1 National Institute on Drug Abuse (NIDA) Tobacco, Nicotine, and E-Cigarettes Last Updated January 2018 https://www.drugabuse.gov
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NationalInstituteonDrugAbuse(NIDA)
Tobacco,Nicotine,andE-Cigarettes
LastUpdatedJanuary2018
https://www.drugabuse.gov
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TableofContents
Tobacco,Nicotine,andE-Cigarettes
Introduction
Whatisthescopeoftobaccouseanditscosttosociety?
Howdoestobaccodeliveritseffects?
Isnicotineaddictive?
Whatarethephysicalhealthconsequencesoftobaccouse?
Whataretheeffectsofsecondhandandthirdhandtobaccosmoke?
Whataretherisksofsmokingduringpregnancy?
Howmanyadolescentsusetobacco?
Whatareelectroniccigarettes?
OtherTobaccoProducts
Aretheregenderdifferencesintobaccosmoking?
Dopeoplewithmentalillnessandsubstanceusedisordersusetobaccomoreoften?
Whataretreatmentsfortobaccodependence?
Howcanwepreventtobaccouse?
Whatresearchisbeingdoneontobaccouse?
References
WherecanIgetfurtherinformationabouttobacco/nicotine?
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Introduction
In2014,theNationmarkedthe50thanniversaryofthefirstSurgeonGeneral’sReportonSmokingandHealth.In1964,morethan40percentoftheadultpopulationsmoked.Oncethelinkbetweensmokinganditsmedicalconsequences—includingcancersandheartandlungdiseases—becameapartofthepublicconsciousness,educationeffortsandpublicpolicychangeswereenactedtoreducethenumberofpeoplewhosmoke.TheseeffortsresultedinsubstantialdeclinesinsmokingratesintheUnitedStates—tohalfthe1964level.
However,ratesofcigarettesmokingandothertobaccousearestilltoohigh,andsomepopulationsaredisproportionatelyaffectedbytobacco’shealthconsequences.Mostnotably,peoplewithmentaldisorders—includingsubstanceusedisorders—smokeathigherratesthanthegeneralpopulation.Additionally,peoplelivingbelowthepovertylineandthosewithlow
educationalattainmentaremorelikelytosmokethanthoseinthegeneralpopulation.AstobaccouseistheleadingpreventablecauseofmortalityintheUnitedStates, differentialratesofsmokinganduseofothertobaccoproductsisasignificantcontributortohealthdisparitiesamongsomeofthemostvulnerablepeopleinoursociety.
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Whatisthescopeoftobaccouseanditscosttosociety?
Approximatelyonefourthofthepopulationusestobaccoproducts,and19.4percentsmokecigarettes.Accordingtothe2016NationalSurveyonDrugUseandHealth(NSDUH),anestimated63.4millionpeopleaged12orolderusedatobaccoproductduringthepastmonth,including51.3millioncigarettesmokers. Smokingratescontinuetogodownyeartoyear;thepercentageofpeopleoverage18whosmokecigarettesdeclinedfrom20.9percentin2005to15.8percentin2016,accordingtothe2017NationalHealthInterviewSurvey.
However,smokingratesaresubstantiallyhigheramongsomeofthemostvulnerablepeopleinoursociety.The25percentofAmericanswithmentaldisorders,includingaddiction,accountfor40percentofthecigarettessmokedintheU.S. (see"Dopeoplewithmentalillnessandsubstanceusedisordersusetobaccomoreoften?").Morethan40percentofpeoplewithaGeneralEducationDevelopmentcertificate(GED)smoke—whichisthehighest
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prevalenceofanysocioeconomicgroup. Also,peoplewholiveinruralareas,particularlyintheSouthAtlanticstates,useallformsoftobaccoathigherratesthanpeoplewholiveinurbanareas.Thesedifferencescannotbefullyexplainedbydifferentlevelsofpovertyoraffluence.
Smokingamongyouthisathistoricallylowlevels.AccordingtotheNIDA-sponsoredMonitoringtheFuture(MTF)survey, in2015,anestimated4.7millionmiddleandhighschoolstudentsusedtobaccoproductsduringthepastmonth,accordingtodatafromtheNationalYouthTobaccoSurvey(NYTS) e-cigarettes)werethemostcommonlyusedtobaccoproductsamongmiddle(5.3percent)andhighschool(16.0percent)studentsin2015. E-cigarettesdeliversyntheticnicotineanddonotcontaintobacco;however,theyareclassifiedastobaccoproductsforregulatorypurposes.Thesefindingsareechoedbyotherstudies, includingthe MTFsurvey. Scientistshavenotyetdeterminedthemedicalconsequencesoflong-terme-cigaretteuseorthesecondhandeffectsofe-cigarettevapor(see"Whatareelectroniccigarettes?").
Between1964and2012,anestimated17.7milliondeathswererelatedtosmoking leadstomorethan480,000deathsannually. Ifcurrentsmokingratescontinue,5.6millionAmericanswhoarecurrentlyyoungerthan18willdieprematurelyfromsmoking-relateddisease.
Inadditiontothetremendousimpactofprematuredeathsrelatedtotobaccouse,theeconomiccostsarehigh.Expertsestimatethatbetween2009and2012,theannualsocietalcostsattributabletosmokingintheUnitedStateswerebetween$289and$332.5billion.Thisincludes$132.5to$175.9billionfordirectmedicalcareofadultsand$151billionforlostproductivityduetoprematuredeaths.In2006,lostproductivityduetoexposuretosecondhandsmokecostthecountry$5.6billion. About70percentofcurrentsmokers’excessmedicalcarecostscouldbepreventedbyquitting.
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Howdoestobaccodeliveritseffects?
Thesmokefromcombustibletobaccoproductscontainsmorethan7,000chemicals.Nicotineistheprimaryreinforcingcomponentoftobacco;itdrivestobaccoaddiction. Hundredsofcompoundsareaddedtotobaccotoenhanceitsflavorandtheabsorptionofnicotine. Cigarettesmokingisthemostpopularmethodofusingtobacco;however,manypeoplealsousesmokelesstobaccoproducts,suchassnuffandchewingtobacco,whichalsocontainnicotine(see"OtherTobaccoProducts").E-cigarettes,whichdelivernicotineintheabsenceofotherchemicalsintobacco,havebecomepopularinrecentyears(see"Whatareelectroniccigarettes?").
Thecigaretteisaveryefficientandhighlyengineereddrug-deliverysystem.Byinhalingtobaccosmoke,theaveragesmokertakesin1–2milligramsofnicotinepercigarette.Whentobaccoissmoked,nicotinerapidlyreachespeaklevelsinthebloodstreamandentersthebrain.Atypicalsmokerwilltake10puffsonacigaretteovertheroughly5minutesthatthecigaretteislit. Thus,apersonwhosmokesabout1pack(20cigarettes)dailygets200"hits"ofnicotinetothebraineachday.Amongthosewhodonotinhalethesmoke—suchascigarandpipesmokersandsmokelesstobaccousers—nicotineisabsorbedthroughmucousmembranesinthemouthandreachespeakbloodandbrainlevelsmoreslowly.
Immediatelyafterexposuretonicotine,thereisa"kick"causedinpartbythedrug’sstimulationoftheadrenalglandsandresultingdischargeofepinephrine(adrenaline).Therushofadrenalinestimulatesthebodyandcausesanincreaseinbloodpressure,respiration,andheartrate. Likeotherdrugs,nicotinealsoactivatesrewardpathwaysinthebrain—circuitrythatregulatesreinforcementandfeelingsofpleasure.
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Isnicotineaddictive?
Yes.Mostsmokersusetobaccoregularlybecausetheyareaddictedtonicotine.Addictionischaracterizedbycompulsivedrug-seekinganduse,eveninthefaceofnegativehealthconsequences.Themajorityofsmokerswouldliketostopsmoking,andeachyearabouthalftrytoquitpermanently.Yet,onlyabout6percentofsmokersareabletoquitinagivenyear. Mostsmokerswillneedtomakemultipleattemptsbeforetheyareabletoquitpermanently.Medicationsincludingvarenicline,andsomeantidepressants(e.g.bupropion),andnicotine-replacementtherapy,canhelpinmanycases(see"Whataretreatmentsfortobaccodependence?").
Atransientsurgeofendorphinsintherewardcircuitsofthebraincausesaslight,briefeuphoriawhennicotineisadministered.Thissurgeismuchbrieferthanthe"high"associatedwithotherdrugs.However,likeotherdrugsofabuse,nicotineincreaseslevelsoftheneurotransmitterdopamineintheserewardcircuits, whichreinforcesthebehavioroftakingthedrug.Repeatedexposurealtersthesecircuits'sensitivitytodopamineandleadstochangesinotherbraincircuitsinvolvedinlearning,stress,andself-control.Formanytobaccousers,thelong-termbrainchangesinducedbycontinuednicotineexposureresultinaddiction,whichinvolveswithdrawalsymptomswhennotsmoking,anddifficultyadheringtotheresolutiontoquit.
