Tobacco smoking is a practice in which tobacco is burned and the smoke inhaled or tasted. Smoking is primarily practiced as a route of administration for nicotine through the lungs; it is a way of getting nicotine into your system rapidly.
The most popular current method of smoking is through cigarettes, mainly industrially manufactured ones. Some people use hand-rolled loose tobacco, while others smoke pipes, cigars or hookahs.
Over one billion people globally smoke tobacco regularly.
USA statistics - according to the American Heart Association, 23.1% of men (24.8 million) and 18.3% of women (21.1 million) are smokers. According to the CDC (Centers for Disease Control and Prevention) an estimated total of 443,000 deaths occur every year in the USA from cigarette smoking - almost 1 in every 5 deaths. That is more deaths than the combined total from HIV, illegal drug use, alcohol use, motor vehicle injuries, suicides and murders.
UK statistics - according to the National Health Service (NHS), UK, about one quarter of the adult population of the UK smokes (20 million people). 25% of British men and 23% of British women smoke. Smoking is the biggest cause of illness and death in the UK, causing 114,000 smokers to die annually. The NHS adds that approximately 70% of smokers would like to stop, but most think they are not able to. About half of all British smokers eventually manage to stop.
Smoking dates back to about 7,000 years ago. The globalization of cigarette smoking originates from the European exploration and conquest of the Americas, where tobacco smoking was common. The Europeans quickly took it up, and it spread around the world rapidly.
People's view of smoking has varied over time, from being a vulgar habit, a sophisticated pastime, to a deadly health hazard. Over the last three decades of the twentieth century, mainly in industrialized countries, smoking became increasingly viewed as an undesirable activity that is bad for the health - a practice that kills. We now know that smoking is one of the leading causes of many diseases, such as heart attacks, erectile dysfunction (male impotence), and lung cancer. Consequently, several nations have significantly increased taxes on tobacco products and regularly launch anti-smoking campaigns.
Many countries have introduced legislation over the last three decades banning smoking in shops, restaurants, pubs and bars, public places, etc. Not that many decades ago movie theaters (cinemas) in England used to have smoking and non-smoking sections. A significant number of young people are not aware that smoking was common in commercial airplanes.
What is nicotine dependence?Nicotine dependence is an addiction to tobacco products caused by one of its ingredients - the drug nicotine. Nicotine is an addictive drug which causes mood-altering changes in the brain which are temporarily pleasing, making people want to use it more and more.
When a person is addicted to nicotine they have unpleasant withdrawal symptoms, which temporarily go away when they receive the nicotine through smoking tobacco. Experts say that nicotine is one of the hardest of all addictions to break.
Put simply - nicotine dependence means the individual cannot stop using the substance.
Unfortunately, while the smoker is addicted to the nicotine, they consume thousands of toxic substances present in tobacco smoke in order to get their fix.
In the USA in 1988, the Surgeon General reported that:
- Cigarettes and other tobacco products are addicting
- The addiction is caused by the drug nicotine
- Pharmacologic and behavioral characteristics that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.
Menthol cigarettes more addictive - the FDA (US Food and Drug Administration) says it is to investigate the usage of menthol in tobacco cigarettes.
According to preliminary findings, menthol cigarettes are more addictive than other tobacco products. The FDA is seeking additional information as it decides whether to introduce new regulations which could include "tobacco product standards, sale and distribution restrictions among other regulatory actions and considerations."
Menthol cigarettes are very popular in the USA. The FDA says that over 40% of young smokers and 30% of older smokers prefer and regularly smoke menthol cigarettes.
What are the signs and symptoms of nicotine addiction?A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, sleepiness may be a symptom while dilated pupils may be a sign.
Signs and symptoms of nicotine addiction may vary, according to the individual. Some people become totally dependent (addicted) fairly rapidly. Examples include:
- The individual smokes and cannot stop - they have made at least one serious attempt to stop, but unsuccessfully.
