Albia Dugger • Miami Dade College

Chapter 7Tobacco

Nicotine

• Nicotine is the addictive ingredient in tobacco – 90% of smokers become dependent

• C. Everett Koop claimed that nicotine dependence is as powerful as heroin and cocaine dependence

• In 1988, the American Psychiatric Association recognized nicotine dependency as a disorder

History of Tobacco Use

• 600-900 AD: Mexican stone carvings depict smoking

• Early 1600s: Thousands of tobacco shops in London

• 17th century: Smoking condemned by the Pope

• 1828: Nicotine was isolated and identified as poisonous and addictive

History of Tobacco Use

• Early 1600s: Jamestown settlers planted tobacco

• 1776: Tobacco production provided funds for colonial settlers to fight the Revolutionary War against England

• Early 1800s: Tobacco was used as snuff, cigars, and pipes, and chewing tobacco – not cigarettes

• 1883: The cigarette rolling machine was patented

History of Tobacco Use

• Early 1900s: Tobacco companies began marketing campaigns to promote cigarettes

• Cigarettes were the first of the tobacco products marketed to women

• Cigarettes were less costly and milder than cigars, which increased their popularity with young people

Opposition and Escalation

• 1798: Physician Benjamin Rush condemned tobacco for its adverse health effects

• Several states banned the sale of tobacco to children

• During World War I, the YMCA, the U.S. Army, and other groups distributed cigarettes to soldiers

• During World War II, cigarette manufacturers donated cigarettes to soldiers in combat

Costs of Smoking

• An increase in cost reduces the demand for cigarettes

• Many states tax cigarettes to pay for programs such as smoking prevention and hospital treatment for the uninsured

• The federal government also amasses substantial tax revenues from tobacco sales

• However, higher taxes encourage a black market for cigarettes

Cigarette Excise Taxes

Cigarette Excise Taxes

Extent of Tobacco Use

• Smoking increased until 1964, when the Public Health Service issued Smoking and Health: Report of the Advisory Committee to the Surgeon General

• The percentage of adult Americans who smoke decreased from 42.4% in 1965 to 20.6% in 2009

Tar and Nicotine Levels

• Tar is a carcinogenic component of tobacco

• Nicotine is the psychoactive component in tobacco responsible for stimulation and tobacco dependence

• Although levels of tar and nicotine in cigarettes have been reduced, this has increased the number of cigarettes smoked, as smokers smoke more to get more nicotine

Demographics of Smoking

• More adult males smoke than adult females

• College students smoke less than young adults who are not in college

• Parents who smoke are more likely to have children who smoke

• Smoking rates are correlated with education and occupation

Smoking by Adolescents

• Smoking by adolescents has declined only slightly

Women and Smoking

• In 1965, 34% of women smoked – currently, approximately 17.9% of women smoke cigarettes

• Less-educated women are three times more likely to smoke than women with more education

• Cigarette smoking reduces a woman’s life by 14 years

• Lung cancer is the leading fatal cancer among US women

• Women smokers have higher rates of depression, osteoporosis, peptic ulcers, and cataracts

Smokeless Tobacco

• Use of smokeless tobacco (snuff and chewing tobacco) has nearly tripled in the last twenty years

• Nicotine in smokeless tobacco is absorbed quickly through the mucous lining of the mouth, making it highly addicting

• The nicotine in one dip of snuff equals four cigarettes

• Smokeless tobacco has a higher level of the carcinogen NNK than regular tobacco

Snus

• Snus are a tobacco product packaged in small pouches that go under one’s upper lip

• Usage is increasing in response to antismoking views, increased taxes on cigarettes and expanding smoke-free ordinances

Oral Cancer caused by Smokeless Tobacco

Tobacco Use in Other Countries

• According to the World Health Organization, tobacco use is the leading cause of preventable death in the world

• In China, over half of all males aged 15 and older smoke

• Smoking rates in industrialized countries are decreasing, but in underdeveloped countries, they are increasing

• US tobacco companies export more than $2 billion worth of tobacco products

Clove Cigarettes and Bidis

• Clove cigarettes • Made from tobacco and cloves; contain more tar, nicotine,

and carbon monoxide than commercial cigarettes

• Eugenol • Ingredient in clove cigarettes that provides aroma and

reduces coughing reflex

• Bidis • Flavored cigarettes from India that have considerably

higher concentrations of nicotine than regular cigarettes

Light Cigarettes

• Light cigarettes are advertised as having less tar and nicotine

• Account for the vast majority of cigarettes sold

• 2011: Federal judge ruled that tobacco companies must admit that they have lied about light cigarettes

• People who smoke light cigarettes receive the same amount of nicotine and tar as those smoking regular cigarettes

Cigars

• 1990: Increase in cigar bars and restaurant cigar nights

• Sales of small cigars (cigarillos) have increased • Taxed at a lower rate than cigarettes• Fewer restrictions placed on their promotion