Thepharmacokineticpropertiesofnicotine,orthewayitisprocessedbythebody,contributetoitsaddictiveness. Whencigarettesmokeentersthelungs,nicotineisabsorbedrapidlyinthebloodanddeliveredquicklytothebrain,sothatnicotinelevelspeakwithin10secondsofinhalation.Buttheacuteeffectsofnicotinealsodissipatequickly,alongwiththeassociatedfeelingsofreward;thisrapidcyclecausesthesmokertocontinuedosingtomaintainthedrug'spleasurableeffectsandpreventwithdrawalsymptoms.
Withdrawaloccursasaresultofdependence,whenthebodybecomesusedtohavingthedruginthesystem.Beingwithoutnicotinefortoolongcancausearegularusertoexperienceirritability,craving,depression,anxiety,cognitiveandattentiondeficits,sleepdisturbances,andincreasedappetite.Thesewithdrawal
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symptomsmaybeginwithinafewhoursafterthelastcigarette,quicklydrivingpeoplebacktotobaccouse.
Whenapersonquitssmoking,withdrawalsymptomspeakwithinthefirstfewdaysofthelastcigarettesmokedandusuallysubsidewithinafewweeks. Forsomepeople,however,symptomsmaypersistformonths,andtheseverityofwithdrawalsymptomsappearstobeinfluencedbyaperson'sgenes.
Inadditiontoitspleasurableeffects,nicotinealsotemporarilyboostsaspectsofcognition,suchastheabilitytosustainattentionandholdinformationinmemory.However,long-termsmokingisassociatedwithcognitivedeclineandriskofAlzheimer'sDisease,suggestingthatshort-termnicotine-relatedenhancementdoesnotoutweighlong-termconsequencesforcognitivefunctioning. Inaddition,peopleinwithdrawalfromnicotineexperienceneurocognitivedeficitssuchasproblemswithattentionormemory. Theseneurocognitivewithdrawalsymptomsareincreasinglyrecognizedasacontributortocontinuedsmoking. Asmallresearchstudyalsosuggestedthatwithdrawalmayimpairsleepforseverelydependentsmokers,andthatthismayadditionallycontributetorelapse.
Inadditiontothedrug'simpactonmultipleneurotransmittersandtheirreceptors, manybehavioralfactorscanaffecttheseverityofwithdrawalsymptoms.Formanypeoplewhosmoke,thefeel,smell,andsightofacigaretteandtheritualofobtaining,handling,lighting,andsmokingthecigaretteareallassociatedwiththepleasurableeffectsofsmokingandcanmakewithdrawalorcravingworse. Learningprocessesinthebrainassociatethesecueswithnicotine-induceddopaminesurgesintherewardsystem —similartowhatoccurswithotherdrugaddictions.Nicotinereplacementtherapiessuchasgum,patches,andinhalers,andothermedicationsapprovedforthetreatmentofnicotineaddictionmayhelpalleviatethephysiologicalaspectsofwithdrawal
(see"Whataretreatmentsfortobaccodependence?");however,cravingsoftenpersistbecauseofthepowerofthesecues.Behavioraltherapiescanhelpsmokersidentifyenvironmentaltriggersofcravingsotheycanusestrategiestoavoidthesetriggersandmanagethefeelingsthatarisewhentriggerscannotbe.
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Arethereotherchemicalsthatmaycontributetotobaccoaddiction?
Researchisshowingthatnicotinemaynotbetheonlyingredientintobaccothataffectsitsaddictivepotential.
Smokingislinkedwithamarkeddecreaseinthelevelsofmonoamineoxidase(MAO),animportantenzymethatisresponsibleforthebreakdownofdopamine,aswellasareductioninMAObindingsitesinthebrain.Thischangeislikelycausedbysomeas-yet-unidentifiedingredientintobaccosmokeotherthannicotine,becauseweknowthatnicotineitselfdoesnotdramaticallyalterMAOlevels.AnimalresearchsuggeststhatMAOinhibitionmakesnicotinemorereinforcing,butmorestudiesareneededtodeterminewhetherMAOinhibitionaffectshumantobaccodependence.
Animalresearchhasalsoshownthatacetaldehyde,anotherchemicalintobaccosmokecreatedbytheburningofsugarsaddedassweeteners,dramaticallyincreasesthereinforcingpropertiesofnicotineandmayalsocontributetotobaccoaddiction.
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Whatarethephysicalhealthconsequencesoftobaccouse?
Cigarettesmokingharmsnearlyeveryorganinthebody, andsmokingistheleadingpreventablecauseofprematuredeathintheUnitedStates.Althoughratesofsmokinghavedeclined,itisestimatedthatitleadstoabout480,000deathsyearly. Smokersaged60andolderhaveatwofoldincreaseinmortalitycomparedwiththosewhohaveneversmoked,dyinganestimated6yearsearlier. Quittingsmokingresultsinimmediatehealthbenefits,andsomeorallofthereducedlifeexpectancycanberecovereddependingontheageapersonquits.
Althoughnicotineitselfdoesnotcausecancer,atleast69chemicalsintobaccosmokearecarcinogenic, andcigarettesmokingaccountsforatleast30percentofallcancerdeaths. Theoverallratesofdeathfromcanceraretwiceashighamongsmokersasnonsmokers,withheavysmokershavingafourtimesgreaterriskofdeathfromcancerthannonsmokers.
Foremostamongthecancerscausedbytobaccouseislungcancer.Cigarettesmokinghasbeenlinkedtoabout80to90percentofallcasesoflungcancer,theleadingcauseofcancerdeathforbothmenandwomen,anditisresponsibleforroughly80percentofdeathsfromthisdisease. Smokingincreaseslungcancerriskfivetotenfold,withgreaterriskamongheavysmokers. Smokingisalsoassociatedwithcancersofthemouth,pharynx,larynx,esophagus,stomach,pancreas,cervix,kidney,andbladder,aswellasacutemyeloid. Cigarettesmokingisnottheonlyformoftobaccouseassociatedwithcancers.Smokelesstobacco(see"OtherTobaccoProducts")hasbeenlinkedtocancerofthepharynx,esophagus,stomach,andlung,aswellastocolorectalcancer.
Inadditiontocancer,smokingcauseslungdiseasessuchaschronicbronchitisandemphysema,andithasbeenfoundtoexacerbateasthmasymptomsinadultsandchildren.Cigarettesmokingisthemostsignificantriskfactorforchronicobstructivepulmonarydisease(COPD). Survivalstatisticsindicatethatquittingsmokingresultsinrepairtomuchofthesmoking-inducedlung
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damageovertime.However,onceCOPDdevelops,itisirreversible;COPD-relatedlungdamageisnotrepairedwithtime.
Smokingalsosubstantiallyincreasestheriskofheartdisease,includingstroke,heartattack,vasculardisease,andaneurysm. Cardiovasculardiseaseisresponsiblefor40percentofallsmoking-relateddeaths. Smokingcausescoronaryheartdisease,theleadingcauseofdeathintheUnitedStates.Smokingisalsolinkedtomanyothermajorhealthconditions—includingdiabetes,rheumatoidarthritis,inflammation,andimpairedimmunefunction.Evenyoungsmokersaged26to41reportreducedhealth-relatedqualityoflifecomparedwithnonsmokingpeers,accordingtoacross-sectionalpopulationstudy.
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Whataretheeffectsofsecondhandandthirdhandtobaccosmoke?
Secondhandsmokeisasignificantpublichealthconcernanddriverofsmoke-freepolicies.Alsocalledpassiveorsecondarysmoke,secondhandsmokeincreasestheriskformanydiseases. Exposuretoenvironmentaltobaccosmokeamongnonsmokersincreaseslungcancerriskbyabout20percent.Secondhandsmokeisestimatedtocauseapproximately53,800deathsannuallyintheUnitedStates. Exposuretotobaccosmokeinthehomeisalsoariskfactorforasthmainchildren.
Smokingalsoleaveschemicalresidueonsurfaceswheresmokinghasoccurred,whichcanpersistlongafterthesmokeitselfhasbeenclearedfromtheenvironment.Thisphenomenon,knownas"thirdhandsmoke,"isincreasinglyrecognizedasapotentialdanger,especiallytochildren,whonotonlyinhalefumesreleasedbytheseresiduesbutalsoingestresiduesthatgetontheirhandsaftercrawlingonfloorsortouchingwallsandfurniture.Moreresearchisneededontherisksposedtohumansbythirdhandsmoke,butastudyinmiceshowedthatthirdhandsmokeexposurehasseveralbehavioralandphysicalhealthimpacts,includinghyperactivityandadverseeffectsontheliverandlungs.
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Whataretherisksofsmokingduringpregnancy?
Smokingduringpregnancyislinkedwitharangeofpoorbirthoutcomes—including:
Lowbirthweightandpretermbirth
Restrictedheadgrowth
Placentalproblems
Increasedriskofstillbirth
Increasedriskofmiscarriage
Healthanddevelopmentalconsequencesamongchildrenhavealsobeen
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linkedtoprenatalsmokeexposure,including:
Poorerlungfunction,persistentwheezing,andasthma,possiblythroughDNAmethylation
Visualdifficulties,suchasstrabismus,refractiveerrors,andretinopathy
Unfortunately,smokingbypregnantwomeniscommon.In2014,8.4percentofwomensmokedatanytimeduringpregnancy,withthoseaged20to24whowereAmericanIndianorAlaskaNativeshavinghigherrates,at13percentand18percent,respectively. Onefifthofwomenwhosmokedduringthefirst6monthsofpregnancyquitbytheirthirdtrimester.Overallcessationrateswerehighestforthosewiththehighesteducationalattainmentandprivateinsurance. Therefore,thereisaclearneedtoexpandsmokingcessationtreatmenttoyoungerwomenandtothoseoflowersocioeconomicstatus(seeBox:"SmokingCessationforPregnantWomen").
