recommendation about smoking essay

Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence (2010)

Chapter: 8 conclusions and recommendations, 8 conclusions and recommendations.

In this report, the committee has examined three relationships in response to its charge (see Box 8-1 for specific questions):

The association between secondhand-smoke exposure and cardiovascular disease, especially coronary heart disease and not stroke (Question 1).

The association between secondhand-smoke exposure and acute coronary events (Questions 2, 3, and 5).

The association between smoking bans and acute coronary events (Questions 4, 5, 6, 7, and 8).

This chapter summarizes the committee’s review of information relevant to those relationships; presents its findings, conclusions, and recommendations on the basis of the weight of evidence; and presents its responses to the specific questions that it was asked in its task.

SUMMARY OF REPORT

Exposure assessment.

To determine the effect of changes in exposure to secondhand smoke it is necessary to quantify changes in epidemiologic studies. Airborne measures and biomarkers of exposure to secondhand smoke are available; they are complementary and provide different information (see Chapter 2 ). Biomarkers (such as cotinine, the major proximate metabolite of nicotine) in-

tegrate all sources of exposure and inhalation rates, but cannot identify the place where secondhand-smoke exposure occurred and, because of a short half-life they reflect only recent exposures. Airborne measures of exposure can demonstrate the contribution of different sources or venues of exposure and can be used to measure changes in secondhand-smoke concentrations at individual venues, but they do not reflect the true dose. Airborne concentration of nicotine is a specific tracer for secondhand smoke. Particulate matter (PM) can also be used as an indicator of secondhand-smoke exposure, but because there are other sources of PM it is a less specific tracer than nicotine. The concentration of cotinine in serum, saliva, or urine is a specific indicator of integrated exposure to secondhand smoke.

Although in most of the smoking-ban studies the magnitude, frequency, and duration of exposures that occurred before a ban are not known, monitoring studies demonstrate that exposure to secondhand smoke is dramatically reduced in places that are covered by bans. Airborne nicotine

and PM concentrations in regulated venues such as workplaces, bars, and restaurants decreased by more than 80% in most studies; serum, salivary, or urinary cotinine concentrations decreased by 50% or more in most studies, probably reflecting continuing exposures in unregulated venues (for example, in homes and cars).

Pathophysiology

The pathophysiology of the induction of cardiovascular disease by cigarette-smoking and secondhand-smoke exposure is complex and undoubtedly involves multiple agents. Many chemicals in secondhand smoke have been shown to exert cardiovascular toxicity (see Table 3-1 ), and both acute and chronic effects of these chemicals have been identified. Experimental studies in humans, animals, and cell cultures have demonstrated effects of secondhand smoke, its components (such as PM, acrolein, polycyclic

aromatic hydrocarbons [PAHs], and metals), or both on the cardiovascular system (see Figure 3-1 for summary). Those studies have yielded sufficient evidence to support an inference that acute exposure to secondhand smoke induces endothelial dysfunction, increases thrombosis, causes inflammation, and potentially affects plaque stability adversely. Those effects appear at concentrations expected to be experienced by people exposed to secondhand smoke.

Data from animal studies also support a dose–response relationship between secondhand-smoke exposure and cardiovascular effects (see Chapter 3 ). The relationship is consistent with the understanding of the pathophysiology of coronary heart disease and the effects of secondhand smoke on humans, including chamber studies. The association comports with known associations between PM, a major constituent of secondhand smoke, and coronary heart disease.

Overall, the pathophysiologic data indicate that it is biologically plausible for secondhand-smoke exposure to have cardiovascular effects, such as effects that lead to cardiovascular disease and acute myocardial infarction (MI). The exact mechanisms by which such effects occur, however, remain to be elucidated.

Smoking-Ban Background

Characteristics of smoking bans can heavily influence their consequences. Interpretation of the results of epidemiologic studies that involve smoking bans must account for information on the bans and their enforcement.

Secondhand smoke should have been measured before and after implementation of a ban, and locations with and without bans should have been compared. Studies that include self-reported assessments of exposure to secondhand smoke cannot necessarily be compared with each other unless the survey instruments (such as interviews) were similar.

The comparability of the time and length of followup of the studies should be assessed. For example, the impact of a ban in one area may differ from the impact of a ban in another solely because the observation times were different and other activities may have occurred during the same periods. In comparing studies, it may be impossible to separate contextual factors associated with ban legislation—such as public comment periods, information announcing the ban, and notices about the impending changes—from the impact of the ban itself. The committee therefore included such contextual factors in drawing conclusions about the effects of a ban.

Interpretation needs to consider the timeframes in the epidemiologic evidence, for example, the time from onset of a smoking ban to the mea-

surement of incidence of a disease, the timing and nature of enforcement, and the time until changes in cardiovascular-event rates were observed in people who had various baseline risks. Interpretation should account for the extent to which studies assessed possible alternative causes of decreases in hospitalizations for coronary events, including changes in health-care availability and in the standard of practice in cardiac care, such as new diagnostic criteria for acute MI during the period of study. The latter is especially important in making before–after comparisons in the absence of a comparison geographic area in which no ban has been implemented.

When designing and analyzing future studies, researchers should examine the time between the implementation of a smoking ban and changes in rates of hospital admission or cardiac death. Future studies could evaluate whether decreases in admissions are transitory, sustained, or increasing, and ideally they would include information on individual subjects, including prior history of cardiac disease, to answer the questions posed to the committee.

Epidemiologic Studies

Cardiovascular disease is a major public-health concern. The results of dozens of epidemiologic studies of both case–control and cohort design carried out in multiple populations consistently indicate about a 25–30% increase in risk of coronary heart disease from exposure to secondhand smoke (see Chapter 4 ). Epidemiologic studies using serum cotinine concentration as a biomarker of overall exposure to secondhand smoke indicated that the relative risk (RR) of coronary heart disease associated with secondhand smoke is even greater than those estimates. The excess risk is unlikely to be explained by misclassification bias, uncontrolled-for confounding effects, or publication bias. Although few studies have addressed the risk of coronary heart disease posed by secondhand-smoke exposure in the workplace, there is no biologically plausible reason to suppose that the effect of secondhand-smoke exposure at work or in a public building differs from the effect of exposure in the home environment. Epidemiologic studies demonstrate a dose–response relationship between chronic secondhand-smoke exposure as assessed by self-reports of exposure (He et al., 1999) and as assessed by biomarkers (cotinine) and long-term risk of coronary heart disease (Whincup et al., 2004). Dose–response curves show a steep initial rise in risk when going from negligible to low exposure followed by a gradual increase with increasing exposure.

The INTERHEART study, a large case–control study of cases of first acute MI, showed that exposure to secondhand smoke increased the risk of nonfatal acute MI in a graded manner (Teo et al., 2006).

Eleven key epidemiologic studies evaluated the effects of eight smok-

ing bans on the incidence of acute coronary events (see Table 8-1 and Chapter 6 ). The results of those studies show remarkable consistency: all showed decreases in the rate of acute MIs after the implementation of smoking bans (Barone-Adesi et al., 2006; Bartecchi et al., 2006; CDC, 2009; Cesaroni et al., 2008; Juster et al., 2007; Khuder et al., 2007; Lemstra et al., 2008; Pell et al., 2008; Sargent et al., 2004; Seo and Torabi, 2007; Vasselli et al., 2008). Two of the studies (Pell et al., 2008; Seo and Torabi, 2007) examined rates of hospitalization for acute coronary events after the implementation of smoking bans and provided direct evidence of the relationship of secondhand-smoke exposure to acute coronary events by presenting results in nonsmokers.

The decreases in acute MIs in the 11 studies ranged from about 6 to 47%, depending on characteristics of the study, including the method of statistical analysis. The consistency in the direction of change gave the committee confidence that smoking bans result in a decrease in the rate of acute MI. The studies took advantage of bans as “natural experiments” to look at questions about the effects of bans, and indirectly of a decrease in secondhand-smoke exposure, on the incidence of acute cardiac events. As discussed in Assessing the Health Impact of Air Quality Regulations: Concepts and Methods for Accountability Research (HEI Accountability Working Group, 2003) in the context of air-pollution regulations, studies of interventions constitute a more definitive approach than other epidemiologic studies to determining whether regulations result in health benefits. All the studies are relevant and informative with respect to the questions posed to the committee, and overall they support an association between smoking bans and a decrease in acute cardiovascular events. The studies have inherent limitations related to their nature, but they directly evaluated the effects of an intervention (a smoking ban, including any concomitant activities) on a health outcome of interest (acute coronary events).

The committee could not determine the magnitude of effect with any reasonable degree of certainty on the basis of those studies. The variability in study design, implementation, and analysis was so large that the committee concluded that it could not conduct a meta-analysis or combine the information from the studies to calculate a point estimate of the effect. In particular, the committee was unable to determine the overall portion of the effect attributable to decreased smoking by smokers as opposed to decreased exposure of nonsmokers to secondhand smoke because of a lack of information on smoking status in nine of the studies (Barone-Adesi et al., 2006; Bartecchi et al., 2006; CDC, 2009; Cesaroni et al., 2008; Juster et al., 2007; Khuder et al., 2007; Lemstra et al., 2008; Sargent et al., 2004; Seo and Torabi, 2007; Vasselli et al., 2008). The results of the studies are consistent with the findings of the pathophysiologic studies discussed in Chapter 3 and the data on PM discussed in Chapters 3 and 7 . At the population level,

results of the key intervention studies reviewed by the committee are for the most part consistent with a decrease in risk as early as a month following reductions in secondhand-smoke exposure; however, given the variability in the studies and the lack of data on the precise timing of interventions, the smoking-ban studies do not provide adequate information on the time it takes to see decreases in acute MIs.

Plausibility of Effect

The committee considered both the biologic plausibility of a causal relationship between a decrease in secondhand-smoke exposure and a decrease in the incidence of acute MI and the plausibility of the magnitude of the effect seen in the key epidemiologic studies after implementation of smoking bans.

The experimental data reviewed in Chapter 3 demonstrate that several components of secondhand smoke, as well as secondhand smoke itself, exert substantial cardiovascular toxicity. The toxic effects include the induction of endothelial dysfunction, an increase in thrombosis, increased inflammation, and possible reductions in plaque stability. The data provide evidence that it is biologically plausible for secondhand smoke to be a potential causative trigger of acute coronary events. The risk of acute coronary events is likely to be increased if a person has preexisting heart disease. The association comports with findings on air-pollution components, such as diesel exhaust (Mills et al., 2007) and PM (Bhatnagar, 2006).

As a “reality check” on the potential effects of changes in secondhand-smoke exposure, the committee estimated the decrease in risk of cardiovascular disease and specifically heart failure that would be expected on the basis of the risk effects of changes in airborne PM concentrations after implementation of smoking bans seen in the PM literature. The PM in cigarette smoke is not identical with that in air pollution, and the committee did not attempt to estimate the risk attributable to secondhand-smoke exposure through the PM risk estimates but rather found this a useful exercise to see whether the decreases seen in the epidemiologic literature are reasonable, given data on other air pollutants that have some common characteristics. The committee’s estimates on the basis of the PM literature support the possibility that changes in secondhand-smoke exposure after implementation of a smoking ban can have a substantial effect on hospital admissions for heart failure and cardiovascular disease.

SUMMARY OF OVERALL WEIGHT OF EVIDENCE

The committee examined three relationships—of secondhand-smoke exposure and cardiovascular disease, of secondhand-smoke exposure and

TABLE 8-1 Summary of Key Studies (Studies Listed by Smoking-Ban Region in Order of Publication)

acute coronary events, and of smoking bans and acute coronary events. The committee used the criteria of causation described in Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service (U.S. Public Health Service, 1964) in drawing conclusions regarding those relationships. The criteria are often referred to as the Bradford Hill criteria because they were, as stated by Hamill (1997), “later expanded and refined by A. B. Hill” (Hill, 1965). Table 8-2 summarizes the available evidence on secondhand-smoke exposure and coronary events in terms of the Bradford Hill criteria.

Secondhand-Smoke Exposure and Cardiovascular Disease

The results of both case–control and cohort studies carried out in multiple populations consistently indicate exposure to secondhand smoke causes about a 25–30% increase in the risk of coronary heart disease; results of some studies indicate a dose–response relationship. Data from animal studies support the dose–response relationship (see Chapter 3 ). Data from experimental studies of animals and cells and from intentional human-dosing studies indicate that a relationship between secondhand-smoke exposure and coronary heart disease is biologically plausible and consistent with understanding of the pathophysiology of coronary heart disease.

Taking all that evidence together, the committee concurs with the conclusions in the 2006 surgeon general’s report (HHS, 2006) that “the evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and increased risks of coronary heart disease morbidity and mortality among both men and women.” Although the committee found strong and consistent evidence of the existence of a positive association between chronic exposure to secondhand smoke and coronary heart disease, determining the magnitude of the risk (the number of cases that are attributable to secondhand-smoke exposure) proved challenging, and the committee has not done it.

Secondhand-Smoke Exposure and Acute Coronary Events

Two of the epidemiologic studies reviewed by the committee that examine rates of hospitalization for acute coronary events after implementation of smoking bans provide direct evidence related to secondhand smoke exposures. The studies either reported events in nonsmokers only (Monroe, Indiana) (Seo and Torabi, 2007) or analyzed nonsmokers and smokers separately on the basis of serum cotinine concentration (Scotland) (Pell et al., 2008). Both studies showed reductions in the RR of acute coronary events in nonsmokers when secondhand-smoke exposure was decreased after implementation of the bans; this indicates an association between a

decrease in exposure to secondhand smoke and a decrease in risk of acute coronary events. Because of differences between and limitations of the two studies (such as in population, population size, and analysis), they do not provide strong sufficient evidence to determine the magnitude of the decrease in RR.

The effect seen after implementation of smoking bans is consistent with data from the INTERHEART study, a case–control study of 15,152 cases of first acute MI in 262 centers in 52 countries (Teo et al., 2006). Increased exposure to secondhand smoke increased the risk of nonfatal acute MI in a graded manner, with adjusted odds ratios of 1.24 (95% confidence interval [CI], 1.17–1.32) and 1.62 (95% CI, 1.45–1.81) in the least exposed people (1–7 hours of exposure per week) and the most exposed (at least 22 hours of exposure per week), respectively. In contrast, a study using data from the Western New York Health Study collected from 1995 to 2001 found that secondhand smoke was not significantly associated with higher risk of MI (Stranges et al., 2007). That study, however, looked at lifetime cumulative exposure to secondhand smoke, a different exposure metric from that in the other studies and one that does not take into account how recent the exposure is.

The other key epidemiologic studies that looked at smoking bans provide indirect evidence of an association between secondhand-smoke exposure and acute coronary events (Barone-Adesi et al., 2006; Bartecchi et al., 2006; CDC, 2009; Cesaroni et al., 2008; Juster et al., 2007; Khuder et al., 2007; Lemstra et al., 2008; Sargent et al., 2004; Vasselli et al., 2008). Although it is not possible to separate the effect of smoking bans in reducing exposure to secondhand smoke and their effect in reducing active smoking in those studies, because they did not report individual smoking status or secondhand-smoke exposure concentrations, monitoring studies of airborne tracers 1 and biomarkers 2 of exposure to secondhand smoke have demonstrated that exposure to secondhand smoke is dramatically reduced after implementation of smoking bans. Those studies therefore provide indirect evidence that at least part of the decrease in acute coronary events seen after implementation of smoking bans could be mediated by a decrease in exposure to secondhand smoke. It is not possible to determine the differential magnitude of the effect that is attributable to changes in nonsmokers and smokers.

Experimental data show that an association between secondhand-

TABLE 8-2 Evaluation of Available Data in Terms of Bradford-Hill Criteria

smoke exposure and acute coronary events is biologically plausible (see Chapter 3 ). Experimental studies in humans, animals, and cell cultures have demonstrated short-term effects of secondhand smoke as a complex mixture or its components individually (such as oxidants, PM, acrolein, PAHs, benzene, and metals) on the cardiovascular system. There is sufficient evidence from such studies to infer that acute exposure to secondhand smoke at concentrations relevant to population exposures induces endothelial dysfunction, increases inflammation, increases thrombosis, and potentially adversely affects plaque stability. Those effects occur at magnitudes relevant to the pathogenesis of acute coronary events. Furthermore, indirect evidence obtained from studies of ambient PM supports the notion that exposure to PM present in secondhand smoke could trigger acute coronary events or induce arrhythmogenesis in a person with a vulnerable myocardium.

Taking all that evidence together, the committee concludes that there is sufficient evidence of a causal relationship between a decrease in secondhand-smoke exposure and a decrease in the risk of acute MI. Given the variability among studies and their limitations, the committee did not provide a quantitative estimate of the magnitude of the effect.

Smoking Bans and Acute Coronary Events

Nine key studies looked at the overall effect of smoking bans on the incidence of acute coronary events in the overall populations—smokers and nonsmokers—studied (Barone-Adesi et al., 2006; Bartecchi et al., 2006; CDC, 2009; Cesaroni et al., 2008; Juster et al., 2007; Khuder et al., 2007; Lemstra et al., 2008; Sargent et al., 2004; Vasselli et al., 2008). Those studies consistently show a decrease in acute MIs after implementation of smoking bans. The combination of experimental data on secondhand-smoke effects discussed above and exposure data that indicate that secondhand-smoke concentrations decrease substantially after implementation of a smoking ban provides evidence that it is biologically plausible for smoking bans to decrease the rate of acute MIs. The committee concludes that there is an association between smoking bans and a reduction in acute coronary events and, given the temporality and biologic plausibility of the effect, that the evidence is consistent with a causal relationship. Although all the studies demonstrated a positive effect of bans in reducing acute MIs, differences among the studies, including the components of the bans and other interventions that promote smoke-free environments that took place during the bans, limited the committee’s confidence in estimating the overall magnitude of the effect. There is little information on how long it would take for such an effect to be seen inasmuch as the studies have not evaluated periods shorter than a month.

DATA GAPS AND RESEARCH RECOMMENDATIONS

Studies of the effect of indoor smoking bans and secondhand-smoke exposure on acute coronary events should be designed to examine the time between an intervention and changes in the effect and to measure the magnitude of the effect. No time to effect can be postulated for individuals on the basis of the available data, and evaluation of population-based effectiveness of a smoking ban depends on societal actions that implement and enforce the ban and on actions that include smoke reduction in homes, cars, and elsewhere. The decrease in secondhand-smoke exposure does not necessarily occur suddenly—it might decline gradually or by steps. In a likely scenario, once a ban is put into place and enforced, a sharp drop in secondhand-smoke exposure might be seen immediately and followed by a slower decrease in exposure as the population becomes more educated about the health consequences of secondhand smoke and exposure becomes less socially acceptable. Future studies that examine the time from initiation of a ban to observation of an effect and that include followup after initiation of enforcement, taking the social aspects into account, would provide better information on how long it takes to see an effect of a ban. Statistical models should clearly articulate a set of assumptions and include sensitivity analyses. Studies that examine whether decreases in hospital admissions for acute coronary events are transitory or sustained would also be informative.

Many factors are likely to influence the effect of a smoking ban on the incidence and prevalence of acute coronary events in a population. They include age, sex, diet, background risk factors and environmental factors for cardiovascular disease, prevalence of smokers in the community, the underlying rate of heart disease in the community (for example, the rate in Italy versus the United States), and the social environment. Future studies should include direct observations on individuals—including their history of cardiac disease, exposure to other environmental agents, and other risk factors for cardiac events—to assess the impact of those factors on study results. Assessment of smoking status is also needed to distinguish between the effects of secondhand smoke in nonsmokers and the effects of a ban that decreases cigarette consumption or promotes smoking cessation in smokers.

Few constituents of secondhand smoke have been adequately studied for cardiotoxicity. Future research should examine the cardiotoxicity of environmental chemicals, including those in secondhand smoke, to define cardiovascular toxicity end points and establish consistent definitions and measurement standards for cardiotoxicity of environmental contaminants. Specifically, information is lacking on the cardiotoxicity of highly reactive smoke constituents, such as acrolein and other oxidants; on techniques for

quantitating those reactive components; and on the toxicity of low concentrations of benzo[ a ]pyrene, of PAHs other than benzo[a]pyrene, and of mixtures of tobacco-smoke toxicants.

Many questions remain with respect to the pathogenesis of cardiovascular disease and acute coronary events and how secondhand-smoke constituents perturb the pathophysiologic mechanisms and result in disease and death. For example, a better understanding of the factors that promote plaque rupture and how they are influenced by tobacco smoke and PM would provide insight into the mechanisms underlying the cardiovascular effects of secondhand smoke and might lead to better methods of detecting preclinical disease and preventing events.

The committee found only sparse data on the prevalence and incidence of cardiovascular disease and acute coronary events at the national level in general compared with other health end points for which there are central data registries and surveillance of all events, such as the Surveillance, Epidemiology, and End Results (SEER) Program for cancer. Although there are national databases that include acute MI patients—such as the National Registry of Myocardial Infarction (Morrow et al., 2001; Rogers et al., 1994), the Health Care Financing Administration database, and the Cooperative Cardiovascular Project (Ellerbeck et al., 1995)—and the Centers for Disease Control and Prevention’s annual National Hospital Discharge Survey and National Health Interview Survey provide some information on cardiovascular end points, these are not comprehensive or inclusive with respect to hospital participation, patient inclusion, or data capture. A national database that captures all cardiovascular end points would facilitate future epidemiologic studies by allowing the tracking of trends and identification of high-risk populations at a more granular level.

A large prospective cohort study could be very helpful in more accurately estimating the magnitude of the risk of cardiovascular disease and acute coronary events posed by secondhand-smoke exposure. It could be a new study specifically designed to assess effects of secondhand smoke or, as was done with the INTERHEART study, take advantage of existing studies—such as the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, the American Cancer Society’s Cancer Prevention Study-3, the European Prospective Investigation into Cancer and Nutrition study, and the Jackson Heart Study—provided that they have adequate information on individual smoking status and secondhand-smoke exposure (or the ability to measure it, for example, in adequate blood samples). If properly designed, such a study could identify subpopulations at highest risk for acute coronary events from secondhand-smoke exposure in relation to such characteristics as age and sex, and concomitant risk factors, such as obesity.

COMMITTEE RESPONSES TO SPECIFIC QUESTIONS

The committee was tasked with responding to eight specific questions. The questions and the committee’s responses are presented below.

What is the current scientific consensus on the relationship between exposure to secondhand smoke and cardiovascular disease? What is the pathophysiology? What is the strength of the relationship?

On the basis of the available studies of chronic exposure to secondhand smoke and cardiovascular disease, the committee concludes that there is scientific consensus that there is a causal relationship between secondhand-smoke exposure and cardiovascular disease. The results of a number of meta-analyses of the epidemiologic studies showed increases of 25–30% in the risk of cardiovascular disease caused by various exposures. The studies include some that use serum cotinine concentration as a biomarker of exposure and show a dose–response relationship. The pathophysiologic data are consistent with that relationship, as are the data from studies of air pollution and PM. The data in support of the relationship are consistent, but the committee could not calculate a point estimate of the magnitude of the effect (that is, the effect size) given the variable strength of the relationship, differences among studies, poor assessment of secondhand-smoke exposure, and variation in concomitant underlying risk factors.

Is there sufficient evidence to support the plausibility of a causal relation between secondhand smoke exposure and acute coronary events such as acute myocardial infarction and unstable angina? If yes, what is the pathophysiology? And what is the strength of the relationship?

The evidence reviewed by the committee is consistent with a causal relationship between secondhand-smoke exposure and acute coronary events, such as acute MI. It is unknown whether acute exposure, chronic exposure, or a combination of the two underlies the occurrence of acute coronary events, inasmuch as the duration or pattern of exposure in individuals is not known. The evidence includes the results of two key studies that have information on individual smoking status and that showed decreases in risks of acute coronary events in nonsmokers after implementation of a smoking ban. Those studies are supported by information from other smoking-ban studies (although these do not have information on individual smoking status, other exposure-assessment studies have demonstrated that secondhand-smoke exposure decreases after implementation of a smoking ban) and by the large body of literature on PM, especially PM 2.5 , a

constituent of secondhand smoke. The evidence is not yet comprehensive enough to determine a detailed mode of action for the relationship between secondhand-smoke exposure and a variety of intervening and preexisting conditions in predisposing to cardiac events. However, experimental studies have shown effects that are consistent with pathogenic factors in acute coronary events. Although the committee has confidence in the evidence of an association between chronic secondhand-smoke exposure and acute coronary events, the evidence on the magnitude of the association is less convincing, so the committee did not estimate that magnitude (that is, the effect size).

Is it biologically plausible that a relatively brief (e.g., under 1 hour) secondhand smoke exposure incident could precipitate an acute coronary event? If yes, what is known or suspected about how this risk may vary based upon absence or presence (and extent) of preexisting coronary artery disease?

There is no direct evidence that a relatively brief exposure to secondhand smoke can precipitate an acute coronary event; few published studies have addressed that question. The circumstantial evidence of such a relationship, however, is compelling. The strongest evidence comes from airpollution research, especially research on PM. Although the source of the PM can affect its toxicity, particle size in secondhand smoke is comparable with that in air pollution, and research has demonstrated a similarity between cardiovascular effects of PM and of secondhand smoke. Some studies have demonstrated rapid effects of brief secondhand-smoke exposure (for example, on platelet aggregation and endothelial function), but more research is necessary to delineate how secondhand smoke produces cardiovascular effects and the role of underlying preexisting coronary arterial disease in determining susceptibility to the effects. Given the data on PM, especially those from time-series studies, which indicate that a relatively brief exposure can precipitate an acute coronary event, and the fact that PM is a major component of secondhand smoke, the committee concludes that it is biologically plausible for a relatively brief exposure to secondhand smoke to precipitate an acute coronary event.

With respect to how the risk might vary in the presence or absence of preexisting coronary arterial disease, it is generally assumed that acute coronary events are more likely to occur in people who have some level of preexisting disease, although that underlying disease is often subclinical. There are not enough data on the presence of pre-existing coronary arterial disease in the populations studied to assess the extent to which the absence or presence of such preexisting disease affects the cardiovascular risk posed by secondhand-smoke exposure.

What is the strength of the evidence for a causal relationship between indoor smoking bans and decreased risk of acute myocardial infarction?

The key intervention studies that have evaluated the effects of indoor smoking bans consistently have shown a decreased risk of heart attack. Research has also indicated that secondhand-smoke exposure is causally related to heart attacks, that smoking bans decrease secondhand-smoke exposure, and that a relationship between secondhand-smoke exposure and acute coronary events is biologically plausible. All the relevant studies have shown an association in a direction consistent with a causal relationship (although the committee was unable to estimate the magnitude of the association), and the committee therefore concludes that the evidence is sufficient to infer a causal relationship.

What is a reasonable latency period between a decrease in secondhand smoke exposure and a decrease in risk of an acute myocardial infarction for an individual? What is a reasonable latency period between a decrease in population secondhand smoke exposure and a measurable decrease in acute myocardial infarction rates for a population?

No direct information is available on the time between a decrease in secondhand-smoke exposure and a decrease in the risk of a heart attack in an individual. Data on PM, however, have shown effects on the heart within 24 hours, and this supports a period of less than 24 hours. At the population level, results of the key intervention studies reviewed by the committee are for the most part consistent with a decrease in risk as early as a month following reductions in secondhand-smoke exposure; however, given the variability in the studies and the lack of data on the precise timing of interventions, the smoking-ban studies do not provide adequate information on the time it takes to see decreases in heart attacks.