- Withdrawal symptoms - when trying to stop the individual had physical and mood-related symptoms. There were cravings, bouts of moodiness and irritability, poor concentration, a feeling of being depressed and hollow/empty, anger, frustration, increased appetite, and insomnia. In some cases there may also have been diarrhea or constipation.
- Smoking prevails despite the emergence of health problems - the individual continues to smoke, even though they have developed smoking related illnesses, such as a lung or heart condition.
- Social and/or recreational sacrifices - some activities were given up because of smoking. For example, certain restaurants or pubs that became smoke free. Perhaps the individual stopped visiting friends whose environments/homes are smoke free. The regular Friday night bowling get-together with friends stopped because smoking was not allowed there anymore.
What are the causes of nicotine addiction?Tobacco contains a substance - nicotine - which keeps the smoker smoking. Experts say it may be as addictive as some recreational drugs, such as cocaine. Nicotine increases the release of neurotransmitters which regulate behavior and mood.
A neurotransmitter is a chemical that is released from a nerve cell. The neurotransmitter transmits an impulse from one nerve cell to another nerve, tissue, organ or muscle - it is a messenger of neurologic information from one cell to another.
Nicotine triggers the release of dopamine, a neurotransmitter which give people a pleasant feeling. Obtaining that dopamine rush is said to be a major part of the addiction process - smokers crave that neurotransmitter (especially dopamine) rush.
Experts say that when nicotine is inhaled the brain is affected within seconds. After an inhalation the smoker's heart rate increases, levels of the hormones noradrelanine also increase, as well as dopamine - the whole experience is said to enhance mood, as well as the ability to concentrate.
Some time after the last cigarette, the levels of these hormones drops, leaving the smoker feeling anxious and possibly irritable, and in need of another nicotine boost.
There are other physical as well as psychological factors which influence the addiction process. The following situations, cues or behaviors may be linked to smoking urges:
- Certain moments during the day may be associated with a greater desire to smoke, such as with the first cup of coffee, during work breaks, or after routine tasks.
- After eating - most smokers have a stronger desire to smoke immediately after a meal.
- Alcohol - most smokers who drink alcohol say that tobacco and alcohol are enjoyed together.
- Some places - smokers often find certain places, such as the toilet, some bars and pubs (if smoking is allowed there), or car parks (after getting down from the car or coming into the car park from a supermarket and walking towards the car) trigger a desire to smoke.
- Some people - smokers often find that meeting other people, especially if they are also smokers, make them want to smoke more.
- Moments of stress - the majority of smokers will typically have an urge to smoke when faced with a stressful, exciting or emotional situation.
- The telephone - when the telephone rings at home many smokers run for their cigarettes before picking it up.
- Tobacco smell - the smell of other people smoking can be a strong trigger for smokers to want to light up.
- Driving - smokers usually smoke when driving on their own.
If a smoker does not receive nicotine for an extended period, for example 24 hours, the following signs and symptoms of withdrawal may emerge:
- A drop in mood (depressed mood)
- Greater appetite
- Heart rate (pulse) slows down
- Problems focusing
- Tetchiness, sometimes even hostility.
New understanding of how nicotine causes addiction has emerged, according to research published in eLife.
What are the risk factors for nicotine addiction?A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.
Nicotine can affect anyone if they smoke. The majority of regular smokers today started smoking when they were teenagers - in some cases even younger. Studies have shown a link between heavy smoking as an adult and starting to smoke at a younger age.
- Parents who smoke - children whose parents both smoke are twice as likely to become smokers themselves, compared to children whose parents don't smoke.
- Friends who smoke - children who have friends who smoke are more likely to start using tobacco products, such as cigarettes.
- Hereditary - geneticists believe that the reason some people try cigarettes and do not become smokers, while others do so very quickly is probably linked to the type of genes we inherit from our parents. Some people can smoke once in a while, throughout their lives, and never seem to become addicted, while others are unable to stop smoking without experiencing the unpleasant withdrawal symptoms. It is most likely that the way the receptors on the surface of our brain nerve cells respond to nicotine is influenced by our genes.