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Howmanyadolescentsusetobacco?
Mostpeoplewhousetobaccostartedduringadolescence,andthosewhobeginatayoungeragearemorelikelytodevelopnicotinedependenceandhavetroublequitting. Accordingtothe2017MonitoringtheFutureSurvey,9.7percentof12thgraders,5.0percentof10thgraders,and1.9percentof8thgradersusedcigarettesinthepastmonth. Analysesofthe2012NationalYouthTobaccoSurvey(NYTS)foundthat20.8percentofcurrentadolescenttobaccousersreportedwantingtousetobaccowithin30minutesofwaking—aclassicsymptomofnicotinedependence.Thisstudyalsofoundthat41.9percentreportedstrongcravingsfortobacco. Otherresearchhasfoundthatlightandintermittentsmokingamongadolescentsisassociatedwiththesamelevelofdifficultyquittingasdailysmoking.
Anyexposuretonicotineamongyouthisaconcern.Theadolescentbrainisstilldeveloping,andnicotinehaseffectsonthebrain’srewardsystemandbrainregionsinvolvedinemotionalandcognitivefunctions. Researchsuggeststhatthenicotine-relatedchangestotheseareasofthebrainduringadolescence
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mayperpetuatecontinuedtobaccouseintoadulthood. Thesechangesalsocontributetoahigherrateofothersubstanceusedisordersamongpeoplewhousetobaccoduringadolescence,sometimesreferredtoasa"gateway"effect.
Mentalhealth,beliefsaboutsmoking,perceptionofschoolmates’smoking,andothersubstanceuseareadditionalfactorsthatcaninfluenceanadolescent’sriskforsmokingandnicotinedependence. Emotionalproblems—includingdepression andrecentnegativelifeevents —areassociatedwithtobaccouseamongadolescents.Smokingamongpeersandwithinsocialgroupsisamajorenvironmentalfactorthatinfluencesadolescentsmoking;socialsmokingisamoreimportantmotivatorforadolescentscomparedtoadultsmokers.
Itiscommonforadolescentsmokingtofollowanintergenerationalpattern,whichhasgenetic,epigenetic,andenvironmentalinfluences. Datafromparentsandadolescentssuggeststhatcurrentparentalnicotinedependenceisstronglylinkedwithadolescentsmokinganddependence.Otherfactors—suchasparents’education,maritalstatus,andparentingbehavioralsoinfluenceteensmoking.
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Whatareelectroniccigarettes?
E-cigarettes(electronicnicotinedeliverysystems)emergedintheU.S.marketin2007andhaverapidlygrowninpopularity. E-cigarettes,ore-vaporizers,aredevicesthatheataliquidcontainingsolvents,flavors,andoftennicotine.Usersinhaletheresultingvapor.Avarietyofdesignsareavailable,somemimickingthelookoftraditionalcigarettes.Morethan7,000flavorsareavailablefore-cigarettes, someofwhichareespeciallyappealingtoyouth.Manyconveniencestores,drugstores,grocerystores,andotherphysicalandonlineretailoutletsselle-cigarettes,althoughasofAugust,2016,itisillegaltosellthemtopeopleunder18.Someconveniencestoresanddrugstorechainshavealsostoppedsellinge-cigarettestopromotepublichealth.
In2013,morethanonethirdofcigarettesmokerssaidtheyhadeverusede-cigarettes. Accordingtodatafromthe2014TobaccoProductsandRiskPerceptionsSurvey,currentcigarettesmokershadagreaterlikelihoodofusinge-cigarettes.Thisanalysisfoundthathalfofcigarettesmokershadeverusedane-cigaretteand20.7percentcurrentlyusedthesedevices.However,approximately10percentofadultswhousede-cigaretteshadneversmokedpreviously. Datafromthe2014NationalHealthInterviewSurveyindicatedthat0.4percentofadultswhohaveneversmokedand0.8percentofformersmokers(abstinent4ormoreyears)currentlyusee-cigarettes. Thesurveyalsofoundthat13percentofdailye-cigaretteuserswereformersmokerswhoquitduringthepastyear.
Aswithcigaretteuse,e-cigaretteuseishigheramongpeoplewithmentalhealthconditions—with3.1percentcurrentlyusingcomparedwith1.1percentofthosewithoutmentalillness. Itisalsoaconcernthatpregnantwomenareusinge-cigarettes,asnicotineexposureduringperiodsofdevelopmentalvulnerability(includingprenataldevelopment)hasadversehealthconsequences.
Usersreportthebeliefthate-cigaretteproductsarelessharmfulthantraditionalcigarettes, andmanyreportusingthemtohelpquitsmokingtraditionalcigarettes.Whileitisnotyetclearife-cigarettesareeffectivesmokingcessation
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aids,thedevicesaresometimesmarketedforthispurpose (see"Aree-cigarettesusefulforsmokingcessation?").Someresearchsuggeststhatolderadultsusethesedevicesasatobaccosubstitute,althoughnotalwaysasacessationmethod. Usersalsociteconvenienceandbeingconscientioustowardsothersasreasonsforusingtheseproducts.
Howdoesthefederalgovernmentregulatee-cigarettes?
TheU.S.FoodandDrugAdministration(FDA),whichregulatescigarettes,tobacco,andsmokelesstobacco,gainedtheauthorityin2016toalsoregulateelectronicnicotinedeliverysystems(suchase-cigarettesandvapepens),allcigars,hookah(waterpipe)tobacco,pipetobacco,andnicotinegels,amongothertobaccoproducts.Underthenewregulations,e-cigarettemanufacturersmustlistingredients,andvendorscannotselle-cigarettestopeopleunderage18.
Isittruethate-cigarettesaresaferthantraditionalcigarettes?
Itislikelythat,onbalance,e-cigarettesaresaferthantraditionalcigarettesfromthestandpointofphysicalhealth.However,asdiscussedabove,thenicotineine-cigarettescancauseaddictionandneurocognitiveimpairments.
Althoughforregulatorypurposese-cigarettesareclassifiedas“tobaccoproducts,”theydonotcontaintobaccoorproducethesametoxiccombustionproducts,liketar,thatcauselungcancerandotherdiseasesinusersandpeopleexposedtosecondhandsmoke.However,thevaporfrome-cigarettestypicallycontainsnicotineandarangeofotherchemicals. Becausetheseproductsarerelativelynew,evidenceontheshort-termeffectsofexposuretoe-cigaretteaerosolsislimited,andverylittleisknownaboutthelong-termhealtheffects.
Areviewofrecentliteraturefoundthatsomeofthechemicalsine-cigaretteliquid,propyleneglycolandglycerol,causethroatirritationand
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coughing. Otherresearchsuggeststhatvaporexposuremaybelinkedwithimpairedlungfunction. Chemicalanalysesthatcomparetheprofilesofelectronicandtraditionalcigaretteshavesuggestedthate-cigaretteshaveareducedcarcinogenicprofileandimpartalowerpotentialfordisease. However,toxicants,carcinogens,andmetalparticleshavebeendetectedintheliquidsandaerosolsofe-cigarettes,anditiscurrentlyunclearwhatrisktheyposewithrepeateduse. Aswithtraditionalcigarettes,useofe-cigarettesinvoluntarilyexposesnonuserstosecondhandandthirdhandaerosol.
Theresearchonsecondhandexposuretotheaerosolfrome-cigarettesislimited,butonestudyfoundthatfineparticulatematterconcentrationsduringanindooreventinalargeroomwithe-cigarettesmokerswerehigherthanthosereportedpreviouslyinvenuesthatallowedcigarettesmoking. Aninvitrostudyshowedthatexposinglungtissuesandcellstoe-cigaretteliquidinducedincreasedinflammatoryresponsesandoxidativestressmarkers. Anotherstudythatanalyzede-cigaretteflavoringsfoundthat39ofthe51flavorstestedpositivefordiacetyl,achemicalassociatedwithanirreversibleobstructivelungdiseasecalledbronchiolitisobliterans.Otherchemicals,2,3-pentanedioneandacetoin,associatedwithsevererespiratorydiseasesamongexposedpeople,werealsofoundinmanye-cigaretteflavorings.
Theamountofnicotineine-cigarettefluidvaries.Someresearchhasfoundthate-cigarettesdeliverlessnicotineonaveragethantraditionalcigarettes, butthatusersmaychangepuffingpatternstocompensate.Inexperiencede-cigaretteuserstakeinmodestnicotineconcentrations,butthosewhoregularlyusethesedevicesadjusttheirpuffingtoconsumesimilarlevelsofthedrugaswithtraditionalcigarettes. Newere-cigarettedevicescandeliversubstantialamountsofnicotine,andsomeusersareabletogetnicotineatlevelssimilarto orevengreaterthanatraditionalcigarette. Onestudyfoundequivalentlevelsofnicotine'smajormetaboliteinthebloodofsmokerswhousetraditionalande-cigarettes. Thus,allthenicotine-relatedconcernsoftraditionalcigarettes—addiction,effectsoncognitivefunction,andeffectsonprenataldevelopment—applytoe-cigarettesaswell.
