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Smoking
INTRODUCTION
Smoking, inhalation and exhalation of the fumes of burning tobacco. Leaves of the tobacco plant are smoked in various ways. After a drying and curing process, they may be rolled into cigars or shredded for insertion into smoking pipes. Cigarettes, the most popular method of smoking, consist of finely shredded tobacco rolled in lightweight paper. About 45 million people in the United States smoke an estimated total of 480 billion cigarettes each year. Until the 1940s, smoking was considered harmless, but laboratory and clinical research has since confirmed that tobacco smoke presents a hazard to health. Smoke from the average cigarette contains around 4,000 chemicals, some of which are highly toxic and at least 43 of which cause cancer. Nicotine, a major constituent of tobacco smoke, is both poisonous and highly addictive. According to the American Cancer Society, smoking is the most preventable cause of death in America today.
European explorers who arrived in the western hemisphere in the 1500s observed Native Americans smoking tobacco plant leaves in pipes. The colonists who followed them grew tobacco plants as a cash crop for export, and smoking became part of European culture by the 1600s. Most tobacco was consumed in pipes and cigars or as snuff (finely pulverized tobacco inhaled into the nostrils). This pattern changed by the early 20th century, by which time smokers consumed more than 1,000 cigarettes per capita each year in the United States and some European countries. The general attitude of society was that smoking relieved tension and produced no ill effects. During World War II (1939-1945) American physicians endorsed sending soldiers tobacco, and cigarettes were included in the field ration kits of U.S. armed forces personnel until 1975.
Early Opposition to Cigarette Smoking
American businessmen and innovators Henry Ford and Thomas A. Edison were among the most prominent supporters of an anticigarette movement that flourished long before the United States Surgeon General issued his 1964 "Report on Smoking and Health." In this excerpt from The Case Against the Little White Slaver (1914), Ford summarizes his objections to cigarettes and responds to a letter of protest from Percival I. Hill, president of the American Tobacco Company. Anticigarette activists succeeded in outlawing the sale of cigarettes in more than a dozen states during the Progressive Era (roughly 1890 to 1920).
Some epidemiologists noticed, however, that lung cancer, which was rare before the 20th century, had increased dramatically since about 1930. The American Cancer Society and other organizations initiated studies comparing deaths among smokers and nonsmokers over a period of several years. All such studies found increased mortality among smokers, both from cancer and other causes. In addition, experimental studies in animals showed that many of the chemicals contained in cigarette smoke are carcinogenic. In 1962 the U.S. government appointed a panel of ten scientists to study the available evidence. Their conclusions were included in the 1964 Surgeon General's report, which stated that "cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action." Smoking in adults, measured as an average number of cigarettes smoked per year, began to decline steadily after the 1964 report and has fallen more than 40 percent.
The American Cancer Society estimates that cigarettes are responsible for more than 400,000 deaths in the United States each year. Lung cancer accounts for about 30 percent of all cancer deaths in the United States and smoking accounts for nearly 90 percent of lung cancer deaths. The risks of dying from lung cancer are 23 times higher for male smokers and 11 times higher for female smokers than for nonsmokers. Additionally, smokers are at increased risk for cancer of the larynx, oral cavity, esophagus, bladder, kidney, and pancreas.
Smoking causes a fivefold increase in the risk of dying from chronic bronchitis and emphysema, and a twofold increase in deaths from diseases of the heart and coronary arteries. Smoking also increases the risk of stroke by 50 percent—40 percent among men and 60 percent among women. Other research has shown that mothers who smoke give birth more frequently to premature or underweight babies, probably because of a decrease in blood flow to the placenta. Babies born to mothers who smoke during pregnancy are also at increased risk for sudden infant death syndrome.
A recent report by the National Cancer Institute contradicts the common misconception that cigar or pipe smoking is less hazardous than cigarette smoking. The report concluded that the mortality rates from cancer of the mouth, throat, larynx, pharynx, and esophagus are approximately equal in users of cigarettes, cigars, and pipes. Rates of coronary heart disease, lung cancer, emphysema, and chronic bronchitis are elevated for cigar and pipe smokers and are correlated to the amount of smoking and the degree of inhalation. Cigar and pipe smoke contains the same toxic and carcinogenic compounds found in cigarette smoke. Nevertheless, cigar sales in the United States have increased 50 percent since 1993.
The ways in which tobacco smoke affects the human body have been studied intensely. Recent findings may explain why cigarettes are addictive. An unknown component of tobacco smoke appears to destroy an important brain enzyme, monoamine oxidase B (MAO B). The enzyme is vital for breaking down excess amounts of dopamine, a neurotransmitter that triggers pleasure-seeking behavior. Smokers have decreased levels of MAO B and abnormally high levels of dopamine, which may encourage the smoker to seek the pleasure of more tobacco smoke.
Recent research has focused on the effects of environmental tobacco smoke (ETS)—that is, the effect of tobacco smoke on nonsmokers who must share the same environment with a smoker. The United States Environmental Protection Agency (EPA) estimates that exposure to ETS, which contains all the toxic agents inhaled by a smoker, causes 3,000 cancer deaths per year in nonsmokers and can aggravate asthma, pneumonia, bronchitis, and impaired blood circulation. A ten-year study published in 1997 concluded that regular exposure to secondhand smoke almost doubled the risk of heart disease.
