What are the medical consequences of tobacco use? See page 4. from the director: Tobacco use kills approximately 440,000 Americans each year, with one in every five U.S. deaths the result of smoking. Smoking harms nearly every organ in the body, causes many diseases, and compromises Tobacco smokers’ health in general. Nicotine, a component of tobacco, is the primary reason that tobacco is addictive, although cigarette smoke contains many other dangerous chemicals, Addiction including tar, carbon monoxide, acetaldehyde, nitrosamines, and more. An improved overall understanding of addiction and of nicotine as an addictive drug has been instrumental in developing medications and behavioral treatments for tobacco addiction. For example, the nicotine patch and gum, now readily available at drugstores and supermarkets nationwide, have proven effective for smoking cessation when combined with behavioral therapy. Advanced neuroimaging technologies make it possible for researchers to observe changes in brain function that result from smoking tobacco. Researchers are now also identifying What Are the Extent and genes that predispose people to Impact of Tobacco Use? tobacco addiction and predict their response to smoking cessation treatments. These findings— ccording to the 2010 National Survey on Drug Use and many other recent research accomplishments—present unique and Health, an estimated 69.6 million Americans aged opportunities to discover, develop, 12 or older reported current use of tobacco — 58.3 and disseminate new treatments A for tobacco addiction, as well as million (23.0 percent of the population) were current cigarette scientifically based prevention smokers, 13.2 million (5.2 percent) smoked cigars, 8.9 million programs to help curtail the public health burden that tobacco use (3.5 percent) used smokeless tobacco, and 2.2 million (0.8 represents. percent) smoked pipes, confirming that tobacco is one of the We hope this Research Report will most widely abused substances in the United States. Although help readers understand the harmful effects of tobacco use and identify the numbers of people who smoke are still unacceptably high, best practices for the prevention and according to the Centers for Disease Control and Prevention treatment of tobacco addiction. there has been a decline of almost 50 percent since 1965. Nora D. Volkow, M.D. Director continued inside National Institute on Drug Abuse Research Report Series Tobacco Addiction NIDA’s 2011 Monitoring the disorder, major depression, and and medical care costs associated Future survey of 8th-, 10th-, and other mental illnesses is twofold to with disease caused by secondhand 12th-graders, which is used to track fourfold higher than in the general smoke. In addition to healthcare drug use patterns and attitudes, has population; and among people with costs, the costs of lost productivity also shown a striking decrease in schizophrenia, smoking rates as high due to smoking effects are estimated smoking trends among the Nation’s as 90 percent have been reported. at $97 billion per year, bringing youth. The latest results indicate Tobacco use is the leading a conservative estimate of the that about 6 percent of 8th-graders, preventable cause of death in the economic burden of smoking to 12 percent of 10th-graders, and United States. The impact of tobacco more than $193 billion per year. 19 percent of 12th-graders had use in terms of morbidity and used cigarettes in the 30 days prior mortality to society is staggering. to the survey—the lowest levels Economically, more than $96 How Does in the history of the survey. billion of total U.S. healthcare costs Tobacco Deliver The declining prevalence of each year are attributable directly Its Effects? cigarette smoking among the general to smoking. However, this is well U.S. population, however, is not below the total cost to society There are more than 4,000 reflected in patients with mental because it does not include burn chemicals found in the smoke illnesses. The rate of smoking care from smoking-related fires, of tobacco products. Of these, in patients suffering from post- perinatal care for low-birthweight nicotine, first identified in the traumatic stress disorder, bipolar infants of mothers who smoke, early 1800s, is the primary reinforcing component of tobacco. Cigarette smoking is the most popular method of using tobacco; however, many people also use smokeless tobacco products, such Trends in Prevalence of Cigarette Use as snuff and chewing tobacco. These smokeless products for 8th-, 10th-, and 12th-Graders also contain nicotine, as well Percentage of Students Using Cigarettes Over a 30-Day Period, 1995–2011 as many toxic chemicals. 40 The cigarette is a very efficient and highly engineered drug delivery 35 system. By inhaling tobacco smoke, 12th grade the average smoker takes in 1–2 30 milligrams of nicotine per cigarette. When tobacco is smoked, nicotine 25 rapidly reaches peak levels in the ting Use 10th grade r bloodstream and enters the brain. epo 20 A typical smoker will take 10 puffs R on a cigarette over a period of 5 8th grade ercent 15 minutes that the cigarette is lit. P Thus, a person who smokes about 10 1½ packs (30 cigarettes) daily gets 300 “hits” of nicotine to the brain 5 each day. In those who typically 1995 96 97 98 99 2000 01 02 03 04 05 06 07 08 09 10 11 Source: University of Michigan, 2011 Monitoring the Future Survey. 