Addictions Case Study: Part 2 – Diagnostic Impressions

(Ksir, 2021)

Ksir, C. C. (2021-05-01). Drugs, Society, and Human Behavior, 18th Edition

Chapter 10

Tobacco

The selling and using of tobacco products has always generated controversy, but never greater than today. Tobacco is an interesting social dilemma—a product that is legal for adults to use, and that a significant proportion of adults enjoy using and expect to continue using, yet a substance that is responsible for more addiction, illness, and death than any other. This chapter examines how tobacco’s current status came to be, and what changes lie on the horizon for this agricultural commodity, dependence-producing substance, and topic for policy discussions from local city councils to Congress.

Tobacco History Page 237

Tobacco was unknown to Europeans when Columbus arrived in the New World in 1492. In fact, one of the first things he was given by the people he met was some dried leaves with a pungent odor. Because no one knew what to do with the leaves, they were thrown away. Tobacco use was remarkably widespread in the Americas, and it had been cultivated for many hundreds of years. It had many names in the various languages of the natives, but the word tabaco was adopted by the Spanish, either from an Arawak term they encountered in the Caribbean, or perhaps because the Arabic word tabbaq was already used in Spain in reference to medicinal herbs. Europeans discovered that Amerindians sometimes put tobacco into tubes made from reeds, started a fire at one end of the reed, and “drank” the smoke from the other end. Or, they did a similar thing with tobacco leaves rolled up like a cigar, or they “drank” smoke from stone or clay pipes. Powdered tobacco was sometimes put into the mouth, or sucked into the nose through a tube. Tobacco leaves were also used to treat wounds, and powdered tobacco was thought to have a variety of medicinal benefits.

Most Europeans who first encountered tobacco found both its taste and the smell of the smoke not only foreign, but disgusting. Furthermore, it was associated with cultural traditions that were rejected by the Church. In fact, it was a hundred years after Columbus’s voyage before tobacco became popular anywhere in Europe. The assimilation of tobacco and chocolate into European culture is the subject of an interesting 2008 book.1 The short form of the story is that merchants and members of the clergy who spent time in the Americas trading with natives, eating meals, and sharing ceremonial occasions, first adopted the use of both tobacco and chocolate. These people became wealthy and powerful members of society back in Europe, and over the years the practices they brought back with them came to be associated with their status. They spread their new habits to their wealthy and powerful friends and family, and included gifts of tobacco and chocolate along with gold, silver, and other treasures they gave to royalty and to the pope. It was this association with respected members of society that eventually made tobacco a desired commodity for the masses. Commercial importation of tobacco into Europe in large quantities began around 1600.

Early Medical Uses

Travelers returning to Europe mentioned the potential medical uses of tobacco, but the medical establishment was leery at first. Beginning with a few trials by physicians, recognition of the potential of tobacco grew during the middle of the 1500s.

The French physician Jean Nicot became enamored with the medical uses of tobacco. He tried it on enough people to convince himself of its value and sent glowing reports of the herb’s effectiveness to the French court. He was successful in “curing” the migraine headaches of Catherine de Medici, queen of Henry II of France, which made tobacco use very much “in.” It was called the herbe sainte, “holy plant,” and the herbe à tous les maux, “the plant against all evils.” By 1565, the plant had been called nicotiane, after Nicot. In 1753, Linnaeus, the Swedish “father of taxonomy,” named the plant genus Nicotiana. When a pair of French chemists isolated the active ingredient in 1828, they acted like true nationalists and called it nicotine.

In the 16th century, Sir Anthony Chute summarized much of the available information and said, “Anything that harms a man inwardly from his girdle upward might be removed by a moderate use of the herb.” Others, however, felt differently: “If taken after meals the herb would infect the brain and liver,” and “Tobacco should be avoided by (among others) women with child and husbands who desired to have children.”1

In 1617, Dr. William Vaughn phrased the last thought a little more poetically:

Tobacco that outlandish weede

It spends the braine and spoiles the seede

It dulls the spirite, it dims the sight

It robs a woman of her right.3

Dr. Vaughn may have been ahead of his time: Current research verifies tobacco’s adverse effects on the developing fetus (see pages 249–250).

The slow advance of medical science through the 18th and 19th centuries gradually removed tobacco from the doctor’s black bag, and nicotine was dropped from The United States Pharmacopoeia in the 1890s.

The Spread of Tobacco Use

There are more than 60 species of Nicotiana, but only two major ones. Nicotiana tobacum, the major species grown today in more than a hundred countries, is a large-leaf species. Tobacum was indigenous only to South America, so the Spanish had a monopoly on its production for over a hundred years. Nicotiana rustica is a small-leaf species and was the plant existing in the West Indies and eastern North America when Columbus arrived.

The Spanish monopoly on tobacco sales to Europe was a thorn in the side of the British. When settlers returned to England in 1586 after failing to colonize Virginia, they took with them seeds of the rustica species and planted them in England, but this species never grew well. The English crown again attempted to establish a tobacco colony in Virginia in 1610, when John Rolfe arrived as leader of a group. From 1610 to 1612, Rolfe tried to cultivate rustica, but the small-leaf plant was weak and poor in flavor, and it had a sharp taste.

In 1612, Rolfe somehow got some seeds of the Spanish tobacum species. This species grew beautifully and sold well. The colony was saved, and every available plot of land was planted with tobacum. By 1619, as much Virginia tobacco as Spanish tobacco was sold in London. That was also the year that King James prohibited the cultivation of any tobacco in England and declared the tobacco trade a royal monopoly.

Page 239

Income from the sale of tobacco became so important to the English colonists that tobacco planting spread to Maryland, Massachusetts, and the other colonies. For a time there was concern that the Virginia colonists were neglecting both food crops and the maintenance of their buildings, they were so focused on tobacco planting. Because tobacco depleted the soil’s nutrients, more and more land was cleared, leading to the first large-scale fighting between the Virginia colonists and the Native Americans in the period 1622–1640. Also, King James’s special taxes and requirement that tobacco be sold only to England became the first source of discontent between the king and the English colonists, who began to meet and openly criticize the crown. Many resorted to smuggling or to bribing customs officials to avoid what they considered an unfair tax—all this more than 150 years before the more well-known “Boston Tea party”4 (see Chapter 11).

Snuff

During the 18th century, smoking gradually diminished, but the use of tobacco did not. Snuff replaced the pipe in England. At the beginning of that century, the upper class was already committed to snuff. The middle and lower classes only gradually changed over, but by 1770 very few people were smoking. The reign of King George III (1760–1820) was the time of the big snuff. His wife, Charlotte, was such a heavy user of the powder that she was called “Snuffy Charlotte,” although for obvious reasons not to her face. On the continent, Napoleon had tried smoking once, gagged horribly, and returned to his 7 pounds of snuff per month.

