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Smoking and Other Tobacco Use

By

Judith J. Prochaska

, PhD, MPH, Stanford Prevention Research Center, Stanford University

Reviewed/Revised Nov 2023
View PATIENT EDUCATION
Topic Resources

Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and many other types of cancer, and COPD (chronic obstructive pulmonary disease). All patients who use tobacco should be advised to quit and offered assistance and/or referrals to increase their success with becoming tobacco-free.

Tobacco is used because of the effects of nicotine. Nicotine is highly addictive when inhaled into the lung. The combustion products of tobacco contain other substances that can cause significant morbidity and mortality.

Tobacco can be smoked in cigarettes Cigarettes Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more , cigars, or pipes, including hookah. Oral tobacco products include chew and dip. Nicotine vaping products (eg, e-cigarettes) are popular, especially among adolescents, due to their high nicotine content, availability in nontobacco flavors, and discrete designs.

Products marketed as tobacco-free oral nicotine pouches are newer to the United States market. They are also available in nontobacco flavors with a discreet design and are offered at higher nicotine concentrations than U.S. Federal Drug Administration (FDA)–approved nicotine gums and lozenges.

With diversification in the tobacco product market, dual or poly-tobacco product use has become more common. Cigarette smoking, which is the most harmful form of tobacco use, remains the predominant form of tobacco use by adults, while e-cigarettes Vaping Vaping refers to the inhalation of volatilized liquid (vapor) produced by battery-powered devices. The vapor is primarily water, which is the vehicle for a variety of pharmacologically active... read more are the most common form of tobacco use among adolescents.

All tobacco products contain carcinogens and other toxins; smokeless tobacco products are not safe alternatives to smoking.

Epidemiology of Tobacco Use

The prevalence of tobacco use in the United States has declined over the past 50 years, but because of population growth, the number of adults in the United States who use any tobacco product has remained relatively stable at an estimated 46 million (1 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ).

Cigarettes

The percentage of people in the United States who smoke cigarettes has declined since 1964, when the Surgeon General first publicized the link between smoking and ill health. Nevertheless, 11.5% of adults (28.3 million) in the United States still smoke cigarettes (1 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ).

Smoking is more prevalent among the following groups:

  • Men

  • Young adults

  • People who identify as lesbian, gay, bisexual, or transgender

  • People with disabilities

  • People with less than a high school education

  • People living at or below the poverty income level

  • People with psychiatric disorders (including alcohol and substance use)

  • American Indian and Alaskan Native people

Smoking is less common among Hispanics and least common among Asian American women.

Nearly all people who smoke start before the age of 18, making tobacco use a pediatric disorder (2 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). Each day, approximately 2300 youth under age 18 smoke their first cigarette, and nearly 200 youth start smoking daily. Major risk factors for childhood initiation of smoking include smoking among family members and peers as well as exposure to tobacco advertising and marketing in print, online, and at the point of sale in stores, along with tobacco use scenes in movies and video games.

Other tobacco and nicotine products

Cigar and pipe smoking are less common in the United States. In 2021, an estimated 8.6 million people aged 18 or older (3.5%) smoked cigars and 2.3 million (0.9%) smoked a pipe, water pipe, or hookah (1 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). These percentages have remained relatively stable over the past 15 years. Health harms of pipe and cigar smoking include cardiovascular disease; COPD Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more Chronic Obstructive Pulmonary Disease (COPD) ; cancers of the oral cavity Overview of Head and Neck Tumors Head and neck cancer develops in almost 65,000 people in the United States each year. Excluding skin and thyroid cancers, > 90% of head and neck cancers are squamous cell (epidermoid) carcinomas... read more , lung Lung Carcinoma Lung carcinoma is the leading cause of cancer-related death in men and women worldwide. About 85% of cases are related to cigarette smoking. Symptoms can include cough, chest discomfort or pain... read more Lung Carcinoma , larynx Laryngeal Cancer Ninety percent of laryngeal cancer is squamous cell carcinoma. Smoking, excessive alcohol use, lower socioeconomic status, and being male and > 60 years increase risk. Early diagnosis is... read more Laryngeal Cancer , esophagus Esophageal Cancer The most common malignant tumor in the proximal two thirds of the esophagus is squamous cell carcinoma; adenocarcinoma is the most common in the distal one third. Symptoms are progressive dysphagia... read more Esophageal Cancer , colon Colorectal Cancer Colorectal cancer is extremely common. Symptoms include blood in the stool and change in bowel habits. Diagnosis is by colonoscopy. Treatment is surgical resection and chemotherapy for nodal... read more Colorectal Cancer , and pancreas Pancreatic Cancer Pancreatic cancer, primarily ductal adenocarcinoma, accounts for an estimated 64,050 cases and 50,550 deaths in the United States annually ( 1). Symptoms include weight loss, abdominal pain... read more ; and periodontal disease Periodontitis Periodontitis is a chronic inflammatory oral disease that progressively destroys the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis and then, if untreated, with... read more Periodontitis and tooth loss.