- Mental illness - people with depression, bipolar disorder, schizophrenia and some other mental illnesses appear to become more easily addicted to nicotine than others.
- Alcohol and substance abuse - individuals who abuse alcohol, as well as those who take illegal drugs are more likely to be regular smokers.
How is nicotine dependence diagnosed?There is no current diagnostic test, such as a blood test or imaging scan which can determine whether somebody is addicted to nicotine, and to what degree.
A GP (general practitioner, primary care physician) can help the patient determine their degree of dependence by asking pertinent questions, or using a specific questionnaire. The following questions may help determine how dependent a patient is:
- How soon after you wake up do you light up?
- How many cigarettes do you smoke per day?
- Do you find it hard not to smoke in places where it is not allowed, such as in a church, school, movie theatre, library, public transport, hospital, etc.?
- If you had to give up, which cigarette would you miss the most (e.g. the first one in the morning)?
- Do you smoke more cigarettes during the first few hours after waking up, than during the rest of the day?
- If you are ill, with a bad cold or the flu, do you still smoke?
- Have you ever smoked more than you intended to?
- Have you ever neglected a duty because you were smoking, or so that you could have a cigarette?
- Have you ever concluded that you needed to control how many cigarettes you smoked each day, but found it very difficult to do?
- Have you ever tried to quit? If so, how many times and for how long?
- Did you experience withdrawal symptoms when you spent an extended period without smoking? Did those symptoms go away when you lit up?
- How long have you been aware of the health dangers of smoking?
- How long do you think you will live if you continue smoking?
- If you gave up now for good, how long do you think you will probably live?
What are the treatment options for nicotine addiction?Hundreds of millions of people have tried to give up smoking, and many have succeeded. Experts say that smokers have a higher chance of permanent success if they pursue treatment that has been proven to be effective in scientific studies. Psychological therapy or medications may help; a combination of the two has been shown to be the most successful.
A study published in the August (2013) issue of BMJ (British Medical Journal) reported that UK government-led "stop-smoking" services saved 25,000 years of life in one decade.
A significant number of smokers find breaking their tobacco dependence difficult. However, the benefits make quitting worthwhile. Anybody who gives up before they are 50 years of age can reduce their risk of dying during the next 15 years by 50%, compared with people who continue smoking.
Below are some of the benefits from quitting smoking:
- Heart rate slows down - the benefits are felt by the body just 20 minutes after stopping, when the heart rate (pulse rate) starts to drop.
- Carbon monoxide - just twelve hours after your last cigarette your blood carbon monoxide levels go back to normal.
- Lung function - within three months of quitting, the individual's lung function starts to improve significantly.
- Circulation - within three months of quitting there are improvements in circulation.
- Heart attack risk - within 12 months of giving up the person's risk of having a heart attack falls by 50%.
- Stroke - within 5 to 15 years an ex-smoker's risk of having a stroke is the same as a lifetime non-smoker's.
Patients who have tried medications without success should talk to their doctor or a specialized health care professional who may offer useful advice.
NRT (nicotine replacement therapy) - smoking is a way of getting nicotine into the nicotine addict. Nicotine is highly addictive. People become addicted to smoking, not because it is nice, but because of the nicotine in cigarettes. NRT releases nicotine into the bloodstream at lower doses than one would obtain from tobacco smoke. For many people, this steady supply can help alleviate the cravings that occur when giving up smoking.
Examples of NRT include:
Nicotine patch - the patch is placed on the skin, where it remains, usually for a whole day. The nicotine enters the bloodstream through the skin. It is replaced each day.
A typical nicotine patch course lasts from 8 to 12 weeks - in many cases it may be longer. Experts say the patient should try not to be impatient. If the patch has worked, there is no hurry to stop using it.
