Tobacco Use and Smoking Cessation

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Basics

Use of tobacco of any form

Description

  • The second leading actual cause of death in the United States
  • Smokeless tobacco refers to tobacco products that are vaporized, sniffed, sucked, or chewed.
  • Nicotine sources: cigars, pipes, water pipes, hookahs, cigarettes, and electronic cigarettes
  • Electronic nicotine delivery system (ENDS) use is on the rise.
  • History of using e-cigarette, or vaping, products

Epidemiology

The Centers for Disease Control (CDC) reported that there are 1,080 cases of lung illness reported from 48 states and 1 U.S territory related to vaping and/or e-cigarette use. Eighteen deaths have been confirmed in 15 states.

Incidence
  • 2.4 million new smokers annually in the United States (2.6% initiation rate)
  • 59% of new smokers are <18 years of age (5.8% initiation rate for teens).
  • 9.7 million people age >18 years smoke 20 or more cigarettes daily.
Prevalence
  • 14% of all adults (34.3 million people): 15.8% of males, 12.2% of females are current cigarette smokers.
  • Age: highest among those ages 45 to 64 years (16.5%)
  • Race: highest among Native Americans (24.0%) and lower among Hispanics (9.9%) and Asians (7.1%)
  • Gender: male > female (15.8% vs. 12.2%)
  • Education: inversely proportional to education level
  • Psychological association: nearly 36% of adults with a serious psychological distress compared to 14% without this distress
  • Cigarette smoking is responsible for >480,000 deaths per year in the United States, including >41,000 deaths from secondhand smoke exposure. This is about 1 in 5 deaths annually or 1,300 deaths every day.
  • Overall, in 2016, 15.3% of adults had ever used an e-cigarette, 3.2% were current users.
  • The prevalence of current e-cigarette use was highest in current cigarette smokers 10.8%, followed by former smokers 4.8%.
  • In 2018, 21% of high school students reported current use of e-cigarettes, up from 12 percent in 2017.
  • 5% of middle school students reported current e-cigarette use.
  • Approximately 80% of patients are under 35 years old. 16% of patients are under 18 years old, 21% of patients are 18 to 20 years old.

Etiology and Pathophysiology

  • Addiction due to nicotine’s rapid stimulation of the brain’s dopamine system (teenage brain especially susceptible)
  • Atherosclerotic risk due to adrenergic stimulation, endothelial damage, carbon monoxide, and adverse effects on lipids
  • Direct airway damage from cigarette tar
  • Carcinogens in all tobacco products
  • E-cigarettes range from nicotine free up to 36 mg/ml.
  • Potential adverse effects of e-cigarettes are related to exposure to nicotine as well as to other vapor components produced by the devices and risk of actual device.
  • If e-cigarette, or vaping product use is suspected as a possible etiology of a patient’s lung injury, obtain detailed history regarding:
    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
    • Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids
    • Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; product/device customization or modification by the user (e.g., exposure of the atomizer or heating coil)

Risk Factors

  • Presence of a smoker in the household
  • Easy access to cigarettes
  • Comorbid stress and psychiatric disorders
  • Low self-esteem/self-worth
  • Poor academic performance
  • Boys: high levels of aggression and rebelliousness
  • Girls: preoccupation with weight and body image
  • Electronic cigarette use has been associated with several cases of idiopathic acute eosinophilic pneumonia
  • Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported.

General Prevention

  • Most first-time tobacco use occurs before high school graduation.
  • The Tar Wars program of the American Academy of Family Physicians has successfully targeted tobacco use prevention in 4th and 5th graders.
  • Smoking bans in public areas and workplaces
  • Restriction of minors’ access to tobacco
  • Restrictions on tobacco advertisements
  • Raising prices through taxation
  • Media literacy education
  • Tobacco-free sports initiatives

Commonly Associated Conditions

  • Coronary artery disease
  • Cerebrovascular disease
  • Peripheral vascular disease
  • Abdominal aortic aneurysm (AAA)
  • Chronic obstructive coronary disease (COPD)
  • Cancer of the lip, oral cavity, pharynx, larynx, lung, esophagus, stomach, pancreas, kidney, urinary bladder, cervix, and blood
  • Pneumonia, osteoporosis
  • Periodontitis
  • Alcohol use
  • Depression and anxiety
  • Reduced fertility
  • Vaping/e-cigarette use has been associated with cough, shortness of breath, fatigue, fever, chest pain, weight loss, nausea, and diarrhea.

Pregnancy Considerations
Women who smoke or are exposed to secondhand smoke during pregnancy have increased risks of miscarriage, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, low-birth-weight infants, and stillbirth.

Pediatric Considerations

  • Secondhand smoke increases the risk for:
    • Sudden infant death syndrome
    • Acute upper and lower respiratory tract infections
    • More severe exacerbations of asthma
    • Otitis media and need for tympanostomies
  • Nicotine passes through breast milk. Effects on growth and development of nursing infants are unknown.

