informative essay on nicotine addiction

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• Nicotine dependence

Nicotine dependence occurs when you need nicotine and can't stop using it. Nicotine is the chemical in tobacco that makes it hard to quit. Nicotine produces pleasing effects in your brain, but these effects are temporary. So you reach for another cigarette.

The more you smoke, the more nicotine you need to feel good. When you try to stop, you experience unpleasant mental and physical changes. These are symptoms of nicotine withdrawal.

Regardless of how long you've smoked, stopping can improve your health. It isn't easy but you can break your dependence on nicotine. Many effective treatments are available. Ask your doctor for help.

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For some people, using any amount of tobacco can quickly lead to nicotine dependence. Signs that you may be addicted include:

• You can't stop smoking. You've made one or more serious, but unsuccessful, attempts to stop.
• You have withdrawal symptoms when you try to stop. Your attempts at stopping have caused physical and mood-related symptoms, such as strong cravings, anxiety, irritability, restlessness, difficulty concentrating, depressed mood, frustration, anger, increased hunger, insomnia, constipation or diarrhea.
• You keep smoking despite health problems. Even though you've developed health problems with your lungs or your heart, you haven't been able to stop.
• You give up social activities. You may stop going to smoke-free restaurants or stop socializing with family or friends because you can't smoke in these situations.

When to see a doctor

You're not alone if you've tried to stop smoking but haven't been able to stop for good. Most smokers make many attempts to stop smoking before they achieve stable, long-term abstinence from smoking.

You're more likely to stop for good if you follow a treatment plan that addresses both the physical and the behavioral aspects of nicotine dependence. Using medications and working with a counselor specially trained to help people stop smoking (a tobacco treatment specialist) will significantly boost your chances of success.

Ask your health care team to help you develop a treatment plan that works for you or to advise you on where to get help to stop smoking.

Video: Smoking — Anatomy of nicotine addiction

In many people, nicotine from cigarettes stimulates receptors in the brain to release dopamine, triggering a pleasure response. Over time, the number of nicotine receptors increases and changes your brain's anatomy. When you quit smoking, you cut off the brain's pleasure response because the receptors don't get nicotine, triggering nicotine withdrawal symptoms. If you stick it out and use stop-smoking products to help with withdrawal symptoms and cravings, the number of nicotine receptors returns to normal, helping you quit smoking for good.

Nicotine is the chemical in tobacco that keeps you smoking. Nicotine reaches the brain within seconds of taking a puff. In the brain, nicotine increases the release of brain chemicals called neurotransmitters, which help regulate mood and behavior.

Dopamine, one of these neurotransmitters, is released in the reward center of the brain and causes feelings of pleasure and improved mood.

The more you smoke, the more nicotine you need to feel good. Nicotine quickly becomes part of your daily routine and intertwined with your habits and feelings.

Common situations that trigger the urge to smoke include:

• Drinking coffee or taking breaks at work
• Talking on the phone
• Drinking alcohol
• Driving your car
• Spending time with friends

To overcome your nicotine dependence, you need to become aware of your triggers and make a plan for dealing with them.

Risk factors

Anyone who smokes or uses other forms of tobacco is at risk of becoming dependent. Factors that influence who will use tobacco include:

• Age. Most people begin smoking during childhood or the teen years. The younger you are when you begin smoking, the greater the chance that you'll become addicted.
• Genetics. The likelihood that you will start smoking and keep smoking may be partly inherited. Genetic factors may influence how receptors on the surface of your brain's nerve cells respond to high doses of nicotine delivered by cigarettes.
• Parents and peers. Children who grow up with parents who smoke are more likely to become smokers. Children with friends who smoke are also more likely to try it.
• Depression or other mental illness. Many studies show an association between depression and smoking. People who have depression, schizophrenia, post-traumatic stress disorder or other forms of mental illness are more likely to be smokers.
• Substance use. People who abuse alcohol and illegal drugs are more likely to be smokers.

Complications

Tobacco smoke contains more than 60 known cancer-causing chemicals and thousands of other harmful substances. Even "all natural" or herbal cigarettes have harmful chemicals.

You already know that people who smoke cigarettes are much more likely to develop and die of certain diseases than people who don't smoke. But you may not realize just how many different health problems smoking causes:

• Lung cancer and lung disease. Smoking is the leading cause of lung cancer deaths. In addition, smoking causes lung diseases, such as emphysema and chronic bronchitis. Smoking also makes asthma worse.
• Other cancers. Smoking increases the risk of many types of cancer, including cancer of the mouth, throat (pharynx), esophagus, larynx, bladder, pancreas, kidney, cervix and some types of leukemia. Overall, smoking causes 30% of all cancer deaths.
• Heart and circulatory system problems. Smoking increases your risk of dying of heart and blood vessel (cardiovascular) disease, including heart attacks and strokes. If you have heart or blood vessel disease, such as heart failure, smoking worsens your condition.
• Diabetes. Smoking increases insulin resistance, which can set the stage for type 2 diabetes. If you have diabetes, smoking can speed the progress of complications, such as kidney disease and eye problems.
• Eye problems. Smoking can increase your risk of serious eye problems such as cataracts and loss of eyesight from macular degeneration.
• Infertility and impotence. Smoking increases the risk of reduced fertility in women and the risk of impotence in men.
• Complications during pregnancy. Mothers who smoke while pregnant face a higher risk of preterm delivery and giving birth to lower birth weight babies.
• Cold, flu and other illnesses. Smokers are more prone to respiratory infections, such as colds, the flu and bronchitis.
• Tooth and gum disease. Smoking is associated with an increased risk of developing inflammation of the gum and a serious gum infection that can destroy the support system for teeth (periodontitis).

Smoking also poses health risks to those around you. Nonsmoking spouses and partners of smokers have a higher risk of lung cancer and heart disease compared with people who don't live with a smoker. Children whose parents smoke are more prone to worsening asthma, ear infections and colds.

The best way to prevent nicotine dependence is to not use tobacco in the first place.

The best way to keep children from smoking is to not smoke yourself. Research has shown that children whose parents do not smoke or who successfully quit smoking are much less likely to take up smoking.

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Mayo Clinic's unique tobacco program brings hope for long-term addiction

Thomas Bennett had tried to quit chewing tobacco 75 to 100 times before he came to Mayo Clinic. Even a precancerous lesion in his mouth hadn’t stopped him. Before every doctor’s appointment, “I’d throw my can of chew out, she would say I don’t have cancer, and then I would go get a can of chew again,” Thomas recalls. “That’s how strong my addiction was.” It was in April 2021 that Thomas joined Mayo Clinic’s…

• Tobacco and cancer fact sheet. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/tobacco-and-cancer-factsheet.pdf. Accessed Feb. 12, 2020.
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• DrugFacts: Cigarettes and other tobacco products. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/cigarettes-other-tobacco-products. Accessed Jan. 17, 2020.
• WHO report on the global tobacco epidemic 2019. https://www.who.int/tobacco/global_report/en/. Accessed Jan. 17, 2020.
• Rigotti NA. Overview of smoking cessation management in adults. http://www.uptodate.com/search. Accessed Feb. 24, 2020.
• Park ER. Behavioral approaches to smoking cessation. http://www.uptodate.com/search. Accessed Feb. 24, 2020.
• Rigotti NA, et al. Benefits and risks of smoking cessation. http://www.uptodate.com/search. Accessed Jan. 20, 2020.
• Goldman L, et al., eds. Nicotine and tobacco. In: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Jan. 17, 2020.
• Press HI, et al., eds. Tobacco control and primary prevention. In: IASLC Thoracic Oncology. 2nd ed. Elsevier; 2018. https://www.clinicalkey.com. Accessed Jan. 17, 2020.
• Get free help: Speak to an expert. Smokefree.gov. http://smokefree.gov/talk-to-an-expert. Accessed Jan. 20, 2020.
• Quit guide: Clearing the air. Smokefree.gov. https://www.cancer.gov/publications/patient-education/clearing-the-air. Accessed Jan. 20, 2020.
• Prepare to quit. https://www.becomeanex.org/prepare-to-quit/. Accessed Jan. 17, 2020.
• I want to quit smoking. American Lung Association. https://www.lung.org/stop-smoking/i-want-to-quit/. Accessed Jan. 20, 2020.
• AskMayoExpert. Tobacco use (adult). Mayo Clinic; 2019.
• Let's make the next generation tobacco-free. Your guide to the 50th anniversary Surgeon General's report on smoking and health. https://www.hhs.gov/sites/default/files/consequences-smoking-consumer-guide.pdf. Accessed Jan. 17, 2020.
• Office of Patient Education. My smoke-free future. Mayo Clinic; 2020.
• Tobacco and kids. American Academy of Child & Adolescent Psychiatry. http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Tobacco-And-Kids-068.aspx. Accessed Jan. 20, 2020.
• Parker MA, et al. Higher smoking prevalence among United States adults with co-occurring affective and drug use diagnoses. Addictive Behaviors. 2019; doi: 10.1016/j.addbeh.2019.106112.
• Secondhand Smoke (SHS) Facts. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm. Accessed Feb. 26, 2020.
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Tobacco, Nicotine, and E-Cigarettes Research Report Introduction

In 2014, the Nation marked the 50th anniversary of the first Surgeon General’s Report on Smoking and Health. In 1964, more than 40 percent of the adult population smoked. Once the link between smoking and its medical consequences—including cancers and heart and lung diseases—became a part of the public consciousness, education efforts and public policy changes were enacted to reduce the number of people who smoke. These efforts resulted in substantial declines in smoking rates in the United States—to half the 1964 level. 1

However, rates of cigarette smoking and other tobacco use are still too high, 2 and some populations are disproportionately affected by tobacco’s health consequences. Most notably, people with mental disorders—including substance use disorders—smoke at higher rates than the general population. 3–6 Additionally, people living below the poverty line and those with low educational attainment are more likely to smoke than those in the general population. As tobacco use is the leading preventable cause of mortality in the United States, 1 differential rates of smoking and use of other tobacco products is a significant contributor to health disparities among some of the most vulnerable people in our society.

• Introduction
• Conclusions
• Article Information

Among adolescents who were currently using any tobacco product, the proportion who initiated use with e-cigarettes increased over time, becoming the dominant first product in 2017. Percentages do not add up to 100% because some users initiated with more than 1 tobacco product at the same age. SLT indicates smokeless tobacco.

Mean age at first use decreased over time for e-cigarettes but remained stable for other tobacco products. Regression analyses are shown in eTable 2 in the Supplement . CCLC indicates cigar, cigarillo, and little cigar; SLT, smokeless tobacco.

Between 2014 and 2021, days of e-cigarette use per month shifted from light use to heavier use. Statistical results are shown in eTable 3 in the Supplement .

Includes e-cigarette users who used no other tobacco products. After remaining stable from 2014 to 2017 ( P = .74 by interrupted time series analysis), the proportion of users who consumed their first e-cigarette within 5 minutes of waking rapidly increased more than 10-fold ( P  = .002 for slope change following 2017 by interrupted time series analysis). Error bars indicate SEs.

A, The estimated number of adolescents with high levels of nicotine dependence and who were sole users of e-cigarettes diverged from the numbers for other products in 2018, exceeding the sum of use of cigarettes and all other products combined. B, Considering dual-product users with the other products confirms that e-cigarette users began to exceed use of all other tobacco products among adolescents with high levels of nicotine dependence. The 2021 numbers may underestimate tobacco use compared with earlier years, as discussed in the Limitations subsection of the Discussion section. SLT indicates smokeless tobacco.

eFigure 1. Number of Adolescents Using Different Tobacco Products

eFigure 2. Current e-Cigarette and Cigarette Use, Separating Out Dual Use (Reporting Current Use of Both e-Cigarettes and Cigarettes in the Same Survey)

eFigure 3. Days per Month Adolescents Used Cigarette, Cigars, and Smokeless Tobacco

eTable 1. NYTS Variables Used in the Analysis

eTable 2. Age of Tobacco Product Initiation Among Ever Users

eTable 3. Metaregressions for Changes in Tobacco Product Use Intensity Over Time, 2014-2021

eTable 4. Use Within 5 Minutes of Waking Among Sole Product Users

eMethods. YRBSS Supplemental Analysis

eAppendix. YRBSS Supplemental Analysis

eTable 5. Current Tobacco Product Use in YRBSS and NYTS (High School Students)

eFigure 4. e-Cigarette and Cigarette Use in YRBSS

eFigure 5. Percentage of e-Cigarette and Cigarette Users Who Used Product ≥20 d/mo

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Glantz S , Jeffers A , Winickoff JP. Nicotine Addiction and Intensity of e-Cigarette Use by Adolescents in the US, 2014 to 2021. JAMA Netw Open. 2022;5(11):e2240671. doi:10.1001/jamanetworkopen.2022.40671

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Nicotine Addiction and Intensity of e-Cigarette Use by Adolescents in the US, 2014 to 2021

• 1 Retired, San Francisco, California
• 2 Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston
• 3 Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
• 4 Julius B. Richmond Center, American Academy of Pediatrics, Itasca, Illinois

Question   How are e-cigarettes associated with nicotine addiction among US adolescents?

Findings   In this survey study of 151 573 respondents, age at initiation of e-cigarette use decreased and intensity of use and addiction increased between 2014 and 2021. By 2019, more e-cigarette users were using their first tobacco product within 5 minutes of waking than users of cigarettes and all other tobacco products combined.

Meaning   These findings suggest that clinicians need to be ready to address youth addiction to these new highly addictive nicotine products during many clinical encounters, and stronger regulation is needed, including comprehensive bans on the sale of flavored tobacco products.

Importance   As e-cigarettes have become more effective at delivering the addictive drug nicotine, they have become the dominant form of tobacco use by US adolescents.

Objective   To measure intensity of use of e-cigarettes, cigarettes, and other tobacco products among US adolescents and their dependence level over time.

Design, Setting, and Participants   This survey study analyzed the cross-sectional National Youth Tobacco Surveys from 2014 to 2021. Confirmatory analysis was conducted using Youth Behavioral Risk Factor Surveillance System from 2015 to 2019. The surveys were administered to national probability samples of US students in grades 6 to 12.

Exposures   Use of e-cigarettes and other tobacco products before and after the introduction of e-cigarettes delivering high levels of nicotine.

Main Outcomes and Measures   First tobacco product used, age at initiation of use, intensity of use (days per month), and nicotine addiction (measured as time after waking to first use of any tobacco product).

Results   A total of 151 573 respondents were included in the analysis (51.1% male and 48.9% female; mean [SEM] age, 14.57 [0.03] years). Prevalence of e-cigarette use peaked in 2019 and then declined. Between 2014 and 2021, the age at initiation of e-cigarette use decreased, and intensity of use and addiction increased. By 2017, e-cigarettes became the most common first product used (77.0%). Age at initiation of use did not change for cigarettes or other tobacco products, and changes in intensity of use were minimal. By 2019, more e-cigarette users were using their first tobacco product within 5 minutes of waking than for cigarettes and all other products combined. Median e-cigarette use also increased from 3 to 5 d/mo in 2014 to 2018 to 6 to 9 d/mo in 2019 to 2020 and 10 to 19 d/mo in 2021.

Conclusions and Relevance   The changes detected in this survey study may reflect the higher levels of nicotine delivery and addiction liability of modern e-cigarettes that use protonated nicotine to make nicotine easier to inhale. The increasing intensity of use of modern e-cigarettes highlights the clinical need to address youth addiction to these new high-nicotine products over the course of many clinical encounters. In addition, stronger regulation, including comprehensive bans on the sale of flavored tobacco products, should be implemented.

Electronic cigarettes (e-cigarettes) are highly engineered drug delivery devices that create and sustain addiction. Early e-cigarettes did not deliver nicotine as efficiently as cigarettes because they delivered freebase nicotine that was hard to inhale. This situation changed with the 2015 introduction of Juul products (Juul Labs Inc), 1 which added benzoic acid to the nicotine e-liquid to lower the pH level and form protonated nicotine. Protonated nicotine increases addictive potential by making it easier to inhale quantities of nicotine that are difficult for naive users to achieve with cigarettes or earlier e-cigarettes. 2 By 2018, Juul held 75% of the market. 3 After the US Food and Drug Administration partially banned cartridge-based flavored products in 2020, 4 disposable flavored protonated nicotine e-cigarettes rapidly gained adolescent market share 3 , 5 ; in 2021 middle and high school students used Puff Bar (Puff Bar [26.8%]), Vuse (R. J. Reynolds Vapor Company [10.5%]), SMOK (Shenzhen IVPS Technology Co Ltd [8.6%]), and Juul (6.8%). 6

In the brain, nicotine attaches to acetylcholine receptors and releases dopamine, which causes feelings of pleasure, 7 - 9 upregulates acetylcholine receptors, 10 and alters brain circuitry involved in learning, stress, and self-control, resulting in addiction and dependence. 11 - 13 Adolescents and young adults are particularly susceptible to nicotine receptor upregulation and addiction because of enhanced brain plasticity. 14 - 16

Prior studies reported changing prevalence of e-cigarette use among middle and high school students. 6 , 17 - 24 By 2019, the Centers for Disease Control and Prevention (CDC) National Youth Tobacco Survey (NYTS) estimated that 5.3 million middle and high school students were using e-cigarettes. 22 This number dropped to 3.6 million in 2020 23 and again to 2.1 million in 2021 during the COVID-19 pandemic. 6

One prior study 25 assessed changes in nicotine dependence after the introduction of Juul. Population Assessment of Tobacco and Health data for individuals aged 12 to 34 years from 2014 to 2016 and 2017 to 2019 revealed increased daily use and nicotine dependence among adolescents aged 14 to 17 years from 2017 to 2019, after the introduction of Juul, with no change in the 2014 to 2016 cohort. Another study 26 using NYTS data from 2015 to 2018 showed that high-frequency use of e-cigarettes and cigarettes was associated with higher odds of nicotine dependence (using tobacco products within 5 minutes of waking). Neither study tracked intensity of e-cigarette use, age at initiation, or dependence over time. This study moves beyond population prevalence as a measure of the changing e-cigarette use patterns among US adolescents over time to capture changes in measures of dependence and intensity of e-cigarette use among adolescents on an annual basis, during an 8-year period from 2014 through 2021.

