Tobacco use by smoking (cigarettes, cigars, pipes) or by smokeless products (chewing tobacco, snuff) is an addictive disease that continues to be a major public health problem. Smoking is the leading cause of preventable death and disease in the United States, resulting in nearly half a million premature deaths per year and more than $200 billion in direct health care costs and lost productivity. In addition, more than 8.6 million persons are disabled because of smoking-related diseases. Smoking causes more than twice as many deaths as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), alcohol abuse, motor vehicle crashes, illicit drug use, and suicide combined. On average, smokers die 10 years earlier than nonsmokers.
The objectives of this chapter are to help readers understand the physical and psychological effects of smoking and tobacco usage and to understand the basic principles involved in a smoking cessation program and how they are used.
CRITICAL COMPLICATIONS: Patients who use tobacco are at high risk for complications such as lung disease, cancer, and infections, as well as complications of other systemic and oral diseases. These complications could prove serious. Dentists must be able to detect these patients based on history and clinical findings, refer them for medical diagnosis and management, and work closely with their physicians to develop dental management plans that will be effective and safe for these patients.
Epidemiology
It is estimated that approximately 20.6% (46 million) of adults older than the age of 18 years in the United States are current smokers and that of these, 78.1% (36.4 million) smoke every day ( Table 8.1 ). Thus, in a dental practice of 2000 patients, it can be expected that approximately 400 patients will be smokers. Over the past few decades, the percentage of daily smokers who smoked more than 25 cigarettes per day (CPD) (i.e., heavy smokers) has decreased steadily. Although this trend is encouraging, the problem continues to be a serious public health issue ( Fig. 8.1 ).
| $4/pack | $5/pack | $6/pack | |
|---|---|---|---|
| 1 pack/day | $1460 | $1825 | $2190 |
| 2 packs/day | $2920 | $3350 | $4380 |
| 3 packs/day | $4380 | $5475 | $6570 |
The prevalence of current cigarette smoking varies substantially across population subgroups. Current smoking rates are higher among men (23.5%) than women (17.9%). Among racial/ethnic populations, Asians (12%) and Hispanics (14.5%) have the lowest prevalence of current smoking; multiracial individuals have the highest (29.5%) followed by Native Americans/Native Alaskans (23.2%), non-Hispanic whites (22.1%), and non-Hispanic blacks (21.3%). By education level, current smoking is most prevalent among adults who have earned graduate educational development (GED) diplomas (49.1%) and lowest in those with graduate degrees (5.6%). Persons 65 years and older have the lowest prevalence of current cigarette smoking (9.5%) among all adults. Current smoking prevalence is higher among adults who live below the poverty level (31.1%) than among those at or above the poverty level (19.4%). Smoking prevalence also varies significantly by state and area, ranging from 9.8% in Utah to 25.6% in Kentucky and West Virginia ( Fig. 8.2 ).
The use of smokeless tobacco is primarily seen in men and adolescent boys who are rural residents of southern and western states, whites, Native Americans and Native Alaskans, and persons with lower levels of education. Prevalence is highest in Wyoming (9.1%), West Virginia (8.5%), and Mississippi (7.5%) and lowest in California (1.3%), the District of Columbia (1.5%), Massachusetts (1.5%), and Rhode Island (1.5%) ( Fig. 8.3 ). The use of smokeless tobacco became a national public health issue in the early to mid-1980s, when tobacco companies aggressively marketed their products by targeting young people. This practice was halted as a result of Congressional legislation and resulted in a gradual decline in prevalence.
The economic impact of smoking is staggering. On a national level, the U.S. Public Health Service estimates a total annual cost of $50 billion for the treatment of patients with smoking-related disease in addition to $47 billion in lost wages and productivity. For the individual smoker, the economic impact of smoking can be substantial, especially given that many smokers have limited financial resources.
Pathophysiology and Complications
Smoking is a learned or conditioned behavior that is reinforced by nicotine. Cigarettes promote this conditioning because they allow precise dosing that can be repeated as often as necessary to avoid discomfort and produce maximal desired effects. In addition, smoking behavior is reinforced by and associated with common daily events such as awakening, eating, and socializing. Thus, these associations become almost unavoidable parts of smokers’ lives.
Nicotine is a highly addictive drug that has been equated with heroin, cocaine, and amphetamine in terms of addiction potential and its effects on brain neurochemistry. The addictive and behavioral effects of nicotine are complex and are due primarily to its effects on dopaminergic pathways. The physiologic and behavioral effects of nicotine include increased heart rate, increased cardiac output, increased blood pressure, appetite suppression, a strong sense of pleasure and well-being, improved task performance, and reduced anxiety. Tolerance develops with repeated exposure so that, over time, it takes more and more nicotine to produce the same level of effect.
Nicotine is absorbed through the skin and the mucosal lining of the nose and mouth and by inhalation in the lungs. A cigarette is a very efficient delivery system for the inhalation of nicotine. Nicotine is rapidly distributed throughout the body after inhalation, reaching the brain in as little as 10 seconds.