Tobacco in Early America

Tobacco played an important role in the Revolutionary War; it was one of the major products for which France would lend the colonies money. Knowing the importance of tobacco to the colonies, one of British general Cornwallis’s major campaign goals in 1780 and 1781 was the destruction of the Virginia tobacco plantations.

After the war, ordinary Americans rejoiced and rejected snuff as well as tea and all other things British. The aristocrats who organized the republic were not as emotional, though, and installed a communal snuff box for members of Congress. However, to emphasize the fact that snuff was a nonessential, the new Congress put a luxury tax on it in 1794.

Chewing Tobacco

If you don’t smoke and you don’t snuff

How can you possibly get enough?

You can get enough by chewing, which gradually increased in the United States. Chewing was a suitable activity for a country on the go; it freed the hands, and the wide-open spaces made an adequate spittoon. There were also other considerations: Boston, for example, passed an ordinance in 1798 forbidding anyone from possessing a lighted pipe or “segar” in public streets. The original impetus was a concern for the fire hazard involved in smoking, not the individual’s health, and the ordinance was finally repealed in 1880. Today it is difficult to appreciate how much of a chewing country we were in the 19th century. In 1860, only 7 of 348 tobacco factories in Virginia and North Carolina manufactured smoking tobacco. The amount of tobacco for smoking did not equal the amount for chewing until 1911 and did not surpass it until the 1920s.

The start of the 20th century was the approximate high point for chewing tobacco, the sales of which slowly declined through the early part of that century, as other tobacco products became more popular. In 1945, cuspidors were removed from all federal buildings.

Cigars

The transition from chewing to cigarettes had a middle point, a combination of both smoking and chewing: cigars. Cigarette smoking was coming, and the cigar manufacturers did their best to keep cigarettes under control. They suggested that cigarettes were drugged with opium, so one could not stop using them and that the paper was bleached with arsenic and, thus, was harmful. They had some help from Thomas Edison in 1914:

The injurious agent in Cigarettes comes principally from the burning paper wrapper. . . . It has a violent action in the nerve centers, producing degeneration of the cells of the brain, which is quite rapid among boys. Unlike most narcotics, this degeneration is permanent and uncontrollable. I employ no person who smokes cigarettes.4

The efforts of the cigar manufacturers worked for a while, and cigar sales reached their highest level in 1920, when 8 billion were sold. As sales increased, though, so did the cost of the product. Lower cost and changing styles led to the emergence of cigarettes as the leading form of tobacco use.

Cigarettes

Thin reeds filled with tobacco had been seen by the Spanish in Yucatan in 1518. Spanish peasants apparently started cigarette use in Europe by shredding discarded cigar butts and rolling the tobacco in scraps of paper. By the 1830s the practice had spread to France, where the word “cigarette” was coined. The first British cigarette factory was started in 1856 by a returning veteran of the Crimean War, and in the late 1850s an English tobacco merchant, Philip Morris, began producing handmade cigarettes.

In the United States, cigarettes were being produced during the same period (14 million in 1870), but their popularity increased rapidly in the 1880s. The date of the first U.S. patent on a cigarette-making machine was 1881, and by 1885 more than a billion cigarettes a year were being sold. Not even that great he-man, boxer John L. Sullivan, could stem the tide, though in 1905 his opinion of cigarette smokers was pretty clear:

Smoke cigarettes? Not on your tut-tut. . . . You can’t suck coffin-nails and be a ring-champion. . . . Who smokes ’em? Dudes and college stiffs—fellows who’d be wiped out by a single jab or a quick undercut. . . .4

At the start of the 20th century, there was a preference for cigarettes with an aromatic component— that is, Turkish tobacco. Camels, a new cigarette in 1913, capitalized on the lure of the Near East while rejecting it in actuality. The Camel brand contained just a hint of Turkish tobacco. Eliminating most of the imported tobacco made the price lower. Low price was combined with a big advertising campaign: “The Camels are coming. Tomorrow there’ll be more CAMELS in town than in all of Asia and Africa combined.” In 1918, Camels had 40 percent of the market and stayed in front until after World War II.

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The first ad showing a woman smoking appeared in 1919. To make the ad easier to accept, the woman was pictured as Asian and the ad was for a Turkish type of cigarette. King-size cigarettes appeared in 1939 in the form of Pall Mall, which became the top seller. Filter cigarettes as filter cigarettes, not cigarettes that happen to have filters along with a mouthpiece, appeared in 1954 with Winston, which rapidly took over the market and continued to be number one until the mid-1970s. Filter cigarettes captured an increasing share of the market and now constitute over 99 percent of all U.S. cigarette sales.

Tobacco under Attack

As with every other psychoactive substance, use by some raises concerns on the part of others, and many efforts have been made over the years to regulate tobacco use. In 1604, King James of England (the same one who had the Bible translated) wrote and published a strong anti-tobacco pamphlet stating that tobacco was “harmefull to the braine, dangerous to the lungs.” Never one to let morality or health concerns interfere with business, he also supported the growing of tobacco in Virginia in 1610, and when the crop prospered, he declared the tobacco trade a royal monopoly.

New York City made it illegal in 1908 for a woman to use tobacco in public, and in the Roaring Twenties women were expelled from schools and dismissed from jobs for smoking. These concerns were partly for society and partly to “protect women from themselves.” Those sensitive to feminist issues will find an analogy to current reactions to drug and alcohol use by pregnant women in this quote from the 1920s:

Smoking by women and even young girls must be considered from a far different standpoint than smoking by men, for not only is the female organism by virtue of its much more frail structure and its more delicate tissues much less able to resist the poisonous action of tobacco than that of men, and thus, like many a delicate flower, apt to fade and wither more quickly in consequence, but the fecundity of woman is greatly impaired by it. Authorities cannot be expected to look on unmoved while a generation of sterile women, rendered incapable of fulfilling their sublime function of motherhood, is being produced on account of the immoderate smoking of foolish young girls.5

And those familiar with the 1930s “Reefer Madness” arguments might find it interesting that earlier in the same decade a weed other than marijuana was blamed for various social ills:

Fifty percent of our insanity is inherited from parents who were users of tobacco. . . . Thirty-three percent of insanity cases are caused direct from cigarette smoking and the use of tobacco. . . .