Patients who have not managed to stop smoking completely after two weeks on the patch should see their doctor, who may suggest a different dosage, or adding another medication.
Nicotine gum - this is a chewing gum which contains nicotine. The nicotine enters the bloodstream through the mucosal lining of the mouth. Heavy smokers should probably use the 4mg dose gums, while others should use the 2mg gums.
The gum should be chewed a few times until a mild peppery taste is felt, at which point it should be placed between the cheek and the gumline for about 20 minutes. While the gum is in place and releasing nicotine, avoid fizzy drinks and coffee.
- Nicotine lozenge - this hard candy-like tablet dissolves in the mouth and delivers a small dose of nicotine into the bloodstream through the mucosal lining of the mouth. There are 2mg and 4mg doses. The user should place it either under the tongue or between the gumline and cheek, and leave it there until it dissolves.
- Nicotine inhaler - a cartridge containing nicotine is placed in a cigarette-holder like device. The user sucks on it, inhaling nicotine vapor. The nicotine is absorbed into the bloodstream through the mucosal lining of the mouth and throat. Initially, some users may experience coughing or throat irritation. Patients who miss having something to suck and hold may find this type of NRT especially effective. In many countries the nicotine inhaler is a prescription-only product.
- Nicotine nasal spray - the user sprays a solution which contains nicotine directly into each nostril. The nicotine enters the bloodstream through the nasal membranes. Some prefer this method because the nicotine reaches the brain more quickly than with a gum, patch or lozenges (but still more slowly than with a cigarette).
Nicotine-assisted reduction to stop - patients who feel they are not ready to give up completely may benefit from progressively reducing their daily consumption of cigarettes beforehand. In such cases the doctor may prescribe an NRT medication to be used between smokes. Lozenges, nasal sprays or gums are better than the nicotine patch because they release a short burst of nicotine between cigarettes, rather than a steady supply.
Smoking cigarettes alongside using the nicotine patch could raise levels of nicotine to such a point that the patient may feel ill. The patient should use his/her prescribed NRT between cigarettes to alleviate a craving. Over time the individual will be encouraged to lengthen the intervals between each smoke, with possibly a target of a 50% reduction in the number of cigarettes smoked daily within six weeks.
Doctors recommend a total quit within six months of starting Nicotine-assisted reduction to stop treatment.
Other non-nicotine medications:
Varenicline (Chantix/Champix) - this drug interferes with the brain nicotine receptors, resulting in less pleasure from smoking and eventually fewer withdrawal symptoms. Varenicline should not be taken by patients under the age of 18 years, pregnant or breastfeeding women, individuals with advanced kidney disease, and people with epilepsy. Side effects may include:
- Dry mouth
- Increased appetite
- Nausea and vomiting
- Slow digestion
- Bloated stomach
- Unusual dreams.
Patients who have not quit completely before starting their first tablet should do so within 7 to 14 days. Most treatment courses last about 12 weeks. Successful patients may be prescribed another 12 weeks to make sure they do not go back to smoking.
- Clonidine (Catapres) - this medication is usually recommended if other therapies have not worked. It is primarily used for treating hypertension (high blood pressure). However, the side effects, such as sedation and drowsiness put many doctors and patients off.
Antidepressants - bupropion (Wellbutrin, Zyban) raise levels of dopamine and norepinephrine, as does nicotine. Some doctors may recommend a combination of bupropion and nicotine patch. This medication also reduces the risks of weight gain; a common consequence of giving up smoking. Patients with a history of seizures or serious head trauma, those under 18 years of age, pregnant or breastfeeding women, patients with anorexia or bulimia, individuals with a central nervous system tumor, and people with severe cirrhosis of the liver should not take bupropion. Bupropion may have the following side effects:
- Difficulty focusing
- Dry mouth
- Upset stomach.
Those who have not quit smoking completely before starting on bupropion therapy should do so within 14 days after taking the first tablet. A treatment course lasts for no longer than 7 to 9 weeks.
