobacco in honor of Grandfather Fire.

These ancient and recent reports show that tobacco was used by the Aztec and numerous tribes living between the Maya and North American Indians in the form of incense, as a drink, or by smoking. Smoking of the sacred herb was also practiced by the gods. Tobacco in all its forms and modes of consumption was regarded as a substance of pervading holiness, a gift from the gods, an offering to the supernatural forces of the heavens and the underworld, and a means to communicate with them.

See Also

Tobacco.

Bibliography

Arents, George. Tobacco. 5 vols. Edited by Jerome E. Brooks. New York, 19371952.

Durán, Diego. Los dioses y ritos and El calendario (c. 1581). Translated by Fernando Horcasitas and Doris Heyden as Book of the Gods and The Ancient Calendar. Norman, Okla., 1971.

Furst, Peter T. Hallucinogens and Culture. San Francisco, 1976.

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