E-cigarettes Vaping Vaping refers to the inhalation of volatilized liquid (vapor) produced by battery-powered devices. The vapor is primarily water, which is the vehicle for a variety of pharmacologically active... read more or vape pens are devices consisting of a battery and a cartridge containing an atomizer to heat a solution with propylene glycol, glycerol, and usually but not always nicotine. E-cigarettes mimic the hand-to-mouth action of smoking, and many e-cigarettes deliver high levels of nicotine deep into the lungs, increasing the risk of addiction. With e-cigarettes, there are fewer defined cues that signal the amount consumed, as is experienced with an extinguished cigarette butt. Many e-cigarette devices deliver 5000 to 6000 puffs, which can equate to 500 to 600 cigarettes or 25 to 30 packs of cigarettes.

While there is no combustion involved in using e-cigarettes, the aerosol emitted from the device is more than water vapor. In addition to often containing nicotine, e-cigarette aerosol has ultrafine particles, which can be inhaled deeply into the lungs; flavoring such as diacetyl, a chemical linked to serious lung disease; volatile organic compounds; cancer-causing chemicals; and heavy metals (eg, nickel, tin, and lead), though all at lower levels than in combusted tobacco smoke. While the long-term effects of inhaling e-cigarette aerosol are not clearly known, it is reasonable to speculate that they are likely to be less detrimental than the well-known adverse effects of smoking combustible cigarettes. For people who use e-cigarettes and continue to smoke, a common practice of dual users, the health benefits of e-cigarette use are unproven.

The effects of maternal e-cigarette use on fetal development are unknown, as are the long-term effects of e-cigarette use on the developing adolescent brain. E-cigarette use among youth exceeds combustible tobacco use (2 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). The long-term risks of e-cigarette smoking, a relatively new phenomenon, are unknown. (See also information about e-cigarettes from the The National Academies of Sciences, Engineering, and Medicine [Health and Medicine Division]: Public health consequences of e-cigarettes.)

E-cigarette and Vaping product-use Associated Lung Injury (EVALI) is a term used by the Centers for Disease Control and Prevention (CDC) to describe a multi-state outbreak of severe lung illness first identified in August 2019 and associated with using e-cigarette and vaping products. The clinical presentation is a diagnosis of exclusion that includes respiratory symptoms (eg, cough, chest pain, shortness of breath), gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, diarrhea), nonspecific constitutional symptoms (eg, fever, chills, weight loss), reduced blood oxygen levels, elevated white blood cell counts, and injuries resembling those caused by exposures to toxic chemical fumes, poisonous gases, and toxic agents. According to the CDC, as of February 2020, there were over 2800 hospitalizations and 68 deaths nationally due to EVALI. The CDC’s guidelines point largely to vaping of tetrahydrocannabinol (THC) liquid as the cause, and in particular THC liquids cut with vitamin E acetate. The CDC stopped monitoring incidence of EVALI in February 2020 because of the decline in cases and deaths, as well as the identification of vitamin E acetate, which is the most recognized agent associated with EVALI (3 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). The CDC encourages clinicians to continue to report possible EVALI cases to their local or state health department for further investigation. If EVALI is suspected, the clinician should obtain a detailed history of substances used, sources of products, duration and frequency of use, and devices used and how those devices were used.

