Action on Smoking and Health

Why People Start Smoking and Why It’s Hard to Stop

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Why do people start smoking?

Most people who smoke started smoking when they were teenagers. Those who have friends and/or parents who smoke are more likely to start smoking than those who don’t. Some teenagers say that they “just wanted to try it,” or they thought it was “cool” to smoke.

The tobacco industry’s ads, price breaks, and other promotions for its products are a big influence in our society. The tobacco industry spends billions of dollars each year to create and market ads that show smoking as exciting, glamorous, and safe. Tobacco use is also shown in video games, online, and on TV. And movies showing people smoking are another big influence. Studies show that young people who see smoking in movies are more likely to start smoking.

A newer influence on tobacco use is the e-cigarette and other high-tech, fashionable electronic “vaping” devices. Often wrongly seen as harmless, and easier to get and use than traditional tobacco products, these devices are a way for new users to learn how to inhale and become addicted to nicotine, which can prepare them for smoking.

Who is most likely to become addicted?

Anyone who starts using tobacco can become addicted to nicotine. Studies show that smoking is most likely to become a habit during the teen years. The younger you are when you begin to smoke, the more likely you are to become addicted to nicotine.

According to the 2014 Surgeon General’s Report (SGR), nearly 9 out of 10 adults who smoke started before age 18, and nearly all started by age 26. The report estimates that about 3 out of 4 high school students who smoke will become adults who smoke – even if they intend to quit in a few years.

Is smoking tobacco really addictive?

Addiction is marked by the repeated, compulsive seeking or use of a substance despite its harmful effects and unwanted consequences. Addiction is mental or emotional dependence on a substance. Nicotine is the known addictive substance in tobacco. Regular use of tobacco products leads to addiction in many users. Nicotine is a drug that occurs naturally in tobacco and it’s thought to be as addictive as heroin or cocaine.

How nicotine affects you

  • Nicotine and other chemicals in tobacco smoke are easily absorbed into the blood through the lungs. From there, nicotine quickly spreads throughout the body.
  • When taken in small amounts, nicotine causes pleasant feelings and distracts the user from unpleasant feelings. This makes the tobacco user want to use more. It acts on the chemistry of the brain and central nervous system, affecting mood. Nicotine works very much like other addicting drugs, by flooding the brain’s reward circuits with a chemical called dopamine. Nicotine also gives a little bit of an adrenaline rush – not enough to notice, but enough to speed up the heart and raise blood pressure.
  • Nicotine reaches the brain within seconds after taking a puff, and its effects start to wear off within a few minutes. The user may start to feel irritated and edgy. Usually it doesn’t reach the point of serious withdrawal symptoms, but the person using the product gets more uncomfortable over time. This is what most often leads the person to light up again. At some point, the person uses tobacco, the unpleasant feelings go away, and the cycle continues. If the person doesn’t smoke again soon, withdrawal symptoms get worse over time.
  • As the body adapts to nicotine, people who use it tend to increase the amount of tobacco they use. This raises the amount of nicotine in their blood, and more tobacco is needed to get the same effect. This is called tolerance. Over time, a certain nicotine level is reached and the person will need to keep up the usage to keep the level of nicotine within a comfortable range.
  • People who smoke can quickly become dependent on nicotine and suffer physical and emotional (mental or psychological) withdrawal symptoms when they stop smoking. These symptoms include irritability, nervousness, headaches, and trouble sleeping. The true mark of addiction, though, is that people still smoke even though they know smoking is bad for them – affecting their lives, their health, and their families in unhealthy ways. In fact, most people who smoke want to quit.

Researchers are also looking at other chemicals in tobacco that make it hard to quit. In the brains of animals, tobacco smoke causes chemical changes that are not fully explained by the effects of nicotine.

The average amount of nicotine in one regular cigarette is about 1 to 2 milligrams (mg). The amount you actually take in depends on how you smoke, how many puffs you take, how deeply you inhale, and other factors.

How powerful is nicotine addiction?