What are the strengths and weaknesses of published population-based studies on the risk of acute myocardial infarction following the institution of comprehensive indoor smoking bans? In light of published studies’ strengths and weaknesses, how much confidence is warranted in reported effect size estimates?

Some of the weaknesses of the published population-based studies of the risk of MI after implementation of smoking bans are

Limitations associated with an open study population and, in some cases, with the use of a small sample.

Concurrent interventions that reduce the observed effect of a smoking ban.

Lack of exposure-assessment criteria and measurements.

Lack of information collected on the time between the cessation of exposure to secondhand smoke and changes in disease rates.

Differences between control and intervention groups.

Nonexperimental design of studies (by necessity).

Lack of assessment of the sensitivity of results to the assumptions made in the statistical analysis.

The different studies had different strengths and weaknesses in relation to the assessment of the effects of smoking bans. For example, the Scottish study had such strengths as prospective design and serum cotinine measurements. The Saskatoon study had the advantage of comprehensive hospital records, and the Monroe County study excluded smokers. The population-based studies of the risk of heart attack after the institution of comprehensive smoking bans were consistent in showing an association between the smoking bans and a decrease in the risk of acute coronary events, and this strengthened the committee’s confidence in the existence of the association. However, because of the weaknesses discussed above and the variability among the studies, the committee has little confidence in the magnitude of the effects and, therefore, thought it inappropriate to attempt to estimate an effect size from such disparate designs and measures.

What factors would be expected to influence the effect size? For example, population age distribution, baseline level of secondhand smoke protection among nonsmokers, and level of secondhand smoke protection provided by the smoke-free law .

A number of factors that vary among the key studies can influence effect size. Although some of the studies found different effects in different age groups, these were not consistently identified. One major factor is the size of the difference in secondhand-smoke exposure before and after implementation of a ban, which would vary and depends on: the magnitude of exposure before the ban, which is influenced by the baseline level of smoking and preexisting smoking bans or restrictions; and the magnitude of exposure after implementation of the ban, which is influenced by the extent of the ban, enforcement of and compliance with the ban, changes in social norms of smoking behaviors, and remaining exposure in areas not covered by the ban (for example, in private vehicles and homes). The baseline rate of acute coronary events or cardiovascular disease could influence the effect

size, as would the prevalence of other risk factors for acute coronary events, such as obesity, diabetes, and age.

What are the most critical research gaps that should be addressed to improve our understanding of the impact of indoor air policies on acute coronary events? What studies should be performed to address these gaps?

The committee identified the following gaps and research needs as those most critical for improving understanding of the effect of indoor-air policies on acute coronary events:

The committee found a relative paucity of data on environmental cardiotoxicity of secondhand smoke compared with other disease end points related to secondhand smoke, such as carcinogenicity and reproductive toxicity. Research should develop standard definitions of cardiotoxic end points in pathophysiologic studies (for example, specific results on standard assays) and a classification system for cardiotoxic agents (similar to the International Agency for Research on Cancer classification of carcinogens). Established cardiotoxicity assays for environmental exposures and consistent definitions of adverse outcomes of such tests would improve investigations of the cardiotoxicity of secondhand smoke and its components and identify potential end points for the investigation of the effects of indoor-air policies on acute coronary events.

The committee found a lack of a system for surveillance of the prevalence of cardiovascular disease and of the incidence of acute coronary events in the United States. Surveillance of incidence and prevalence trends would allow secular trends to be taken into account better and to be compared among different populations to establish the effects of indoor-air policies. Although some national databases and surveys include cardiovascular end points, a national database that tracks hospital admission rates and deaths from acute coronary events, similar to the SEER database for cancer, would improve epidemiologic studies.

The committee found a lack of understanding of a mechanism that leads to plaque rupture and from that to an acute coronary event and of how secondhand smoke affects that process. Additional research is necessary to develop reliable biomarkers of early effects on plaque vulnerability to rupture and to improve the design of pathophysiologic studies of secondhand smoke that examine effects of exposure on plaque stability.

All 11 key studies reviewed by the committee have strengths and limitations due to their study design, and none was designed to test the hypothesis that secondhand-smoke exposure causes cardiovascular disease or acute coronary events. Because of those limitations and the consequent variability in results, the committee did not have enough information to estimate the magnitude of the decrease in cardiovascular risk due to smoking bans or to a decrease in secondhand-smoke exposure. A large, well-designed study could permit estimation of the magnitude of the effect. An ideal study would be prospective; would have individual-level data on smoking status; would account for potential confounders, including other risk factors for cardiovascular events (such as obesity and age), would have biomarkers of mainstream and secondhand-smoke exposures (such as blood cotinine concentrations); and would have enough cases to allow separate analyses of smokers and nonsmokers or, ideally, stratification of cases by cotinine concentrations to examine the dose–response relationship. Such a study could be specifically designed for secondhand smoke or potentially could take advantage of existing cohort studies that might have data available or attainable for investigating secondhand-smoke exposure and its cardiovascular effects, such as was done with the INTERHEART study. Existing studies that could be explored to determine their utility and applicability to questions related to secondhand smoke include the Multi-Ethnic Study of Atherosclerosis (MESA) study, the American Cancer Society’s CPS-3, the European Prospective Investigation of Cancer (EPIC), the Framingham Heart Study, and the Jackson Heart Study. Researchers should clearly articulate the assumptions used in their statistical models and include analysis of the sensitivity of results to model choice and assumptions.

Barone-Adesi, F., L. Vizzini, F. Merletti, and L. Richiardi. 2006. Short-term effects of Italian smoking regulation on rates of hospital admission for acute myocardial infarction. European Heart Journal 27(20):2468-2472.

Bartecchi, C., R. N. Alsever, C. Nevin-Woods, W. M. Thomas, R. O. Estacio, B. B. Bartelson, and M. J. Krantz. 2006. Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation 114(14):1490-1496.

Bhatnagar, A. 2006. Environmental cardiology: Studying mechanistic links between pollution and heart disease. Circulation Research 99(7):692-705.

CDC (Centers for Disease Control and Prevention). 2009. Reduced hospitalizations for acute myocardial infarction after implementation of a smoke-free ordinance—city of Pueblo, Colorado, 2002–2006. MMWR—Morbidity & Mortality Weekly Report 57(51):1373-1377.

Cesaroni, G., F. Forastiere, N. Agabiti, P. Valente, P. Zuccaro, and C. A. Perucci. 2008. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 117(9):1183-1188.

Ellerbeck, E. F., S. F. Jencks, M. J. Radford, T. F. Kresowik, A. S. Craig, J. A. Gold, H. M. Krumholz, and R. A. Vogel. 1995. Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the cooperative cardiovascular project. JAMA 273(19):1509-1514.

Hamill, P. V. 1997. Re: “Invited commentary: Response to Science article, ‘Epidemiology faces its limits.’” American Journal of Epidemiology 146(6):527-528.

He, J., S. Vupputuri, K. Allen, M. R. Prerost, J. Hughes, and P. K. Whelton. 1999. Passive smoking and the risk of coronary heart disease--a meta-analysis of epidemiologic studies. New England Journal of Medicine 340(12):920-926.

HEI (Health Effects Institute) Accountability Working Group. 2003. Assessing the health impact of air quality regulations: Concepts and methods for accountability research. Communication 11. Boston, MA: Health Effects Institute.

HHS (U.S. Department of Health and Human Services). 2006. The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Hill, A. B. 1965. The environment and disease: Association or causation? Proceedings of the Royal Society of Medicine 58:295-300.

Juster, H. R., B. R. Loomis, T. M. Hinman, M. C. Farrelly, A. Hyland, U. E. Bauer, and G. S. Birkhead. 2007. Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban. American Journal of Public Health 97(11):2035-2039.

Khuder, S. A., S. Milz, T. Jordan, J. Price, K. Silvestri, and P. Butler. 2007. The impact of a smoking ban on hospital admissions for coronary heart disease. Preventive Medicine 45(1):3-8.

Lemstra, M., C. Neudorf, and J. Opondo. 2008. Implications of a public smoking ban. Canadian Journal of Public Health 99(1):62-65.

Mills, N. L., H. Tornqvist, M. C. Gonzalez, E. Vink, S. D. Robinson, S. Soderberg, N. A. Boon, K. Donaldson, T. Sandstrom, A. Blomberg, and D. E. Newby. 2007. Ischemic and thrombotic effects of dilute diesel-exhaust inhalation in men with coronary heart disease. New England Journal of Medicine 357(11):1075-1082.

Morrow, D. A., E. M. Antman, L. Parsons, J. A. de Lemos, C. P. Cannon, R. P. Giugliano, C. H. McCabe, H. V. Barron, and E. Braunwald. 2001. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. JAMA 286(11):1356-1359.

Pell, J. P., S. Haw, S. Cobbe, D. E. Newby, A. C. H. Pell, C. Fischbacher, A. McConnachie, S. Pringle, D. Murdoch, F. Dunn, K. Oldroyd, P. Macintyre, B. O’Rourke, and W. Borland. 2008. Smoke-free legislation and hospitalizations for acute coronary syndrome. New England Journal of Medicine 359(5):482-491.

Rogers, W. J., L. J. Bowlby, N. C. Chandra, W. J. French, J. M. Gore, C. T. Lambrew, R. M. Rubison, A. J. Tiefenbrunn, and W. D. Weaver. 1994. Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction. Circulation 90(4):2103-2114.

Sargent, R. P., R. M. Shepard, and S. A. Glantz. 2004. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: Before and after study. BMJ 328(7446):977-980.

Seo, D.-C., and M. R. Torabi. 2007. Reduced admissions for acute myocardial infarction associated with a public smoking ban: Matched controlled study. Journal of Drug Education 37(3):217-226.

Stranges, S., M. Cummings, F. P. Cappuccio, and M. Travisan. 2007. Secondhand smoke exposure and cardiovascular disease. Current Cardiovascular Risk Reports 1(5):373-378.

Teo, K. K., S. Ounpuu, S. Hawken, M. R. Pandey, V. Valentin, D. Hunt, R. Diaz, W. Rashed, R. Freeman, L. Jiang, X. Zhang, S. Yusuf, and I. S. Investigators. 2006. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: A case-control study. Lancet 368(9536):647-658.

U.S. Public Health Service. 1964. Smoking and health: Report of the Advisory Committee of the Surgeon General of the Public Health Service . PHS Publication No. 1103. Washington, DC.

Vasselli, S., P. Papini, D. Gaelone, L. Spizzichino, E. De Campora, R. Gnavi, C. Saitto, N. Binkin, and G. Laurendi. 2008. Reduction incidence of myocardial infarction associated with a national legislative ban on smoking. Minerva Cardioangiologica 56(2):197-203.

Whincup, P. H., J. A. Gilg, J. R. Emberson, M. J. Jarvis, C. Feyerabend, A. Bryant, M. Walker, and D. G. Cook. 2004. Passive smoking and risk of coronary heart disease and stroke: Prospective study with cotinine measurement. BMJ 329(7459):200-205.

Data suggest that exposure to secondhand smoke can result in heart disease in nonsmoking adults. Recently, progress has been made in reducing involuntary exposure to secondhand smoke through legislation banning smoking in workplaces, restaurants, and other public places. The effect of legislation to ban smoking and its effects on the cardiovascular health of nonsmoking adults, however, remains a question.

Secondhand Smoke Exposure and Cardiovascular Effects reviews available scientific literature to assess the relationship between secondhand smoke exposure and acute coronary events. The authors, experts in secondhand smoke exposure and toxicology, clinical cardiology, epidemiology, and statistics, find that there is about a 25 to 30 percent increase in the risk of coronary heart disease from exposure to secondhand smoke. Their findings agree with the 2006 Surgeon General's Report conclusion that there are increased risks of coronary heart disease morbidity and mortality among men and women exposed to secondhand smoke. However, the authors note that the evidence for determining the magnitude of the relationship between chronic secondhand smoke exposure and coronary heart disease is not very strong.

Public health professionals will rely upon Secondhand Smoke Exposure and Cardiovascular Effects for its survey of critical epidemiological studies on the effects of smoking bans and evidence of links between secondhand smoke exposure and cardiovascular events, as well as its findings and recommendations.

READ FREE ONLINE

Welcome to OpenBook!

You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

Do you want to take a quick tour of the OpenBook's features?

Show this book's table of contents , where you can jump to any chapter by name.

...or use these buttons to go back to the previous chapter or skip to the next one.

Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

Switch between the Original Pages , where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

To search the entire text of this book, type in your search term here and press Enter .

Share a link to this book page on your preferred social network or via email.

View our suggested citation for this chapter.

Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

Get Email Updates

Do you enjoy reading reports from the Academies online for free ? Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're released.

Tobacco, Nicotine, and E-Cigarettes Research Report How can we prevent tobacco use?

The medical consequences of tobacco use—including secondhand exposure—make tobacco control and smoking prevention crucial parts of any public health strategy. Since the first Surgeon General’s Report on Smoking and Health in 1964, states and communities have made efforts to reduce initiation of smoking, decrease exposure to smoke, and increase cessation. Researchers estimate that these tobacco control efforts are associated with averting an estimated 8 million premature deaths and extending the average life expectancy of men by 2.3 years and of women by 1.6 years. 18 But there is a long way yet to go: roughly 5.6 million adolescents under age 18 are expected to die prematurely as a result of an illness related to smoking. 13

Prevention can take the form of policy-level measures, such as increased taxation of tobacco products; stricter laws (and enforcement of laws) regulating who can purchase tobacco products; how and where they can be purchased; where and when they can be used (i.e., smoke-free policies in restaurants, bars, and other public places); and restrictions on advertising and mandatory health warnings on packages. Over 100 studies have shown that higher taxes on cigarettes, for example, produce significant reductions in smoking, especially among youth and lower-income individuals. 217  Smoke-free workplace laws and restrictions on advertising have also shown benefits. 218

Prevention can also take place at the school or community level. Merely educating potential smokers about the health risks has not proven effective. 218 Successful evidence-based interventions aim to reduce or delay initiation of smoking, alcohol use, and illicit drug use, and otherwise improve outcomes for children and teens by reducing or mitigating modifiable risk factors and bolstering protective factors. Risk factors for smoking include having family members or peers who smoke, being in a lower socioeconomic status, living in a neighborhood with high density of tobacco outlets, not participating in team sports, being exposed to smoking in movies, and being sensation-seeking. 219 Although older teens are more likely to smoke than younger teens, the earlier a person starts smoking or using any addictive substance, the more likely they are to develop an addiction. Males are also more likely to take up smoking in adolescence than females.

Some evidence-based interventions show lasting effects on reducing smoking initiation. For instance, communities utilizing the intervention-delivery system, Communities that Care (CTC) for students aged 10 to14 show sustained reduction in male cigarette initiation up to 9 years after the end of the intervention. 220

Smoking and Tobacco Use

Check-out New People and Stories

State Tobacco-Related Disparities

Electronic Cigarettes

Menthol and Cigarettes

Learn the mission, vision, goals, organization, and other information about this office.

Links to the Tips ® Campaign, benefits of quitting, and cessation materials for state tobacco control programs.

Information on the dangers of tobacco use, including its health effects and details on secondhand smoke and smokeless products.

Patterns, prevention, and treatment of tobacco use among population groups in the United States.

There is no safe level of exposure to secondhand smoke.

Tobacco-related reports from Surgeon Generals, as well as related materials.

Data and other information from various sources, such as CDC surveillance systems, journal articles, and reports.

Information and resources to help ensure patients have the right tools to quit smoking.

Information and resources related to tobacco control programs.

Resources and the GTSSData, a data-driven site using four surveys conducted worldwide.

Exit Notification / Disclaimer Policy

• The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
• Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
• You will be subject to the destination website's privacy policy when you follow the link.
• CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

• Paper writing help
• Buy an Essay
• Pay for essay
• Buy Research Paper
• Write My Research Paper
• Research Paper Help
• Custom Research Paper
• Custom Dissertation
• Dissertation Help
• Buy Dissertation
• Dissertation Writer
• Write my Dissertation
• How it works

How To Write A Smoking Essay That Will Blow Your Classmates out of the Water

A smoking essay might not be your first choice, but it is a common enough topic, whether it is assigned by a professor or left to your choice. Today we’ll take you through the paces of creating a compelling piece, share fresh ideas for writing teen smoking essays, and tackle the specifics of the essential parts of any paper, including an introduction and a conclusion.

Why Choose a Smoking Essay?

If you are free to select any topic, why would you open this can of worms? There are several compelling arguments in favor, such as:

• A smoking essay can fit any type of writing assignment. You can craft an argumentative essay about smoking, a persuasive piece, or even a narration about someone’s struggle with quitting. It’s a rare case of a one-size-fits-all topic.
• There is an endless number of  environmental essay topics ideas . From the reasons and history of smoking to health and economic impact, as well as psychological and physiological factors that make quitting so challenging.
• A staggering number of reliable sources are available online. You won’t have to dig deep to find medical or economic research, there are thousands of papers published in peer-reviewed journals, ready and waiting for you to use them. 

Essential Considerations for Your Essay on Smoking

Whether you are writing a teenage smoking essay or a study of health-related issues, you need to stay objective and avoid including any judgment into your assignment. Even if you are firmly against smoking, do not let emotions direct your writing. You should also keep your language tolerant and free of offensive remarks or generalizations.

The rule of thumb is to keep your piece academic. It is an essay about smoking cigarettes you have to submit to your professor, not a blog post to share with friends.

How to Generate Endless Smoking Essay Topic Ideas

At first, it might seem that every theme has been covered by countless generations of your predecessors. However, there are ways to add a new spin to the dullest of topics. We’ll share a unique approach to generating new ideas and take the teenage smoking essay as an example. To make it fresh and exciting, you can:

• Add a historic twist to your topic. For instance, research the teenage smoking statistics through the years and theorize the factors that influence the numbers.
• Compare the data across the globe. You can select the best scale for your paper, comparing smoking rates in the neighboring cities, states, or countries.
• Look at the question from an unexpected perspective. For instance, research how the adoption of social media influenced smoking or whether music preferences can be related to this habit.

The latter approach on our list will generate endless ideas for writing teen smoking essays. Select the one that fits your interests or is the easiest to research, depending on the time and effort you are willing to put into essay writing .

How To Write An Essay About Smoking Cigarettes

A smoking essay follows the same rules as an academic paper on any other topic. You start with an introduction, fill the body paragraphs with individual points, and wrap up using a conclusion. The filling of your “essay sandwich” will depend on the topic, but we can tell for sure what your opening and closing paragraphs should be like.

Smoking Essay Introduction

Whether you are working on an argumentative essay about smoking or a persuasive paper, your introduction is nothing but a vessel for a thesis statement. It is the core of your essay, and its absence is the first strike against you. Properly constructed thesis sums up your point of view on the economic research topics and lists the critical points you are about to highlight. If you allude to the opposing views in your thesis statement, the professor is sure to add extra points to your grade.

The first sentence is crucial for your essay, as it sets the tone and makes the first impression. Make it surprising, exciting, powerful with facts, statistics, or vivid images, and it will become a hook to lure the reader in deeper. 

Round up the introduction with a transition to your first body passage and the point it will make. Otherwise, your essay might seem disjointed and patchy. Alternatively, you can use the first couple of sentences of the body paragraph as a transition.

Smoking Essay Conclusion

Any argumentative and persuasive essay on smoking must include a short conclusion. In the final passage, return to your thesis statement and repeat it in other words, highlighting the points you have made throughout the body paragraphs. You can also add final thoughts or even a personal opinion at the end to round up your assignment.

Think of the conclusion as a mirror reflection of your introduction. Start with a transition from the last body paragraph, follow it with a retelling of your thesis statement, and complete the passage with a powerful parting thought that will stay with the reader. After all, everyone remembers the first and last points most vividly, and your opening and closing sentences are likely to have a significant influence on the final grade.

Bonus Tips on How to Write a Persuasive Essay About Smoking

With the most challenging parts of the smoking essay out of the way, here are a couple of parting tips to ensure your paper gets the highest grade possible:

• Do not rely on samples you find online to guide your writing. You can never tell what grade a random essay about smoking cigarettes received. Unless you use winning submissions from essay competitions, you might copy faulty techniques and data into your paper and get a reduced grade.
• Do not forget to include references after the conclusion and cite the sources throughout the paper. Otherwise, you might get accused of academic dishonesty and ruin your academic record. Ask your professor about the appropriate citation style if you are not sure whether you should use APA, MLA, or Chicago.
• Do not submit your smoking essay without editing and proofreading first. The best thing you can do is leave the piece alone for a day or two and come back to it with fresh eyes and mind to check for redundancies, illogical argumentation, and irrelevant examples. Professional editing software, such as Grammarly, will help with most typos and glaring errors. Still, it is up to you to go through the paper a couple of times before submission to ensure it is as close to perfection as it can get.
• Do not be shy about getting help with writing smoking essays if you are out of time. Professional writers can take over any step of the writing process, from generating ideas to the final round of proofreading. Contact our agents or skip straight to the order form if you need our help to complete this assignment.

We hope our advice and ideas for writing teen smoking essays help you get out of the slump and produce a flawless piece of writing worthy of an A. For extra assistance with choosing the topic, outlining, writing, and editing, reach out to our support managers .

235 Smoking Essay Topics & Examples

Looking for smoking essay topics? Being one of the most serious psychological and social issues, smoking is definitely worth writing about.

🏆 Best Smoking Essay Examples & Topic Ideas

🥇 good titles for smoking essay, 👍 best titles for research paper about smoking, ⭐ simple & easy health essay titles, 💡 interesting topics to write about health, ❓ essay questions about smoking.

In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we’ve gathered a range of catchy titles for research papers about smoking together with smoking essay examples. Get inspired with us!

Smoking is a well-known source of harm yet popular regardless, and so smoking essays should cover various aspects of the topic to identify the reasons behind the trend.

You will want to discuss the causes and effects of smoking and how they contributed to the persistent refusal of large parts of the population to abandon the habit, even if they are aware of the dangers of cigarettes. You should provide examples of how one may become addicted to tobacco and give the rationales for smokers.

You should also discuss the various consequences of cigarette use, such as lung cancer, and identify their relationship with the habit. By discussing both sides of the issue, you will be able to write an excellent essay.

Reasons why one may begin smoking, are among the most prominent smoking essay topics. It is not easy to begin to enjoy the habit, as the act of smoke inhalation can be difficult to control due to a lack of experience and unfamiliarity with the concept.

As such, people have to be convinced that the habit deserves consideration by various ideas or influences. The notion that “smoking is cool” among teenagers can contribute to the adoption of the trait, as can peer pressure.

If you can find polls and statistics on the primary factors that lead people to tweet, they will be helpful to your point. Factual data will identify the importance of each cause clearly, although you should be careful about bias.

The harmful effects of tobacco have been researched considerably more, with a large body of medical studies investigating the issue available to anyone.

Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

• Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
• Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
• Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