Mucosal absorption from smokeless tobacco is slower, but the effects are more sustained. Nicotine that is swallowed is not well absorbed in the stomach because of the acidic environment.
The effects of nicotine gradually diminish over 30 to 120 minutes; this produces withdrawal effects that may include agitation, restlessness, anxiety, difficulty concentrating, insomnia, hunger, and a craving for cigarettes. The elimination half-life of nicotine is about 2 hours, which allows it to accumulate with repeated exposure to cigarettes throughout the day, with effects persisting for hours.
A typical smoker will take 10 puffs of every cigarette over a period of about 5 minutes that the cigarette is lit. Each cigarette delivers about 1 mg of nicotine. Thus, a person who smokes about packs (30 cigarettes) a day gets 300 hits of nicotine to the brain every day, each one within 10 seconds after a puff. This repeated reinforcement is a strong contributor to the highly addictive nature of nicotine.
Cigarette smoking is a major risk factor for stroke, myocardial infarction, peripheral vascular disease, aortic aneurysm, and sudden death. It is the leading cause of lung disease, including chronic obstructive pulmonary disease (COPD), pneumonia, and lung cancer. It is also strongly linked to cancers of the mouth, esophagus, stomach, pancreas, cervix, kidney, colon, and bladder. Other effects include premature skin aging and an increased risk for cataracts. Cigar and pipe smokers are subject to similar addictive and general health risks as are cigarette smokers, although pipe and cigar users typically do not inhale. Evidence suggests that smokeless tobacco use may be associated with adverse pregnancy outcomes and pancreatic cancer.
Health care professionals must be vigilant in identifying patients who use tobacco with the goals of encouraging them to stop smoking and assisting them in their efforts. Studies indicate that 70% of smokers want to quit smoking. However, for every smoker who successfully quits, many more do not succeed. Tobacco dependence is a chronic condition that often requires repeated attempts at intervention. Smokers typically fail multiple attempts to quit before they achieve success.
People who quit smoking live longer than those who continue to smoke because of avoiding the development of smoking-related fatal diseases. The extent to which a smoker’s risk is reduced by quitting depends on several factors, including number of years as a smoker, number of cigarettes smoked per day, and presence or absence of disease at the time of quitting. Data show that persons who quit smoking before 50 years of age have half the risk of dying in the next 15 years compared with those who continue smoking. Risks of dying of lung cancer are 22 times higher among male smokers and 12 times higher among female smokers than in those who have never smoked. Smokers have twice the risk of dying of coronary heart disease as lifetime nonsmokers. Compared with lifetime nonsmokers, smokers have about twice the risk of dying from a stroke. Smoking increases the risk of COPD by accelerating the age-related decline in lung function. Box 8.1 lists short- and long-term benefits of smoking cessation.
- •
20 minutes after quitting: Your heart rate drops. (U.S. Surgeon General’s Report, 1988, pp 39, 202)
- •
12 hours after quitting: Carbon monoxide level in your blood drops to normal. (U.S. Surgeon General’s Report, 1988, p 202)
- •
2 weeks to 3 months after quitting: Your circulation improves, and your lung function increases. (U.S. Surgeon General’s Report, 1990, pp 193, 194, 196, 285, 323)
- •
1 to 9 months after quitting: Coughing and shortness of breath decrease; cilia (tiny hairlike structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce the risk of infection. (U.S. Surgeon General’s Report, 1990, pp 285-287, 304)
- •
1 year after quitting: The excess risk of coronary heart disease is half that of a smoker’s. (U.S. Surgeon General’s Report, 1990, p vi)
- •
5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting. (U.S. Surgeon General’s Report, 1990, p vi)
- •
10 years after quitting: The lung cancer death rate is about half that of a continuing smoker. Risks of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease. (U.S. Surgeon General’s Report, 1990, pp vi, 131, 148, 152, 155, 164, 166)
- •
15 years after quitting: The risk of coronary heart disease is that of a nonsmoker. (U.S. Surgeon General’s Report, 1990, p vi)
Quitting helps to stop the damaging effects of tobacco on your appearance, including the following:
- •
Premature wrinkling of the skin
- •
Bad breath
- •
Stained teeth
- •
Gum disease
- •
Bad-smelling clothes and hair
- •
Yellow fingernails
- •
Food tastes better
- •
Sense of smell returns to normal
- •
Ordinary activities (e.g., climbing stairs, light housework) no longer leave you out of breath
Pathophysiology and Complications
Smoking is a learned or conditioned behavior that is reinforced by nicotine. Cigarettes promote this conditioning because they allow precise dosing that can be repeated as often as necessary to avoid discomfort and produce maximal desired effects. In addition, smoking behavior is reinforced by and associated with common daily events such as awakening, eating, and socializing. Thus, these associations become almost unavoidable parts of smokers’ lives.