About 2 out of 3 of people who smoke say they want to quit and about half try to quit each year, but few succeed without help. This is because they not only become physically dependent on nicotine. There’s also a strong emotional (psychological) dependence. Nicotine affects behavior, mood, and emotions. If a person uses tobacco to help manage unpleasant feelings and emotions, it can become a problem for some when they try to quit. Someone who smokes may link smoking with social activities and many other activities, too. All of these factors make smoking a hard habit to break.

In fact, it may be harder to quit smoking than to stop using cocaine or opiates like heroin. In 2012, researchers reviewed 28 different studies of people who were trying to quit using the substance they were addicted to. They found that about 18% were able to quit drinking, and more than 40% were able to quit opiates or cocaine, but only 8% were able to quit smoking.

What about nicotine in other tobacco products?

Nicotine in cigars

People who inhale cigar smoke absorb nicotine through their lungs as quickly as people who smoke cigarettes. For those who don’t inhale, the nicotine is absorbed more slowly through the lining of the mouth. This means people who smoke cigars can get the desired dose of nicotine without inhaling the smoke directly into their lungs.

Most full-size cigars have as much nicotine as several cigarettes. Cigarettes contain an average of about 8 milligrams (mg) of nicotine, but only deliver about 1 to 2 mg of nicotine. Many popular brands of larger cigars have between 100 and 200 mg, or even as many as 444 mg of nicotine. The amount of nicotine a cigar delivers to a person who smokes can vary a great deal, even among people smoking the same type of cigar. How much nicotine is taken in depends on things like:

  • How long the person smokes the cigar
  • How many puffs are taken
  • Whether the smoke is inhaled

Given these factors and the large range of cigar sizes, it’s almost impossible to make good estimates of the amounts of nicotine larger cigars deliver.

Small cigars that are the size and shape of cigarettes have about the same amount of nicotine as a cigarette. If these are smoked like cigarettes (inhaled), they would be expected to deliver a similar amount of nicotine – 1 to 2 mg.

Nicotine in smokeless tobacco

Smokeless tobacco delivers a high dose of nicotine. Nicotine enters the bloodstream from the mouth or nose and is carried to every part of your body.

Nicotine in smokeless tobacco is measured in milligrams (mg) of nicotine per gram (g) of tobacco. It’s been found to vary greatly, for instance as much as 4 to 25 mg/g for moist snuff, 11 to 25 mg/g for dry snuff, and 3 to 40 mg/g for chew tobacco. Other factors that affect the amount of nicotine a person gets include things like:

  • Brand of tobacco
  • Product pH level (how acidic it is)
  • Amount chewed
  • Cut of tobacco

Still, blood levels of nicotine have been shown to be much the same when comparing people who smoke cigarettes to those who use smokeless tobacco.

Nicotine in non-combusted products

Non-combusted tobacco products come in various forms and are used in different ways. Non-combusted products contain nicotine and can lead to nicotine addiction.

  • Non-combusted (heat-not-burn) cigarettes have a heating source and tobacco. The tobacco is heated to a lower temperature than a regular (combustible) cigarette. The heat creates an aerosol that is inhaled by the user.
  • Dissolvable tobacco products are edible. They can be lozenges, strips, gummies, or sticks. They can be easily hidden and can look like candy.
  • Nicotine gels are tobacco products that are rubbed on, and absorbed by, the skin.

Nicotine in e-cigarettes

The e-liquid in most e-cigarettes (vapes) contains nicotine. However, nicotine levels are not the same in all types of e-cigarettes, and sometimes product labels do not list the true nicotine content.

There are some e-cigarette brands that claim to be nicotine-free but have been found to contain nicotine.

Why is it so hard to quit tobacco?

Stopping or cutting back on tobacco causes symptoms of nicotine withdrawal. Withdrawal is both physical and mental. Physically, your body is reacting to the absence of nicotine. Mentally, you are faced with giving up a habit, which calls for a major change in behavior. Emotionally, you might feel like as if you’ve lost your best friend. Studies have shown that smokeless tobacco users have as much trouble giving up tobacco as people who want to quit smoking cigarettes.

People who have used tobacco regularly for a few weeks or longer will have withdrawal symptoms if they suddenly stop or greatly reduce the amount they use. There’s no danger in nicotine withdrawal, but the symptoms can be uncomfortable. They usually start within a few hours and peak about 2 to 3 days later when most of the nicotine and its by-products are out of the body. Withdrawal symptoms can last a few days to up to several weeks. They get better every day that a person stays tobacco-free.

