The leaves of the tobacco plant were originally harvested and smoked by Native Americans and were introduced to Europe by Christopher Columbus in the 15th century. The botanical name for tobacco, Nicotiana tabacum, is derived from the Jean Nicot, who sent the tobacco leaf to the Queen of France in the 16th century. During the late 18th century, packaged cigarettes and cigars rapidly gained popularity. Although it was suspected in the early 20th century that tobacco was linked to throat and mouth cancers, it was not until 1964 when the US government released the document titled Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. It has since been the prominent topic of most annual Surgeon Generals Reports.
The original report was an objective review of literature that pointed to tobacco use as being causal to a number of deleterious health conditions. There has since been much research conducted, and many new findings regarding the disease-causing aspects of tobacco smoking have been elucidated. Despite the widely published results of this research tobacco smoking-related illnesses remain the leading cause of preventable death in the United States.
About 23% of the worldwide population smokes cigarettes. This includes 32% of all males and 7% of all women. Eastern and Southeast Asia have the highest prevalence of smokers in the world with about 45%, while the Caribbean and North America have the lowest prevalence at 20%.
In 2017, the CDC estimates that 19.3% of the United States population over 18 years old uses some kind of tobacco product. About 14% of the total population use cigarettes while the remaining 5% use cigars, electronic cigarettes, smokeless tobacco, or pipes. Furthermore, 24.8% of men smoke cigarettes, while 14.2% of women smoke cigarettes. By age group, smokers represent 18.3% of adults aged 18 to 24 years old, 22.5% of adults aged 25 to 44 years old, 21.3% of adults aged 45 to 64 years old and 11% of adults 65% and older.
Although some of the exact mechanisms for tobacco smoking-related illnesses have yet to be elucidated, several studies have linked tobacco smoking to a plethora of devastating illnesses including coronary artery disease (CAD), cancers in every human organ system, chronic obstructive pulmonary disease (COPD), and decreased reproductive health.
Several potential mechanisms have been described linking tobacco smoking with CAD. Inhaled tobacco smoke increases the amount of exogenous and endogenous free radicals in the body, leading to an increased amount of oxidative stress. This increased oxidative stress leads to vasomotor dysfunction, increased pro-thrombotic and decreased fibrinolytic factors, leukocyte, and platelet activation, increased lipid peroxidation, increased adhesion and inflammatory molecules, and smooth muscle proliferation. Researchers postulate that a combination of these factors leads to the development of CAD in tobacco smokers.
Tobacco smoking correlates with an increased risk of developing at least 17 classes of human cancers. There are roughly 60 known cancer-causing molecules, called carcinogens, in tobacco smoke. It has been proposed that these carcinogens directly damage the DNA by forming covalent bonds with DNA, forming molecules called DNA adducts. These DNA adducts are damaged pieces of DNA that, if not repaired properly, cause mutations during cellular division when their reproduction results in a mutated copy of the DNA. Over time, these mutations collectively lead to disruption of the normal cell reproductive cycle leading to neoplastic tumor formation.
Chronic obstructive pulmonary disease (COPD) has also been shown to heavily correlate with tobacco smoking. The reactive oxidants found with cigarette smoke create a chronic inflammatory state in the lungs, which may persist even after smoking cessation. This inflammatory state causes the lungs to remodel and can eventually lead to gross structural changes. It has also been proposed that there is an auto-immune component to lung disease, caused by the reaction of autoantibodies to antigens created either directly or indirectly from TS.
Tobacco smoking has several deleterious effects on human reproductive health. In men, smoking has been linked to decreased semen volume, decreased sperm density, and decreased total sperm count. In women, tobacco smoking has been shown to disrupt the normal menstruation cycle and decrease ovarian reserve. SMoking tobacco while pregnant is also associated with low birth weight and cryptorchidism.
Tobacco smoke is comprised of a mixture of more than 4000 different compounds. Mainstream smoke, which is the smoke directly inhaled from the end of the cigarette into the smoker’s lungs, is hotter, denser, and contains more compounds than the sidestream smoke that emanates from the lit end of the cigarette. Mainstream smoke is the most type dangerous type of cigarette smoke although sidestream smoke has also been linked to significant illnesses. Many of the molecular compounds found in tobacco smoke form via the process of combustion as the cigarette burns between 600 F and 900 F. After the smoke is drawn from the cigarette, the particles rapidly increase in size due to humidification from the moist air in the upper respiratory tract. The mainstream smoke subsequently condenses as it heads into the lungs, leaving an estimated 50% to 95% of these molecules deposited into the bronchi, bronchioles, and alveoli.