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RisksofE-CigarettestoChildren
Youngchildrenmayaccidentallyingesttheconcentratednicotine(whichoftencontainsflavors)ine-cigaretteliquid. TheCentersforDiseaseControlandPreventionrecentlycomparedcallstopoisoncentersintheUnitedStatesrelatedtohumanexposurestoe-cigarettesandtraditionalcigarettes.ThestudyfoundthatbetweenSeptember2010andFebruary2014,theproportionofe-cigarettecallsamongallcigarette-relatedcallsincreasedfrom0.3percentto41.7percent. Mostofthee-cigaretteexposureswereamongchildrenundertheageof5years(51.1percent)andpeopleoverage20(42.0percent),whereasalmostalltraditionalcigaretteexposurecallsinvolvedyoungchildren. Dataindicatedthatagreaterproportionofe-cigaretteexposurecalls(57.8percent)resultedinadversehealtheffectsthantraditionalcigaretteexposure(36.0percent).Theseadversehealtheffectsincludedvomiting,nausea,andeyeirritation.
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Aree-cigarettesusefulforsmokingcessation?
Someresearchsuggestse-cigarettesmayhelppeoplequitsmokingcigarettes,whileotherdatasuggestthattheycanimpedequittingandthattheymayopenthedoortotraditionalcigaretteuseforpeoplewhomightnototherwisetrythem.Thus,muchmoreresearchisneededonthisquestion.
Onereviewofrecentstudiessuggestedthatthelikelihoodofquittingcigaretteswas28percentloweramongindividualswhousede-cigarettescomparedwiththosewhodidnotusethesedevices,regardlessofwhetheruserswereinterestedinquitting. ResearchfromtheUnitedKingdomsuggeststhatamongsmokerswhocontinuetousetraditionalcigarettes,dailyuseofe-cigaretteswasassociatedwithincreasedattemptstoquitandcutback,butnotwithsuccess. However,anotheranalysisestimatedthat,inEngland,16,000smokerswereabletoquitin2014whowouldnothavequitife-cigaretteshadnotbeenavailable. Areviewandmeta-analysisalsosuggestedthatusinge-cigarettesforaminimumof6monthswasassociatedwithquittingorreducingthenumberofcigarettesused.
E-cigarettesandTeens
Nationalsurveydatasuggestthate-cigaretteswerethemostcommonlyusednicotinedeliveryproductamongyouth. Areviewoftheliteraturefoundthatupto20percentofadolescentswhocurrentlyusee-cigaretteshadneversmokedatraditionalcigarette.
Amajorconcernisthate-cigarettes’flavors,design,andmarketingparticularlyappealtoyouth, andthatbyintroducingyoungpeopletonicotineandglamorizingasmoking-likebehavior,e-cigarettescouldopenthedoortocigaretteuseinapopulationthatisparticularlyvulnerabletoaddictionandthathasseenhistoricdeclinesincigarettesmoking.
Someresearchindicatesthate-cigaretteusemayleadtotheuseof
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traditionalcigarettesamongadolescentsandyoungadults. Accordingtodatafromthe2012NYTS,youthwhohadonlyusede-cigarettesreportedanincreasedintentiontosmoketraditionalcigarettescomparedwithpeerswhohadneverusedthesedevices.Thesurveyfoundnolinkbetweene-cigaretteuseandintentiontoquitsmokingamongyouthwhowerecurrentsmokers,indicatingthatthisagegroupdoesnotseetheseproductsprimarilyassmoking-cessationaids. Alongitudinalcohortstudyof16-to26-year-oldswhohadneversmokedtraditionalcigarettesfoundthat2.3percent(16participants)usede-cigarettesatthestartofthestudy.Afteraone-yearfollow-up,approximately69percent(11of16)oftheseparticipantsprogressedtosmokingtraditionalcigarettescomparedto18.9percent(128of678)amongthosewhoneverusedane-cigarette. Anotherstudyfoundthatpast-monthe-cigaretteusepredictedfuturecigaretteuse,butthatpast-monthcigaretteusedidnotpredictfuturee-cigaretteuse.
Manyyoungpeoplereportexperimentingwithe-cigarettesoutofcuriosity,becausetheflavorsappealtothem,orbecauseofpeerinfluences. Themajorityofyouthwhoreportede-cigaretteuseinonestudyhadfriendswhousedtheseproducts.Almosthalfofadolescentswhousede-cigarettessaidthattheydidnotbelievetheseproductswereassociatedwithhealthrisks. Youngpeoplealsoperceivede-cigarettesaseasytoobtain,"cool,"andabetteralternativetocigarettesbecausetheywerethoughttobehealthierandcouldbeusedanywhere.Amongyouthwhostoppedusinge-cigarettes,themajorunderlyingreasonswerehealthconcerns,lossofinterest,highcost,badtaste,andviewofe-cigarettesaslesssatisfyingthancigarettes.
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OtherTobaccoProducts
Whilecigarettesmokinghasdeclinedsignificantlyduringthepast40years,useofothertobaccoproductsisincreasing—particularlyamongyoungpeople. Theseinclude:
Cigars:tobaccowrappedinleaftobaccooranothertobacco-containingsubstanceinsteadofpaper,whichcanbeboughtindividually
Cigarillos:smallcigarsthatcostlessandarealsoavailableforpurchaseindividually
Hookahsorwaterpipes:pipeswithalong,flexibletubefordrawingsmokefromlit,flavoredtobaccothroughwatercontainedinabowl
Smokelesstobacco:productslikechewingtobaccoandsnuffthatareplacedinthemouthbetweentheteethandgums
Powdertobacco:mixturesthatareinhaledthroughthenose
In2014,almostone-quarterofhighschoolstudentsreportedpast-monthuseofatobaccoproduct—withe-cigarettes(13.4percent),hookahs(9.4percent),cigarettes(9.2percent),cigars(8.2percent),smokelesstobacco(5.5percent),andsnus(moistpowdertobacco)(1.9percent)asthemostpopular.
Cigars
In2016,anestimated12millionpeopleaged12orolder(4.6percentoftheadolescentandadultpopulation)smokedcigarsduringthepastmonth. Themajorityofadolescentsandyoungadultswhosmokedcigarsalsosmokecigarettes.
Cigarillos
DatafromtheTobaccoUseSupplementtotheCurrentPopulationSurveyandNSDUHsuggestthatyoungerandlesseconomicallyadvantagedmalesinitiate
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tobaccousewithcigarillos. From2002to2011,past-monthcigarettesmokingdeclinedformalesandfemalesofallagegroups.However,duringthissameperiod,ratesofcigarillouseamongmalesaged18to25remainedconstant(atapproximately9percent).
Hookahsorwaterpipes
Between2011and2014,useofhookahincreasedamongmiddleandhighschoolstudents,despitedecreaseduseofcigarettesandcigars,accordingtotheNYTS. Researchalsosuggeststhatratesofhookahusefortobaccosmokingincreaseduringthefirstmonthofcollege. Nationallyrepresentativedatafromcollegestudentsindicatethatdailycigaretteorcigarsmokers(aswellasmarijuanausers)weremorelikelytobefrequentwaterpipeusers.
Hookahusersmaymistakenlybelievethatitislessaddictiveordangerousthancigarettes;however,onesessionofhookahsmokingexposeduserstogreatersmokevolumesandhigherlevelsoftobaccotoxicants(e.g.,tar)thanasinglecigarette. Additionally,hookahsmokingislinkedwithnicotinedependenceanditsassociatedmedicalconsequences (see"Whatarethephysicalhealthconsequencesoftobaccouse?").Reviewsoftheliteratureonwaterpipeuserssuggestthatlikethosewhouseotherformsoftobacco,manyhavetriedtoquitbuthavebeenunsuccessfulontheirown. Thesefindingsindicatetheneedfortobaccocontrolpoliciesandpreventionandtreatmentinterventionsforthisformofnicotinedeliverythataresimilartothoseseenforcigarettes.
Smokelesstobacco
In2016,8.8millionpeopleaged12orolder(3.3percentofthispopulation)usedsmokelesstobaccoduringthepastmonth. Overall,useofsmokelesstobaccoamongadultsdecreasedfrom1992to2003buthasheldconstantsince. Longitudinaldatasuggestthatpeoplearemorelikelytoswitchfromsmokelesstobaccousetocigarettesmokingthanviceversa. Althoughsmokersmayattempttousesmokelessproductstocutdownorquit,researchsuggeststhatthisapproachisnoteffective. However,somearguethatusingsmokelesstobaccoinlieuofcigarettesmayhelpreducetheharmsassociatedwithsmokingtraditionalcigarettes.