- Nicotine vaccine - this is still under development. The vaccine triggers the immune system to develop antibodies to nicotine, which bind to it as it enters the bloodstream, preventing the nicotine from ever reaching the brain. If this vaccine works, it will eliminate the brain rush that smokers experience, thereby doing away with the pleasure people derive from smoking. If nicotine does not enter the brain, there is no point in smoking for most addicted smokers.
- Telephone counseling - several countries worldwide have local or national telephone counseling services for patients who are trying to quit. People in the United Kingdom should call the NHS Stop Smoking helpline on 0800 022 4 332 for more information. Those in the USA may call the National Cancer Institute's 800-QUIT-NOW (800-784-8669) and the American Cancer Society's Quitline at 800-ACS-2345 (800-227-2345).
- Counseling with a tobacco treatment specialist - the patient can learn new techniques for quitting. Depending on which part of the world you live, these services may be available in hospitals, some health care plans, and health care providers.
- Internet - there are some web sites which offer support and encouragement for people who are trying to give up smoking. An example of a reputable web site is Nicotine Anonymous.
Lead author, Kimberly Horn, EdD, said "This study adds to evidence suggesting that exercise can help teenagers who are trying to quit smoking. Teens who boosted the number of days on which they engaged in at least 20 minutes of exercise, equivalent to a short walk, were more likely than their peers to resist lighting up a cigarette."
The authors say they do not know the exact mechanisms behind their findings. They believe that possibly the release of endorphins during exercise helps reduce the cravings for nicotine.
Does quitting smoking reduce or raise anxiety levels?Contrary to popular belief, giving up smoking usually results in lower levels of anxiety, British researchers reported in the British Journal of Psychiatry, January 2013 issue.
The authors wrote "The belief that smoking is stress relieving is pervasive, but almost certainly wrong. The reverse is true: smoking is probably anxiogenic (causes anxiety) and smokers deserve to know this and understand how their own experience may be misleading."
They found that smokers who light up as soon as they wake up had the most noticeable reductions in anxiety levels after they had quit.
What are the possible complications of nicotine dependence?
Lung diseases - the majority of lung cancers, cases of chronic bronchitis and emphysema are caused by smoking. Smoking is responsible for 90% of male lung cancer deaths and 80% of female lung cancer deaths in the USA. 90% of deaths in the USA from COPD (chronic obstructive lung disease) are caused by smoking.
"Healthy" smokers often have early signs of lung cancer - many smokers whose doctors tell them they are "healthy" after a normal examination could still have some early signs of lung cancer, researchers from Weill Cornell Medical College, New York, reported in the journal Stem Cells (July 2013 issue).
- Asthma - people with asthma usually find that smoking makes it worse.
- Cardiovascular problems - people who smoke regularly have a significantly higher risk of dying of heart attack, angina, peripheral vascular disease, and stroke. Even people who smoke just five cigarettes a day have an increased risk of cardiovascular diseases. Somebody who smokes 15 cigarettes per day runs twice the risk of having a heart attack, compared to a lifetime non-smoker. Smokers with cardiovascular disease usually have worse symptoms than non-smokers with cardiovascular disease.
- Cancer - not only does smoking increase the risk of developing lung cancer. Smokers are at higher risk of developing various other types of cancers, including cancer of the bladder, cervix, stomach, lip, throat, esophagus and larynx.
- Skin - smokers' skin tends to age faster than non-smokers'.
- Infertility - female regular smokers have a higher risk of infertility.
- Male impotence - male regular smokers have a significantly higher risk of developing erectile dysfunction (inability to get or sustain an erection).
Pregnancy and the baby - smoking while pregnant significantly raises the risk of miscarriage. Babies of mothers who smoked regularly during pregnancy tend to weigh less than other babies. Incidence of sudden infant death syndrome (SIDS) is higher among babies whose mothers smoke.