Smokeless tobacco (chewing tobacco and snuff) is used by approximately 2.1% of people ≥ 18 years of age (1 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ) and approximately 1.6% of high school students (2 Epidemiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). Toxicity of smokeless tobacco varies by brand. Harms include cardiovascular disease, oral disorders (eg, cancers, gum recession, gingivitis, periodontitis and its consequences), and teratogenicity.

Inadvertent oral exposure to tobacco is uncommon but may cause serious toxicity. Young children occasionally ingest cigarettes from unguarded packs, cigarette butts from ashtrays, e-cigarette liquid, or nicotine gum. In 2022, 6745 cases of potentially toxic exposure to e-cigarettes and liquid nicotine products were reported to the American Association of Poison Control Centers (AAPCC) (see AAPCC: E-cigarettes and Nicotine).

Cutaneous exposure to tobacco can be toxic. Tobacco harvesters and processors who handle raw tobacco (especially if wet) without protection may absorb nicotine through the skin and develop symptoms of nicotine toxicity, a syndrome termed green tobacco sickness.

Epidemiology references

  • 1. Cornelius ME, Loretan CG, Jamal A, et al: Tobacco Product Use Among Adults - United States, 2021. MMWR Morb Mortal Wkly Rep 72(18):475-483, 2023. Published 2023 May 5. doi:10.15585/mmwr.mm7218a1

  • 2. Park-Lee E, Ren C, Cooper M, et al: Tobacco Product Use Among Middle and High School Students - United States, 2022. MMWR Morb Mortal Wkly Rep 71(45):1429-1435, 2022. Published 2022 Nov 11. doi:10.15585/mmwr.mm7145a1

  • 3. Rebuli ME, Rose JJ, Noël A, et al: The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 20(1):1-17, 2023. doi:10.1513/AnnalsATS.202209-796ST

  • 4. Homa DM, Neff LJ, King BA, et al: Vital signs: disparities in nonsmokers' exposure to secondhand smoke--United States, 1999-2012. MMWR Morb Mortal Wkly Rep 64(4):103-108, 2015

Pathophysiology of Tobacco Use

Nicotine is a highly addictive drug present in tobacco and is a major component of cigarette smoke. Cravings can begin within days of first use. Nicotine stimulates brain nicotinic cholinergic receptors, releasing dopamine and other neurotransmitters, which activate the brain reward system during pleasurable activities in a manner similar to that of many other addictive drugs Overview of Substance Use Substance-related disorders involve substances that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics... read more . Dopamine, glutamate, and gamma-aminobutyric acid (GABA) are important mediators of nicotine dependence.

Psychologic dependence exists when people smoke to affect their mood or avoid withdrawal symptoms; it can develop within 2 weeks after starting smoking and occurs in up to approximately 25% of adolescents who try smoking. Physical dependence (ie, occurrence of withdrawal symptoms with cessation) also develops within 2 weeks. People smoke to feed their nicotine dependence but simultaneously inhale thousands of other components, including carcinogens, noxious gases, and chemical additives that are a part of cigarette smoke. These toxic components, rather than nicotine, are responsible for the multiple health harms of smoking. The tar byproducts from tobacco smoke induce metabolizing enzymes in the liver (primarily CYP2A6), leading to increased metabolic clearance of certain medications Indirect effects of smoking .

Chronic effects of smoking

Smoking harms nearly every organ in the body. Smoking is the leading cause of preventable mortality in the United States and globally. In the United States, smoking accounts for approximately 500,000 deaths each year. People who smoke are more likely to die prematurely of a disease directly caused by smoking, losing as much as 10 years of life on average. (See also Health Consequences of Smoking, Surgeon General fact sheet.)

The major chronic effects are an increased likelihood of the following:

Coronary artery disease is a major cause of tobacco-related deaths. Risk of myocardial infarction is doubled if smoking 1 pack a day, and risk of cardiovascular mortality is increased by > 50% over a 35-year period. Mechanisms include endothelial cell damage, transient increases in blood pressure and heart rate, induction of a prothrombotic state, and adverse effects on serum lipids. Smoking causes approximately 32% of coronary heart disease deaths (1 Pathophysiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ).