• Health hazards are associated with cigar smoking:• Nicotine levels higher than cigarettes• 34% higher cancer rate than nonsmokers• Higher rates of cancers of the mouth, throat, and

esophagus than cigarette smokers

Cigar Use

Characteristics of Smoking and Smokers

• Tobacco use tends to have triggers:• Following a meal• Talking on the phone• Drinking coffee• Being around other smokers

• Tobacco contains acetaldehyde, a chemical with sedating properties similar to those of alcohol

• Nicotine improves cognitive performance slightly

Tobacco Use by Young People

• 60% of new smokers initiate smoking prior age 18

• One third of youths who smoked three or four cigarettes a day developed nicotine dependence

• By 8th grade, 2.9% of students smoke on a daily basis

• One predictor of tobacco use among boys is aggressive/disruptive behavior

Tobacco Use by Young People

• Young people smoke to appear mature, to display independence, to cope with stress, or to bond with peers

• Adolescent smoking has a high correlation with psychological distress

• Most important factors in whether a teenager smokes:• If the teenager’s friends smoke• If perceived benefits outweigh the risks• If the teenager’s household includes smokers

Tobacco Use by Young People

• When teaching young people about the dangers of tobacco, one challenge is that harmful effects take years to appear

• Emphasizing short-term or cosmetic effects may have a greater impact

• Most programs that are information based have been ineffective in reducing the onset of smoking

• Tobacco prevention programs outside of schools are more effective with high-risk youths

Nicotine Dependence in Younger Smokers

Respected Adults Influence Decisions

Nicotine Tolerance and Dependence

• Smokers and chewers build-up tolerance quickly, some in a matter of weeks

• Most people continue to use tobacco products because nicotine is addictive – however, most people who quit are able to do so without nicotine replacement

• Nicotine addicts develop tolerance, have a strong desire for continued use, and undergo withdrawal

Nicotine Withdrawal Symptoms

• Lower heart rate• Tremors• Aggressiveness• Hunger• Heart palpitations• Headaches• Anxiety

• Lower blood pressure• Shorter attention span• Increased circulation• Insomnia• Fatigue• Drowsiness• Craving for nicotine

Pharmacology of Tobacco

• 4,000 chemicals are found in tobacco smoke• Used as an insecticide• 60 mg can cause human death• Carcinogenic

• Nicotine • Releases stimulant norepinephrine• Depression follows arousal• Constricts blood vessels• Stays in the body for 8 to 12 hours

Physical Effects on the Individual

• Smoking is responsible for nearly one in five US deaths

• Most prominent behavioral cause of lung cancer, other respiratory diseases, and cardiovascular diseases

• Responsible for $167 billion in annual health-related economic losses in the US• $75 billion in direct medical costs • $92 billion in lost productivity

Health Effects of Smoking

Lost Productivity

Heart Disease and Strokes

• Smoking causes more cardiovascular deaths than cancer deaths

• Smoking is implicated in 30% of all deaths from coronary heart disease

• Risk of heart attack and stroke increases among women who smoke cigarettes and use oral contraceptives

• Cardiovascular damage is correlated with the frequency and length of time a person smokes

Heart Disease and Strokes

• Nicotine raises the heart rate and blood pressure, forcing the heart to work harder

• Carbon monoxide impedes the oxygen-carrying capacity of the blood, impairs circulation, increases cholesterol deposits and arteriosclerosis

• Buerger’s disease can result in amputation of the extremities as a result of poor circulation

Respiratory Diseases

• Respiratory conditions caused by smoking:• Chronic coughing and shortness of breath• Chronic bronchitis and emphysema (COPD)

• Bronchitis • Smoke irritates bronchi; tar builds up on cilia; breathing

becomes more labored

• Emphysema• Disabling, incurable disease• Lungs lose elasticity, unable to retain air

Cancer

• There are dozens of carcinogenic gases in tobacco smoke, including ammonia, benzopyrene, hydrogen cyanide, nitrosamines, and vinyl chloride

• Most cancer-causing substances are found in the tar of tobacco, though nicotine has been implicated as well

• Cigarette smoking is responsible for at least 30% of all cancers deaths and 87% of lung cancer deaths

Cancer

• Cigarette smoking is the leading risk factor for cancers of the larynx, mouth, esophagus, pancreas, and bladder

• Increases chances of developing cancers of the oral cavity, pancreas, esophagus, kidney, larynx, trachea, and bladder

• Higher risk of developing non-Hodgkin’s lymphoma

• Oral and pharyngeal cancers account for almost 8,000 deaths annually in the United States

Warning Signs of Oral Cancer

• Sore in the mouth that does not heal • White or red patch on the gums, tongue, tonsil, or mouth• Lump or thickening in the cheek• Sore throat or a feeling that something is caught in the throat• Difficulty chewing or swallowing• Difficulty moving the jaw or tongue• Numbness of the tongue or other area of the mouth• Swelling of the jaw that causes dentures to fit poorly• Loosening of teeth or pain around the teeth or jaw• Voice changes• Lump or mass in the neck• Weight loss

