Tobacco, Nicotine, and

E-Cigarette Use, Dependence,

and Treatment

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Introduction

In2014,theNationmarkedthe50thanniversaryofthefirstSurgeonGeneral’s

ReportonSmokingandHealth.In1964,morethan40percentoftheadult

populationsmoked.Oncethelinkbetweensmokinganditsmedical

consequences—includingcancersandheartandlungdiseases—becamea

partofthepublicconsciousness,educationeffortsandpublicpolicychanges

wereenactedtoreducethenumberofpeoplewhosmoke.Theseefforts

resultedinsubstantialdeclinesinsmokingratesintheUnitedStates—tohalf

the1964level.

However,ratesofcigarettesmokingandothertobaccousearestilltoohigh,

andsomepopulationsaredisproportionatelyaffectedbytobacco’shealth

consequences.Mostnotably,peoplewithmentaldisorders—including

substanceusedisorders—smokeathigherratesthanthegeneralpopulation.

Additionally,peoplelivingbelowthepovertylineandthosewithlow

educationalattainmentaremorelikelytosmokethanthoseinthegeneral

population.Astobaccouseistheleadingpreventablecauseofmortalityinthe

UnitedStates, differentialratesofsmokinganduseofothertobaccoproductsis

asignificantcontributortohealthdisparitiesamongsomeofthemostvulnerable

peopleinoursociety.

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Whatisthescopeoftobaccouseand

itscosttosociety?

Approximatelyonefourthofthepopulationusestobaccoproducts,and19.4

percentsmokecigarettes.Accordingtothe2016NationalSurveyonDrugUse

andHealth(NSDUH),anestimated63.4millionpeopleaged12orolderuseda

tobaccoproductduringthepastmonth,including51.3millioncigarette

smokers. Smokingratescontinuetogodownyeartoyear;thepercentageof

peopleoverage18whosmokecigarettesdeclinedfrom20.9percentin2005to

15.8percentin2016,accordingtothe2017NationalHealthInterviewSurvey.

However,smokingratesaresubstantiallyhigheramongsomeofthemost

vulnerablepeopleinoursociety.The25percentofAmericanswithmental

disorders,includingaddiction,accountfor40percentofthecigarettessmoked

intheU.S. (see"Dopeoplewithmentalillnessandsubstanceusedisorders

usetobaccomoreoften?").Morethan40percentofpeoplewithaGeneral

EducationDevelopmentcertificate(GED)smoke—whichisthehighest

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prevalenceofanysocioeconomicgroup. Also,peoplewholiveinruralareas,

particularlyintheSouthAtlanticstates,useallformsoftobaccoathigherrates

thanpeoplewholiveinurbanareas.Thesedifferencescannotbefully

explainedbydifferentlevelsofpovertyoraffluence.

Smokingamongyouthisathistoricallylowlevels.AccordingtotheNIDA-

sponsoredMonitoringtheFuture(MTF)survey, in2015,anestimated4.7

millionmiddleandhighschoolstudentsusedtobaccoproductsduringthepast

month,accordingtodatafromtheNationalYouthTobaccoSurvey(NYTS) e-

cigarettes)werethemostcommonlyusedtobaccoproductsamongmiddle(5.3

percent)andhighschool(16.0percent)studentsin2015. E-cigarettesdeliver

syntheticnicotineanddonotcontaintobacco;however,theyareclassifiedas

tobaccoproductsforregulatorypurposes.Thesefindingsareechoedbyother

studies, includingthe MTFsurvey. Scientistshavenotyetdeterminedthe

medicalconsequencesoflong-terme-cigaretteuseorthesecondhandeffects

ofe-cigarettevapor(see"Whatareelectroniccigarettes?").

Between1964and2012,anestimated17.7milliondeathswererelatedto

smoking leadstomorethan480,000deathsannually. Ifcurrentsmoking

ratescontinue,5.6millionAmericanswhoarecurrentlyyoungerthan18willdie

prematurelyfromsmoking-relateddisease.

Inadditiontothetremendousimpactofprematuredeathsrelatedtotobacco

use,theeconomiccostsarehigh.Expertsestimatethatbetween2009and

2012,theannualsocietalcostsattributabletosmokingintheUnitedStates

werebetween$289and$332.5billion.Thisincludes$132.5to$175.9billion

fordirectmedicalcareofadultsand$151billionforlostproductivitydueto

prematuredeaths.In2006,lostproductivityduetoexposuretosecondhand

smokecostthecountry$5.6billion. About70percentofcurrentsmokers’

excessmedicalcarecostscouldbepreventedbyquitting.

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Howdoestobaccodeliveritseffects?

Thesmokefromcombustibletobaccoproductscontainsmorethan7,000

chemicals.Nicotineistheprimaryreinforcingcomponentoftobacco;itdrives

tobaccoaddiction. Hundredsofcompoundsareaddedtotobaccoto

enhanceitsflavorandtheabsorptionofnicotine. Cigarettesmokingisthe

mostpopularmethodofusingtobacco;however,manypeoplealsouse

smokelesstobaccoproducts,suchassnuffandchewingtobacco,whichalso

containnicotine(see"OtherTobaccoProducts").E-cigarettes,whichdeliver

nicotineintheabsenceofotherchemicalsintobacco,havebecomepopularin

recentyears(see"Whatareelectroniccigarettes?").

Thecigaretteisaveryefficientandhighlyengineereddrug-deliverysystem.By

inhalingtobaccosmoke,theaveragesmokertakesin1–2milligramsofnicotine

percigarette.Whentobaccoissmoked,nicotinerapidlyreachespeaklevelsin

thebloodstreamandentersthebrain.Atypicalsmokerwilltake10puffsona

cigaretteovertheroughly5minutesthatthecigaretteislit. Thus,aperson

whosmokesabout1pack(20cigarettes)dailygets200"hits"ofnicotinetothe

braineachday.Amongthosewhodonotinhalethesmoke—suchascigarand

pipesmokersandsmokelesstobaccousers—nicotineisabsorbedthrough

mucousmembranesinthemouthandreachespeakbloodandbrainlevels

moreslowly.

Immediatelyafterexposuretonicotine,thereisa"kick"causedinpartbythe

drug’sstimulationoftheadrenalglandsandresultingdischargeofepinephrine

(adrenaline).Therushofadrenalinestimulatesthebodyandcausesan

increaseinbloodpressure,respiration,andheartrate. Likeotherdrugs,

nicotinealsoactivatesrewardpathwaysinthebrain—circuitrythatregulates

reinforcementandfeelingsofpleasure.

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Isnicotineaddictive?

Yes.Mostsmokersusetobaccoregularlybecausetheyareaddictedtonicotine.

Addictionischaracterizedbycompulsivedrug-seekinganduse,eveninthe

faceofnegativehealthconsequences.Themajorityofsmokerswouldliketo

stopsmoking,andeachyearabouthalftrytoquitpermanently.Yet,onlyabout

6percentofsmokersareabletoquitinagivenyear. Mostsmokerswillneed

tomakemultipleattemptsbeforetheyareabletoquitpermanently.

Medicationsincludingvarenicline,andsomeantidepressants(e.g.bupropion),

andnicotine-replacementtherapy,canhelpinmanycases(see"Whatare

treatmentsfortobaccodependence?").

Atransientsurgeofendorphinsintherewardcircuitsofthebraincausesa

slight,briefeuphoriawhennicotineisadministered.Thissurgeismuchbriefer

thanthe"high"associatedwithotherdrugs.However,likeotherdrugsofabuse,

nicotineincreaseslevelsoftheneurotransmitterdopamineinthesereward

circuits, whichreinforcesthebehavioroftakingthedrug.Repeated

exposurealtersthesecircuits'sensitivitytodopamineandleadstochangesin

otherbraincircuitsinvolvedinlearning,stress,andself-control.Formany

tobaccousers,thelong-termbrainchangesinducedbycontinuednicotine

exposureresultinaddiction,whichinvolveswithdrawalsymptomswhennot

smoking,anddifficultyadheringtotheresolutiontoquit.

Thepharmacokineticpropertiesofnicotine,orthewayitisprocessedbythe

body,contributetoitsaddictiveness. Whencigarettesmokeentersthelungs,

nicotineisabsorbedrapidlyinthebloodanddeliveredquicklytothebrain,so

thatnicotinelevelspeakwithin10secondsofinhalation.Buttheacuteeffectsof

nicotinealsodissipatequickly,alongwiththeassociatedfeelingsofreward;this

rapidcyclecausesthesmokertocontinuedosingtomaintainthedrug's

pleasurableeffectsandpreventwithdrawalsymptoms.