Lung cancer is another major source of tobacco-related deaths. Smoking tobacco is the most common cause of lung cancer in North America and Europe, and accounts for more than 87% of lung cancer deaths (1 Pathophysiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). Inhaled carcinogens are directly exposed to lung tissue.

COPD also accounts for a significant portion of tobacco-related deaths. Tobacco accounts for 79% of all cases of COPD (1 Pathophysiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). Smoking impairs local respiratory tract defense mechanisms and, particularly in genetically susceptible people, tends to accelerate decline in pulmonary functions. Coughing and dyspnea on exertion are common.

Less common yet serious smoking-related disorders include age-related macular degeneration, noncardiac vascular diseases (eg, stroke, aortic aneurysm), other cancers (eg, bladder, cervical, colorectal, esophageal, kidney, laryngeal, liver, oropharyngeal, pancreatic, stomach, throat, acute myeloid leukemia), diabetes, pneumonia, rheumatoid arthritis, and tuberculosis.

In addition, smoking is a risk factor for other conditions that convey significant morbidity and disability, such as frequent upper respiratory infections Overview of Viral Respiratory Infections Viral infections commonly affect the upper or lower respiratory tract. Although respiratory infections can be classified by the causative virus (eg, influenza), they are generally classified... read more , asthma Asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea... read more , cataracts Cataract A cataract is a congenital or degenerative opacity of the lens. The main symptom is gradual, painless vision blurring. Diagnosis is by ophthalmoscopy and slit-lamp examination. Treatment is... read more Cataract , infertility Overview of Infertility Infertility is a disease defined by the inability to achieve a pregnancy and/or the need for medical intervention to achieve a successful pregnancy. In patients who have not achieved a pregnancy... read more , erectile dysfunction Erectile Dysfunction Erectile dysfunction is the inability to attain or sustain an erection satisfactory for sexual intercourse. Most erectile dysfunction is related to vascular, neurologic, psychologic, and hormonal... read more , premature menopause Menopause Menopause is the permanent cessation of menses (amenorrhea) due to loss of ovarian follicular function. Clinical manifestations may include hot flushes, night sweats, sleep disruption, and genitourinary... read more , peptic ulcer disease Peptic Ulcer Disease A peptic ulcer is an erosion in a segment of the gastrointestinal mucosa, typically in the stomach (gastric ulcer) or the first few centimeters of the duodenum (duodenal ulcer), that penetrates... read more Peptic Ulcer Disease , osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more Osteoporosis , hip fractures Hip Fractures Hip fractures may occur in the head, neck, or area between or below the trochanters (prominences) of the femur. These fractures are most common among older patients, particularly those with... read more Hip Fractures , and periodontitis Periodontitis Periodontitis is a chronic inflammatory oral disease that progressively destroys the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis and then, if untreated, with... read more Periodontitis .

Secondhand smoke

Secondhand smoke is tobacco smoke that is exhaled by a person smoking or given off from the end of a lit cigarette. Secondhand smoke is linked to the same neoplastic, respiratory, and cardiovascular diseases that threaten people who smoke. The risk of illness is related to dose. For example, between spouses, average risk is increased by approximately 20% for lung cancer and by approximately 20 to 30% for coronary artery disease. (See also CDC: Secondhand Smoke.)

Children exposed to cigarette smoke lose more school days because of illness than nonexposed children. Treating children for smoking-related illnesses has been estimated to cost $4.6 billion/year (2 Pathophysiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ).

Overall, secondhand smoke is estimated to cause more than 41,000 deaths each year in the United States (between 2% and 3% of all deaths), with lost productivity costs due to premature deaths from secondhand smoke exposure estimated to be $5.6 billion per year (in 2006) (1 Pathophysiology references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). These findings led states and municipalities across the United States to ban smoking within workplaces in an effort to protect the health of workers and others from the substantive risks of environmental tobacco smoke. In 2000, no state or the District of Columbia had a comprehensive indoor smoke-free ordinance in effect. This increased to 26 by the end of 2010, and one additional state was added by the end of 2015. Subsequently, 28 states, Washington DC, Puerto Rico, and the US Virgin Islands have comprehensive smoke-free air laws covering workplaces, restaurants, and bars. In some states without statewide comprehensive smoke-free laws, substantial progress has been made at the local level in adopting comprehensive smoke-free laws. However, 7 states without statewide comprehensive smoke-free laws (Florida, New Hampshire, North Carolina, Oklahoma, Pennsylvania, Tennessee, and Virginia) have preemption statutes that prohibit adoption of local smoke-free air laws. (See also American Lung Association: Smokefree Air Laws)