Impact of Smoking During Pregnancy

• Smoking interferes with the fetus:• Babies weigh less and are more likely to be premature• Higher incidence of spontaneous abortions• Higher rate of stillbirths• Higher rate of sudden infant death syndrome (SIDS)• Higher risk of cleft lip and cleft palate• Higher rates of psychological problems

• Significantly reduces fertility in women

Smoking During Pregnancy

• Maternal smoking is the most important avoidable risk factor for SIDS

Tobacco and Physical Activity

• Ability to engage in physical activity is impaired:• Mucous membranes of the trachea and the bronchial

tubes enlarge, restricting air passage• Alveoli in the lungs receive less oxygen

• Smoking impairs sexual activity:• Carbon monoxide reduces testosterone production• Erectile dysfunction due to nicotine • Sperm count and motility is reduced• Impairs normal sexual response in young women

Passive Smoke

• Passive smoke • Tobacco smoke present in the air from someone else’s

smoking and inhaled by others

• Environmental tobacco smoke • Smoke in the air as a result of someone smoking

• Mainstream smoke • Smoke exhaled by a smoker

• Sidestream smoke • Smoke from the burning end of a cigarette, pipe, or cigar

Passive Smoke

• Passive smoke is blamed for 3,400 lung cancer deaths each year

• The extent of harm is related to the degree of exposure

• Sidestream smoke contains more nicotine and carbon monoxide than mainstream smoke

• Children of smokers have five times as much cotinine in their urine as children of nonsmokers

Composition of mainstream smoke

Effects on Nonsmokers

• Passive smoke is linked to:• Lung cancer• Urinary tract problems • Cancers of the liver, pancreas, and breast cancer• Type 2 diabetes and multiple sclerosis• Heart attack

• The Environmental Protection Agency declared secondhand smoke a carcinogen in 1993

Effects on Children of Smokers

• Children exposed to cigarette smoke:• Higher incidence of atopic dermatitis (eczema)• Respiratory infections (colds, bronchitis, pneumonia)• Absent from school more often• Higher incidence of asthma• Childhood allergies• Physical aggression and hyperactivity-impulsivity• Dental cavities

Rights of Smokers versus Nonsmokers

• Anti-smoking legislation:• Federal minimum age of 18 to purchase tobacco products• Local tobacco control ordinances against smoking in

public areas and private workplaces• Airline passengers on commercial flights within the US

were forbidden from smoking• 2012, FDA mandates more prominent health warnings on

all cigarette packaging and advertisements• New York City banned smoking in restaurants, and

tobacco ads within 1,000 feet of a school

State Cigarette Excise Tax Rates

Rights of Smokers versus Nonsmokers

• The Master Settlement Agreement:• Legislation requires the tobacco industry to pay $206

billion among all 50 states in exchange for an end to litigation against the four largest tobacco companies

• Compensate states for medical costs resulting from cigarette smoking

• Creates a $500 million fund to educate young people about the risks of smoking

• Tobacco companies are no longer liable for addiction or dependence claims, class action suits, and claims of punitive damages

Cessation Techniques

• Seventy percent of smokers say that they want to quit

• Withdrawal symptoms can be intense, leading to anxiety and depressed mood

• Most people require five to seven attempts to quit before they are successful

• Stopping smokeless tobacco is more difficult than quitting cigarettes

Cessation Techniques

• Obstacles:• Many activities trigger smoking• Many are concerned about gaining weight once they stop• Confidence is crucial in how long one remains abstinent

• Smoking cessation programs:• 90% quit without a formal treatment program• Nicotine replacement therapy helps many smokers• Other therapies have not been proven to help

Cessation Techniques

• Nicotine Gum and Lozenges• Reduce withdrawal symptoms• Increases success by 10%

• Nicotine Patches• Can deliver dangerously high doses to those who continue

smoking

• Nicotine Inhalers• Can irritate nasal passages

Cessation Techniques

• Drug Therapy• Zyban reduces the desire for nicotine; side effects include

convulsions and delirium• Chantix treats nicotine addiction• Antianxiety drugs can reduce irritability• Three vaccines are being developed to prevent nicotine

addiction

Cessation Techniques

• Aversive Techniques• Rapid smoking causes smokers to exceed their tolerance

levels and become ill• Electric shock – benefits are short-term at best

• Behavior Modification• The smoker learns new or alternative behaviors to use in

place of smoking• May include support groups or a buddy system

Cessation Techniques

• Hypnosis• Works best with people who want it to work• Not found any more effective than other treatments

• Acupuncture• Minimal evidence of effectiveness• Claims to release endorphins and reduce physical

symptoms of withdrawal