Tobacco smoking history should be routinely obtained from the patient while taking social history. Pack-year history provides an estimated number of cigarettes a patient has consumed over a lifetime and is calculated as packs smoked per day multiplied by the total number of years smoked. Obtaining a pack-year history has shown to be of some value when determining the presence and severity of smoking-related illnesses such as CAD and COPD, as smoking-related cancers have all been linked to increased pack-year history.
Many physical exam findings can be directly or indirectly related to tobacco smoking. On exam of the oropharynx, periodontal disease, tooth loss, and cancers of the tongue and oropharynx may be visualized. The scent of tobacco smoke often lingers on the patient's breath and clothing. Auscultation of the lungs may reveal decreased or asynchronous breath sounds. The cardiac exam often reveals an increased resting heart rate when compared to that of non-smokers. Tobacco stains may be present on the skin of the face and fingers. There may be decreased peripheral pulses due to smoking-related peripheral vascular disease.
Tobacco smoking is directly associated with multiple serious health problems that endanger and shorten the life of smokers and those subjected to cigarette smoke. For an active smoker, quitting smoking has proven to reduce the chances of developing a smoking-related illness.
Daily cigarette smokers keep smoking because they are physically addicted to nicotine - a substance that is naturally found in tobacco leaves. Because nicotine is one of the most addictive substances known to man, tobacco smoking is often very difficult to quit, often requiring repeated attempts at quitting involving various cessation methods. Five nicotine-based medications (gum, lozenges, inhaler, nasal spray, patch) and 2 non-nicotine-based medications (varenicline and bupropion SR) have been shown to aid in long-term smoking cessation. Recent evidence includes a potential role for cytisine and naltrexone. For patients willing to quit, a combination of counseling and one or more the medications has proven more effective than just counseling or medication alone.
Tobacco smoking is extremely hazardous to human health. For smokers, the rate of death from any cause is about 3-times those who have never smoked. The excess mortality of smokers is mostly attributed to vascular illness such as CAD, respiratory illnesses such as COPD, at least 17 different classes of tobacco-smoking related cancers. It has been demonstrated that smokers lose at least 10 years of life expectancy on average. Quitting smoking before the age of 40 has been shown to reduce smoking-related death by about 90%.
Fear of weight gain
Tobacco smoking is a life-threatening addiction that, if untreated, can cause damage to every organ system in the human body. The best way to avoid a TS related illness is never to start smoking, and the second-best way is to stop smoking cigarettes as soon as possible. Helping a patient to stop smoking is one of the most beneficial preventive medicine interventions currently in existence. Nearly every member of the healthcare team may play an important role in the assistance of smoking cessation.
Nurses play a large role in assisting clinicians in tobacco cessation programs. In some hospitals, nurses are being trained to deliver behavioral and pharmaceutical interventions to inpatient smokers. These interventions have shown great promise in significantly reducing smoking in certain populations.
Clinicians are also at the front lines in the fight against tobacco smoking. Unfortunately, several studies have shown that brief episodes of clinician advice do very little to aid in smoking cessation; reinforcement must come from the entire healthcare team including pharmacists and nurses. It has been demonstrated that individually focused counseling, when delivered by a physician, can aid in the patient's cessation of smoking. There is also evidence that clinician-prescribed or recommended over-the-counter medications can play an effective role in treating these patients. The best outcomes in convincing patients to quit smoking are by use of an interprofessional team all working together to educate the patient.
Clinical scientists also play a very important role in the fight to end tobacco addiction and tobacco-related diseases. They continue to investigate and discover the physiology of tobacco-related illnesses, the effectiveness of tobacco cessation medications and interventions, and study tobacco smoking-related conditions across a broad spectrum of populations. From the toils of scientific research, much about tobacco smoking has been elucidated and yet we as a society have much to learn, but an interprofessional team appraoch to smoking cessation will yield better patient results. [Level 5].