Withdrawaloccursasaresultofdependence,whenthebodybecomesusedto

havingthedruginthesystem.Beingwithoutnicotinefortoolongcancausea

regularusertoexperienceirritability,craving,depression,anxiety,cognitiveand

attentiondeficits,sleepdisturbances,andincreasedappetite.Thesewithdrawal

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symptomsmaybeginwithinafewhoursafterthelastcigarette,quicklydriving

peoplebacktotobaccouse.

Whenapersonquitssmoking,withdrawalsymptomspeakwithinthefirstfew

daysofthelastcigarettesmokedandusuallysubsidewithinafewweeks. For

somepeople,however,symptomsmaypersistformonths,andtheseverityof

withdrawalsymptomsappearstobeinfluencedbyaperson'sgenes.

Inadditiontoitspleasurableeffects,nicotinealsotemporarilyboostsaspectsof

cognition,suchastheabilitytosustainattentionandholdinformationin

memory.However,long-termsmokingisassociatedwithcognitivedeclineand

riskofAlzheimer'sDisease,suggestingthatshort-termnicotine-related

enhancementdoesnotoutweighlong-termconsequencesforcognitive

functioning. Inaddition,peopleinwithdrawalfromnicotineexperience

neurocognitivedeficitssuchasproblemswithattentionormemory. These

neurocognitivewithdrawalsymptomsareincreasinglyrecognizedasa

contributortocontinuedsmoking. Asmallresearchstudyalsosuggestedthat

withdrawalmayimpairsleepforseverelydependentsmokers,andthatthismay

additionallycontributetorelapse.

Inadditiontothedrug'simpactonmultipleneurotransmittersandtheir

receptors, manybehavioralfactorscanaffecttheseverityofwithdrawal

symptoms.Formanypeoplewhosmoke,thefeel,smell,andsightofacigarette

andtheritualofobtaining,handling,lighting,andsmokingthecigaretteareall

associatedwiththepleasurableeffectsofsmokingandcanmakewithdrawalor

cravingworse. Learningprocessesinthebrainassociatethesecueswith

nicotine-induceddopaminesurgesintherewardsystem —similartowhat

occurswithotherdrugaddictions.Nicotinereplacementtherapiessuchasgum,

patches,andinhalers,andothermedicationsapprovedforthetreatmentof

nicotineaddictionmayhelpalleviatethephysiologicalaspectsofwithdrawal

(see"Whataretreatmentsfortobaccodependence?");however,cravings

oftenpersistbecauseofthepowerofthesecues.Behavioraltherapiescanhelp

smokersidentifyenvironmentaltriggersofcravingsotheycanusestrategiesto

avoidthesetriggersandmanagethefeelingsthatarisewhentriggerscannot

be.

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Arethereotherchemicalsthatmaycontributetotobacco

addiction?

Researchisshowingthatnicotinemaynotbetheonlyingredientin

tobaccothataffectsitsaddictivepotential.

Smokingislinkedwithamarkeddecreaseinthelevelsofmonoamine

oxidase(MAO),animportantenzymethatisresponsibleforthebreakdown

ofdopamine,aswellasareductioninMAObindingsitesinthebrain.

Thischangeislikelycausedbysomeas-yet-unidentifiedingredientin

tobaccosmokeotherthannicotine,becauseweknowthatnicotineitself

doesnotdramaticallyalterMAOlevels.Animalresearchsuggeststhat

MAOinhibitionmakesnicotinemorereinforcing,butmorestudiesare

neededtodeterminewhetherMAOinhibitionaffectshumantobacco

dependence.

Animalresearchhasalsoshownthatacetaldehyde,anotherchemicalin

tobaccosmokecreatedbytheburningofsugarsaddedassweeteners,

dramaticallyincreasesthereinforcingpropertiesofnicotineandmayalso

contributetotobaccoaddiction.

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Whatarethephysicalhealth

consequencesoftobaccouse?

Cigarettesmokingharmsnearlyeveryorganinthebody, andsmokingisthe

leadingpreventablecauseofprematuredeathintheUnitedStates.Although

ratesofsmokinghavedeclined,itisestimatedthatitleadstoabout480,000

deathsyearly. Smokersaged60andolderhaveatwofoldincreaseinmortality

comparedwiththosewhohaveneversmoked,dyinganestimated6years

earlier. Quittingsmokingresultsinimmediatehealthbenefits,andsomeorall

ofthereducedlifeexpectancycanberecovereddependingontheagea

personquits.

Althoughnicotineitselfdoesnotcausecancer,atleast69chemicalsintobacco

smokearecarcinogenic, andcigarettesmokingaccountsforatleast30

percentofallcancerdeaths. Theoverallratesofdeathfromcanceraretwice

ashighamongsmokersasnonsmokers,withheavysmokershavingafour

timesgreaterriskofdeathfromcancerthannonsmokers.

Foremostamongthecancerscausedbytobaccouseislungcancer.Cigarette

smokinghasbeenlinkedtoabout80to90percentofallcasesoflungcancer,

theleadingcauseofcancerdeathforbothmenandwomen,anditis

responsibleforroughly80percentofdeathsfromthisdisease. Smoking

increaseslungcancerriskfivetotenfold,withgreaterriskamongheavy

smokers. Smokingisalsoassociatedwithcancersofthemouth,pharynx,

larynx,esophagus,stomach,pancreas,cervix,kidney,andbladder,aswellas

acutemyeloid. Cigarettesmokingisnottheonlyformoftobaccouse

associatedwithcancers.Smokelesstobacco(see"OtherTobaccoProducts")

hasbeenlinkedtocancerofthepharynx,esophagus,stomach,andlung,as

wellastocolorectalcancer.

Inadditiontocancer,smokingcauseslungdiseasessuchaschronicbronchitis

andemphysema,andithasbeenfoundtoexacerbateasthmasymptomsin

adultsandchildren.Cigarettesmokingisthemostsignificantriskfactorfor

chronicobstructivepulmonarydisease(COPD). Survivalstatisticsindicate

thatquittingsmokingresultsinrepairtomuchofthesmoking-inducedlung

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damageovertime.However,onceCOPDdevelops,itisirreversible;COPD-

relatedlungdamageisnotrepairedwithtime.

Smokingalsosubstantiallyincreasestheriskofheartdisease,includingstroke,

heartattack,vasculardisease,andaneurysm. Cardiovasculardiseaseis

responsiblefor40percentofallsmoking-relateddeaths. Smokingcauses

coronaryheartdisease,theleadingcauseofdeathintheUnitedStates.

Smokingisalsolinkedtomanyothermajorhealthconditions—including

diabetes,rheumatoidarthritis,inflammation,andimpairedimmunefunction.

Evenyoungsmokersaged26to41reportreducedhealth-relatedqualityoflife

comparedwithnonsmokingpeers,accordingtoacross-sectionalpopulation

study.

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Whataretheeffectsofsecondhand

andthirdhandtobaccosmoke?

Secondhandsmokeisasignificantpublichealthconcernanddriverofsmoke-

freepolicies.Alsocalledpassiveorsecondarysmoke,secondhandsmoke

increasestheriskformanydiseases. Exposuretoenvironmentaltobacco

smokeamongnonsmokersincreaseslungcancerriskbyabout20percent.

Secondhandsmokeisestimatedtocauseapproximately53,800deaths

annuallyintheUnitedStates. Exposuretotobaccosmokeinthehomeisalso

ariskfactorforasthmainchildren.

Smokingalsoleaveschemicalresidueonsurfaceswheresmokinghas

occurred,whichcanpersistlongafterthesmokeitselfhasbeenclearedfrom

theenvironment.Thisphenomenon,knownas"thirdhandsmoke,"is

increasinglyrecognizedasapotentialdanger,especiallytochildren,whonot

onlyinhalefumesreleasedbytheseresiduesbutalsoingestresiduesthatget

ontheirhandsaftercrawlingonfloorsortouchingwallsandfurniture.More

researchisneededontherisksposedtohumansbythirdhandsmoke,buta

studyinmiceshowedthatthirdhandsmokeexposurehasseveralbehavioral

andphysicalhealthimpacts,includinghyperactivityandadverseeffectsonthe

liverandlungs.

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Whataretherisksofsmokingduring

pregnancy?