In this survey study, we analyzed data from the NYTS, a nationally representative survey of middle and high school students. 27 We used 2014 through 2021, all years in which the NYTS provided information on number of days per month that respondents used e-cigarettes, cigarettes, cigars (including cigarillos and little cigars), and smokeless tobacco (ie, chewing tobacco, snuff, or dip). This was a secondary analysis of 2 deidentified public use data sets released by the CDC and was therefore deemed exempt from human participant research per the Massachusetts General Brigham Human Research Committee. This study followed the American Association for Public Opinion Research ( AAPOR ) reporting guideline.

Because of COVID-19, the 2021 NYTS transitioned from an in-person, tablet-based administration to a fully online administration where students could participate in classrooms, at home, or in another remote learning environment. Because of these differences in data collection, the CDC recommended that 2021 NYTS not be compared with earlier years. 6 Indeed, the NYTS 2021 data demonstrate higher prevalence of e-cigarette use in those who took the survey at school (15.0%) vs at home (8.1%). 6 To clarify behavioral reporting in different learning environments, the CDC performed the Adolescent Behaviors and Experiences Survey between January and June 2021, reporting current e-cigarette use rates of 25.2% among in-person, 17.2% among hybrid, and 9.1% among home-based high school students. 28 These results are consistent with data from the 1990s and early 2000s showing that in-home surveys report lower prevalence of smoking than in-school surveys. 29 - 31 Nevertheless, with these cautions and caveats in mind, and because this study focused on changes in consumption patterns within self-reported ever and current users of tobacco products, we have included the 2021 data for these users in our analysis. We reasoned that students who reported that they use tobacco products are less likely to be concerned about reporting details of their use patterns.

eTable 1 in the Supplement lists all the specific questions and variable definitions used in the analysis. Ever use of a tobacco product was coded as “yes” if the respondent reported ever using the product, even 1 or 2 times. Current use was coded as “yes” if the respondent reported using the product 1 or more of the past 30 days. There was no required threshold of lifetime use (such as 100 cigarettes in their lifetime) for current use. Dual use was coded “yes” if respondents reported current use of 2 or more tobacco products in the same survey year. We used the CDC’s categorization of days used for each product in the past 30 days established in 2014: 0, 1 to 2, 3 to 5, 6 to 9, 10 to 19, 20 to 29, and 30. The days used for each product among current users are tabulated separately, so each one includes users of that product as well as dual users and polyusers of other products.

We determined first tobacco product used with the question, “How old were you when you first smoked a cigarette, even 1 or 2 puffs?” and equivalent questions for other products. Respondents who gave the same age for multiple products were treated as having started using those products in the same year.

We assessed respondents’ level of tobacco dependence using the standard question 32 : “How soon after you wake up do you want to use a tobacco product of any kind?” The responses were coded as 0 for “I do not want to use tobacco products”; 1 for “I rarely want to use tobacco products”; 2 for “after more than 1 hour but less than 24 hours”; 3 for “from more than 30 minutes to 1 hour”; 4 for “from 6 to 30 minutes”; and 5 for “within 5 minutes.” The time to first cigarette is a commonly used measure of nicotine dependence in tobacco control research because it is a strong and consistent factor associated with smoking cessation success. 33

We repeated our primary analyses with the CDC Youth Behavioral Risk Surveillance System 34 (YRBSS) data, a nationally representative in-school survey of high school students. We used 2015, 2017, and 2019, all years in which the YRBSS provided information on the number of days per month that respondents used e-cigarettes, cigarettes, cigars, and smokeless tobacco. Details of the YRBSS analysis are provided in the eMethods in the Supplement .

We used CDC-provided weights and stratification variables to adjust for clustering and nonresponse and to match sample characteristics to national estimates. Results were tabulated for each year accounting for the complex survey design and weights for each year using Stata, version 15.0 (StataCorp LLC), commands syv, subpop():proportion, svy, subpop():regress, and svy, subpop():logistic. To test for trends over time while accounting for the uncertainties in each year’s estimates, metaregressions 35 were computed for trends in proportion of adolescents in each intensity of use group (days per month) across years based on point estimates and SEs for each year using the Stata command metareg .

A total of 151 573 respondents were included in the analysis (mean [SEM] age, 14.57 [0.03] years). Because all respondents were in middle or high school, 99% of respondents were between 11 and 18 years of age, with 86% between 12 and 17 years of age. A total of 51.1% of the sample were male and 48.9% were female (weighted numbers).

Among adolescents who currently use any tobacco product, the proportion whose first tobacco product used was e-cigarettes increased from 27.2% in 2014 to 78.3% in 2019 and remained at 77.0% in 2021 ( Figure 1 ). By 2017, e-cigarettes were the most popular initial tobacco product. For each year from 2019 to 2021, more current tobacco users were initiating use with e-cigarettes than all other products combined ( Figure 1 and eFigure 1 in the Supplement ).

Age at first use for e-cigarettes decreased by −0.159 (95% CI, −0.176 to 0.143) years (1.9 months) per calendar year ( P  < .001), controlling for respondent age at the time they completed the survey ( Figure 2 and eTable 2 in the Supplement ). In contrast, change in age at first use for cigarettes (0.017 [95% CI, −0.011 to 0.045] years; P = .24), cigars (0.015 [95% CI, −0.011 to 0.041] years; P = .25), and smokeless tobacco (−0.036 [95% CI, −0.074 to 0.0002] years; P = .64) was not significant.

Intensity of e-cigarette use shifted from using 9 or fewer days a month to 10 or more days a month ( Figure 3 and eTable 3 in the Supplement ). This shift in e-cigarette use intensity is also reflected in median number of days used, which increased from 3 to 5 d/mo in 2014 to 2018 to 6 to 9 d/mo in 2019 to 2020 and 10 to 19 d/mo in 2021. Intensity of use of cigarettes, cigars, and smokeless tobacco generally did not shift over time (eFigure 3 and eTable 3 in the Supplement ).

Addiction to e-cigarette nicotine, measured as the odds of having use of first tobacco product within 5 minutes of waking, increased over time for sole e-cigarette users (eTable 4 in the Supplement ). These changes over time were not uniform. From 2014 to 2017, the percentage of sole e-cigarette users who used e-cigarettes within 5 minutes of waking was less than 1% ( Figure 4 and eTable 4 in the Supplement ). However, beginning in 2017 through 2021, a shift occurred, with 10.3% using their first e-cigarette within 5 minutes of waking by 2021. During this same time, addiction did not change for sole cigarette smokers (odds ratio [OR] per year, 0.99 [95% CI, 0.85-1.16]; P  = .92) or smokeless tobacco users (OR per year, 0.97 [95% CI, 0.81-1.16]; P  = .73), but did increase among sole cigar users (OR per year, 1.49 [95% CI, 1.16-1.90]; P  = .002) (eTable 4 in the Supplement ). For comparison, between 2014 and 2021, a mean (SE) of 6.1% (0.8%) of smokers with sole use of cigarettes first used cigarettes within 5 minutes of waking and 5.2% (1.0%) of smokeless tobacco users used the product within 5 minutes of waking. The highest mean (SE) percentage for sole cigar users was 6.3% (2.4%) in 2020.

To isolate the population effect of addictiveness of different product types, we considered those adolescents who used only 1 product type and measured use of the product within 5 minutes of waking ( Figure 5 ). Beginning in 2019, the number of addicted e-cigarette users (n = 177 000) exceeded the numbers of all other tobacco product users (n = 23 000) on this high-addiction measure.

Results from the YRBSS were similar to those of the NYTS (eAppendix, eTable 5, and eFigures 4 and 5 in the Supplement ), showing a shift in e-cigarette use to more days per month with minimal changes in patterns of cigarette use. The frequent use of e-cigarettes (≥20 days in the past month) increased between 2017 and 2019 to the point where it was 700% higher than frequent use of cigarettes by 2019.

In 2017, e-cigarettes became the most common first tobacco product used, with the proportion of adolescents who initiated tobacco product use with e-cigarettes increasing over time ( Figure 1 ) and the age at initiation of e-cigarette use decreasing ( Figure 2 ). In addition, measures of addiction increased: days per month ( Figure 3 ) and the fraction of users who used their first product within 5 minutes of waking ( Figure 4 ) increased, and e-cigarette addiction surpassed that for all other forms of tobacco products combined ( Figure 5 ). Age at initiation of use did not change for cigarettes and other products, and changes in intensity of use for them were minimal.

As has been reported elsewhere, 6 , 17 - 24 the historic decline in use of tobacco products by US adolescents reversed after the advent of e-cigarettes, with e-cigarette use peaking in 2019 at a higher level than cigarette smoking in 2006 (eFigure 2 in the Supplement ). The shift to e-cigarettes being the first tobacco product used is consistent with Monitoring the Future data from 8th and 10th grade students in 2015 to 2017. 36 , 37 Likewise, the decrease in age at initiation of e-cigarette use but not use of other tobacco products is consistent with earlier NYTS results 38 : the 8.8% of ever users of e-cigarettes aged 16 to 17 years who initiated use at 14 years or younger in 2014 increased to 28.6% in 2018, whereas initiation age did not change for cigarettes, cigars, and smokeless tobacco products. Our results are consistent with the prior Population Assessment of Tobacco and Health study that showed increased intensity of use and nicotine dependence among adolescents through 2019 after the introduction of Juul and the diffusion of protonated nicotine technology in e-cigarettes 25 ; our results also show that the shift toward increased e-cigarette use and higher levels of addiction continued through 2021. In addition, the 2022 NYTS reported that 2.6 million adolescents used e-cigarettes and 27.6% of them used e-cigarettes daily; the comparable numbers reported herein for 2021 are 2.1 million and 24.7%. 39 Our findings are also consistent with the finding that using e-cigarettes on more days per month is associated with higher levels of nicotine dependence. 26

The decrease in e-cigarette use from 2019 levels may be attributable to a variety of factors, including local, state, and national strategies to address e-cigarette use among adolescents and enacting comprehensive restrictions on the sale of flavored tobacco products, 40 - 42 as well as raising the federal minimum age for tobacco product sale to 21 years. 43 Heightened health concerns because of e-cigarette– or vaping–associated lung injury 44 may also have contributed to this decrease. The effects of COVID-19 on the 2021 results are likely more reflected in the prevalence estimates than in the measures of behavior among self-identified tobacco product users. The fact that adolescents were predominately at home and outside social environments may have affected tobacco use. A national online survey in May 2020, during the COVID-19 pandemic, found that 36.5% of adolescents and young adults (aged 13 to 20 years) who used e-cigarettes reported quitting and another 2.2% switched to other nicotine products. 45

The extent to which decreases in tobacco product use for the 2021 NYTS data may reflect a long-term trend, owing perhaps to education about e-cigarettes, increased concern about the health risks of e-cigarettes, 44 restrictions on available products such as the US Food and Drug Administration’s 2020 partial ban on flavored products, 4 short-term lack of access to products and stimuli for use among peers, biases in the data collection, or some combination of these factors is unknown. Some of this decrease may be an artifact due to NYTS being administered at home as well as in school. Although adolescent prevalence of e-cigarette use appeared to decrease in the NYTS, data from the CDC’s Adolescent Behaviors and Experiences Survey from January to June 2021 suggested that the in-person high school student respondents in 2021 had rates of current e-cigarette use of 25.2% (95% CI, 13.9%-41.2%), 28 similar to the 2019 NYTS levels of 27.5% (95% CI, 23.5%-29.7%) 22 measured among in-person high school student respondents. It will be important to determine to what degree prevalence of e-cigarette use among adolescents rebounds as the return to school and contact with their peers and society generally proceeds.

Regardless of falling prevalence, e-cigarette users were initiating use at younger ages, use became more intensive (in days per month), and a higher percentage used them within 5 minutes of waking. These changes may reflect the increased addictive potential of protonated nicotine delivery products that make it easier to inhale nicotine than from cigarettes or other combustible tobacco products. 1 , 2 The fact that e-cigarette addiction trends are continuing to increase despite the 2019 federal legislation raising the tobacco sales age to 21 years suggests that tighter regulation, additional legislative action, or both may be necessary to protect adolescents.

Despite the COVID-19 pandemic leading to people being socially isolated, students being out of school, and the increased risk of adolescents and young adults contracting COVID-19 with e-cigarette use, 46 intensity of use among adolescents continued to increase. This increase in intensity may reflect increasing use of nicotine for self-medication in response to increases in adolescent depression, anxiety, tic disorders, and suicidality that occurred during the COVID-19 pandemic. 28 The pandemic has also been a lost year for school-based prevention and treatment efforts, meaning that abatement plans will need to be intensified to address the nicotine addiction in those adolescents who missed a year of contact with adults who might have otherwise helped them get treatment. 47

The change in e-cigarette use and intensity of use among adolescents contrasts with what was happening in the adult e-cigarette market at the same time. 48 - 50 The prevalence of current adult e-cigarette use in the Tobacco Use Supplement to the Current Population Survey showed an upward trend from 2010 until 2014, 51 followed by a decline to the 2019 rate of 2.3%, 52 less than one-tenth of the 27.5% prevalence among high school respondents in the NYTS that year. 22 High-dose concealable nicotine e-cigarettes entered the market as a product targeting adolescents, as shown by the fact that by 2018, only 2% of adults used a flash drive–shaped e-cigarette regularly. 53 Despite several years of intensive adolescent e-cigarette users becoming 18 years of age and therefore part of a different category, the 2020 National Health Interview Survey found only 3.7% prevalence of adult e-cigarette use, 54 compared with 19.6% among high school students. 23 These findings suggest that the primary effect of the modern e-cigarette has been to addict adolescents to nicotine. Clinicians should be vigilant for new tobacco products that may come into the youth tobacco product market.

The primary limitation of this study is that it was based on the NYTS, which is a cross-sectional survey. The NYTS collects self-reported data from respondents without biochemical verification of tobacco use behavior, which could lead to recall bias.

In addition to the changes in how the NYTS was administered in 2021, the NYTS was conducted via paper-and-pencil questionnaires until 2019, when it shifted to electronic data collection. In 1 study, 30 paper-administered questionnaires tended to result in nonsignificantly lower prevalence reporting. Beginning in 2019, the electronic survey contained skip patterns and tobacco product images, which may limit comparability with data collected via paper-and-pencil surveys, in which respondents were asked to answer all questions (regardless of tobacco product use) and did not have any images to aid with product recall. In addition, owing to COVID-19, 2020 NYTS data collection ended early, in March, yielding a smaller sample size and lower response rate than usual. The CDC performed additional nonresponse bias analysis assessing differences in responding and nonresponding schools for 2020 and concluded that they were able to create survey weights that compensated for these problems. 23

Use of e-cigarettes reversed the long-term decline in US youth tobacco use and expanded the tobacco epidemic by attracting many adolescents at low risk of initiating nicotine use with cigarettes. 55 - 57 This survey study found that between 2014 and 2021, although prevalence of e-cigarette use among adolescents peaked in 2019 and then declined, the age of initiation among ever users continued to decrease and the intensity of use and level of addiction among adolescents who are current e-cigarette users increased. This increasing intensity of use may reflect the higher nicotine delivery and addiction liability of e-cigarettes that use protonated nicotine. 1 , 2 Clinicians should question all their patients about nicotine and tobacco product use, including e-cigarettes and other new nicotine products. Because tobacco addiction is a chronic disease, clinicians should be ready to address youth addiction to these new high-nicotine products during the course of many clinical encounters. The increasing intensity of use of modern e-cigarettes highlights the need for local, state, and federal comprehensive bans on the sale of flavored tobacco products and consideration of ending the sale of these products on the open retail market, as has been done in 47 countries as of 2021. 58

Accepted for Publication: September 11, 2022.