Judge Gimmill, of the court of Domestic Relations of Chicago, declared that, without exception, every boy appearing before him that had lost the faculty of blushing was a cigarette fiend. The poison in cigarettes has the same effect upon girls: it perverts the morals and deadens the sense of shame and refinement.6

Page 242

The long and slowly developing attack on tobacco as a major health problem had its seeds in reports in the 1930s and 1940s indicating a possible link between smoking and cancer. A 1952 article in Readers’ Digest called “Cancer by the Carton” drew public attention to the issue, and led to a temporary decline in cigarette sales. The major U.S. tobacco companies recognized the threat and responded vigorously in two important ways. One was the formation of the supposedly independent Council for Tobacco Research to look into the health claims (later investigations revealed this council was not independent of tobacco company influence and served largely to try to undermine any scientific evidence demonstrating the negative health consequences of tobacco use). The other response was the mass marketing of filter cigarettes and cigarettes with lowered tar and nicotine content. The public apparently had faith in these “less hazardous” cigarettes, because cigarette sales again began to climb. In the early 1960s, the U.S. Surgeon General’s office formed an Advisory Committee on Smoking and Health. Its first official report, released in 1964, stated clearly that cigarette smoking was a cause for increased lung cancer in men (at the time, the evidence for women was less extensive). Per-capita sales of cigarettes began a decline that continued over the next 40 years (see Figure 10.1). In 1965, Congress required cigarette packages to include the surgeon general’s warning. All television and radio advertising of cigarettes was banned in 1971, and smoking was banned on interstate buses and domestic airline flights in 1990.7 The list of state and local laws prohibiting smoking in public buildings, offices, restaurants, and even bars grows every year. Clearly, momentum is behind efforts to restrict smoking and exposure to secondhand smoke.

Figure 10.1 Trends in Cigarette Sales 1945–2018

Source: Federal Trade Commission, Cigarette Report 2018 ( www.ftc.gov).

The original laws regulating drugs had specifically excluded tobacco products, reflecting their status as an agricultural commodity, their widespread use among the social elite, and the economic importance of tobacco to the U.S. economy. In 1995, the Food and Drug Administration announced plans to regulate tobacco. After a year of discussion, rules were proposed that further limited advertising on billboards and other public displays, sponsorship of sporting events, promotional giveaways of caps and T-shirts, and advertising in magazines with significant youth readership.

One important attack on tobacco came from lawsuits seeking compensation for the health consequences of smoking. For years the tobacco companies had succeeded in winning such lawsuits, based on the idea that smokers had a significant share of the responsibility for their smoking-related illnesses. But internal tobacco company documents were disclosed demonstrating both the companies’ knowledge of the adverse health consequences of smoking and their efforts to hide that knowledge from customers. A group of attorneys representing individual clients joined with several state governments seeking compensation for increased Medicaid costs, and eventually 46 states reached a 1998 settlement with the major U.S. tobacco producers that included $205 billion in payments to the states as well as agreeing to the previously proposed FDA advertising regulations and a federally supported program to enforce laws prohibiting sales to minors. In exchange, the companies received a cap on certain aspects of their legal liability, which otherwise threatened to bankrupt the industry.7

The Quest for “Safer” Cigarettes Page 243

Nicotine appears to be the constituent in tobacco that keeps smokers coming back for more—if the nicotine content of cigarettes is varied, people tend to adjust their smoking behavior, taking more puffs when given low-nicotine cigarettes.8 Another complex product of burning tobacco is something called tar, the sticky brown stuff that can be seen on the filter after a cigarette is smoked. Beginning in the mid-1950s with the mass marketing of filter cigarettes, the tobacco companies began to promote the idea of a “safer” cigarette, without actually admitting that there was anything unsafe about their older products. Because the companies were advertising their cigarettes as being lower in tar and nicotine, for many years the Federal Trade Commission (with industry support and cooperation) monitored the tar and nicotine yields of the various cigarette brands and made those results public. The U.S. Congress and the National Cancer Institute promoted research to develop safer cigarettes. The public listened to all this talk about safer cigarettes and bought in—sales of filter cigarettes took off, and by the 1980s low-tar and nicotine cigarettes dominated the market.

The problem with all this is that “safer” doesn’t mean “safe,” and it wasn’t at all clear how much safer these low-tar and nicotine cigarettes actually are for people over a lifetime of smoking. Some early studies had indicated that those who had smoked lower-yield cigarettes for years were at less risk for cancer and heart disease than those who smoked high-yield brands. But other studies showed that if a smoker switched from a high-yield to a low-yield cigarette, changes in puff rate and depth of inhalation would compensate for the lower yield per puff, and there might be no advantage to switching. The tobacco industry was caught in an ironic position, as evidenced by the plight of Liggett (former manufacturer of Chesterfield, L&M, and Lark, now selling Eve and other brands). During the 1960s, Liggett developed a cigarette that in the laboratory significantly reduced tumors in mice compared to the company’s standard brand. Lawyers advised Liggett against reporting these results because the data would confirm that the standard brand was hazardous. Liggett suppressed the information and did not market the “safer” cigarette, a fact that was revealed in a lawsuit during the 1980s.9

A major blow to the “healthier cigarette” notion was dealt in 2006 when the U.S. government obtained a conviction against nine tobacco companies and two tobacco industry trade organizations for racketeering and fraud. The purposeful manipulation of nicotine levels to increase nicotine dependence was one charge, but another was that for years the tobacco companies promoted low-tar and nicotine cigarettes as safer alternatives, when their own research and other evidence showed these claims to be misleading.

Electronic Cigarettes

The “safer” cigarette controversy took a high-tech turn in 1988 when R. J. Reynolds attempted to market Premier, a sort of noncigarette cigarette. Although packaged like cigarettes and having the appearance of a plastic cigarette, the product contained catalytic crystals coated with a tobacco extract but no actual tobacco. When “lit” with a flame, these cigarettes produced no smoke, but inhaling through them allowed the user to absorb some nicotine. The FDA couldn’t accept that this was the traditional agricultural product rather than a nicotine “delivery device,” something it would have to regulate as a drug. Reynolds was unable to find a legal way to sell the product and was forced to drop it. But the company did not give up. In 2004, Reynolds marketed Eclipse, another high-tech “cigarette” that the company said “may present less risk,” and produced up to 80 percent less smoke than a regular cigarette. This one did contain tobacco, so they could claim it was an agricultural product. Instead of burning the tobacco, a carbon element heated the tobacco to release nicotine vapors. In 2008, a Vermont judge ruled that Reynolds had not presented sufficient scientific evidence for their claim that Eclipse “may present less risk of cancer.” Eclipse is no longer being marketed. However, several battery-powered electronic cigarettes began to be imported from China in 2004. These contain some form of nicotine liquid that is warmed by a small electric element inside the cigarette. These products were widely marketed as safer alternatives to regular cigarettes, but none of the companies involved had submitted them to the FDA for review. The FDA attempted to ban these products, but in early 2010 a federal judge ruled that they could not do so. A wide variety of electronic cigarettes and other devices are currently available, although they are now subject to new FDA rules.

