Tobacco Use and Smoking Cessation

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  • Use of tobacco of any form
  • 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, and cigarettes and electronic cigarettes
  • Electronic nicotine delivery system (ENDS) use is on the rise.


  • 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.

  • 15% of all adults (37.8 million people): 17.5% of males, 13.5% of females are current cigarette smokers.
  • Age: highest among those aged 25 to 44 years (17%)
  • Race: highest among Native Americans (32%) and is lower among Hispanics (11%) and Asians (9%)
  • Gender: male > female (22% vs. 17%)
  • 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.

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

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

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)
  • 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

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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