Smoking, inhalation and exhalation of the fumes of burning tobacco. Leaves of the tobacco plant are smoked in various ways. After a drying and curing process, they may be rolled into cigars or shredded for insertion into smoking pipes. Cigarettes, the most popular method of smoking, consist of finely shredded tobacco rolled in lightweight paper. About 46 million people in the United States smoke an estimated 420 billion cigarettes each year.
Until the 1940s smoking was considered harmless, but laboratory and clinical research has since confirmed that tobacco smoke presents a hazard to health. Smoke from the average cigarette contains around 4,000 chemicals, some of which are highly toxic and at least 43 of which cause cancer. Nicotine, a major constituent of tobacco smoke, is both poisonous and highly addictive. According to the American Cancer Society, smoking is the most preventable cause of death in America today.
European explorers who arrived in the Western Hemisphere in the 1500s observed Native Americans smoking tobacco plant leaves in pipes. The colonists who followed them grew tobacco plants as a cash crop for export, and smoking became part of European culture by the 1600s. Most tobacco was consumed in pipes and cigars or as snuff (finely pulverized tobacco inhaled into the nostrils). This pattern changed by the early 20th century, by which time smokers consumed more than 1,000 cigarettes per capita each year in the United States and some European countries. The general attitude of society was that smoking relieved tension and produced no ill effects. During World War II (1939-1945) American physicians endorsed sending soldiers tobacco, and cigarettes were included in the field ration kits of U.S. armed forces personnel until 1975.
Some scientists noticed, however, that lung cancer, which was rare before the 20th century, had increased dramatically since about 1930. The American Cancer Society and other organizations initiated studies comparing deaths among smokers and nonsmokers over a period of several years. All such studies found increased mortality among smokers, both from cancer and other causes. In addition, experimental studies in animals showed that many of the chemicals contained in cigarette smoke are carcinogenic.
In 1962 the U.S. government appointed a panel of ten scientists to study the available evidence concerning the health effects of smoking. Their conclusions were included in the 1964 surgeon general’s report, which stated that “cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action.” Smoking in adults, measured as an average number of cigarettes smoked per year, began to decline steadily after the 1964 report and has fallen more than 40 percent since 1965.
III HEALTH EFFECTS OF SMOKING
About 442,000 people in the United States die each year from illnesses caused by cigarette smoking. Smoking accounts for nearly 90 percent of lung cancer deaths. Additionally, smokers are at increased risk for cancer of the larynx, oral cavity, esophagus, bladder, kidney, and pancreas. While some negative health effects of smoking manifest slowly over time, others can be measured almost immediately. Sticky brown tar leaves yellow stains on fingers and teeth. Some of the inhaled tar is absorbed by lung cells, causing them to die. Tar also damages the cilia in the upper airways that protect against infection. Nicotine causes arteries to constrict, lowering skin temperature and reducing blood flow to the hands and feet. Carbon monoxide deprives the body of oxygen, binding to red blood cells in place of the oxygen molecule and forcing the heart to pump more blood through the body.
One-third of smoking-related deaths are caused by coronary heart disease or chronic airway obstruction. For example, the nicotine in tobacco combines with carbon monoxide in tobacco smoke to damage the lining of blood vessels and make blood platelets stickier. Platelets form part of the damaging plaque buildup in artery walls (see Arteriosclerosis). These effects in combination contribute to the development of heart disease. Smoking also increases the risk of stroke by 50 percent—40 percent among men and 60 percent among women. Other research has shown that mothers who smoke give birth more frequently to premature or underweight babies, probably because of a decrease in blood flow to the placenta. Babies born to mothers who smoke during pregnancy are also at increased risk for sudden infant death syndrome.
Cigar and pipe smoke contains the same toxic and carcinogenic compounds found in cigarette smoke. A report by the National Cancer Institute concluded that the mortality rates from cancer of the mouth, throat, larynx, pharynx, and esophagus are approximately equal in users of cigarettes, cigars, and pipes. Rates of coronary heart disease, lung cancer, emphysema, and chronic bronchitis are elevated for cigar and pipe smokers and are correlated to the amount of smoking and the degree of inhalation.
Studies have found that cigarettes are addictive because an unknown component of tobacco smoke appears to destroy an important brain enzyme known as monoamine oxidase B (MAO B). The enzyme is vital for breaking down excess amounts of dopamine, a neurotransmitter that triggers pleasure-seeking behavior. Smokers have decreased levels of MAO B and abnormally high levels of dopamine, which may encourage the smoker to seek the pleasure of more tobacco smoke.
Even nonsmokers are at risk from smoking. Recent research has focused on the effects of environmental tobacco smoke (ETS)—that is, the effect of tobacco smoke on nonsmokers who must share the same environment with a smoker. The United States Environmental Protection Agency (EPA) estimates that exposure to ETS, which contains all the toxic agents inhaled by a smoker, causes 3,000 lung cancer deaths and an estimated 35,000 deaths from heart disease per year among nonsmokers. Secondhand smoke can aggravate asthma, pneumonia, and bronchitis, and impair blood circulation.
The smoking habit and addiction to nicotine usually begin at an early age. In the United States, more than 90 percent of adults who smoke started by age 21, and nearly half of them were regular smokers by the age of 18. Despite increasing warnings about the health hazards of smoking and widespread bans on smoking in public places, smoking remains common among teenagers and young adults. In 2001 surveys of students in grades 9 through 12 found that more than 38 percent of male students and nearly 30 percent of female students smoke. Although black teenagers have the lowest smoking rates of any racial group, cigarette smoking among black teens increased 80 percent in the late 1990s. Advertisements aimed at a young audience are largely blamed for this new generation of smokers.