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Basics

Use of tobacco of any form

Description

  • The second leading actual cause of death in the United States
  • Smokeless tobacco refers to tobacco products that are vaporized, sniffed, sucked, or chewed.
  • Nicotine sources: cigars, pipes, water pipes, hookahs, cigarettes, and electronic cigarettes
  • Electronic nicotine delivery system (ENDS) use is on the rise.
  • History of using e-cigarette, or vaping, products

Epidemiology

The Centers for Disease Control (CDC) reported that there are 1,080 cases of lung illness reported from 48 states and 1 U.S territory related to vaping and/or e-cigarette use. Eighteen deaths have been confirmed in 15 states.

Incidence
  • 2.4 million new smokers annually in the United States (2.6% initiation rate)
  • 59% of new smokers are <18 years of age (5.8% initiation rate for teens).
  • 9.7 million people age >18 years smoke 20 or more cigarettes daily.
Prevalence
  • 14% of all adults (34.3 million people): 15.8% of males, 12.2% of females are current cigarette smokers.
  • Age: highest among those ages 45 to 64 years (16.5%)
  • Race: highest among Native Americans (24.0%) and lower among Hispanics (9.9%) and Asians (7.1%)
  • Gender: male > female (15.8% vs. 12.2%)
  • Education: inversely proportional to education level
  • Psychological association: nearly 36% of adults with a serious psychological distress compared to 14% without this distress
  • Cigarette smoking is responsible for >480,000 deaths per year in the United States, including >41,000 deaths from secondhand smoke exposure. This is about 1 in 5 deaths annually or 1,300 deaths every day.
  • Overall, in 2016, 15.3% of adults had ever used an e-cigarette, 3.2% were current users.
  • The prevalence of current e-cigarette use was highest in current cigarette smokers 10.8%, followed by former smokers 4.8%.
  • In 2018, 21% of high school students reported current use of e-cigarettes, up from 12 percent in 2017.
  • 5% of middle school students reported current e-cigarette use.
  • Approximately 80% of patients are under 35 years old. 16% of patients are under 18 years old, 21% of patients are 18 to 20 years old.

Etiology and Pathophysiology

  • Addiction due to nicotine’s rapid stimulation of the brain’s dopamine system (teenage brain especially susceptible)
  • Atherosclerotic risk due to adrenergic stimulation, endothelial damage, carbon monoxide, and adverse effects on lipids
  • Direct airway damage from cigarette tar
  • Carcinogens in all tobacco products
  • E-cigarettes range from nicotine free up to 36 mg/ml.
  • Potential adverse effects of e-cigarettes are related to exposure to nicotine as well as to other vapor components produced by the devices and risk of actual device.
  • If e-cigarette, or vaping product use is suspected as a possible etiology of a patient’s lung injury, obtain detailed history regarding:
    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
    • Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids
    • Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; product/device customization or modification by the user (e.g., exposure of the atomizer or heating coil)

Risk Factors

  • Presence of a smoker in the household
  • Easy access to cigarettes
  • Comorbid stress and psychiatric disorders
  • Low self-esteem/self-worth
  • Poor academic performance
  • Boys: high levels of aggression and rebelliousness
  • Girls: preoccupation with weight and body image
  • Electronic cigarette use has been associated with several cases of idiopathic acute eosinophilic pneumonia
  • Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported.

General Prevention

  • Most first-time tobacco use occurs before high school graduation.
  • The Tar Wars program of the American Academy of Family Physicians has successfully targeted tobacco use prevention in 4th and 5th graders.
  • Smoking bans in public areas and workplaces
  • Restriction of minors’ access to tobacco
  • Restrictions on tobacco advertisements
  • Raising prices through taxation
  • Media literacy education
  • Tobacco-free sports initiatives

Commonly Associated Conditions

  • Coronary artery disease
  • Cerebrovascular disease
  • Peripheral vascular disease
  • Abdominal aortic aneurysm (AAA)
  • Chronic obstructive coronary disease (COPD)
  • Cancer of the lip, oral cavity, pharynx, larynx, lung, esophagus, stomach, pancreas, kidney, urinary bladder, cervix, and blood
  • Pneumonia, osteoporosis
  • Periodontitis
  • Alcohol use
  • Depression and anxiety
  • Reduced fertility
  • Vaping/e-cigarette use has been associated with cough, shortness of breath, fatigue, fever, chest pain, weight loss, nausea, and diarrhea.

Pregnancy Considerations
Women who smoke or are exposed to secondhand smoke during pregnancy have increased risks of miscarriage, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, low-birth-weight infants, and stillbirth.

Pediatric Considerations

  • Secondhand smoke increases the risk for:
    • Sudden infant death syndrome
    • Acute upper and lower respiratory tract infections
    • More severe exacerbations of asthma
    • Otitis media and need for tympanostomies
  • Nicotine passes through breast milk. Effects on growth and development of nursing infants are unknown.

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