If a mother smokes at least a pack of 20 cigarettes per day while pregnant, her baby will have lower reading scores and struggle more with reading tests compared to peers whose mothers did not smoking during pregnancy, researchers from Yale School of Medicine reported in The Journal of Pediatrics.
- Respiratory infections - smokers tend to get more respiratory infections than non-smokers, such as flu, colds and bronchitis. Smokers are more prone to pneumonia, a potentially fatal infection in which the lungs become inflamed.
- Insulin resistance - smoking raises insulin resistance, increasing the risk of developing diabetes type 2. People with diabetes who smoke are more likely to suffer from complications compared to people with diabetes who don't smoke.
- Buerger's disease (thromboangiitis obliterans) - smoking can cause Buerger's disease; a disease of the arteries and veins in the arms and legs. The blood vessels swell and become blocked with thrombi (blood clots), eventually damaging or destroying skin tissues. Sometimes this may lead to infection and gangrene.
Premature death - on average, a man who has smoked throughout his life lives ten years less than a lifetime non-smoker. In the vast majority of cases the deaths were due to smoking-related diseases, including:
- Lung cancer
- COPD (chronic obstructive pulmonary disease) - including chronic bronchitis and emphysema
- Heart disease
- Sudden cardiac death - smokers, even light-to-moderate smokers have a much higher risk of sudden cardiac death than non-smokers, researchers from the University of Alberta's Mazankowski Heart Institute in Edmonton, Alberta, Canada, revealed in the journal Circulation: Arrhythmia & Electrophysiology. They added that the sudden cardiac death risk grows by 8% every five years, but starts dropping immediately as soon as the person quits.
Coping when you give up smokingMany smokers are daunted by the prospect of coping without cigarettes. Experts say the first step is to think carefully about how you feel about smoking. Then compile a list of all your reasons for quitting. And finally to set a quit date.
Although the thought of giving up and coping is sometimes frightening, it is important to remember that quitting is an incredibly positive step. The benefits for your body are huge. Experts say the following tips may help the individuals remain an ex-smoker forever:
- What makes you want to smoke? Identify your triggers and situations where not smoking is more challenging. This will help you to plan and prepare yourself.
- Support - family, friends, work colleagues, school friends can all help you with support and encouragement. It is important to tell them what you are doing and to explain how vital their encouragement is.
- Focus on the positive - focus on thoughts that make you pleased you are no longer a smoker. See this move as liberation, and not a sacrifice.
- Protect yourself from smokers - if you can, reduce your exposure to smokers as much as possible. If there are people in your household who smoke, talk to them and try to come to some arrangement, at least until you have become more confident about your long-term non-smoking prospects.
- Keep reading your list - regularly read the list of reasons why you wanted to give up smoking. Remind yourself how important it was for you then, and how important it will always be.
- Alcohol - until you are completely smoke free, avoid drinking alcohol if you can.
- Give yourself treats - when you reach certain milestones, treat yourself. What you are accomplishing is not easy and you deserve a reward. You could put money you would have spent on cigarettes in a special place - after a while you may be able to buy yourself a nice treat.
- Activities - find things to do to relieve stress. Exercise, apart from being good for the health, also helps relieve stress. An exercise program will also encourage you to remain smoke-free as you see your fitness levels improve. Some people who started an exercise program just before they quit were shocked at how quickly their fitness levels improved. If your exercise equipment can measure your pulse rate (heartbeat) you will soon find that you can achieve the same levels of exertion at lower heartbeats.
- Deep breathing - deep breathing is an integral part of smoking when the smoker is inhaling smoke. When you have a craving breathe deeply and visualize how your lungs are filling with fresh, clean air. Remind yourself why you quit and the benefits you are gaining.
- Delay - if you reach crisis point and feel you are about to light up, put it off. Give yourself at least 10 minutes. This 10 minute break will probably give you time to move beyond the craving. Cravings come, but they also go.
Written by Christian Nordqvist