Tobacco Products and the FDA

After the 1995 FDA proposals that cigarettes be regulated, it was not clear exactly how they could do this, since tobacco products had originally been excluded as neither food nor drug. And in 2000, the U.S. Supreme Court ruled that existing federal law did not give the FDA authority to regulate tobacco. Various members of Congress proposed legislation to allow the FDA to regulate tobacco products as drugs. In this book, we are considering tobacco as a drug because it delivers nicotine, a known psychoactive chemical. But the drugs that the FDA reviews and approves all claim to have therapeutic benefits of some kind. What is the intended use or health benefit of a tobacco cigarette? How could the FDA balance the benefits versus the risks without someone defining the benefits?

In June 2009, President Barack Obama signed the Family Smoking Prevention and Tobacco Control Act, authorizing the FDA to regulate tobacco products themselves in specific ways. The FDA began studying and proposing new regulations for a wide variety of products, and after input from industry and the public, final rules were published in 2016. One important rule is that claims for “modified health risk” are now prohibited until such claims can be clearly demonstrated—in other words, a seller cannot claim that e-cigarettes or hookahs are safer than regular cigarettes. Also, all tobacco products will be regulated in a manner similar to drugs, in that companies will have to apply to the FDA, describing their product and its intended uses. Current products will remain available until the application and review process is finished, expected to be around 2020 for most existing products. Also, any product containing nicotine intended for human consumption is included under this law. This aspect of the law is aimed primarily at e-cigarettes and pipes but also includes a nicotine gel that is “consumed” by rubbing it on the hands. These new rules are likely to have a major impact on the market for tobacco and nicotine products over the next few years.

Current Cigarette Use Page 245

Cigarette smoking is declining in the United States (Figure 10.1). Per-capita consumption has declined since 1963, when the surgeon general’s report officially linked smoking and cancer. Total sales increased until 1981 due to the rise in the adult population, but there has been a continued decline for over 30 years. Large drops in sales occurred in 1999, when the companies increased prices to pay for the tobacco settlement, and again in 2009, when the federal tax increased by $0.62 per pack. Among high-school seniors, there has been a dramatic decline in the percentage reporting current cigarette smoking since 2000. The rate of past-month smoking decreased from about 30 percent in 2000 to 5.7 percent in 2018. It appears that most of the decrease since 2010 is due to replacement by e-cigarettes, which 25.5 percent of students reported using in 2018. E-cigarettes are now more widely used among young people than regular cigarettes.10,11 By far the single biggest factor influencing smoking rates among adults is their level of education. In 2018, 12 percent of adults who had graduated from college reported being current smokers, compared to 31 percent of those with only a high-school education. Why are high-school educated adults almost three times as likely to be smokers as college-educated adults? Does more education imply greater knowledge of the health consequences? Or is the difference attributable to the different kinds of jobs people have? Let’s look at a younger population to see when this difference begins to appear. In the 2015 Monitoring the Future study among full-time college students 1 to 4 years beyond high school, 7 percent reported smoking within the past 30 days, compared to 17 percent for same-age people not attending college.12 From this we can see that this big education effect appears before people graduate from college. An even more interesting look at this issue can be found in the 2018 Monitoring the Future data for eighth-graders. Among eighth-graders who say they plan to complete a 4-year college degree, 2 percent reported smoking cigarettes within the past month. Those eighth-graders whose plans do not include a full college degree (no college, a trade school, or an associate’s degree) are three times as likely to be current smokers: 6.3 percent report using cigarettes in the past month. Thus, we can see that this difference in cigarette smoking based on college education probably reflects the considerable influences of socioeconomic status, family background, and expectations, and apparently has little to do with any knowledge a college graduate might have obtained, or differences in type of employment after high school.

Smokeless Tobacco

In the early 1970s, many cigarette smokers apparently began to look for alternatives that would reduce the risk of lung cancer. Pipe and cigar smoking enjoyed a brief, small increase, followed by a long period of decline. Sales of smokeless tobacco products—specifically, different kinds of chewing tobacco—began to increase.

The most common type of oral smokeless tobacco in the United States is moist snuff (Copenhagen, Skoal), which is sold in a can. Moist snuff is not “snuffed” into the nose in the traditional manner; a small pinch is dipped out of the can and placed beside the gum, often behind the lower lip. One form of moist snuff also comes in a little teabag type of packet, so that loose tobacco fragments don’t stray out onto the teeth. Moist snuff, which has its traditional popularity base in the rural West, continued to show sales gains through the 1980s, until a federal excise tax was imposed. With all forms of oral smokeless tobacco, nicotine is absorbed through the mucous membranes of the mouth into the bloodstream, and users achieve blood nicotine levels comparable to those of smokers.

Smokeless tobacco enjoys many advantages over smoking. First, it is unlikely to cause lung cancer. Smokeless tobacco is less expensive than cigarettes, with an average user spending only a few dollars a week. Despite the Marlboro advertisements, a cowboy or anyone else who is working outdoors finds it more convenient to keep some tobacco in the mouth than to try to light cigarettes in the wind and then have ashes blowing in the face. And chewing might be more socially acceptable than smoking under most circumstances. After all, the user doesn’t blow smoke all around, and most people don’t even notice when someone is chewing, unless the chewer has a huge wad in the mouth or spits frequently. Many users can control the amount of tobacco they put in their mouths so that they don’t have to spit very often. What they do with the leftover quid of tobacco is a different story and often not a pretty sight.

The use of chewing tobacco had never completely died out in rural areas, and its resurgence was strongest there. The high-school senior class of 2019 reported that 6 percent of the boys and about 1 percent of the girls were using smokeless tobacco in the past month, down from 19 percent of boys and 2 percent of girls in 1993.10

Chewing tobacco might not be as unhealthy as smoking it. However, smokeless tobacco is not without its hazards. Of most concern is the increased risk of cancer of the mouth, pharynx, and esophagus. Snuff and chewing tobacco do contain potent carcinogens, including high levels of tobacco-specific nitrosamines. Many users experience tissue changes in the mouth, with leukoplakia (a whitening, thickening, and hardening of the tissue) a relatively frequent finding. Leukoplakia is considered to be a precancerous lesion (a tissue change that can develop into cancer). The irritation of the gums can cause them to become inflamed or to recede, exposing the teeth to disease. The enamel of the teeth can also be worn down by the abrasive action of the tobacco. Dentists are also becoming more aware of the destructive effects of oral tobacco.

Concerns about these oral diseases led the surgeon general’s office to sponsor a conference and produce a 1986 report, The Health Consequences of Using Smokeless Tobacco.13 This report went into some depth in reviewing epidemiological, experimental, and clinical data and concluded “the oral use of smokeless tobacco represents a significant health risk. It is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addiction and dependence.” Packages of smokeless tobacco now carry a series of rotating warning labels describing these dangers.