Smokingduringpregnancyislinkedwitharangeofpoorbirthoutcomes—

including:

Lowbirthweightandpretermbirth

Restrictedheadgrowth

Placentalproblems

Increasedriskofstillbirth

Increasedriskofmiscarriage

Healthanddevelopmentalconsequencesamongchildrenhavealsobeen

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linkedtoprenatalsmokeexposure,including:

Poorerlungfunction,persistentwheezing,andasthma,possiblythrough

DNAmethylation

Visualdifficulties,suchasstrabismus,refractiveerrors,andretinopathy

Unfortunately,smokingbypregnantwomeniscommon.In2014,8.4percentof

womensmokedatanytimeduringpregnancy,withthoseaged20to24who

wereAmericanIndianorAlaskaNativeshavinghigherrates,at13percentand

18percent,respectively. Onefifthofwomenwhosmokedduringthefirst6

monthsofpregnancyquitbytheirthirdtrimester.Overallcessationrateswere

highestforthosewiththehighesteducationalattainmentandprivate

insurance. Therefore,thereisaclearneedtoexpandsmokingcessation

treatmenttoyoungerwomenandtothoseoflowersocioeconomicstatus(see

Box:"SmokingCessationforPregnantWomen").

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Howmanyadolescentsusetobacco?

Mostpeoplewhousetobaccostartedduringadolescence,andthosewho

beginatayoungeragearemorelikelytodevelopnicotinedependenceand

havetroublequitting. Accordingtothe2017MonitoringtheFutureSurvey,9.7

percentof12thgraders,5.0percentof10thgraders,and1.9percentof8th

gradersusedcigarettesinthepastmonth. Analysesofthe2012National

YouthTobaccoSurvey(NYTS)foundthat20.8percentofcurrentadolescent

tobaccousersreportedwantingtousetobaccowithin30minutesofwaking—a

classicsymptomofnicotinedependence.Thisstudyalsofoundthat41.9

percentreportedstrongcravingsfortobacco. Otherresearchhasfoundthat

lightandintermittentsmokingamongadolescentsisassociatedwiththesame

levelofdifficultyquittingasdailysmoking.

Anyexposuretonicotineamongyouthisaconcern.Theadolescentbrainisstill

developing,andnicotinehaseffectsonthebrain’srewardsystemandbrain

regionsinvolvedinemotionalandcognitivefunctions. Researchsuggeststhat

thenicotine-relatedchangestotheseareasofthebrainduringadolescence

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mayperpetuatecontinuedtobaccouseintoadulthood. Thesechangesalso

contributetoahigherrateofothersubstanceusedisordersamongpeoplewho

usetobaccoduringadolescence,sometimesreferredtoasa

"gateway"effect.

Mentalhealth,beliefsaboutsmoking,perceptionofschoolmates’smoking,and

othersubstanceuseareadditionalfactorsthatcaninfluenceanadolescent’s

riskforsmokingandnicotinedependence. Emotionalproblems—including

depression andrecentnegativelifeevents —areassociatedwithtobacco

useamongadolescents.Smokingamongpeersandwithinsocialgroupsisa

majorenvironmentalfactorthatinfluencesadolescentsmoking;socialsmoking

isamoreimportantmotivatorforadolescentscomparedtoadultsmokers.

Itiscommonforadolescentsmokingtofollowanintergenerationalpattern,

whichhasgenetic,epigenetic,andenvironmentalinfluences. Datafrom

parentsandadolescentssuggeststhatcurrentparentalnicotinedependenceis

stronglylinkedwithadolescentsmokinganddependence.Otherfactors—such

asparents’education,maritalstatus,andparentingbehavioralsoinfluence

teensmoking.

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Whatareelectroniccigarettes?

E-cigarettes(electronicnicotinedeliverysystems)emergedintheU.S.marketin

2007andhaverapidlygrowninpopularity. E-cigarettes,ore-vaporizers,are

devicesthatheataliquidcontainingsolvents,flavors,andoftennicotine.

Usersinhaletheresultingvapor.Avarietyofdesignsareavailable,some

mimickingthelookoftraditionalcigarettes.Morethan7,000flavorsare

availablefore-cigarettes, someofwhichareespeciallyappealingtoyouth.

Manyconveniencestores,drugstores,grocerystores,andotherphysicaland

onlineretailoutletsselle-cigarettes,althoughasofAugust,2016,itisillegalto

sellthemtopeopleunder18.Someconveniencestoresanddrugstorechains

havealsostoppedsellinge-cigarettestopromotepublichealth.

In2013,morethanonethirdofcigarettesmokerssaidtheyhadeverusede-

cigarettes. Accordingtodatafromthe2014TobaccoProductsandRisk

PerceptionsSurvey,currentcigarettesmokershadagreaterlikelihoodofusing

e-cigarettes.Thisanalysisfoundthathalfofcigarettesmokershadeverusedan

e-cigaretteand20.7percentcurrentlyusedthesedevices.However,

approximately10percentofadultswhousede-cigaretteshadneversmoked

previously. Datafromthe2014NationalHealthInterviewSurveyindicated

that0.4percentofadultswhohaveneversmokedand0.8percentofformer

smokers(abstinent4ormoreyears)currentlyusee-cigarettes. Thesurvey

alsofoundthat13percentofdailye-cigaretteuserswereformersmokerswho

quitduringthepastyear.

Aswithcigaretteuse,e-cigaretteuseishigheramongpeoplewithmental

healthconditions—with3.1percentcurrentlyusingcomparedwith1.1percent

ofthosewithoutmentalillness. Itisalsoaconcernthatpregnantwomenare

usinge-cigarettes,asnicotineexposureduringperiodsofdevelopmental

vulnerability(includingprenataldevelopment)hasadversehealth

consequences.

Usersreportthebeliefthate-cigaretteproductsarelessharmfulthantraditional

cigarettes, andmanyreportusingthemtohelpquitsmokingtraditional

cigarettes.Whileitisnotyetclearife-cigarettesareeffectivesmokingcessation

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aids,thedevicesaresometimesmarketedforthispurpose (see"Aree-

cigarettesusefulforsmokingcessation?").Someresearchsuggeststhatolder

adultsusethesedevicesasatobaccosubstitute,althoughnotalwaysasa

cessationmethod. Usersalsociteconvenienceandbeingconscientious

towardsothersasreasonsforusingtheseproducts.

Howdoesthefederalgovernmentregulatee-cigarettes?

TheU.S.FoodandDrugAdministration(FDA),whichregulatescigarettes,

tobacco,andsmokelesstobacco,gainedtheauthorityin2016toalso

regulateelectronicnicotinedeliverysystems(suchase-cigarettesand

vapepens),allcigars,hookah(waterpipe)tobacco,pipetobacco,and

nicotinegels,amongothertobaccoproducts.Underthenewregulations,

e-cigarettemanufacturersmustlistingredients,andvendorscannotselle-

cigarettestopeopleunderage18.

Isittruethate-cigarettesaresaferthantraditionalcigarettes?

Itislikelythat,onbalance,e-cigarettesaresaferthantraditionalcigarettes

fromthestandpointofphysicalhealth.However,asdiscussedabove,the

nicotineine-cigarettescancauseaddictionandneurocognitive

impairments.

Althoughforregulatorypurposese-cigarettesareclassifiedas“tobacco

products,”theydonotcontaintobaccoorproducethesametoxic

combustionproducts,liketar,thatcauselungcancerandotherdiseasesin

usersandpeopleexposedtosecondhandsmoke.However,thevapor

frome-cigarettestypicallycontainsnicotineandarangeofother

chemicals. Becausetheseproductsarerelativelynew,evidenceonthe

short-termeffectsofexposuretoe-cigaretteaerosolsislimited,andvery

littleisknownaboutthelong-termhealtheffects.

Areviewofrecentliteraturefoundthatsomeofthechemicalsine-cigarette

liquid,propyleneglycolandglycerol,causethroatirritationand

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coughing. Otherresearchsuggeststhatvaporexposuremaybelinked

withimpairedlungfunction. Chemicalanalysesthatcomparetheprofiles

ofelectronicandtraditionalcigaretteshavesuggestedthate-cigarettes

haveareducedcarcinogenicprofileandimpartalowerpotentialfor

disease. However,toxicants,carcinogens,andmetalparticleshavebeen

detectedintheliquidsandaerosolsofe-cigarettes,anditiscurrently

unclearwhatrisktheyposewithrepeateduse. Aswithtraditional

cigarettes,useofe-cigarettesinvoluntarilyexposesnonusersto

secondhandandthirdhandaerosol.

Theresearchonsecondhandexposuretotheaerosolfrome-cigarettesis

limited,butonestudyfoundthatfineparticulatematterconcentrations

duringanindooreventinalargeroomwithe-cigarettesmokerswere

higherthanthosereportedpreviouslyinvenuesthatallowedcigarette

smoking. Aninvitrostudyshowedthatexposinglungtissuesandcellsto

e-cigaretteliquidinducedincreasedinflammatoryresponsesandoxidative

stressmarkers. Anotherstudythatanalyzede-cigaretteflavoringsfound

that39ofthe51flavorstestedpositivefordiacetyl,achemicalassociated

withanirreversibleobstructivelungdiseasecalledbronchiolitisobliterans.