Nicotine withdrawal symptoms can include any of the following:

  • Dizziness (which may last a day or 2 after quitting)
  • Depression
  • Feelings of frustration, impatience, and anger
  • Anxiety
  • Irritability
  • Trouble sleeping, including trouble falling asleep and staying asleep, and having bad dreams or even nightmares
  • Trouble concentrating
  • Restlessness or boredom
  • Headaches
  • Tiredness
  • Increased appetite
  • Weight gain
  • Slower heart rate
  • Constipation and gas
  • Cough, dry mouth, sore throat, and nasal drip
  • Chest tightness

These symptoms can lead a person to start using tobacco again to boost blood levels of nicotine and stop symptoms.

Smoking Can Shrink Your Brain

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News Picture: Smoking Can Shrink Your Brain

Smoking shrinks the human brain, and once that brain mass is lost then it’s gone for good, a new study warns.

Brain scans from more than 32,000 people strongly link a history of smoking with a gradual loss of brain volume. In fact, the more packs a person smoked per day, the smaller their brain volume, researchers found.

The study also establishes the potential series of events that leads to smoking-related brain loss, with a genetic predisposition to smoking eventually causing decreased brain volume.

“It sounds bad, and it is bad,” said senior study author Laura Bierut, a professor of psychiatry at Washington University School of Medicine in St. Louis.

“A reduction in brain volume is consistent with increased aging,” Bierut added in a university news release. “This is important as our population gets older, because aging and smoking are both risk factors for dementia.”

The study, published recently in the journal Biological Psychiatry: Global Open Science, helps explain previous studies that have found smokers at higher risk for age-related brain decline and Alzheimer’s disease.

“Up until recently, scientists have overlooked the effects of smoking on the brain, in part because we were focused on all the terrible effects of smoking on the lungs and the heart,” Bierut said. “But as we’ve started looking at the brain more closely, it’s become apparent that smoking is also really bad for your brain.”

Scientists have long known that smoking and smaller brain volume are linked, but they haven’t been able to figure out which causes the other.
There’s also a third factor to consider — genetics. Both brain size and smoking behavior are influenced by genetics; in fact, about half a person’s risk of smoking can be attributed to their genes.

To untangle the relationship, Bierut and her colleagues analyzed smoking history, genetic data and brain scans on more than 32,000 people gathered as part of a large United Kingdom database that contains info on half a million people.

Analysis revealed that a person’s genetic predisposition leads to smoking, and smoking then causes a decline in brain volume.

Unfortunately, the shrinkage seems to be irreversible. The brains of people who had quit smoking years before remained permanently smaller than those of people who never smoked, data show.

“You can’t undo the damage that has already been done, but you can avoid causing further damage,” said lead researcher Yoonhoo Chang, a graduate student at Washington University. “Smoking is a modifiable risk factor. There’s one thing you can change to stop aging your brain and putting yourself at increased risk of dementia, and that’s to quit smoking.”

Current smoking strong predictor of suicide, overdose among those with smoking history

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Current smoking, use of sedative hypnotics and dyspnea increased the risk for death by suicide or drug overdose among adults with a smoking history with or without COPD, according to study results published in CHEST.

Further, risk for suicide in this patient population was not linked to airflow limitation, measured as FEV1 percent predicted, or other measures of COPD severity, according to researchers.

Infographic showing hazard ratio for death by suicide/overdose among patients with a history of smoking.
Data were derived from Adviento BA, et al. CHEST. 2022;doi:10.1016/j.chest.2022.09.022.

Karin F. Hoth

“An important aspect of our findings was that the objective measures of COPD severity (eg, airflow limitation from spirometry) that we examined were not associated with suicide/overdose, although symptom severity, specifically dyspnea, was,” Karin F. Hoth, PhD, associate professor of psychiatry at the University of Iowa, told Healio. “This finding suggests that the subjective experience of COPD is important in assessing suicide risk among individuals with smoking exposure. Further research is required to examine how COPD and current smoking interact on suicide risk and whether there is evidence of synergy between these two converging risk factors.”