Smoking during pregnancy increases the risk of spontaneous abortion, ectopic pregnancy, preterm birth, and congenital defects. Infants born of mothers who smoke tend to have a lower birth weight and are at increased risk of

Indirect effects of smoking

Indirect effects of smoking can be serious.

Smoking-related fires occur in approximately 7800 residential buildings in the United States each year, according to the Federal Emergency Management Agency (FEMA). These fires cause approximately 275 deaths, 750 injuries, and $361 million in property loss annually. (See FEMA: Residential Building Smoking Fire Trends [2012-2021].) Such fires are the leading cause of deaths resulting from unintentional fires in the United States.

Drug interactions with smoking are common. The effects are largely due to induction of metabolic enzymes in the liver by tar byproducts of smoking. Nicotine does not similarly induce metabolic enzymes, and thus drug-induction effects do not occur with nicotine replacement therapy or e-cigarettes. Levels and sometimes clinical effects of the following medications and substances are decreased by chronic smoking, primarily by induction of CYP2A6 enzymes:

  • Antiarrhythmics (some): Flecainide, lidocaine, mexiletine

  • Antidepressants (some): Clomipramine, fluvoxamine, imipramine, trazodone

  • Antipsychotics (some): Chlorpromazine, clozapine, fluphenazine, haloperidol, olanzapine, thiothixene

  • Caffeine

  • Estrogens (oral)

  • Insulin (delayed absorption caused by skin vasoconstriction)

  • Pentazocine

  • Theophylline

Two exceptions are benzodiazepines, for which sedation effects are decreased likely due to the stimulating effects of nicotine, and beta-blockers, with reduced blood pressure and heart rate control possibly caused by nicotine-mediated sympathetic activation.

Pathophysiology references

Symptoms and Signs of Tobacco Use

Acute effects

Nicotine slightly increases heart rate, blood pressure, and respiratory rate. People who smoke may feel increased energy and arousal, increased ability to concentrate, decreased tension and anxiety, and a sense of pleasure and reward. Nausea is common on a person's first exposure to nicotine. Nicotine reduces appetite and can be a behavioral substitute for eating. Nicotine's effects are transient given its short half-life. If not repeatedly dosed, the individual experiences the effects of nicotine withdrawal including lethargy, difficulty concentrating, restlessness, anxiety, tension, depressed mood, irritability, and hunger.

With combustible tobacco, exercise tolerance tends to decrease because of respiratory tract irritation. Low-grade carbon monoxide toxicity can also limit exercise tolerance, but this is probably only a factor in elite athletes.

Toxicity or overdose

Acute nicotine poisoning is usually caused by oral (eg, children eating a cigarette or nicotine gum or ingesting e-liquid) or dermal (eg, handling raw tobacco products) exposure, rather than smoking.

Mild nicotine toxicity, as is common with green tobacco sickness and minor ingestions by children (eg, < 1 cigarette or 3 butts), typically manifests with nausea, vomiting, headache, and weakness. Symptoms spontaneously resolve, usually in 1 to 2 hours after ingestion if poisoning is mild; however, symptoms can persist for 24 hours if poisoning is severe.

Severe nicotine poisoning causes a cholinergic toxidrome with nausea, vomiting, salivation, lacrimation, diarrhea, urination, fasciculations, and muscle weakness. Patients usually have crampy abdominal pain and, if poisoning is very severe, arrhythmias, hypotension, seizures, and coma. The fatal dose of nicotine is approximately 60 mg in nonsmoking adults, 120 mg in adults who smoke, and as little as 10 mg in young children. Each cigarette contains approximately 8 mg of nicotine (only about 1 mg is absorbed by smoking). However, the amount ingested by children is usually difficult to ascertain by history because ingestion is rarely observed; any ingestion should be considered potentially dangerous.