Otherchemicals,2,3-pentanedioneandacetoin,associatedwithsevere

respiratorydiseasesamongexposedpeople,werealsofoundinmanye-

cigaretteflavorings.

Theamountofnicotineine-cigarettefluidvaries.Someresearchhasfound

thate-cigarettesdeliverlessnicotineonaveragethantraditional

cigarettes, butthatusersmaychangepuffingpatternstocompensate.

Inexperiencede-cigaretteuserstakeinmodestnicotineconcentrations,but

thosewhoregularlyusethesedevicesadjusttheirpuffingtoconsume

similarlevelsofthedrugaswithtraditionalcigarettes. Newere-

cigarettedevicescandeliversubstantialamountsofnicotine,andsome

usersareabletogetnicotineatlevelssimilarto orevengreaterthana

traditionalcigarette. Onestudyfoundequivalentlevelsofnicotine's

majormetaboliteinthebloodofsmokerswhousetraditionalande-

cigarettes. Thus,allthenicotine-relatedconcernsoftraditionalcigarettes

—addiction,effectsoncognitivefunction,andeffectsonprenatal

development—applytoe-cigarettesaswell.

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RisksofE-CigarettestoChildren

Youngchildrenmayaccidentallyingesttheconcentratednicotine

(whichoftencontainsflavors)ine-cigaretteliquid. TheCentersfor

DiseaseControlandPreventionrecentlycomparedcallstopoison

centersintheUnitedStatesrelatedtohumanexposurestoe-

cigarettesandtraditionalcigarettes.Thestudyfoundthatbetween

September2010andFebruary2014,theproportionofe-cigarette

callsamongallcigarette-relatedcallsincreasedfrom0.3percentto

41.7percent. Mostofthee-cigaretteexposureswereamong

childrenundertheageof5years(51.1percent)andpeopleoverage

20(42.0percent),whereasalmostalltraditionalcigaretteexposure

callsinvolvedyoungchildren. Dataindicatedthatagreater

proportionofe-cigaretteexposurecalls(57.8percent)resultedin

adversehealtheffectsthantraditionalcigaretteexposure(36.0

percent).Theseadversehealtheffectsincludedvomiting,nausea,and

eyeirritation.

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Aree-cigarettesusefulforsmokingcessation?

Someresearchsuggestse-cigarettesmayhelppeoplequitsmoking

cigarettes,whileotherdatasuggestthattheycanimpedequittingandthat

theymayopenthedoortotraditionalcigaretteuseforpeoplewhomight

nototherwisetrythem.Thus,muchmoreresearchisneededonthis

question.

Onereviewofrecentstudiessuggestedthatthelikelihoodofquitting

cigaretteswas28percentloweramongindividualswhousede-cigarettes

comparedwiththosewhodidnotusethesedevices,regardlessofwhether

userswereinterestedinquitting. ResearchfromtheUnitedKingdom

suggeststhatamongsmokerswhocontinuetousetraditionalcigarettes,

dailyuseofe-cigaretteswasassociatedwithincreasedattemptstoquit

andcutback,butnotwithsuccess. However,anotheranalysisestimated

that,inEngland,16,000smokerswereabletoquitin2014whowouldnot

havequitife-cigaretteshadnotbeenavailable. Areviewandmeta-

analysisalsosuggestedthatusinge-cigarettesforaminimumof6months

wasassociatedwithquittingorreducingthenumberofcigarettesused.

E-cigarettesandTeens

Nationalsurveydatasuggestthate-cigaretteswerethemostcommonly

usednicotinedeliveryproductamongyouth. Areviewoftheliterature

foundthatupto20percentofadolescentswhocurrentlyusee-cigarettes

hadneversmokedatraditionalcigarette.

Amajorconcernisthate-cigarettes’flavors,design,andmarketing

particularlyappealtoyouth, andthatbyintroducingyoungpeopleto

nicotineandglamorizingasmoking-likebehavior,e-cigarettescouldopen

thedoortocigaretteuseinapopulationthatisparticularlyvulnerableto

addictionandthathasseenhistoricdeclinesincigarettesmoking.

Someresearchindicatesthate-cigaretteusemayleadtotheuseof

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traditionalcigarettesamongadolescentsandyoungadults. Accordingto

datafromthe2012NYTS,youthwhohadonlyusede-cigarettesreported

anincreasedintentiontosmoketraditionalcigarettescomparedwithpeers

whohadneverusedthesedevices.Thesurveyfoundnolinkbetweene-

cigaretteuseandintentiontoquitsmokingamongyouthwhowerecurrent

smokers,indicatingthatthisagegroupdoesnotseetheseproducts

primarilyassmoking-cessationaids. Alongitudinalcohortstudyof16-to

26-year-oldswhohadneversmokedtraditionalcigarettesfoundthat2.3

percent(16participants)usede-cigarettesatthestartofthestudy.Aftera

one-yearfollow-up,approximately69percent(11of16)ofthese

participantsprogressedtosmokingtraditionalcigarettescomparedto18.9

percent(128of678)amongthosewhoneverusedane-

cigarette. Anotherstudyfoundthatpast-monthe-cigaretteusepredicted

futurecigaretteuse,butthatpast-monthcigaretteusedidnotpredictfuture

e-cigaretteuse.

Manyyoungpeoplereportexperimentingwithe-cigarettesoutofcuriosity,

becausetheflavorsappealtothem,orbecauseofpeerinfluences. The

majorityofyouthwhoreportede-cigaretteuseinonestudyhadfriends

whousedtheseproducts.Almosthalfofadolescentswhousede-

cigarettessaidthattheydidnotbelievetheseproductswereassociated

withhealthrisks. Youngpeoplealsoperceivede-cigarettesaseasyto

obtain,"cool,"andabetteralternativetocigarettesbecausetheywere

thoughttobehealthierandcouldbeusedanywhere.Amongyouthwho

stoppedusinge-cigarettes,themajorunderlyingreasonswerehealth

concerns,lossofinterest,highcost,badtaste,andviewofe-cigarettesas

lesssatisfyingthancigarettes.

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OtherTobaccoProducts

Whilecigarettesmokinghasdeclinedsignificantlyduringthepast40years,use

ofothertobaccoproductsisincreasing—particularlyamongyoung

people. Theseinclude:

Cigars:tobaccowrappedinleaftobaccooranothertobacco-containing

substanceinsteadofpaper,whichcanbeboughtindividually

Cigarillos:smallcigarsthatcostlessandarealsoavailableforpurchase

individually

Hookahsorwaterpipes:pipeswithalong,flexibletubefordrawingsmoke

fromlit,flavoredtobaccothroughwatercontainedinabowl

Smokelesstobacco:productslikechewingtobaccoandsnuffthatare

placedinthemouthbetweentheteethandgums

Powdertobacco:mixturesthatareinhaledthroughthenose

In2014,almostone-quarterofhighschoolstudentsreportedpast-monthuseof

atobaccoproduct—withe-cigarettes(13.4percent),hookahs(9.4percent),

cigarettes(9.2percent),cigars(8.2percent),smokelesstobacco(5.5percent),

andsnus(moistpowdertobacco)(1.9percent)asthemostpopular.

Cigars

In2016,anestimated12millionpeopleaged12orolder(4.6percentofthe

adolescentandadultpopulation)smokedcigarsduringthepastmonth. The

majorityofadolescentsandyoungadultswhosmokedcigarsalsosmoke

cigarettes.

Cigarillos

DatafromtheTobaccoUseSupplementtotheCurrentPopulationSurveyand

NSDUHsuggestthatyoungerandlesseconomicallyadvantagedmalesinitiate

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tobaccousewithcigarillos. From2002to2011,past-monthcigarette

smokingdeclinedformalesandfemalesofallagegroups.However,duringthis

sameperiod,ratesofcigarillouseamongmalesaged18to25remained

constant(atapproximately9percent).

Hookahsorwaterpipes

Between2011and2014,useofhookahincreasedamongmiddleandhigh

schoolstudents,despitedecreaseduseofcigarettesandcigars,accordingto

theNYTS. Researchalsosuggeststhatratesofhookahusefortobacco

smokingincreaseduringthefirstmonthofcollege. Nationallyrepresentative

datafromcollegestudentsindicatethatdailycigaretteorcigarsmokers(aswell

asmarijuanausers)weremorelikelytobefrequentwaterpipeusers.