Published: November 7, 2022. doi:10.1001/jamanetworkopen.2022.40671

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Glantz S et al. JAMA Network Open .

Corresponding Author: Jonathan P. Winickoff, MD, MPH, Division of General Academic Pediatrics, Massachusetts General Hospital for Children, 55 Fruit St, Yawkey Room 6D, Boston, MA 02114 ( [email protected] ).

Author Contributions: Drs Glantz and Jeffers had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Glantz, Winickoff.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Glantz, Winickoff.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Winickoff.

Administrative, technical, or material support: Winickoff.

Supervision: Winickoff.

Conflict of Interest Disclosures: Dr Glantz reported receiving personal fees from the World Health Organization outside the submitted work. Dr Winickoff reported receiving grant funding from the National Institutes of Health (NIH) during the conduct of the study and serving as a paid expert witness against the tobacco industry outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported in part by grants R01CA248742 and R01CA245145 from the National Cancer Institute (Dr Winickoff).

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Article Contents

Introduction, supplementary material, declaration of interests.

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Smokers’ Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research

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Daniel Pfeffer, Britta Wigginton, Coral Gartner, Kylie Morphett, Smokers’ Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research, Nicotine & Tobacco Research , Volume 20, Issue 9, September 2018, Pages 1038–1046, https://doi.org/10.1093/ntr/ntx186

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Despite the centrality of addiction in academic accounts of smoking, there is little research on smokers’ beliefs about addiction to smoking, and the role of nicotine in tobacco dependence. Smokers’ perspectives on nicotine’s role in addiction are important given the increasing prevalence of nontobacco nicotine products such as e-cigarettes. We conducted a systematic review of studies investigating smokers’ understandings and lay beliefs about addiction to smoking and nicotine.

We searched PubMed, Embase, CINAHL, and PsycINFO for studies investigating lay beliefs about addiction to smoking. Twenty-two quantitative and 24 qualitative studies met inclusion criteria. Critical interpretive synthesis was used to analyze the results.

Very few studies asked about addiction to nicotine. Quantitative studies that asked about addiction to smoking showed that most smokers believe that cigarettes are an addictive product, and that they are addicted to smoking. Across qualitative studies, nicotine was not often mentioned by participants. Addiction to smoking was most often characterized as a feeling of “need” for cigarettes resulting from an interplay between physical, mental, and social processes. Overall, we found that understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the biological aspects of addiction.

Researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. More research on lay beliefs about nicotine is required, particularly considering the increasing use of e-cigarettes and their potential for long-term nicotine maintenance for harm reduction.

Quantitative studies show that most smokers believe that smoking is addictive and that they are addicted. A feeling of “need” for cigarettes was central to qualitative accounts of addiction, but nicotine was not often discussed. Overall, smokers’ understandings of addiction reflect a biopsychosocial model rather than a neurobiological one. Given the growing market for e-cigarettes and therapeutic nicotine, more research is required on lay beliefs about nicotine and addiction.

Nicotine was declared addictive by the US Surgeon General in 1988, 1 and it is increasingly recommended that nicotine addiction be approached as a disorder requiring medical treatment. 2–4 Various measures of nicotine dependence have been developed, validated and are in regular use in both research and clinical applications. 5–8 The constellation of features included in such measures include continued smoking despite known harms, difficulty quitting, feelings of craving or compulsion, and how long after waking someone smokes their first cigarette. An example of a commonly used measure of dependence is the Fagerstrom Test for Nicotine Dependence (FTND). 6 In 2012, this test was renamed the Fagerstrom Test for Cigarette Dependence, in acknowledgement of the fact that dependence on cigarettes encompasses more than an addiction to nicotine. 9 In a similar vein, the DSM-IV labeled addictive smoking as “nicotine dependence,” 10 however, was labeled “tobacco use disorder” in the DSM 5. 5 The complexity of the relationship between tobacco dependence and nicotine dependence has largely focused on academic arguments about the role of nicotine replacement therapy (NRT), and the neurobiology of nicotine and cigarette smoking. 9 The distinction between nicotine and tobacco dependence has become very relevant to contemporary legal and public health arguments about the potential for dependence on nontobacco forms of nicotine such as e-cigarettes. 11 , 12

Unlike other psychoactive substances such as opiates and alcohol that have long been associated with addiction, nicotine has relatively recently joined the realms of substances defined as addictive. Historically, smoking has been more closely associated with a public health approach than an addiction medicine approach. 13 The increasing recommendation for health professionals to identify smokers and to provide them with pharmacological treatments such as NRT or prescription medications has medicalized smoking to some extent. 14 Also contributing to the medicalization of smoking is the increasing emphasis on the neurobiological aspects of smoking that create and maintain addiction. 15–17 Tobacco dependence is increasingly defined in terms of “nicotine addiction” and is beginning to be labeled a “chronic brain disorder” and a “chronic disease.” 3 , 18

However, whether smokers view themselves as addicted to nicotine, and the role they ascribe to nicotine in their smoking, is less clear. The answer to this question is important for two current public health debates: (1) the amount of emphasis that should be given to therapeutic nicotine (NRT) for quitting smoking, given the limited population impact of cessation medicines despite widespread availability and public subsidization in high income countries; and (2) what contribution nontherapeutic nicotine products (eg, e-cigarettes) will play in reducing the burden of tobacco-related disease. The marketing of NRT a medicinal smoking cessation product, and the recommendation to use it for only a limited period of time, meant that long-term dependence on NRT products has not been a big concern. E-cigarettes have been controversial in the tobacco control field because they are marketed as consumer products that are much safer alternatives to conventional cigarettes. Their potential to foster long-term nicotine dependence and their appeal as a recreational form of nicotine delivery has brought to the fore arguments about how nicotine should be conceptualized and regulated. 11 , 19 , 20

It is important to investigate whether smokers see themselves as addicted to smoking and what meanings they associate with this term. The role that smokers ascribe to nicotine in their understandings of smoking is likely to influence their views about cessation methods and also switching to alternative nicotine products such as NRT or e-cigarettes.

Only one previous systematic review has examined lay perceptions of addiction to smoking. 21 This review focused on youth perceptions of addiction and the health harms of smoking. The authors found that young people were optimistic about their ability to quit before their smoking became problematic, and many did not believe that they were addicted to smoking. However, this review excluded the views of older and more established smokers. Also, the search strategy may have excluded relevant studies because it only included publications that contained one of the following terms: “invincibility, in denial, denial, invulnerable, optimism.” Although a stated aim was to examine perceptions of addiction, no search terms about addiction were used.

Our systematic review aimed to examine smokers’ subjective assessment of tobacco addiction in both adolescent and adult smokers, with an emphasis on investigating beliefs about nicotine. We collated data on smokers’ perceptions, beliefs, and understandings of addiction to smoking in general, or to nicotine specifically where available. We applied critical interpretive synthesis (CIS) 22 to analyze smokers’ understandings of addiction, and the methods by which they have been studied. PRISMA guidelines, which were developed to encourage standardized reporting of systematic reviews, were used to report the method and findings wherever appropriate. 23

Search Strategy

We searched PubMed, Embase, CINAHL, and PsycINFO using broad search terms to capture all relevant studies. While search strategies were adjusted for each database’s features, the key search terms were (cigarette OR tobacco OR nicotine OR smoking) AND (addiction OR habit OR dependence OR “tobacco use disorder”) AND (attitude OR belief OR understanding OR perception OR awareness OR “health belief”). Supplementary File 1 includes the full search strategy for each database.

Searches were conducted in June 2015, restricting results to English language articles published in peer-reviewed journals in or after 1988, to coincide with the publication of the US Surgeon General’s report that declared that nicotine was addictive. 1 The reference lists of relevant studies were manually searched for additional publications that met the selection criteria.

Inclusion/Exclusion Criteria

Figure 1 illustrates the process for identifying studies. After excluding 1087 duplicates, 2424 articles were screened by title and abstract, retaining those that involved current or ex-smokers and investigated beliefs, attitudes, or self-assessment regarding addiction to tobacco or nicotine. Studies that did not report participants’ understandings of “addiction” or “dependence” were excluded. Qualitative studies were included if they explored the meanings that smokers associate with addiction. Quantitative studies were included if they provided smokers’ ratings of their own addiction, or their ratings on the general addictiveness of smoking. Two authors (KM and DP) screened the full texts of 97 publications. Five of these studies were identified from the manual searching of reference lists of relevant articles. Where KM and DP disagreed over inclusion, third author (BW) independently reviewed the article and inclusion was based on majority judgment. Forty-six articles were deemed to meet the selection criteria.

Process of study inclusion.

Data Extraction

Separate data extraction forms were used for qualitative and quantitative articles ( Supplementary File 2 ). One mixed-methods article 24 was included as qualitative because the quantitative component did not address perceptions of addiction. For each study, BW and DP extracted information on research aims, context and methodology, key findings, conclusions, and study quality. Where studies included data from both smokers and nonsmokers, only data from smokers and ex-smokers was extracted. For qualitative studies, all text relating to addiction were imported into NVivo10 25 to enable further analysis.

While formal quality appraisal is common in conventional systematic reviews, many quality appraisal criteria for clinical trials are not applicable to observational studies, and quality appraisal is a contentious exercise for qualitative research. 22 , 26 , 27 For this review, formal quality appraisal in the form of scoring or ranking studies was not appropriate because it predominantly included qualitative or cross-sectional survey studies. Instead, we integrated reporting criteria from the NICE guidelines (quantitative and qualitative) 28 , 29 and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklists 30 into our extraction forms and quality concerns informed our interpretation of these studies. These reporting guidelines include many items which assist researchers in judging the quality of a study such as details about selection of participants, validity, and generalizability of the results, how the study was explained to participants, and the explicitness of data analysis methods. No articles were excluded based on judgments about quality.

Quantitative studies ( n = 22) varied in aims, methodology, and survey items; therefore meta-analysis was not possible. For qualitative studies ( n = 24), DP conducted a secondary analysis of extracted results (ie, participant quotes and authors’ interpretations) using Nvivo 10. KM independently coded eight randomly chosen studies and differences were discussed until a consensus was reached. Codes were organized into themes, and then further into overarching thematic domains.

We drew on the approach of CIS to interpret the identified literature. 22 CIS has been applied to a wide range of research areas and is particularly useful when reviewing a methodologically diverse body of literature. 22 , 26 , 31 A CIS approach goes beyond the aggregation of data and aims to interpret the findings. The process of CIS includes an evolving research question; a pragmatic approach to quality appraisal based strongly on relevance rather than specific criteria of methodological rigor; and a critical approach to key concepts and assumptions. 22

Quantitative Studies

Key characteristics and results of the 22 quantitative studies (20 research articles and 2 research letters) 32–53 are provided in Supplementary File 3 . These were published between 1990 and 2012 and were cross-sectional designs, with the exception of one prospective cohort study. 39 The study target populations varied, with some focused exclusively on smokers ( n = 12), while others also included nonsmokers for comparison ( n = 10). Most focused on adults ( n = 14), while a number recruited adolescents only ( n = 6), and a minority included both age groups ( n = 2). Some included subgroup analysis based on age ( n = 2), sex ( n = 2), smoking status ( n = 11), and/or ethnicity ( n = 3).

There were substantial differences between studies in the way perceptions of the addictiveness of smoking were measured. Some studies asked about perceptions of personal addiction, for example, “Are you [not at all, somewhat, or very] addicted to cigarettes?” 39 Others used more general questions about the addictiveness of smoking, particularly when comparing smoker and nonsmoker ratings. For example, one study asked participants “How much of a risk is it for someone to get addicted if they try smoking cigarettes even once?” 37 Several studies asked participants to provide ratings of both their own addiction to cigarettes, and the general addictiveness of tobacco/cigarettes. 40 , 49 , 52 , 53

Other aspects of smoking included the ease/difficulty of quitting 38 , 41 , 43 , 44 , 46 ; the addictiveness of tobacco compared to other drugs 34 , 40 , 49 ; and the extent to which they believed addiction was a reason for their smoking. 42 , 45 In many cases, participants’ perceptions of addiction were not the major focus of the study, however, ratings of addiction were included as a relevant variable.

Another important difference between studies was whether participants were asked about addiction to “cigarettes”, “smoking”, “tobacco”, or “nicotine”. Most items asked about the addictiveness of “tobacco”, “cigarettes” or “smoking”. Only two articles contained items that specifically questioned participants about addiction to nicotine. 52 , 53 Weinstein et al. 52 asked “If a teenager starts smoking half a pack of cigarettes a day, how long do you think it takes them to show signs of nicotine addiction?” However, they switched to asking about addiction to cigarettes when questioning participants about their own addiction: “Do you consider yourself addicted to cigarettes?” The survey administered by Zinser et al. 53 included the item “People who smoke cigarettes regularly are addicted to nicotine.” No quantitative studies asked if participants personally felt they were addicted to nicotine.

The included studies consistently found that the majority of smokers agreed that smoking is addictive 32 , 34 , 36 , 37 or that “smokers” in general are addicted. 33 , 40 , 42 , 53 The single study that asked whether people who smoke are addicted to nicotine found that 89% Latino participants and 94% non-Latino Whites agreed with the statement. 53 When asked whether they personally were addicted, most adult daily smokers reported that they were. 39 , 52 , 53 Adolescent smokers were less likely than adults to agree that they personally were addicted, 32 , 52 but most agreed that smoking was addictive, 34 , 36 , 41 and that quitting would be difficult. 35 Other groups who were less likely to report being addicted to smoking were Hispanics in US studies 46 , 49 , 53 and lighter or “occasional” smokers. 39 , 40 , 48

While most studies did not ask about different aspects of addiction to smoking, there were exceptions. Four studies presented more than one explanation for smoking, for example, asking to what extent participants agreed that smoking was a habit and/or an addiction, or that addiction to smoking was physical and/or mental. 42–44 , 48 Where participants were given the option to rate their agreement with each item separately, both smoking as a habit and an addiction were endorsed in adults. 42 One study found that smokers reported psychological addiction to be more of a motive for smoking than physical addiction, but the difference was not large. 44 Three further studies suggested that smokers tend to agree that smoking tobacco is as addictive as other drugs (eg, cocaine or heroin). 34 , 40 , 49

Common methodological limitations included the absence of reporting on response rates; a lack of descriptive statistics on addiction-related variables; information about ethical clearance not being provided; and a lack of clarity about how participants were categorized in relation to smoking status.

Qualitative Studies

Twenty-three qualitative studies were included from 24 articles (one study was reported in two separate articles) published between 1997 and 2015. 24 , 54–76 Details of the studies are included in Supplementary File 4 . Data collection methods were primarily focus groups, individual interviews, or a combination of both. One study used Q-methodology. 61 Sampling strategies varied, with most articles including current smokers ( n = 12) or a combination of current smokers and ex-smokers ( n = 8). Three articles included data from never smokers in their sample. 64 , 69 , 73 Fourteen articles focused on adults and 10 on adolescents.

Similar to the quantitative studies, exploring smokers’ understandings of addiction was not the explicit aim for many studies. However, addiction often arose as a major theme as it was closely tied to discussions around starting and stopping smoking. Although some studies did not report their interview questions, and the results presented were not always linked to specific questions, discussions of addiction appeared to arise from a range of questions about quitting, reasons for smoking, and thoughts about smoking in general. This shows that addiction is a central concern of smokers.

Many studies did not provide sufficient information to allow judgments on study quality. There was often limited reporting on the role of the researcher in the analysis, including whether multiple team members coded the data, and how researcher beliefs and practices may have influenced the results (reflexivity); details about interview questions; recruitment methods or the study’s context; evidence to support claims (eg, few participant quotes); and the analytic approach. These issues are not uncommon in the reporting of qualitative research, particularly in journals with tight word count restrictions, where methodological detail is often sacrificed to allow more room for the reporting of results.

Qualitative findings across studies revealed smokers attach a range of meanings to their addiction. We first discuss common ways in which smokers described addiction to smoking. We then delineate the ways in which these “signs” of addiction were used by some participants to separate themselves from “addicted smokers” or to downplay their own addiction. Last, we explore instances where discussions around nicotine arose, and draw preliminary conclusions about the role of nicotine in smokers’ understandings of addiction.

What Does Addiction Look Like to Smokers?

