Tobacco Use and Smoking Cessation

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Basics

Use of tobacco of any form

Description

  • Cigarette smoking remains the leading cause of preventable disease and death in the U.S.
  • Nicotine sources: cigars, pipes, water pipes, hookahs, cigarettes, and electronic cigarettes (e-cigarettes)
  • Electronic nicotine delivery system (ENDS) use is on the rise. E-cigarettes are called e-cigs, vapes, e-hookahs, vape pens, and electronic nicotine delivery systems.

Epidemiology

E-cigarettes or vaping product use-associated lung injury (EVALI) cases or deaths have been reported to the CDC from all 50 states.

Incidence
  • 2.4 million new smokers annually in the U.S.
  • 59% of new smokers are <18 years of age (5.8% initiation rate for teens).
Prevalence
  • 13.7% of all adults (15% of males, 12% of females) are current cigarette smokers.
  • Age: highest among those ages 45 to 64 years (16%)
  • Cigarette smoking among adults has declined from 42% in 1965 to 14% in 2019.
  • Gender: male > female (15% vs. 12%)
  • Cigarette smoking is responsible for >480,000 deaths per year in the United States, including >41,000 deaths from secondhand smoke exposure. This is about 1 in 5 deaths annually or 1,300 deaths every day.
  • Each day, about 2,000 people <18 years smoke their first cigarette. Each day, about 1,600 youth try their first cigarette.
  • In 2018, 21% of high school students reported current use of e-cigarettes, 5% of middle school students report current e-cigarette use.

Etiology and Pathophysiology

  • Addiction due to nicotine’s rapid stimulation of the brain’s dopamine system (teenage brain especially susceptible)
  • Atherosclerotic risk due to adrenergic stimulation, endothelial damage, carbon monoxide, and adverse effects on lipids
  • Direct airway damage from cigarette tar
  • Carcinogens in all tobacco products
  • E-cigarettes produce an aerosol by heating liquid nicotine, flavoring, and chemicals.
  • Potential adverse effects of e-cigarettes are related to exposure to nicotine as well as to other vapor components produced by the devices.
  • If e-cigarette, or vaping product use is suspected as a possible etiology of a patient’s lung injury, obtain detailed history regarding:
    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
    • Substance source(s): commercially available liquids, homemade liquids
    • Device(s) used: manufacturer; brand name; product name; model
    • Vitamin E acetate is strongly linked to the EVALI.
    • Most product use-associated lung injury (EVALI) associated with products containing THC

Risk Factors

  • Presence of a smoker in the household
  • Easy access to cigarettes
  • Comorbid stress and psychiatric disorders
  • Low self-esteem/self-worth
  • Poor academic performance
  • Boys: high levels of aggression and rebelliousness
  • Girls: preoccupation with weight and body image
  • E-cigarette use has been associated with several cases of idiopathic acute eosinophilic pneumonia.

General Prevention

  • Most first-time tobacco use occurs before high school graduation.
  • Smoking bans in public areas and workplaces
  • Restrict minors’ access to tobacco.
  • Restrict tobacco advertisements.
  • Tobacco-free sports initiatives

Commonly Associated Conditions

  • Coronary artery disease, cerebrovascular disease
  • Peripheral vascular disease
  • Abdominal aortic aneurysm (AAA)
  • Chronic obstructive pulmonary disease (COPD)
  • Cancer of the lip, oral cavity, pharynx, larynx, lung, esophagus, stomach, pancreas, kidney, urinary bladder, cervix, and blood
  • Pneumonia, osteoporosis
  • Periodontitis
  • Alcohol use
  • Depression and anxiety, reduced fertility

Pregnancy Considerations
Women who smoke or are exposed to secondhand smoke during pregnancy have increased risks of miscarriage, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, low-birth-weight infants, and stillbirth.

Pediatric Considerations

  • Secondhand smoke increases the risk for:
    • Sudden infant death syndrome
    • Acute upper and lower respiratory tract infections, exacerbations of asthma, otitis media
  • Nicotine passes through breast milk.