Hookahusersmaymistakenlybelievethatitislessaddictiveordangerousthan

cigarettes;however,onesessionofhookahsmokingexposeduserstogreater

smokevolumesandhigherlevelsoftobaccotoxicants(e.g.,tar)thanasingle

cigarette. Additionally,hookahsmokingislinkedwithnicotinedependence

anditsassociatedmedicalconsequences (see"Whatarethephysical

healthconsequencesoftobaccouse?").Reviewsoftheliteratureonwaterpipe

userssuggestthatlikethosewhouseotherformsoftobacco,manyhavetriedto

quitbuthavebeenunsuccessfulontheirown. Thesefindingsindicatethe

needfortobaccocontrolpoliciesandpreventionandtreatmentinterventionsfor

thisformofnicotinedeliverythataresimilartothoseseenforcigarettes.

Smokelesstobacco

In2016,8.8millionpeopleaged12orolder(3.3percentofthispopulation)

usedsmokelesstobaccoduringthepastmonth. Overall,useofsmokeless

tobaccoamongadultsdecreasedfrom1992to2003buthasheldconstant

since. Longitudinaldatasuggestthatpeoplearemorelikelytoswitchfrom

smokelesstobaccousetocigarettesmokingthanviceversa. Although

smokersmayattempttousesmokelessproductstocutdownorquit,research

suggeststhatthisapproachisnoteffective. However,somearguethatusing

smokelesstobaccoinlieuofcigarettesmayhelpreducetheharmsassociated

withsmokingtraditionalcigarettes.

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PolytobaccoUse

Someusersoftobaccoconsumeitinmultipleforms(polytobaccouse);this

behaviorisassociatedwithgreaternicotinedependence andtheriskfor

othersubstanceusedisorder. AnalysesofadecadeofdatafromNSDUH

foundsteadyratesofpolytobaccousefrom2002to2011(8.7percentto7.4

percent)amongpeopleage12andolder.However,useofsomeproduct

combinations—suchascigarettesandsmokelesstobacco,cigarsand

smokelesstobacco,anduseofmorethantwoproducts—increasedoverthat

period.

Amongindividualsyoungerthan26,ratesofpolytobaccouseincreaseddespite

declinesinoveralltobaccouse.Polytobaccousewasassociatedwithbeing

male,havingrelativelylowincomeandeducation,andengaginginrisk-taking

behaviors. In2014,anestimated2.2millionmiddleandhighschoolstudents

hadusedtwoormoretypesoftobaccoproductsduringthepastmonth,

accordingtotheNYTS. Polytobaccousewascommon,evenamongstudents

whousedtobaccoproducts5daysorfewerduringthepastmonth. The2012

NYTShadfoundthat4.3percentofstudentsusedthreeormoretypesof

tobacco.Thisstudyalsoobservedthatmalegender,useofflavoredproducts,

nicotinedependence,receptivitytotobaccomarketing,andperceivedpeeruse

wereallassociatedwithyouthpolytobaccouse.

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FlavoredTobaccoUseAmongAdolescentsandYoung

Adults

Onespecificconcernaboute-cigarettesandtobaccoproductslike

cigarillosandhookahsistheadditionofflavorings,whichmaymakethem

particularlyappealingtoyouth. TheFamilySmokingPreventionand

TobaccoControlActof2009bannedthesaleofcigaretteswithflavors

otherthanmenthol,butotherflavoredtobaccoproducts(e.g.,smallcigars,

cigarillos,andsmokelesstobacco)canstillbesold.Addingflavorsto

tobaccoproductsortothenicotinesolutionofe-cigarettescanmakethem

moreappealingtosomeusersbecausetheycanmasktheharsh

taste. Althoughmoreresearchisneededonhowflavorsaffectlong-

termuse,healthexpertshaveexpressedconcernsthatmanyofthe

flavoringsusedintobaccoproductsarealsofoundincandiesand

beverages. Suchflavorsmaymakethemmoreappealingtoyouthand

maycontributetoincreaseduseoftheseproductsamongyoungpeople.

Approximately6.3percentofmiddleandhighschoolstudentsreported

usingeitherflavoredcigarettesorsmallcigars,accordingtothe2011

NYTS. Datafromthe2014NYTSindicatethatofmiddleandhighschool

studentswhocurrentlyusedtobacco,about70percent—anestimated3.26

millionyouths—hadusedatleastoneflavoredtobaccoproductduringthe

pastmonth. Amongpast-monthusers,themostcommonlyusedflavored

productsweree-cigarettes,hookahtobacco,andcigars. Itseemsthat

youthmaynotnecessarily“growoutof”usingflavoredtobaccoproducts.

Amongyoungadultsaged18to34,nearlyone-fifth(18.5percent)ofthose

whousetobacco,consumedflavored(includingmenthol)products.

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Aretheregenderdifferencesin

tobaccosmoking?

Generally,mentendtousealltobaccoproductsathigherratesthan

women. In2015,16.7percentofadultmalesand13.6percentofadult

femalessmokedcigarettes. Suchdifferencesmayrelatetoacombinationof

physiological(particularlyovarianhormones),cultural,andbehavioral

factors.

Resultsfromneuroimagingstudiessuggestthatsmokingactivatesmen’s

rewardpathwaysmorethanwomen's. Thisfindingisconsistentwiththeidea

thatmensmokeforthereinforcingeffectsofnicotine,whereaswomensmoketo

regulatemoodorinresponsetocigarette-relatedcues.Astudyofstress

responsesandcravingamongmaleandfemalesmokerswhoweretryingto

quitfoundthatduringabstinence,lowerlevelsofthestresshormonecortisol

predictedrelapseinmen.However,highcortisollevelswerepredictiveof

relapseinwomen. Otherworkonabstinencefoundthatsmokingacigarette

withnicotine,ascomparedtoade-nicotinizedcigarette,alleviatedthe

Photoby©Thinkstock.com/BananaStock

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symptomsofwithdrawalandnegativemoodtoagreaterextentinmenthan

women.Womenobtainedequalrelieffromcigaretteswithandwithoutnicotine,

suggestingthattheyfoundthedruglessrewardingthanmen.

Cigarettecravingisamajorreasonwhysmokersfindithardtoquit,andthis

strongurgetosmokecanbeevokedbysensorycuesandstress.Research

suggeststhatwomenexperiencestrongercravingthanmeninresponseto

stress, butmenmaybemoreresponsivetoenvironmental

cues. Additionally,longitudinaldatafrominternationalsurveysconductedin

fourindustrializedcountriesindicatedthatmenandwomendidnotdifferintheir

desiretoquit,planstoquit,orquitattempts.However,womenwere31percent

lesslikelytoquitsuccessfully. Onereasonwhywomenmayhavedifficulty

quittingispost-cessationweightgain.Thisconcernshouldbeaddressedin

behavioralcounselingandadjuncttreatmentsforallsmokers.

Theoveralllowercessationrateforwomenmayreflectsexdifferencesin

responsetoparticularmedications(see"Whataretreatmentsfortobacco

dependence?").Forexample,vareniclinehasgreatershort-andimmediate-

termefficacy(at3and6months)amongwomensmokers.However,women

andmenshowsimilar1-yearquitrateswhenusingvarenicline. Incontrast,a

combinationofvareniclineplusbupropionwaslesseffectiveforcessation

amongwomencomparedwithmen.

Anotherparticularconcernrelatedtotobaccouseamongwomenissmoking

duringpregnancy(see"Whataretherisksofsmokingduringpregnancy?").

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Dopeoplewithmentalillnessand

substanceusedisordersusetobacco

moreoften?

Thereissignificantcomorbiditybetweentobaccouseandmentaldisorders.

Peoplewithmentalillnesssmokeattwotofourtimestherateofthegeneral

population.Amongpeoplewithamentalillness,36.1percentsmokedfrom

2009to2011,comparedwith21.4percentamongadultswithnomental

illness. Smokingratesareparticularlyhighamongpatientswithserious

mentalillness(i.e.,thosewhodemonstrategreaterfunctionalimpairment).

Whileestimatesvary,asmanyas70-85percentofpeoplewithschizophrenia

andasmanyas50-70percentofpeoplewithbipolardisordersmoke.