The most commonly reported sign of addiction to smoking was a feeling of “need” for cigarettes that was seen to set apart addicted smokers from nonaddicted smokers. 55 , 56 , 59 , 63–69 , 73 The feeling of need was often associated with the sensation of craving, such as “sweating at the bit for a fag,” 55 “not satisfied until I have one,” 67 and “twitching ... aching for a cigarette.” 65 Smokers described having emotional withdrawal symptoms, such as “you get these mood swings and temper and everything,” 76 and “you feel more nervous.” 66 Frequent reference to physical withdrawal symptoms occurred across studies including headaches, 58 insomnia, 54 nausea, 59 concentration difficulties, 54 , 59 shakiness, 63 , 68 cold sweats, and dry mouth. 63 Smoking cigarettes relieved these symptoms, but was also associated with pleasure in the form of “a tingly feeling,” 69 a “buzz,” 70 a pleasurable smell and taste, 74 or an enjoyable feeling “going down my throat.” 65 Smoking was often portrayed as necessary to enable “normal” functioning. In some studies, participants described “tanking up” before periods of enforced abstinence 56 and exaggerated reactions to running out of cigarettes, such as willingness to walk for two hours to buy more. 63

Another key aspect of addiction according to smokers was diminished control over smoking, and an associated difficulty in quitting. Addiction was seen as, “trying and trying to give up”, 56 “want to quit, but can’t” 64 or “if it controls you.” 58 Control was tied to notions of choice and those who denied that they were addicted to smoking asserted their autonomy in statements such as “I feel like I’m not addicted because I can stop myself at any time. I choose to smoke that cigarette,” 58 and “Every time it is my own decision to smoke.” 54 The themes of need and control are closely linked, as demonstrated by one participant who stressed that her smoking was not a need, but a “want.” She reflected on times when she had said no to a cigarette as evidence that her addiction is “not too bad.”

I mean the amount of times I’ve said no when people have offered me and I say no and they say go on have one, but I go no it’s alright (laughs), yeah so I’d say you know I’m not too bad really ’cos some people just smoke for the sake of it, I try and just smoke when I want one. 62

A number of factors were offered to explain why only some people become addicted, with frequent references to “overdoing smoking.” 59 In particular, some smokers were viewed as being very controlled and constrained, while others were thought to smoke excessively. Views that, “a cigarette every so often doesn’t get you addicted” 65 ; “the more that somebody smokes for a while, the greater the chance of them getting addicted” 59 ; or “if I was addicted to smoking then I’d be smoking every day” 55 reveal how notions of excess and addiction are intertwined.

Some studies noted a highly physical conception of the process of addiction, employing ideas of tolerance in regards to the development of addiction. Tolerance was seen as a gradual progression toward addiction: “they just need a little bit and then they need more and then they need more” 59 ; “It’s a boring feeling after a while. It doesn’t feel the same anymore. You have to like smoke more to get that feeling—to get that like little high.” 69 Inherent in these descriptions was the identification of subtypes of smoking behavior, based on varying criteria. These included the “in control social smoker” versus the “habitual smoker” versus the “full-fledged addicted smoker” 55 ; light versus moderate versus heavy degrees of addiction 59 ; and “wanting/enjoying” versus “needing” cigarettes. 63 In each case, the process of becoming addicted was associated with progression and moving up a ladder of smoking typologies. This comparison between different smoker “types” was common across studies.

Ambivalence About Addiction to Smoking

Many participants expressed uncertainty about whether they were addicted to smoking, or as to the nature or strength of their addiction. This was particularly the case for adolescent smokers. 54 , 59 , 70 , 71 While an acknowledgement of addiction in some form was common, views on what this meant varied widely. Where addiction was challenged, alternative discourses of smoking were often employed, commonly that it was primarily a social activity. ‘Social smoking’ was presented as an alternative to addiction, for example, “I do have a craving like other people, but it’s more a social thing really” 55 or as a precursor to addiction from which smoking progresses to become “more than just sitting with friends.” 55 One participant stated that the social aspects were as addictive as nicotine: “it is a social aspect of their life that they have become dependent on, as much as the nicotine, you know. I think the social setting of it all is something that is somewhat addictive itself.” 63 Adolescents in particular frequently referenced the social aspects of smoking.

“Habit” was another frequently employed term across studies. While its meaning was not often elaborated on, several studies suggested that smokers associated it with regular and repeated smoking. Yet, how this relates to “addiction” was often unclear due to the varied use of the term both within and across studies. Phrases such as, “I think it’s a habit, it’s not really an addiction …”; “probably an addiction now, it used to be a habit, but now it’s not” 55 ; and “not a habit, it’s an addiction,” 56 seem to suggest a dichotomy, in which “habit” is conceived as a distinctly different phenomenon to “addiction.” 56 , 63 However, other examples reveal less simplistic conceptualizations of the addiction/habit divide.

(. . .) It’s like it’s a drug, it’s er addictive, er I do enjoy it sometimes um, I suppose really it’s become part of my life, it’s a habit really . . . I think if you haven’t had a fag for a long time the first fag you have is like a stimulant, it’s um goes straight into the bloodstream and goes to the brain . . . I think it relaxes people um and I think then it just becomes a habit, a habit-forming er er thing really (. . .). It’s just a habit it’s just a just a really nasty horrible bad habit and I just don’t think I can break out (. . .) 62

Taken together, smokers appear to use the term “habit” to refer to the routine nature to their smoking behavior. While it is sometimes framed as being in contrast to addiction, others refer to it being a sign of addiction.

Across studies there was recognition of the stigma associated with being an addicted smoker. Resisting addiction was seen as a matter of being “strong enough,” 66 revealing a negative perception that “they are weak if they are addicted because they don’t have the willpower to quit.” 59 This conceptualization of addiction more closely aligns with a moral rather than neurobiological framing of addiction.

There was a tendency across studies for participants to use depersonalized language to distance themselves from discussions of their own smoking or addiction. Bottorff et al. 59 explicitly observed this in their interviews with adolescent smokers, and we also found this depersonalization to be common across studies. One example is the limited use of personal pronouns in accounts of addiction, with references to smoking’s effect on “ the body,” “ the brain,” or “ the bloodstream.” 59 , 62 For example, “Your body says you need one at that time; you just can’t ignore what your body says.” 59 Similarly, when discussing addiction, many participants discussed smoking in general terms rather than reflecting on their own smoking. If they did refer to their own smoking, it was often in comparison to “other” smokers who they considered heavier smokers, and more addicted. For example, Farrimond et al. 61 , p.995 stated that some participants made “positive comparisons between themselves as ‘social smokers’ and addicted smokers, for example, by emphasizing their high self-control and external ‘social’ motivation.” Young people used this strategy of distancing themselves from addiction by comparing themselves to older and heavier smokers. 55 , 59

How Do Smokers Understand the Role of Nicotine in Addiction to Smoking?

As described above, feeling a need to smoke was seen as a sign of addiction to smoking. But what aspect of smoking was “needed” was often not clarified. While some participants specifically discussed the role of nicotine, it was uncommon for researchers to probe about nicotine, and many of the discussions about smoking and addiction did not mention it. The chemical composition of cigarettes in general was seen as playing a role in promoting addiction, but participants rarely elaborated on how nicotine contributed to their addiction to cigarettes, and some displayed misunderstandings. For example, one participant implicated the tobacco industry in adding an addictive ingredient to cigarettes, suggesting they were unaware that nicotine is naturally found in tobacco: “If the cigarette manufacturers are putting stuff in the cigarettes that make your body addicted to ‘em, then how are you going to quit?” 57

While nicotine was only occasionally discussed, the physical nature of addiction to smoking was often acknowledged. Cravings were described as when the body “needs the stuff” 62 ; and “is basically crying out for a fag.” 56 Others referred specifically to the brain in describing this physical process, claiming the “brain tricks you” 63 and “forces you to think you need a cigarette.” 59 One participant explained that the brain “is already addicted to it, and the thinking just can’t go away.” 57 These participants often used such physical descriptions to attribute responsibility and development of addiction to the “the body” or “the brain,” situating them as entities external to themselves over which they had little or no control.

Where discussions about the role of nicotine did arise, it was often in the context of comparing tobacco dependence to other drug addictions. For example, “it’s like it’s a drug,” 62 “we’re just junkies, we need nicotine,” 56 “it’s worse than heroin,” 57 or “smokers are preoccupied with where the next nicotine fix is, the nicotine monkey on their backs.” 61 Although, others denied this relationship, claiming they don’t view their relationship to smoking like that of “a heroin addict.” 55

Accounts of addiction that refer to nicotine in the “bloodstream,” 57 , 62 a “chemical dependency” 57 , 62 ; and “tolerance,” 59 reflect—with varying degrees of sophistication—a biomedical understanding of “nicotine dependence.” Participants across studies often presented addiction as a “physical need,” however, we found that physical descriptions of addiction were rarely discussed in isolation from other factors such as family and peer influence. These influences were seen to act at a young age either through access to cigarettes, 59 , 65 children “getting used” to the idea of smoking, 59 , 62 or direct pressure to smoke. 69 A further psychosocial influence that arose was one’s personality, with some mentioning an “addictive personality” 74 or “inner weakness.” 59 , 73 Such a personality was attributed to genetics, immaturity, 59 or one’s mental health status. 73 These discussions implicated a complex web of factors that are seen to mediate addiction, illustrating a common view that tobacco dependence is not caused solely by the brain’s exposure to nicotine.

DiFranza 77 , p.1 has written that “Those who claim to have the power to define nicotine addiction are burdened to provide that they can identify it more accurately than those who live with it every day of their lives.” In this research, we reviewed studies examining smokers’ perceptions and understandings of addiction to smoking. By prioritizing participants’ own views and interpretations, theoretical debates surrounding the nature of addiction to smoking can become grounded in the daily lives and realities of cigarette smokers. The quantitative findings summarized here suggest that most smokers agree that smoking is addictive and that they themselves are addicted to cigarettes. However, when smokers are asked open-ended questions about what addiction means to them, a complex and multidimensional picture emerges. Moreover, there remains a considerable number of smokers who express ambivalence about their own addiction or reject the “addicted” label entirely, even if they believe smoking is addictive for others.

Our qualitative analysis shows that addiction is perceived as a complex process involving relationships between physical processes and sensations, behavioral patterns and the social contexts in which these occur. A feeling of “need” and lack of control over smoking were identified by smokers as the most common signs of addiction, and these align with the “craving” and “loss of control” criteria of the DSM 5. 5 These symptoms that smokers recognize are also consistent with other self-reported data on nicotine addiction, where a developmental sequence of “wanting, craving, needing” was identified during quit attempts. 78 However, smokers often distanced themselves from these symptoms of addiction by referring to addiction in a general way, and using depersonalized terms. Descriptions of smoking as a social practice or habit were sometimes invoked as an alternative to addiction. While the difficulty of quitting was often acknowledged, it was also common for smokers to maintain some sense of autonomy over their smoking. Overall, we found that subjective understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the neurobiological or genetic aspects of addiction. 79–81

Largely absent from this literature was a thorough investigation of smokers’ understandings of “nicotine addiction”—as most studies neglected to ask participants specifically about nicotine. It was more common to ask about addiction to smoking, tobacco or cigarettes. Before the emergence of e-cigarettes, nicotine and tobacco were by and large interchangeable since the vast majority of long-term nicotine consumption was in the form of smoking cigarettes. Previous studies may not have specifically explored nicotine separately from other aspects of addiction because addiction to nicotine separated from smoking tobacco was less common. It is important to ask about smoking and cigarettes, as addiction to smoking cannot be reduced to nicotine dependence. However, understanding how smokers conceptualize the role of nicotine in their smoking is more and more important in light of increasing recommendation for smokers to use NRT, and because of the growing market for e-cigarettes, which offer nicotine in a form that could induce and sustain addiction, but without smoking tobacco. Smokers’ attitudes to, and ideas about, nicotine addiction, may influence the uptake and use of nontobacco nicotine products as substitutes for tobacco cigarettes. More specifically, if people do not believe that nicotine plays a central role in their smoking, they may be less likely to use NRT to assist quitting and be less interested in switching to e-cigarettes.

The qualitative studies we reviewed show that smoking is rarely understood primarily through the lens of nicotine addiction. This suggests that a biomedical understanding of addiction to smoking, where nicotine induces neurochemical changes to the brain, which make it very difficult to stop, does not dominate lay beliefs about addiction to cigarettes. These findings are consistent with previous research on how addicted individuals understand the biological basis of their addiction. 15 , 82–84 While the physical aspects of addiction are often acknowledged, smokers’ explanations of addiction are much broader, referring to the role of peers, routine, emotions, habits, inner strength or weakness, and contextual cues. These aforementioned aspects of smoking are not often linked with the mechanisms of nicotine dependence. The role of nicotine in addiction, where it was discussed, was often glossed over, rather than considered in detail. These findings suggest that promises of effective nicotine delivery may not provide sufficient motivation for many smokers to switch from combustible cigarettes to reduced harm alternatives such as NRT or e-cigarettes. Other factors, such as the extent to which e-cigarette use satisfies the social factors that smokers believe contribute to their addiction (eg, the smoking “routine” and sociability) 85 could influence its acceptability as a substitute for smoking. Therefore, the use of e-cigarettes (vaping) as a social practice may be just as important as it’s more functional role of relieving nicotine withdrawal symptoms.

These findings may partly explain the limited uptake of medicinal cessation aids, despite evidence of efficacy from clinical trials, wide availability, promotional advertising and public subsidization to make them more affordable. Cessation medicines may be viewed as addressing only one aspect of addiction (nicotine dependence), which smokers may not consider to be the most important factor driving their addiction. Furthermore, many have written of the increasing stigmatization of smokers that has occurred as tobacco use has become denormalized. 11 , 86–89 The extent to which medicinal cessation aids are associated with notions of substance (nicotine) addiction and the identity of a nicotine addict may make them unattractive to smokers given the techniques used by smokers to distance themselves from “addiction.” 90 This strong association between cigarettes and nicotine, and negative perceptions of being addicted, may also deter some smokers from experimenting with nicotine containing e-cigarettes. 91 Further research on how attitudes toward addiction influence smokers’ choices in relation to quitting smoking would be helpful.

These findings have a number of methodological implications. In limiting our review to literature on smokers’ understandings, the question arose—‘ who is a smoker ?’ How should we classify those who have recently taken up, or stopped smoking, or who smoke regularly but do not classify themselves as smokers? Our approach was to include any studies that claimed to include smokers or ex-smokers and to explicitly report the criteria used to identify and classify their participants. In doing so, we found there was significant diversity in the way that smoking status was classified across the reviewed studies. A number of studies provided either no information on how smokers were classified, or very vague descriptions of smoking status such as ‘known smokers’ 66 or ‘those with recent smoking experience.’ 65 Furthermore, very few studies discussed the rationale or implications of their chosen classifications.

This has a number of implications for interpretations of the above findings. First, adding these disparate classifications to the existing variation between study populations and context resulted in a sample of studies representing a very heterogeneous body of ‘smokers.’ Hence, the reported findings should be interpreted as providing an overall indication of the range of ways in which smokers conceptualize addiction. Further research in this area should ensure that methods for selecting and classifying smokers are reported. This is crucial both for reporting and analytical purposes.

A second methodological issue surrounds variation in the questions used to investigate addiction to smoking. It is likely that the framing of these questions significantly constrained the possible range of responses. For example, studies asking both “is tobacco physically addictive?” and “is tobacco mentally addictive?” presuppose that these are the ways in which addiction is experienced and preclude consideration of other explanations of addiction. While it is necessary to limit responses among large samples of smokers, qualitative literature can inform the most pertinent and useful questions to ask when there is limited scope. Finally, although investigations of addiction were not the primary aim of many studies, addiction consistently arose as a central theme. In the qualitative studies, detailed discussions of addiction sometimes arose from questions exploring smoking in general. This illustrates the significance of the concept of addiction both within smokers’ relationship with smoking as well as smoking research more broadly.

Based on these results, we recommend that researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. There is little research on perceptions of nicotine addiction, and more is needed, particularly considering the increasing use of nontobacco nicotine products and the potential for long-term nicotine maintenance. 19 Researchers should be deliberate in their choice of terms used in surveys and interviews to examine understandings of addiction to smoking and nicotine to improve the clarity of their research findings.

Supplementary data are available at Nicotine and Tobacco Research online.

DP received a UQ Winter Research Scholarship from the UQ School of Public Health to work on this project. KM was supported by an Australian Government Australian Postgraduate Award (APA) scholarship, as well as a top up scholarship from the University of Queensland. CG was supported by a National Health and Medical Research Council Career Development Fellowship (GNT1061978).

None declared.

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• Published: 24 March 2022

Tobacco and nicotine use

• Bernard Le Foll 1 , 2 ,
• Megan E. Piper 3 , 4 ,
• Christie D. Fowler 5 ,
• Serena Tonstad 6 ,
• Laura Bierut 7 ,
• Lin Lu   ORCID: orcid.org/0000-0003-0742-9072 8 , 9 ,
• Prabhat Jha 10 &
• Wayne D. Hall 11 , 12  

Nature Reviews Disease Primers volume  8 , Article number:  19 ( 2022 ) Cite this article

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• Disease genetics
• Experimental models of disease
• Preventive medicine

Tobacco smoking is a major determinant of preventable morbidity and mortality worldwide. More than a billion people smoke, and without major increases in cessation, at least half will die prematurely from tobacco-related complications. In addition, people who smoke have a significant reduction in their quality of life. Neurobiological findings have identified the mechanisms by which nicotine in tobacco affects the brain reward system and causes addiction. These brain changes contribute to the maintenance of nicotine or tobacco use despite knowledge of its negative consequences, a hallmark of addiction. Effective approaches to screen, prevent and treat tobacco use can be widely implemented to limit tobacco’s effect on individuals and society. The effectiveness of psychosocial and pharmacological interventions in helping people quit smoking has been demonstrated. As the majority of people who smoke ultimately relapse, it is important to enhance the reach of available interventions and to continue to develop novel interventions. These efforts associated with innovative policy regulations (aimed at reducing nicotine content or eliminating tobacco products) have the potential to reduce the prevalence of tobacco and nicotine use and their enormous adverse impact on population health.

