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Cigarette smoking has great societal and clinical significance. It is a major cause of several diseases, including a variety of cancers. The practice of cigarette smoking is pervasive; about a quarter of all adult Americans smoke cigarettes, and smoking rates are even higher in many other countries. Despite the high personal cost associated with cigarette smoking, it is a prototypical addictive disorder manifesting such features as tolerance, withdrawal, and chronic use. The peak age for smoking prevalence is between eighteen and twenty-five years. Retrospective data from the National Household Survey on Drug Abuse suggests that the average age of first use of tobacco products in 1999 among all persons who ever used in their lifetime was 15.4 for cigarettes, 20.5 for cigars, and 16.7 for smokeless tobacco across all age groups (Kopstein 2001). Data from the National Comorbidity Survey suggests that the onset of nicotine dependence is delayed for at least one year after the onset of daily smoking. Smoking rates decline among people who have reached their mid-twenties, but these declines are modest in comparison to other forms of substance use. This may be due to the fact that cigarette smoking is highly addictive, legal, and not immediately performance-impairing.
Biological Aspects Of Nicotine Addiction
Nicotine, independently, yields the trademark effects of an addictive drug. It produces tolerance and physical dependence, and heightened doses produce euphoria and satisfaction (Corrigall 1999; USDHHS 1998). Smokers will not self-administer tobacco on a chronic basis if it does not contain nicotine. Nicotine is essential for the development and maintenance of a smoking habit. However, once nicotine dependence is established, cues related to nicotine release become greatly influential in controlling self-administration behaviors. When a cigarette is smoked, about 80 percent of the inhaled nicotine is absorbed in the lungs (Armitage et al. 1975). Absorption is both efficient and extremely rapid. Despite the overall recognition that the rapid onset of drug action promotes addictive drug use, it remains unclear why this is so. Researchers do not fully understand which characteristics of drug pharmacokinetics are most determinant of addictiveness.
Behavioral Aspects And Environmental Influence
Data published in 2002 suggest that smoking among American adolescents is fairly common, with 27 percent of twelfth graders, 18 percent of tenth graders, and 11 percent of eighth graders reporting that they had smoked in the past month (Johnston et al. 2002). This level of smoking prevalence represents a decline from peaks in the mid-1990s. Much less is known about the epidemiology of tobacco dependence in adolescents. Dependence is a term often correlated with addiction, and adolescent smokers are less likely to be diagnosed with tobacco dependence than are adult smokers (Colby et al. 2000), although many adolescent smokers consider themselves addicted. Adolescents who are dependent report the same symptoms as do dependent adults, including cravings, withdrawal, tolerance, and a desire to reduce smoking (Colby et al. 2000). Compared to adults at the same level of self-reported intake, adolescents who smoke are more likely to be diagnosed as dependent, which suggests that adolescents may be especially vulnerable to dependence or sensitive to the effects of nicotine (Kandel and Chen 2000).
Before they experiment with cigarettes, adolescents form beliefs and attitudes about the effects of smoking. These attitudes and beliefs prospectively predict both the onset and escalation of smoking. Many adolescents believe that there are no health risks related to smoking in the first few years, and they believe that they will stop smoking before any damage is done. Existing evidence suggests that adolescents and adults exhibit unrealistic optimism about the personalized risks of smoking (Arnett 2000; Weinstein 1999). Whether adolescents are any more likely than adults to underestimate the personalized risks of smoking is unclear.
Evidence indicates that as smokers become more dependent, there is a shift in the motivational basis for their tobacco use. Social motives and contextual factors are rated as influential to beginner smokers, while heavy smokers emphasize the importance of control over negative moods and urges, and the fact that smoking has become involuntary (Piper et al. 2004). When smoking becomes less linked to external cues and more linked to internal stimuli, smokers are classified as dependent. There is also evidence suggesting that smoking cigarettes may lead to the use of illicit drugs. Cigarette smoking is endemic among substance abusers, with rates as high as 74 percent to 88 percent (Kalman 1998), compared to 23 percent of the general population (CDC 2002).
Greater parental education is associated with less likelihood of smoking in offspring. Additionally, girls appear to be more influenced by peer smoking than boys (Mermelstein 1999). In the United States, the highest smoking rates are among American Indian and Alaska Native adolescents, followed by whites and then Hispanics, with lowers rates among Asian Americans and African Americans. While studies that sample multiethnic groups are sparse, research has suggested that African American and Asian American adolescents report stronger antismok-ing socialization messages from parents and that African American parents report feeling particularly empowered to influence their children’s smoking (for reviews, see Mermelstein 1999; USDHHS 1998). Peer smoking is a relatively weak predictor of smoking for African American adolescents compared to white adolescents.
