Key Points

• Tobacco use is the leading cause of death in the United States.

• Toxins from cigarette smoke cause disease in most organs of the body.

• Smokers die an average of 13 or 14 years earlier than nonsmokers, and 50% of continuing smokers will die of a tobacco-related disease.

• Smoking is responsible for 40% of all deaths from cancer and 21% of deaths from cardiovascular disease.

• Almost 10% of deaths attributable to smoking occur in nonsmokers exposed to secondhand smoke.

The power of nicotine addiction became clear when I saw malnourished and hungry people trading food rations for cigarettes.

William Foege (1989), commenting on refugee camps during the

Nigerian Civil War

Tobacco smoking leads to a dependence on nicotine that is indistinguishable from other forms of drug dependence. The revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association (APA, 2000) classifies tobacco dependence as an addiction. In such a dependency, the drug is needed to maintain an optimal state of well-being. Nicotine, the addictive constituent of tobacco, meets these criteria because a typical withdrawal syndrome occurs after smoking cessation, tolerance to its use develops, and most importantly, use persists after developing symptoms attributable to the substance and in the face of its known harm. Some believe that nicotine is more addicting than cocaine or alcohol (Krasnegor, 1979; Lee and D'Alonzo, 1993; Kandel et al., 1997). However, a substantial fraction of daily smokers, perhaps as many as half, do not meet the DSM-IV criteria for nicotine dependence (Hughes et al., 2006; Donny and Dierker, 2007).

Nicotine acts on specific a4p2 nicotinic acetylcholine receptors in the mesocorticolimbic system, through neural pathways that are now seen as a common pathway for addictive drugs. Nicotine modulates the release of dopamine in the brain's reward centers in the ventral tegmental area and the nucleus accumbens, decreasing the normal rate of degradation of dopamine as well. High concentrations of nicotine are delivered to the central nervous system (CNS) within seconds of a puff during smoking, with complete saturation of nicotinic receptors with as few as three cigarettes, and lasting as long as 3 hours (Brody, 2006).

It may take only one cigarette to hook an adolescent. About one fourth of young people experience a first-inhalation relaxation experience (FIRE) with their first cigarette, a large percentage of whom become addicted (DiFranza et al., 2007).

For tobacco-dependent persons, craving results when nicotine occupancy on receptors declines over time (e.g., during sleep at night). Relief from craving requires that the smoker replenish the nicotine within the receptor as completely as possible, which is why the first cigarette of the morning is often the most "satisfying" to addicted smokers. Since the cigarette is the most efficient rapid-delivery device for nicotine and the concurrent relief of craving, physicians and patients need to understand that medicinal nicotine replacement products are quite inefficient, by comparison, delivering lower concentrations of nicotine and incompletely resolving cravings.

The sheer number of nicotine doses is also highly reinforcing. A typical one-pack-daily smoker receives about 100,000 reinforcing hits a year, much more than with cocaine or heroin (Brunton, 1999).

Tobacco contributes to about 443,000 deaths annually in the United States and has rightly been dubbed the "leading cause of death in the United States" (McGinnis and Foege, 1993; Mokdad et al., 2004). One third of these smoking-related deaths are from cardiovascular disease and cerebro-vascular accident (CVA, stroke), 29% from lung cancer, 20% from chronic respiratory disease, and at least 8% from cancers other than lung (Fig. 50-1). Just over 10% of deaths attributable to smoking occur in nonsmokers exposed to secondhand smoke, most from cardiovascular causes (CDC, 2008). Each year, smoking is responsible for 18% of the total deaths in the United States—seven times more Americans than were killed in the Vietnam War. Smoking has killed more Americans during the 20th century than were killed in battle or died of war-related diseases in all U.S. wars ever fought (Pollin and Ravenholt, 1984). Furthermore, cigarettes kill more Americans than alcohol, car accidents, suicide, AIDS, homicide, and illegal drugs combined (ACS, 2005).

As shown by the grim, disease-specific facts, most smokers do not understand the implications for longevity involved in continued tobacco use. On the average, male smokers in the United States die 13.2 years earlier and females 14.5 years earlier than nonsmokers (Manson et al., 2000). Half of all continuing adult smokers will die of a cigarette-related illness (Doll et al., 2004). This relative lack of knowledge about tobacco harm may be in part because


Other cancers 35,300

Lung cancer 128,900

Other diagnoses 44,000

Other cancers 35,300

Lung cancer 128,900

Other diagnoses 44,000

Chronic obstructive pulmonary disease 92,900

Ischemic heart disease 126,000

of the lack of publicity given to celebrities who die from smoking-related diseases (see eTable 50-1), although the death of news anchor Peter Jennings from lung cancer in 2005 received considerable attention and spurred increased interest in cessation.

The Centers for Disease Control and Prevention (CDC; 2009) estimated that in 2007, 19.8% of American adults smoked cigarettes (21.3% of men and 18.4% of women). Smoking prevalence is lowest among Asians (9.6%) and His-panics (13.3%) and highest among American Indians and Alaska Natives (36.4%). Smoking prevalence is also higher among adults living below the poverty level (28.8%). Higher educational status confers additional protection against smoking, with persons holding a graduate degree smoking the least (6.2%). Thus, cigarette-related disease is increasingly becoming a set of afflictions suffered by the poor and undereducated, persons who understand the least about their risks and who have the poorest access to medical care resources (CDC, 2008).

In 2008, about one in five (20.4%) high school seniors smoked, the lowest level since monitoring started in the 1970s. Boys smoke more than girls in high school, (21.3% vs. 18.7%), and many more boys use smokeless tobacco (13.6% vs. 2.2%). The tobacco industry spends more than $12 billion annually on marketing (>$42 million/day) (Campaign for Tobacco-Free Kids, 2008).

Although few people start smoking as adults, each day 4000 children and adolescents try smoking for the first time, and 3000 of them become regular users of tobacco. Half of high school seniors who smoke started by age 14. Most smokers start smoking before 18, and only 5% start after age 20. Each year, 70% of those who smoke say that they would like to stop, and about 50% attempt to quit, but less than 5% succeed (Fiore et al., 2008). The likelihood of success in smoking cessation increases with the number of attempts, and those with a college education are twice as likely to succeed as less educated smokers. Family physicians must view tobacco addiction as a chronic disease that requires frequent intervention.

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