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Tobacco is the second most commonly used psychoactive substance worldwide, with more than one billion smokers globally 1 . Although smoking prevalence has reduced in many high-income countries (HICs), tobacco use is still very prevalent in low-income and middle-income countries (LMICs). The majority of smokers are addicted to nicotine delivered by cigarettes (defined as tobacco dependence in the International Classification of Diseases, Tenth Revision (ICD-10) or tobacco use disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)). As a result of the neuro-adaptations and psychological mechanisms caused by repeated exposure to nicotine delivered rapidly by cigarettes, cessation can also lead to a well-characterized withdrawal syndrome, typically manifesting as irritability, anxiety, low mood, difficulty concentrating, increased appetite, insomnia and restlessness, that contributes to the difficulty in quitting tobacco use 2 , 3 , 4 .

Historically, tobacco was used in some cultures as part of traditional ceremonies, but its use was infrequent and not widely disseminated in the population. However, since the early twentieth century, the use of commercial cigarettes has increased dramatically 5 because of automated manufacturing practices that enable large-scale production of inexpensive products that are heavily promoted by media and advertising. Tobacco use became highly prevalent in the past century and was followed by substantial increases in the prevalence of tobacco-induced diseases decades later 5 . It took decades to establish the relationship between tobacco use and associated health effects 6 , 7 and to discover the addictive role of nicotine in maintaining tobacco smoking 8 , 9 , and also to educate people about these effects. It should be noted that the tobacco industry disputed this evidence to allow continuing tobacco sales 10 . The expansion of public health campaigns to reduce smoking has gradually decreased the use of tobacco in HICs, with marked increases in adult cessation, but less progress has been achieved in LMICs 1 .

Nicotine is the addictive compound in tobacco and is responsible for continued use of tobacco despite harms and a desire to quit, but nicotine is not directly responsible for the harmful effects of using tobacco products (Box  1 ). Other components in tobacco may modulate the addictive potential of tobacco (for example, flavours and non-nicotine compounds) 11 . The major harms related to tobacco use, which are well covered elsewhere 5 , are linked to a multitude of compounds present in tobacco smoke (such as carcinogens, toxicants, particulate matter and carbon monoxide). In adults, adverse health outcomes of tobacco use include cancer in virtually all peripheral organs exposed to tobacco smoke and chronic diseases such as eye disease, periodontal disease, cardiovascular diseases, chronic obstructive pulmonary disease, stroke, diabetes mellitus, rheumatoid arthritis and disorders affecting immune function 5 . Moreover, smoking during pregnancy can increase the risk of adverse reproductive effects, such as ectopic pregnancy, low birthweight and preterm birth 5 . Exposure to secondhand cigarette smoke in children has been linked to sudden infant death syndrome, impaired lung function and respiratory illnesses, in addition to cognitive and behavioural impairments 5 . The long-term developmental effects of nicotine are probably due to structural and functional changes in the brain during this early developmental period 12 , 13 .

Nicotine administered alone in various nicotine replacement formulations (such as patches, gum and lozenges) is safe and effective as an evidence-based smoking cessation aid. Novel forms of nicotine delivery systems have also emerged (called electronic nicotine delivery systems (ENDS) or e-cigarettes), which can potentially reduce the harmful effects of tobacco smoking for those who switch completely from combustible to e-cigarettes 14 , 15 .

This Primer focuses on the determinants of nicotine and tobacco use, and reviews the neurobiology of nicotine effects on the brain reward circuitry and the functioning of brain networks in ways that contribute to the difficulty in stopping smoking. This Primer also discusses how to prevent tobacco use, screen for smoking, and offer people who smoke tobacco psychosocial and pharmacological interventions to assist in quitting. Moreover, this Primer presents emerging pharmacological and novel brain interventions that could improve rates of successful smoking cessation, in addition to public health approaches that could be beneficial.

Box 1 Tobacco products

Conventional tobacco products include combustible products that produce inhaled smoke (most commonly cigarettes, bidis (small domestically manufactured cigarettes used in South Asia) or cigars) and those that deliver nicotine without using combustion (chewing or dipping tobacco and snuff). Newer alternative products that do not involve combustion include nicotine-containing e-cigarettes and heat-not-burn tobacco devices. Although non-combustion and alternative products may constitute a lesser risk than burned ones 14 , 15 , 194 , no form of tobacco is entirely risk-free.

Epidemiology

Prevalence and burden of disease.

The Global Burden of Disease Project (GBDP) estimated that around 1.14 billion people smoked in 2019, worldwide, increasing from just under a billion in 1990 (ref. 1 ). Of note, the prevalence of smoking decreased significantly between 1990 and 2019, but increases in the adult population meant that the total number of global smokers increased. One smoking-associated death occurs for approximately every 0.8–1.1 million cigarettes smoked 16 , suggesting that the estimated worldwide consumption of about 7.4 trillion cigarettes in 2019 has led to around 7 million deaths 1 .

In most populations, smoking prevalence is much higher among groups with lower levels of education or income 17 and among those with mental health disorders and other co-addictions 18 , 19 . Smoking is also more frequent among men than women (Figs  1 – 3 ). Sexual and/or gender minority individuals have disproportionately high rates of smoking and other addictions 17 , 20 . In addition, the prevalence of smoking varies substantially between regions and ethnicities; smoking rates are high in some regions of Asia, such as China and India, but are lower in North America and Australia. Of note, the prevalence of mental health disorders and other co-addictions is higher in individuals who smoke compared with non-smokers 18 , 19 , 21 . For example, the odds of smoking in people with any substance use disorder is more than five times higher than the odds in people without a substance use disorder 19 . Similarly, the odds of smoking in people with any psychiatric disorder is more than three times higher than the odds of smoking in those without a psychiatric diagnosis 22 . In a study in the USA, compared with a population of smokers with no psychiatric diagnosis, subjects with anxiety, depression and phobia showed an approximately twofold higher prevalence of smoking, and subjects with agoraphobia, mania or hypomania, psychosis and antisocial personality or conduct disorders showed at least a threefold higher prevalence of smoking 22 . Comorbid disorders are also associated with higher rates of smoking 22 , 23 .

a | Number of current male smokers aged 15 years or older per country expressed in millions. b | Former male smokers aged 45–59 years per country expressed in millions. c | Former male smokers aged 45–59 years per country expressed as the percentage of smokers who stopped. The data shown are for male smokers for the period 2015–2019 from countries with direct smoking surveys. The prevalence of smoking among males is less variable than among females. Data from ref. 1 .

a | Number of current female smokers aged 15 years or older per country expressed in millions. b | Former female smokers aged 45–59 years per country expressed in millions. c | Former female smokers aged 45–59 years per country expressed as the percentage of smokers who stopped. The data shown are for female smokers for the period 2015–2019 from countries with direct smoking surveys. The prevalence of smoking among females is much lower in East and South Asia than in Latin America or Eastern Europe. Data from ref. 1 .

a | Number of current male and female smokers aged 15 years or older per country expressed in millions. b | Former male and female smokers aged 45–59 years per country expressed in millions. c | Former male and female smokers aged 45–59 years per country expressed as the percentage of smokers who stopped. The data shown are for the period 2015–2019 from countries with direct smoking surveys. Cessation rates are higher in high-income countries, but also notably high in Brazil. Cessation is far less common in South and East Asia and Russia and other Eastern European countries, and also low in South Africa. Data from ref. 1 .

Age at onset

Most smokers start smoking during adolescence, with almost 90% of smokers beginning between 15 and 25 years of age 24 . The prevalence of tobacco smoking among youths substantially declined in multiple HICs between 1990 and 2019 (ref. 25 ). More recently, the widespread uptake of ENDS in some regions such as Canada and the USA has raised concerns about the long-term effects of prolonged nicotine use among adolescents, including the possible notion that ENDS will increase the use of combustible smoking products 25 , 26 (although some studies have not found much aggregate effect at the population level) 27 .

Smoking that commences in early adolescence or young adulthood and persists throughout life has a more severe effect on health than smoking that starts later in life and/or that is not persistent 16 , 28 , 29 . Over 640 million adults under 30 years of age smoke in 22 jurisdictions alone (including 27 countries in the European Union where central efforts to reduce tobacco dependence might be possible) 30 . In those younger than 30 years of age, at least 320 million smoking-related deaths will occur unless they quit smoking 31 . The actual number of smoking-related deaths might be greater than one in two, and perhaps as high as two in three, long-term smokers 5 , 16 , 29 , 32 , 33 . At least half of these deaths are likely to occur in middle age (30–69 years) 16 , 29 , leading to a loss of two or more decades of life. People who smoke can expect to lose an average of at least a decade of life versus otherwise similar non-smokers 16 , 28 , 29 .

Direct epidemiological studies in several countries paired with model-based estimates have estimated that smoking tobacco accounted for 7.7 million deaths globally in 2020, of which 80% were in men and 87% were current smokers 1 . In HICs, the major causes of tobacco deaths are lung cancer, emphysema, heart attack, stroke, cancer of the upper aerodigestive areas and bladder cancer 28 , 29 . In some lower income countries, tuberculosis is an additional important cause of tobacco-related death 29 , 34 , which could be related to, for example, increased prevalence of infection, more severe tuberculosis/mortality and higher prevalence of treatment-resistant tuberculosis in smokers than in non-smokers in low-income countries 35 , 36 .

Despite substantial reductions in the prevalence of smoking, there were 34 million smokers in the USA, 7 million in the UK and 5 million in Canada in 2017 (ref. 16 ), and cigarette smoking remains the largest cause of premature death before 70 years of age in much of Europe and North America 1 , 16 , 28 , 29 . Smoking-associated diseases accounted for around 41 million deaths in the USA, UK and Canada from 1960 to 2020 (ref. 16 ). Moreover, as smoking-associated diseases are more prevalent among groups with lower levels of education and income, smoking accounts for at least half of the difference in overall mortality between these social groups 37 . Any reduction in smoking prevalence reduces the absolute mortality gap between these groups 38 .

Smoking cessation has become common in HICs with good tobacco control interventions. For example, in France, the number of ex-smokers is four times the number of current smokers among those aged 50 years or more 30 . By contrast, smoking cessation in LMICs remains uncommon before smokers develop tobacco-related diseases 39 . Smoking cessation greatly reduces the risks of smoking-related diseases. Indeed, smokers who quit smoking before 40 years of age avoid nearly all the increased mortality risks 31 , 33 . Moreover, individuals who quit smoking by 50 years of age reduce the risk of death from lung cancer by about two-thirds 40 . More modest hazards persist for deaths from lung cancer and emphysema 16 , 28 ; however, the risks among former smokers are an order of magnitude lower than among those who continue to smoke 33 .

Mechanisms/pathophysiology

Nicotine is the main psychoactive agent in tobacco and e-cigarettes. Nicotine acts as an agonist at nicotinic acetylcholine receptors (nAChRs), which are localized throughout the brain and peripheral nervous system 41 . nAChRs are pentameric ion channels that consist of varying combinations of α 2 –α 7 and β 2 –β 4 subunits, and for which acetylcholine (ACh) is the endogenous ligand 42 , 43 , 44 . When activated by nicotine binding, nAChR undergoes a conformational change that opens the internal pore, allowing an influx of sodium and calcium ions 45 . At postsynaptic membranes, nAChR activation can lead to action potential firing and downstream modulation of gene expression through calcium-mediated second messenger systems 46 . nAChRs are also localized to presynaptic membranes, where they modulate neurotransmitter release 47 . nAChRs become desensitized after activation, during which ligand binding will not open the channel 45 .

nAChRs with varying combinations of α-subunits and β-subunits have differences in nicotine binding affinity, efficacy and desensitization rate, and have differential expression depending on the brain region and cell type 48 , 49 , 50 . For instance, at nicotine concentrations found in human smokers, β 2 -containing nAChRs desensitize relatively quickly after activation, whereas α 7 -containing nAChRs have a slower desensitization profile 48 . Chronic nicotine exposure in experimental animal models or in humans induces an increase in cortical expression of α 4 β 2 -containing nAChRs 51 , 52 , 53 , 54 , 55 , but also increases the expression of β 3 and β 4 nAChR subunits in the medial habenula (MHb)–interpeduncular nucleus (IPN) pathway 56 , 57 . It is clear that both the brain localization and the type of nAChR are critical elements in mediating the various effects of nicotine, but other factors such as rate of nicotine delivery may also modulate addictive effects of nicotine 58 .

Neurocircuitry of nicotine addiction

Nicotine has both rewarding effects (such as a ‘buzz’ or ‘high’) and aversive effects (such as nausea and dizziness), with the net outcome dependent on dose and others factors such as interindividual sensitivity and presence of tolerance 59 . Thus, the addictive properties of nicotine involve integration of contrasting signals from multiple brain regions that process reward and aversion (Fig.  4 ).

During initial use, nicotine exerts both reinforcing and aversive effects, which together determine the likelihood of continued use. As the individual transitions to more frequent patterns of chronic use, nicotine induces pharmacodynamic changes in brain circuits, which is thought to lead to a reduction in sensitivity to the aversive properties of the drug. Nicotine is also a powerful reinforcer that leads to the conditioning of secondary cues associated with the drug-taking experience (such as cigarette pack, sensory properties of cigarette smoke and feel of the cigarette in the hand or mouth), which serves to enhance the incentive salience of these environmental factors and drive further drug intake. When the individual enters into states of abstinence (such as daily during sleep at night or during quit attempts), withdrawal symptomology is experienced, which may include irritability, restlessness, learning or memory deficits, difficulty concentrating, anxiety and hunger. These negative affective and cognitive symptoms lead to an intensification of the individual’s preoccupation to obtain and use the tobacco/nicotine product, and subsequently such intense craving can lead to relapse.

The rewarding actions of nicotine have largely been attributed to the mesolimbic pathway, which consists of dopaminergic neurons in the ventral tegmental area (VTA) that project to the nucleus accumbens and prefrontal cortex 60 , 61 , 62 (Fig.  5 ). VTA integrating circuits and projection regions express several nAChR subtypes on dopaminergic, GABAergic, and glutamatergic neurons 63 , 64 . Ultimately, administration of nicotine increases dopamine levels through increased dopaminergic neuron firing in striatal and extrastriatal areas (such as the ventral pallidum) 65 (Fig.  6 ). This effect is involved in reward and is believed to be primarily mediated by the action of nicotine on α 4 -containing and β 2 -containing nAChRs in the VTA 66 , 67 .

Multiple lines of research have demonstrated that nicotine reinforcement is mainly controlled by two brain pathways, which relay predominantly reward-related or aversion-related signals. The rewarding properties of nicotine that promote drug intake involve the mesolimbic dopamine projection from the ventral tegmental area (VTA) to the nucleus accumbens (NAc). By contrast, the aversive properties of nicotine that limit drug intake and mitigate withdrawal symptoms involve the fasciculus retroflexus projection from the medial habenula (MHb) to the interpeduncular nucleus (IPN). Additional brain regions have also been implicated in various aspects of nicotine dependence, such as the prefrontal cortex (PFC), ventral pallidum (VP), nucleus tractus solitarius (NTS) and insula (not shown here for clarity). All of these brain regions are directly or indirectly interconnected as integrative circuits to drive drug-seeking and drug-taking behaviours.

Smokers received brain PET scans with [ 11 C]PHNO, a dopamine D 2/3 PET tracer that has high sensitivity in detecting fluctuations of dopamine. PET scans were performed during abstinence or after smoking a cigarette. Reduced binding potential (BP ND ) was observed after smoking, indicating increased dopamine levels in the ventral striatum and in the area that corresponds to the ventral pallidum. The images show clusters with statistically significant decreases of [ 11 C]PHNO BP ND after smoking a cigarette versus abstinence condition. Those clusters have been superimposed on structural T1 MRI images of the brain. Reprinted from ref. 65 , Springer Nature Limited.

The aversive properties of nicotine are mediated by neurons in the MHb, which project to the IPN. Studies in rodents using genetic knockdown and knockout strategies demonstrated that the α 5 -containing, α 3 -containing and β 4 -containing nAChRs in the MHb–IPN pathway mediate the aversive properties of nicotine that limit drug intake, especially when animals are given the opportunity to consume higher nicotine doses 68 , 69 , 70 , 71 , 72 . In addition to nAChRs, other signalling factors acting on the MHb terminals in the IPN also regulate the actions of nicotine. For instance, under conditions of chronic nicotine exposure or with optogenetic activation of IPN neurons, a subtype of IPN neurons co-expressing Chrna5 (encoding the α 5 nAChR subunit) and Amigo1 (encoding adhesion molecule with immunoglobulin-like domain 1) release nitric oxide from the cell body that retrogradely inhibits MHb axon terminals 70 . In addition, nicotine activates α 5 -containing nAChR-expressing neurons that project from the nucleus tractus solitarius to the IPN, leading to release of glucagon-like peptide-1 that binds to GLP receptors on habenular axon terminals, which subsequently increases IPN neuron activation and decreases nicotine self-administration 73 . Taken together, these findings suggest a dynamic signalling process at MHb axonal terminals in the IPN, which regulates the addictive properties of nicotine and determines the amount of nicotine that is self-administered.