• Conclusion of Smoking Should Be Banned on College Campuses Essay However, it is hard to impose such a ban in some colleges because of the mixed reactions that are held by different stakeholders about the issue of smoking, and the existing campus policies which give […]
• Should Smoking Be Banned in Public Places? Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment.
• Smoking: Problems and Solutions To solve the problem, I would impose laws that restrict adults from smoking in the presence of children. In recognition of the problems that tobacco causes in the country, The Canadian government has taken steps […]
• How Smoking Is Harmful to Your Health The primary purpose of the present speech is to inform the audience about the detrimental effects of smoking. The first system of the human body that suffers from cigarettes is the cardiovascular system.
• Smoking Cigarette Should Be Banned Ban on tobacco smoking has resulted to a decline in the number of smokers as the world is sensitized on the consequences incurred on 31st May.
• Causes and Effects of Smoking Some people continue smoking as a result of the psychological addiction that is associated with nicotine that is present in cigarettes.
• Smoking: Effects, Reasons and Solutions This presentation provides harmful health effects of smoking, reasons for smoking, and solutions to smoking. Combination therapy that engages the drug Zyban, the concurrent using of NRT and counseling of smokers under smoking cessation program […]
• Advertisements on the Effect of Smoking Do not Smoke” the campaign was meant to discourage the act of smoking among the youngsters, and to encourage them to think beyond and see the repercussions of smoking.
• On Why One Should Stop Smoking Thesis and preview: today I am privileged to have your audience and I intend to talk to you about the effects of smoking, and also I propose to give a talk on how to solve […]
• Smoking and Its Negative Effects on Human Beings Therefore, people need to be made aware of dental and other health problems they are likely to experience as a result of smoking.
• “Thank You For Smoking” by Jason Reitman Film Analysis Despite the fact that by the end of the film the character changes his job, his nature remains the same: he believes himself to be born to talk and convince people.
• Summary of “Smokers Get a Raw Deal” by Stanley Scott Lafayette explains that people who make laws and influence other people to exercise these laws are obviously at the top of the ladder and should be able to understand the difference between the harm sugar […]
• Smoking Cessation Programs Through the Wheel of Community Organizing The first step of the wheel is to listen to the community’s members and trying to understand their needs. After the organizer and the person receiving treatment make the connection, they need to understand how […]
• Teenage Smoking and Solution to This Problem Overall, the attempts made by anti-smoking campaigners hardly yield any results, because they mostly focus on harmfulness of tobacco smoking and the publics’ awareness of the problem, itself, but they do not eradicate the underlying […]
• Hookah Smoking and Its Risks The third component of a hookah is the hose. This is located at the bottom of the hookah and acts as a base.
• Introducing Smoking Cessation Program: 5 A’s Intervention Plan The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program.
• Tobacco Debates in “Thank You for Smoking” The advantage of Nick’s strategy is that it offers the consumer a role model to follow: if smoking is considered to be ‘cool’, more people, especially young ones, will try to become ‘cool’ using cigarettes.
• Causes and Effects of Smoking in Public The research has further indicated that the carcinogens are in higher concentrations in the second hand smoke rather than in the mainstream smoke which makes it more harmful for people to smoke publicly.
• Aspects of Anti-Smoking Advertising Thus, it is safe to say that the authors’ main and intended audience is the creators of anti-smoking public health advertisements.
• Smoking Qualitative Research: Critical Analysis Qualitative research allows researchers to explore a wide array of dimensions of the social world, including the texture and weave of everyday life, the understandings, experiences and imaginings of our research participants, the way that […]
• Smoking Among Teenagers as Highlighted in Articles The use of tobacco through smoking is a trend among adolescents and teenagers with the number of young people who involve themselves in smoking is growing each day.
• The Change of my Smoking Behavior With the above understanding of my social class and peer friends, I was able to create a plan to avoid them in the instances that they were smoking.
• Ban Smoking in Cars Out of this need, several regulations have been put in place to ensure children’s safety in vehicles is guaranteed; thus, protection from second-hand smoke is an obvious measure that is directed towards the overall safety […]
• Smoking and Its Effect on the Brain Since the output of the brain is behavior and thoughts, dysfunction of the brain may result in highly complex behavioral symptoms. The work of neurons is to transmit information and coordinate messengers in the brain […]
• Smoking Cessation and Health Promotion Plan Patients addicted to tobacco are one of the major concerns of up-to-date medicine as constant nicotine intake leads to various disorders and worsens the health state and life quality of the users.
• Smoking Culture in Society Smoking culture refers to the practice of smoking tobacco by people in the society for the sheer satisfaction and delight it offers.
• Health Promotion for Smokers The purpose of this paper is to show the negative health complications that stem from tobacco use, more specifically coronary heart disease, and how the health belief model can help healthcare professionals emphasize the importance […]
• Gender-Based Assessment of Cigarette Smoking Harm Thus, the following hypothesis is tested: Women are more likely than men to believe that smoking is more harmful to health.
• Hazards of Smoking and Benefits of Cessation Prabhat Jha is the author of the article “The Hazards of Smoking and the Benefits of Cessation,” published in a not-for-profit scientific journal, eLife, in 2020.
• The Impact of Warning Labels on Cigarette Smoking The regulations requiring tobacco companies to include warning labels are founded on the need to reduce nicotine intake, limit cigarette dependence, and mitigate the adverse effects associated with addiction to smoking.
• Psilocybin as a Smoking Addiction Remedy Additionally, the biotech company hopes to seek approval from FDA for psilocybin-based therapy treatment as a cigarette smoking addiction long-term remedy.
• Tobacco Smoking: The Health Outcomes Tobacco smoke passing through the upper respiratory tract irritates the membrane of the nasopharynx, and other organism parts, generating copious separation of mucus and saliva.
• Investing Savings from Quitting Smoking: A Financial Analysis The progression of interest is approximately $50 per year, and if we assume n equal to 45 using the formula of the first n-terms of the arithmetic progression, then it comes out to about 105 […]
• Smoking as a Community Issue: The Influence of Smoking A review of the literature shows the use of tobacco declined between 1980 and 2012, but the number of people using tobacco in the world is increasing because of the rise in the global population.
• Smoking Public Education Campaign Assessment The major influence of the real cost campaign was to prevent the initiation of smoking among the youth and prevent the prevalence of lifelong smokers.
• Smoking Cessation Therapy: Effectiveness of Electronic Cigarettes Based on the practical experiments, the changes in the patients’ vascular health using nicotine and electronic cigarettes are improved within one-month time period. The usage only of electronic cigarettes is efficient compared to when people […]
• Quitting Smoking and Related Health Benefits The regeneration of the lungs will begin: the process will touch the cells called acini, from which the mucous membrane is built. Therefore, quitting the habit of smoking a person can radically change his life […]
• Smoking and Stress Among Veterans The topic is significant to explore because of the misconception that smoking can alleviate the emotional burden of stress and anxiety when in reality, it has an exacerbating effect on emotional stress.
• Smoking as a Predictor of Underachievement By comparing two groups smoking and non-smoking adolescents through a parametric t-test, it is possible to examine this assumption and draw conclusions based on the resulting p-value.
• Smoking and the Pandemic in West Virginia In this case, the use of the income variable is an additional facet of the hypothesis described, allowing us to evaluate whether there is any divergence in trends between the rich and the poor.
• Anti-Smoking Policy in Australia and the US The anti-smoking policy is to discourage people from smoking through various means and promotion of a healthy lifestyle, as well as to prevent the spread of the desire to smoke.
• Smoking Prevalence in Bankstown, Australia The secondary objective of the project was to gather and analyze a sufficient amount of auxiliary scholarly sources on smoking cessation initiatives and smoking prevalence in Australia.
• Drug Addiction in Teenagers: Smoking and Other Lifestyles In the first part of this assignment, the health problem of drug addiction was considered among teens and the most vulnerable group was established.
• Anti-Smoking Communication Campaign’s Analysis Defining the target audience for an anti-smoking campaign is complicated by the different layers of adherence to the issue of the general audience of young adults.
• Smoking as a Risk Factor for Lung Cancer Lung cancer is one of the most frequent types of the condition, and with the low recovery rates. If the problem is detected early and the malignant cells are contained to a small region, surgery […]
• Smoking Cessation Project Implementation In addition, the review will include the strengths and weaknesses of the evidence presented in the literature while identifying gaps and limitations.
• Maternal and Infant Health: Smoking Prevention Strategies It is known that many women know the dangers of smoking when pregnant and they always try to quit smoking to protect the lives of themselves and the child.
• A Peer Intervention Program to Reduce Smoking Rates Among LGBTQ Therefore, the presumed results of the project are its introduction into the health care system, which will promote a healthy lifestyle and diminish the level of smoking among LGBTQ people in the SESLHD.
• Tackling Teenage Smoking in Community The study of the problem should be comprehensive and should not be limited by the medical aspect of the issue. The study of the psychological factor is aimed at identifying the behavioral characteristics of smoking […]
• Peer Pressure and Smoking Influence on Teenagers The study results indicate that teenagers understand the health and social implications of smoking, but peer pressure contributes to the activity’s uptake.
• Smoking: Benefits or Harms? Hundreds of smokers every day are looking for a way to get rid of the noose, which is a yoke around the neck, a cigarette.
• The Culture of Smoking Changed in Poland In the 1980-90s, Poland faced the challenge of being a country with the highest rates of smoking, associated lung cancer, and premature mortality in the world.
• The Stop Smoking Movement Analysis The paper discusses the ideology, objective, characteristics, context, special techniques, organization culture, target audience, media strategies, audience reaction, counter-propaganda and the effectiveness of the “Stop Smoking” Movement.”The Stop Smoking” campaign is a prevalent example of […]
• Health Promotion Plan: Smokers in Mississippi The main strategies of the training session are to reduce the number of smokers in Mississippi, conduct a training program on the dangers of smoking and work with tobacco producers.
• Smoking Health Problem Assessment The effects of smoking correlate starkly with the symptoms and diseases in the nursing practice, working as evidence of the smoking’s impact on human health.
• Integration of Smoking Cessation Into Daily Nursing Practice Generally, smoking cessation refers to a process structured to help a person to discontinue inhaling smoked substances. It can also be referred to as quitting smoking.
• E-Cigarettes and Smoking Cessation Many people argue that e-cigarettes do not produce secondhand smoke. They believe that the e-fluids contained in such cigarettes produce vapor and not smoke.
• Outdoor Smoking Ban in Public Areas of the Community These statistics have contributed to the widespread efforts to educate the public regarding the need to quit smoking. However, most of the chronic smokers ignore the ramifications of the habit despite the deterioration of their […]
• Nicotine Replacement Therapy for Adult Smokers With a Psychiatric Disorder The qualitative research methodology underlines the issue of the lack of relevant findings in the field of nicotine replacement therapy in people and the necessity of treatment, especially in the early stages of implementation.
• Smoking and Drinking: Age Factor in the US As smoking and drinking behavior were both strongly related to age, it could be the case that the observed relationship is due to the fact that older pupils were more likely to smoke and drink […]
• Poland’s Smoking Culture From Nursing Perspective Per Kinder, the nation’s status as one of Europe’s largest tobacco producers and the overall increase in smoking across the developing nations of Central and Eastern Europe caused its massive tobacco consumption issues.
• Smoking Cessation Clinic Analysis The main aim of this project is to establish a smoking cessation clinic that will guide smoker through the process of quitting smoking.
• Cigarette Smoking Among Teenagers in the Baltimore Community, Maryland The paper uses the Baltimore community in Maryland as the area to focus the event of creating awareness of cigarette smoking among the teens of this community.
• Advocating for Smoking Cessation: Health Professional Role Health professionals can contribute significantly to tobacco control in Australia and the health of the community by providing opportunities for smoking patients to quit smoking.
• Lifestyle Management While Quitting Smoking Realistically, not all of the set goals can be achieved; this is due to laxity in implementing them and the associated difficulty in letting go of the past lifestyle.
• Smoking in the Actuality The current use of aggressive marketing and advertising strategies has continued to support the smoking of e-cigarettes. The study has also indicated that “the use of such e-cigarettes may contribute to the normalization of smoking”.
• Analysis of the Family Smoking Prevention and Tobacco Control Act The law ensures that the FDA has the power to tackle issues of interest to the public such as the use of tobacco by minors.
• “50-Year Trends in Smoking-Related Mortality in the United States” by Thun et al. Thun is affiliated with the American Cancer Society, but his research interests cover several areas. Carter is affiliated with the American Cancer Society, Epidemiology Research Program.
• Pulmonology: Emphysema Caused by Smoking The further development of emphysema in CH can lead to such complications caused by described pathological processes as pneumothorax that is associated with the air surrounding the lungs.
• Smoking and Lung Cancer Among African Americans Primarily, the research paper provides insight on the significance of the issue to the African Americans and the community health nurses.
• Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
• Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
• Nursing Interventions for Smoking Cessation For instance, the authors are able to recognize the need to classify the level of intensity in respect to the intervention that is employed by nurses towards smoking cessation.
• Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
• Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
• Smoking Among the Youth Population Between 12-25 Years I will use the theory to strengthen the group’s beliefs and ideas about smoking. I will inform the group about the relationship between smoking and human health.
• Risks of Smoking Cigarettes Among Preteens Despite the good news that the number of preteen smokers has been significantly reducing since the 1990s, there is still much to be done as the effects of smoking are increasingly building an unhealthy population […]
• Public Health Education: Anti-smoking Project The workshop initiative aimed to achieve the following objectives: To assess the issues related to smoking and tobacco use. To enhance the health advantages of clean air spaces.
• Healthy People Program: Smoking Issue in Wisconsin That is why to respond to the program’s effective realization, it is important to discuss the particular features of the target population in the definite community of Wisconsin; to focus on the community-based response to […]
• Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
• Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
• Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
• Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
• Smoking Cessation Program Evaluation in Dubai The most important program of this campaign is the Quit and Win campaign, which is a unique idea, launched by the DHCC and is in the form of an open contest.
• Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
• Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
• Smoking Cessation for Patients With Cardio Disorders It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis.
• Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
• Drinking, Smoking, and Violence in Queer Community Consequently, the inequality and discrimination against LGBTQ + students in high school harm their mental, emotional, and physical health due to the high level of stress and abuse of various substances that it causes.
• Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
• “Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
• “The Smoking Plant” Project: Artist Statement It is the case when the art is used to pass the important message to the observer. The live cigarette may symbolize the smokers while the plant is used to denote those who do not […]
• Dangers of Smoking While Pregnant In this respect, T-test results show that mean birthweight of baby of the non-smoking mother is 3647 grams, while the birthweight of smoking mother is 3373 grams. Results show that gestation value and smoking habit […]
• The Cultural Differences of the Tobacco Smoking The Middle East culture is connected to the hookah, the Native American cultures use pipes, and the Canadian culture is linked to cigarettes.
• Ban on Smoking in Enclosed Public Places in Scotland The theory of externality explains the benefit or cost incurred by a third party who was not a party to the reasoning behind the benefit or cost. This will also lead to offer of a […]
• How Smoking Cigarettes Effects Your Health Cigarette smoking largely aggravates the condition of the heart and the lung. In addition, the presence of nicotine makes the blood to be sticky and thick leading to damage to the lining of the blood […]
• Alcohol and Smoking Abuse: Negative Physical and Mental Effects The following is a range of effects of heavy alcohol intake as shown by Lacoste, they include: Neuropsychiatric or neurological impairment, cardiovascular, disease, liver disease, and neoplasm that is malevolent.
• Smoking Prohibition: Local Issues, Personal Views This is due to the weakening of blood vessels in the penis. For example, death rate due to smoking is higher in Kentucky than in other parts of the country.
• Smoking During Pregnancy Issues Three things to be learned from the research are the impact of smoking on a woman, possible dangers and complications and the importance of smoking cessation interventions.
• The Smoking Problem: Mortality, Control, and Prevention The article presents smoking as one of the central problems for many countries throughout the world; the most shocking are the figures related to smoking rate among students. Summary: The article is dedicated to the […]
• Tobacco Smoking: Bootleggers and Baptists Legislation or Regulation The issue is based on the fact that tobacco smoking also reduces the quality of life and ruins the body in numerous ways.
• Smoking: Causes and Effects Considering the peculiarities of a habit and of a disease, smoking can be considered as a habit rather than a disease.
• Smoking Behavior Under Clinical Observation The physiological aspect that influences smokers and is perceived as the immediate effect of smoking can be summarized as follows: Within ten seconds of the first inhalation, nicotine, a potent alkaloid, passes into the bloodstream, […]
• Smoking Causes and Plausible Arguments In writing on the cause and effect of smoking we will examine the issue from the point of view of temporal precedence, covariation of the cause and effect and the explanations in regard to no […]
• Smoking and Its Effects on Human Body The investigators explain the effects of smoking on the breath as follows: the rapid pulse rate of smokers decreases the stroke volume during rest since the venous return is not affected and the ventricles lose […]
• Post Smoking Cessation Weight Gain The aim of this paper is to present, in brief, the correlation between smoking cessation and weigh gain from biological and psychological viewpoints.
• Marketing a Smoking Cessation Program In the case of the smoking cessation program, the target group is made up of smokers who can be further subdivided into segments such as heavy, medium, and light smokers.
• Smoking Cessation for Ages 15-30 The Encyclopedia of Surgery defines the term “Smoking Cessation” as an effort to “quit smoking” or “withdrawal from smoking”. I aim to discuss the importance of the issue by highlighting the most recent statistics as […]
• Motivational Interviewing as a Smoking Cessation Intervention for Patients With Cancer The dependent variable is the cessation of smoking in 3 months of the interventions. The study is based on the author’s belief that cessation of smoking influences cancer-treated patients by improving the efficacy of treatment.
• Factors Affecting the Success in Quitting Smoking of Smokers in West Perth, WA Australia Causing a wide array of diseases, health smoking is the second cause of death in the world. In Australia, the problem of smoking is extremely burning due to the high rates of diseases and deaths […]
• Media Effects on Teen Smoking But that is not how an adult human brain works, let alone the young and impressionable minds of teenagers, usually the ads targeted at the youth always play upon elements that are familiar and appealing […]
• “Passive Smoking Greater Health Hazard: Nimhans” by Stephen David The article focuses on analyzing the findings of the study and compares them to the reactions to the ban on public smoking.
• Partnership in Working About Smoking and Tobacco Use The study related to smoking and tobacco use, which is one of the problematic areas in terms of the health of the population.
• Cigar Smoking and Relation to Disease The article “Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease and cancer in Men” by Iribarren et al.is a longitudinal study of cigar smokers and the impact of cigar […]
• Quitting Smoking: Motivation and Brain As these are some of the observed motivations for smoking, quitting smoking is actually very easy in the sense that you just have to set your mind on quitting smoking.
• Health Effects of Tobacco Smoking in Hispanic Men The Health Effects of Tobacco Smoking can be attributed to active tobacco smoking rather than inhalation of tobacco smoke from environment and passive smoking.
• Smoking in Adolescents: A New Threat to the Society Of the newer concerns about the risks of smoking and the increase in its prevalence, the most disturbing is the increase in the incidences of smoking among the adolescents around the world.
• The Importance of Nurses in Smoking-Cessation Programs When a patient is admitted to the hospital, the nursing staff has the best opportunity to assist them in quitting in part because of the inability to smoke in the hospital combined with the educational […]
• Smoking and Youth Culture in Germany The report also assailed the Federal Government for siding the interest of the cigarette industry instead of the health of the citizens.
• New Jersey Legislation on Smoking The advantages and disadvantages of the legislation were discussed in this case because of the complexity of the topic at hand as well as the potential effects of the solution on the sphere of public […]
• Environmental Health: Tabaco Smoking and an Increased Concentration of Carbon Monoxide The small size of the town, which is around 225000 people, is one of the reasons for high statistics in diseases of heart rate.
• Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
• Legislation Reform of Public Smoking Therefore, the benefit of the bill is that the health hazard will be decreased using banning smoking in public parks and beaches.
• Female Smokers Study: Inferential Statistics Article The article “Differential Effects of a Body Image Exposure Session on Smoking Urge between Physically Active and Sedentary Female Smokers” deepens the behavioral mechanisms that correlate urge to smoke, body image, and physical activity among […]
• Smoking Bans: Protecting the Public and the Children of Smokers The purpose of the article is to show why smoking bans aim at protecting the public and the children of smokers.
• Clinical Effects of Cigarette Smoking Smoking is a practice that should be avoided or controlled rigorously since it is a risk factor for diseases such as cancer, affects the health outcomes of direct and passive cigarette users, children, and pregnant […]
• Public Health and Smoking Prevention Smoking among adults over 18 years old is a public health issue that requires intervention due to statistical evidence of its effects over the past decades.
• Smoking in the US: Statistics and Healthcare Costs According to the Centers for Disease Control and Prevention, tobacco smoking is the greatest preventable cause of death in the US.
• Smoking Should Be Banned Internationally The questions refer to the knowledge concerning the consequences of smoking and the opinions on smoking bans. 80 % of respondents agree that smoking is among the leading causes of death and 63, 3 % […]
• Microeconomics: Cigarette Taxes and Public Smoking Ban The problem of passive smoking will be minimized when the number of smokers decreases. It is agreeable that the meager incomes of such families will be used to purchase cigarettes.
• Alcohol and Smoking Impact on Cancer Risk The research question is to determine the quantity of the impact that different levels of alcohol ingestion combined with smoking behavioral patterns make on men and women in terms of the risks of cancer.
• Teenagers Motivated to Smoking While the rest of the factors also matter much in the process of shaping the habit of smoking, it is the necessity to mimic the company members, the leader, or any other authority that defines […]
• Indoor Smoking Restriction Effects at the Workplace Regrettably, they have neglected research on the effect of the legislation on the employees and employers. In this research, the target population will be the employees and employers of various companies.
• Hypnotherapy Session for Smoking Cessation When I reached the age of sixty, I realized that I no longer wanted to be a smoker who was unable to take control of one’s lifestyle.
• Stopping Tobacco Smoking: Lifestyle Management Plan In addition, to set objective goals, I have learned that undertaking my plan with reference to the modifying behaviour is essential for the achievement of the intended goals. The main intention of the plan is […]
• Smoking Epidemiology Among High School Students In this way, with the help of a cross-sectional study, professionals can minimalize the risk of students being afraid to reveal the fact that they smoke. In this way, the number of students who smoke […]
• Social Marketing: The Truth Anti-Smoking Campaign The agreement of November 1998 between 46 states, five territories of the United States, the District of Columbia, and representatives of the tobacco industry gave start to the introduction of the Truth campaign.
• Vancouver Coastal Health Smoking Cessation Program The present paper provides an evaluation of the Vancouver Coastal Health smoking cessation program from the viewpoint of the social cognitive theory and the theory of planned behavior.
• Smoking Experience and Hidden Dangers When my best college friend Jane started smoking, my eyes opened on the complex nature of the problem and on the multiple negative effects of smoking both on the smoker and on the surrounding society.
• South Illinois University’s Smoking Ban Benefits The purpose of this letter is to assess the possible benefits of the plan and provide an analysis of the costs and consequences of the smoking ban introduction.
• Smoking Cessation in Patients With COPD The strategy of assessing these papers to determine their usefulness in EBP should include these characteristics, the overall quality of the findings, and their applicability in a particular situation. The following article is a study […]
• Smoking Bans: Preventive Measures There have been several public smoking bans that have proved to be promising since the issue of smoking prohibits smoking in all public places. This means it is a way of reducing the exposure to […]
• Ban Smoking Near the Child: Issues of Morality The decision to ban smoking near the child on father’s request is one of the demonstrative examples. The father’s appeal to the Supreme Court of California with the requirement to prohibit his ex-wife from smoking […]
• The Smoking Ban: Arguments Comparison The first argument against banning smoking employs the idea that smoking in specially designated areas cannot do harm to the health of non-smokers as the latter are supposed to avoid these areas.
• Smoking Cessation and Patient Education in Nursing Pack-years are the concept that is used to determine the health risks of a smoking patient. The most important step in the management plan is to determine a date when the man should quit smoking.
• Philip Morris Company’s Smoking Prevention Activity Philip Morris admits the existence of scientific proof that smoking leads to lung cancer in addition to other severe illnesses even after years of disputing such findings from health professionals.
• Tobacco Smoking and Its Dangers Sufficient evidence also indicates that smoking is correlated with alcohol use and that it is capable of affecting one’s mental state to the point of heightening the risks of development of disorders.
• Virginia Slims’ Impact on Female Smokers’ Number Considering this, through the investigation of Philip Morris’ mission which it pursued during the launch of the Virginia Slims campaign in 1968-1970 and the main regulatory actions undertaken by the Congress during this period, the […]
• Cigarette Smoking and Parkinson’s Disease Risk Therefore, given the knowledge that cigarette smoking protects against the disease, it is necessary to determine the validity of these observations by finding the precise relationship between nicotine and PD.
• Tuberculosis Statistics Among Cigarette Smokers The proposal outlines the statistical applications of one-way ANOVA, the study participants, the variables, study methods, expected results and biases, and the practical significance of the expected results.
• Smoking Habit, Its Causes and Effects Smoking is one of the factors that are considered the leading causes of several health problems in the current society. Smoking is a habit that may be easy to start, but getting out of this […]
• Smoking Ban and UK’s Beer Industry However, there is an intricate type of relationship between the UK beer sector, the smoking ban, and the authorities that one can only understand by going through the study in detail The history of smoking […]
• Status of Smoking around the World Economic factors and level of education have contributed a lot to the shift of balance in the status of smoking in the world.
• Redwood Associates Company’s Smoking Ethical Issues Although employees are expected to know what morally they are supposed to undertake at their work place, it is the responsibility of the management and generally the Redwood’s hiring authority to give direction to its […]
• Smokers’ Campaign: Finding a Home for Ciggy Butts When carrying out the campaign, it is important to know what the situation on the ground is to be able to address the root cause of the problem facing the population.
• Mobile Applications to Quit Smoking A critical insight that can be gleaned from the said report is that one of the major factors linked to failure is the fact that smokers were unable to quit the habit on their own […]
• Behavior Modification Technique: Smoking Cessation Some of its advantages include: its mode of application is in a way similar to the act of smoking and it has very few side effects.
• Quitting Smoking: Strategies and Consequences Thus, for the world to realize a common positive improvement in population health, people must know the consequences of smoking not only for the smoker but also the society. The first step towards quitting smoking […]
• Effects of Thought Suppression on Smoking Behavior In the article under analysis called I suppress, Therefore I smoke: Effects of Thought Suppression on Smoking Behavior, the authors dedicate their study to the evaluation of human behavior as well as the influence of […]
• Suppressing Smoking Behavior and Its Effects The researchers observed that during the first and the second weeks of the suppressed behavior, the participants successfully managed to reduce their intake of cigarettes.
• Smoking Cessation Methods
• Understanding Advertising: Second-Hand Smoking
• People Should Quit Smoking
• Importance of Quitting Smoking
• Cigarette Smoking in Public Places
• Ban of Tobacco Smoking in Jamaica
• Anti-Smoking Campaign in Canada
• Electronic Cigarettes: Could They Help University Students Give Smoking Up?
• Psychosocial Smoking Rehabilitation
• The Program on Smoking Cessation for Employees
• Tips From Former Smokers (Campaign)
• Combating Smoking: Taxation Policies vs. Education Policies
• The Program to Quit Smoking
• Possible Smoking Policies in Florida
• Smoking Ban in the State of Florida
• Core Functions of Public Health in the Context of Smoking and Heart Disease
• Smoking: Pathophysiological Effects
• Putting Out the Fires: Will Higher Taxes Reduce the Onset of Youth Smoking?
• Smoking Bans in US
• Smoking as Activity Enhancer: Schizophrenia and Gender
• Health Care Costs for Smokers
• Medical Coverage for Smoking Related Diseases
• Exposure to mass media proliferate smoking
• The Realm of reality: Smoking
• Ethical Problem of Smoking
• The Rate of Smoking Among HIV Positive Cases.
• Studying the Government’s Anti-Smoking Measures
• Smoking Should Be Banned In the United States
• Effectiveness of Cognitive Behavioral Theory on Smoking Cessation
• Effectiveness of the Cognitive Behavioral Therapy for Smoking Cessation
• Wayco Company’s Non-smoking Policy
• Adverse Aspects of Smoking
• Negative Impacts of Smoking on Individuals and Society
• Dealing With the Increase in the Number of Smokers Between Ages 17 and 45
• Cannabis Smoking in Canada
• Smoking Ban in the United States of America
• Dangers of Smoking Campaign
• Should Cigarettes Be Banned? Essay
• Smoking Ban in New York
• Smoking and Adolescents
• Trends in Smoking Prevalence by Race/Ethnicity
• Business Ethics: Smoking Issue
• Should Smoking Tobacco Be Classified As an Illegal Drug?
• Where Does the Path to Smoking Addiction Start?
• Public Health Communication: Quit Smoking
• Are Estimated Peer Effects on Smoking Robust?
• Are There Safe Smoking and Tobacco Options?
• What Are the Health Risks of Smoking?
• Does Cigarette Smoking Affect Body Weight?
• Does Cigarette Smuggling Prop Up Smoking Rates?
• What Foods Help You Quit Smoking?
• How Can People Relax Without Smoking?
• Does Education Affect Smoking Behaviors?
• Is Vaping Worse Than Smoking?
• Do Movies Affect Teen Smoking?
• What Is Worse: Drinking or Smoking?
• Does Smoking Affect Breathing Capacity?
• Does Smoking Cause Lung Cancer?
• Does Having More Children Increase the Likelihood of Parental Smoking?
• Does Smoking Cigarettes Relieve Stress?
• Does Time Preference Affect Smoking Behavior?
• How Does Smoking Affect Cardiovascular Endurance?
• How Hypnosis Can Help You Quit Smoking?
• How Does Smoking Affect Brain?
• How Nicotine Affects Your Quit Smoking Victory?
• How Does Secondhand Smoking Affect Us?
• Why Is Smoking Addictive?
• How Smoking Bans Are Bad for Business?
• Why Smoking Should Not Be Permitted in Restaurants?
• Why Public Smoking Should Be Banned?
• Why Has Cigarette Smoking Become So Prominent Within the American Culture?
• What Makes Smoking and Computers Similar?
• Does Smoking Affect Schooling?
• What Effects Can Cigarette Smoking Have on the Respiratory System?
• What Are the Most Prevalent Dangers of Smoking and Drinking?
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2024, February 29). 235 Smoking Essay Topics & Examples. https://ivypanda.com/essays/topic/smoking-essay-examples/

"235 Smoking Essay Topics & Examples." IvyPanda , 29 Feb. 2024, ivypanda.com/essays/topic/smoking-essay-examples/.

IvyPanda . (2024) '235 Smoking Essay Topics & Examples'. 29 February.

IvyPanda . 2024. "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

1. IvyPanda . "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

Bibliography

IvyPanda . "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

• Ban Smoking Research Ideas
• Health Promotion Research Topics
• Public Safety Research Ideas
• Social Norms Essay Ideas
• Drug Abuse Research Topics
• Social Problems Essay Ideas
• Public Relations Titles
• Social Security Paper Topics
• Drugs Titles
• Cannabis Essay Titles
• Global Issues Essay Topics
• Cardiovascular Diseases Titles
• Marijuana Ideas
• NHS Research Ideas
• Hypertension Topics

Essay on Smoking

500 words essay on  smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

Customize your course in 30 seconds

Which class are you in.