Chronic effects

Findings due to smoking itself include yellow stains of teeth and fingers, and in comparison to age-matched controls, weight is slightly lower (≤ 5 kg difference), skin is drier and more wrinkled, and hair is thinner.

Other symptoms are those of smoking-related lung and cardiovascular disease. Chronic cough and dyspnea on exertion are common. Circulatory and respiratory impairments decrease exercise tolerance, often resulting in a more sedentary lifestyle and thus further lowering of exercise tolerance.

Withdrawal

Smoking cessation often causes intense nicotine withdrawal symptoms Nicotine Withdrawal Most people who smoke want to quit and have tried doing so with limited success. Effective interventions include cessation counseling and pharmacologic treatment, such as varenicline, bupropion... read more , primarily a craving for cigarettes but also other symptoms (eg, anxiety, difficulty concentrating, sleep disruption, depression) and eventual weight gain.

Diagnosis of Tobacco Use

  • Direct questioning

Acute toxicity is not always apparent on history. Children may not have been observed ingesting tobacco, nicotine gum, or e-liquids, and patients with green tobacco sickness may not think to mention that they handle tobacco. Thus, children and agricultural workers presenting with typical symptoms, particularly cholinergic manifestations, should be queried about possible tobacco exposure. Testing is not necessary.

Of the > 70% of adults who smoke who present in a primary care setting every year, only a minority receive counseling and medications to help them quit. To maximize identification of tobacco use and thus the public health benefit of cessation, all patients should be asked about tobacco use during medical visits regardless of presenting symptoms and particularly during visits for symptoms possibly related to tobacco use (eg, circulatory or respiratory symptoms). In addition, assessing patients' quantity of use (eg, the number of cigarettes smoked per day) and how soon they smoke upon wakening (within 30 minutes is a sign of addiction) can help indicate the severity of tobacco dependence and nicotine addiction and help guide selection and dosing of cessation medications.

Treatment of Tobacco Use

Skin exposed to nicotine should be irrigated. Otherwise, treatment for acute nicotine poisoning is supportive. Gastric emptying is not recommended. In patients with mild symptoms or who have vomited, charcoal is not given; some clinicians would recommend charcoal for patients who have severe symptoms or have ingested large quantities and have not vomited. Airway protection and assisted ventilation may be needed for patients who are obtunded, have excessive respiratory secretions, or have respiratory muscle weakness. Seizures are treated with benzodiazepines. Shock is treated with IV fluids and, if fluids are ineffective, pressors. Atropine can be considered for patients who have excessive respiratory secretions or bradycardia; otherwise, anticholinergics are not recommended.

All people who smoke should be advised to stop smoking by their health care provider. Assistance with quitting includes smoking cessation counseling and typically pharmacologic treatment (see table ). Referrals to the tobacco quit-line (1-800-QUIT-NOW), web sites (eg, Smokefree.gov), and other resources may help. Pregnant women who smoke should be advised to stop smoking and helped to quit by intensive smoking cessation counseling. However, the 2021 US Preventive Services Task Force concluded that the evidence was insufficient to assess the benefits and harms of pharmacologic therapy for tobacco cessation in pregnant women (see Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions).

Prevention of Tobacco Use

Preventing youth smoking is important because 90% of adults who smoke start before the age of 18, and very few adults will begin to smoke or use smokeless tobacco products after age 26 (1 Prevention references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). An estimated 5.6 million youth < 18 in the United States today will die prematurely from a smoking-related illness; these deaths can be averted through concerted public health measures and regulatory actions (1 Prevention references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). For example, restricting depictions of smoking in movies and video games, enforcing the federal minimum age of 21 for tobacco product sales, banning menthol and characterizing flavors in all forms of tobacco, increasing the price of cigarettes, and restricting tobacco industry product discounting at the point of sale are important interventions for preventing smoking among youth.

The National Academies of Sciences has concluded that there is substantial evidence that e-cigarette use increases the risk of ever using combustible tobacco cigarettes among youth and young adults (2 Prevention references Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more ). Still unknown is whether this translates into sustained use of combusted cigarettes.