Nicotine is a highly addictive drug that has been equated with heroin, cocaine, and amphetamine in terms of addiction potential and its effects on brain neurochemistry. The addictive and behavioral effects of nicotine are complex and are due primarily to its effects on dopaminergic pathways. The physiologic and behavioral effects of nicotine include increased heart rate, increased cardiac output, increased blood pressure, appetite suppression, a strong sense of pleasure and well-being, improved task performance, and reduced anxiety. Tolerance develops with repeated exposure so that, over time, it takes more and more nicotine to produce the same level of effect.
Nicotine is absorbed through the skin and the mucosal lining of the nose and mouth and by inhalation in the lungs. A cigarette is a very efficient delivery system for the inhalation of nicotine. Nicotine is rapidly distributed throughout the body after inhalation, reaching the brain in as little as 10 seconds.
Mucosal absorption from smokeless tobacco is slower, but the effects are more sustained. Nicotine that is swallowed is not well absorbed in the stomach because of the acidic environment.
The effects of nicotine gradually diminish over 30 to 120 minutes; this produces withdrawal effects that may include agitation, restlessness, anxiety, difficulty concentrating, insomnia, hunger, and a craving for cigarettes. The elimination half-life of nicotine is about 2 hours, which allows it to accumulate with repeated exposure to cigarettes throughout the day, with effects persisting for hours.
A typical smoker will take 10 puffs of every cigarette over a period of about 5 minutes that the cigarette is lit. Each cigarette delivers about 1 mg of nicotine. Thus, a person who smokes about packs (30 cigarettes) a day gets 300 hits of nicotine to the brain every day, each one within 10 seconds after a puff. This repeated reinforcement is a strong contributor to the highly addictive nature of nicotine.
Cigarette smoking is a major risk factor for stroke, myocardial infarction, peripheral vascular disease, aortic aneurysm, and sudden death. It is the leading cause of lung disease, including chronic obstructive pulmonary disease (COPD), pneumonia, and lung cancer. It is also strongly linked to cancers of the mouth, esophagus, stomach, pancreas, cervix, kidney, colon, and bladder. Other effects include premature skin aging and an increased risk for cataracts. Cigar and pipe smokers are subject to similar addictive and general health risks as are cigarette smokers, although pipe and cigar users typically do not inhale. Evidence suggests that smokeless tobacco use may be associated with adverse pregnancy outcomes and pancreatic cancer.
Health care professionals must be vigilant in identifying patients who use tobacco with the goals of encouraging them to stop smoking and assisting them in their efforts. Studies indicate that 70% of smokers want to quit smoking. However, for every smoker who successfully quits, many more do not succeed. Tobacco dependence is a chronic condition that often requires repeated attempts at intervention. Smokers typically fail multiple attempts to quit before they achieve success.
People who quit smoking live longer than those who continue to smoke because of avoiding the development of smoking-related fatal diseases. The extent to which a smoker’s risk is reduced by quitting depends on several factors, including number of years as a smoker, number of cigarettes smoked per day, and presence or absence of disease at the time of quitting. Data show that persons who quit smoking before 50 years of age have half the risk of dying in the next 15 years compared with those who continue smoking. Risks of dying of lung cancer are 22 times higher among male smokers and 12 times higher among female smokers than in those who have never smoked. Smokers have twice the risk of dying of coronary heart disease as lifetime nonsmokers. Compared with lifetime nonsmokers, smokers have about twice the risk of dying from a stroke. Smoking increases the risk of COPD by accelerating the age-related decline in lung function. Box 8.1 lists short- and long-term benefits of smoking cessation.
- •
20 minutes after quitting: Your heart rate drops. (U.S. Surgeon General’s Report, 1988, pp 39, 202)
- •
12 hours after quitting: Carbon monoxide level in your blood drops to normal. (U.S. Surgeon General’s Report, 1988, p 202)
- •
2 weeks to 3 months after quitting: Your circulation improves, and your lung function increases. (U.S. Surgeon General’s Report, 1990, pp 193, 194, 196, 285, 323)
- •
1 to 9 months after quitting: Coughing and shortness of breath decrease; cilia (tiny hairlike structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce the risk of infection. (U.S. Surgeon General’s Report, 1990, pp 285-287, 304)
- •
1 year after quitting: The excess risk of coronary heart disease is half that of a smoker’s. (U.S. Surgeon General’s Report, 1990, p vi)
- •
5 years after quitting: Your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting. (U.S. Surgeon General’s Report, 1990, p vi)
- •
10 years after quitting: The lung cancer death rate is about half that of a continuing smoker. Risks of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease. (U.S. Surgeon General’s Report, 1990, pp vi, 131, 148, 152, 155, 164, 166)
- •
15 years after quitting: The risk of coronary heart disease is that of a nonsmoker. (U.S. Surgeon General’s Report, 1990, p vi)
Quitting helps to stop the damaging effects of tobacco on your appearance, including the following:
- •
Premature wrinkling of the skin
- •
Bad breath
- •
Stained teeth
- •
Gum disease
- •
Bad-smelling clothes and hair
- •
Yellow fingernails
- •
Food tastes better
- •
Sense of smell returns to normal
- •
Ordinary activities (e.g., climbing stairs, light housework) no longer leave you out of breath
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