• Travelling Essay
• Picnic Essay
• Our Country Essay
• My Parents Essay
• Essay on Favourite Personality
• Essay on Memorable Day of My Life
• Essay on Knowledge is Power
• Essay on Gurpurab
• Essay on My Favourite Season
• Essay on Types of Sports

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Download the App

Persuasive Essay Guide

Persuasive Essay About Smoking

Persuasive Essay About Smoking - Making a Powerful Argument with Examples

People also read

A Comprehensive Guide to Writing an Effective Persuasive Essay

200+ Persuasive Essay Topics to Help You Out

Learn How to Create a Persuasive Essay Outline

30+ Free Persuasive Essay Examples To Get You Started

Read Excellent Examples of Persuasive Essay About Gun Control

How to Write a Persuasive Essay About Covid19 | Examples & Tips

Crafting a Convincing Persuasive Essay About Abortion

Learn to Write Persuasive Essay About Business With Examples and Tips

Check Out 12 Persuasive Essay About Online Education Examples

Are you wondering how to write your next persuasive essay about smoking?

Smoking has been one of the most controversial topics in our society for years. It is associated with many health risks and can be seen as a danger to both individuals and communities.

Writing an effective persuasive essay about smoking can help sway public opinion. It can also encourage people to make healthier choices and stop smoking. 

But where do you begin?

In this blog, we’ll provide some examples to get you started. So read on to get inspired!

• 1. What You Need To Know About Persuasive Essay
• 2. Persuasive Essay Examples About Smoking
• 3. Argumentative Essay About Smoking Examples
• 4. Tips for Writing a Persuasive Essay About Smoking

What You Need To Know About Persuasive Essay

A persuasive essay is a type of writing that aims to convince its readers to take a certain stance or action. It often uses logical arguments and evidence to back up its argument in order to persuade readers.

It also utilizes rhetorical techniques such as ethos, pathos, and logos to make the argument more convincing. In other words, persuasive essays use facts and evidence as well as emotion to make their points.

A persuasive essay about smoking would use these techniques to convince its readers about any point about smoking. Check out an example below:

Simple persuasive essay about smoking

Tough Essay Due? Hire Tough Writers!

Persuasive Essay Examples About Smoking

Smoking is one of the leading causes of preventable death in the world. It leads to adverse health effects, including lung cancer, heart disease, and damage to the respiratory tract. However, the number of people who smoke cigarettes has been on the rise globally.

A lot has been written on topics related to the effects of smoking. Reading essays about it can help you get an idea of what makes a good persuasive essay.

Here are some sample persuasive essays about smoking that you can use as inspiration for your own writing:

Persuasive speech on smoking outline

Persuasive essay about smoking should be banned

Persuasive essay about smoking pdf

Persuasive essay about smoking cannot relieve stress

Persuasive essay about smoking in public places

Speech about smoking is dangerous

Persuasive Essay About Smoking Introduction

Persuasive Essay About Stop Smoking

Short Persuasive Essay About Smoking

Stop Smoking Persuasive Speech

Check out some more persuasive essay examples on various other topics.

Argumentative Essay About Smoking Examples

An argumentative essay is a type of essay that uses facts and logical arguments to back up a point. It is similar to a persuasive essay but differs in that it utilizes more evidence than emotion.

If you’re looking to write an argumentative essay about smoking, here are some examples to get you started on the arguments of why you should not smoke.

Argumentative essay about smoking pdf

Argumentative essay about smoking in public places

Argumentative essay about smoking introduction

Check out the video below to find useful arguments against smoking:

Tips for Writing a Persuasive Essay About Smoking

You have read some examples of persuasive and argumentative essays about smoking. Now here are some tips that will help you craft a powerful essay on this topic.

Choose a Specific Angle

Select a particular perspective on the issue that you can use to form your argument. When talking about smoking, you can focus on any aspect such as the health risks, economic costs, or environmental impact.

Think about how you want to approach the topic. For instance, you could write about why smoking should be banned. 

Check out the list of persuasive essay topics to help you while you are thinking of an angle to choose!

Research the Facts

Before writing your essay, make sure to research the facts about smoking. This will give you reliable information to use in your arguments and evidence for why people should avoid smoking.

You can find and use credible data and information from reputable sources such as government websites, health organizations, and scientific studies. 

For instance, you should gather facts about health issues and negative effects of tobacco if arguing against smoking. Moreover, you should use and cite sources carefully.

Paper Due? Why Suffer? That's our Job!

Make an Outline

The next step is to create an outline for your essay. This will help you organize your thoughts and make sure that all the points in your essay flow together logically.

Your outline should include the introduction, body paragraphs, and conclusion. This will help ensure that your essay has a clear structure and argument.

Use Persuasive Language

When writing your essay, make sure to use persuasive language such as “it is necessary” or “people must be aware”. This will help you convey your message more effectively and emphasize the importance of your point.

Also, don’t forget to use rhetorical devices such as ethos, pathos, and logos to make your arguments more convincing. That is, you should incorporate emotion, personal experience, and logic into your arguments.

Introduce Opposing Arguments

Another important tip when writing a persuasive essay on smoking is to introduce opposing arguments. It will show that you are aware of the counterarguments and can provide evidence to refute them. This will help you strengthen your argument.

By doing this, your essay will come off as more balanced and objective, making it more convincing.

Finish Strong

Finally, make sure to finish your essay with a powerful conclusion. This will help you leave a lasting impression on your readers and reinforce the main points of your argument. You can end by summarizing the key points or giving some advice to the reader.

A powerful conclusion could either include food for thought or a call to action. So be sure to use persuasive language and make your conclusion strong.

To conclude,

By following these tips, you can write an effective and persuasive essay on smoking. Remember to research the facts, make an outline, and use persuasive language.

However, don't stress if you need expert help to write your essay! Our professional essay writing service is here for you!

Our persuasive essay writing service is fast, affordable, and trustworthy. 

Try it out today!

Write Essay Within 60 Seconds!

Caleb S. has been providing writing services for over five years and has a Masters degree from Oxford University. He is an expert in his craft and takes great pride in helping students achieve their academic goals. Caleb is a dedicated professional who always puts his clients first.

Paper Due? Why Suffer? That’s our Job!

Keep reading

Recommendations

Public comments and nominations, about the uspstf.

• Recommendation Topics
• Recommendation: Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions

Final Recommendation Statement

Tobacco smoking cessation in adults, including pregnant persons: interventions, january 19, 2021.

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Recommendation Summary

Clinician summary.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation.

  Abbreviation: FDA=US Food and Drug Administration.

• View the Clinician Summary in PDF

Additional Information

• Supporting Evidence and Research Taxonomy
• Related Resources & Tools
• Final Evidence Review (January 19, 2021)
• Evidence Summary (January 19, 2021)
• Final Research Plan (July 12, 2018)
• Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: AFP's Putting Prevention Into Practice - Educational Tools
• SmokeFree.Gov Health Professionals Page - For Providers
• Smoking and Tobacco Use: Patient Care (Centers for Disease Control and Prevention) - For Providers
• Intervenciones para promover el abandono del tabaco
• JAMA Patient Page: Interventions to Promote Tobacco Cessation
• JAMA Podcast: Interventions to Promote Tobacco Cessation
• SmokeFreeWomen
• Tips From Former Smokers

Recommendation Information

Full recommendation:.

Tobacco use is the leading preventable cause of disease, disability, and death in the US. In 2014, it was estimated that 480,000 deaths annually are attributed to cigarette smoking, including second hand smoke. 1 Smoking during pregnancy can increase the risk for miscarriage, congenital anomalies, stillbirth, fetal growth restriction, preterm birth, placental abruption, and complications in the offspring, including sudden infant death syndrome and impaired lung function in childhood. 1-4 In 2019 (the most recent data currently available), an estimated 50.6 million US adults (20.8% of the adult population) used tobacco; 14.0% of the US adult population currently smoked cigarettes; and 4.5% of the US adult population used electronic cigarettes (e-cigarettes). 5 According to data from the National Vital Statistics System, in 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy. 6 There are disparities in smoking behaviors associated with certain sociodemographic factors: smoking rates are particularly high in non-Hispanic American Indian/Alaska Native persons; lesbian, gay, or bisexual adults; adults whose highest level of educational attainment is a General Educational Development certificate; persons who are uninsured and those with Medicaid; adults with a disability; and persons with mild, moderate, or severe generalized anxiety symptoms. 5 According to the 2015 National Health Interview Survey, which reported responses from 33,672 adults, 68% of adults who smoked reported that they wanted to stop smoking and 55% attempted quitting in the past year; 7 only 7% reported having recently quit smoking and 31% reported having used cessation counseling, medication, or both when trying to quit. 7

The USPSTF concludes with high certainty that the net benefit of behavioral interventions and US Food and Drug Administration (FDA)–approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial .

The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial .

The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined.

The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient , and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials (RCTs) on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine net benefit, see the USPSTF Procedure Manual. 8

Patient Population Under Consideration

This recommendation applies to adults 18 years or older, including pregnant persons. The USPSTF has issued a separate recommendation statement on primary care interventions for the prevention and cessation of tobacco use in children and adolescents. 9

Definitions

Key definitions related to tobacco use are reported in the Box . Although tobacco use refers broadly to the use of any tobacco product, cigarette smoking has historically been the most prevalent form of tobacco use in the US, and most of the evidence surrounding cessation of tobacco products relates to quitting combustible cigarette smoking. Thus, the current USPSTF recommendations focus on interventions for tobacco smoking cessation. Additionally, although e-cigarettes are considered a tobacco product that should also be the focus of tobacco prevention and cessation efforts, for this recommendation statement, the evidence on e-cigarettes as a potential cessation aid for cigarette smoking was also evaluated.

Assessment of Tobacco Use

All patients should be asked about their tobacco use, whether or not risk factors for use are present, and encouraged to stop using tobacco. When smoking is identified, all patients should be provided interventions to quit smoking. Higher smoking prevalence has been observed in men; persons younger than 65 years; non-Hispanic American Indian/Alaska Native persons; persons who are lesbian, gay, or bisexual; persons whose highest level of educational attainment is a General Educational Development certificate; persons with an annual household income less than $35,000; persons with a disability; and persons with mild, moderate, or severe anxiety symptoms. 5

Common approaches for clinicians to assess patients’ tobacco use include the following.

• The 5 As: (1) Ask about tobacco use; (2) Advise to quit through clear, personalized messages; (3) Assess willingness to quit; (4) Assist in quitting; and (5) Arrange follow-up and support. 12
• “Ask, Advise, Refer,” which encourages clinicians to ask patients about tobacco use, advise them to quit, and refer them to telephone quit lines, other evidence-based cessation interventions, or both. 12
• Vital Sign: Treating smoking status as a vital sign and recording smoking status at every health visit are also frequently used to assess smoking status. 12

Because many pregnant women who smoke do not report it, using multiple choice questions to assess smoking status in this group may improve disclosure. 12

Interventions for Tobacco Cessation and Implementation Considerations

Nonpregnant adults.

Effective tobacco smoking cessation interventions for nonpregnant adults include behavioral counseling and pharmacotherapy, either individually or in combination. 13 , 14

Combined behavioral counseling interventions and pharmacotherapy. Combining behavioral and pharmacotherapy interventions has been shown to increase tobacco smoking cessation rates compared with either usual care/brief cessation interventions alone or pharmacotherapy alone. 13 Most combination interventions include behavioral counseling involving several sessions (≥4), with planned total contact time usually ranging from 90 to 300 minutes. 13 The largest effect was found in interventions that provided 8 or more sessions, although the difference in effect among the number of sessions was not significant. 13

Behavioral counseling interventions. Many behavioral counseling interventions are available to increase tobacco smoking cessation in adults. These interventions can be delivered in the primary care setting or can be referred to community settings with feedback to the primary care clinician. Effective behavioral interventions include physician advice, nurse advice, individual counseling with a cessation specialist, group behavioral interventions, telephone counseling, and mobile phone–based interventions. 13 Behavioral counseling interventions used in studies typically targeted individuals who were motivated to quit tobacco smoking. 13 For additional information about behavioral counseling interventions in nonpregnant adults, see Table 2 .

Pharmacotherapy. The current pharmacotherapy interventions approved by the FDA for the treatment of tobacco smoking dependence in adults are nicotine replacement therapy (NRT) (including nicotine transdermal patches, lozenges, gum, inhalers, or nasal spray), bupropion hydrochloride sustained-release (SR), and varenicline. 46 All 3 types of pharmacotherapy increase tobacco smoking cessation rates. Using a combination of NRT products (in particular, combining short-acting plus long-acting forms of NRT) has been found to be more effective than using a single form of NRT. 13 Based on a smaller number of studies, varenicline appears to be more effective than NRT or bupropion SR. 13 Information on dosing regimens is available in the package inserts of individual medications or in the 2020 Surgeon General Report on Smoking Cessation. 47  

Pregnant Persons

Behavioral counseling interventions. Providing any psychosocial intervention to pregnant persons who smoke tobacco can increase smoking cessation. The behavioral counseling intervention type most often studied in pregnant persons who smoke was counseling. Behavioral interventions were more effective when they provided more intensive counseling, were augmented with messages and self-help materials tailored for pregnant persons, and included messages about the effects of smoking on both maternal and fetal health and strong advice to quit as soon as possible. 12 , 13 Although smoking cessation at any point during pregnancy yields substantial health benefits for the expectant mother and infant, quitting early in pregnancy provides the greatest benefit to the fetus. 12 , 13 Other interventions included feedback, incentives, health education, and social support, although provision of health education alone, without counseling, was not found to be effective. For additional information about behavioral counseling interventions in pregnant persons, see Table 2 .

Additional Resources

Primary care clinicians may find the following resources useful in talking with adults and pregnant persons about tobacco smoking cessation.

• Health care clinician resources for treatment of tobacco use and dependence https://www.cdc.gov/tobaccoHCP
• Tips From Former Smokers https://www.cdc.gov/tobacco/campaign/tips/partners/health/index.html
• SmokeFree.Gov Health Professionals Page https://smokefree.gov/help-others-quit/health-professionals
• SmokeFreeWomen http://women.smokefree.gov/pregnancy-motherhood

In addition, the following resources may be useful to primary care clinicians and practices trying to implement interventions for tobacco smoking cessation.

• Million Hearts tools for clinicians for tobacco cessation https://millionhearts.hhs.gov/tools-protocols/tools/tobacco-use.html
• Centers for Disease Control and Prevention state and community resources for tobacco control programs https://www.cdc.gov/tobacco/stateandcommunity/index.htm
• The US Department of Veterans Affairs (VA) Primary Care & Tobacco Cessation Handbook https://www.mentalhealth.va.gov/quit-tobacco/docs/IB_10-565-Primary-Care-Smoking-Handbook-PROVIDERS-508.pdf
• World Health Organization’s toolkit for delivering brief smoking interventions in primary care http://www.who.int/tobacco/publications/smoking_cessation/9789241506953/en/

In 2020, the Surgeon General issued a Report on Smoking Cessation. 47 The report’s findings were largely similar to that of the USPSTF. The Surgeon General’s report issued some additional findings regarding internet-based interventions for cessation and describes some suggestive but not sufficient evidence about specific e-cigarette use behaviors and increased cessation. Overall, the Surgeon General’s report found that there is inadequate evidence to conclude that e-cigarettes increase smoking cessation. More information on the Surgeon General’s Report on Smoking Cessation is available at https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/#fact-sheets .

Suggestions for Practice Regarding the I Statements

Pharmacotherapy for pregnant persons.

According to data from the National Vital Statistics System, in 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy, 6 and among 1071 pregnant women aged 18 to 44 years, 3.6% reported using e-cigarettes. 48 Smoking during pregnancy reduces fetal growth, increases the risk of preterm birth, and doubles the risk for delivering an infant with low birth weight. It also increases the relative risk for stillbirth death by 25% to 50%. 1 , 2 Quitting smoking early in pregnancy can reduce or eliminate the adverse effects of smoking on fetal growth. 47 For pregnant persons for whom behavioral counseling alone does not work, evidence to support other options to increase smoking cessation during pregnancy are limited. Few clinical trials have evaluated the effectiveness of NRT for smoking cessation in pregnant women. Although most studies were in the direction of benefit, no statistically significant increase in cessation was seen. 13 There is limited evidence on harms of NRT from trials in pregnant persons. Potential adverse maternal events reported in studies of NRT include slightly increased diastolic blood pressure and skin reactions to the patch. 13 Potential adverse events reported in nonpregnant adults include higher rates of low-risk cardiovascular events, such as tachycardia. 13 It has been suggested that NRT may be safer than smoking during pregnancy given that cigarette smoke contains harmful substances in addition to nicotine. The USPSTF identified no studies on bupropion SR or varenicline pharmacotherapy for tobacco smoking cessation during pregnancy.

In the absence of clear evidence on the balance of benefits and harms of pharmacotherapy in pregnant women, clinicians are encouraged to consider the severity of tobacco dependence in each patient and engage in shared decision-making to determine the best individual treatment course.

e-Cigarettes in Nonpregnant Adults and Pregnant Persons

No tobacco product use is risk-free, including the use of e-cigarettes. Tobacco smoking cessation can be difficult for many individuals; thus, having a variety of tools available to help persons quit smoking would potentially be helpful. Findings from small surveys and qualitative data report mixed findings on whether physicians are recommending e-cigarettes to patients to help them quit smoking. 13 , 49-51 Few randomized trials have evaluated the effectiveness of e-cigarettes to increase tobacco smoking cessation in nonpregnant adults, and no trials have evaluated e-cigarettes for tobacco smoking cessation in pregnant persons. 13 Overall, results were mixed on whether smoking cessation increased with e-cigarettes; however, continued e-cigarette use after the intervention phase of trials remained high, indicating continued nicotine dependence. Trial evidence on harms of e-cigarettes used for smoking cessation is also limited. The most commonly reported adverse effects from e-cigarette use reported in trials included coughing, nausea, throat irritation, and sleep disruption. 13 Generally, no significant difference in short-term serious adverse events associated with e-cigarette use was reported. 13 Evidence on potential harms of e-cigarette use in general (whether for tobacco smoking cessation or not) has been reviewed in the National Academies of Science, Engineering, and Medicine report Public Health Consequences of E-Cigarettes. 52 For example, the report found conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances. Additionally, an outbreak of e-cigarette, or vaping product, use–associated lung injury (EVALI) that occurred in the US in late 2019 also suggests potential harms of e-cigarette use. The vast majority of cases have been associated with tetrahydrocannabinol (THC)–containing e-cigarettes. 53

Given the high rates of e-cigarette use in children and adolescents currently in the US, 54 the USPSTF recognizes that an overall public health question remains on whether the potential use of e-cigarettes as a tobacco smoking cessation aid (if ever proven effective) could be balanced with the high rates of e-cigarette use in youth as a driver for increasing overall tobacco use. The USPSTF has issued a separate recommendation statement on the prevention of tobacco use, including e-cigarettes, in children and adolescents. 9 The current USPSTF recommendation statement for adults evaluated the evidence on the benefits and harms of e-cigarettes to increase tobacco cessation; the USPSTF found this evidence to be insufficient. Given the proven effectiveness of behavioral counseling interventions in both nonpregnant and pregnant adults, and of pharmacotherapy in nonpregnant adults, the USPSTF recommends that clinicians focus on offering behavioral counseling and pharmacotherapy to increase smoking cessation in nonpregnant adults, and behavioral counseling to increase smoking cessation in pregnant persons.

Other Related USPSTF Recommendations

In 2020, the USPSTF recommended that primary care clinicians provide interventions, including education or brief counseling, to prevent the initiation of tobacco use (including e-cigarettes) in school-aged children and adolescents. 9 The USPSTF found the evidence on primary care interventions for the cessation of tobacco use in youth to be insufficient.

This recommendation statement replaces the 2015 USPSTF recommendation statement on behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women. 55 The current recommendation statement has been updated to reflect newer evidence and language in the field of tobacco cessation and includes a description of the 2019 EVALI outbreak in the US. However, the recommendations on the services primary care clinicians should provide for tobacco cessation are the same as in 2015.

Scope of Review

The USPSTF commissioned a systematic review to evaluate the benefits and harms of primary care interventions on tobacco use cessation in adults, including pregnant persons. 13 , 14 The USPSTF considered evidence on the benefits and harms of behavioral counseling interventions, pharmacotherapy interventions, and e-cigarettes in nonpregnant adults and pregnant persons. The vast majority of evidence identified focused on cigarette smoking cessation.

Benefits of Tobacco Cessation Interventions

Behavioral counseling interventions. The USPSTF reviewed evidence on the benefits of behavioral counseling interventions on tobacco use cessation in general adults primarily from 20 systematic reviews that covered approximately 830 RCTs and more than 500,000 participants. 13 The evidence almost exclusively evaluated interventions for cessation of cigarette smoking. Physician advice, nurse advice, individual counseling with a cessation specialist, group behavioral interventions, telephone counseling, and mobile phone–based interventions have all been found to be effective to increase cessation of cigarette smoking. 13

Based on a 2013 systematic review that pooled 26 trials (n = 22,239), rates of smoking cessation at 6 months or more were an average of 8.0% in groups that received physician advice compared with 4.8% in groups that received no advice or usual care (risk ratio [RR], 1.76 [95% CI, 1.58-1.96]). 13 , 56 When stratified by intensity level, both minimal advice (defined as a single session lasting <20 minutes with ≤1 follow-up sessions) and intensive advice (defined as a single session lasting ≥20 minutes or >1 follow-up session) from a physician was associated with significantly increased cessation rates compared with no advice. Although not definitive, some subgroup analyses suggest that more intensive physician counseling (>20 minutes for initial consult, use of additional materials, or >1 follow-up visit) may be associated with an increase in cessation rates, particularly in patients who have smoking-related disease. 13 , 56

Based on a 2017 systematic review that pooled 44 trials evaluating nurse advice, 14.2% of participants who received interventions from nurses achieved smoking cessation at 6 months or more compared with 12.2% of those who received usual care or minimal intervention (RR, 1.29 [95% CI, 1.21-1.38]). 13 , 57 No evidence of effect modification was found when comparing higher- or lower-intensity counseling provided by nurses.

A systematic review from 2017 that pooled 33 trials (n = 13,762) found that an average of 11.4% of participants who received individual counseling with a cessation specialist achieved smoking cessation, compared with 7.7% of those who received minimal contact of less than 15 minutes of advice (RR, 1.48 [95% CI, 1.34-1.64]). 13 , 58 The review found some evidence suggesting that more intensive counseling was associated with higher cessation rates. Another systematic review published in 2017 that pooled 13 trials (n = 4395) also found that participants receiving group behavioral interventions had higher cessation rates compared with those who received a self-help program (10.4% cessation rate in intervention group vs 5.8% cessation rate in control group; RR, 1.88 [95% CI, 1.52-2.33]). 13 , 59

A 2019 review on telephone counseling interventions found that proactive telephone counseling (where telephone counselors called participants directly either to initiate counseling or in response to a participant calling a quitline) was associated with increased cessation rates. 13 , 60 If the telephone counseling was a “cold call” from telephone counselors to initiate counseling, smoking cessation rates were 11.0% in control participants and 13.9% in telephone counseling recipients (RR, 1.25 [95% CI, 1.15-1.35]; 65 trials; n = 41,233). 13 , 60 If telephone counseling occurred in response to a participant contacting a quitline, cessation rates were 7.8% in control participants and 10.8% in intervention recipients (RR, 1.38 [95% CI, 1.19-1.61]; 14 trials; n = 32,484). 13 , 60

A 2019 review that pooled 13 trials (n = 14,133) found higher cessation rates associated with mobile phone–based interventions. 13 , 61 All studies primarily used text messaging as the main intervention component, although a limited number of studies looked at individual mobile phone applications. Smoking cessation rates were an average of 5.6% in participants receiving usual or minimal care and 9.5% in those receiving mobile phone–based interventions (RR, 1.54 [95% CI, 1.19-2.00]).

The USPSTF considered evidence on other behavioral counseling interventions such as print-based, nontailored self-help materials, internet-based interventions, motivational interviewing, biofeedback, exercise, acupuncture, and hypnotherapy; 13 however, limited evidence was available on these interventions.

Pharmacotherapy. The USPSTF reviewed evidence from 4 systematic reviews on pharmacotherapy that reported smoking cessation at 6 months or more. 13

A 2018 review on NRT (133 studies; n = 64,640) 62 found that 16.9% of participants taking any form of NRT achieved smoking abstinence at 6 months or more compared with 10.5% of participants receiving placebo or taking no NRT (RR, 1.55 [95% CI, 1.49-1.61]). All forms of NRT (patch, gum, inhaler, intranasal, and tablets) were found to be effective. Another review found that using combination NRT (patch plus a fast-acting form) was associated with higher smoking cessation rates than using a single form of NRT (16.9% vs 13.9%; RR, 1.25 [95% CI, 1.15-1.36]). 63

A 2020 systematic review on the use of antidepressants for smoking cessation (46 studies; n = 17,866) found that bupropion SR was associated with a significantly higher rate of smoking abstinence at 6 months or more than placebo or no bupropion SR (19.0% vs 11.0%; RR, 1.64 [95% CI, 1.52-1.77]). 64

Based on pooled analyses of 27 studies (n = 12,625), a 2016 systematic review found that varenicline was associated with higher rates of smoking cessation over placebo (25.6% vs 11.1%; RR, 2.24 [95% CI, 2.06-2.43]). 65

Smaller subsets of studies from these reviews directly compared types of pharmacotherapy for smoking cessation. Eight studies (n = 6264) compared varenicline and NRT and found that varenicline was associated with a greater smoking cessation rate over any form of NRT.65 Six studies (n = 6286) evaluated varenicline vs bupropion SR and found that varenicline was associated with a higher cessation rate. 64 , 65 Smoking cessation rates among participants using NRT vs bupropion SR at 6 months or more did not significantly differ (10 studies; n = 9230). 64

Combined behavioral counseling interventions and pharmacotherapy. Combinations of behavioral counseling and pharmacotherapy for smoking cessation were also effective, and potentially more effective than behavioral counseling or pharmacotherapy alone. 13 A 2016 systematic review (52 studies; n = 19,488) 66 found that participants who received combination pharmacotherapy and intensive behavioral counseling had a higher abstinence rate at 6 months or more compared with control participants who received usual care, self-help materials, or brief advice on quitting (which was less intensive than the counseling or support given to the intervention groups) (15.2% vs 8.6%; RR, 1.83 [95% CI, 1.68-1.98]). These combination interventions often have behavioral components delivered by specialized smoking cessation counselors or trained staff; however, no difference in effectiveness was seen in studies in which a nonspecialist provided the counseling. 13 Most studies used NRT as the pharmacotherapy. The intensity and format of the behavioral counseling component of the intervention varied greatly, with the majority of studies offering at least 4 behavioral counseling sessions, with a total planned contact time generally ranging from 90 to 300 minutes. Most of the behavioral counseling was delivered by a specialized smoking cessation counselor or trained trial staff.