Hookahs

In the early 2000s, an ancient form of tobacco use increased somewhat in popularity. Hookahs are large, ornate water pipes, imported to the United States from Egypt and other Arab countries where their use has never completely gone out of style. Burning charcoal is put into the pipe bowl, and a piece of prepared flavored tobacco (shisha) is placed on a screen over the charcoal. The smoke is drawn down through a tube into a water reservoir by drawing on mouthpieces connected to tubes that enter the hookah above the water. The water-filtered smoke is milder, and the social nature of smoking in this manner has led to some bars providing hookahs for their customers’ use (in cities that do not outlaw smoking in bars). Hookahs and shisha are being sold over the Internet and in tobacco shops, and in 2019 4 percent of high-school seniors reported smoking tobacco using a hookah within the past 30 days.10

Causes for Concern Page 248

Although the first clear scientific evidence linking smoking and lung cancer appeared in the 1950s, acceptance of the evidence was slow to come. Each decade brought clearer evidence and more forceful warnings from the surgeon general. The tobacco industry fought back by establishing in 1954 the Council for Tobacco Research to provide funds to independent scientists to study the health effects of tobacco use. A 1993 exposé in The Wall Street Journal14 detailed the manipulation of this “independent” research by tobacco industry lawyers, who arranged direct funding for research casting doubt on smoking-related health problems and who suppressed the publication of findings that threatened the industry. Despite tobacco industry efforts, it is abundantly clear that tobacco is America’s true “killer weed” and is a bigger public health threat than all the other drug substances combined, including alcohol. It was not until the late 1990s, however, that a tobacco manufacturer finally admitted in public that cigarettes have seriously adverse effects on health.

Adverse Health Effects

Fifty years after the 1964 surgeon general’s report first linked cigarette smoking to lung cancer, we now know that there are several other deadly diseases for which smoking significantly increases the risk. In the 2014 report, it was estimated that smoking was responsible for an additional 20 million early deaths over that 50-year period, and that millions more will die early unless smoking is further reduced. This is why: Although lung cancer is not common, over 80 percent of all lung cancers occur in smokers. Among deaths resulting from all types of cancer, smoking is estimated to be related to almost half, or about 160,000 premature deaths per year. However, cancer is only the second leading cause of death in the United States. It now appears that smoking is also related to about 30 percent of deaths from the leading killer, cardiovascular disease, or about 150,000 premature deaths per year. In addition, cigarette smoking is the cause of 80 percent of deaths resulting from chronic obstructive lung disease—another 100,000 cigarette-related premature deaths per year. The total “smoking attributable mortality” is more than 440,000 premature deaths per year in the United States, representing about 20 percent of all U.S. deaths.15 No wonder these reports keep saying that “cigarette smoking is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.” In an effort to raise awareness about the potential harmful effects of smoking, many countries require tobacco companies to place warning labels on the packaging of their tobacco products (Figure 10.2).

Think of anything related to good physical health; the research says that cigarette smoking will impair it. The earlier the age at which you start smoking, the more smoking you do, and the longer you do it, the greater the impairment. Smoking doesn’t do any part of the body any good, at any time, under any conditions.

Secondhand Smoke

A great deal has been said and written about secondhand smoke—that is, the inhaling of cigarette smoke from the environment by nonsmokers.

It is obvious that cigarette smoke can be irritating to others, but is it damaging? Besides the cases of individuals who have lung disorders or are allergic to smoke, is there evidence that cigarette smoke is harmful to exposed nonsmokers? Research is complicated; the smoke rising from the ash of the cigarette (sidestream smoke) is higher in many carcinogens than is the mainstream smoke delivered to the smoker’s lungs. Of course, it is also more diluted. How many smokers are in the room? How much do they smoke? How good is the ventilation? How much time does the nonsmoker spend in this room? These variables have made definitive research difficult, but enough studies have produced consistent enough findings that the Environmental Protection Agency in 1993 declared secondhand smoke to be a known carcinogen and estimated that passive smoking is responsible for several thousand lung cancer deaths each year. The Centers for Disease Control now estimates that secondhand smoke is responsible for about 7,300 lung cancer deaths and 34,000 deaths from heart disease each year.15

Concerns about the effects of secondhand smoke have led to many more restrictions on smoking in the workplace and in public. Most states and municipalities now have laws prohibiting smoking in public conveyances and requiring the establishment of smoking and nonsmoking areas in public buildings and restaurants, and some communities have banned smoking in all restaurants. A few employers have gone so far as to either encourage or attempt to force their employees to quit smoking both on the job and elsewhere, citing health statistics indicating more sick days and greater health insurance costs associated with smoking. This conflict between smoker and nonsmoker seems destined to get worse before it gets better. Although to some observers this battle might seem silly, it represents a very basic conflict between individual freedom and public health.

Smoking and Health in Other Countries

Cigarette smoking is a social and medical problem worldwide. The World Health Organization (WHO) estimates that tobacco causes 8 million deaths a year worldwide.16 In recent years, as sales declined in developed countries, advertising and promotions in Third World countries (touting cigarettes as delivering “the great taste of America”) resulted in large increases in exports of American cigarettes. Asians, in particular, seemed to want American cigarettes, and one of the major efforts was to open Japanese, Taiwanese, Korean, and Chinese cigarette markets to U.S. imports. However, in recent years the WHO has promoted tobacco control and cessation measures in many countries throughout the world, and smoking rates have begun to decline.16

Smoking and Pregnancy

The nicotine, hydrogen cyanide, and carbon monoxide in a smoking mother’s blood also reach the developing fetus and have significant negative consequences there. On the average, infants born to smokers are about half a pound lighter than infants born to nonsmokers. This basic fact has been known for almost 30 years and has been confirmed in numerous studies. There is a dose-response relationship: The more the woman smokes during pregnancy, the greater the reduction in birth weight. Is the reduced birth weight the result of an increased frequency of premature births or of retarded growth of the fetus? Smoking shortens the gestation period by an average of only 2 days, and when gestation length is accounted for, the smokers still have smaller infants. Ultrasonic measurements taken at various intervals during pregnancy show smaller fetuses in smoking women for at least the last 2 months of pregnancy. The infants of smokers are normally proportioned, are shorter and smaller than the infants of nonsmokers, and have smaller head circumference. The reduced birth weight of infants of women smokers is not related to how much weight the mother gains during pregnancy, and the consensus is that a reduced availability of oxygen is responsible for the diminished growth rate. Women who give up smoking early in pregnancy (by the fourth month) have infants with weights similar to those of nonsmokers.