|||Wipfli H,Samet JM, One Hundred Years in the Making: The Global Tobacco Epidemic. Annual review of public health. 2016 [PubMed PMID: 26772406]|
|||Warren GW,Alberg AJ,Kraft AS,Cummings KM, The 2014 Surgeon General's report: [PubMed PMID: 24687615]|
|||de Micheli A, [The tobacco in the light of history and medicine]. Archivos de cardiologia de Mexico. 2015 Oct-Dec [PubMed PMID: 25769236]|
|||Gowing LR,Ali RL,Allsop S,Marsden J,Turf EE,West R,Witton J, Global statistics on addictive behaviours: 2014 status report. Addiction (Abingdon, England). 2015 Jun [PubMed PMID: 25963869]|
|||Wang TW,Asman K,Gentzke AS,Cullen KA,Holder-Hayes E,Reyes-Guzman C,Jamal A,Neff L,King BA, Tobacco Product Use Among Adults - United States, 2017. MMWR. Morbidity and mortality weekly report. 2018 Nov 9 [PubMed PMID: 30408019]|
|||Ambrose JA,Barua RS, The pathophysiology of cigarette smoking and cardiovascular disease: an update. Journal of the American College of Cardiology. 2004 May 19 [PubMed PMID: 15145091]|
|||Alexandrov LB,Ju YS,Haase K,Van Loo P,Martincorena I,Nik-Zainal S,Totoki Y,Fujimoto A,Nakagawa H,Shibata T,Campbell PJ,Vineis P,Phillips DH,Stratton MR, Mutational signatures associated with tobacco smoking in human cancer. Science (New York, N.Y.). 2016 Nov 4 [PubMed PMID: 27811275]|
|||Kovac JR,Khanna A,Lipshultz LI, The effects of cigarette smoking on male fertility. Postgraduate medicine. 2015 Apr [PubMed PMID: 25697426]|
|||Budani MC,Fensore S,Di Marzio M,Tiboni GM, Cigarette smoking impairs clinical outcomes of assisted reproductive technologies: A meta-analysis of the literature. Reproductive toxicology (Elmsford, N.Y.). 2018 Sep [PubMed PMID: 29906539]|
|||Balbo S,Turesky RJ,Villalta PW, DNA adductomics. Chemical research in toxicology. 2014 Mar 17 [PubMed PMID: 24437709]|
|||Miller EC, Some current perspectives on chemical carcinogenesis in humans and experimental animals: Presidential Address. Cancer research. 1978 Jun [PubMed PMID: 348302]|
|||Laniado-Laborín R, Smoking and chronic obstructive pulmonary disease (COPD). Parallel epidemics of the 21 century. International journal of environmental research and public health. 2009 Jan [PubMed PMID: 19440278]|
|||Li Y,Lin H,Li Y,Cao J, Association between socio-psycho-behavioral factors and male semen quality: systematic review and meta-analyses. Fertility and sterility. 2011 Jan [PubMed PMID: 20674912]|
|||Firns S,Cruzat VF,Keane KN,Joesbury KA,Lee AH,Newsholme P,Yovich JL, The effect of cigarette smoking, alcohol consumption and fruit and vegetable consumption on IVF outcomes: a review and presentation of original data. Reproductive biology and endocrinology : RB [PubMed PMID: 26669322]|
|||Pereira PP,Da Mata FA,Figueiredo AC,de Andrade KR,Pereira MG, Maternal Active Smoking During Pregnancy and Low Birth Weight in the Americas: A Systematic Review and Meta-analysis. Nicotine [PubMed PMID: 28403455]|
|||Zhang L,Wang XH,Zheng XM,Liu TZ,Zhang WB,Zheng H,Chen MF, Maternal gestational smoking, diabetes, alcohol drinking, pre-pregnancy obesity and the risk of cryptorchidism: a systematic review and meta-analysis of observational studies. PloS one. 2015 [PubMed PMID: 25798927]|
|||Stratton K,Shetty P,Wallace R,Bondurant S, Clearing the smoke: the science base for tobacco harm reduction--executive summary. Tobacco control. 2001 Jun [PubMed PMID: 11387543]|
|||Yano M,Miura S,Shiga Y,Miyase Y,Suematsu Y,Norimatsu K,Nakamura A,Adachi S,Nishikawa H,Saku K, Association between smoking habits and severity of coronary stenosis as assessed by coronary computed tomography angiography. Heart and vessels. 2016 Jul [PubMed PMID: 26187325]|