Another systematic review, 67 which pooled analyses of 65 studies (n = 23,331), found that cessation rates at 6 months or more were modestly higher in participants who received behavioral support as an adjunct to pharmacotherapy than in those who received pharmacotherapy alone. Most studies offered NRT as the pharmacotherapy. Participants in the control group may have also received some counseling or support, but it was less intensive than in the intervention group. The addition of behavioral support to pharmacotherapy was associated with significantly higher cessation rates, approximately 17% in persons using pharmacotherapy alone vs 20% in those using a combination of pharmacotherapy and behavioral support (RR, 1.15 [95% CI, 1.08-1.22]). 13

For benefits of tobacco use cessation interventions in pregnant persons, the USPSTF reviewed evidence from an existing systematic review on behavioral counseling interventions 68 and from primary studies of pharmacotherapy. As with the evidence base in nonpregnant adults, the available evidence primarily addressed smoking cessation.

Behavioral counseling interventions. Based on a systematic review from 2017, 68 the USPSTF found that behavioral counseling interventions in pregnant women were effective at improving rates of smoking cessation as well as some perinatal health outcomes. Pooled analyses from 97 studies (n = 26,637) found that use of any psychosocial intervention was associated with higher smoking cessation rates in late pregnancy relative to control groups (an average quit rate of 12.2% in control groups and 16.4% in intervention groups) (RR, 1.35 [95% CI, 1.23-1.48]). The majority of studies used counseling interventions, and analyses of only counseling interventions (51 studies; n = 18,276) found a significant increase in smoking cessation rates late in pregnancy, from 10.8% in control groups to 14.5% in intervention groups (RR, 1.31 [95% CI, 1.16-1.47]). Studies of other intervention types (health education, feedback, incentives, social support, and exercise) were much fewer, with fewer total participants. Findings of smoking cessation effectiveness by intervention type were all in the direction of benefit, although not all were statistically significant. No subgroup differences by intervention type were found. The same systematic review also assessed the association of behavioral counseling interventions with perinatal outcomes and found lower rates of low birth weight (RR, 0.83 [95% CI, 0.72-0.94]; 18 trials; n = 9402) and increased mean birth weight (mean difference, 55.6 g [95% CI, 29.82-81.38]; 26 trials; n = 11,338). No statistically significant difference in rates of preterm births or stillbirths was found.

Pharmacotherapy. The USPSTF identified 5 placebo-controlled trials on NRT during pregnancy.13 All 5 trials included behavioral counseling or support in addition to NRT. One trial used NRT gum as the intervention, one used an inhaler, while the other 3 trials used a NRT patch. Adherence to NRT in studies was low (<10% in 1 study). Findings of the 5 trials were all generally in the direction of benefit with NRT; however, none of the studies, either individually or when pooled, found a statistically significant difference in smoking cessation (11.9% in NRT intervention groups vs 10.1% in control groups; RR, 1.11 [95% CI, 0.79-1.56]; 5 trials; n = 2033). 13 Seven trials (the 5 placebo-controlled trials previously mentioned plus 2 additional non–placebo-controlled trials) reported on perinatal and health outcomes with NRT during pregnancy; 13 findings were inconsistent and imprecise. No studies on bupropion SR or varenicline for smoking cessation during pregnancy were identified.

The FDA classifies e-cigarettes as a tobacco product and to date, no e-cigarettes have been approved as a smoking cessation aid. Approximately 4.5% of adults 5 , 69 and 3.6% of pregnant women 48 report using e-cigarettes. Higher e-cigarette use is reported among young adults aged 18 to 24 years (7.6%) 70 and has been increasing in recent years. 70 In addition to young adults, e-cigarette use among adults is higher in men; non-Hispanic White adults and other non-Hispanic adults; lesbian, gay, or bisexual 5 persons; and persons with chronic illnesses (such as cardiovascular disease, diabetes, cancer, asthma, chronic obstructive pulmonary disease, chronic kidney disease, and depression). 13 , 71 Most adult e-cigarette users report that quitting smoking and health improvement are major reasons why they started using e-cigarettes. 72 , 73 This is in contrast to youth, where it has been found that e-cigarette use increases risk of ever smoking cigarettes. 52 Nineteen percent of tobacco users use 2 or more tobacco products, the most common combination being cigarettes and e-cigarettes. 74

The USPSTF identified 5 RCTs (n = 3117) on e-cigarettes for smoking cessation in nonpregnant adults 13 , 75-80 and no studies in pregnant persons. 13 All 5 studies were conducted outside of the US (2 in New Zealand, 1 in Italy, 1 in Korea, and 1 in the UK). Four of the studies included participants who either wanted to stop smoking or were attending a stop smoking service. The type of e-cigarette interventions (nicotine content, whether NRT was also given, nicotine cartridge vs e-liquid, and whether behavioral support was also provided) and control interventions (NRT vs nonnicotine e-cigarette) varied across studies, making comparisons difficult. Only 3 of the e-cigarettes used in the studies are currently available in the US. Study size ranged from 150 to 1124 participants.

Reported trial findings were mixed. The 2 largest and most recent trials reported a statistically significant increase in smoking cessation at 6 months; 1 study reported smoking cessation rates of 4% in control groups vs 7% 79 in intervention groups; the second trial reported smoking cessation rates of 25% in control groups vs 35% 78 in intervention groups. The 3 remaining trials reported no statistically significant differences in smoking cessation rates. Three of the studies reported on continued e-cigarette use after achievement of smoking cessation in intervention groups at 6 months to 1 year, with continued e-cigarette use ranging from 38% to 80%. One study reported that 26.9% of all study participants were using e-cigarettes at 1 year. 77

Harms of Tobacco Cessation Interventions

Behavioral counseling interventions. The USPSTF identified limited evidence on harms from behavioral counseling interventions for tobacco cessation. Three systematic reviews (1 on internet-based interventions, another on incentives, and 1 on hypnotherapy) did not find evidence of serious adverse events associated with interventions. 13

Pharmacotherapy. The USPSTF identified 4 systematic reviews on NRT that reported on harms 13 : 3 reviews compared harms of NRT vs placebo 62 , 81 , 82 and 1 compared harms from various types of NRT. 63 Twelve to 21 studies (n = 10,234 to 11,647) reported on cardiovascular harms. Statistically significantly more cardiovascular adverse events (in particular, heart palpitations and chest pain) were found for participants randomized to NRT vs placebo (RR, 1.81 [95% CI, 1.35-2.43]; 21 trials; n = 11,647). 82 However, when analyses focused on major cardiovascular adverse events (combined outcome of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke), findings were no longer statistically significant (RR, 1.38 [95% CI, 0.58-3.26]; 21 trials; n = 11,647). 82 Other reported harms associated with NRT included nausea, vomiting, gastrointestinal symptoms, and insomnia. Localized increased skin irritation at the NRT patch site has also been reported. No statistically significant increase in headaches, dizziness, anxiety, or depression were found. Cardiac adverse events and other serious adverse events did not differ by type of NRT. 63

The USPSTF considered evidence on harms from bupropion SR for tobacco smoking cessation from 4 systematic reviews.13 No difference in serious adverse events (RR, 1.30 [95% CI, 1.00-1.69]; 33 trials; n = 9631), 83 cardiovascular adverse events (RR, 1.03 [95% CI, 0.71-1.50]; 27 trials; n = 10,402), 82 or major cardiovascular events (RR, 0.57 [95% CI, 0.31-1.04]; 27 trials; n = 10,402) 82 were found with bupropion SR (compared with placebo or no bupropion SR). No difference in moderate and severe neuropsychiatric events, including rates of suicidal behavior and ideation, were found with bupropion SR (compared with varenicline or NRT) in the recent Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES) trial. 84 , 85

Evidence on harms of varenicline for tobacco cessation are available from 3 systematic reviews on varenicline in unselected smokers, 4 systematic reviews of varenicline among persons with severe mental illness, and 1 review on varenicline for cessation of smokeless tobacco. 13 Common adverse effects reported with varenicline include nausea, insomnia, abnormal dreams, headache, and fatigue. 13 One review found an increase in serious adverse events with varenicline in unselected smokers (RR, 1.25 [95% CI, 1.04-1.49]; 29 trials; n = 15,370); however, many of these events included comorbidities that were mostly considered by the study authors to be unrelated to the treatments. 65 Across 3 systematic reviews (encompassing 18 to 38 studies; n = 8587 to 12,706), no statistically significant difference in cardiovascular adverse events or cardiovascular severe adverse events was found. 13 Additionally, no statistically significant increase in neuropsychiatric adverse events (including depression, suicidal ideation, and suicide attempt) was found across several systematic reviews. 13

Combinations of behavioral counseling interventions and pharmacotherapy. The USPSTF did not identify any reports of adverse events related to combinations of behavioral counseling interventions and pharmacotherapy. Any harms of combined therapy are assumed to be similar to those of the pharmacotherapy being used.

Behavioral counseling intervention. The primary review that informed the USPSTF on the benefits of behavioral counseling interventions for smoking cessation during pregnancy also summarized evidence on harms of behavioral counseling interventions. 68 Based on analyses of 13 trials (n = 5831), no increase in adverse effects from psychosocial interventions was seen.

Pharmacotherapy. Nicotine in general has been shown in animal studies to cause fetal harms. However, NRT does not contain many harmful substances, such as hydrogen cyanide and carbon monoxide, that are present in cigarette smoke. 86 Evidence on harms of NRT during pregnancy is limited; the USPSTF identified 5 placebo-controlled trials (n = 3117), 2 non–placebo-controlled trials (n = 233), and 3 cohort studies (n = 306,721). 13 Findings on potential harms of NRT on birth outcomes from trial evidence is mixed, although most studies reported findings in the direction of benefit rather than harm. Observational evidence from cohort studies generally did not indicate an increase in stillbirth or low birth weight with NRT. Based on observational evidence, there was no evidence of increased risk of premature delivery, small for gestational age, stillbirth, or congenital anomalies associated with the use of NRT, bupropion, and varenicline vs smoking. According to FDA labeling, some fetal harms with bupropion were noted in animal studies, but currently, no adequate, well-controlled studies of bupropion SR use during pregnancy (for any indication) in humans are available. 87 Labeling for varenicline states that available studies cannot definitively establish or exclude varenicline-associated risk during pregnancy. 88

The USPSTF identified 9 RCTs (n = 3942) that reported on harms of e-cigarette interventions for tobacco smoking cessation in nonpregnant adults 13 (the 5 trials previously described that reported cessation rates at 6 months or more, as well as an additional 4 trials that reported on cessation rates at less than 6 months). No trials on harms of e-cigarettes for smoking cessation in pregnant persons was identified. The most commonly reported adverse effects from e-cigarette use reported in trials include coughing, nausea, throat irritation, and sleep disruption. 13 Generally, no significant difference in short-term serious adverse events associated with e-cigarette use was reported. 13 Data on potential long-term harms of e-cigarette use are currently lacking.

Additional evidence on harms from e-cigarette use (whether used for tobacco cessation or not) considered by the USPSTF included data of the 2019 EVALI outbreak in the US 53 and the 2018 report Public Health Consequences of E-Cigarettes by the National Academies of Sciences, Engineering, and Medicine. 52 In late 2019, an outbreak of EVALI occurred in the US. Symptoms of EVALI include cough, shortness of breath, chest pain, nausea, vomiting, stomach pain, diarrhea, fever, chills, and weight loss. As of February 2020, more than 2800 cases of EVALI were reported, with 68 deaths. 53 Based on testing of bronchoalveolar lavage fluid samples of patients with EVALI 89 and testing of products used by patients with EVALI, 53 vitamin E acetate (an additive in some THC-containing e-cigarettes) was found to be strongly linked to EVALI. 53 However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non–THC–containing products, in some reported EVALI cases. 53

The National Academies of Sciences, Engineering, and Medicine report found that in youth and young adults, there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco and moderate evidence that e-cigarette use increases the frequency and intensity of subsequent cigarette smoking. 52 The report also found conclusive evidence that e-cigarettes contain and emit potentially toxic substances, although substantial evidence shows that other than nicotine, there is significantly lower exposure to potentially toxic substances from e-cigarettes compared with combustible tobacco cigarettes. 52

Response to Comments

A draft version of this recommendation statement was posted for public comment on the USPSTF website from June 2, 2020, to June 29, 2020. Several comments expressed concern about the insufficient evidence statement on e-cigarettes for cessation. Some respondents wanted the USPSTF to recommend against e-cigarettes for tobacco cessation, while others wanted the USPSTF to recommend in favor of e-cigarettes. Based on the evidence reviewed, the USPSTF could not determine whether e-cigarettes are effective in helping persons to quit smoking cigarettes, nor could it determine what the potential long-term harms of e-cigarette use are; thus, it cannot recommend for or against their use. Some comments were also received requesting that the USPSTF recommend NRT for smoking cessation during pregnancy. Too few trials were identified for the USPSTF to determine whether NRT during pregnancy provides overall more benefits or harms, and the USPSTF calls for more research on NRT and other pharmacotherapy to help pregnant persons quit using tobacco. Last, edits to clarify language, as well as additional information from the recent 2020 Surgeon General’s Report on Smoking Cessation, have been provided in response to comments.

How Does Evidence Fit With Biological Understanding?

Because of the well-established health benefits of smoking cessation, 1 , 12 , 47 most of the research on interventions for smoking cessation focuses on cessation (rather than health outcomes) as a primary outcome. The current review identified 1 study 90 of middle-aged men at high risk for cardiorespiratory disease that found lower (although not statistically significant) total mortality, fatal coronary disease, and lung cancer death at 20 years of follow-up in participants who received advice from medical practitioners. 91 The study also found some reduction in all-cause mortality, coronary disease mortality, and lung cancer incidence and mortality at 20 years of follow-up, although these outcomes were not significant. 91

Although not zero, less toxins have been found to be released by e-cigarettes than by cigarettes. It is hypothesized that health outcomes may be improved in adults who completely switch from cigarette smoking to e-cigarette use, although long-term data are not available yet to support this. Evidence on long-term harms of e-cigarette use in general is lacking and is needed. Additionally, emerging evidence suggests that toxicant levels in dual users of e-cigarettes and cigarettes may be higher than in conventional cigarette–only users. 92

The greatest research needs are to gain a better understanding of the effectiveness of e-cigarettes for smoking cessation, as well as potential short- and long-term harms of e-cigarette use, and to understand whether there are effective pharmacotherapy options for pregnant persons.

• Studies must be well-designed RCTs that compare e-cigarette interventions with placebo, as well as established, effective combinations of pharmacotherapy and behavioral support.
• Studies should be adequately powered to detect differences in continued smoking abstinence rates at 6 months or more.
• Given the high rate of continued e-cigarette use after smoking cessation, research on both the short- and long-term harms of e-cigarette use is needed, as well as the harms in dual users of e-cigarettes and conventional cigarettes. More research is needed on smoking relapse rates in adults who have used e-cigarettes for smoking cessation and how to help with cessation of e-cigarette use once smoking abstinence has been achieved.
• Given the rapidly evolving landscape of e-cigarettes, trials should include current generations of e-cigarettes. Additionally, to successfully conduct these types of studies, standardization of how to quantify e-cigarette use and levels of nicotine exposure from e-cigarettes is needed.
• More research is needed to understand the patterns of e-cigarette use in youth and the risk factors for their transition from e-cigarette use to conventional cigarette smoking.
• More research is also needed to better understand patterns of e-cigarette use in pregnant persons and potential harms of e-cigarette use to both pregnant persons and their offspring.
• More research is needed on understanding how to help adults quit e-cigarettes.
• Larger studies adequately powered to detect an effect on both smoking cessation rates (during pregnancy and postpartum) and changes in perinatal and child health outcomes are needed.
• A better understanding of why adherence rates to NRT during pregnancy is so low would also be helpful.

Although the benefits of behavioral counseling interventions and pharmacotherapy in nonpregnant adults and the benefits of behavioral counseling interventions in pregnant adults are well established, additional research on effective components of behavioral counseling and who to target specific interventions to would be informative. More research on newer modalities and remotely delivered interventions (mobile phone apps, internet-based interventions) would also be helpful. Additionally, the effectiveness of interventions for cessation of other forms of tobacco and whether interventions need to be tailored to individual tobacco product types are also needed. Last, more research is needed on interventions to prevent relapse of tobacco use.

Numerous professional societies and health organizations, including the American Academy of Family Physicians, 93 American College of Physicians, 94 and American College of Obstetricians and Gynecologists (ACOG), 95 recommend that clinicians screen for tobacco use and provide interventions to patients who smoke.

For pregnant persons, ACOG recommends brief behavioral counseling and the use of evidence-based smoking cessation aids as effective strategies for achieving smoking cessation, even for very heavy smokers. 96 ACOG also recommends that NRT should be considered only after a detailed discussion with the patient of the known risks of continued smoking, the possible risks of NRT, and need for close supervision. 95

The American Academy of Pediatrics also has a policy statement recommending that pediatricians screen for the tobacco exposure of children during pediatric care visits and recommend nicotine dependence treatment, including behavioral interventions and pharmacotherapy, to tobacco-dependent parents. 97

More recently some organizations have addressed e-cigarette use in their tobacco use guidelines. The American Academy of Family Physicians, 98 the American College of Preventive Medicine, 99 and the American Heart Association 100 recommend that clinicians screen for e-cigarette use. Organizations vary somewhat in terms of whether they recommend e-cigarettes for smoking cessation. ACOG recommends against use of e-cigarettes in pregnant and postpartum individuals. 95 , 101 The American Cancer Society does not recommend e-cigarettes as a smoking cessation method, 102 and the American Heart Association 100 states that there is not enough evidence for clinicians to counsel patients on using e-cigarettes as a primary smoking cessation aid.

The US Preventive Services Task Force members include the following individuals: Alex H. Krist, MD, MPH (Fairfax Family Practice Residency, Fairfax, Virginia, and Virginia Commonwealth University, Richmond); Karina W. Davidson, PhD, MASc (Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York); Carol M. Mangione, MD, MSPH (University of California, Los Angeles); Michael J. Barry, MD (Harvard Medical School, Boston, Massachusetts); Michael Cabana, MD, MA, MPH (University of California, San Francisco); Aaron B. Caughey, MD, PhD (Oregon Health & Science University, Portland); Katrina Donahue, MD, MPH (University of North Carolina at Chapel Hill); Chyke A. Doubeni, MD, MPH (Mayo Clinic, Rochester, MN); John W. Epling Jr, MD, MSEd (Virginia Tech Carilion School of Medicine, Roanoke); Martha Kubik, PhD, RN (George Mason University, Fairfax, Virginia); Seth Landefeld, MD (University of Alabama, Birmingham); Gbenga Ogedegbe, MD, MPH (New York University, New York, New York); Lori Pbert, PhD (University of Massachusetts Medical School, Worcester); Michael Silverstein, MD, MPH (Boston University, Boston, Massachusetts); Melissa A. Simon, MD, MPH (Northwestern University, Evanston, Illinois); Chien-Wen Tseng, MD, MPH, MSEE (University of Hawaii, Honolulu); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Authors followed the policy regarding conflicts of interest described at https://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures . All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. Dr Barry reported receiving grants and personal fees from Healthwise.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Additional Information: The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.

AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.

This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.

1. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Altanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 2. Women and Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2001. 3. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 4. WHO Recommendations for the Prevention and Management of Tobacco Use and Second-Hand Smoke Exposure in Pregnancy. Geneva, Switzerland: World Health Organization; 2013. 5. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco product use among adults—United States, 2019. MMWR Morb Mortal Wkly Rep . 2020;69(46):1736-1742. Medline:33211681 doi:10.15585/mmwr.mm6946a4 6. Drake P, Driscoll AK, Mathews TJ. Cigarette smoking during pregnancy: United States, 2016. NCHS Data Brief. 2018;(305):1-8. Medline:29528282 7. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults - United States, 2000-2015. MMWR Morb Mortal Wkly Rep. 2017;65(52):1457-1464. Medline:28056007 doi:10.15585/mmwr.mm6552a1 8. Procedure Manual. U.S. Preventive Services Task Force. Updated 2017. Accessed November 24, 2020. www.uspreventiveservicestaskforce.org/uspstf/procedure-manual . 9. Owens DK, Davidson KW, Krist AH, et al; US Preventive Services Task Force. Primary care interventions for prevention and cessation of tobacco use in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA . 2020;323(16):1590-1598. Medline:32343336 doi:10.1001/jama.2020.4679 10. US Food and Drug Administration. Products, ingredients & components. Updated May 2020. Accessed November 24, 2020. https://www.fda.gov/tobacco-products/products-guidance-regulations/products-ingredients-components 11. Centers for Disease Control and Prevention. About electronic cigarettes (e-cigarettes). Updated November 16, 2020. Accessed November 24, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html 12. Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, U.S. Public Health Service; 2008. 13. Patnode CD, Henderson JT, Melknikow J, Coppola EL, Durbin S, Thomas R. Interventions for Tobacco Cessation in Adults, Including Pregnant Persons: An Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 196. Rockville, MD: Agency for Healthcare Research and Quality; 2021. AHRQ Publication No. 20-05264-EF-1. 14. Patnode CD, Henderson JT, Melknikow J, Coppola EL, Durbin S, Thomas R. Interventions for tobacco cessation in adults, including pregnant women: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA . Published January 19, 2021. doi:10.1001/jama.2020.23541 15. Morgan GD, Noll EL, Orleans CT, Morgan GD, Noll EL, Orleans CT. Reaching midlife and older smokers: tailored interventions for routine medical care. Prev Med. 1996;25(3):346-354. Medline:8781013 doi:10.1006/pmed.1996.0065 16. Orleans CT, Rimer BK, Fleisher L. Clear Horizons: A Quit Smoking Guide Especially for Those 50 and Over. Fox Chase Cancer Center; 1989. 17. Canga N, De Irala J, Vara E, Duaso MJ, Ferrer A, Martínez-González MA. Intervention study for smoking cessation in diabetic patients: a randomized controlled trial in both clinical and primary care settings. Diabetes Care. 2000;23(10):1455-1460. Medline:11023136 doi:10.2337/diacare.23.10.1455 18. Glynn TJ, Manley MW. How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Washington, DC: U.S. Department of Health and Human Services; 1998. 19. Hurt RD, Dale LC, McClain FL, et al. A comprehensive model for the treatment of nicotine dependence in a medical setting. Med Clin North Am. 1992;76:495-514. Medline:1312657 doi:10.1016/S0025-7125(16)30364-9 20. Weissfeld JL, Holloway JL. Treatment for cigarette smoking in a Department of Veterans Affairs outpatient clinic. Arch Intern Med. 1991;151(5):973-977. Medline:2025147 doi:10.1001/archinte.1991.00400050117022 21. Clearing the Air: How to Quit Smoking and Quit for Keeps. National Cancer Institute; 1987. 22. Fiore MC, McCarthy DE, Jackson TC, et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Prev Med. 2004;38(4):412-420. Medline:15020174 doi:10.1016/j.ypmed.2003.11.002 23. Glasgow RE, Whitlock EP, Eakin EG, Lichtenstein E. A brief smoking cessation intervention for women in low-income planned parenthood clinics. Am J Public Health. 2000;90(5):786-789. Medline:10800431 doi:10.2105/AJPH.90.5.786 24. Bock B, Heron K, Jennings E, et al. A text message delivered smoking cessation intervention: the initial trial of TXT-2-Quit: randomized controlled trial. JMIR Mhealth Uhealth . 2013;1(2):e17. Medline:25098502 doi:10.2196/mhealth.2522 25. Strecher VJ, Rimer BK, Monaco KD. Development of a new self-help guide—Freedom From Smoking for you and your family. Health Educ Q . 1989;16(1):101–112. 2703347 doi:10.1177/109019818901600111 26. Orleans CT, Schoenbach VJ, Wagner EH, et al. Self-help quit smoking interventions: effects of self-help materials, social support instructions, and telephone counseling. J Consult Clin Psychol . 1991;59(3):439-448. Medline:2071729 doi:10.1037/0022-006X.59.3.439 27. A Lifetime of Freedom From Smoking. American Lung Association; 1980. 28. McBride CM, Scholes D, Grothaus LC, Curry SJ, Ludman E, Albright J. Evaluation of a minimal self-help smoking cessation intervention following cervical cancer screening. Prev Med. 1999;29(2):133-138. Medline:10446040 doi:10.1006/pmed.1999.0514 29. Curry SJ, McBride C, Grothaus LC, Louie D, Wagner EH. A randomized trial of self-help materials, personalized feedback, and telephone counseling with nonvolunteer smokers. J Consult Clin Psychol. 1995;63(6):1005-1014. Medline:8543703 doi:10.1037/0022-006X.63.6.1005 30. Ellerbeck EF, Mahnken JD,, Cupertino AP, et al. Effect of varying levels of disease management on smoking cessation: a randomized trial. Ann Intern Med. 2009;150(7):437-446. Medline:19349629 doi:10.7326/0003-4819-150-7-200904070-00003 31. McClure JB, Westbrook E, Curry SJ, Wetter DW. Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk. Nicotine Tob Res. 2005;7(6):881-889. Medline:16298723 doi:10.1080/14622200500266080 32. Rigotti NA, Park ER, Regan S, et al. Efficacy of telephone counseling for pregnant smokers: a randomized controlled trial. Obstet Gynecol. 2006;108(1):83-92. Medline:16816060 doi:10.1097/01.AOG.0000218100.05601.f8 33. Solomon L, Quinn V. Spontaneous quitting: self-initiated smoking cessation in early pregnancy. Nicotine Tob Res . 2004;6(suppl):S203-S216. 34. Windsor R, Woodby L, Miller T, Hardin M. Effectiveness of Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) methods in Medicaid-supported prenatal care: trial III. Health Educ Behav. 2011;38(4):412-422. Medline:21551424 doi:10.1177/1090198110382503 35. Fiore MB, Bailey WC, Cohen S, et al. Smoking Cessation. Clinical Practice Guideline No. 18 . Rockville, MD: Agency for Health Care Policy and Research; 1996. 36. Windsor RA, Cutter G, Morris J, et al. The effectiveness of smoking cessation methods for smokers in public health maternity clinics: a randomized trial. Am J Public Health . 1985;75(12):1389-1392. Medline:4061709 doi:10.2105/AJPH.75.12.1389 37. Windsor R, Lowe JB, Perkins L, et al. Health education for pregnant smokers: its behavioral impact and cost benefit. Am J Public Health. 1993;83:201-206. Medline:4061709 doi:10.2105/AJPH.75.12.1389 38. Windsor R, Crawford M, Woodby L. Commit to Quit Smoking During and After Pregnancy. DVD. Society for Public Health Education: 1998; edited 2004. 39. Windsor R. A Pregnant Woman’s Guide to Quit Smoking.Washington, DC: Society for Public Health Education; 2005. 40. Laine C, Davidoff F. Patient-centered medicine, a professional evolution. JAMA. 1996;275:152-156. Medline:8531314 doi:10.1001/jama.1996.03530260066035 41. Bullock L, Everett KD, Mullen PD, Geden E, Longo DR, Madsen R. Baby BEEP: a randomized controlled trial of nurses' individualized social support for poor rural pregnant smokers. Matern Child Health J. 2009;13(3):395-406. Medline:18496746 doi:10.1007/s10995-008-0363-z 42. Lee M, Miller SM, Wen KY, Hui SK, Roussi P, Hernandez E. Cognitive-behavioral intervention to promote smoking cessation for pregnant and postpartum inner city women. J Behav Med. 2015;38(6):932-943. Medline:26335312 doi:10.1007/s10865-015-9669-7 43. Pollak KI, Lyna P, Bilheimer A, et al. A pilot study testing SMS text delivered scheduled gradual reduction to pregnant smokers. Nicotine Tob Res. 2013;15(10):1773-1776. Medline:23569007 doi:10.1093/ntr/ntt045 44. Stotts AL, Groff JY, Velasquez MM, et al. Ultrasound feedback and motivational interviewing targeting smoking cessation in the second and third trimesters of pregnancy. Nicotine Tob Res. 2009;11(8):961-968. Medline:19553282 doi:10.1093/ntr/ntp095 45. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. Medline:24609605 doi:10.1136/bmj.g1687 46. U.S. Food and Drug Administration. Want to quit smoking? FDA-approved products can help. Updated December 2017. Accessed November 24, 2020. https://www.fda.gov/consumers/consumer-updates/want-quit-smoking-fda-approved-products-can-help 47. Smoking Cessation. A Report of the Surgeon General. Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020. 48. Liu B, Xu G, Rong S, et al. National estimates of e-cigarette use among pregnant and nonpregnant women of reproductive age in the United States, 2014-2017. JAMA Pediatr. 2019;173(6):600-602. Medline:31034001 doi:10.1001/jamapediatrics.2019.0658 49. Kandra KL, Ranney LM, Lee JG, Goldstein AO. Physicians' attitudes and use of e-cigarettes as cessation devices, North Carolina, 2013. PLoS One. 2014;9(7):e103462. Medline:25072466 doi:10.1371/journal.pone.0103462 50. Ofei-Dodoo S, Kellerman R, Nilsen K, Nutting R, Lewis D. Family physicians' perceptions of electronic cigarettes in tobacco use counseling. J Am Board Fam Med. 2017;30(4):448-459. Medline:28720626 doi:10.3122/jabfm.2017.04.170084 51. Nickels AS, Warner DO, Jenkins SM, Tilburt J, Hays JT. Beliefs, practices, and self-efficacy of US physicians regarding smoking cessation and electronic cigarettes: a national survey. Nicotine Tob Res. 2017;19(2):197-207. Medline:27613879 doi:10.1093/ntr/ntw194 52. National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes.Washington, DC: National Academies Press; 2018. 53. Centers for Disease Control and Prevention. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Updated February 25, 2020. Accessed November 24, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html 54. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and associated factors among middle and high school students—United States, 2019. MMWR Surveill Summ. 2019;107(5):702. Medline:31805035 doi:10.15585/mmwr.ss6812a1 55. Siu AL; U.S. Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(8):622-634. Medline:26389730 doi:10.7326/M15-2023 56. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev . 2013;5:CD000165. Medline:23728631 57. Rice VH, Heath L, Livingstone-Banks J, Hartmann-Boyce J. Nursing interventions for smoking cessation. Cochrane Database Syst Rev. 2017;12(12):CD001188. Medline:29243221 58. Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2017;3(3):CD001007. Medline:28361497 doi:10.1002/14651858.CD001007.pub3 59. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2017;3(3):CD001292. Medline:28361496 60. Matkin W, Ordóñez-Mena JM, Hartmann-Boyce J. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2019;5(5):CD002850. Medline:31045250 61. Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y, Dobson R. Mobile phone text messaging and app-based interventions for smoking cessation. Cochrane Database Syst Rev. 2019;10(10):CD006611. Medline:31638271 doi:10.1002/14651858.CD006611.pub5 62. Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Syst Rev. 2018;5(5):CD000146. Medline:29852054 doi:10.1002/14651858.CD000146.pub5 63. Lindson N, Chepkin S, Ye W, Fanshawe T, Bullen C, Hartmann-Boyce J. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2019;4(4):CD013308. Medline:30997928 doi:10.1002/14651858.CD013308 64. Howes S, Hartmann-Boyce J, Livingstone-Banks J, Hong B, Lindson N. Antidepressants for smoking cessation. Cochrane Database Syst Rev . 2020;4(4):CD000031. Medline:32319681 65. Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2016;5(5):CD006103. Medline:27158893 doi:10.1002/14651858.CD006103.pub7 66. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3(3):CD008286. Medline:27009521 doi:10.1002/14651858.CD008286.pub3 67. Hartmann-Boyce J, Hong B, Livingstone-Banks J, Wheat H, Fanshawe TR. Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database Syst Rev. 2019;6(6):CD009670. Medline:31166007 doi:10.1002/14651858.CD009670.pub4 68. Chamberlain C, O'Mara-Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;2(2):CD001055. Medline:28196405 doi:10.1002/14651858.CD001055.pub5 69. Creamer M, Case K, Loukas A, Cooper M, Perry CL. Patterns of sustained e-cigarette use in a sample of young adults. Addict Behav. 2018;92:28-31. Medline:30579114 doi:10.1016/j.addbeh.2018.12.011 70. Dai H, Leventhal A. Prevalence of e-cigarette use among adults in the United States, 2014-2018. JAMA. 2019;322(18):1824-7. Medline:31524940 doi:10.1001/jama.2019.15331 71. Mirbolouk M, Charkhchi P, Kianoush S, et al. Prevalence and distribution of e-cigarette use among U.S. adults: Behavioral Risk Factor Surveillance System, 2016. Ann Intern Med. 2018;169(7):429-438. Medline:30167658 doi:10.7326/M17-3440 72. Patel D, Davis KC, Cox S, et al. Reasons for current e-cigarette use among U.S. adults. Prev Med. 2016;93:14-20. Medline:27612572 doi:10.1016/j.ypmed.2016.09.011 73. Zhuang YL, Cummins SE, Sun JY, Zhu SH. Long-term e-cigarette use and smoking cessation: a longitudinal study with US population. Tob Control. 2016;25(Suppl 1):i90-i95. Medline:27697953 doi:10.1136/tobaccocontrol-2016-053096 74. Wang TW, Asman K, Gentzke AS, et al. Tobacco product use among adults—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(44):1225-1232. Medline:30408019 doi:10.15585/mmwr.mm6744a2 75. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382:1629-37. Medline:24029165 doi:10.1016/S0140-6736(13)61842-5 76. O'Brien B, Knight-West O, Walker N, Parag V, Bullen C. E-cigarettes versus NRT for smoking reduction or cessation in people with mental illness: secondary analysis of data from the ASCEND trial. Tob Induc Dis. 2015;13(1):5. Medline:25814920 doi:10.1186/s12971-015-0030-2 77. Caponnetto P, Campagna D, Cibella F, et al. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One . 2013;8:e66317. Medline:23826093 doi:10.1371/journal.pone.0066317 78. Hajek P, Phillips-Waller A, Przulji D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380:629-637. Medline:30699054 doi:10.1056/NEJMoa1808779 79. Walker N, Parag V, Verbiest M, Laking G, Laugesen M, Bullen C. Nicotine patches used in combination with e-cigarettes (with and without nicotine) for smoking cessation: a pragmatic, randomised trial. Lancet Respir Med. 2020;8(1):54-64. Medline:31515173 doi:10.1016/S2213-2600(19)30269-3 80. Lee SH, Ahn SH, Cheong YS. Effect of electronic cigarettes on smoking reduction and cessation in Korean male smokers: a randomized controlled study. J Am Board Fam Med . 2019;32(4):567-574. Medline:31300577 doi:10.3122/jabfm.2019.04.180384 81. Mills EJ, Wu P, Lockhart I, Wilson K, Ebbert JO. Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals. Tob Induc Dis . 2010;8:8. Medline:20626883 doi:10.1186/1617-9625-8-8 82. Mills EJ, Thorlund K, Eapen S, Wu P, Prochaska JJ. Cardiovascular events associated with smoking cessation pharmacotherapies: a network meta-analysis. Circulation . 2014;129:28-41. Medline:24323793 doi:10.1161/CIRCULATIONAHA.113.003961 83. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev . 2014;1(1):CD000031. Medline:24402784 84. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507-2520. Medline:27116918 doi:10.1016/S0140-6736(16)30272-0 85. Benowitz NL, Pipe A, West R, et al. Cardiovascular safety of varenicline, bupropion, and nicotine patch in smokers: a randomized clinical trial. JAMA Intern Med. 2018;178(5):622-631. Medline:29630702 doi:10.1001/jamainternmed.2018.0397 86. U.S. Food and Drug Administration. Nicotrol inhaler. Updated August 2019. Accessed November 4, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020714s018lbl.pdf . 87. U.S. Food and Drug Administration. Highlights of prescribing information: Zyban. June 2016. Accessed November 24, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020711s048lbl.pdf . 88. U.S. Food and Drug Administration. Highlights of prescribing information: Chantix. Updated December 2012. Accessed November 24, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021928s014s017lbl.pdf . 89. Blount BC, Karwowski MP, Shields PG, et al; Lung Injury Response Laboratory Working Group. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med. 2020;382(8):697-705. Medline:31860793 doi:10.1056/NEJMoa1916433 90. Rose G, Hamilton PJ. A randomised controlled trial of the effect on middle-aged men of advice to stop smoking. J Epidemiol Community Health . 1978;32:275-81. Medline:370171 doi:10.1136/jech.32.4.275 91. Rose G, Colwell L. Randomised controlled trial of anti-smoking advice: final (20 year) results. J Epidemiol Community Health . 1992;46:75-7. Medline:1573365 doi:10.1136/jech.46.1.75 92. Goniewicz ML, Smith DM, Edwards KC, et al. Comparison of nicotine and toxicant exposure in users of electronic cigarettes and combustible cigarettes. JAMA Netw Open . 2018;1(8):e185937. Medline:30646298 doi:10.1001/jamanetworkopen.2018.5937 93. Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012;85(6):591-598. Medline:22534270 94. Patel MS, Steinberg MB. In the clinic: smoking cessation. Ann Intern Med. 2016;164(5):ITC33-ITC48. Medline:26926702 doi:10.7326/AITC201603010 95. American College of Obstetricians and Gynecologists. Tobacco and nicotine cessation during pregnancy: ACOG Committee Opinion, Number 807. Obstet Gynecol. 2020;135(5):e221-e229. Medline:32332417 doi:10.1097/AOG.0000000000003822 96. Committee on Health Care for Underserved Women. Committee opinion number 503: tobacco use and women’s health. Obstet Gynecol . 2011;118(3):746-750. Medline:21860316 doi:10.1097/AOG.0b013e3182310ca9 97. Farber HJ, Walley SC, Groner JA, Nelson KE; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics . 2015;136(5):1008-1017. Medline:26504137 doi:10.1542/peds.2015-3110 98. American Academy of Family Physicians. Electronic Nicotine Delivery Systems (ENDS). Accessed November 24, 2020. https://www.aafp.org/about/policies/all/e-cigarettes.html 99. Livingston CJ, Freeman RJ, Costales VC, et al. Electronic nicotine delivery systems or e-cigarettes: American College of Preventive Medicine's Practice Statement. Am J Prev Med. 2019;56(1):167-178. Medline:30573147 doi:10.1016/j.amepre.2018.09.010 100. Bhatnagar A, Whitsel LP, Ribisl KM, et al; American Heart Association Advocacy Coordinating Committee, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Electronic cigarettes: a policy statement from the American Heart Association. Circulation . 2014;130:1418-36. Medline:25156991 doi:10.1161/CIR.0000000000000107 101. American College of Obstetricians and Gynecologists. Practice advisory: lung injury associated with e-cigarettes (“vaping”). Published October 2019. Accessed November 24, 2020. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2019/10/lung-injury-associated-with-e-cigarettes-vaping 102. American Cancer Society. American Cancer Society Position Statement on Electronic Cigarettes. Accessed November 24, 2020. https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html

Abbreviations: NRT, nicotine replacement therapy; SR, sustained release; USPSTF, US Preventive Services Task Force.

Abbreviation: RR, risk ratio. a Adapted from Appendix H Table 1 in Patnode et al 13 and a modified Template for Intervention Description and Replication (TIDieR) checklist. 45 b Example interventions are those that demonstrated a positive direction of effect on smoking cessation, were at low risk of bias, and took place in the United States in primary care or a primary care–applicable setting among an unselected sample of adults (ie, those not selected based on having smoking-related disease or other comorbid conditions). Inclusion of studies and materials is for example purposes only and does not indicate endorsement by the USPSTF. c Materials provided for practice include materials or protocols that were noted within the source study and that were able to be located. d Demonstrated benefit of intervention type is based on comparison of that intervention type with a given control and should not be used to compare the effectiveness of one intervention type with another.

USPSTF indicates US Preventive Services Task Force. Supplement. eFigure. US Preventive Services Task Force (USPSTF) Grades and Levels of Evidence

• Get Care Now
• Primary Care
• Video Visits
• Walk-in Care at Publix
• Express Care
• Emergency Room

The Top 5 Reasons to Quit Smoking

Almost 70% of adults who smoke say they want to quit, but that doesn’t always mean it’s easy to do. Whether it’s your first or fifteenth attempt at quitting, you can do it.

“I always tell my patients quitting is possible, no matter how difficult it may be,” says Dr. Carl Derrick , a board-certified specialist in internal medicine at Beaufort Memorial Lowcountry Medical Group . “Quitting smoking has a ton of benefits, and it’s worth the effort.”

If you need motivation, these five reasons why you should quit smoking can encourage you to start or continue your journey to becoming tobacco free.

1. Your heart and lungs will get the rest they deserve.

Twenty minutes after your last cigarette, your heart rate and blood pressure drop, which, over the long term, could lower your risk of cardiovascular disease. After three months, your circulation and lung function will improve. When you reach your one-year anniversary, your risk of coronary heart disease will be half the risk of someone who smokes.

2. You won’t put others at risk anymore.

Secondhand smoke — the smoke others breathe when another person exhales or from the lit end of someone else’s cigarette — poses a variety of health risks to the people around you, even if they have never smoked themselves. In addition to increasing their risk of lung cancer, heart attack and stroke, secondhand smoke can also exacerbate their asthma. Also, when you quit, you no longer expose your friends and loved ones to the 7,000 chemicals that exist in secondhand smoke.

“There’s also something called third-hand smoke, which is the smoke that lingers on clothes, hair, carpet and furniture after someone smokes,” Dr. Derrick says. “Like secondhand smoke, it exposes people to the carcinogens present in smoke. While those smoke particles are still on you, they can cause health problems for those around you. Quitting is the No. 1 way to reduce that risk.”

3. You can learn mindfulness or other good mental health habits.

“I find a lot of patients miss the habit of smoking when they quit,” Dr. Derrick says. “They find themselves at the bar they smoked in, or with the friend they took smoke breaks with, and before they know it, they’re smoking again. I always tell them being mindful is a good thing. It helps them recognize their patterns and avoid those situations or plan accordingly if those situations can’t be avoided.”

For many people, smoking can also be a calming ritual, which Dr. Derrick understands. However, quitting gives you an opportunity to choose healthy stress relievers, such as yoga or meditation, instead.

4. Your cancer risk will plummet.

Smoking doesn’t just increase your lung cancer risk. It also makes you more likely to develop cancers of the:

• Colon and rectum

When you quit smoking, you reduce your risk of all of these types of cancer and other conditions. “We’ve found that if you quit smoking, your risk of lung cancer is back to the average nonsmoker’s risk by 15 years,” Dr. Derrick says. “That’s why, for lung cancer screenings, the U.S. Preventive Services Task Force recommends patients who currently smoke or have quit in the past 15 years have a low-dose CT scan to screen for lung cancer.”

Read More: Mike Binkowski’s Lung Cancer Survival Story

5. You’ll live a longer, happier life.

“More than anything else, I always stress to my patients that quitting smoking will improve their quality of life,” Dr. Derrick says. “You save money, you don’t smell of smoke, you can breathe easier and your body functions better. I had one gentleman who quit smoking because he didn’t want his second hand or third hand smoke to impact his new granddaughter.”

Many people who quit smoking also report that food tastes better and their sense of smell returns to normal. Daily activities won’t leave you out of breath, and you won’t have to leave your friends and family in smoke-free buildings to go outside for a cigarette. You’ll find few places in your life that aren’t improved by your decision to quit.

Read More: How to Quit Smoking

How to Stop Smoking

If you’re ready to quit smoking once and for all, we can connect you with the smoking cessation resources you need to be successful. You should also schedule an appointment with your primary care provider to see if you qualify for a low-dose CT lung cancer screening . These highly detailed imaging tests detect very small lung cancers, giving you the best chances of overcoming the disease before it has a significant impact on your life.

“The earlier we find lung cancer, the more likely it is you’ll survive,” Dr. Derrick says. “I’ve had patients receive lobectomies when, if it weren’t for their screening, they could have lost a lung entirely. Screenings reduce death and disease, plain and simple.”

To learn more about low-dose CT scans, call us at 843-522-5015 .

Screening requires a referral from your primary care provider. If you need a provider, find one accepting new patients .

Search for Living Well Articles

Related articles.

Get Inspiration For Living Well

Join hundreds of others receiving a monthly round-up of our top Lowcountry health and wellness articles.

Smoking Patients. Practice Recommendations

Evidence for practice recommendations, application of practice recommendation, reflection on the three practice recommendations.

There are several ways to handle smoking patients. 1.1 work recommendation relating to integrating tobacco management into daily practice suggests “brief interventions to screen all clients for all forms of tobacco use and initiate treatment as appropriate” (RNAO, 2017). This nursing necessity fits in Mr. Philobosan’s case because he has just realized that his cigarette use has led him to chronic obstructive pulmonary disease (COPD). Mr Philobosan wishes he could stop smoking, and the health care provider has to assess to understand whether Mr. Philobosan wants to change or is scared of the present situation.

The second strategy, as per 2.1 working manual notes, is to “develop a person-centered tobacco intervention plan with the client” (RNAO, 2017). This medical requirement is applicable in Mr. Philobosan’s case because he has used tobacco for the better part of his life. For a nurse to get any good results with this client, treatment has to focus on unique features to Mr. Philobosan concerning smoking.

Thirdly, section 3.1 recommendation says that it is necessary to “provide clients with, refer them to, intensive interventions and counseling on the use of pharmacotherapy, and express an interest in reducing or quitting tobacco use” (RNAO, 2017). This section is relevant to the client because he has smoked for more than half of his life. The aforementioned means that tobacco is part of Mr. Philobosan’s living, and quitting will not be an easy task as it will require serious treatment, and medical and psychological intervention.

Evidence to support practice recommendation 1.1 argues that brief treatment can raise the probability of an effective quit trial. The initial intercession further increases the time a patient remains free from tobacco after starting their medication. The short-term therapy has the possibility of leading to long-term healing goals (RNAO, 2017). Moreover, the evidence shows that smoking termination therapy offered by clinicians who have the first conduct with the patient are efficient in helping individuals quit smoking.

Working sanction 2.1 indicates that each client is unique and comes with special needs and characteristics which should be looked at for effective service delivery. The personal aspects might be physical, emotional, psychological, cultural or socio-economical, influencing individual lifestyles (RNAO, 2017). Additionally, the therapist should be aware of their biases which can hinder the client’s healing process and focus mainly on what benefits the patient. The medics and their customers should collaborate to pinpoint obstacles to stopping client-specific tobacco use.

Information to validate nursing guideline 3.1 suggests that intensive interventions are a phase to evaluate the inspiration behind the need for the client to stop using tobacco. This practice also incorporates categorization of risky circumstances, triggers to smoke, and discussion of problem-solving tactics to control the hazardous environments. Exhaustive therapy contains behavioral management and counseling, nicotine replacement therapy and prescription medicine (RNAO, 2017). It is recommended that if the clinician is not able to offer thorough treatment, he or she should refer the patient to where they can get the resources.

In the case scenario, Mr. Philobosan has developed chronic obstructive pulmonary disease and is suspected of having a lung infection from smoking tobacco. Using nursing guideline 1.1 as a nurse taking care of him, I will do a thorough screening on his tobacco use history. I will then proceed with brief interventions and inform Mr. Philobosan how tobacco has damaged his lungs leading to infection and his current condition of inability to breathe normally. Further, I will request him not to use tobacco while admitted to the hospital. I will be concurrently medicating for the withdrawal symptoms if Mr. Philobosan exhibits any.

The 2.1 clinical guidelines in integrating tobacco interventions in daily practice will help me explore with the client and develop a unique rehabilitation plan for Mr. Philobosan. First, I would assess how and why he began using nicotine. Secondly, I could investigate what has encouraged his behavior for so many years. Thirdly, I might ask to what extent he thinks he can quit his fifty-year lifestyle. Lastly, I can enquire to understand how he thinks he can end smoking. With the above information, I will develop a client-centered model which considers client characteristics which can impact healing and those which can trigger a relapse.

After developing the client-centered approach plan, 3.1 clinical sanctions will guide me in begging intensive interventions for Mr. Philobosam. In this stage, I can engage both counseling and medication. I will take the client through the first therapeutic session and explain the exact condition he is in currently. The following sessions will deal with factors that have influenced the client’s behavior in the past and aspects that could hinder the healing process. The psychological treatment will be done together with relevant medication. This will commence if my client is ready and willing to change.

From the three best practice guidelines used in this case study, I have learned that most patients do not fully realize the magnitude of their illnesses or conditions until it is elaborated by a professional. As a medic, I have understood that it is our duty to support these clients and guide them systematically through the healing process. One important thing I have learned is that every person whom we serve is unique, and treatment should be client-centered. I have captured that it is essential to work together with the patient to achieve maximum recovery.

RNAO. (2017). Integrating Tobacco interventions into daily practice . Registered Nurses’ Association of Ontario.

Cite this paper

• Chicago (N-B)
• Chicago (A-D)

StudyCorgi. (2022, September 7). Smoking Patients. Practice Recommendations. https://studycorgi.com/smoking-patients-practice-recommendations/

"Smoking Patients. Practice Recommendations." StudyCorgi , 7 Sept. 2022, studycorgi.com/smoking-patients-practice-recommendations/.

StudyCorgi . (2022) 'Smoking Patients. Practice Recommendations'. 7 September.

1. StudyCorgi . "Smoking Patients. Practice Recommendations." September 7, 2022. https://studycorgi.com/smoking-patients-practice-recommendations/.

Bibliography

StudyCorgi . "Smoking Patients. Practice Recommendations." September 7, 2022. https://studycorgi.com/smoking-patients-practice-recommendations/.

StudyCorgi . 2022. "Smoking Patients. Practice Recommendations." September 7, 2022. https://studycorgi.com/smoking-patients-practice-recommendations/.

This paper, “Smoking Patients. Practice Recommendations”, was written and voluntary submitted to our free essay database by a straight-A student. Please ensure you properly reference the paper if you're using it to write your assignment.

Before publication, the StudyCorgi editorial team proofread and checked the paper to make sure it meets the highest standards in terms of grammar, punctuation, style, fact accuracy, copyright issues, and inclusive language. Last updated: November 21, 2022 .

If you are the author of this paper and no longer wish to have it published on StudyCorgi, request the removal . Please use the “ Donate your paper ” form to submit an essay.

• Share full article

Advertisement

Supported by

Letter of Recommendation

In Defense of Never Learning How to Cook

I hated domesticity so much that for years, I lived happily without a kitchen. This $19 device helped me survive.

By Iva Dixit

Iva Dixit is a staff editor for the magazine.

I found it while walking through the home-goods section of T.J. Maxx, the American retail equivalent of the Garden of Earthly Delights, at 8:00 on a Tuesday night in 2015. It was two days after Easter, and in this Hieronymus Bosch land of shopping anarchy, the shelves were stocked with pastel-colored objects of uncertain usefulness: sacks of fruit-medley popcorn dyed green and purple; a giant tub of millennial-pink Himalayan crystal salt. Somewhere among these novelties I spotted a carelessly abandoned gadget calling itself the Dash Rapid Egg Cooker. The cashier who rang me up did not share my enthusiasm for the cheery cockiness of its packaging, which proclaimed that it “Perfectly Cooks 6 Eggs at a Time!” Baffled, she asked me a question, the answer to which would have embarrassed anyone but me: “Don’t you know how to boil water?”

No. I didn’t.

And at 22, not only did I not know how to boil water, I didn’t even know how to turn on a stove. Now, these may both seem like gaps in knowledge that could have been easily rectified with a 60-second trip to the kitchen, but you see: I did not have one.

Earlier that day, I had finally moved into my first solo “apartment”: the garden-level basement of a Manhattan brownstone that was rented to me by an absentee owner, which, in lieu of a real kitchen, came outfitted with a minifridge, a hot plate and a microwave. That evening, after a long day of unpacking, I sat down on the building’s stoop, ate my way through a bag of discounted Cadbury Mini Eggs and, after 20 minutes spent wallowing in disbelief at where life had deposited me, broke into a series of earthquake-size sobs. But it wasn’t misery making me dry-heave — it was relief.

At 22, not only did I not know how to boil water, I didn’t even know how to turn on a stove.

In 2013, I fled my old life for New York, the promised land for stunted young adults evading responsibility. I had spent my childhood, teenhood and earliest adulthood consumed with daydreams of an imaginary future in which I lived alone — my only ambition in life. In these painstakingly detailed fantasies, the greatest luxury I could imagine was that my space and my empty hours all belonged to me and me only. In these visions, there was no one snatching “storybooks” (the beloved Indian-parent euphemism even if you read adult fiction) from my hands and barking at me to get up and make tea whenever guests came to visit, or grating at me to bring out hot rotis straight from the stove and put them onto the plates of fathers and uncles. The milieu I was raised in tried to drill into me the idea that keeping a home, and the domestic labor it entails — the cooking, the serving, the dusting, the wiping — were acts of profound nobility. That they were crucial to the formation of the only life I was predestined for, one that came prepackaged with a husband and children, two species, I had been warned, that were equally incapable of feeding themselves, and whose supervision would fall to me.

In rebellion, I refused to learn even a single tenet of good housekeeping. If I remained useless in the kitchen and egregiously incompetent at household chores, then I could at least retain some control over my life — and no amount of yelling, berating or shaming from parents, elders or concerned strangers could sway me from this zealotry.

At no point during this teenage mutiny, however, had I considered what I would do if these prolonged daydreams were ever granted. It escaped me that actually living alone as an adult involves being in possession of some basic skills I had avoided acquiring. Yes, now I was finally king of my kitchenless fief. But what was I going to eat? Cinnamon Toast Crunch and rubbery takeout every day, for eternity? That night I paid the skeptical cashier $19 for the spaceship-shaped device and took it home, feeling the first cracks of doubt emerging in my lifelong belligerence toward domesticity.

It escaped me that actually living alone as an adult involves being in possession of some basic skills I had avoided acquiring.

The Dash Rapid Egg Cooker is exactly what the name declares, a device that has precisely one purpose: It cooks eggs, rapidly. In the rare case of reality’s matching up with an advertising slogan, they are indeed perfect. I followed the instructions, starting by placing just one egg and pouring in the few centimeters of water it needed to cook. Through some magic of steam and electrical engineering, the Dash magically conjured an egg of ideal consistency in less time than it took me to brush my teeth, wash my face and apply my acne cream (I did thankfully have a bathroom).

As French chefs and inept bachelors of various nationalities can attest, mastering a perfect egg is the gateway to mastering a cuisine altogether. A good egg is breakfast, lunch, dinner and all snacks in between. A good egg is the foundation of bigger cooking ambitions, now that you have mastered the trickiest basic of them all. A good egg is the start of complete self-sufficiency, because it is a meal and an accompaniment all in itself. On that April night nine years ago, giddy and drunk on my own invincibility, I ate the first thing I had ever “cooked” by myself, for myself: a half-boiled egg, sliced neatly in half on top of plain supermarket white bread that I lathered with cold scrapes of salted butter and thin slivers of red onion .