Nicotine withdrawal in animal models can be assessed by examining somatic signs (such as shaking, scratching, head nods and chewing) and affective signs (such as increased anxiety-related behaviours and conditioned place aversion). Interestingly, few nicotine withdrawal somatic signs are found in mice with genetic knockout of the α 2 , α 5 or β 4 nAChR subunits 74 , 75 . By contrast, β 2 nAChR-knockout mice have fewer anxiety-related behaviours during nicotine withdrawal, with no differences in somatic symptoms compared with wild-type mice 74 , 76 .

In addition to the VTA (mediating reward) and the MHb–IPN pathway (mediating aversion), other brain areas are involved in nicotine addiction (Fig.  5 ). In animals, the insular cortex controls nicotine taking and nicotine seeking 77 . Moreover, humans with lesions of the insular cortex can quit smoking easily without relapse 78 . This finding led to the development of a novel therapeutic intervention modulating insula function (see Management, below) 79 , 80 . Various brain areas (shell of nucleus accumbens, basolateral amygdala and prelimbic cortex) expressing cannabinoid CB 1 receptors are also critical in controlling rewarding effects and relapse 81 , 82 . The α 1 -adrenergic receptor expressed in the cortex also control these effects, probably through glutamatergic afferents to the nucleus accumbens 83 .

Individual differences in nicotine addiction risk

Vulnerability to nicotine dependence varies between individuals, and the reasons for these differences are multidimensional. Many social factors (such as education level and income) play a role 84 . Broad psychological and social factors also modulate this risk. For example, peer smoking status, knowledge on effect of tobacco, expectation on social acceptance, exposure to passive smoking modulate the risk of initiating tobacco use 85 , 86 .

Genetic factors have a role in smoking initiation, the development of nicotine addiction and the likelihood of smoking cessation. Indeed, heritability has been estimated to contribute to approximatively half of the variability in nicotine dependence 87 , 88 , 89 , 90 . Important advances in our understanding of such genetic contributions have evolved with large-scale genome-wide association studies of smokers and non-smokers. One of the most striking findings has been that allelic variation in the CHRNA5 – CHRNA3 – CHRNB4 gene cluster, which encodes α 5 , α 3 and β 4 nAChR subunits, correlates with an increased vulnerability for nicotine addiction, indicated by a higher likelihood of becoming dependent on nicotine and smoking a greater number of cigarettes per day 91 , 92 , 93 , 94 , 95 . The most significant effect has been found for a single-nucleotide polymorphism in CHRNA5 (rs16969968), which results in an amino acid change and reduced function of α 5 -containing nAChRs 92 .

Allelic variation in CYP2A6 (encoding the CYP2A6 enzyme, which metabolizes nicotine) has also been associated with differential vulnerability to nicotine dependence 96 , 97 , 98 . CYP2A6 is highly polymorphic, resulting in variable enzymatic activity 96 , 99 , 100 . Individuals with allelic variation that results in slow nicotine metabolism consume less nicotine per day, experience less-severe withdrawal symptoms and are more successful at quitting smoking than individuals with normal or fast metabolism 101 , 102 , 103 , 104 . Moreover, individuals with slow nicotine metabolism have lower dopaminergic receptor expression in the dopamine D2 regions of the associative striatum and sensorimotor striatum in PET studies 105 and take fewer puffs of nicotine-containing cigarettes (compared with de-nicotinized cigarettes) in a forced choice task 106 . Slower nicotine metabolism is thought to increase the duration of action of nicotine, allowing nicotine levels to accumulate over time, therefore enabling lower levels of intake to sustain activation of nAChRs 107 .

Large-scale genetic studies have identified hundreds of other genetic loci that influence smoking initiation, age of smoking initiation, cigarettes smoked per day and successful smoking cessation 108 . The strongest genetic contributions to smoking through the nicotinic receptors and nicotine metabolism are among the strongest genetic contributors to lung cancer 109 . Other genetic variations (such as those related to cannabinoid, dopamine receptors or other neurotransmitters) may affect certain phenotypes related to smoking (such as nicotine preference and cue-reactivity) 110 , 111 , 112 , 113 , 114 , 115 .

Diagnosis, screening and prevention

Screening for cigarette smoking.

Screening for cigarette smoking should happen at every doctor’s visit 116 . In this regard, a simple and direct question about a person’s tobacco use can provide an opportunity to offer information about its potential risks and treatments to assist in quitting. All smokers should be offered assistance in quitting because even low levels of smoking present a significant health risk 33 , 117 , 118 . Smoking status can be assessed by self-categorization or self-reported assessment of smoking behaviour (Table  1 ). In people who smoke, smoking frequency can be assessed 119 and a combined quantity frequency measure such as pack-year history (that is, average number of cigarettes smoked per day multiplied by the number of years, divided by 20), can be used to estimate cumulative risk of adverse health outcomes. The Association for the Treatment of Tobacco Use and Dependence recommends that all electronic health records should document smoking status using the self-report categories listed in Table  1 .

Owing to the advent of e-cigarettes and heat-not-burn products, and the popularity of little cigars in the US that mimic combustible cigarettes, people who use tobacco may use multiple products concurrently 120 , 121 . Thus, screening for other nicotine and tobacco product use is important in clinical practice. The self-categorization approach can also be used to describe the use of these other products.

Traditionally tobacco use has been classified according to whether the smoker meets criteria for nicotine dependence in one of the two main diagnostic classifications: the DSM 122 (tobacco use disorder) and the ICD (tobacco dependence) 123 . The diagnosis of tobacco use disorder according to DSM-5 criteria requires the presence of at least 2 of 11 symptoms that have produced marked clinical impairment or distress within a 12-month period (Box  2 ). Of note, these symptoms are similar for all substance use disorder diagnoses and may not all be relevant to tobacco use disorder (such as failure to complete life roles). In the ICD-10, codes allow the identification of specific tobacco products used (cigarettes, chewing tobacco and other tobacco products).

Dependence can also be assessed as a continuous construct associated with higher levels of use, greater withdrawal and reduced likelihood of quitting. The level of dependence can be assessed with the Fagerström Test for Nicotine Dependence, a short questionnaire comprising six questions 124 (Box  2 ). A score of ≥4 indicates moderate to high dependence. As very limited time may be available in clinical consultations, the Heaviness of Smoking Index (HSI) was developed, which comprises two questions on the number of cigarettes smoked per day and how soon after waking the first cigarette is smoked 125 . The HSI can guide dosing for nicotine replacement therapy (NRT).

Other measures of cigarette dependence have been developed but are not used in the clinical setting, such as the Cigarette Dependence Scale 126 , Hooked on Nicotine Checklist 127 , Nicotine Dependence Syndrome Scale 128 , the Wisconsin Inventory of Smoking Dependence Motives (Brief) 129 and the Penn State Cigarette Dependence Index 130 . However, in practice, these are not often used, as the most important aspect is to screen for smoking and encourage all smokers to quit smoking regardless of their dependence status.

Box 2 DSM-5 criteria for tobacco use disorder and items of the Fagerström Test for nicotine dependence

DSM-5 (ref. 122 )

Taxonomic and diagnostic tool for tobacco use disorder published by the American Psychiatric Association.

A problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring within a 12-month period.

Tobacco often used in larger amounts or over a longer period of time than intended

A persistent desire or unsuccessful efforts to reduce or control tobacco use

A great deal of time spent in activities necessary to obtain or use tobacco

Craving, or a strong desire or urge to use tobacco

Recurrent tobacco use resulting in a failure to fulfil major role obligations at work, school or home

Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (for example, arguments with others about tobacco use)

Important social, occupational or recreational activities given up or reduced because of tobacco use

Recurrent tobacco use in hazardous situations (such as smoking in bed)

Tobacco use continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco use

Tolerance, defined by either of the following.

A need for markedly increased amounts of tobacco to achieve the desired effect

A markedly diminished effect with continued use of the same amount of tobacco

Withdrawal, manifesting as either of the following.

Withdrawal syndrome for tobacco

Tobacco (or a closely related substance, such as nicotine) taken to relieve or avoid withdrawal symptoms

Fagerström Test for Nicotine Dependence 124

A standard instrument for assessing the intensity of physical addiction to nicotine.

How soon after you wake up do you smoke your first cigarette?

Within 5 min (scores 3 points)

5 to 30 min (scores 2 points)

31 to 60 min (scores 1 point)

After 60 min (scores 0 points)

Do you find it difficult not to smoke in places where you should not, such as in church or school, in a movie, at the library, on a bus, in court or in a hospital?

Yes (scores 1 point)

No (scores 0 points)

Which cigarette would you most hate to give up; which cigarette do you treasure the most?

The first one in the morning (scores 1 point)

Any other one (scores 0 points)

How many cigarettes do you smoke each day?

10 or fewer (scores 0 points)

11 to 20 (scores 1 point)

21 to 30 (scores 2 points)

31 or more (scores 3 points)

Do you smoke more during the first few hours after waking up than during the rest of the day?

Do you still smoke if you are so sick that you are in bed most of the day or if you have a cold or the flu and have trouble breathing?

A score of 7–10 points is classified as highly dependent; 4–6 points is classified as moderately dependent; <4 points is classified as minimally dependent.

DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Young people who do not start smoking cigarettes between 15 and 25 years of age have a very low risk of ever smoking 24 , 131 , 132 . This age group provides a critical opportunity to prevent cigarette smoking using effective, evidence-based strategies to prevent smoking initiation and reduce escalation from experimentation to regular use 131 , 132 , 133 , 134 , 135 .

Effective prevention of cigarette uptake requires a comprehensive package of cost-effective policies 134 , 136 , 137 to synergistically reduce the population prevalence of cigarette smoking 131 , 135 . These policies include high rates of tobacco taxation 30 , 134 , 137 , 138 , widespread and rigorously enforced smoke-free policies 139 , bans on tobacco advertising and promotions 140 , use of plain packaging and graphic warnings about the health risks of smoking 135 , 141 , mass media and peer-based education programmes to discourage smoking, and enforcement of laws against the sale of cigarettes to young people below the minimum legal purchase age 131 , 135 . These policies make cigarettes less available and affordable to young people. Moreover, these policies make it more difficult for young people to purchase cigarettes and make smoking a much less socially acceptable practice. Of note, these policies are typically mostly enacted in HICs, which may be related to the declining prevalence of smoking in these countries, compared with the prevalence in LMICs.

Pharmacotherapy

Three evidence-based classes of pharmacotherapy are available for smoking cessation: NRT (using nicotine-based patches, gum, lozenges, mini-lozenges, nasal sprays and inhalers), varenicline (a nAChR partial agonist), and bupropion (a noradrenaline/dopamine reuptake inhibitor that also inhibits nAChR function and is also used as an antidepressant). These FDA-approved and EMA-approved pharmacotherapies are cost-effective smoking cessation treatments that double or triple successful abstinence rates compared with no treatment or placebo controls 116 , 142 .

Combinations of pharmacotherapies are also effective for smoking cessation 116 , 142 . For example, combining NRTs (such as the steady-state nicotine patch and as-needed NRT such as gum or mini-lozenge) is more effective than a single form of NRT 116 , 142 , 143 . Combining NRT and varenicline is the most effective smoking cessation pharmacotherapy 116 , 142 , 143 . Combining FDA-approved pharmacotherapy with behavioural counselling further increases the likelihood of successful cessation 142 . Second-line pharmacotherapies (for example, nortriptyline) have some potential for smoking cessation, but their use is limited due to their tolerability profile.

All smokers should receive pharmacotherapy to help them quit smoking, except those in whom pharmacotherapy has insufficient evidence of effectiveness (among adolescents, smokeless tobacco users, pregnant women or light smokers) or those in whom pharmacotherapy is medically contraindicated 144 . Table  2 provides specific information regarding dosing and duration for each FDA-approved pharmacotherapy. Extended use of pharmacotherapy beyond the standard 12-week regimen after cessation is effective and should be considered 116 . Moreover, preloading pharmacotherapy (that is, initiating cessation medication in advance of a quit attempt), especially with the nicotine patch, is a promising treatment, although further studies are required to confirm efficacy.

Cytisine has been used for smoking cessation in Eastern Europe for a long time and is available in some countries (such as Canada) without prescription 145 . Cytisine is a partial agonist of nAChRs and its structure was the precursor for the development of varenicline 145 . Cytisine is at least as effective as some approved pharmacotherapies for smoking cessation, such as NRT 146 , 147 , 148 , and the role of cytisine in smoking cessation is likely to expand in the future, notably owing to its much lower cost than traditional pharmacotherapies. E-cigarettes also have the potential to be useful as smoking cessation devices 149 , 150 . The 2020 US Surgeon General’s Report concluded that there was insufficient evidence to promote cytisine or e-cigarettes as effective smoking cessation treatments, but in the UK its use is recommended for smoking cessation (see ref. 15 for regularly updated review).

Counselling and behavioural treatments

Psychosocial counselling significantly increases the likelihood of successful cessation, especially when combined with pharmacotherapy. Even a counselling session lasting only 3 minutes can help smokers quit 116 , although the 2008 US Public Health Service guidelines and the Preventive Services Task Force 151 each concluded that more intensive counselling (≥20 min per session) is more effective than less intensive counselling (<20 min per session). Higher smoking cessation rates are obtained by using behavioural change techniques that target associative and self-regulatory processes 152 . In addition, behavioural change techniques that will favour commitment, social reward and identity associated with changed behaviour seems associated with higher success rates 152 . Evidence-based counselling focuses on providing social support during treatment, building skills to cope with withdrawal and cessation, and problem-solving in challenging situations 116 , 153 . Effective counselling can be delivered by diverse providers (such as physicians, nurses, pharmacists, social workers, psychologists and certified tobacco treatment specialists) 116 .

Counselling can be delivered in a variety of modalities. In-person individual and group counselling are effective, as is telephone counselling (quit lines) 142 . Internet and text-based intervention seem to be effective in smoking cessation, especially when they are interactive and tailored to a smoker’s specific circumstances 142 . Over the past several years, the number of smoking cessation smartphone apps has increased, but there the evidence that the use of these apps significantly increases smoking cessation rates is not sufficient.

Contingency management (providing financial incentives for abstinence or engagement in treatment) has shown promising results 154 , 155 but its effects are not sustained once the contingencies are removed 155 , 156 . Other treatments such as hypnosis, acupuncture and laser treatment have not been shown to improve smoking cessation rates compared with placebo treatments 116 . Moreover, no solid evidence supports the use of conventional transcranial magnetic stimulation (TMS) for long-term smoking cessation 157 , 158 .

Although a variety of empirically supported smoking cessation interventions are available, more than two-thirds of adult smokers who made quit attempts in the USA during the past year did not use an evidence-based treatment and the rate is likely to be lower in many other countries 142 . This speaks to the need to increase awareness of, and access to, effective cessation aids among all smokers.

Brain stimulation

The insula (part of the frontal cortex) is a critical brain structure involved in cigarette craving and relapse 78 , 79 . The activity of the insula can be modulated using an innovative approach called deep insula/prefrontal cortex TMS (deep TMS), which is effective in helping people quit smoking 80 , 159 . This approach has now been approved by the FDA as an effective smoking cessation intervention 80 . However, although this intervention was developed and is effective for smoking cessation, the number of people with access to it is limited owing to the limited number of sites equipped and with trained personnel, and the cost of this intervention.

Quality of life

Generic instruments (such as the Short-Form (SF-36) Health Survey) can be used to evaluate quality of life (QOL) in smokers. People who smoke rate their QOL lower than people who do not smoke both before and after they become smokers 160 , 161 . QOL improves when smokers quit 162 . Mental health may also improve on quitting smoking 163 . Moreover, QOL is much poorer in smokers with tobacco-related diseases, such as chronic respiratory diseases and cancers, than in individuals without tobacco-related diseases 161 , 164 . The dimensions of QOL that show the largest decrements in people who smoke are those related to physical health, day-to-day activities and mental health such as depression 160 . Smoking also increases the risk of diabetes mellitus 165 , 166 , which is a major determinant of poor QOL for a wide range of conditions.

The high toll of premature death from cigarette smoking can obscure the fact that many of the diseases that cause these deaths also produce substantial disability in the years before death 1 . Indeed, death in smokers is typically preceded by several years of living with the serious disability and impairment of everyday activities caused by chronic respiratory disease, heart disease and cancer 2 . Smokers’ QOL in these years may also be adversely affected by the adverse effects of the medical treatments that they receive for these smoking-related diseases (such as major surgery and radiotherapy).