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PolytobaccoUse
Someusersoftobaccoconsumeitinmultipleforms(polytobaccouse);thisbehaviorisassociatedwithgreaternicotinedependence andtheriskforothersubstanceusedisorder. AnalysesofadecadeofdatafromNSDUHfoundsteadyratesofpolytobaccousefrom2002to2011(8.7percentto7.4percent)amongpeopleage12andolder.However,useofsomeproductcombinations—suchascigarettesandsmokelesstobacco,cigarsandsmokelesstobacco,anduseofmorethantwoproducts—increasedoverthatperiod.
Amongindividualsyoungerthan26,ratesofpolytobaccouseincreaseddespitedeclinesinoveralltobaccouse.Polytobaccousewasassociatedwithbeingmale,havingrelativelylowincomeandeducation,andengaginginrisk-takingbehaviors. In2014,anestimated2.2millionmiddleandhighschoolstudentshadusedtwoormoretypesoftobaccoproductsduringthepastmonth,accordingtotheNYTS. Polytobaccousewascommon,evenamongstudentswhousedtobaccoproducts5daysorfewerduringthepastmonth. The2012NYTShadfoundthat4.3percentofstudentsusedthreeormoretypesoftobacco.Thisstudyalsoobservedthatmalegender,useofflavoredproducts,nicotinedependence,receptivitytotobaccomarketing,andperceivedpeerusewereallassociatedwithyouthpolytobaccouse.
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FlavoredTobaccoUseAmongAdolescentsandYoungAdults
Onespecificconcernaboute-cigarettesandtobaccoproductslikecigarillosandhookahsistheadditionofflavorings,whichmaymakethemparticularlyappealingtoyouth. TheFamilySmokingPreventionandTobaccoControlActof2009bannedthesaleofcigaretteswithflavorsotherthanmenthol,butotherflavoredtobaccoproducts(e.g.,smallcigars,cigarillos,andsmokelesstobacco)canstillbesold.Addingflavorstotobaccoproductsortothenicotinesolutionofe-cigarettescanmakethemmoreappealingtosomeusersbecausetheycanmasktheharshtaste. Althoughmoreresearchisneededonhowflavorsaffectlong-termuse,healthexpertshaveexpressedconcernsthatmanyoftheflavoringsusedintobaccoproductsarealsofoundincandiesandbeverages. Suchflavorsmaymakethemmoreappealingtoyouthandmaycontributetoincreaseduseoftheseproductsamongyoungpeople.
Approximately6.3percentofmiddleandhighschoolstudentsreportedusingeitherflavoredcigarettesorsmallcigars,accordingtothe2011NYTS. Datafromthe2014NYTSindicatethatofmiddleandhighschoolstudentswhocurrentlyusedtobacco,about70percent—anestimated3.26millionyouths—hadusedatleastoneflavoredtobaccoproductduringthepastmonth. Amongpast-monthusers,themostcommonlyusedflavoredproductsweree-cigarettes,hookahtobacco,andcigars. Itseemsthatyouthmaynotnecessarily“growoutof”usingflavoredtobaccoproducts.Amongyoungadultsaged18to34,nearlyone-fifth(18.5percent)ofthosewhousetobacco,consumedflavored(includingmenthol)products.
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Aretheregenderdifferencesintobaccosmoking?
Generally,mentendtousealltobaccoproductsathigherratesthanwomen. In2015,16.7percentofadultmalesand13.6percentofadultfemalessmokedcigarettes. Suchdifferencesmayrelatetoacombinationofphysiological(particularlyovarianhormones),cultural,andbehavioralfactors.
Resultsfromneuroimagingstudiessuggestthatsmokingactivatesmen’srewardpathwaysmorethanwomen's. Thisfindingisconsistentwiththeideathatmensmokeforthereinforcingeffectsofnicotine,whereaswomensmoketoregulatemoodorinresponsetocigarette-relatedcues.Astudyofstressresponsesandcravingamongmaleandfemalesmokerswhoweretryingtoquitfoundthatduringabstinence,lowerlevelsofthestresshormonecortisolpredictedrelapseinmen.However,highcortisollevelswerepredictiveofrelapseinwomen. Otherworkonabstinencefoundthatsmokingacigarettewithnicotine,ascomparedtoade-nicotinizedcigarette,alleviatedthe
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symptomsofwithdrawalandnegativemoodtoagreaterextentinmenthanwomen.Womenobtainedequalrelieffromcigaretteswithandwithoutnicotine,suggestingthattheyfoundthedruglessrewardingthanmen.
Cigarettecravingisamajorreasonwhysmokersfindithardtoquit,andthisstrongurgetosmokecanbeevokedbysensorycuesandstress.Researchsuggeststhatwomenexperiencestrongercravingthanmeninresponsetostress, butmenmaybemoreresponsivetoenvironmentalcues. Additionally,longitudinaldatafrominternationalsurveysconductedinfourindustrializedcountriesindicatedthatmenandwomendidnotdifferintheirdesiretoquit,planstoquit,orquitattempts.However,womenwere31percentlesslikelytoquitsuccessfully. Onereasonwhywomenmayhavedifficultyquittingispost-cessationweightgain.Thisconcernshouldbeaddressedinbehavioralcounselingandadjuncttreatmentsforallsmokers.
Theoveralllowercessationrateforwomenmayreflectsexdifferencesinresponsetoparticularmedications(see"Whataretreatmentsfortobaccodependence?").Forexample,vareniclinehasgreatershort-andimmediate-termefficacy(at3and6months)amongwomensmokers.However,womenandmenshowsimilar1-yearquitrateswhenusingvarenicline. Incontrast,acombinationofvareniclineplusbupropionwaslesseffectiveforcessationamongwomencomparedwithmen.
Anotherparticularconcernrelatedtotobaccouseamongwomenissmokingduringpregnancy(see"Whataretherisksofsmokingduringpregnancy?").
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Dopeoplewithmentalillnessandsubstanceusedisordersusetobaccomoreoften?
Thereissignificantcomorbiditybetweentobaccouseandmentaldisorders.Peoplewithmentalillnesssmokeattwotofourtimestherateofthegeneralpopulation.Amongpeoplewithamentalillness,36.1percentsmokedfrom2009to2011,comparedwith21.4percentamongadultswithnomentalillness. Smokingratesareparticularlyhighamongpatientswithseriousmentalillness(i.e.,thosewhodemonstrategreaterfunctionalimpairment).Whileestimatesvary,asmanyas70-85percentofpeoplewithschizophreniaandasmanyas50-70percentofpeoplewithbipolardisordersmoke.
Ratesofsmokingamongpeoplewithmentalillnesswerehighestforthoseyoungerthan45,thosewithlowlevelsofeducation,andthoselivingbelowthepovertylevel. LongitudinaldatafromNSDUH(2005–2013)indicatethatsmokingamongadultswithoutchronicconditionshasdeclinedsignificantly,butremainsparticularlyhighamongthosereportinganxiety,depression,andsubstanceusedisorders. Smokingisbelievedtobemoreprevalentamongpeoplewithdepressionandschizophreniabecausenicotinemaytemporarilylessenthesymptomsoftheseillnesses,suchaspoorconcentration,lowmood,andstress. Butitisimportanttonotethatsmokingcessationhasbeenlinkedwithimprovedmentalhealth—includingreduceddepression,anxiety,andstress,andenhancedmoodandqualityoflife.
AnalysesoflongitudinalNSDUHdataalsofoundahigherprevalenceofsmokelesstobaccouseamongindividualswithmentalhealthandsubstanceusedisorders. OtherresearchdrawingondatafromtheNationalEpidemiologicSurveyonAlcoholandRelatedConditionsfoundthatalltypesofsubstancedependencewereassociatedwithdependenceonnicotine. Smokingisalsohighlyprevalentamongpeopleintreatmentforsubstanceusedisorders, withmoststudiesfindingratesbetween65-85percentamongpatientsinaddictiontreatment.
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Additionally,smokerswithamentalhealthdisordertendtosmokemorecigarettesthanthoseinthegeneralpopulation.Theaveragenumberofcigarettessmokedduringthepastmonthwashigheramongthosewithamentalillnesscomparedwiththosewithoutone—331versus310cigarettes. Highcigaretteconsumptionisaparticularproblemforpeoplewithseriousmentalillness.Althoughadultswithseriousmentalillnesscomprisedonly6.9percentofpast-monthsmokers,theyconsumed8.7percentofallcigarettessold,accordingtodatafromthe2008–2012NSDUH.
HighPrevalenceofSmokingAmongPeoplewithSchizophrenia
Researchersareworkingtoidentifythebraincircuitsthatcontributetothehighprevalenceofsmokingamongpeoplewithschizophrenia.Schizophreniaisassociatedwithwidespreadreductionsinfunctionalconnectivitybetweenthedorsalanteriorcingulatecortexanddiversepartsofthelimbicsystem.Onereportidentified15circuitsforwhichthereductionoffunctionalconnectivitycorrelatedwithseverityofnicotineaddiction.