2 NIDA Research Report Series do not inhale the smoke—such other drugs of abuse and is thought as cigar and pipe smokers and to underlie the pleasurable sensations smokeless tobacco users—nicotine experienced by many smokers. is absorbed through the mucosal For many tobacco users, long-term membranes and reaches peak blood brain changes induced by continued levels and the brain more slowly. nicotine exposure result in addiction. Immediately after exposure to Nicotine’s pharmacokinetic nicotine, there is a “kick” caused properties also enhance its abuse in part by the drug’s stimulation potential. Cigarette smoking of the adrenal glands and produces a rapid distribution of resulting discharge of epinephrine nicotine to the brain, with drug (adrenaline). The rush of adrenaline levels peaking within 10 seconds stimulates the body and causes of inhalation. However, the acute an increase in blood pressure, effects of nicotine dissipate respiration, and heart rate. quickly, as do the associated feelings of reward, which causes the smoker to continue dosing to Is Nicotine maintain the drug’s pleasurable Addictive? effects and prevent withdrawal. Nicotine withdrawal symptoms Yes. Most smokers use tobacco include irritability, craving, regularly because they are depression, anxiety, cognitive and addicted to nicotine. Addiction is attention deficits, sleep disturbances, Tobacco plants characterized by compulsive drug- and increased appetite. These seeking and abuse, even in the face symptoms may begin within a few of negative health consequences. It is hours after the last cigarette, quickly well-documented that most smokers driving people back to tobacco Most smokers identify tobacco use as harmful use. Symptoms peak within the and express a desire to reduce or first few days of smoking cessation identify tobacco stop using it, and nearly 35 million and usually subside within a few use as harmful and of them want to quit each year. weeks. For some people, however, express a desire Unfortunately, more than 85 percent symptoms may persist for months. of those who try to quit on their Although withdrawal is related to reduce or stop own relapse, most within a week. to the pharmacological effects using it, and nearly Research has shown how of nicotine, many behavioral 35 million want to nicotine acts on the brain to produce factors can also affect the severity a number of effects. Of primary of withdrawal symptoms. For quit each year. importance to its addictive nature some people, the feel, smell, and are findings that nicotine activates sight of a cigarette and the ritual reward pathways—the brain circuitry of obtaining, handling, lighting, that regulates feelings of pleasure. and smoking the cigarette are all A key brain chemical involved in associated with the pleasurable cravings often persist. Behavioral mediating the desire to consume effects of smoking and can make therapies can help smokers drugs is the neurotransmitter withdrawal or craving worse. identify environmental triggers dopamine, and research has shown Nicotine replacement therapies such of craving so they can employ that nicotine increases levels of as gum, patches, and inhalers may strategies to prevent or circumvent dopamine in the reward circuits. This help alleviate the pharmacological these symptoms and urges. reaction is similar to that seen with aspects of withdrawal; however, NIDA Research Report Series 3 adolescent animals display far overall rates of death from cancer more sensitivity to this reinforcing are twice as high among smokers as Nicotine replacement effect, which suggests that the nonsmokers, with heavy smokers therapies such as gum, brains of adolescents may be more having rates that are four times patches, and inhalers vulnerable to tobacco addiction. greater than those of nonsmokers. may help alleviate Foremost among the cancers caused the pharmacological by tobacco use is lung cancer— cigarette smoking has been linked to aspects of withdrawal. What Are about 90 percent of all cases of lung the Medical cancer, the number one cancer killer Consequences of both men and women. Smoking of Tobacco Use? is also associated with cancers of the Are There Other mouth, pharynx, larynx, esophagus, Cigarette smoking kills an estimated stomach, pancreas, cervix, kidney, Chemicals That 440,000 U.S. citizens each year— May Contribute bladder, and acute myeloid leukemia. more than alcohol, illegal drug use, In addition to cancer, smoking to Tobacco homicide, suicide, car accidents, causes lung diseases such as chronic Addiction? and AIDS combined. Between 1964 bronchitis and emphysema, and and 2004, more than 12 million Yes, research is showing that it has been found to exacerbate Americans died prematurely from nicotine may not be the only asthma symptoms in adults and smoking, and another 25 million U.S.