Besides the developmental effects evident at birth, several studies indicate small but consistent differences in body size, neurological problems, reading and mathematical skills, and hyperactivity at various ages. It therefore appears that smoking during pregnancy can have long-lasting effects on both the intellectual and physical development of the child. The increased perinatal (close to the time of birth) smoking-attributable mortality associated with sudden infant death syndrome (SIDS), low birth weight, and respiratory difficulties adds up to about 10,000 infant deaths per year in the United States.15

So far we have been talking about normal deliveries of babies. Spontaneous abortion (miscarriage) has also been studied many times in relation to smoking and with consistent results: Smokers have more spontaneous abortions than nonsmokers (perhaps 1.5 to 2 times as many). As for congenital malformations, the evidence for a relationship to maternal smoking is not as clear. If there is a small effect here, it could be either related to or obscured by the fact that many smokers also drink alcohol and coffee. One study indicated an increased risk of facial malformations associated with the father’s smoking. Several studies have also found an increased risk of SIDS if the mother smokes, but it is not clear if this is related more to the mother’s smoking during pregnancy or to passive smoking (the infant’s breathing smoke) after birth.

Several studies have reported an increased risk for nicotine dependence in adolescents whose mothers smoked during pregnancy. One obvious question is whether this relationship is due entirely to cultural and social similarities between the mothers and their offspring, but a number of animal studies have demonstrated that prenatal nicotine exposure produces changes in brain chemistry in the offspring, as well as differences in behavioral response to nicotine and other drugs in adolescence.17

The overall message is very clear. Definite, serious risks are associated with smoking during pregnancy. In fact, the demonstrated effects of cigarette smoking on the developing fetus are of the same magnitude and type as those reported for infants prenatally exposed to cocaine and many more pregnant women are smoking cigarettes than using cocaine. If a woman smoker discovers she is pregnant, she should quit smoking.

Pharmacology of Nicotine

Nicotine is a naturally occurring liquid alkaloid that is colorless and volatile. On oxidation, it turns brown and smells much like burning tobacco. Tolerance to its effects develops, along with the dependency that led Mark Twain to remark how easy it was to stop smoking—he’d done it several times!

Nicotine was isolated in 1828 and has been studied extensively since then. The structure of nicotine is shown in Figure 10.3; there are both d and l forms, but they are equipotent. It is of some importance that nicotine in smoke has two forms, one with a positive charge and one that is electrically neutral. The neutral form is more easily absorbed through the mucous membranes of the mouth, nose, and lungs.

Absorption and Metabolism

Inhalation is a very effective drug-delivery system; 90 percent of inhaled nicotine is absorbed. The physiological effects of smoking one cigarette have been mimicked by injecting about 1 mg of nicotine intravenously.

Acting with almost as much speed as cyanide, nicotine is well established as one of the most toxic drugs known. In humans, 60 mg is a lethal dose, and death follows intake within a few minutes. A cigar contains enough nicotine for two lethal doses (who needs to take a second one?), but not all of the nicotine is delivered to the smoker or absorbed in a short enough time period to kill a person.

Nicotine is primarily deactivated in the liver, with 80 to 90 percent being modified before excretion through the kidneys. Part of the tolerance that develops to nicotine might result from the fact that either nicotine or the tars increase the activity of the liver microsomal enzymes that are responsible for the deactivation of drugs. These enzymes increase the rate of deactivation and thus decrease the clinical effects of the benzodiazepines and some antidepressants and analgesics. The final step in eliminating deactivated nicotine from the body may be somewhat slowed by nicotine itself, since it acts on the hypothalamus to cause a release of the hormone that acts to reduce the loss of body fluids.

Physiological Effects

The effect of nicotine on areas outside the central nervous system has been studied extensively. Nicotine mimics acetylcholine by acting at several nicotinic subtypes of cholinergic receptor site. Nicotine is not rapidly deactivated, and continued occupation of the receptor prevents incoming impulses from having an effect, thereby blocking the transmission of information at the synapse. Thus, nicotine first stimulates and then blocks the receptor. These effects at cholinergic synapses are responsible for some of nicotine’s effects, but others seem to be the result of an indirect action.

Nicotine also causes a release of adrenaline from the adrenal glands and other sympathetic sites and thus has, in part, a sympathomimetic action. Additionally, it stimulates and then blocks some sensory receptors, including the chemical receptors found in some large arteries and the thermal pain receptors found in the skin and tongue.

The symptoms of low-level nicotine poisoning are well known to beginning smokers and small children behind barns and in alleys: nausea, dizziness, and a general weakness. In acute poisoning, nicotine causes tremors, which develop into convulsions, terminated frequently by death. The cause of death is suffocation resulting from paralysis of the muscles used in respiration. This paralysis stems from the blocking effect of nicotine on the cholinergic system that normally activates the muscles. With lower doses, respiration rate actually increases because the nicotine stimulates oxygen-need receptors in the carotid artery. At these lower doses of 6 to 8 mg, there is also a considerable effect on the cardiovascular system as a result of the release of adrenaline. Such release leads to an increase in coronary blood flow, along with vasoconstriction in the skin and increased heart rate and blood pressure. The increased heart rate and blood pressure raise the oxygen need of the heart but not the oxygen supply. Another action of nicotine with negative health effects is that it increases platelet adhesiveness, which increases the tendency to clot. Within the central nervous system, nicotine seems to act at the level of the cortex to increase somewhat the frequency of the electrical activity, that is, to shift the electroencephalogram (EEG) toward an arousal pattern.

Many effects of nicotine are easily discernible in the smoking individual. The heat releases the nicotine from the tobacco into the smoke. Inhaling while smoking one cigarette has been shown to inhibit hunger contractions of the stomach for up to an hour. That finding, along with a very slight increase in blood sugar level and a deadening of the taste buds, might be the basis for a decrease in hunger after smoking.

In line with the last possibility, it has long been folklore that a person who stops smoking begins to nibble food and thus gains weight. Carbohydrate-rich snack foods appear to be even more appealing when smokers are deprived of nicotine.18 In addition, there is evidence that smoking increases metabolism rate, so that a weight gain on quitting might be partially due to a decreasing metabolism rate or less energy utilization by the body.

In a regular smoker, smoking results in a constriction of the blood vessels in the skin, along with a decrease in skin temperature and an increase in blood pressure. The blood supply to the skeletal muscles does not change with smoking, but in regular smokers the amount of carboxyhemoglobin in the blood is usually abnormally high (up to 10 percent of all hemoglobin). All smoke contains carbon monoxide; cigarette smoke is about 1 percent carbon monoxide, pipe smoke 2 percent, and cigar smoke 6 percent. The carbon monoxide combines with the hemoglobin in the blood, so that it can no longer carry oxygen. This effect of smoking, a decrease in the oxygen-carrying ability of the blood, probably explains the shortness of breath smokers experience when they exert themselves.

The decrease in oxygen-carrying ability of the blood and the decrease in placental blood flow probably are related to the many results showing that pregnant women who smoke greatly endanger their unborn children.