Peoplewithmentalandsubstanceusedisordersdonotquitsmokingatthesamerateasthoseinthegeneralpopulation.4Surveyresponsesfrompeoplewhohavesmokedatsomepointduringtheirlivesindicatedthatfewersmokerswithmentalillnesshadquitcomparedtothosewithoutpsychiatricdisorders:47.4percentoflifetimesmokerswithoutmentalillnesssmokedduringthepastmonth,comparedwith66percentofthosewithmentalillness. Havingamentaldisorderatthetimeofcessationisariskfactorforrelapsetosmoking,evenforthosewhohavesustainedabstinenceformorethanayear. Manysmokerswithmentalillnesswanttoquitforthesamereasonscitedbyothers(suchashealthandfamily),buttheymaybemorevulnerabletorelapserelatedtostressandnegativefeelings.
Thedisparityinsmokingprevalenceiscostinglives.Arecentstudyfoundthattobacco-relateddiseasesaccountedforapproximately53percentofdeathsamongpeoplewithschizophrenia,48percentamongthosewithbipolar
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disorder,and50percentamongthosewithdepression.
Sincethe1980s,manyprovidershavebelievedthatpeoplewithschizophreniasmoketoobtainrelieffromsymptomslikepoorconcentration,lowmood,andstress. Butresearchisnowshowingthatsmokingisassociatedwithworsebehavioralandphysicalhealthoutcomesinpeoplewithmentalillness,andquittingsmokingisshowingclearbenefitsforthispopulation. Comprehensivetobaccocontrolprogramsandenhancedeffortstopreventandtreatnicotineaddictionamongthosewithmentalillnesswouldreduceillnessanddeaths.Integratedtreatment—concurrenttherapyformentalillnessandnicotineaddiction—willlikelyhavethebestoutcomes.
Smokerswhoreceivementalhealthtreatmenthavehigherquitratesthanthosewhodonot. Moreover,evidence-basedtreatmentsthatworkinthegeneralpopulationarealsoeffectiveforpatientswithmentalillness.Forexample,peoplewithschizophreniashowedbetterquitrateswiththemedicationbupropion,comparedwithplacebo,andshowednoworseningofpsychiatricsymptoms. Acombinationofthemedicationvareniclineandbehavioralsupporthasshownpromiseforhelpingpeoplewithbipolarandmajordepressivedisordersquit,withnoworseningofpsychiatricsymptoms. Aclinicaltrialfoundthatacombinationofvareniclineandcognitivebehavioraltherapy(CBT)wasmoreeffectivethanCBTaloneforhelpingpeoplewithseriousmentalillnessstopsmokingforaprolongedperiod—after1yearoftreatmentandat6monthsaftertreatmentended.
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Whataretreatmentsfortobaccodependence?
Thereareeffectivetreatmentsthatsupporttobaccocessation,includingbothbehavioraltherapiesandFDA-approvedmedications.FDA-approvedpharmacotherapiesincludevariousformsofnicotinereplacementtherapyaswellasbupropionandvarenicline.Researchindicatesthatsmokerswhoreceiveacombinationofbehavioraltreatmentandcessationmedicationsquitathigherratesthanthosewhoreceiveminimalintervention.
Interventionssuchasbriefadvicefromahealthcareworker,telephonehelplines,automatedtextmessaging,andprintedself-helpmaterialscanalsofacilitatesmokingcessation. Cessationinterventionsutilizingmobiledevicesandsocialmediaalsoshowpromiseinboostingtobaccocessation. Itisimportantforcessationtreatmenttobeaspersonalizedaspossible,assomepeoplesmoketoavoidnegativeeffectsofwithdrawalwhileothersaremoredrivenbytherewardingaspectsofsmoking.
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Theprevalenceoftobaccouseanddependenceamongadolescents—aswellastheneurobiologicalimpactandmedicalconsequencesofnicotineexposure—suggestthatpediatricprimarycaresettingsshoulddelivertobaccocessationtreatmentstobothyouthandparentswhousetobacco. Currentclinicalguidancedoesnotrecommendmedicationsforadolescenttobaccocessationbecauseofalackofhigh-qualitystudies; however,acombinationofbehavioraltreatments—suchasmotivationalenhancementandCBT—hasshownpromiseforhelpingadolescentsquittobacco. Morewell-designedsmokingcessationstudiesneedtobeconductedwithadolescentsmokers,particularlyintheareaofpharmacologictreatmentsfornicotinedependence.
BehavioralTreatments
Behavioralcounselingistypicallyprovidedbyspecialistsinsmokingcessationforfourtoeightsessions. Bothin-personandtelephonecounselinghavebeenfoundbeneficialforpatientswhoarealsousingcessationmedications. Avarietyofapproachestosmokingcessationcounselingareavailable.
CognitiveBehavioralTherapy(CBT)—CBThelpspatientsidentifytriggers—thepeople,places,andthingsthatspurbehavior—andteachesthemrelapse-preventionskills(e.g.,relaxationtechniques)andeffectivecopingstrategiestoavoidsmokinginthefaceofstressfulsituationsandtriggers. AstudythatcomparedCBTandbasichealtheducationobservedthatbothinterventionsreducednicotinedependence. However,anotherstudyfoundthatamongsmokerstryingtoquitwiththenicotinereplacementtherapy(NRT)patch,patientswhoparticipatedinsixsessionsofintensivegroupCBThadbetterquitratesthanthosewhoreceivedsixsessionsofgeneralhealtheducation.
MotivationalInterviewing(MI)—InMI,counselorshelppatientsexploreandresolvetheirambivalenceaboutquittingsmokingandenhancetheirmotivationtomakehealthychanges.MIispatient-focusedandnonconfrontational,andproviderspointoutdiscrepanciesbetweenpatients’goalsorvaluesandtheircurrentbehaviors.Theyadjusttopatients’resistancetochangeandsupportself-efficacyandoptimism. StudiesofMIsuggestthatthisinterventionresultsinhigherquitratesthanbriefadvicetostopsmokingorusualcare.
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Mindfulness—Inmindfulness-basedsmokingcessationtreatments,patientslearntoincreaseawarenessofanddetachmentfromsensations,thoughts,andcravingsthatmayleadtorelapse. Inthistherapy,patientspurposelyattendtothethoughtsthattriggercravingsandurgesfortobaccoandcognitivelyreframethemasexpectedandtolerable.Patientslearntechniquesthathelpthemtoleratenegativeemotions—includingstressandcravings—withoutreturningtotobaccouseorotherunhealthybehaviors. Interestinmindfulness-basedtreatmentshasincreasedduringthepastdecade,andstudiesshowthatthisapproachbenefitsoverallmentalhealthandcanhelppreventrelapsetosmoking. However,well-controlledclinicaltrialsareneeded.
Telephonesupportandquitlines—Aspartoftobaccocontrolefforts,allstatesoffertoll-freetelephonenumbers(orquitlines)withsmokingcessationcounselorswhoprovideinformationandsupport(800-QUIT-NOWor800-784-8669).Studiesofquitlineinterventionsindicatethatsmokerswhocallquitlinesbenefitfromtheseservices, particularlywhenacounselorcallsthembackformultiplesessions. Thereislimitedevidenceontheoptimalnumberofcallsneeded,butsmokerswhoparticipatedinthreeormorecallshadagreaterlikelihoodofquitting,comparedwiththosewhoonlyreceivededucationalmaterials,briefadvice,orpharmacotherapyalone. Quitlineshavealsobeenshowntohelpsmokelesstobaccocessation. TheU.S.DepartmentofHealthandHumanServicesprovidesaSmokingQuitline(877-44U-QUITor877-448-7848),aswellasmoreinformationandtoolsforquitting(includingtextmessagesandothertelephone-basedsupport)athttps://smokefree.gov/.
Textmessaging,web-basedservices,andsocialmediasupport—Technology,includingmobilephones,internet,andsocialmediaplatformscanbeusedtoprovidesmokingcessationinterventions.Thesetechnologieshavethepowertoincreaseaccesstocarebyextendingtheworkofcounselorsandovercomingthegeographicalbarriersthatmaydeterpeoplefromenteringtreatment.
Areviewoftheliteratureontechnology-basedsmokingcessationinterventions(internet,personalcomputer,andmobiletelephone)foundthatthesesupportscanincreasethelikelihoodofadultsquitting,comparedwithnointerventionorself-helpinformation,andtheycanbeacost-effectiveadjuncttoothertreatments. Atechnologydoesnotnecessarilyhavetoberecentorhighly
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sophisticatedtohelpboostcessationrates.Forexample,studiessuggestthatadultswhoreceiveencouragement,advice,andquittingtipsviatext-message—acapabilityoneventhemostbasicmobiledevices—showimprovedquitratescomparedwithcontrolprograms.
Amongadulttobaccouserswhocalledastatequitline,mostselectedanintegratedphone/webcessationprograminfavorofaweb-onlyintervention. Participantswhochosetheweb-onlyoptiontendedtobeyoungerandhealthiersmokers,withahighersocioeconomicstatus.Theseparticipantstendedtointeractintenselywiththesiteonce,butdidnotre-engageasmuchasthosewhooptedforthephone/webcombination.Areviewofinternet-basedsmokingcessationprogramsforadultssuggestedthatinteractiveinternet-basedinterventionsthataretailoredtoindividualneedscanhelppeoplequitfor6monthsorlonger. Futureresearchshoulddeterminetheeffectivenessofdifferenttechnologiesforsmokingcessationsupportamongpopulationsthatmaybehardtoreach,includingthoseoflowsocioeconomicstatusandadultsolderthanage50.