Until then, mine was a life that often felt cobbled together from accidents and gambles. That immaculate half-boiled egg, with its semi-liquefied insides roiling on my tongue, was the first thing I felt I’d actually earned on my own. I still didn’t know how to boil water. I had a job that paid me the queenly sum of $30,000 per year, yet it was still more money than I’d ever conceived of.

More important, I finally — finally — had the only thing I ever really wanted: my independence, my time.

Iva Dixit is a staff editor at the magazine. She has previously written about the joys of eating raw onions , the evergreen popularity of Sean Paul and why “Oppenheimer” is for the girlies .

Explore The New York Times Magazine

A Playwright Reimagines America: In her new play, “Sally & Tom,” Suzan-Lori Parks brings exuberant provocation  to the gravest historical questions.

The New Mood Music: The Texan trio Khruangbin’s vibes  have spawned countless imitators, but their magic isn’t so easy to replicate.

Inside a Media-Fighting Law Firm: Tensions had been brewing for years inside Clare Locke, a top defamation law firm. Then came the biggest defamation case of them all : a case against Fox News.

Is Corporate America in Denial?: Despite Donald Trump’s populist promises , many bigwigs are keeping the faith that it couldn’t really happen here.

Larry David’s Rule Book: He’s a wild, monomaniacal jerk . He’s also our greatest interpreter of American manners since Emily Post.

Inside The National Enquirer : An ex-editor at the tabloid reveals the story of the notorious “catch and kill” campaign  that now stands at the heart of Donald Trump’s’s legal trial.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Taylor & Francis Open Select

Tobacco smoking: Health impact, prevalence, correlates and interventions

Robert west.

a Department of Behavioural Science and Health , University College London , London, UK

Background and objectives : Despite reductions in prevalence in recent years, tobacco smoking remains one of the main preventable causes of ill-health and premature death worldwide. This paper reviews the extent and nature of harms caused by smoking, the benefits of stopping, patterns of smoking, psychological, pharmacological and social factors that contribute to uptake and maintenance of smoking, the effectiveness of population and individual level interventions aimed at combatting tobacco smoking, and the effectiveness of methods used to reduce the harm caused by continued use of tobacco or nicotine in some form.

Results and conclusions : Smoking behaviour is maintained primarily by the positive and negative reinforcing properties of nicotine delivered rapidly in a way that is affordable and palatable, with the negative health consequences mostly being sufficiently uncertain and distant in time not to create sufficient immediate concern to deter the behaviour. Raising immediate concerns about smoking by tax increases, social marketing and brief advice from health professionals can increase the rate at which smokers try to stop. Providing behavioural and pharmacological support can improve the rate at which those quit attempts succeed. Implementing national programmes containing these components are effective in reducing tobacco smoking prevalence and reducing smoking-related death and disease.

Introduction

The continued popularity of tobacco smoking appears to defy rational explanation. Smokers mostly acknowledge the harm they are doing to themselves and many report that they do not enjoy it – yet they continue to smoke (Fidler & West, 2011 ; Ussher, Brown, Rajamanoharan, & West, 2014 ). The reason is that nicotine from cigarettes generates strong urges to smoke that undermine and overwhelm concerns about the negative consequences of smoking, and the resolve not to smoke in those trying to stop (West & Shiffman, 2016 ). Progress is being made in many countries in reducing smoking prevalence but it remains one of the main causes of ill health and premature death worldwide (Gowing et al., 2015 ).

This paper provides a broad overview of smoking in terms of: the health effects, benefits of stopping, prevalence and patterns of use, psychological, pharmacological and social factors leading to uptake and maintenance of the behaviour, effectiveness of population level and individual level interventions to combat it, and methods used to reduce the harm despite continued use of tobacco or nicotine.

Definitions of smoking and smoking cessation

Tobacco smoking consists of drawing into the mouth, and usually the lungs, smoke from burning tobacco (West & Shiffman, 2016 ). The type of product smoked is most commonly cigarettes, but can also include cigarillos, cigars, pipes or water pipes. ‘Smokeless’ tobacco is also popular in some parts of the world. This typically involves using tobacco preparations for chewing, sniffing into the nose or placing as a wad in the mouth between the cheeks and gums (Critchley & Unal, 2003 ). Smokeless tobacco use has features that are similar to smoking and can carry significant health risks (Critchley & Unal, 2003 ); however, this article focuses on smoked tobacco only as this has been the subject of by far the largest volume of research and is the most harmful form of tobacco use.

Stopping smoking usually involves an intention not to smoke any more cigarettes from a given point in time (a ‘quit attempt’), followed by self-conscious resistance of urges to smoke resulting in a period of abstinence. If someone making a quit attempt smokes one or more cigarettes on an occasion but then resumes abstinence, this is usually termed a ‘lapse’. If this person resumes smoking on a regular basis s/he is said to have ‘relapsed’. ‘Short-term abstinence’ is commonly defined in terms of achieving up to 4 weeks of abstinence. ‘Long-term abstinence’ often refers to abstinence for at least 6 months but more typically involves abstinence for at least 12 months. There is no agreed criterion for deciding when someone has ‘stopped smoking’ so it is essential when using the term to be clear about how long the abstinence period has been.

Health impact of smoking and the benefits of stopping

Tobacco smoking increases the risk of contracting a wide range of diseases, many of which are fatal. Stopping smoking at any age is beneficial compared with continuing to smoke. For some diseases, the risk can be reversed while for others the risk is approximately frozen at the point when smoking stopped.

Health impact of smoking

Table ​ Table1 1 lists the main causes of death from smoking. Tobacco smoking is estimated to lead to the premature death of approximately 6 million people worldwide and 96,000 in the UK each year (Action on Smoking and Health, 2016b ; World Health Organization, 2013 ). A ‘premature death from smoking’ is defined as a death from a smoking-related disease in an individual who would otherwise have died later from another cause. On average, these premature deaths involve 10 years of life years lost (US Department of Health and Human Services, 2004 ). Many of these deaths occur in people who have stopped smoking but whose health has already been harmed by smoking. It also happens to be the case that smokers who do not stop smoking lose an average of 10 years of life expectancy compared with never-smokers and they start to suffer diseases of old age around 10 years earlier than non-smokers (Jha & Peto, 2014 ).

Most smoking-related deaths arise from cancers (mainly lung cancer), respiratory disease (mainly chronic obstructive pulmonary disease – COPD), and cardiovascular disease (mainly coronary heart disease) (Action on Smoking and Health, 2016b ). Smoking is an important risk factor for stroke, blindness, deafness, back pain, osteoporosis, and peripheral vascular disease (leading to amputation) (US Department of Health and Human Services, 2004 ). After the age of 40, smokers on average have higher levels of pain and disability than non-smokers (US Department of Health and Human Services, 2004 ).

Smoking in both women and men reduces fertility (Action on Smoking and Health, 2013 ). Smoking in pregnancy causes underdevelopment of the foetus and increases the risk of miscarriage, neonatal death, respiratory disease in the offspring, and is probably a cause of mental health problems in the offspring (Action on Smoking and Health, 2013 ).

People used to think that smoking was protective against Alzheimer’s disease but we now know that the opposite is the case: it is a major risk factor for both Alzheimer’s and vascular dementia (Ferri et al., 2011 ; US Department of Health and Human Services, 2004 ).

There is a positive association between average daily cigarette consumption and risk of smoking-related disease, but in the case of cardiovascular disease the association is non-linear, so that low levels of cigarette consumption carry a higher risk than would be expected from a simple linear relationship (US Department of Health and Human Services, 2004 ).

Tobacco smoke contains biologically significant concentrations of known carcinogens as well as many other toxic chemicals. Some of these, including a number of tobacco-specific nitrosamines (particularly NNK and NNN) are constituents of tobacco, largely as a result of the way it is processed, while others such as benzopyrine result from combustion of tobacco (Action on Smoking and Health, 2014b ). These chemicals form part of the particulate matter in smoke. Tobacco smoke also contains the gas, carbon monoxide (CO). CO is a potent toxin, displacing oxygen from haemoglobin molecules. However, acutely the amount of CO in tobacco smoke is too small to lead to hypoxia and the body produces increased numbers of red blood cells to compensate.

The nicotine in tobacco smoke may cause a small part of the increase in cardiovascular disease but none or almost none of the increase in risk of respiratory disease or cancer (Benowitz, 1997 , 1998 ). It is the other components of cigarette smoke that do almost all the damage. It has been proposed on the basis of studies with other species that nicotine damages the adolescent brain but there is no evidence for clinically significant deficits in cognition or emotion in adults who smoked during adolescence and then stopped (US Department of Health and Human Services, 2004 ).

Exposure to second-hand smoke carries a significant risk for both children and adults. Thus, non-smokers who are exposed to a smoky environment have an increased risk of cancer, heart disease and respiratory disease (Action on Smoking and Health, 2014a ).

Benefits of stopping smoking

Table ​ Table1 1 lists the main benefits of stopping smoking. Smokers who stop before their mid-30s have approximately the same life expectancy as never smokers (Doll, Peto, Boreham, & Sutherland, 2004 ; Pirie, Peto, Reeves, Green, & Beral, 2013 ). After the age of 35 years or so, stopping smoking recovers 2–3 months of healthy life expectancy for every year of smoking avoided, or 4–6 h for every day (Jha & Peto, 2014 ).

Stopping smoking has different effects on different smoking-related diseases. Excess risk of heart attack caused by smoking reduces by 50% within 12 months of stopping smoking. Stopping smoking returns the rate of decline in lung function to the normal age-related decline, but does not reverse this; it reduces the frequency of ‘exacerbations’ (acute attacks of breathing difficulty resulting in death or hospitalisation) in COPD patients (US Surgeon General, 1990 ). Stopping smoking ‘freezes’ the risk of smoking-related cancers at the level experienced when stopping occurs but does not decrease it in absolute terms (US Surgeon General, 1990 ).

Smokers who stop show reduced levels of stress and mood disorder than those who continue (Royal College of Physicians and Royal College of Psychiatrists, 2013 ). They also report higher levels of happiness and life satisfaction than those who continue (Shahab & West, 2009 , 2012 ). This suggests that smoking may harm mental health, though other explanations cannot be ruled out on the current evidence.

Prevalence and patterns of smoking

Smoking prevalence.

There are estimated to be approximately 1 billion tobacco smokers worldwide (Eriksen, Mackay, & Ross, 2013 ), amounting to approximately 30% of men and 7% of women (Gowing et al., 2015 ).

Cigarette smoking prevalence in Great Britain was estimated to be 16.9% in 2015, the most recent year for which figures are available at the time of writing: slightly lower in women than men (Office of National Satistics, 2016 ). Smoking in Great Britain has declined by 0.7 percentage points per year since 2001 (from 26.9% of adults in 2001). In Australia, daily cigarette smoking has declined by 0.6 percentage points per year over a similar time period (from 22.4% of adults aged 18 + years in 2001 to 14.5% in 2015) (Australian Bureau of Statistics, 2015 ). However, international comparisons are confused by different countries using a different definition of what counts as being a smoker, and different methods for assessing prevalence. Australia only counts daily smokers in their headline figures. The situation in the US is even more misleading. The headline prevalence figure for the US is below 16%, but this does not include occasional smokers and people who smoke cigarillos which are essentially cigarettes in all but name and which have become increasingly popular in recent years. So the figure for prevalence that is most comparable to the figure for Great Britain is 20% (Jamal, 2016 ).

With the above caveats in mind, the figures in Table ​ Table2 2 for smoking prevalence in world regions in men and women provide very broad estimates (Gowing et al., 2015 ). Most noteworthy is that smoking prevalence in men is more than four times that in women globally but that the difference is much less in most parts of Europe, and that Eastern Europe as a whole has the highest smoking prevalence of any region in the world.

Note: Current smoking of any tobacco product, adults aged 15 years and older, age-standardised rate, by gender. ‘Tobacco smoking’ includes cigarettes, cigars, pipes or any other smoked tobacco products. ‘Current smoking’ includes both daily and non-daily or occasional smoking. From Gowing et al. ( 2015 ).

Smoking patterns

The most common age of first trying a cigarette in countries that have been studied is 10–15 years (Action on Smoking and Health, 2015b ; Talip, Murang, Kifli, & Naing, 2016 ); take up of regular smoking usually continues up to early 20s (Dierker et al., 2008 ).

Average daily cigarette consumption among smokers in the US and UK has declined steadily since the 1970s. In the UK, it is currently 11 cigarettes per day, and non-daily smoking is very rare (Action on Smoking and Health, 2016c ; Jarvis, Giovino, O’Connor, Kozlowski, & Bernert, 2014 ). Smokers take in an average of 1–1.5 mg of nicotine per cigarette (US Department of Health Human Services, 2014 ). The US figures on patterns of smoking are distorted by not counting ‘cigarillos’ and other smoked tobacco products which are used very much like cigarettes, whose prevalence has increased in recent years (Jamal et al., 2015 ). The reduction in daily cigarette consumption has not been accompanied by a reduction in daily nicotine intake (Jarvis et al., 2014 ). This could be due to the use of other smoked tobacco products (in the case of the US) or smokers smoking their cigarettes more intensively (taking more, deeper or longer puffs).

Smokers in England spend an average of £23 per week on cigarettes and this figure is slowly rising (West & Brown, 2015 ). In the UK, hand-rolled cigarettes have become increasingly popular with 34% of smokers currently reporting use of these products (Action on Smoking and Health, 2016c ). Men and people in more deprived socio-economic groups are more likely to smoke hand-rolled cigarettes (Action on Smoking and Health, 2016c ).

In most countries, there are strong negative associations between smoking prevalence and educational level, affluence and mental health; and positive associations with alcohol use disorder and substance use disorder (Action on Smoking and Health, 2016a , 2016c ; Royal College of Physicians and Royal College of Psychiatrists, 2013 ; Talati, Keyes, & Hasin, 2016 ). In the UK, average daily cigarette consumption is higher for men than women, and higher in smokers in more deprived socio-economic groups and those with mental health problems (Action on Smoking and Health, 2016c ).

Psychological, pharmacological and social factors involved in smoking and smoking cessation

The natural history of smoking can be modelled as states and factors that influence the transition between these. Figure ​ Figure1 1 shows transitions that have been researched – the variables identified in the diagram are listed descriptively without attempting to explain how they may be connected.

Factors associated with transitions in the natural history of smoking (parentheses indicate negative associations).

Smoking initiation

Important factors predicting initiation in western societies are: having friends who smoke, having parents who smoke, low social grade, tendency to mental health problems and impulsivity (Action on Smoking and Health, 2015b ). Transition to daily smoking follows a highly variable pattern sometimes being very rapid and sometimes taking several years (Schepis & Rao, 2005 ). Important factors predicting transition to regular smoking are: having friends who smoke, weak academic orientation, low parental support, pro-smoking attitudes, drinking alcohol and low socio-economic status (Action on Smoking and Health, 2015b ).

Smoking initiation has a ‘heritability’ (the proportion of variance in a characteristic that is attributable to genetic rather than environmental variance) of approximately 30–50% in western societies (Vink, Willemsen, & Boomsma, 2005 ). This means that differences in genetic make-up account for almost half of the difference in likelihood of starting smoking between individuals. This does not mean that environmental factors do not also play a crucial role as is evident from the very large decline in smoking initiation since the 1970s in many western countries.

The heritability of cigarette addiction (as distinct from smoking) is approximately 70–80% in western societies (Vink et al., 2005 ). Cigarette addiction here refers to the extent to which someone experiences a strong need to smoke. It is usually indexed by a combination of number of cigarettes per day and time from waking to smoking the first cigarette of the day (Kozlowski, Porter, Orleans, Pope, & Heatherton, 1994 ). It can also be indexed by the self-reported strength of urges to smoke (Fidler, Shahab, & West, 2011 ). Heritability of cigarette addiction, as indexed by failure of attempts to stop, is higher than the heritability for smoking and for initiation of smoking. This suggests that differences in genetic inheritance play a larger role in being able to stop smoking than in starting to smoke.

Cigarette addiction

Cigarette addiction stems from the fact that smoking provides highly controllable doses of the drug, nicotine, rapidly to the brain in a form that is accessible, affordable and palatable (West, 2009 ; West & Shiffman, 2016 ). Nicotine provided more slowly, for example by the nicotine transdermal patch, is much less addictive. It is possible that one or more mono-amine oxidase inhibitors in cigarette smoke add to, or synergise, the addictive properties of nicotine (Hogg, 2016 ).

The psychopharmacology of cigarette addiction is complex and far from fully understood. The following paragraphs summarise the current narrative.

Nicotine resembles the naturally occurring neurotransmitter, acetylcholine, sufficiently to attach itself to a subset of neuronal receptors for this neurotransmitter in the brain. These are called ‘nicotinic acetylcholine receptors’. When it does this with receptors in the ventral tegmental area in the midbrain, it causes an increased rate of firing of the nerves projecting forward from that area to another part of the brain called the nucleus accumbens. This causes release of another neurotransmitter called dopamine in the nucleus accumbens.

Dopamine release and uptake by neurones in the nucleus accumbens is believed to be central to all addictive behaviours. It acts as a neural ‘teaching signal’ which causes the brain to form an association between the current situation as perceived and the impulse to engage in whatever action immediately preceded this release. In the case of smoking, this creates an urge to smoke in situations in which smoking frequently occurs. These are often referred to as ‘cue-driven smoking urges’ or ‘situational cravings’ (West, 2009 ; West & Shiffman, 2016 ). This explains why even non-daily smokers often find it difficult to stop smoking altogether.

Repeated ingestion of nicotine from cigarettes causes changes to the functioning of the ventral tegmental area and nucleus accumbens such that when brain concentrations of nicotine are lower than usual, there is an abnormally low level of neural activity in these regions. This leads to feelings of need for behaviours that have in the past restored normal functioning, typically smoking. This feeling of need can be thought of as a kind of ‘nicotine hunger’, also called ‘background craving’ (West, 2009 ; West & Shiffman, 2016 ). This is probably why time between waking and first cigarette of the day is a useful predictor of difficulty stopping smoking (Vangeli, Stapleton, Smit, Borland, & West, 2011 ). So ‘cue-driven smoking urges’ and ‘nicotine hunger’ are important factors contributing to smoking behaviour and thought to be the primary mechanisms underpinning cigarette addiction (West, 2009 ; West & Shiffman, 2016 ).

When smokers abstain from cigarettes, within a few hours many of them start to experience nicotine withdrawal symptoms. Withdrawal symptoms from a drug are temporary symptoms that arise when the drug dose is reduced or use is terminated. They arise from neural adaptation to the presence of the drug in the central nervous system. For smoking, the most common early onset symptoms are: irritability, restlessness and difficult concentrating. Depression and anxiety have also been observed in some smokers. These symptoms typically last 1 to 4 weeks (West, 2009 ; West & Shiffman, 2016 ).

After a day or two of stopping smoking, many smokers experience other symptoms: increased appetite, constipation, mouth ulcers, cough, and weight gain. Increased appetite tends to last for at least 3 months; weight gain (averaging around 6 kg) tends to be permanent; other symptoms tend to last a few weeks. The increased appetite, weight gain and constipation arise from termination of nicotine intake but the others are probably related to other effects of stopping smoking (West, 2009 ; West & Shiffman, 2016 ).

Any of the above effects of abstinence may in individual cases promote resumption of smoking following a quit attempt but statistically the association is inconsistent and weak; the main factors driving relapse appear to be cue-driven smoking urges and nicotine hunger (Fidler & West, 2011 ; West, 2009 ; West & Shiffman, 2016 ).

Many smokers report that smoking helps them cope with stress and increases their ability to concentrate. However, this appears to be because when they go for a period without smoking they experience nicotine withdrawal symptoms that are relieved by smoking. Long-term smokers who stop report lower levels of stress than when they were smoking and no reduction in ability to concentrate (West, 2009 ; West & Shiffman, 2016 ).

It is commonly thought that smokers with mental health problems are using cigarettes to ‘self-medicate’ or treat their psychological symptoms. However, the evidence indicates that neither nicotine nor smoking improves psychological symptoms, and people with serious mental health disorders who stop smoking do not experience a worsening of mental health. In fact some studies have found an improvement (Royal College of Physicians and Royal College of Psychiatrists, 2013 ).

Smoking cessation

For most smokers, cessation requires a determined attempt to stop and then sufficient resolve in the following weeks and months to overcome what are often powerful urges to smoke. Factors that predict quit attempts differ from those that predict the success of those attempts (Vangeli et al., 2011 ). Approximately 5% of unaided quit attempts succeed for at least 6 months (Hughes, Keely, & Naud, 2004 ). Relapse after this point is estimated to be around 50% over subsequent years (Stapleton & West, 2012 ).

The most common self-reported reasons for smoking are stress relief and enjoyment, with around half of smokers reporting these smoking motives. Weight control, aiding concentration and socialising are also quite commonly cited (Fidler & West, 2009 ). Smoking for supposed stress relief, improved concentration, weight control or other functions has not been found to be related to attempts to stop or success of attempts to stop (Fidler & West, 2009 ). Smokers who report enjoying smoking are less likely to try to stop but not less likely to succeed if they do try (Fidler & West, 2011 ). In addition, having a positive smoker identity (liking being a smoker) predicts not trying to quit, over and above enjoyment of smoking (Fidler & West, 2009 ).

No clear association has been found between the number of times smokers have tried to stop in the past and their chances of success the next time they try (Vangeli et al., 2011 ). However, having tried to stop in the past few months is predictive of failure of the next quit attempt (Zhou et al., 2009 ). Belief in the harm caused by smoking is predictive of smokers making quit attempts but not the success of those attempts (Vangeli et al., 2011 ).

Some clinical studies have found that women were less likely to succeed in quit attempts than men but large population studies have found no difference in success rates between the genders (Vangeli et al., 2011 ) so it may be the case that women who seek help with stopping have greater difficulty than men who seek help with stopping.

Number of cigarettes smoked per day, time between waking and the first cigarette of the day and rated strength of urges to smoke prior to a quit attempt have been found to predict success of quit attempts (Vangeli et al., 2011 ).

Quit attempts that involve gradual reduction are less likely to succeed than those that involve quitting abruptly, even after controlling statistically for measures of cigarette addiction, confidence in quitting, other methods used to quit (e.g. nicotine replacement therapy) and sociodemographic factors (Lindson-Hawley et al., 2016 ).

Interventions to combat smoking

There is extensive evidence on interventions that can reduce smoking prevalence, either by reducing initiation or promoting cessation. Table ​ Table3 3 lists those that have the strongest evidence.

Population-level interventions

Increasing the financial cost of smoking through tax increases and control of illicit supply on average reduces overall consumption with a typical price elasticity globally of 0.4 (meaning that for every 10% increase in the real cost there is a 4% decrease in the number of cigarettes purchased). Most of the effect is in getting smokers to reduce their daily cigarette consumption so the effect on smoking prevalence has been found to be an average of a 1–2 percentage point prevalence reduction for every 10% increase in the real cost (Levy, Huang, Havumaki, & Meza, 2016 ). It has been claimed that increasing taxes on tobacco increases the amount of smuggling of cheap tobacco, but the evidence does not support this (Action on Smoking and Health, 2015a ; Joossens & Raw, 2003 ).

Social marketing campaigns (e.g. TV advertising) can prevent smoking uptake, increase the rate at which smokers try to quit and improve the chances of success. This can lead to a reduction in smoking prevalence. Their effectiveness varies considerably with intensity, type of campaign and context (Bala, Strzeszynski, Topor-Madry, & Cahill, 2013 ; Hoffman & Tan, 2015 ).

Legislating to ban smoking in all indoor public areas may have a one-off effect on reducing smoking prevalence but findings are inconsistent across different countries (Bala et al., 2013 ). For example, in countries such as France it was not possible to detect an effect while in England, there did appear to be a decline in prevalence following the ban.

Although it is hard to show conclusively, circumstantial evidence suggests that banning tobacco advertising and putting large graphic health warnings on cigarette packets may have reduced smoking prevalence in some countries (Hoffman & Tan, 2015 ; Noar et al., 2016 ).

Individual-level interventions to promote smoking cessation

Brief advice.

Brief advice to stop smoking from a physician and offer of support to all smokers, regardless of motivation to quit, has been found in randomised trials to increase rate of quitting by an average of 2 percentage points of all those receiving it, whether or not they were initially interested in quitting (Stead et al., 2013 ). The offer of support appears to be more effective in getting smokers to try to quit than just advising smokers to stop (Aveyard, Begh, Parsons, & West, 2012 ).

Pharmacotherapy

Using a form of nicotine replacement therapy (NRT: transdermal patch, chewing gum, nasal spray, mouth spray, lozenge, inhalator, dissolvable strip) for at least 6 weeks from the start of a quit attempt increases the chances of long-term success of that quit attempt by about 3–7 percentage points if the user is under the care of a health professional or provided as part of a structured support programme (Stead et al., 2012 ). Some studies have found that NRT when bought from a shop and used without any additional structured support does not improve the chances of success at stopping (Kotz, Brown, & West, 2014a , 2014b ). A small proportion of people who use NRT to stop smoking continue to use it for months or even years after stopping smoking, but NRT appears to carry minimal risk to long-term users (Royal College of Physicians, 2016 ; Stead et al., 2012 ).

Data are sparse but at present, using an electronic cigarette in a quit attempt appears to increase the chances of success at stopping on average by an amount broadly similar to that from NRT; the variety of products available and the greater similarity to smoking appear to make them more attractive to many smokers as a means of stopping than NRT (McNeill et al., 2015 ; Royal College of Physicians, 2016 ). Electronic cigarettes deliver nicotine to users by heating a liquid containing nicotine, propylene glycol or glycerol and usually flavourings to create a vapour that is inhaled. They appear to carry minimal acute risk to users. If they are used long-term, their risk is almost certainly much less than that of smoking (based on concentrations of chemicals in the vapour) (McNeill et al., 2015 ; Royal College of Physicians, 2016 ).

‘Dual-form NRT’ (combining a transdermal NRT patch and one of the other forms) increases the chances of success at stopping more than ‘single-form NRT’ (just using one of the products) (Stead et al., 2012 ). Starting to use a nicotine transdermal patch several weeks before the target quit date may improve the chances of success at quitting compared with starting on the quit date (Stead et al., 2012 ).

Taking the prescription anti-depressant, bupropion (brand name Zyban), improves the chances of success of quit attempts by a similar amount to single-form NRT (Hughes, Stead, Hartmann-Boyce, Cahill, & Lancaster, 2014 ). Bupropion often leads to sleep disturbance and carries a very small risk of seizure. Bupropion probably works by reducing urges to smoke rather than any effect on depressed mood, but how it does this is not known. It is contra-indicated in pregnant smokers and people with an elevated seizure risk or history of eating disorder (Hughes et al, 2014 ). Taking the tricyclic anti-depressant, nortriptyline also improves the chances of success of quit attempts, probably by about the same amount as bupropion and NRT (Hughes et al., 2014 ). Its mechanism of action is not known. Nortriptyline often leads to dry mouth and sleep disorder and can be fatal in overdose (Hughes et al., 2014 ).