IV QUITTING SMOKING
Nicotine PatchA nicotine patch, a type of transdermal patch, is applied to the upper arm. The patch will continually release a small amount of nicotine into the body through the bloodstream. This will reduce the patient’s craving to smoke cigarettes.Mark C. Burnett/Photo Researchers, Inc.
Studies of former smokers show that their risk of dying from smoking-related disease decreases with each year of abstinence. According to the World Health Organization (WHO), smokers who quit smoking before the age of 50 reduce their risk of life-threatening disease by half after just one year, compared with those who continue smoking.
Other benefits of quitting smoking include more disposable income, admission to social activities and institutions that ban smoking, and often, lower health insurance premiums. Nonetheless, to quit smoking is difficult, most likely because smokers crave the effect of the nicotine in the smoke. The U.S. surgeon general declared nicotine an addictive drug comparable to other addictive substances, including cocaine, heroin, and alcohol, in its ability to induce dependence. Overall, tobacco smoking causes about 20 times the number of deaths in the United States than all other addictive drugs combined.
Smoking cessation methods are plentiful, and many books and products are available to help an individual stop smoking. Many smokers turn to group help because of the support and understanding provided by other former smokers or people trying to quit. Most successful group-help techniques involve a challenge and reward system that also bolsters the self-discipline of the former smoker.
A number of nicotine replacement products are available to help a person quit smoking. Nicotine patches are small, nicotine-containing adhesive disks that must be applied to the skin. The nicotine is slowly absorbed through the skin and enters the bloodstream. Over time, a smoker uses nicotine patches containing smaller and smaller doses of nicotine until eventually the craving for nicotine ends. Nicotine gum works in a similar manner, providing small doses of nicotine when chewed. A nicotine nasal spray is a physician-prescribed spray that relieves cravings for a cigarette by delivering nicotine to the nasal membranes. Also available by prescription, the nicotine inhaler looks like a cigarette; when puffed, the inhaler releases nicotine into the mouth.
An approach combining three different smoking cessation therapies has found remarkable success. This approach combines an antidepressant drug called bupropin, marketed under the brand name Zyban, with a nicotine replacement product and counseling. While less than 25 percent of smokers who use nicotine replacement products alone remain smoke-free for more than a year, 40 to 60 percent of smokers using this combination approach achieved this milestone.
V ANTISMOKING ACTION IN SOCIETY
In the United States, the first direct action to curb smoking after the U.S. surgeon general’s 1964 report on smoking was the mandate of a warning on cigarette packages by the Federal Trade Commission. This warning took effect in 1964 and was strengthened in 1969 to read: “Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health.” A stronger sequence of four alternative warnings was developed in 1984. In 1971 all cigarette advertising was banned from radio and television, and cities and states passed laws requiring nonsmoking sections in public places and workplaces.
This trend has continued and smoking is now banned at the federal and state levels in most government buildings and in many private businesses. As of February 1990 federal law banned smoking on all domestic United States airline flights under six hours in duration. By 1998 more than 90 percent of nonstop flights between the United States and all foreign countries were also smoke free.
In 2002 President George W. Bush signed into law the Safe and Drug-Free Schools and Communities Act. The law bans smoking within any indoor facility used for childhood education. By 2003 a number of states (including New York, Connecticut, Maine, and California) and cities (including Boston, Massachusetts and Austin, Texas) passed laws banning smoking in all bars, restaurants, and clubs. Several European countries also began to ban smoking in public places—especially in restaurants, bars, and cafes. They include Ireland, Italy, Netherlands, and Norway. A ban in the United Kingdom is scheduled to take effect in 2007; a ban in France, in 2008.
The tobacco industry has been increasingly criticized for its role in encouraging smoking, particularly in young people. Various lawsuits have been brought against tobacco companies to reclaim damages due to disease or death associated with smoking. The first major successful suit occurred in March 1996 when the Liggett Group, a consortium of companies, agreed to pay damages to five states. An onslaught of litigation against the tobacco industry followed. In part to avoid potentially ruinous lawsuits filed by states, in 1998 the tobacco industry and attorneys general from 46 U.S. states agreed to a $206-billion settlement. The settlement, to be paid over 25 years, will be used to compensate states for the costs of treating smoking-related illness, to finance nationwide antismoking programs, and to underwrite health care for uninsured children.
The tobacco industry must also contend with a barrage of lawsuits filed by individual smokers and their families seeking damages for smoking-related health problems and deaths. Across the United States, such lawsuits have had mixed results. In several cases, juries have cleared the tobacco companies of all responsibility. While several other cases have resulted in large awards for the plaintiffs, few hold up under the appeals process.
Tobacco industry representatives long denied that nicotine is addictive and that there is a link between smoking and poor health. In recent years, however, cigarette makers have faced increased pressure from smoking-related lawsuits and federal regulators to accept prevailing scientific opinions about the health risks of smoking. In late 1999 Philip Morris, now known as Altria, the nation’s largest cigarette maker, publicly acknowledged that smoking is addictive and causes serious health problems. This latest admission was considered a way to make it more difficult for those who have recently started smoking to claim they were unaware of the dangers if they choose to sue cigarette companies. In 2003 an Illinois judge ordered Philip Morris to pay $10.1 billion in damages for using misleading advertising campaigns suggesting that cigarette brands marketed as “low tar” or “light” are safer than regular brands. Numerous scientific studies prove that the use of low-tar cigarettes does not reduce the risk of developing smoking-related disease, and the judge found that Philip Morris intentionally disregarded consumer rights by spreading disinformation.