Expanding cessation worldwide

The major global challenge is to consider individual and population-based strategies that could increase the substantially low rates of adult cessation in most LMICs and indeed strategies to ensure that even in HICs, cessation continues to increase. In general, the most effective tools recommended by WHO to expand cessation are the same tools that can prevent smoking initiation, notably higher tobacco taxes, bans on advertising and promotion, prominent warning labels or plain packaging, bans on public smoking, and mass media and educational efforts 29 , 167 . The effective use of these policies, particularly taxation, lags behind in most LMICs compared with most HICs, with important exceptions such as Brazil 167 . Access to effective pharmacotherapies and counselling as well as support for co-existing mental health conditions would also be required to accelerate cessation in LMICs. This is particularly important as smokers living in LMICs often have no access to the full range of effective treatment options.

Regulating access to e-cigarettes

How e-cigarettes should be used is debated within the tobacco control field. In some countries (for example, the UK), the use of e-cigarettes as a cigarette smoking cessation aid and as a harm reduction strategy is supported, based on the idea that e-cigarette use will lead to much less exposure to toxic compounds than tobacco use, therefore reducing global harm. In other countries (for example, the USA), there is more concern with preventing the increased use of e-cigarettes by youths that may subsequently lead to smoking 25 , 26 . Regulating e-cigarettes in nuanced ways that enable smokers to access those products whilst preventing their uptake among youths is critical.

Regulating nicotine content in tobacco products

Reducing the nicotine content of cigarettes could potentially produce less addictive products that would allow a gradual reduction in the population prevalence of smoking. Some clinical studies have found no compensatory increase in smoking whilst providing access to low nicotine tobacco 168 . Future regulation may be implemented to gradually decrease the nicotine content of combustible tobacco and other nicotine products 169 , 170 , 171 .

Tobacco end games

Some individuals have proposed getting rid of commercial tobacco products this century or using the major economic disruption arising from the COVID-19 pandemic to accelerate the demise of the tobacco industry 172 , 173 . Some tobacco producers have even proposed this strategy as an internal goal, with the idea of switching to nicotine delivery systems that are less harmful ( Philip Morris International ). Some countries are moving towards such an objective; for example, in New Zealand, the goal that fewer than 5% of New Zealanders will be smokers in 2025 has been set (ref. 174 ). The tobacco end-game approach would overall be the best approach to reduce the burden of tobacco use on society, but it would require coordination of multiple countries and strong public and private consensus on the strategy to avoid a major expansion of the existing illicit market in tobacco products in some countries.

Innovative interventions

The COVID-19 pandemic has shown that large-scale investment in research can lead to rapid development of successful therapeutic interventions. By contrast, smoking cessation has been underfunded compared with the contribution that it makes to the global burden of disease. In addition, there is limited coordination between research teams and most studies are small-scale and often underpowered 79 . It is time to fund an ambitious, coordinated programme of research to test the most promising therapies based on an increased understanding of the neurobiological basis of smoking and nicotine addiction (Table  3 ). Many of those ideas have not yet been tested properly and this could be carried out by a coordinated programme of research at the international level.

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Acknowledgements

B.Le F. is supported by a clinician-scientist award from the Department of Family and Community Medicine at the University of Toronto and the Addiction Psychiatry Chair from the University of Toronto. The funding bodies had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. The authors thank H. Fu (University of Toronto) for assistance with Figs 1–3.

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Bernard Le Foll

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Department of Medicine, University of Wisconsin, Madison, WI, USA

Megan E. Piper

University of Wisconsin Center for Tobacco Research and Intervention, Madison, WI, USA

Department of Neurobiology and Behaviour, University of California Irvine, Irvine, CA, USA

Christie D. Fowler

Section for Preventive Cardiology, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway

Serena Tonstad

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Laura Bierut

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Contributions

Introduction (B.Le F.); Epidemiology (P.J. and W.D.H.); Mechanisms/pathophysiology (C.D.F., L.B., L.L. and B.Le F.); Diagnosis, screening and prevention (P.J., M.E.P., S.T. and B.Le F.); Management (M.E.P., S.T., W.D.H., L.L. and B.Le F.); Quality of life (P.J. and W.D.H.); Outlook (all); Conclusions (all). All authors contributed substantially to the review and editing of the manuscript.

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Correspondence to Bernard Le Foll .

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B.Le F. has obtained funding from Pfizer (GRAND Awards, including salary support) for investigator-initiated projects. B.Le F. has received some in-kind donations of cannabis product from Aurora and medication donation from Pfizer and Bioprojet and was provided a coil for TMS study from Brainsway. B.Le F. has obtained industry funding from Canopy (through research grants handled by CAMH or the University of Toronto), Bioprojet, ACS, Indivior and Alkermes. B.Le F. has received in-kind donations of nabiximols from GW Pharma for past studies funded by CIHR and NIH. B.Le F. has been an advisor to Shinoghi. S.T. has received honoraria from Pfizer the manufacturer of varenicline for lectures and advice. All other authors declare no competing interests.

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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.

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Addressing Use of Nicotine Pouches

What to know.

Individuals and organizations can work together to reduce use of all tobacco products, including nicotine pouches.

States, communities, tribes, and territories can implement evidence-based, population-level strategies that address the use of all forms of tobacco products, including nicotine pouches. These strategies include:

• Incorporating all tobacco products, including nicotine pouches, into tobacco-free policies.
• Licensing retailers who sell tobacco products.
• Restricting young people's access to tobacco products in retail settings.
• Enforcing laws that penalize retailers who sell tobacco products to underage people.
• Implementing policies to raise the price of tobacco products to encourage cessation and discourage youth initiation.
• Reducing access to flavored tobacco products.
• Curbing advertising and marketing for tobacco products that appeal to young people.
• Developing educational initiatives that warn about the risks of tobacco product use, especially among young people.

Parents and teachers can:

• Learn about the different types of tobacco products and the risks of using tobacco products, including nicotine pouches.
• Set a good example by being tobacco-free and maintaining a tobacco-free home.
• Talk to children, teens, and young adults about why all forms of tobacco products are harmful for them.
• Encourage and support young people who use tobacco products to quit. Talk to their health care provider about getting quitting help. You can also call 1-800-QUIT-NOW and visit Teen.smokefree.gov for more help.
• Develop, implement, and enforce tobacco-free school policies and prevention programs. Ensure that these policies and programs are free from tobacco industry influence and address all types of tobacco products, including nicotine pouches.
• Learn more about ways to protect youth from tobacco products, including e-cigarettes and nicotine pouches.

Health professionals can:

• Learn about the different types of tobacco products and their associated risks.
• Ask all patients if they use any tobacco products, including nicotine pouches.
• Encourage patients to quit using tobacco products. Provide support and evidence-based treatments to help them quit successfully.

Smoking and Tobacco Use

Commercial tobacco use is the leading cause of preventable disease, disability, and death in the United States.

For Everyone

Health care providers, public health.

Northampton Board of Health to discuss proposed generational ban on nicotine products

NORTHAMPTON, Mass. (WGGB/WSHM) - The Northampton Board of Health will be meeting to discuss a nicotine free generation policy that would ban the sale of tobacco and nicotine products to anyone born on or after January 1st, 2004.

If approved this measure would prohibit the sale of products including cigarettes, e-cigarettes, cigars, chewing tobacco and nicotine pouches.

This move comes after a similar measure was recently passed by the town of Brookline.

A virtual meeting will be held Thursday evening at 5:30 p.m.

Copyright 2024. Western Mass News (WGGB/WSHM). All rights reserved.

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Tucker Carlson starts his own nicotine-pouch brand as he claims Zyn is run by ‘humorless, left-wing drones’

Right-wing pundit has also claimed that men ‘should not use’ zyn, article bookmarked.

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Former Fox News personality Tucker Carlson is launching his own nicotine pouch brand after claiming Zyn is run by “humorless, left-wing drones.”

Carlson plans to launch the brand, Alp, in November, he told The Wall Street Journal . This comes after he made a strange comment about Zyn back in October – and the company fired back.

“The truth is, Zyn is a powerful work enhancer, and also a male enhancer, if you know what I mean,” Carlson said last October on the This Past Weekend politics podcast hosted by right-wing social media personality Theo Von.

Zyn pouches are small, nicotine-filled pouches that a user places between their gum and their upper lip. Zyn pouches also differ from snus — another oral nicotine product — because they contain nicotine powder, rather than shredded tobacco leaf.

Carlson’s team later pitched a partnership with Zyn, which their owner Philip Morris International shot down, the WSJ reports.

“While we understand that these may be Mr. Carlson’s views, or made in jest, these statements lack a scientific foundation,” the company said in response. “Given Mr. Carlson’s popularity and reach, these statements could promote a misunderstanding and misuse of our products.”

Carlson told the WSJ the company’s response inspired him to start the new brand.

“Of course I wasn’t making a medical claim about their product. I was just joking,” he told the outlet on Wednesday. “So I thought: ‘I’m going to launch my own product that’s not controlled by, you know, humorless, left-wing drones.’”

A ZYN spokesperson responded to his comments.

“It’s frustrating that Mr. Carlson wants to turn ZYN into a political football to promote his own business venture,” the spokesperson wrote in a statement. “ZYN enjoys bipartisan support in Washington, D.C., and around the country because it provides adults who smoke, Republicans and Democrats alike, a better alternative to combustible cigarettes.”

Last week, the former Fox News host also claimed Zyn donates to Kamala Harris – and commented that men should not use it.

“I’m embarrassed to say it, it’s made by a huge company, huge donors to Kamala Harris, I’m not gonna use that brand anymore,” Carlson said in an interview with the apparel company Old Row on Tuesday. “I mean I think it’s fine ... for like your girlfriend or whatever, but I don’t think men should use that brand. It starts with a ‘Z.’”

Philip Morris International and its subsidiaries do not donate to presidential candidates, according to the company’s spokesperson.

However, its subsidiary and Zyn’s parent company Swedish Match North America operates a political action committee that has spent $42,500 on Republicans and $18,000 on Democrats during this election cycle, Daily Dot reports.

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Tucker Carlson launches nicotine pouches to compete with Zyn

By Jack Aylmer (Energy Correspondent), Brent Jabbour (Senior Producer), Emma Stoltzfus (Editor), Ali Caldwell (Motion Graphic Designer)

Conservative talker Tucker Carlson launched a nicotine pouch that he hopes will compete with the massive popularity of Zyn .  Carlson ’s foray into the business started with an appearance on comedian Theo Von’s podcast last year where he was actually talking about his love for Zyn. 

“The truth is, Zyn is a powerful work enhancer, and also a male enhancer,” Carlson said as he covered the microphone. “If you know what I mean.”

Download the SAN app today to stay up-to-date with Unbiased. Straight Facts™.

Point phone camera here

Shortly after the appearance, Carlson’s team reportedly reached out to Zyn-maker Philip Morris International to form a partnership. But the tobacco giant declined the offer at the time, according to the Wall Street Journal . 

“While we understand that these may be Mr. Carlson’s views, or made in jest, these statements lack a scientific foundation,” the company said at the time. “Given Mr. Carlson’s popularity and reach, these statements could promote a misunderstanding and misuse of our products.”

Research shows nicotine can result in erectile dysfunction, decreased sex drive and infertility, according to anti-smoking group the Truth Initiative. 

The response from Philip Morris upset Carlson and prompted the new venture. 

“I’m going through a period of transition in my life with nicotine pouches,” Carlson said in a video posted on Old Row on X . “I’ve used a certain brand. I’m embarrassed to say it. It’s made by a huge company, huge donors to Kamala Harris. I’m not going to use that brand anymore. I think it’s fine. It’s good for your girlfriend or whatever. But I don’t think men should use that brand. It starts with a Z. And we’re launching our own brand today called Alp .”

For its part, Philip Morris International told both the Journal and USA Today that it doesn’t contribute to presidential campaigns. But the subsidiary that does oversee Zyn does make contributions to federal campaigns, and nearly 60% of those have gone to Republicans, according to OpenSecrets.

It’s no surprise Carlson wants to get into the nicotine pouch industry as Zyn pouches have  beco m e somewhat of a staple of young conservative men .

Additionally, Alp will offer more nicotine to users while Zyn only comes in three and six milligrams. Alp will also feature a 9 milligram pouch.

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With the popularity of a product with nicotine, it has caught the eye of lawmakers and regulators alike that fear it may attract young people and get them addicted to the drug.

Research found a very small amount of middle and high school students are pouch users. But, Zyn pouches have become so popular, there was a shortage over the summer. 

Related Stories

• Philip Morris pauses online Zyn sales amid legal challenge
• Teen e-cig use drops to lowest in decade amid crackdown on popular brands
• Tucker Carlson interviewed Putin. How is the media covering the story?

JACK AYLMER:

Conservative firebrand Tucker Carlson has a new business venture sure to illicit the fuel of the right, lib tears.

He’s not trying to reinvigorate the TV dinner market, taking a page from his step-mom’s grandfather. Instead Carlson is getting into the growing and highly lucrative nicotine pouch game.

If you’re asking how and why a tv turned social media broadcaster got into the tobacco industry it all started with an appearance on comedian Theo von’s podcast last year where he talked about his love for Zyn, the most popular pouches out there..

TUCKER CARLSON:

“The truth is, Zyn is a powerful work enhancer, and also a male enhancer. If you know what I mean.”

Shortly after that, Carleson’s team reportedly reached out to Zyn maker Phillip Morris to form a partnership. As the tobacco giant declined they said…

“While we understand that these may be Mr. Carlson’s views, or made in jest, these statements lack a scientific foundation. Given Mr. Carlson’s popularity and reach, these statements could promote a misunderstanding and misuse of our products.”

In fact, while they have a vested interest in the anti-nicotine movement, the Truth initiative points to research showing nicotine can result in Erectile dysfunction, decreased sex drive and infertility.

But anyway, according to the Wall Street Journal, the response infuriated Carleson and prompted the new venture.

“I’m going through a period of transition in my life with nicotine pouches. I’ve used a certain brand. I’m embarrassed to say it. It’s made by a huge company, huge donors to Kamala Harris. I’m not going to use that brand anymore. I think it’s fine. It’s good for your girlfriend or whatever. But I don’t think men should use that brand. It starts with a Z. And we’re launching our own brand today called Alp.”

Philip Morris International told both the Journal and USA Today that it doesn’t contribute to presidential campaigns.

But the subsidiary that does oversee Zyn does make contributions to federal campaigns. And nearly 60% of those have gone to Republicans according to OpenSecrets.

It’s still no surprise Carlson is getting into the game considering the pouches have become somewhat of a staple of young conservative men.

And Alp will offer more nicotine to users while Zyn only comes in 3 and 6 milligrams, it will also feature a 9 milligram pouch.

And with the popularity of a product with nicotine, it has caught the eye of lawmakers and regulators alike that fear it may attract young people and get them addicted to the drug.

Sen. Chuck Schumer, D-NY: “Pouch packed with problems. High levels of nicotine. So today, I’m delivering a warning to parents because these nicotine pouches seem to lock their sites on young kids, teenagers and even lower. And then use the social media to hook em.”

Research found a very small amount of middle and high school students are pouch users. But, Zyn pouches have become so popular there was a shortage over the summer.

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Scientific Evidence for the Addictiveness of Tobacco and Smoking Cessation in Tobacco Litigation

Smokers keep smoking despite knowing that tobacco claims many lives, including their own and others’. What makes it hard for them to quit smoking nonetheless? Tobacco companies insist that smokers choose to smoke, according to their right to self-determination. Moreover, they insist that with motivation and willpower to quit smoking, smokers can easily stop smoking. Against this backdrop, this paper aims to discuss the addictive disease called tobacco use disorder, with an assessment of the addictiveness of tobacco and the reasons why smoking cessation is challenging, based on neuroscientific research. Nicotine that enters the body via smoking is rapidly transmitted to the central nervous system and causes various effects, including an arousal response. The changes in the nicotine receptors in the brain due to continuous smoking lead to addiction symptoms such as tolerance, craving, and withdrawal. Compared with other addictive substances, including alcohol and opioids, tobacco is more likely to cause dependence in smokers, and smokers are less likely to recover from their dependence. Moreover, the thinning of the cerebral cortex and the decrease in cognitive functions that occur with aging accelerate with smoking. Such changes occur in the structure and functions of the brain in proportion to the amount and period of smoking. In particular, abnormalities in the neural circuits that control cognition and decision-making cause loss of the ability to exert self-control and autonomy. This initiates nicotine dependence and the continuation of addictive behaviors. Therefore, smoking is considered to be a behavior that is repeated due to dependence on an addictive substance, nicotine, instead of one’s choice by free will.

INTRODUCTION

Smoking is known as one of the top 3 disease-causing factors worldwide, along with hypertension and air pollution [ 1 ]. The World Health Organization reported that tobacco claims half of smokers’ lives and that smoking causes about six million deaths every year [ 2 ]. Among these deaths, over 600 000 occur in non-smokers exposed to secondhand smoke.