Ratesofsmokingamongpeoplewithmentalillnesswerehighestforthose

youngerthan45,thosewithlowlevelsofeducation,andthoselivingbelowthe

povertylevel. LongitudinaldatafromNSDUH(2005–2013)indicatethat

smokingamongadultswithoutchronicconditionshasdeclinedsignificantly,but

remainsparticularlyhighamongthosereportinganxiety,depression,and

substanceusedisorders. Smokingisbelievedtobemoreprevalentamong

peoplewithdepressionandschizophreniabecausenicotinemaytemporarily

lessenthesymptomsoftheseillnesses,suchaspoorconcentration,lowmood,

andstress. Butitisimportanttonotethatsmokingcessationhasbeen

linkedwithimprovedmentalhealth—includingreduceddepression,anxiety,

andstress,andenhancedmoodandqualityoflife.

AnalysesoflongitudinalNSDUHdataalsofoundahigherprevalenceof

smokelesstobaccouseamongindividualswithmentalhealthandsubstance

usedisorders. OtherresearchdrawingondatafromtheNational

EpidemiologicSurveyonAlcoholandRelatedConditionsfoundthatalltypesof

substancedependencewereassociatedwithdependenceon

nicotine. Smokingisalsohighlyprevalentamongpeopleintreatmentfor

substanceusedisorders, withmoststudiesfindingratesbetween65-85

percentamongpatientsinaddictiontreatment.

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Additionally,smokerswithamentalhealthdisordertendtosmokemore

cigarettesthanthoseinthegeneralpopulation.Theaveragenumberof

cigarettessmokedduringthepastmonthwashigheramongthosewithamental

illnesscomparedwiththosewithoutone—331versus310cigarettes. High

cigaretteconsumptionisaparticularproblemforpeoplewithseriousmental

illness.Althoughadultswithseriousmentalillnesscomprisedonly6.9percent

ofpast-monthsmokers,theyconsumed8.7percentofallcigarettessold,

accordingtodatafromthe2008–2012NSDUH.

HighPrevalenceofSmokingAmongPeoplewith

Schizophrenia

Researchersareworkingtoidentifythebraincircuitsthatcontributetothe

highprevalenceofsmokingamongpeoplewithschizophrenia.

Schizophreniaisassociatedwithwidespreadreductionsinfunctional

connectivitybetweenthedorsalanteriorcingulatecortexanddiverseparts

ofthelimbicsystem.Onereportidentified15circuitsforwhichthe

reductionoffunctionalconnectivitycorrelatedwithseverityofnicotine

addiction.

Peoplewithmentalandsubstanceusedisordersdonotquitsmokingatthe

samerateasthoseinthegeneralpopulation.4Surveyresponsesfrompeople

whohavesmokedatsomepointduringtheirlivesindicatedthatfewersmokers

withmentalillnesshadquitcomparedtothosewithoutpsychiatricdisorders:

47.4percentoflifetimesmokerswithoutmentalillnesssmokedduringthepast

month,comparedwith66percentofthosewithmentalillness. Havinga

mentaldisorderatthetimeofcessationisariskfactorforrelapsetosmoking,

evenforthosewhohavesustainedabstinenceformorethanayear. Many

smokerswithmentalillnesswanttoquitforthesamereasonscitedbyothers

(suchashealthandfamily),buttheymaybemorevulnerabletorelapserelated

tostressandnegativefeelings.

Thedisparityinsmokingprevalenceiscostinglives.Arecentstudyfoundthat

tobacco-relateddiseasesaccountedforapproximately53percentofdeaths

amongpeoplewithschizophrenia,48percentamongthosewithbipolar

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disorder,and50percentamongthosewithdepression.

Sincethe1980s,manyprovidershavebelievedthatpeoplewithschizophrenia

smoketoobtainrelieffromsymptomslikepoorconcentration,lowmood,and

stress. Butresearchisnowshowingthatsmokingisassociatedwithworse

behavioralandphysicalhealthoutcomesinpeoplewithmentalillness,and

quittingsmokingisshowingclearbenefitsforthis

population. Comprehensivetobaccocontrolprogramsandenhanced

effortstopreventandtreatnicotineaddictionamongthosewithmentalillness

wouldreduceillnessanddeaths.Integratedtreatment—concurrenttherapyfor

mentalillnessandnicotineaddiction—willlikelyhavethebestoutcomes.

Smokerswhoreceivementalhealthtreatmenthavehigherquitratesthanthose

whodonot. Moreover,evidence-basedtreatmentsthatworkinthegeneral

populationarealsoeffectiveforpatientswithmentalillness.Forexample,

peoplewithschizophreniashowedbetterquitrateswiththemedication

bupropion,comparedwithplacebo,andshowednoworseningofpsychiatric

symptoms. Acombinationofthemedicationvareniclineandbehavioral

supporthasshownpromiseforhelpingpeoplewithbipolarandmajor

depressivedisordersquit,withnoworseningofpsychiatricsymptoms. A

clinicaltrialfoundthatacombinationofvareniclineandcognitivebehavioral

therapy(CBT)wasmoreeffectivethanCBTaloneforhelpingpeoplewith

seriousmentalillnessstopsmokingforaprolongedperiod—after1yearof

treatmentandat6monthsaftertreatmentended.

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Whataretreatmentsfortobacco

dependence?

Thereareeffectivetreatmentsthatsupporttobaccocessation,includingboth

behavioraltherapiesandFDA-approvedmedications.FDA-approved

pharmacotherapiesincludevariousformsofnicotinereplacementtherapyas

wellasbupropionandvarenicline.Researchindicatesthatsmokerswho

receiveacombinationofbehavioraltreatmentandcessationmedicationsquitat

higherratesthanthosewhoreceiveminimalintervention.

Interventionssuchasbriefadvicefromahealthcareworker,telephone

helplines,automatedtextmessaging,andprintedself-helpmaterialscanalso

facilitatesmokingcessation. Cessationinterventionsutilizingmobiledevices

andsocialmediaalsoshowpromiseinboostingtobaccocessation. Itis

importantforcessationtreatmenttobeaspersonalizedaspossible,assome

peoplesmoketoavoidnegativeeffectsofwithdrawalwhileothersaremore

drivenbytherewardingaspectsofsmoking.

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Theprevalenceoftobaccouseanddependenceamongadolescents—aswell

astheneurobiologicalimpactandmedicalconsequencesofnicotineexposure

—suggestthatpediatricprimarycaresettingsshoulddelivertobaccocessation

treatmentstobothyouthandparentswhousetobacco. Currentclinical

guidancedoesnotrecommendmedicationsforadolescenttobaccocessation

becauseofalackofhigh-qualitystudies; however,acombinationof

behavioraltreatments—suchasmotivationalenhancementandCBT—has

shownpromiseforhelpingadolescentsquittobacco. Morewell-designed

smokingcessationstudiesneedtobeconductedwithadolescentsmokers,

particularlyintheareaofpharmacologictreatmentsfornicotinedependence.

BehavioralTreatments

Behavioralcounselingistypicallyprovidedbyspecialistsinsmokingcessation

forfourtoeightsessions. Bothin-personandtelephonecounselinghave

beenfoundbeneficialforpatientswhoarealsousingcessation

medications. Avarietyofapproachestosmokingcessationcounselingare

available.

CognitiveBehavioralTherapy(CBT)—CBThelpspatientsidentifytriggers—

thepeople,places,andthingsthatspurbehavior—andteachesthemrelapse-

preventionskills(e.g.,relaxationtechniques)andeffectivecopingstrategiesto

avoidsmokinginthefaceofstressfulsituationsandtriggers. Astudythat

comparedCBTandbasichealtheducationobservedthatbothinterventions

reducednicotinedependence. However,anotherstudyfoundthatamong

smokerstryingtoquitwiththenicotinereplacementtherapy(NRT)patch,

patientswhoparticipatedinsixsessionsofintensivegroupCBThadbetterquit

ratesthanthosewhoreceivedsixsessionsofgeneralhealtheducation.

MotivationalInterviewing(MI)—InMI,counselorshelppatientsexploreand

resolvetheirambivalenceaboutquittingsmokingandenhancetheirmotivation

tomakehealthychanges.MIispatient-focusedandnonconfrontational,and

providerspointoutdiscrepanciesbetweenpatients’goalsorvaluesandtheir

currentbehaviors.Theyadjusttopatients’resistancetochangeandsupport

self-efficacyandoptimism. StudiesofMIsuggestthatthisinterventionresults

inhigherquitratesthanbriefadvicetostopsmokingorusualcare.

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Mindfulness—Inmindfulness-basedsmokingcessationtreatments,patients

learntoincreaseawarenessofanddetachmentfromsensations,thoughts,and

cravingsthatmayleadtorelapse. Inthistherapy,patientspurposelyattendto

thethoughtsthattriggercravingsandurgesfortobaccoandcognitivelyreframe

themasexpectedandtolerable.Patientslearntechniquesthathelpthem

toleratenegativeemotions—includingstressandcravings—withoutreturningto

tobaccouseorotherunhealthybehaviors. Interestinmindfulness-based

treatmentshasincreasedduringthepastdecade,andstudiesshowthatthis

approachbenefitsoverallmentalhealthandcanhelppreventrelapseto

smoking. However,well-controlledclinicaltrialsareneeded.