The smoking habit and addiction to nicotine usually begin at an early age. In the United States, more than 70 percent of adults who smoke began smoking before the age of 18. This fact has led to particular concern over smoking in teenagers and young adults. From the early to mid-1990s the proportion of teenage smokers in the United States rose from one-quarter to one-third, despite increasing warnings about the health hazards of smoking and widespread bans on smoking in public places. A 1998 report from the Surgeon General confirmed that this trend continues, especially among racial and ethnic minorities. For example, although black teenagers have the lowest smoking rates of any racial group, cigarette smoking among black teens increased 80 percent in the later half of the 1990s. Advertisements aimed at a young audience are largely blamed for this new generation of smokers.
Studies of ex-smokers show that their risk of dying from smoking-related disease decreases with each year of abstinence. Since the Surgeon General's report in 1964, the proportion of males who smoke has decreased from more than 50 percent to about 28 percent while the percentage of women who smoke has fallen from about 34 percent to 23 percent. Today, more than 40 million Americans have quit smoking cigare; there are now as many ex-smokers as there are active smokers.
Smoking cessation methods are plentiful, and many books and pamphlets are available to help an individual stop smoking. Many smokers turn to group help because of the support and understanding provided by other ex-smokers or people trying to quit. Most successful group-help techniques involve a challenge and reward system that also bolsters the self-discipline of the ex-smoker.
A number of nicotine replacement products are available to help a quit smoking. Nicotine patches are small, nicotine-containing adhesive disks that must be applied to the skin. The nicotine is slowly absorbed through the skin and enters the bloodstream. Over time, the nicotine dose is lessened and eventually the craving for nicotine is alleviated. Nicotine gum works in a similar manner, providing small doses of nicotine when chewed. Other nicotine replacement therapies include a nicotine nasal spray. This physician-prescribed spray relieves cravings for a cigarette by delivering nicotine to the nasal membranes. Also available by prescription, the nicotine inhaler looks like a cigarette; when puffed, the inhaler releases nicotine into the mouth.
Recently, an approach combining three different smoking cessation therapies has gained favor. This new approach combines an antidepressant drug called bupropin, marketed under the brand name Zyban, with nicotine replacement therapy and counseling. This approach to smoking cessation has shown remarkable results in the short term. While less than 25 percent of smokers who use nicotine replacement alone remain smoke-free for more than a year, 40 to 60 percent of smokers using the combination approach achieved this milestone.
The benefits of smoking cessation include the immediate reduction of health hazards for the smoker, easier admission to social activities and institutions that ban smoking, and often, lower health insurance premiums. Nonetheless, to quit smoking is difficult, most likely because smokers crave the effect of the nicotine in the smoke. In a 1988 report, the U.S. Surgeon General declared nicotine an addictive drug comparable to other addictive substances in its ability to induce dependence. The report also called the monetary and human costs far greater than those attributed to cocaine, alcohol, or heroin. Recent evidence supports this claim, indicating that the overall mortality attributable to tobacco smoking in the United States is about 20 times the mortality due to all other addictive drugs combined.
In the United States, the first direct action to curb smoking after the U.S. Surgeon General's 1964 report on smoking was the mandate of a warning on cigarette packages by the Federal Trade Commission. This warning took effect in 1964 and was strengthened in 1969 to read: "Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health." A stronger sequence of four alternative warnings was developed in 1984. In 1971 all cigarette advertising was banned from radio and television, and cities and states passed laws requiring nonsmoking sections in public places and workplaces. This trend has continued and smoking is now banned at the federal and state levels in most government buildings and in many private businesses. As of February 1990 federal law banned smoking on all domestic United States airline flights under six hours in duration. By 1998 more than 90 percent of nonstop flights between the United States and all foreign countries were also smoke free.
Recently, the United States Food and Drug Administration (FDA) has attempted to increase its jurisdiction over the marketing and advertising of tobacco products with the aim of reducing smoking, especially among teenage Americans. The United States Occupational Safety and Health Administration (OSHA) has proposed that smoking be banned in all workplaces, although such a law has not yet been passed.
The tobacco industry has been increasingly criticized for its role in encouraging smoking, particularly in young people. Some tobacco industry representatives deny a direct link between smoking and poor health and that nicotine is addictive. Various lawsuits have been brought against tobacco companies to reclaim damages due to disease or death associated with smoking. The first major successful suit occurred in March 1996 when the Liggett Group, a consortium of companies, agreed to pay damages to five states. An onslaught of litigation against the tobacco industry followed. In part to avoid potentially ruinous lawsuits filed by states, in 1998 the tobacco industry and attorneys general from 46 U.S. states agreed to a $206-billion settlement. The settlement, to be paid over 25 years, will be used to compensate states for the costs of treating smoking-related illness, to finance nationwide antismoking programs, and to underwrite health care for uninsured children.
The tobacco industry must also contend with a barrage of lawsuits filed by individual smokers and their families seeking damages for smoking-related health problems and deaths. Across the United States, such lawsuits have had mixed results. In several cases, juries have cleared the tobacco companies of all responsibility. While several other cases have resulted in large awards for the plaintiffs, none have held up under the appeals process.