Behavioral Effects

Despite all the protests and cautionary statements, the evidence is overwhelming that nicotine is the primary, if not the only, reinforcing substance in tobacco. The more nicotine in a cigarette, the lower the level of smoking. Intravenous injections and oral administration of nicotine will decrease smoking under some conditions—but not all.

Nicotine has the unusual ability to act as a mild stimulant, helping people to stay awake and to focus attention, as well as providing a sense of relaxation. Even initial smokers report both kinds of effects, with large individual differences based on the situation and several genetic factors.19 Smokers report seeking both effects, and experimental results are heavily influenced by the smoker’s history and the situation.

Most people smoke in a fairly consistent way, averaging one to two puffs per minute, with each puff lasting about 2 seconds with a volume of 25 ml. This rate delivers to the individual about 1 to 2 μg of nicotine per kilogram of body weight with each puff. Smokers could increase the dose by increasing the volume of smoke with each puff or puffing more often, but this dose appears to be optimal for producing stimulation of the cerebral cortex.

Several studies have shown that smokers are able to sustain their attention to a task requiring rapid processing of information from a computer screen much better if they are allowed to smoke before beginning the task. This could be either because the nicotine produces a beneficial effect on this performance or because when the smokers are not allowed to smoke they suffer from some sort of withdrawal symptom.

Nicotine Dependence

Evidence that nicotine is a reinforcing substance in nonhumans, that most people who smoke want to stop and can’t, that when people do stop smoking they gain weight and exhibit other withdrawal signs, and that people who chew tobacco also have trouble stopping led to a need for a thorough look at the dependence-producing properties of nicotine. A 1988 surgeon general’s report provided it, in the form of a 600-page tome.20 This had been a traditionally difficult subject: Not many years ago, psychiatrists were arguing that smoking fulfilled unmet needs for oral gratification and therefore represented a personality defect. It has come to light that the cigarette manufacturing company Philip Morris obtained evidence of the dependence-producing nature of nicotine with rats in the early 1980s, but, instead of publishing the results, it fired the researchers and closed the laboratory.21 Industry executives in 1994 congressional hearings unanimously testified that nicotine was not “addicting,” still arguing that smoking was simply a matter of personal choice and that many people have been able to quit. One can theoretically choose to stop using a drug, but one has a very difficult time doing so because of the potent reinforcing properties of the substance. That is the case with nicotine. The following conclusions of the surgeon general’s report were pretty strong:

1. Cigarettes and other forms of tobacco are addicting.

2. Nicotine is the drug in tobacco that causes addiction.

3. The pharmacological and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.

Recent research is focusing on the role of genetic differences in how people respond to their first smoking experience and whether they develop a rapid dependence or remain occasional smokers. Most of the focus has been on genes that are responsible for the structure of the various parts of the acetylcholine receptors in the brain. There are certainly wide individual differences in how easily people can stop smoking, and for those who have repeatedly failed to stop in spite of health consequences, the hope is that someday this genetic research will lead to a pharmacological treatment that can assist them in quitting.22

The past decade has seen a great deal of research into the different subtypes of nicotinic cholinergic receptors, and several companies are developing new drugs targeted more specifically to certain subtypes. The three main potential uses for these drugs would be in treating Alzheimer’s disease and other cognitive disorders of aging, controlling pain, and possibly in treating ADHD. Although several such drugs are being tested in human trials, none is yet on the market.

How to Stop Smoking

When you’re young and healthy, it’s difficult, if not impossible, to imagine dying, being chronically ill, or having emphysema so that you can’t get enough oxygen to walk across the room without having to stop to catch your breath. By the time you’re old enough to worry about those things, it’s difficult to change your health habits.

Many people want to stop smoking. A lot of people have already stopped. Are there ways to efficiently and effectively help those individuals who want to stop smoking to stop? With any form of pleasurable drug use, it is easier to keep people from starting to use the drug than it is to get them to stop once they have started. All the educational programs have had an effect on our society and on our behavior. There are now more than 40 million former smokers in the United States, and about 90 percent of them report that they quit smoking without formal treatment programs. There is some indication that those who have quit on their own do better than those who have been in a treatment program, but then those who quit on their own also tend not to have been smoking as much or for as long.

One reason it is so hard for people to stop is that a pack-a-day smoker puffs at least 50,000 times a year. That’s a lot of individual nicotine “hits” reinforcing the smoking behavior. A variety of behavioral treatment approaches are available to assist smokers who want to quit, and hundreds of research articles have been published on them. Although most of these programs are able to get almost everyone to quit for a few days, by 6 months 70 to 80 percent of participants are smoking again.

If nicotine is the critical thing, why not provide nicotine without the tars and carbon monoxide? Prescription nicotine chewing gum became available in 1984, after carefully controlled studies showed it to be a useful adjunct to smoking cessation programs. This gum is now available over the counter. In 1991, several companies marketed nicotine skin patches that allow slow release of nicotine to be absorbed through the wearer’s skin. Nicotine lozenges are now available over the counter, and smokers can also get a prescription for a nicotine inhaler or nasal spray. Also, the prescription drug bupropion (Zyban) has been shown to help many people.

In 2006, the FDA approved varenicline (Chantix), a nicotine partial-agonist drug. Then in 2009, the FDA required both Chantix and Zyban to include black box warnings about the chances of changes in behavior, depressed mood, hostility, and suicidal thoughts. While some have joked that these are possibly just the symptoms associated with quitting cigarettes, the number of serious complaints from users of these products is a real concern, and the FDA is requiring the companies to conduct careful clinical trials to determine how great these risks are.

There is money to be made helping people quit smoking, especially if it can apparently be done painlessly with a substitute. The controlled studies done to demonstrate the usefulness of gum or skin patches have been carried out under fairly strict conditions, with a prescribed quitting period, several visits to the clinic to assess progress, and the usual trappings of a clinical research study, often including the collection of saliva or other samples to detect tobacco use. That’s a far cry from buying nicotine gum and a patch off the shelf, with no plan for quitting, no follow-up interviews, and no monitoring. No wonder that some people have found themselves, despite warnings, wearing a nicotine patch and smoking at the same time.

Is there an effective nondrug program for quitting smoking? Yes and no. The effect of any program varies—some people do very well, some very poorly—and if one program won’t work for an individual, maybe another one will. Combining counseling and pharmacological treatments increases the odds of quitting.23 We don’t yet know which program will be best for any particular individual. If you want to stop smoking, keep trying programs; odds are you’ll find one that works—eventually.

Summary

· Tobacco was introduced to Europe and the East after Columbus’s voyage to the Americas.

· As with most other “new” drugs, Europeans at first rejected tobacco, and then its use slowly spread.

· The predominant style of tobacco use went from pipes to snuff to chewing to cigars to cigarettes.