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Basics

Use of tobacco of any form

Description

  • Cigarette smoking remains the leading cause of preventable disease and death in the U.S.
  • Nicotine sources: cigars, pipes, water pipes, hookahs, cigarettes, and electronic cigarettes (e-cigarettes)
  • Electronic nicotine delivery system (ENDS) use is on the rise. E-cigarettes are called e-cigs, vapes, e-hookahs, vape pens, and electronic nicotine delivery systems.

Epidemiology

E-cigarettes or vaping product use-associated lung injury (EVALI) cases or deaths have been reported to the CDC from all 50 states.

Incidence
  • 2.4 million new smokers annually in the U.S.
  • 59% of new smokers are <18 years of age (5.8% initiation rate for teens).
Prevalence
  • 13.7% of all adults (15% of males, 12% of females) are current cigarette smokers.
  • Age: highest among those ages 45 to 64 years (16%)
  • Cigarette smoking among adults has declined from 42% in 1965 to 14% in 2019.
  • Gender: male > female (15% vs. 12%)
  • Cigarette smoking is responsible for >480,000 deaths per year in the United States, including >41,000 deaths from secondhand smoke exposure. This is about 1 in 5 deaths annually or 1,300 deaths every day.
  • Each day, about 2,000 people <18 years smoke their first cigarette. Each day, about 1,600 youth try their first cigarette.
  • In 2018, 21% of high school students reported current use of e-cigarettes, 5% of middle school students report current e-cigarette use.

Etiology and Pathophysiology

  • Addiction due to nicotine’s rapid stimulation of the brain’s dopamine system (teenage brain especially susceptible)
  • Atherosclerotic risk due to adrenergic stimulation, endothelial damage, carbon monoxide, and adverse effects on lipids
  • Direct airway damage from cigarette tar
  • Carcinogens in all tobacco products
  • E-cigarettes produce an aerosol by heating liquid nicotine, flavoring, and chemicals.
  • Potential adverse effects of e-cigarettes are related to exposure to nicotine as well as to other vapor components produced by the devices.
  • If e-cigarette, or vaping product use is suspected as a possible etiology of a patient’s lung injury, obtain detailed history regarding:
    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
    • Substance source(s): commercially available liquids, homemade liquids
    • Device(s) used: manufacturer; brand name; product name; model
    • Vitamin E acetate is strongly linked to the EVALI.
    • Most product use-associated lung injury (EVALI) associated with products containing THC

Risk Factors

  • Presence of a smoker in the household
  • Easy access to cigarettes
  • Comorbid stress and psychiatric disorders
  • Low self-esteem/self-worth
  • Poor academic performance
  • Boys: high levels of aggression and rebelliousness
  • Girls: preoccupation with weight and body image
  • E-cigarette use has been associated with several cases of idiopathic acute eosinophilic pneumonia.

General Prevention

  • Most first-time tobacco use occurs before high school graduation.
  • Smoking bans in public areas and workplaces
  • Restrict minors’ access to tobacco.
  • Restrict tobacco advertisements.
  • Tobacco-free sports initiatives

Commonly Associated Conditions

  • Coronary artery disease, cerebrovascular disease
  • Peripheral vascular disease
  • Abdominal aortic aneurysm (AAA)
  • Chronic obstructive pulmonary disease (COPD)
  • Cancer of the lip, oral cavity, pharynx, larynx, lung, esophagus, stomach, pancreas, kidney, urinary bladder, cervix, and blood
  • Pneumonia, osteoporosis
  • Periodontitis
  • Alcohol use
  • Depression and anxiety, reduced fertility

Pregnancy Considerations
Women who smoke or are exposed to secondhand smoke during pregnancy have increased risks of miscarriage, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, low-birth-weight infants, and stillbirth.

Pediatric Considerations

  • Secondhand smoke increases the risk for:
    • Sudden infant death syndrome
    • Acute upper and lower respiratory tract infections, exacerbations of asthma, otitis media
  • Nicotine passes through breast milk.

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