|||Jaén Díaz JI,de Castro Mesa C,Gontán García-Salamanca MJ,López de Castro F, [Prevalence of chronic obstructive pulmonary disease and risk factors in smokers and ex-smokers]. Archivos de bronconeumologia. 2003 Dec [PubMed PMID: 14636492]|
|||Tindle HA,Stevenson Duncan M,Greevy RA,Vasan RS,Kundu S,Massion PP,Freiberg MS, Lifetime Smoking History and Risk of Lung Cancer: Results From the Framingham Heart Study. Journal of the National Cancer Institute. 2018 Nov 1 [PubMed PMID: 29788259]|
|||Zee KY, Smoking and periodontal disease. Australian dental journal. 2009 Sep [PubMed PMID: 19737267]|
|||Mineshita M,Kida H,Handa H,Nishine H,Furuya N,Inoue T,Matsuoka S,Miyazawa T, Regional Lung Sound Asynchrony in Chronic Obstructive Pulmonary Disease Patients. Respiration; international review of thoracic diseases. 2016 [PubMed PMID: 27626282]|
|||Linneberg A,Jacobsen RK,Skaaby T,Taylor AE,Fluharty ME,Jeppesen JL,Bjorngaard JH,Åsvold BO,Gabrielsen ME,Campbell A,Marioni RE,Kumari M,Marques-Vidal P,Kaakinen M,Cavadino A,Postmus I,Ahluwalia TS,Wannamethee SG,Lahti J,Räikkönen K,Palotie A,Wong A,Dalgård C,Ford I,Ben-Shlomo Y,Christiansen L,Kyvik KO,Kuh D,Eriksson JG,Whincup PH,Mbarek H,de Geus EJ,Vink JM,Boomsma DI,Smith GD,Lawlor DA,Kisialiou A,McConnachie A,Padmanabhan S,Jukema JW,Power C,Hyppönen E,Preisig M,Waeber G,Vollenweider P,Korhonen T,Laatikainen T,Salomaa V,Kaprio J,Kivimaki M,Smith BH,Hayward C,Sørensen TI,Thuesen BH,Sattar N,Morris RW,Romundstad PR,Munafò MR,Jarvelin MR,Husemoen LL, Effect of Smoking on Blood Pressure and Resting Heart Rate: A Mendelian Randomization Meta-Analysis in the CARTA Consortium. Circulation. Cardiovascular genetics. 2015 Dec [PubMed PMID: 26538566]|
|||Alberg AJ,Shopland DR,Cummings KM, The 2014 Surgeon General's report: commemorating the 50th Anniversary of the 1964 Report of the Advisory Committee to the US Surgeon General and updating the evidence on the health consequences of cigarette smoking. American journal of epidemiology. 2014 Feb 15 [PubMed PMID: 24436362]|
|||King AC,Cao D,O'Malley SS,Kranzler HR,Cai X,deWit H,Matthews AK,Stachoviak RJ, Effects of naltrexone on smoking cessation outcomes and weight gain in nicotine-dependent men and women. Journal of clinical psychopharmacology. 2012 Oct [PubMed PMID: 22926596]|
|||Walker N,Howe C,Glover M,McRobbie H,Barnes J,Nosa V,Parag V,Bassett B,Bullen C, Cytisine versus nicotine for smoking cessation. The New England journal of medicine. 2014 Dec 18 [PubMed PMID: 25517706]|
|||A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. American journal of preventive medicine. 2008 Aug [PubMed PMID: 18617085]|
|||Jha P,Ramasundarahettige C,Landsman V,Rostron B,Thun M,Anderson RN,McAfee T,Peto R, 21st-century hazards of smoking and benefits of cessation in the United States. The New England journal of medicine. 2013 Jan 24 [PubMed PMID: 23343063]|
|||Duffy SA,Ronis DL,Karvonen-Gutierrez CA,Ewing LA,Dalack GW,Smith PM,Carmody TP,Hicks T,Hermann C,Reeves P,Flanagan P, Effectiveness of the tobacco tactics program in the Department of Veterans Affairs. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2014 Oct [PubMed PMID: 24823842]|
|||Stead LF,Buitrago D,Preciado N,Sanchez G,Hartmann-Boyce J,Lancaster T, Physician advice for smoking cessation. The Cochrane database of systematic reviews. 2013 May 31 [PubMed PMID: 23728631]|
|||Duffy SA,Ignacio RV,Kim HM,Geraci MC,Essenmacher CA,Hall SV,Chow A,Pfeiffer PN,Sherman SE,Bohnert KM,Zivin K,Barnett PG, Effectiveness of tobacco cessation pharmacotherapy in the Veterans Health Administration. Tobacco control. 2018 Sep 4 [PubMed PMID: 30181383]|