Telephonesupportandquitlines—Aspartoftobaccocontrolefforts,allstates

offertoll-freetelephonenumbers(orquitlines)withsmokingcessation

counselorswhoprovideinformationandsupport(800-QUIT-NOWor800-784-

8669).Studiesofquitlineinterventionsindicatethatsmokerswhocallquitlines

benefitfromtheseservices, particularlywhenacounselorcallsthembackfor

multiplesessions. Thereislimitedevidenceontheoptimalnumberofcalls

needed,butsmokerswhoparticipatedinthreeormorecallshadagreater

likelihoodofquitting,comparedwiththosewhoonlyreceivededucational

materials,briefadvice,orpharmacotherapyalone. Quitlineshavealsobeen

showntohelpsmokelesstobaccocessation. TheU.S.DepartmentofHealth

andHumanServicesprovidesaSmokingQuitline(877-44U-QUITor877-448-

7848),aswellasmoreinformationandtoolsforquitting(includingtext

messagesandothertelephone-basedsupport)athttps://smokefree.gov/.

Textmessaging,web-basedservices,andsocialmediasupport—

Technology,includingmobilephones,internet,andsocialmediaplatformscan

beusedtoprovidesmokingcessationinterventions.Thesetechnologieshave

thepowertoincreaseaccesstocarebyextendingtheworkofcounselorsand

overcomingthegeographicalbarriersthatmaydeterpeoplefromentering

treatment.

Areviewoftheliteratureontechnology-basedsmokingcessationinterventions

(internet,personalcomputer,andmobiletelephone)foundthatthesesupports

canincreasethelikelihoodofadultsquitting,comparedwithnointerventionor

self-helpinformation,andtheycanbeacost-effectiveadjuncttoother

treatments. Atechnologydoesnotnecessarilyhavetoberecentorhighly

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sophisticatedtohelpboostcessationrates.Forexample,studiessuggestthat

adultswhoreceiveencouragement,advice,andquittingtipsviatext-message—

acapabilityoneventhemostbasicmobiledevices—showimprovedquitrates

comparedwithcontrolprograms.

Amongadulttobaccouserswhocalledastatequitline,mostselectedan

integratedphone/webcessationprograminfavorofaweb-only

intervention. Participantswhochosetheweb-onlyoptiontendedtobe

youngerandhealthiersmokers,withahighersocioeconomicstatus.These

participantstendedtointeractintenselywiththesiteonce,butdidnotre-engage

asmuchasthosewhooptedforthephone/webcombination.Areviewof

internet-basedsmokingcessationprogramsforadultssuggestedthat

interactiveinternet-basedinterventionsthataretailoredtoindividualneedscan

helppeoplequitfor6monthsorlonger. Futureresearchshould

determinetheeffectivenessofdifferenttechnologiesforsmokingcessation

supportamongpopulationsthatmaybehardtoreach,includingthoseoflow

socioeconomicstatusandadultsolderthanage50.

Technology-basedcessationinterventionsareparticularlyrelevanttoyoung

adultsaged18to25—about3.2millionofwhomsmokeddailyin2016. A

systematicreviewandmeta-analysisofpublishedrandomizedtrialsof

technology-basedinterventions—includingcomputerprograms,internet,

telephone,andtextmessaging—forsmokingcessationamongthispopulation

foundthattheyincreasedabstinenceby1.5timesthatofcomparison

subjects. Researchersrecommendembeddingcessationinterventionsin

commonlyusedsocialnetworkingplatforms, andtherehasbeensome

exploratoryworkinthisarea.Resultsofatrialwitharelativelysmallnumberof

participantssuggestedthatFacebookwasanaccessible,low-costplatformfor

engagingyoungadultsconsideringcessation.However,thestudypointedto

challengesinmaintainingparticipation,retainingyoungpeopleintheprogram,

andtheneedforgender-specificfeatures. Arandomizedcontrolledtrialhas

beendesignedtotestastage-basedsmokingcessationinterventionon

Facebooktailoredforsmokersaged18to25.Participantswillberecruited

online,randomlyassignedtoaFacebookgroupaccordingtotheirreadinessto

quit,andwillreceivetailoreddailymessagesandweeklycounseling.Thestudy

willassesstheintervention’simpactonabstinencefromsmoking3,6,and12

monthsaftertreatment,numberofcigarettessmoked,quitattemptslasting24

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hoursormore,andcommitmenttoabstinence.

SmokingCessationforPregnantWomen

Giventherisksassociatedwithsmokingduringpregnancy,butalsothe

challengesfacedbyallsmokerswhentryingtoquit,researchershave

studiedanarrayofapproachestoimprovecessationratesforthis

population.Manywomenaremotivatedtoquitduringpregnancy,butlike

othersmokers,mostwillneedassistance.

Studiesshowthatbehavioraltreatmentsareeffective,whereas

pharmacotherapieshaveonlymarginalsuccess. Acombinationof

incentivesandbehavioralcounselingismosteffectiveforpregnant

women. Addingvoucherstoroutinecare(whichincludedfreenicotine

replacementtherapyfor10weeksandfourweeklysupportphonecalls)

morethandoubledcessationratesduringpregnancy. Pooledresultsof

behavioralinterventionstudiesindicatethattreatmentreducedpreterm

birthsandtheproportionofinfantsbornwithlowbirthweight,compared

withusualcare. Thisfindingissupportedbyananalysisofpooled

resultsfromstudieswitheconomicallydisadvantagedpregnantsmokers,

whichfoundthatvoucher-basedincentivesimprovedsonographically

estimatedfetalgrowth,birthweight,percentageoflow-birth-weight

deliveries,andbreastfeedingduration.

Medications

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NicotineReplacementTherapy(NRT)—Avarietyofformulationsofnicotine

NRTsareavailableoverthecounter—includingthetransdermalpatch,spray,

gum,andlozenges—andareequallyeffectiveforcessation. NRTs

stimulatethebrainreceptorstargetedbynicotine,helpingrelievenicotine

withdrawalsymptomsandcravingsthatleadtorelapse. Manypeopleuse

NRTtohelpthemgetthroughtheearlystagesofcessation,andthosewith

moreseverenicotineaddictioncanbenefitfromlonger-termtreatment.Useof

NRTimprovessmokingcessationoutcomes,andaddingbehavioraltherapies

furtherincreasesquitrates. Acombinationofcontinualnicotinedelivery

throughthetransdermalpatchandoneotherformofnicotinetakenasneeded

(e.g.,lozenge,gum,nasalspray,inhaler)hasbeenfoundtobemoreeffectiveat

relievingwithdrawalsymptomsandcravingsthanasingletypeof

NRT. ResearchersestimatethatNRTincreasesquitratesby50to70

percent. Usingthepatchforupto24weekshasbeenshowntobesafe.

Bupropion—Bupropion(immediate-releaseandextended-release)was

originallyapprovedasanantidepressant.Itworksbyinhibitingthereuptakeof

thebrainchemicalsnorepinephrineanddopamineaswellasstimulatingtheir

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release.Bupropionhasbeenfoundtoincreasequitratescomparedwith

placeboinbothshort-andlong-termfollow-upstudies andisindicated

forsmokingcessation.ItisequallyeffectivetoNRT.

Varenicline—Vareniclinehelpsreducenicotinecravingsbystimulatingthe

alpha-4beta-2nicotinicreceptorbuttoalesserdegreethannicotine.

Vareniclinebooststheoddsofsuccessfullyquitting,comparedwithunassisted

attempts. Vareniclineincreasedthelikelihoodofquittingcomparedwith

placebo,andsomestudiesfindthatitismoreeffectivethansingleformsof

NRT andbupropion. Inaprimarycaresetting,44percentofpatientson

varenicline,eitheraloneorcombinedwithcounseling,wereabstinentatthe2-

yearfollow-up.Patientswhoparticipatedingrouptherapyandadheredtothe

medicationweremorelikelytoremainabstinent. Researchalsosuggests

thatthismedicationmaybemoreeffectivethanbupropion.