In a prospective cohort study, Hoth and colleagues analyzed 9,930 adults (mean age, 59.6 ± 9 years; 53.4% men; 67.3% non-Hispanic white; 52.6% current smokers; mean BMI, 28.8 ± 6.3 kg/m2) with a 10-pack-year smoking history from the COPDGene Study to determine the factors that can predict suicide or drug overdose mortality in this patient population.

To evaluate time to suicide/overdose, researchers used Cox regression models that accounted for several time-varying independent variables in the past year: age, sex, race, BMI, pack-years, current smoking status, airflow limitation, dyspnea (modified Medical Research Council Dyspnea Scale score 2), 6-minute walk distance, supplemental oxygen use and severe exacerbations.

Results

Of the cohort, 12.4% of adults had preserved ratio impaired spirometry, 26.8% had mild to moderate COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] 1-2), 17.6% had severe to very severe COPD (GOLD 3-4) and 42.5% had normal spirometry.

Additionally, 18.9% of adults used antidepressants, 10.1% used sedative/hypnotics, 3.5% used antipsychotics, 2% used mood stabilizers and 0.5% used stimulants. Fourteen percent of those with GOLD stage 3-4 COPD used sedative/hypnotics, which was the largest recorded use across groups.

Of the total cohort, seven adults died by suicide and 56 died by overdose for a total of 63 deaths during a median follow-up of 7.8 years.

Univariable models adjusted for age and sex demonstrated that race, BMI, current smoking status, use of sedative/hypnotics and dyspnea all significantly were linked to death of suicide or overdose.

In a multivariable model adjusted for univariable significant factors, age and sex, researchers observed several risk factors related to suicide/overdose mortality including a 6.44-fold (95% CI, 2.64-15.67) increased risk with current smoking, a 2.33-fold (95% CI, 1.24-4.38) increased risk with use of sedative/hypnotics and a 2.23-fold (95% CI, 1.34-3.7) increased risk with dyspnea.

Conversely, older age (HR per decade = 0.45; 95% CI, 0.31-0.67), higher BMI (HR = 0.95; 95% CI, 0.91-0.99) and African American race (HR = 0.41; 95% CI, 0.23-0.74) showed a decreased risk for suicide/overdose mortality in this model.

Mean FEV1 percent predicted was 76.1 ± 25.5 for the total cohort, but researchers noted this measure was not linked to risk for suicide.

Future studies, recommendations for clinicians

The results of this study underscore the importance of incorporating subjective measures of disease symptom severity when assessing suicide/overdose risk among individuals with smoking exposure and COPD, according to Hoth.

“Future studies can be improved by gathering more information about comorbid mental health conditions at baseline so that the impact of depression and anxiety can be included in modeling predicting suicide/overdose,” she said.

Based on the study’s results, clinicians should check adults with a smoking history and heavy symptom burden for depression, anxiety and suicidal ideation, Hoth added.

“Some suggestions for the clinician who is concerned about risk for suicide/overdose for one of their patients include:

  • approach interactions with patients with a calm, open, curious manner asking about quality of life and things that matter to the patient — a move toward whole-person care has a positive impact;
  • familiarize themselves with determining level of suicide risk and tools available in their health care setting, with recommendations available in an article by Weber and colleagues in Medical Clinics of North America;
  • contact family or friends with permission when needed for information and support;
  • work with the patient or family to reduce access to lethal means (eg, firearms, excess medications); and
  • facilitate mental health treatment when appropriate, emergently if necessary.”

This study by Hoth and colleagues emphasizes the importance of quitting smoking and implementation of a more specific suicide risk assessment for patients who have a history of smoking, according to an accompanying editorial by Natalie B. V. Riblet, MD, MPH, assistant professor of psychiatry at Dartmouth Institute, and Bradley V. Watts, MD, MPH, associate professor of psychiatry at Dartmouth Geisel School of Medicine.