Adolescents sometimes start smoking as a result of self-image. The social image of an adolescent smoker is an ambivalent one, with negative aspects but also images of toughness, sociability, and precocity that may be particularly valued by “deviance-prone” adolescents who are at risk to smoke (Barton et al. 1982). Additionally, adolescents may start smoking and continue smoking because of their perception of the effect that smoking has on weight control and dieting. The belief that smoking can control body weight has been shown to predict smoking initiation among adolescent girls, but not boys (Austin and Gortmaker 2001). In addition, this belief is held more widely by white girls than by African American girls (Klesges et al. 1997). Despite the above-mentioned indicators, peer smoking is the most consistently identified predictor of adolescent smoking (Derzon and Lipsey 1999). In addition to cigarette smoking by peers, affiliation with peers who engage in high levels of other problem behaviors also prospectively predicts smoking initiation, as does self-identification with a high-risk social group (Sussman et al. 1994).
Smoking Cessation And Prevention
The tobacco industry spends millions of dollars per day on advertising and promotional materials to keep their products in the public eye. Beyond such reminders of the availability of tobacco products, smoking is not an easy habit to break. Smokers must not only break the physical addiction to nicotine, but also the habit of lighting up at certain times of the day. Successful quitters confess that quitting is often a lengthy process that involves several unsuccessful attempts. Although one-third of smokers attempt to quit each year, 90 percent or more of those who attempt to quit will fail.
Nicotine replacement therapies (NRTs) have been used to help some people quit smoking. The two most common forms of NRTs are chewing gum and the nicotine patch, both of which are available over the counter. Nicorette, a prescription chewing gum containing nicotine, is often used to help reduce the consumption of nicotine over time. Users have reported experiencing fewer cravings for nicotine as the dosage is reduced, until they are completely weaned. The nicotine patch was first marketed in 1991 for smokers with a desire to quit. Generally, the nicotine patch is used in conjunction with a comprehensive smoking-behavior cessation program. Additionally, a nicotine nasal spray, nicotine inhaler, and nicotine pill have been approved by the FDA to help cigarette smokers quit smoking. In order to prevent the initiation and maintenance of smoking, there has been an increase since the mid-1980s in the development and implementation of smoking cessation and prevention programs, especially for young people and adolescents.
Global Economics Of Smoking
Approximately 80 percent of the world’s 1.1 billion smokers live in low- and middle-income countries. In 1998 about four million people died of tobacco-related disease worldwide (WHO 1999). This number is projected to increase to ten million annually by 2030, with 70 percent of these deaths occurring in low-income countries. Death counts of this magnitude could be prevented if current smokers quit, but it is rare for smokers living in low- to middle-income countries to attempt to quit smoking (Jha and Chaloupka 2000). Although few dispute that smoking is damaging to human health on a global scale (Peto and Lopez 2000), governments have avoided taking action to control smoking. This is mainly due to concerns that such interventions might have harmful economic consequences, such as permanent job losses. Despite these concerns, several common measures aimed at the control of smoking, such as higher tobacco taxes, consumer information, bans on advertising and promotion, and regulatory policies, have had a significant impact. Each will be discussed below.
An increase in tobacco taxes is the single most effective intervention to reduce the demand for tobacco. A review by Prabhat Jha and Frank Chaloupka (2000) suggests that a price increase of 10 percent would reduce smoking by 4 percent in high-income countries and by about 8 percent in low- and middle-income countries. This evidence also implies that young people, individuals on low incomes, and those with less education are more responsive to price changes (Chaloupka et al. 2000). Policies to improve the quality and extent of tobacco information can also reduce smoking, particularly in low-and middle-income countries. For example, in the 1960s and 1970s, the promulgation in the United States and Britain of new evidence on the health risks of smoking helped reduce consumption between 4 and 9 percent. In addition, warning labels on cigarette packages were also found to reduce consumption during that era (Kenkel and Chen 2000). In a review of 102 countries and econometric analyses of income, Henry Saffer and Chaloupka (2000) revealed that bans on advertising and promotion led to considerable reductions in tobacco consumption.
Enforcing regulatory policies designed to prevent smoking in public places, worksites, and other facilities can also significantly reduce cigarette consumption worldwide (Yurekli and Zhang 2000). Attempts to impose restrictions on the sale of cigarettes to young people in high-income countries have mostly been unsuccessful (Siegel et al. 1999). Furthermore, it may be difficult to implement and enforce such restrictions in low-income countries. Evidence indicates that freer trade in tobacco products has led to an increase in smoking and other types of tobacco use. One solution is for countries to adopt measures that effectively reduce demand and apply those measures to both imported and domestically produced cigarettes (Taylor et al. 2000).
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