Because of all the harms that smoking causes to smokers’ own health as well as to others, many smokers attempt to stop smoking. However, the quit rates are low. Likewise, it is not easy to stop smoking based on willpower alone. For instance, smokers with lung cancer or cardiovascular diseases (for which tobacco is a critical risk factor) commonly keep smoking, failing to quit either before or after surgery for cancer or their heart condition. This suggests that smoking and smoking cessation cannot be considered to be controlled by smokers’ reasonable decisions and free will alone.

A litigation claim for damages by smoking brought by the Korea National Health Insurance Service against 3 tobacco companies, including KT&G, British American Tobacco Korea, and Philip Morris Korea (Seoul Central District Court 2014 Ga Hap 525 054 case) in April 2014 is ongoing. There have been arguments regarding various issues, and the focus of the eighth argument was the addictiveness of tobacco.

The statement “Addictiveness of tobacco and smokers’ ability to quit smoking,” submitted by the defense counsel of the tobacco companies [ 3 ], contains content that contradicts the scientific evidence in many ways. In this paper, the author intends to discuss the scientific evidence of the addictiveness of tobacco as a counterargument against that statement, based on the state of the art of medical research on subjects including smoking, tobacco, nicotine, and smoking cessation.

ADDICTIVENESS OF TOBACCO

According to the statement of the tobacco companies, nicotine is distinct from other addictive substances since it does not cause abuse or intoxication [ 3 ]. Regarding abuse, in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (the latest version published by the American Psychiatric Association in 2013), the distinction between abuse and dependence that had been used for substance use disorders in the prior version no longer exists [ 4 ]. Instead, the concepts of abuse and dependence are merged into a single type of disease, called “substance use disorders.”

In case of tobacco, the corresponding disease is known as “tobacco use disorder.” Intoxication is a negative behavioral or psychological change that occurs in the central nervous system due to physiological influences during or immediately after consuming a substance. For alcohol, the symptoms of intoxication include unpleasant responses, such as slurred speech, unstable gait, nystagmus, impaired attention and/or memory, stupor, and coma. However, the 11 criteria for diagnosing tobacco use disorder in the DSM-5 do not include symptoms related to intoxication [ 4 ]. In other words, the presence of intoxication does not affect the diagnosis of a substance use disorder; it is merely a manifestation of the immediate effects of a given substance.

The logic that nicotine is not an addictive substance because it does not cause intoxication leads to the unreasonable conclusion that caffeine, which can cause intoxication, is a more serious addictive substance than nicotine. Thus, the concepts of intoxication and addiction should not be confused even though both terms are translated into the same word in Korean language. The meaning of the former is as presented above. Addiction is commonly used to refer to obsessive and habitual substance use. However, as the word carries negative and extreme connotations, a more neutral term, “substance use disorder,” is preferred, which involves a broader range of mild to severe symptoms. The absence of intoxication does not mean that a given substance is not addictive.

According to the statement of the tobacco companies [ 3 ], tobacco withdrawal symptoms are subjective and non-specific. Moreover, the reasons why smokers resume smoking after cessation are related to situational cognition and social values, rather than physical responses due to the nicotine withdrawal. Furthermore, they argue that no correlation exists between the seriousness of withdrawal symptoms and the success of cessation.

Nonetheless, tobacco withdrawal symptoms, including irritability, anxiety, impaired attention, increased appetite, restlessness, depression, and insomnia, are common: nearly 50% of smokers who quit smoking for 2 or more days experience 4 or more of the above 7 symptoms [ 4 ].

Smoking cessation leads to clinically severe suffering, to the point of agony. Nicotine withdrawal symptoms affect one’s ability to continue smoking cessation, which may result in failure in smoking cessation and reuse of tobacco [ 4 ]. According to the Fagerström Test for Nicotine Dependence (FTND), which evaluates individuals’ dependence on nicotine, the more severe withdrawal symptoms are, the stronger the nicotine dependence [ 5 ]. Moreover, the more severe one’s nicotine dependence is, the more likely the person is to resume smoking [ 6 ].

The argument of the tobacco companies that the changes in the brain caused by smoking are easily reversible, as the brain recovers to its previous state in 12 weeks from the time of smoking cessation, is cited based on findings regarding changes in the availability of the nicotinic acetylcholine receptor after smoking cessation [ 7 ]. The nicotinic receptor increases by 3 to 4 times in the cerebral cortex due to smoking, and that level does not change until a month after smoking cessation. The level reverts to normal only when cessation lasts for 6 to 12 weeks [ 7 , 8 ].

The paper concludes that the maintenance of the change in the availability of the nicotinic receptor due to smoking at significant levels for a long period of time is what makes smoking cessation challenging. According to recent studies, with increased pack-years, the cerebral cortex thins more, which is linked with a decrease in cognitive functions [ 9 , 10 ]. Moreover, a maximum of 25 years of smoking cessation was found to be necessary for these changes in the cortex to recover [ 9 ].

Smokers’ brains undergo structural changes in comparison to the brains of non-smokers, proportionally to the amount of smoking. The thinning of smokers’ cerebral cortex in the frontal lobe suggests functional impairment in the circuitry of the brain that regulates rewards, impulse control, and decision-making [ 10 ]. Another study reported that a longer smoking history was associated with lower performance in cognitive functions, including intelligence in general, visuospatial learning ability, memory, and fine coordination [ 11 ].

Some studies have compared the addictiveness of tobacco and other addictive substances. One of the most well-known studies, by Nutt et al. [ 12 ] in the UK, ranked tobacco third in dependence, following heroin and cocaine. Tobacco dependence was more highly rated than that of other substances, including alcohol, benzodiazepines, methamphetamine, and cannabis [ 12 ]. High dependence can be understood as the cumulative rate of users who try a substance out of curiosity and wind up being dependent on it: nicotine showed the highest rate (67.5%), followed by alcohol (22.7%), cocaine (20.9%), and cannabis (8.9%) [ 13 ].

Another study conducted by the same research team examined the rates of remission from life-time substance dependence among patients with substance dependence. Nicotine showed the lowest rate, followed by alcohol, cannabis, and cocaine, in order [ 14 ]. Likewise, tobacco causes stronger dependence than other addictive substances. Treating tobacco use disorder is therefore very challenging.

SMOKERS’ ABILITY TO QUIT SMOKING

According to a 2016 report on social survey by Statistics Korea [ 15 ], approximately 50.4% of smokers had attempted to quit smoking during the last year. In contrast, despite the variability across treatment modalities, the general quit rates remain between a mere 5 and 30% [ 16 ]. According to the statement of the tobacco companies, anyone can quit smoking, as 96% of those who succeeded in quitting in Korea did so through their own willpower. As smoking is a voluntary act, they argue, we can start, continue, or quit smoking by our own free will [ 3 ].

Their statement continues to state that when smokers resume smoking after quitting, that should be understood as a choice of what they had previously enjoyed. Quitting smoking is possible. However, tobacco is an addictive substance. As mentioned earlier, although remission from life-time substance dependence rates vary by substance, that of tobacco was lower than the corresponding rates for alcohol or other substances [ 14 ]. Furthermore, the possibility of recovering from addiction does not mean that the substance that caused the addiction is not addictive.

In other words, although there are cases of people who succeed in abstaining from other substances, such as alcohol and opioids, as is the case for smoking cessation, this does not change the fact that those substances are addictive. The observation that those who used to be smokers, or 96% of quitters, were successful in smoking cessation by their willpower does not mean that 96% of smokers quit smoking through their willpower alone.

Extensive research has documented that quit rates vary by therapy method: self-quit has a quit rate, 5%; self-help books or physician advice, 10%; nicotine patch or gum, 15%; medication plus advice or behavioral therapy alone, 20%; and medication plus group therapy, 30% [ 16 - 18 ]. Even with such diverse therapies, quit rates do not exceed 50%.

As such a large portion of smokers have attempted to quit smoking through their own willpower, a high percentage of quitters did so through their own willpower; nonetheless, quitting through one’s own willpower does not lead to high quit rates. In short, approximately 20 times as many smokers as succeed in quitting through willpower are estimated to fail and resume smoking.

It has been reported that heavier smokers are more strongly dependent on nicotine and have more severe withdrawal symptoms when quitting. They are also more likely to fail to quit [ 19 ]. In contrast, a shorter duration of smoking [ 20 ] and lower smoking amounts [ 21 ] lead to higher quit rates. This can be documented through FTND, which evaluates one’s severity of nicotine dependence [ 5 ], and the Heaviness of Smoking Index [ 22 ]. Both instruments include a question about cigarettes per day. Thus, the smoking amount is an essential factor in assessing the seriousness of nicotine dependence. Additionally, the level of addition to tobacco is an important predictor of success in quitting.

The defense counsel of the tobacco companies insists that the decreasing smoking rates and increasing number of quitters are proof that anyone can easily quit smoking. The logic behind this statement is that as cigarette prices increase, quitting smoking can be interpreted as an economic response by consumers. However, the decrease in smoking rates does not imply that anyone can easily quit smoking. It is well known that taxation is one of the most cost-effective strategy for addiction prevention for other widely-consumed major addictive substances, including alcohol, not only tobacco [ 23 ].

Approximately 80% or more smokers try quitting smoking at some point. Nonetheless, 60% resume within a week and fewer than 5% succeed in quitting for their lifetime [ 4 ]. About half of the smokers who attempt to quit several times eventually quit smoking. This also shows that despite all their efforts to quit smoking, the other half of the smokers continue smoking, regardless of their will.

Despite the high mortality rate caused by smoking, quit rates are very low. Many smokers already meet the criteria for the diagnosis of tobacco use disorder in their late adolescence: this shows that tobacco is the cause of an addictive disorder [ 4 ]. This is because nicotine is a psychoactive and addictive substance that works in the brain neurobiologically in various ways.

The state of the art of current medical research into the structure and function of the brain, based on various research methods such as neurophysiological studies, neuroimaging studies, and neurocognitive function tests, demonstrates that changes occur in smokers’ brains. Such changes include changes in the nicotine receptor; changes in the reward circuit in the midbrain and limbic system, which is strongly related to drug addiction; and structural and functional changes in the frontal lobe of the cerebrum, which governs higher cognitive functions.

Tobacco causes physical tolerance, withdrawal, loss of control, craving, and compulsive smoking behaviors. Such changes occur proportionally to the amount and duration of smoking. Therefore, the argument made by the tobacco companies that anyone can succeed in smoking with a will to quit and self-confidence is flawed and is not consistent with the scientific evidence on nicotine’s influence on the brain. In conclusion, tobacco alters the human brain and causes an addictive disorder called tobacco use disorder. Smokers become dependent on nicotine regardless of their will.

Acknowledgments

This work was supported by the research fund of Hanyang University (HY-2017).

CONFLICT OF INTEREST

The author is a member of the Korean Medical Association and Korean Neuropsychiatric Association (both of which participate in the Allied Countermeasure Committee against Tobacco), a board member of the Korean Society for Research on Nicotine and Tobacco and Korean Academy of Addiction Psychiatry, and serves as a member of the advisory board for tobacco litigation of the Korea National Health Insurance Service.

Importance of Quitting Smoking Essay

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Smoking is a practice which involves the burning of a substance, for instance tobacco or cannabis, and later the smoke that emanates from it is inhaled. When referring to smoking, many people refer to tobacco smoking or cigarette smoking. The most widely used substance for smoking is tobacco, which is manufactured as cigarettes or hand-rolled tobacco. Smoking is an addictive habit and most smokers would attest that they wish they were able to stop the habit.

As much as it may seem to be a comfortable habit, smoking is in its actual sense not pleasurable and in any case it does not bring any relief. It is therefore the desire of many smokers to quit smoking. The knowledge that smoking can lead to serious health problems is one that is conscious in every smoker. This may make the smoker stay worried yet overcoming the addiction is a problem.

As such, quitting smoking is important since it helps relief the worry and the fear associated with possibility of developing cancer among other smoking-related illnesses. The smell that comes with smoking is very embarrassing and most people hate it.

Quitting smoking is therefore an important way of regaining self confidence by doing away with the embarrassing smell of cigarette smoke. Quitting smoking is an important way of shedding off the worry of the constant coughs and short breath brought about by smoking (Quit Smoking Review para 2-3).

Quitting smoking comes with a myriad of benefits which place more weight on the importance of quitting this addictive habit. If one quits smoking, it is no doubt that someone else is also saved from the problem of chain smoking. It is important that smokers reconsider their actions and identify that they spread the negative effects of smoking to persons who would not like to smoke.

It is therefore important to quit smoking if the problems associated with chain smoking are to be solved. The unborn are also beneficiaries of quitting smoking, especially among pregnant mothers. The elimination of very dangerous chemicals from the body motivates many people to avoid the practice. Most smokers thus find the health benefits as an encouraging gesture to quit smoking.

Quitting smoking is important since it leads to saving of monies that would have been used to buy cigarettes. These daily savings resulting from quitting smoking can be put into wiser and productive ways such as helping the family to settle bills as well as saving the money for investing. The fact that every individual’s lifestyle seems to influence another person’s life is an important reason why it is advisable to quit smoking. For instance, parents can act as good role models to their children by choosing to quit smoking.

In such a case, children are able to appreciate that smoking is a harmful habit and they will view the parent as a proactive parent as far as achieving good health is concerned. Additionally, quitting smoking gives the individual whiter and good looking teeth coupled with a fresh breath (Quit Smoking Review para 4-5). Most smokers are prone to gum diseases among other mouth diseases in comparison to non-smokers.

The individual’s health is also greatly improved as the breathing system that was once clogged with tobacco particles becomes clear and the lung capacity improves generally by about 10% (Gilman & Xun 45). Young smokers may not experience the negative effects of smoking until their later years but lung capacity generally weakens and diminishes with age.

Further, quitting smoking increases the individual’s life span, as Gilman and Xun (51) notes that half of all long-term smokers die from smoking related diseases such as heart attacks, lung cancer and others such as chronic bronchitis.

Those who quit smoking at age 30 are at an advantage as they add almost 10 years of their life span. As earlier mentioned stress levels are lower after one quits smoking since one has overcome the annoying habit. Most smokers suffer from withdrawal effects especially from nicotine, and the pleasant feeling of satisfying a craving is very temporary. Thus, non-smokers can concentrate better than smokers.

The body senses are also improved to a great extent as the system gets rid of many toxic chemicals found in the body as a result of cigarette smoke. Additionally, the individual experiences more energy as two weeks after quitting smoking, the circulation improves making many physical activities much easier. Additionally, the immune system is improved as mild diseases such as flu, colds and headaches can be easily fought.

In general, quitting smoking is an important step towards realizing an overall improvement in quality of life. Quitting smoking is also an important measure of ensuring cleanliness in one’s environment (American Academy of Family Physicians para 6).

Once one has quit smoking, the cigarette butts and ashes that are common in houses or cars of the smoker are no longer seen. This leads to greater happiness to the individual as well as those who live with the smoker. In addition, there is no need to worry much over the possible fire outbreaks brought about by careless disposal of burning cigarette butts.

Works Cited

American Academy of Family Physicians. Do I want to quit smoking ? 2000. Web.

Gilman, Sander and Xun, Zhou. Smoke: A global history of smoking . London, UK: Reaktion Books. 2004. Print.

Quit Smoking Review. The importance of quitting smoking . Web.

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Tucker Carlson plans to start a nicotine-pouch company after deciding Zyn is ‘not a brand for men’

Tucker Carlson, for years, has talked up the Zyn nicotine pouch to whoever would listen. Now, however, he is renouncing the brand and says he plans to launch a competing product called Alp.

The fallout between the media personality and the tobacco product comes down, predictably, to politics. Carlson is upset that employees at Zyn’s parent company Philip Morris donated money to Kamala Harris. He told The Wall Street Journal that he now thinks Zyn is a “ladies brand” and “not a brand for men”.

That’s a big reversal for Carlson, who just last October said on a podcast “The truth is, Zyn is a powerful work enhancer, and also a male enhancer—if you know what I mean.”

Carlson’s team reached out to Philip Morris to inquire about a partnership. The company declined and cited those comments, saying that even if they were made in jest “given Mr. Carlson’s popularity and reach, these statements could promote a misunderstanding and misuse of our products.”

That lit the fuse.

“They have nothing in common with their consumers,” Carlson told the WSJ . “I thought: ‘I’m going to launch my own product that’s not controlled by, you know, humorless, left-wing drones.’”

Alp, Tucker’s competing product, will come in four flavors and three strengths, including one that is 33% stronger than Zyn’s most powerful product. They will go on sale this November. “The all-new nicotine pouch by Tucker Carlson . ALP satisfies and frees your mind. At ALP, we believe in a better time,” reads the website promoting the brand, which is based in Miami.

Philip Morris itself does not make political contributions to any presidential candidates, it says. The subsidiary that oversees Zyn, however, does run a political action committee, which has given to both Republican and Democratic campaigns, with 70% of donations were to Republicans.

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