“The results reiterate the critical need to promote smoking cessation as a strategy to reduce morbidity and death in the population,” Riblet and Watts wrote. “Patients who smoke heavily will also be helped by having access to mental health treatment. Patients with comorbid COPD and depression or anxiety, in particular, can benefit from pulmonary rehabilitation. Suicide risk assessment in this population may also be improved by incorporation into the clinical evaluation specific factors such as current smoking, use of sedatives, and the presence of dyspnea.”

E-cigarettes face new restrictions.

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Electronic cigarettes will be licensed as a medicine in the UK from 2016, under new regulations.

The UK currently has few restrictions on the use of e-cigarettes, despite moves in some countries to ban them.

The Medicines and Healthcare Products Regulatory Agency says it will regulate e-cigarettes as medicines when new European tobacco laws come into force.

Sales of tobacco-free cigarettes have boomed worldwide since bans on smoking in public places were introduced.

Campaigners say the growing popularity of e-cigarettes could undermine years of anti-smoking efforts, with particular concerns about promotion to children and non-smokers.

Research suggests around 1.3m smokers and ex-smokers in the UK use the products, which are designed to replicate smoking behaviour without the use of tobacco.

They turn nicotine and other chemicals into a vapour that is inhaled.

 “Start Quote

Regulation can ensure that adult smokers can continue to be able to buy e-cigarettes as easily as tobacco, but promotion to children or non-smokers will be prohibited”

Deborah ArnottASH

Jeremy Mean of The Medicines and Healthcare Products Regulatory Agency (MHRA) said the government had concluded that e-cigarettes currently on the market do not meet appropriate standards of safety, quality and efficacy.

He said “levels of contamination” had been found in the products and some were poorly manufactured.

Not recommended

There will be no compulsory licensing of the products until 2016 but until then they are not recommended for use, he said.

“We can’t recommend these products because their safety and quality is not assured, and so we will recommend that people don’t use them,” he told a news conference.

The MHRA had decided not to ban the products entirely but to work towards a position where they are licensed, he added.

“Smoking is the riskiest thing you can do – we want to enable people to cut down and quit – we don’t think a ban is a proportionate action.”

The health campaign body, Action on Smoking and Health (ASH), said the action will ensure promotion to children or non-smokers is prohibited.

E-cigarettes: pros and cons

  • The British Medical Association says health professionals should encourage their patients to use a regulated and licensed nicotine replacement therapy (such as patches or gum) to help quit smoking
  • It says health professional may advise patients that while e-cigarettes are unregulated and their safety cannot be assured, they are likely to be a lower risk option than continuing to smoke

Deborah Arnott, chief executive of ASH, said: “MHRA regulation can ensure that adult smokers can continue to be able to buy e-cigarettes as easily as tobacco, but promotion to children or non-smokers will be prohibited.”

Chief Medical Officer Professor Dame Sally Davies said with more people using e-cigarettes it was only right that the products were properly regulated to be safe and work effectively.

“Smokers are harmed by the deadly tar and toxins in tobacco smoke, not the nicotine,” she said.

“While it’s best to quit completely, I realise that not every smoker can and it is much better to get nicotine from safer sources such as nicotine replacement therapy.”

Manufacturers of e-cigarettes say the products have the potential to save lives and should not be restricted.

Adrian Everrett, chief executive officer of E-Lites, told the BBC: “So far not one person globally has been killed by an electronic cigarette and yet every 5 minutes in this country alone someone dies from tobacco use.

“To remove or restrict the use or availability of the electronic cigarette from this market would be a significant health loss.”

Once licensed, e-cigarettes are expected to remain on sale over-the-counter in the UK.

In some countries, such as New Zealand, e-cigarettes are regulated as medicines and can be purchased only in pharmacies.

In other countries, including Denmark, Canada and Australia, they are subject to restrictions on sale, import and marketing. Complete bans are in place in Brazil, Norway and Singapore.

Dr Mike Knapton, Associate Medical Director at the British Heart Foundation, said more research was needed into the potential health implications of long-term nicotine use.

“The MHRA has rightly addressed the worrying dearth of regulation around nicotine-containing products and electronic cigarettes – an important step to ensuring their safety,” he said.

“Marketing of these products must now be closely monitored to ensure non-smokers and children don’t end up using them.”

Source: BBC