Prevention references

Key Points

  • Cigarette smoking is the leading cause of preventable mortality in the United States.

  • Most adults who smoke started start before age 18.

  • Cravings can begin within days of first use and persist long after quitting smoking.

  • Cigarettes create and sustain addiction through the rapid delivery of nicotine to the brain.

  • In addition to nicotine, cigarette smoke contains carcinogens, noxious gases, and chemical additives, which are responsible for the adverse health effects that cigarettes cause.

  • Harmful effects of smoking include increased risk of debilitating and fatal disorders (eg, lung cancer, COPD, coronary artery disease), residential and wild fires, and drug interactions.

  • Nicotine acts as a mild stimulant acutely in the usual doses but can cause a cholinergic toxidrome in acute overdose (usually due to oral ingestion or direct dermal exposure).

  • Ask all patients about tobacco use, regardless of presenting symptom; advise all people who use tobacco to quit; offer assistance to support quitting; and arrange follow-up to prevent relapse.

More Information

The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.

Drugs Mentioned In This Article

Drug Name Select Trade
Intropin
Tambocor
7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, AsperFlex, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidocan II, DermacinRx Lidocan III, DermacinRx Lidogel, DermacinRx Lidorex, DermacinRx Lidotral, DERMALID, Dologesic, Ela-Max, GEN7T, Glydo, Gold Bond, Icy Hot , LidaFlex, LidaMantle, Lido King Maximum Strength, Lidocan, LIDOCANNA, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , LidoLite, Lidomar , Lidomark, Lidopin, LidoPure, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, Lidtopic, Lidtopic Max, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lubricaine, Lubricaine For Her, Lydexa, MENTHO-CAINE , Moxicaine, Numbonex, Professional DNA Collection Kit, Proxivol, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Regenecare HA, Salonpas Lidocaine, Senatec, Solarcaine, SOLUPAK, SUN BURNT PLUS, Suvicort, Topicaine, Tranzarel, VacuStim Silver, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, ZiloVal, Zingo, Zionodi, ZTlido
Mexitil
Anafranil
Luvox, Luvox CR
Tofranil, Tofranil-PM
Desyrel, Oleptro
Thorazine
Clozaril, Fazaclo, Versacloz
Prolixin, Prolixin Decanoate
Haldol, Haldol Decanoate
Zyprexa, Zyprexa Intramuscular, Zyprexa Relprevv, Zyprexa Zydis
Navane
Cafcit, NoDoz, Stay Awake, Vivarin
Afrezza, Exubera
No brand name available
Elixophyllin, Quibron T, Quibron T/SR, Respbid, Slo-Bid, Slo-Phyllin, Theo X, Theo-24, Theo-Bid Duracap, TheoCap, Theochron, Theo-Dur, Theo-Dur Sprinkle , Theolair, Theolair SR, Theovent LA, T-Phyl, Uni-Dur, Uniphyl
Commit, Habitrol, Nicoderm CQ, NICOrelief , Nicorette, Nicotrol, Nicotrol NS
Actidose With Sorbitol , Actidose-Aqua, Charcoal Plus DS , CharcoCaps Anti-Gas, EZ Char , Kerr INSTA-CHAR
Atreza, Atropine Care , Atropisol , Isopto Atropine, Ocu-Tropine, Sal-Tropine
Absorbine Jr, A-R Extreme, Arctic Relief, Arthritis Wonder, Aspercreme, Bengay Cold Therapy, BenGay Pain Relieving, BenGay Ultra Strength, BenGay Vanishing Scent, Bengay Zero Degrees, BiOFREEZE, BIOFREEZE Cold Therapy Pain Relieving, BIOFREEZE Overnight, BIOFREEZE Overnight Pain Relieving, BIOFREEZE Patch, BIOFREEZE PROFESSIONAL, Blue Gel, Cold & Hot Pain Relief Therapy, Eucerin Itch Relief, FLEXALL, Gold Bond, Icy Hot , Luden's, Medicated Topical Body, Mineral Ice, NitroVal Blue, PERFORM Pain Relieving, Ricola with Swiss Alpine Herbs, Therapy Ice, Vicks VapoDrop
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