Technology-basedcessationinterventionsareparticularlyrelevanttoyoungadultsaged18to25—about3.2millionofwhomsmokeddailyin2016. Asystematicreviewandmeta-analysisofpublishedrandomizedtrialsoftechnology-basedinterventions—includingcomputerprograms,internet,telephone,andtextmessaging—forsmokingcessationamongthispopulationfoundthattheyincreasedabstinenceby1.5timesthatofcomparisonsubjects. Researchersrecommendembeddingcessationinterventionsincommonlyusedsocialnetworkingplatforms, andtherehasbeensomeexploratoryworkinthisarea.ResultsofatrialwitharelativelysmallnumberofparticipantssuggestedthatFacebookwasanaccessible,low-costplatformforengagingyoungadultsconsideringcessation.However,thestudypointedtochallengesinmaintainingparticipation,retainingyoungpeopleintheprogram,andtheneedforgender-specificfeatures. Arandomizedcontrolledtrialhasbeendesignedtotestastage-basedsmokingcessationinterventiononFacebooktailoredforsmokersaged18to25.Participantswillberecruitedonline,randomlyassignedtoaFacebookgroupaccordingtotheirreadinesstoquit,andwillreceivetailoreddailymessagesandweeklycounseling.Thestudywillassesstheintervention’simpactonabstinencefromsmoking3,6,and12monthsaftertreatment,numberofcigarettessmoked,quitattemptslasting24
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hoursormore,andcommitmenttoabstinence.
SmokingCessationforPregnantWomen
Giventherisksassociatedwithsmokingduringpregnancy,butalsothechallengesfacedbyallsmokerswhentryingtoquit,researchershavestudiedanarrayofapproachestoimprovecessationratesforthispopulation.Manywomenaremotivatedtoquitduringpregnancy,butlikeothersmokers,mostwillneedassistance.
Studiesshowthatbehavioraltreatmentsareeffective,whereaspharmacotherapieshaveonlymarginalsuccess. Acombinationofincentivesandbehavioralcounselingismosteffectiveforpregnantwomen. Addingvoucherstoroutinecare(whichincludedfreenicotinereplacementtherapyfor10weeksandfourweeklysupportphonecalls)morethandoubledcessationratesduringpregnancy. Pooledresultsofbehavioralinterventionstudiesindicatethattreatmentreducedpretermbirthsandtheproportionofinfantsbornwithlowbirthweight,comparedwithusualcare. Thisfindingissupportedbyananalysisofpooledresultsfromstudieswitheconomicallydisadvantagedpregnantsmokers,whichfoundthatvoucher-basedincentivesimprovedsonographicallyestimatedfetalgrowth,birthweight,percentageoflow-birth-weightdeliveries,andbreastfeedingduration.
Medications
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NicotineReplacementTherapy(NRT)—AvarietyofformulationsofnicotineNRTsareavailableoverthecounter—includingthetransdermalpatch,spray,gum,andlozenges—andareequallyeffectiveforcessation. NRTsstimulatethebrainreceptorstargetedbynicotine,helpingrelievenicotinewithdrawalsymptomsandcravingsthatleadtorelapse. ManypeopleuseNRTtohelpthemgetthroughtheearlystagesofcessation,andthosewithmoreseverenicotineaddictioncanbenefitfromlonger-termtreatment.UseofNRTimprovessmokingcessationoutcomes,andaddingbehavioraltherapiesfurtherincreasesquitrates. Acombinationofcontinualnicotinedeliverythroughthetransdermalpatchandoneotherformofnicotinetakenasneeded(e.g.,lozenge,gum,nasalspray,inhaler)hasbeenfoundtobemoreeffectiveatrelievingwithdrawalsymptomsandcravingsthanasingletypeofNRT. ResearchersestimatethatNRTincreasesquitratesby50to70percent. Usingthepatchforupto24weekshasbeenshowntobesafe.
Bupropion—Bupropion(immediate-releaseandextended-release)wasoriginallyapprovedasanantidepressant.Itworksbyinhibitingthereuptakeofthebrainchemicalsnorepinephrineanddopamineaswellasstimulatingtheir
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release.Bupropionhasbeenfoundtoincreasequitratescomparedwithplaceboinbothshort-andlong-termfollow-upstudies andisindicatedforsmokingcessation.ItisequallyeffectivetoNRT.
Varenicline—Vareniclinehelpsreducenicotinecravingsbystimulatingthealpha-4beta-2nicotinicreceptorbuttoalesserdegreethannicotine.Vareniclinebooststheoddsofsuccessfullyquitting,comparedwithunassistedattempts. Vareniclineincreasedthelikelihoodofquittingcomparedwithplacebo,andsomestudiesfindthatitismoreeffectivethansingleformsofNRT andbupropion. Inaprimarycaresetting,44percentofpatientsonvarenicline,eitheraloneorcombinedwithcounseling,wereabstinentatthe2-yearfollow-up.Patientswhoparticipatedingrouptherapyandadheredtothemedicationweremorelikelytoremainabstinent. Researchalsosuggeststhatthismedicationmaybemoreeffectivethanbupropion.
Medicationcombinations—SomestudiessuggestthatcombiningNRTwithothermedicationsmayfacilitatecessation.Forexample,ameta-analysisfoundthatacombinationofvareniclineandNRT(especially,providinganicotinepatchpriortocessation)wasmoreeffectivethanvareniclinealone. Similarly,addingbupropiontoNRTalsoimprovedcessationrates. ForsmokerswhocouldnotcutdownsignificantlybyusingtheNRTpatch,combiningextended-releasebupropionandvareniclinewasmoreeffectivethanplacebo,particularlyformenandthosewhowereseverelynicotinedependent.
Otherantidepressants—Inadditiontobupropion,someotherantidepressantmedicationshavealsobeenfoundeffectiveforsmokingcessation,independentoftheirantidepressanteffects,andareconsideredsecond-linetreatments.AfewsmallstudiessuggestthatnortriptylineisequallyeffectiveasNRT. Althoughnortriptylinemayhavesideeffectsinsomepatients,thesmallstudiesforitsuseinsmokingcessationhavenotreportedany.Researchershavenotobservedanyimpactofselectiveserotoninreuptakeinhibitors(SSRIs)(e.g.,fluoxetine,paroxetine,andsertraline)onsmoking,eitheraloneorincombinationwithNRT.
PrecisionMedicine—Researchershavebeenexaminingwaystopersonalizetreatmentbasedonimportantindividualbiologicaldifferences,including
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geneticdifferences.Thefieldofpharmacogeneticsexamineshowgenesinfluencetherapeuticresponsetomedications,providingcriticalinformationtohelptailorpharmacotherapiestotheindividualformaximumbenefit.Forexample,peoplemetabolizenicotineatdifferentratesbecauseofvariationsinseveralgenes.Individualswhometabolizenicotinequicklysmokemore,showgreaterdependence,andhavemoredifficultyquitting. SuchgeneticvariationinfluencesthetherapeuticresponsestoNRTandothercessationmedications. Arecentstudycomparedratesofabstinence1weekaftertreatmentforslow,normal,andfastmetabolizersofnicotinewhowererandomlyassignedtoeitherplacebo,NRT,orvarenicline.Resultsindicatedthatvareniclineworkedbestfornormalnicotinemetabolizers,whereasNRTpatchesweremosteffectiveforslowmetabolizers.
Promisingmedicationsandongoingresearch—NIDAsupportsresearchtodevelopnewandimprovecurrenttreatmentoptionsforsmokingcessationbasedonagrowingunderstandingoftheneurobiologyofaddiction.Intheareaofmedications,researchisfocusingonthereceptorstargetedbynicotineandthebraincircuitsandregionsknowntoinfluencenicotineconsumption. Newerbraintargets—includingtheorexinandglutamatesignalingsystems—havealsoshownpromiseformedicationtreatment. Repurposingmedicationsalreadyonthemarketforotherindicationsmayalsoproveusefulinthesearchfornewsmokingcessationtherapies. Thisapproachhasbeensuccessfulinthepast,asbupropionwasanestablishedantidepressantbeforetheFDAapproveditasasmokingcessationmedication.OnecurrentcandidateisN-acetylcysteine,amedicationforacetaminophenoverdose,whichhasshownpromiseasatreatmentforvarioussubstanceusedisorders—includingnicotinedependence. Anotherapproachthatcouldpreventrelapseandthathasshownpromiseinearlystudiesisanicotinevaccine,whichwouldgenerateantibodiesthatkeepnicotinefromreachingthebrain.
TranscranialMagneticStimulation
Transcranialmagneticstimulation(TMS)isarelativelynewapproachbeingtestedtotreataddiction.Itisaphysiologicalinterventionthatnoninvasivelystimulatesneuralactivityintargetedareasofthebrainusingmagneticfields.MultipleTMSpulsesgivenconsecutivelyarereferredtoasrepetitiveTMS
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(rTMS).TheFDAhasapprovedtworTMSdevicesfordepressiontreatmentinadults.