· The typical modern cigarette is about half as strong in tar and nicotine content as a cigarette of 50 years ago.

· Cigarette smoking has declined considerably since the 1960s, but the use of e-cigarettes has recently increased.

· The use of smokeless tobacco increased during the 1980s, causing concerns about increases in oral cancer.

· Although tobacco continues to be an important economic factor in American society, it is also responsible for more annual deaths than all other drugs combined, including alcohol.

· Cigarette smoking is clearly linked to increased risk of heart disease, lung and other cancers, emphysema, and stroke.

· There is increased concern about the health consequences of secondhand smoke.

· Smoking cessation leads to immediate improvements in mortality statistics, and new products, including different types of nicotine replacement therapy, are being widely used by those who wish to quit.

Review Questions

1. Why was nicotine named after Jean Nicot?

2. Which was the desired species of tobacco that saved the English colonies in Virginia?

3. What techniques have been used to produce “safer” cigarettes?

4. About what proportion of adults are smokers in the United States?

5. What is the significance of tobacco-specific nitrosamines?

6. What are the major causes of death associated with cigarette smoking?

7. What evidence is there that passive smoking can harm nonsmokers?

8. What are the effects of smoking during pregnancy?

9. Nicotine acts through which neurotransmitter in the brain? How does it interact with this neurotransmitter?

10. What is the evidence as to why cigarette smoking produces such strong dependence?

References

1. Norton, M. Sacred Gifts, Profane Pleasures. Ithaca, NY: Cornell University Press, 2008.

2. Centers for Disease Control and Prevention. “Smoking in Top-Grossing Movies—United States, 2018.” Morbidity and Mortality Weekly Report, November 1, 2019.

3. Vaughn, W. Quoted in Dunphy, E. B. “Alcohol and Tobacco Amblyopia: A Historical Survey.” American Journal of Ophthalmology 68 (1969), p. 573.

4. Burns, E. The Smoke of the Gods. Philadelphia: Temple University Press, 2007.

5. Lorand, A. Life Shortening Habits and Rejuvenation. Philadelphia: F. A. Davis, 1927.

6. Eaglin, J. The CC Cough-fin Brand Cigarettes. Cincinnati: Raisbeck, 1931.

7. U.S. Institute of Medicine. Ending the Tobacco Problem. Washington, DC: The National Academies Press, 2007.

8. Kassel, J. D., J. E. Greenstein, D. P. Evatt, et al. “Smoking Topography in Response to Denicotinized and High-Yield Nicotine Cigarettes in Adolescent Smokers.” Journal of Adolescent Health 40 (1) (2007), pp. 54–60.

9. Fairchild, A., and J. Colgrove. “Out of the Ashes: The Life, Death, and Rebirth of the “Safer” Cigarette in the United States.” American Journal of Public Health 94 (2004), pp. 192–205.

10. Miech, R. A., L. D. Johnston, P. M. O’Malley, J. G. Bachman, J. E. Schulenberg, and M. E. Patrick. Monitoring the Future National Survey Results on Drug Use, 1975–2019: Volume I, Secondary School Students. Ann Arbor: Institute for Social Research, the University of Michigan, 2020. Available at http://monitoringthefuture.org/pubs.html#monographs

11. Center for Behavioral Health Statistics and Quality. 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. Available at www.samhsa.gov/data

12. Schulenberg, J. E., L. D. Johnston, P. M. O’Malley, J. G. Bachman, R. A. Miech, and M. E. Patrick. Monitoring the Future National Survey Results on Drug Use, 1975–2018: Volume II, College Students and Adults Ages 19–60. Ann Arbor: Institute for Social Research, the University of Michigan, 2019. Available at http://monitoringthefuture.org/pubs.html#monographs

13. The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General. (NIH Pub. No. 86-2874). Washington, DC: U.S. Government Printing Office, 1986.

14. “Smoke and Mirrors: How Cigarette Makers Keep Health Question Open Year after Year.” Wall Street Journal, February 11, 1993.

15. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

16. World Health Organization. WHO Report on the Global Tobacco Epidemic. Geneva, Switzerland: WHO, 2019. Available at www.who.int/tobacco/global_report/en/

17. Lacy, R. T., R. W. Brown, A. J. Morgan, C. F. Mactutus, and S. B. Harrod. “Intravenous Prenatal Nicotine Exposure Alters METH-Induced Hyperactivity, Conditioned Hyperactivity, and BDNF in Adult Rat Offspring.” Developmental Neuroscience 38 (2016), pp. 171–85.

18. Geha, P. Y., and others. “Altered Hypothalamic Response to Food in Smokers.” American Journal of Clinical Nutrition 97 (2013), pp. 15–22.

19. Haberstick, B. C., and others. “Dizziness and the Genetic Influences on Subjective Experiences to Initial Cigarette Use.” Addiction 106 (2011), pp. 391–99.

20. U.S. Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction, a Report of the Surgeon General. DHHS Pub. No. (CDC) 88-8406. Washington, DC: U.S. Government Printing Office, 1988.

21. Kessler, D. A Question of Intent. New York: Public Affairs, 2001, pp. 113–39.

22. Fisher, M. L., J. R. Pauly, B. Froeliger, and J. R. Turner. “Translational Research in Nicotine Addiction” [published online ahead of print, 2020 Jun 8]. Cold Spring Harbor Perspectives in Medicine 2020, p. a039776.

23. M. A. Jackson, A. L. Brown, A. L. Baker, A. J. Dunlop, A. Dunford, and G. S. Gould. “Intensive Behavioural and Pharmacological Treatment for Tobacco Dependence in Pregnant Women with Complex Psychosocial Challenges: A Case Report.” International Journal of Environmental Research and Public Health 17 (13) (2020), p. E4770.

Design Credits: (Drugs in the Media) ©Glow Images; (Drugs in Depth) ©Ingram Publishing/SuperStock

Check Yourself

Test Your Tobacco Awareness

Whether you smoke, chew, or don’t use tobacco at all, tobacco is an important economic and political issue in virtually every community and in every country. See how well you do with these questions about tobacco’s place in the United States and the world:

1. About what proportion of adults in the United States are smokers?

2. About how many Americans die each day from tobacco-related illnesses?

3. What two tobacco-related health problems account for most deaths among smokers?

4. Which country produces the most cigarettes?

Answers

1. About 25 percent (Most people tend to overestimate the proportion of smokers, which makes smoking seem to be a typical behavior, when in fact, it’s not.)

2. About 1,200 per day, representing about 20 percent of all deaths in the United States.

3. Smoking-related heart disease kills about 140,000 in the United States each year, along with about 160,000 smoking-related lung cancer deaths.

4. China produces about 30 percent of the world’s cigarettes, with the United States a distant second. Most of the cigarettes produced in China are consumed in China.