Medicationcombinations—SomestudiessuggestthatcombiningNRTwith

othermedicationsmayfacilitatecessation.Forexample,ameta-analysisfound

thatacombinationofvareniclineandNRT(especially,providinganicotine

patchpriortocessation)wasmoreeffectivethanvareniclinealone. Similarly,

addingbupropiontoNRTalsoimprovedcessationrates. Forsmokerswho

couldnotcutdownsignificantlybyusingtheNRTpatch,combiningextended-

releasebupropionandvareniclinewasmoreeffectivethanplacebo,particularly

formenandthosewhowereseverelynicotinedependent.

Otherantidepressants—Inadditiontobupropion,someotherantidepressant

medicationshavealsobeenfoundeffectiveforsmokingcessation,independent

oftheirantidepressanteffects,andareconsideredsecond-linetreatments.A

fewsmallstudiessuggestthatnortriptylineisequallyeffectiveas

NRT. Althoughnortriptylinemayhavesideeffectsinsomepatients,the

smallstudiesforitsuseinsmokingcessationhavenotreportedany.

Researchershavenotobservedanyimpactofselectiveserotoninreuptake

inhibitors(SSRIs)(e.g.,fluoxetine,paroxetine,andsertraline)onsmoking,

eitheraloneorincombinationwithNRT.

PrecisionMedicine—Researchershavebeenexaminingwaystopersonalize

treatmentbasedonimportantindividualbiologicaldifferences,including

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geneticdifferences.Thefieldofpharmacogeneticsexamineshowgenes

influencetherapeuticresponsetomedications,providingcriticalinformationto

helptailorpharmacotherapiestotheindividualformaximumbenefit.For

example,peoplemetabolizenicotineatdifferentratesbecauseofvariationsin

severalgenes.Individualswhometabolizenicotinequicklysmokemore,show

greaterdependence,andhavemoredifficultyquitting. Suchgeneticvariation

influencesthetherapeuticresponsestoNRTandothercessation

medications. Arecentstudycomparedratesofabstinence1weekafter

treatmentforslow,normal,andfastmetabolizersofnicotinewhowererandomly

assignedtoeitherplacebo,NRT,orvarenicline.Resultsindicatedthat

vareniclineworkedbestfornormalnicotinemetabolizers,whereasNRT

patchesweremosteffectiveforslowmetabolizers.

Promisingmedicationsandongoingresearch—NIDAsupportsresearchto

developnewandimprovecurrenttreatmentoptionsforsmokingcessation

basedonagrowingunderstandingoftheneurobiologyofaddiction.Inthearea

ofmedications,researchisfocusingonthereceptorstargetedbynicotineand

thebraincircuitsandregionsknowntoinfluencenicotine

consumption. Newerbraintargets—includingtheorexinandglutamate

signalingsystems—havealsoshownpromiseformedication

treatment. Repurposingmedicationsalreadyonthemarketforother

indicationsmayalsoproveusefulinthesearchfornewsmokingcessation

therapies. Thisapproachhasbeensuccessfulinthepast,asbupropion

wasanestablishedantidepressantbeforetheFDAapproveditasasmoking

cessationmedication.OnecurrentcandidateisN-acetylcysteine,amedication

foracetaminophenoverdose,whichhasshownpromiseasatreatmentfor

varioussubstanceusedisorders—includingnicotinedependence. Another

approachthatcouldpreventrelapseandthathasshownpromiseinearly

studiesisanicotinevaccine,whichwouldgenerateantibodiesthatkeep

nicotinefromreachingthebrain.

TranscranialMagneticStimulation

Transcranialmagneticstimulation(TMS)isarelativelynewapproachbeing

testedtotreataddiction.Itisaphysiologicalinterventionthatnoninvasively

stimulatesneuralactivityintargetedareasofthebrainusingmagneticfields.

MultipleTMSpulsesgivenconsecutivelyarereferredtoasrepetitiveTMS

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(rTMS).TheFDAhasapprovedtworTMSdevicesfordepressiontreatmentin

adults.

ResearchonrTMSasatreatmentforsmokingcessationisinearlystagesbut

hasshownpromise. Amongadultsmokerswhohadnotbeenabletoquit

usingothertreatments,high-frequencyTMStreatmentsignificantlyreducedthe

numberofcigarettessmoked.Combininghigh-frequencyTMSwithexposureto

smokingcuesimprovedeffectivenessandboostedtheoverallabstinencerate

to44percentattheendofthetreatment.Sixmonthsaftertreatment,33percent

ofparticipantsremainedabstinentfromcigarettes. Futurerandomized

controlledclinicaltrialswithlargenumbersofpatientswillbeneededto

establishitsefficacyforsmokingcessation.

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Howcanwepreventtobaccouse?

Themedicalconsequencesoftobaccouse—includingsecondhandexposure—

maketobaccocontrolandsmokingpreventioncrucialpartsofanypublichealth

strategy.SincethefirstSurgeonGeneral’sReportonSmokingandHealthin

1964,statesandcommunitieshavemadeeffortstoreduceinitiationofsmoking,

decreaseexposuretosmoke,andincreasecessation.Researchersestimate

thatthesetobaccocontroleffortsareassociatedwithavertinganestimated8

millionprematuredeathsandextendingtheaveragelifeexpectancyofmenby

2.3yearsandofwomenby1.6years. Butthereisalongwayyettogo:

roughly5.6millionadolescentsunderage18areexpectedtodieprematurely

asaresultofanillnessrelatedtosmoking.

Preventioncantaketheformofpolicy-levelmeasures,suchasincreased

taxationoftobaccoproducts;stricterlaws(andenforcementoflaws)regulating

whocanpurchasetobaccoproducts;howandwheretheycanbepurchased;

whereandwhentheycanbeused(i.e.,smoke-freepoliciesinrestaurants,bars,

andotherpublicplaces);andrestrictionsonadvertisingandmandatoryhealth

warningsonpackages.Over100studieshaveshownthathighertaxeson

cigarettes,forexample,producesignificantreductionsinsmoking,especially

amongyouthandlower-incomeindividuals. Smoke-freeworkplacelawsand

restrictionsonadvertisinghavealsoshownbenefits.

Photoby©Shutterstock/Kenishirotie

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Preventioncanalsotakeplaceattheschoolorcommunitylevel.Merely

educatingpotentialsmokersaboutthehealthriskshasnotproven

effective. Successfulevidence-basedinterventionsaimtoreduceordelay

initiationofsmoking,alcoholuse,andillicitdruguse,andotherwiseimprove

outcomesforchildrenandteensbyreducingormitigatingmodifiableriskfactors

andbolsteringprotectivefactors.Riskfactorsforsmokingincludehavingfamily

membersorpeerswhosmoke,beinginalowersocioeconomicstatus,livingin

aneighborhoodwithhighdensityoftobaccooutlets,notparticipatinginteam

sports,beingexposedtosmokinginmovies,andbeingsensation-

seeking. Althougholderteensaremorelikelytosmokethanyoungerteens,

theearlierapersonstartssmokingorusinganyaddictivesubstance,themore

likelytheyaretodevelopanaddiction.Malesarealsomorelikelytotakeup

smokinginadolescencethanfemales.

Someevidence-basedinterventionsshowlastingeffectsonreducingsmoking

initiation.Forinstance,communitiesutilizingtheintervention-deliverysystem,

CommunitiesthatCare(CTC)forstudentsaged10to14showsustained

reductioninmalecigaretteinitiationupto9yearsaftertheendofthe

intervention.

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Whatresearchisbeingdoneon

tobaccouse?

Newscientificdevelopmentscanimproveourunderstandingofnicotine

addictionandspurthedevelopmentofbetterpreventionandtreatment

strategies.

GeneticsandEpigenetics

Anestimated50-75percentoftheriskfornicotineaddictionisattributableto

geneticfactors. Aclusterofgenes(CHRNA5-CHRNA3-CHRNB4)on

chromosome15thatencodethe5,3,and4proteinsubunitsthatmakeupthe

brainreceptorfornicotine areparticularlyimplicatedinnicotine

dependenceandsmokingamongpeopleofEuropeandescent.Variationinthe

CHRNA5geneinfluencestheeffectivenessofcombinationNRT,butnot

varenicline. Otherresearchhasidentifiedgenesthatinfluencenicotine

metabolismandtherefore,thenumberofcigarettessmoked, responsiveness

tomedication, andchancesofsuccessfullyquitting. Forexample,the

therapeuticresponsetovareniclineisassociatedwithvariantsfortheCHRNB2,

CHRNA5,andCHRNA4genes,whilebupropion-relatedcessationislinked

withvariationingenesthataffectnicotinemetabolism.

Smokingcanalsoleadtopersistentchangesingeneexpression(epigenetic

changes),whichmaycontributetoassociatedmedicalconsequencesoverthe

longterm,evenfollowingcessation.