ResearchonrTMSasatreatmentforsmokingcessationisinearlystagesbuthasshownpromise. Amongadultsmokerswhohadnotbeenabletoquitusingothertreatments,high-frequencyTMStreatmentsignificantlyreducedthenumberofcigarettessmoked.Combininghigh-frequencyTMSwithexposuretosmokingcuesimprovedeffectivenessandboostedtheoverallabstinencerateto44percentattheendofthetreatment.Sixmonthsaftertreatment,33percentofparticipantsremainedabstinentfromcigarettes. Futurerandomizedcontrolledclinicaltrialswithlargenumbersofpatientswillbeneededtoestablishitsefficacyforsmokingcessation.
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Howcanwepreventtobaccouse?
Themedicalconsequencesoftobaccouse—includingsecondhandexposure—maketobaccocontrolandsmokingpreventioncrucialpartsofanypublichealthstrategy.SincethefirstSurgeonGeneral’sReportonSmokingandHealthin1964,statesandcommunitieshavemadeeffortstoreduceinitiationofsmoking,decreaseexposuretosmoke,andincreasecessation.Researchersestimatethatthesetobaccocontroleffortsareassociatedwithavertinganestimated8millionprematuredeathsandextendingtheaveragelifeexpectancyofmenby2.3yearsandofwomenby1.6years. Butthereisalongwayyettogo:roughly5.6millionadolescentsunderage18areexpectedtodieprematurelyasaresultofanillnessrelatedtosmoking.
Preventioncantaketheformofpolicy-levelmeasures,suchasincreasedtaxationoftobaccoproducts;stricterlaws(andenforcementoflaws)regulatingwhocanpurchasetobaccoproducts;howandwheretheycanbepurchased;whereandwhentheycanbeused(i.e.,smoke-freepoliciesinrestaurants,bars,andotherpublicplaces);andrestrictionsonadvertisingandmandatoryhealthwarningsonpackages.Over100studieshaveshownthathighertaxesoncigarettes,forexample,producesignificantreductionsinsmoking,especiallyamongyouthandlower-incomeindividuals. Smoke-freeworkplacelawsandrestrictionsonadvertisinghavealsoshownbenefits.
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Preventioncanalsotakeplaceattheschoolorcommunitylevel.Merelyeducatingpotentialsmokersaboutthehealthriskshasnotproveneffective. Successfulevidence-basedinterventionsaimtoreduceordelayinitiationofsmoking,alcoholuse,andillicitdruguse,andotherwiseimproveoutcomesforchildrenandteensbyreducingormitigatingmodifiableriskfactorsandbolsteringprotectivefactors.Riskfactorsforsmokingincludehavingfamilymembersorpeerswhosmoke,beinginalowersocioeconomicstatus,livinginaneighborhoodwithhighdensityoftobaccooutlets,notparticipatinginteamsports,beingexposedtosmokinginmovies,andbeingsensation-seeking. Althougholderteensaremorelikelytosmokethanyoungerteens,theearlierapersonstartssmokingorusinganyaddictivesubstance,themorelikelytheyaretodevelopanaddiction.Malesarealsomorelikelytotakeupsmokinginadolescencethanfemales.
Someevidence-basedinterventionsshowlastingeffectsonreducingsmokinginitiation.Forinstance,communitiesutilizingtheintervention-deliverysystem,CommunitiesthatCare(CTC)forstudentsaged10to14showsustainedreductioninmalecigaretteinitiationupto9yearsaftertheendoftheintervention.
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Whatresearchisbeingdoneontobaccouse?
Newscientificdevelopmentscanimproveourunderstandingofnicotineaddictionandspurthedevelopmentofbetterpreventionandtreatmentstrategies.
GeneticsandEpigenetics
Anestimated50-75percentoftheriskfornicotineaddictionisattributabletogeneticfactors. Aclusterofgenes(CHRNA5-CHRNA3-CHRNB4)onchromosome15thatencodethe5,3,and4proteinsubunitsthatmakeupthebrainreceptorfornicotine areparticularlyimplicatedinnicotinedependenceandsmokingamongpeopleofEuropeandescent.VariationintheCHRNA5geneinfluencestheeffectivenessofcombinationNRT,butnotvarenicline. Otherresearchhasidentifiedgenesthatinfluencenicotinemetabolismandtherefore,thenumberofcigarettessmoked, responsivenesstomedication, andchancesofsuccessfullyquitting. Forexample,thetherapeuticresponsetovareniclineisassociatedwithvariantsfortheCHRNB2,CHRNA5,andCHRNA4genes,whilebupropion-relatedcessationislinkedwithvariationingenesthataffectnicotinemetabolism.
Smokingcanalsoleadtopersistentchangesingeneexpression(epigeneticchanges),whichmaycontributetoassociatedmedicalconsequencesoverthelongterm,evenfollowingcessation. Epigeneticchangesmayserveasapotentialbiomarkerforprenataltobaccosmokeexposure.Researchersfoundtobacco-specificchangesat26sitesontheepigenome,andthispatternpredictedprenatalexposurewith81percentaccuracy. Alargescalemeta-analysisofdataonepigeneticchangesassociatedwithprenatalexposuretocigarettesmokealsoidentifiedmanyepigeneticchangesthatpersistedintolaterchildhood. Moreresearchisneededtounderstandthelong-termhealthimpactsofthesechanges.
Neuroimaging
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Cutting-edgeneuroimagingtechnologieshaveidentifiedbrainchangesassociatedwithnicotinedependenceandsmoking.Usingfunctionalmagneticresonanceimaging(fMRI),scientistscanvisualizesmokers’brainsastheyrespondtocigarette-associatedcuesthatcantriggercravingandrelapse. Suchresearchmayleadtoabiomarkerforrelapseriskandformonitoringtreatmentprogress,aswellaspointtoregionsofthebraininvolvedinthedevelopmentofnicotineaddiction.
Aneuroimagingtechnologycalleddefault-modeorresting-statefMRI(rs-fMRI)revealsintrinsicbrainactivitywhenpeoplearealertbutnotperformingaparticulartask.Usingthistechnique,researchersareexaminingtheneurobiologicalprofileassociatedwithwithdrawalandhownicotineimpactscognition. Comparisonsbetweensmokersandnonsmokerssuggestthatchronicnicotinemayweakenconnectivitywithinbraincircuitsinvolvedinplanning,payingattention,andbehavioralcontrol—possiblycontributingtodifficultywithquitting. fMRIstudiesalsorevealtheimpactofsmokingcessationmedicationsonthebrain—particularlyhowtheymodulatetheactivityofdifferentbrainregionstoalleviatewithdrawalsymptomsandreducesmoking.AreviewofthesestudiessuggestedthatNRTenhancescognitionduringwithdrawalbymodulatingactivityindefault-networkregions,butmaynotaffectneuralcircuitsassociatedwithnicotineaddiction.
Someimagingtechniquesallowresearcherstovisualizeneurotransmittersandtheirreceptors,furtherinformingourunderstandingofnicotineaddictionanditstreatment. Usingthesetechniques,researchershaveestablishedthatsmokingincreasesthenumberofbrainreceptorsfornicotine.Individualswhoshowgreaterreceptorupregulationarelesslikelytostopsmoking. Combiningneuroimagingandgeneticsmayyieldparticularlyusefulinformationforimprovingandtailoringtreatment.Forexample,nonsmokingadolescentswithaparticularvariantintheCHRNA5-CHRNA3-CHRNB4genecluster(whichisassociatedwithnicotinedependenceandsmoking)showedreducedbrainactivityinresponsetorewardinthestriatumaswellastheorbitofrontalandanteriorcingulatecortex.Thisfindingsuggeststhatgeneticscaninfluencehowthebrainprocessesrewardswhichmayinfluencevulnerabilitytonicotinedependence. Neuroimaginggeneticsalsoshowsthatothergenes,includingonesthatinfluencedopamineneurotransmission,influencerewardsensitivityandriskforaddictiontonicotine.
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WherecanIgetfurtherinformationabouttobacco/nicotine?
Tolearnmoreabouttobacco,nicotine,andotherdrugsofuseandmisuse,visittheNIDAwebsiteatwww.drugabuse.govorcontactDrugPubsat877-NIDA-NIH(877-643-2644;TTY/TDD:240-645-0228).
NIDA'swebsiteincludes:
Informationondrugsofuseandmisuseandrelatedhealthconsequences
NIDApublications,news,andevents
Resourcesforhealthcareprofessionals,educators,andpatientsandfamilies
InformationonNIDAresearchstudiesandclinicaltrials
Fundinginformation(includingprogramannouncementsanddeadlines)
Internationalactivities
Linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsinthefield)
InformationinSpanish(enespañol)
NIDAwebsitesandwebpages
drugabuse.gov/publications/drugfacts/cigarettes-other-tobacco-products
drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
drugabuse.gov
teens.drugabuse.gov
easyread.drugabuse.gov
researchstudies.drugabuse.gov
72
irp.drugabuse.gov
Forphysicianinformation
NIDAMED:drugabuse.gov/nidamed
Otherwebsites
Informationonnicotine/tobaccoabuseisalsoavailablethroughthefollowingwebsites:
NationalCancerInstitute
CentersforDiseaseControlandPrevention
SubstanceAbuseandMentalHealthServicesAdministration
MonitoringtheFuture
ThePartnershipforDrug-FreeKids
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