Taking the nicotinic-acetylcholine receptor partial agonist, varenicline (brand name Chantix in the US and Champix elsewhere), improves the chances of success by about 50% more than bupropion or single-form NRT (Cahill, Lindson-Hawley, Thomas, Fanshawe, & Lancaster, 2016 ). This is true for smokers with or without a psychiatric disorder (Anthenelli et al., 2016 ). Varenicline appears to work both by reducing urges to smoke and the rewarding effect of nicotine should a lapse occur (West, Baker, Cappelleri, & Bushmakin, 2008 ). Varenicline often leads to sleep disturbance and nausea. Serious neuropsychiatric and cardiovascular adverse reactions have been reported, but in comparative studies these have not been found to be more common than placebo or NRT (Anthenelli et al., 2016 ; Cahill et al., 2016 ; Sterling, Windle, Filion, Touma, & Eisenberg, 2016 ).

Taking the nicotinic-acetylcholine receptor partial agonist, cytisine, appears to improve the chances of success at least as much as single-form NRT and probably more (Cahill et al., 2016 ). Cytisine often causes nausea. No serious adverse reactions have been reported to date (Cahill et al., 2016 ). Where it is licensed for sale, cytisine is less than 1/10th the cost of other smoking cessation medications (Cahill et al., 2016 ).

Behavioural support

There is good evidence that behavioural interventions of many kinds, delivered though several modalities can help smokers to stop. Thus, behavioural support (encouragement, advice and discussion) from a trained stop-smoking specialist, provided at least weekly until at least 4 weeks following the target quit date can increase the chances of long-term success of a quit attempt by about 3–7 percentage points, whether it is given by phone or face-to-face (Lancaster & Stead, 2005 ). Group behavioural support (specialist-led groups of smokers stopping together and engaging in a structured discussion about their experiences), involving at least weekly sessions lasting until at least 4 weeks after the target quit date can increase the chances of success of a quit attempt by a similar amount or possibly more than individual support (Stead & Lancaster, 2005 ). Scheduled, multi-session telephone support can improve rates of success at stopping smoking by a broadly similar amount (Stead, Hartmann-Boyce, Perera, & Lancaster, 2013 ) but some large studies have failed to detect an effect so contextual factors and/or the precise type of support could be crucial to success. The effects of behavioural support and medication/NRT on success at stopping smoking appear to combine roughly additively (Stead, Koilpillai, & Lancaster, 2015 ). Smoking cessation support appears to be effective in primary care, secondary care and worksite settings (Cahill & Lancaster, 2014 ; West et al., 2015 ). Financial incentives, in the form of vouchers, have been found to increase smoking cessation rates for as long as they are in place (Cahill, Hartmann-Boyce, & Perera, 2015 ; Higgins & Solomon, 2016 ). Printed self-help materials can improve the chances of success at stopping long term by around 1–2 percentage points (Hartmann-Boyce, Lancaster, & Stead, 2014 ).

There is still relatively limited evidence on the effectiveness of digital support interventions for smoking cessation. Thus, while there is evidence that tailored, interactive websites can improve the chances of success at stopping smoking compared with no support, brief written materials or static information websites, many of those tested have not been found to be effective and it is not clear what differentiates those that are effective from those that are not (Graham et al., 2016 ). Text messaging programmes have been found to increase the chances of success of quit attempts by about 2–7 percentage points (Whittaker, McRobbie, Bullen, Rodgers, & Gu, 2016 ). There is currently insufficient evidence to know whether smartphone applications can improve success rates of quit attempts, although preliminary data suggest that they might (Whittaker et al., 2016 ). Evidence on alternative and complementary therapies is not sufficient to make confident statements about their effectiveness as aids to smoking cessation (Barnes et al., 2010 ; White, Rampes, Liu, Stead, & Campbell, 2014 ).

Overall, the highest smoking cessation rates appear to be achieved using specialist face-to-face behavioural support together with either varenicline or dual form NRT. With this support, continuous abstinence rates up to 52 weeks, verified by expired-air carbon monoxide tests, of more than 40% have been achieved (Kralikova et al., 2013 ). More commonly, 52-week continuous abstinence rates with this treatment are between 15 and 25% (West et al., 2015 ).

Smoking cessation support for pregnant smokers

In pregnant smokers, there is some evidence that NRT can help promote smoking cessation but evidence for an effect sustained to end of pregnancy is not conclusive (Sterling et al., 2016 ). There is also evidence that written self-help materials and face-to-face behavioural support can aid smoking cessation (Jones, Lewis, Parrott, Wormall, & Coleman, 2016 ), and financial incentives have also been found to improve quitting rates among pregnant smokers (Tappin et al., 2015 ). Almost half of women who stop smoking during pregnancy as a result of a clinical intervention relapse to smoking within 6 months of the birth (Jones et al., 2016 ).

Effectiveness of programmes to reduce smoking uptake

School-based programmes that involve both social competence training and peer-led social influence have been found to reduce smoking uptake (Georgie, Sean, Deborah, Matthew, & Rona, 2016 ) but educational programmes have not (Thomas, McLellan, & Perera, 2013 ). Mass media campaigns and increasing the financial cost of smoking reduce smoking uptake (Brinn, Carson, Esterman, Chang, & Smith, 2012 ; van Hasselt et al., 2015 ).

Reducing the harm from tobacco and nicotine use

Smokers who report that they are reducing their cigarette consumption smoke only 1–2 fewer cigarettes per day on average than when they say they are not (Beard et al., 2013 ). Clinical trials have found that use of NRT while smoking can substantially reduce cigarette consumption compared with placebo (Royal College of Physicians, 2016 ) but national surveys show very little reduction in cigarette consumption when smokers take up use of NRT in real-world settings (Beard et al., 2013 ). The benefit from using NRT while continuing to smoke appears to be in promoting subsequent smoking cessation. Using NRT (or varenicline) to reduce cigarette smoking with no immediate plans to quit leads to increased rates of quitting subsequently (Wu, Sun, He, & Zeng, 2015 ).

‘Snus’, a form of tobacco that is placed between the gums and the cheek and which is prepared in a way that is very low in carcinogens, gives high doses of nicotine but without evidence of an increase in risk of major tobacco-related cancers and either no, or a small, increase in risk of heart disease. It does appear to increase risk of periodontal disease, however. Snus is very popular in Sweden. Sweden has very low rates of smoking and tobacco-related disease indicating that a form of nicotine intake other than smoking can become popular and suggesting that this can contribute to a substantial reduction in tobacco-related harm (Royal College of Physicians, 2016 ).

The introduction of complete bans on smoking in indoor public areas can also be considered as a harm reduction measure. In this case, the main issue is harm to non-tobacco users. The evidence shows that such bans have been rapidly followed in the UK and several other jurisdictions by a reduction in heart attacks in non-smokers (Action on Smoking and Health, 2014a ).

Conclusions

Tobacco smoking causes death and disability on a huge scale and only about half of smokers report enjoying it. Despite this, approximately 1 billion adults engage in this behaviour worldwide and only around 5% of unaided quit attempts succeed for 6 months or more. The main reason appears to be that cigarettes deliver nicotine rapidly to the brain in a form that is convenient, and palatable. Nicotine acts on the brain to create urges to smoke in situations where smoking would normally occur and when brain nicotine levels become depleted. Concern about the harm from, and financial cost of, smoking are mostly not sufficient to counter this.

Governments can reduce smoking prevalence by raising the cost of smoking through taxation, mounting sustained social marketing campaigns, ensuring that health professionals routinely advise smokers to stop and offer support for quitting, and make available pharmacological and behavioural support for stopping.

Statement of competing interests

RW has, within the past 3 years, undertaken research and consultancy for companies that develop and manufacture smoking cessation medications (Pfizer, GSK, and J&J). He is an unpaid advisor to the UK’s National Centre for Smoking cessation and Training. His salary is funded by Cancer Research UK.

Disclosure statement

No potential conflict of interest was reported by the author.

This work was supported by Cancer Research UK [grant number C1417/A22962].

• Action on Smoking and Health (2013). Smoking and reproduction . London: ASH; Retrieved from http://www.ash.org.uk/files/documents/ASH_112.pdf [ Google Scholar ]
• Action on Smoking and Health (2014a). Secondhand smoke . London: ASH; Retrieved from http://www.ash.org.uk/files/documents/ASH_113.pdf [ Google Scholar ]
• Action on Smoking and Health (2014b). What’s in a cigarette? London: ASH; Available from http://www.ash.org.uk/files/documents/ASH_117.pdf [ Google Scholar ]
• Action on Smoking and Health (2015a). Illicit trade in tobacco . London: ASH; Available from http://www.ash.org.uk/files/documents/ASH_122.pdf [ Google Scholar ]
• Action on Smoking and Health (2015b). Young people and smoking . London: ASH; Retrieve from http://www.ash.org.uk/files/documents/ASH_108.pdf [ Google Scholar ]
• Action on Smoking and Health (2016a). Smoking and mental health . London: ASH; Retrieved from http://www.ash.org.uk/files/documents/ASH_120.pdf [ Google Scholar ]
• Action on Smoking and Health (2016b). Smoking statistics: Illness and death . London: ASH; Retrieved from http://www.ash.org.uk/files/documents/ASH_107.pdf [ Google Scholar ]
• Action on Smoking and Health (2016c). Smoking statistics: Who smokes and how much? London: ASH; Retrieved from http://www.ash.org.uk/files/documents/ASH_106.pdf [ Google Scholar ]
• Anthenelli R. M., Benowitz N. L., West R., St Aubin L., McRae T., Lawrence D., & Evins A. E. (2016). Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): A double-blind, randomised, placebo-controlled clinical trial . The Lancet , , 2507–2520. doi: 10.1016/s0140-6736(16)30272-0 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Australian Bureau of Statistics (2015). National health survey . Canberra: Author. [ Google Scholar ]
• Aveyard P., Begh R., Parsons A., & West R. (2012). Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance . Addiction , , 1066–1073. doi: 10.1111/j.1360-0443.2011.03770.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bala M. M., Strzeszynski L., Topor-Madry R., & Cahill K (2013). Mass media interventions for smoking cessation in adults . Cochrane Database of Systematic Reviews , , Cd004704. doi: 10.1002/14651858.CD004704.pub3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barnes J., Dong C. Y., McRobbie H., Walker N., Mehta M., & Stead L. F. (2010). Hypnotherapy for smoking cessation . Cochrane Database of Systematic Reviews , , Cd001008. doi: 10.1002/14651858.CD001008.pub2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Beard E., McNeill A., Aveyard P., Fidler J., Michie S., & West R. (2013). Association between use of nicotine replacement therapy for harm reduction and smoking cessation: A prospective study of English smokers . Tobacco Control , , 118–122. 10.1136/tobaccocontrol-2011-050007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Benowitz N. L. (1997). The role of nicotine in smoking-related cardiovascular disease . Preventive Medicine , , 412–417. 10.1006/pmed.1997.0175 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Benowitz N. L. (1998). Nicotine safety and toxicity . Oxford: Oxford University Press. [ Google Scholar ]
• Brinn M. P., Carson K. V., Esterman A. J., Chang A. B., & Smith B. J. (2012). Cochrane review: Mass media interventions for preventing smoking in young people . Evidence-based Child Health: A Cochrane Review Journal , , 86–144. 10.1002/ebch.v7.1 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cahill K., Hartmann-Boyce J., & Perera R (2015). Incentives for smoking cessation . Cochrane Database of Systematic Reviews , , Cd004307. doi: 10.1002/14651858.CD004307.pub5 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cahill K., & Lancaster T (2014). Workplace interventions for smoking cessation . Cochrane Database of Systematic Reviews , , Cd003440. doi: 10.1002/14651858.CD003440.pub4 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cahill K., Lindson-Hawley N., Thomas K. H., Fanshawe T. R., & Lancaster T (2016). Nicotine receptor partial agonists for smoking cessation . Cochrane Database of Systematic Reviews , , Cd006103. doi: 10.1002/14651858.CD006103.pub7 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Critchley J., & Unal B. (2003). Health effects associated with smokeless tobacco: A systematic review . Thorax , , 435–443. 10.1136/thorax.58.5.435 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dierker L., He J., Kalaydjian A., Swendsen J., Degenhardt L., Glantz M., & Merikangas K. (2008). The importance of timing of transitions for risk of regular smoking and nicotine dependence . Annals of Behavioral Medicine , , 87–92. doi: 10.1007/s12160-008-9051-x [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Doll R., Peto R., Boreham J., & Sutherland I. (2004). Mortality in relation to smoking: 50 years’ observations on male British doctors . British Medical Journal , , 1519. doi: 10.1136/bmj.38142.554479.AE [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Eriksen M., Mackay J., & Ross H (2013). The tobacco atlas . New York, NY: American Cancer Society. [ Google Scholar ]
• Ferri C. P., West R., Moriyama T. S., Acosta D., Guerra M., Huang Y., … Prince M. J. (2011). Tobacco use and dementia: Evidence from the 1066 dementia population-based surveys in Latin America, China and India . International Journal of Geriatric Psychiatry , , 1177–1185. doi: 10.1002/gps.2661 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fidler J., Shahab L., & West R. (2011). Strength of urges to smoke as a measure of severity of cigarette dependence: Comparison with the fagerström test for nicotine dependence and its components . Addiction , , 631–638. 10.1111/add.2011.106.issue-3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fidler J., & West R. (2009). Self-perceived smoking motives and their correlates in a general population sample . Nicotine & Tobacco Research , , 1182–1188. doi: 10.1093/ntr/ntp120 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fidler J., & West R. (2011). Enjoyment of smoking and urges to smoke as predictors of attempts and success of attempts to stop smoking: A longitudinal study . Drug and Alcohol Dependence , , 30–34. doi: 10.1016/j.drugalcdep.2010.10.009 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Georgie J. M., Sean H., Deborah M. C., Matthew H., & Rona C. (2016). Peer-led interventions to prevent tobacco, alcohol and/or drug use among young people aged 11–21 years: a systematic review and meta-analysis . Addiction , , 391–407. doi: 10.1111/add.13224 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gowing L. R., Ali R. L., Allsop S., Marsden J., Turf E. E., West R., & Witton J. (2015). Global statistics on addictive behaviours: 2014 status report . Addiction , , 904–919. doi: 10.1111/add.12899 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Graham A. L., Carpenter K. M., Cha S., Cole S., Jacobs M. A., Raskob M., & Cole-Lewis H. (2016). Systematic review and meta-analysis of internet interventions for smoking cessation among adults . Substance Abuse and Rehabilitation , , 55–69. doi: 10.2147/sar.s101660 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hartmann-Boyce J., Lancaster T., & Stead L. F (2014). Print-based self-help interventions for smoking cessation . Cochrane Database of Systematic Reviews , , Cd001118. doi: 10.1002/14651858.CD001118.pub3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Higgins S. T., & Solomon L. J. (2016). Some recent developments on financial incentives for smoking cessation among pregnant and newly postpartum women . Current Addiction Reports , , 9–18. doi: 10.1007/s40429-016-0092-0 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hoffman S. J., & Tan C. (2015). Overview of systematic reviews on the health-related effects of government tobacco control policies . BMC Public Health , , 744. doi: 10.1186/s12889-015-2041-6 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hogg R. C. (2016). Contribution of monoamine oxidase inhibition to tobacco dependence: A review of the evidence . Nicotine & Tobacco Research , , 509–523. doi: 10.1093/ntr/ntv245 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hughes J. R., Keely J., & Naud S. (2004). Shape of the relapse curve and long-term abstinence among untreated smokers . Addiction , , 29–38. 10.1111/add.2004.99.issue-1 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hughes J. R., Stead L. F., Hartmann-Boyce J., Cahill K., & Lancaster T (2014). Antidepressants for smoking cessation . Cochrane Database of Systematic Reviews , , Cd000031. doi: 10.1002/14651858.CD000031.pub4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jamal A. (2016). Current cigarette smoking among adults – United States, 2005–2015 . Morbidity and Mortality Weekly Report , , 1205–1211 [ PubMed ] [ Google Scholar ]
• Jamal A., Homa D., O’Connor E., Babb S., Caraballo R., Singh T., & King B. (2015). Current cigarette smoking among adults – United States, 2005–2014 . Morbidity and Mortality Weekly Report , , 1233–1240. 10.15585/mmwr.mm6444a2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jarvis M. J., Giovino G. A., O’Connor R. J., Kozlowski L. T., & Bernert J. T. (2014). Variation in nicotine intake among U.S. cigarette smokers during the past 25 years: Evidence from NHANES surveys . Nicotine & Tobacco Research , , 1620–1628. doi: 10.1093/ntr/ntu120 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jha P., & Peto R. (2014). Global effects of smoking, of quitting, and of taxing tobacco . New England Journal of Medicine , , 60–68. doi: 10.1056/NEJMra1308383 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jones M., Lewis S., Parrott S., Wormall S., & Coleman T. (2016). Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: A systematic review . Addiction , , 981–990. doi: 10.1111/add.13309 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Joossens L., & Raw M. (2003). Turning off the tap: The real solution to cigarette smuggling . International Journal of Tuberculosis and Lung Disease , , 214–222. [ PubMed ] [ Google Scholar ]
• Kotz D., Brown J., & West R. (2014a). Prospective cohort study of the effectiveness of smoking cessation treatments used in the “real world” . Mayo Clinic Proceedings , , 1360–1367. doi: 10.1016/j.mayocp.2014.07.004 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kotz D., Brown J., & West R. (2014b). ‘Real-world’ effectiveness of smoking cessation treatments: A population study . Addiction , , 491–499. doi: 10.1111/add.12429 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kozlowski L. T., Porter C. Q., Orleans C. T., Pope M. A., & Heatherton T. (1994). Predicting smoking cessation with self-reported measures of nicotine dependence: FTQ, FTND, and HSI . Drug and Alcohol Dependence , , 211–216. 10.1016/0376-8716(94)90158-9 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kralikova E., Kmetova A., Stepankova L., Zvolska K., Davis R., & West R. (2013). Fifty-two-week continuous abstinence rates of smokers being treated with varenicline versus nicotine replacement therapy . Addiction , , 1497–1502. doi: 10.1111/add.12219 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lancaster T., & Stead L. F (2005). Individual behavioural counselling for smoking cessation . Cochrane Database of Systematic Reviews , , Cd001292. doi: 10.1002/14651858.CD001292.pub2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Levy D. T., Huang A. T., Havumaki J. S., & Meza R. (2016). The role of public policies in reducing smoking prevalence: Results from the Michigan SimSmoke tobacco policy simulation model . Cancer Causes and Control , , 615–625. doi: 10.1007/s10552-016-0735-4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lindson-Hawley N., Banting M., West R., Michie S., Shinkins B., & Aveyard P. (2016). Gradual versus abrupt smoking cessation: A randomized, controlled noninferiority trial . Annals of Internal Medicine , , 585–592. doi: 10.7326/m14-2805 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• McNeill A., Brose L., Calder R., Hitchman S., Hajek P., & McRobbie H. (2015). E-cigarettes: An evidence update. A report commissioned by Public Health England . London: Public Health England. [ Google Scholar ]
• Noar S. M., Francis D. B., Bridges C., Sontag J. M., Ribisl K. M., & Brewer N. T. (2016). The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies . Social Science & Medicine , , 118–129. doi: 10.1016/j.socscimed.2016.06.011 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Office of National Satistics (2016). Smoking prevalence in Great Britain . London: ONS; Retrieved from https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/adultsmokinghabitsingreatbritain [ Google Scholar ]
• Royal College of Physicians and Royal College of Psychiatrists (2013). Smoking and mental health . London: RCP. [ Google Scholar ]
• Pirie K., Peto R., Reeves G. K., Green J., & Beral V. (2013). The 21st century hazards of smoking and benefits of stopping: A prospective study of one million women in the UK . Lancet , , 133–141. doi: 10.1016/s0140-6736(12)61720-6 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Royal College of Physicians. (2016). Nicotine without smoke: Tobacco harm reduction . London: RCP. [ Google Scholar ]
• Schepis T. S., & Rao U. (2005). Epidemiology and etiology of adolescent smoking . Current Opinion in Pediatrics , , 607–612. 10.1097/01.mop.0000176442.49743.31 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shahab L., & West R. (2009). Do ex-smokers report feeling happier following cessation? Evidence from a cross-sectional survey . Nicotine & Tobacco Research , , 553–557. doi: 10.1093/ntr/ntp031 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shahab L., & West R. (2012). Differences in happiness between smokers, ex-smokers and never smokers: cross-sectional findings from a national household survey . Drug and Alcohol Dependence , , 38–44. doi: 10.1016/j.drugalcdep.2011.08.011 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stapleton J. A., & West R. (2012). A direct method and ICER tables for the estimation of the cost-effectiveness of smoking cessation interventions in general populations: application to a new cytisine trial and other examples . Nicotine & Tobacco Research , , 463–471. doi: 10.1093/ntr/ntr236 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stead L. F., Buitrago D., Preciado N., Sanchez G., Hartmann-Boyce J., & Lancaster T (2013). Physician advice for smoking cessation . Cochrane Database of Systematic Reviews , , Cd000165. doi: 10.1002/14651858.CD000165.pub4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stead L. F., Hartmann-Boyce J., Perera R., & Lancaster T (2013). Telephone counselling for smoking cessation . Cochrane Database of Systematic Reviews , , Cd002850. doi: 10.1002/14651858.CD002850.pub3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stead L. F., Koilpillai P., & Lancaster T (2015). Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation . Cochrane Database of Systematic Reviews , , Cd009670. doi: 10.1002/14651858.CD009670.pub3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stead L. F., & Lancaster T (2005). Group behaviour therapy programmes for smoking cessation . Cochrane Database of Systematic Reviews , , Cd001007. doi: 10.1002/14651858.CD001007.pub2 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stead L. F., Perera R., Bullen C., Mant D., Hartmann-Boyce J., Cahill K., & Lancaster T. (2012). Nicotine replacement therapy for smoking cessation . Cochrane Database of Systematic Reviews , , Cd000146. doi: 10.1002/14651858.CD000146.pub4 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sterling L. H., Windle S. B., Filion K. B., Touma L., & Eisenberg M. J. (2016). Varenicline and adverse cardiovascular events: A systematic review and meta-analysis of randomized controlled trials . Journal of the American Heart Association , , doi: 10.1161/jaha.115.002849 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Talati A., Keyes K., & Hasin D. (2016). Changing relationships between smoking and psychiatric disorders across twentieth century birth cohorts: Clinical and research implications . Molecular Psychiatry , , 464–471. doi: 10.1038/mp.2015.224 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Talip T., Murang Z., Kifli N., & Naing L. (2016). Systematic review of smoking initiation among Asian Adolescents, 2005–2015: Utilizing the frameworks of triadic influence and planned behavior . Asian Pacific Journal of Cancer Prevention , , 3341–3355. [ PubMed ] [ Google Scholar ]
• Tappin D., Bauld L., Purves D., Boyd K., Sinclair L., MacAskill S., & Coleman T. (2015). Financial incentives for smoking cessation in pregnancy: Randomised controlled trial . British Medical Journal , , h134. doi: 10.1136/bmj.h134 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Thomas R. E., McLellan J., & Perera R. (2013). School-based programmes for preventing smoking . Evidence-based Child Health: A Cochrane Review Journal , , 1616–2040. 10.1002/ebch.v8.5 [ CrossRef ] [ Google Scholar ]
• US Department of Health and Human Services (2004). The health consequences of smoking: a report of the surgeon general (p. 62). Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. [ Google Scholar ]
• US Department of Health Human Services (2014). The health consequences of smoking – 50 years of progress: A report of the surgeon general (p. 17). Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. [ Google Scholar ]
• US Surgeon General. (1990). The health benefits of smoking cessation . Washington, DC: Department of Health and Human Services. [ Google Scholar ]
• Ussher M., Brown J., Rajamanoharan A., & West R. (2014). How do prompts for attempts to quit smoking relate to method of quitting and quit success? Annals of Behavioral Medicine , , 358–368. doi: 10.1007/s12160-013-9545-z [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Hasselt M., Kruger J., Han B., Caraballo R. S., Penne M. A., Loomis B., & Gfroerer J. C. (2015). The relation between tobacco taxes and youth and young adult smoking: What happened following the 2009 US federal tax increase on cigarettes? Addictive Behaviors , , 104–109. 10.1016/j.addbeh.2015.01.023 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vangeli E., Stapleton J., Smit E. S., Borland R., & West R. (2011). Predictors of attempts to stop smoking and their success in adult general population samples: A systematic review . Addiction , , 2110–2121. doi: 10.1111/j.1360-0443.2011.03565.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vink J. M., Willemsen G., & Boomsma D. I. (2005). Heritability of smoking initiation and nicotine dependence . Behavior Genetics , , 397–406. doi: 10.1007/s10519-004-1327-8 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• West R. (2009). The multiple facets of cigarette addiction and what they mean for encouraging and helping smokers to stop . Chronic Obstructive Pulmonary Disease , , 277–283. 10.1080/15412550903049181 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• West R., Baker C. L., Cappelleri J. C., & Bushmakin A. G. (2008). Effect of varenicline and bupropion SR on craving, nicotine withdrawal symptoms, and rewarding effects of smoking during a quit attempt . Psychopharmacology (Berl) , , 371–377. doi: 10.1007/s00213-007-1041-3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• West R., & Brown J. (2015). Smoking in England 2007–2014 . Retrieved from www.smokinginengland.info/latest-statistics/ [ Google Scholar ]
• West R., Raw M., McNeill A., Stead L., Aveyard P., Bitton J., & Borland R. (2015). Health-care interventions to promote and assist tobacco cessation: A review of efficacy, effectiveness and affordability for use in national guideline development . Addiction , , 1388–1403. doi: 10.1111/add.12998 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• West R., & Shiffman S (2016). Smoking cessation (3rd ed.). Abingdon: Health Press. [ Google Scholar ]
• White A. R., Rampes H., Liu J. P., Stead L.F., & Campbell J (2014). Acupuncture and related interventions for smoking cessation . Cochrane Database of Systematic Reviews , , Cd000009. doi: 10.1002/14651858.CD000009.pub4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Whittaker R., McRobbie H., Bullen C., Rodgers A., & Gu Y. (2016). Mobile phone-based interventions for smoking cessation . Cochrane Database of Systematic Reviews , , Cd006611. doi: 10.1002/14651858.CD006611.pub4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization (2013). WHO report on the global tobacco epidemic, 2013: enforcing bans on tobacco advertising, promotion and sponsorship . Geneva: WHO. [ Google Scholar ]
• Wu L., Sun S., He Y., & Zeng J. (2015). Effect of smoking reduction therapy on smoking cessation for smokers without an intention to quit: An updated systematic review and meta-analysis of randomized controlled . International Journal of Environmental Research and Public Health , , 10235–10253. doi: 10.3390/ijerph120910235 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zhou X., Nonnemaker J., Sherrill B., Gilsenan A. W., Coste F., & West R. (2009). Attempts to quit smoking and relapse: Factors associated with success or failure from the ATTEMPT cohort study . Addictive Behaviors , , 365–373. doi: 10.1016/j.addbeh.2008.11.013 [ PubMed ] [ CrossRef ] [ Google Scholar ]