Tobacco 101: Fact Sheets for a Foundational Knowledge in Tobacco and Cessation

Table of Contents

TYPES OF TOBACCO PRODUCTS…………………………………………………………………………….4 This fact sheet provides a brief summary of the various tobacco products including each product’s nicotine content and history of advertising and social perception.

E-CIGARETTES……………………………………………………………………………………………………..6 This fact sheet includes a description of the various types of e-cigarettes, how they work, potential health consequences, and use of e-cigarettes as a smoking cessation tool

HEALTH EFFECTS OF SMOKING TOBACCO.…………………………………………………………...8 Cigarettes are widely known as dangerous to one’s health. This fact sheet summarizes the most common smoking related diseases and offers explanations for the link between smoking and the various disorders.

SHORT-TERM & LONG-TERM BENEFITS OF QUITTING………………………………..………..10 Quitting can rapidly reverse many of the negative health effects associated with tobacco use. This fact sheet provides a brief introduction to the benefits of quitting and outlines the timeline for expected health improvements upon quitting.

STRESS & WITHDRAWAL……………………………………………………………………………..……...12 Smoking is frequently associated with stress, but not in the way you might think. This fact sheet outlines the link between stress and smoking, likely attributable to withdrawal symptoms. It also provides a rationale for how smoking can actually reduce one’s stress.

SMOKING CESSATION WITH BEHAVIORAL HEALTH CLIENTS…..…….……………….…..14 This fact sheet discusses challenges specific to smoking cessation among behavioral health clients and provides helpful strategies to address such obstacles.

SPECIAL POPULATIONS……………………………………………………………………………………….16 Special populations include those who are smoking at higher rates than the general population, are disproportionately affected by smoking related illnesses, and/or require special considerations for cessation. This fact sheet briefly describes several special population groups, including pregnant women, individuals living with HIV, LGBT individuals, and adolescents, with respect to smoking and important considerations for cessation.

SECOND & THIRDHAND SMOKE…………………………………………………………………………..18 Smoking is dangerous not only to the smoker but also to those around them, in the form of secondhand and thirdhand smoke. This fact sheet describes secondhand and thirdhand smoke and associated health consequences.

SOCIAL JUSTICE……………………………………………………………………………………………..…..20 The tobacco industry is responsible for not only negative health outcomes of smoking but also several critical social justice issues. This fact sheet describes the “sins” of the tobacco industry, including smoking-related disparities, exploitation of youth, and corruption.

COSTS TO SOCIETY……………………………………………………………………………………….……..22 Not only does smoking greatly impact the individual smoker; it also has a significant effect on society as a whole. This fact sheet discusses the major societal consequences associated with smoking, including healthcare costs, loss of workplace productivity, and environmental expenses.

TOBACCO CONTROL & POLICY……………………………………………………………………………..24 This fact sheet provides a summary of the various tobacco regulations and policies currently in place, as well as a rationale for these policies. Additionally, it discusses how to institute smoke- free policies in the home.

Types of Tobacco Products

Product Nicotine Content Advertising & Perceptions CIGARETTES Filterless (“straights”)1, 2 A comparison study of nicotine Early advertising focused on the Short, strongest/most content in cigarettes and flavor of the papers and exotic dangerous type available; “straights” shows on average, nature of the tobacco origins to entire cigarette can be inhaled, nicotine content in unfiltered add to smoking’s mystery and resulting in higher smoke cigarettes is 13.5mg/g. allure. content in smoker’s body. Filters1, 2 According to a study on filter In the early 1950’s, filtered Have a cotton filter, allow as ventilation and nicotine cigarettes were falsely advertised much nicotine as filterless content in tobacco, it was as having the ability to filter out cigarettes to be inhaled, but do found that the total nicotine the tar in regular cigarettes. less harm to person’s throat in content was 10.2mg. terms of irritation. Lights3,4,5 Conforming to a University of Smokers think light cigarettes Have tiny holes drilled into the California, Los Angeles (UCLA) contain less tar and nicotine filter to allow air to mix with study, it was found that the because of the “light” label. smoke. User is still inhaling nicotine content in light However, a smoker’s fingers or nicotine, tar, and other harmful cigarettes lies in the range of lips typically block the vents, additives. 0.6mg – 1mg. causing inhalation of amounts of chemicals and nicotine comparable to regular cigarettes. Ultra-lights4 Nicotine content ranging 0.1- Smokers think ultra-light Have even more holes than 0.5mg. cigarettes contain less tar and lights, allowing more air to mix nicotine. with tobacco smoke. Wides According to Camel’s Advertised to men as a more Fat and short (look like a small advertisement, Camel Wides “manly” cigarette. cigar) with a shorter filter. Cigarettes have 1.2mg of nicotine. Menthol6 According to the Federal Trade Early advertisements presented Menthol is an organic Commission Report (FTC), menthol cigarettes as healthier compound derived from mint nicotine content is 1.37mm. alternatives to smoking, while oils which is added to tobacco also improving breath and cigarettes to produce a cool decreasing throat burn. These feeling during inhalation. cigarettes are heavily advertised to African Americans to embrace as a part of cultural identity.

Product Nicotine Content Advertising & Perceptions CIGARS, CIGARILLOS, & LITTLE CIGARS Cigars7, 8 Nicotine levels can range from  They come in different flavors, Do not have a filter, are larger 100-200mg. including many fruity or sweet than cigarettes, and have a flavors that increase their higher nicotine content. appeal among youth. Cigarillos8  Secret tobacco industry Are short cigars, are wrapped in documents revealed the tobacco leaves, and typically do industry’s intention to increase not have a filter. They do popularity of little cigars as sometimes have a tip. taxes and restrictions on Little cigars8 advertisements for cigarettes Are smaller and look more like a increased. cigarette in shape and size. They are wrapped in paper containing tobacco and typically have a filter. KRETEKS & BIDIS Kreteks9, 10  In a clove cigarette smoking  Kreteks and bidis are illegal to Are sometimes referred to as study, nicotine content of a sell in the U.S. clove cigarettes, are typically clove cigarette can be up to  Youth mostly consider bidis and imported from Indonesia, 7.4mg. kreteks to be alternatives to contain cloves, tobacco, and  According to a comparison cigarettes; however, they are other additives. study of the nicotine content not safe substitutes. Bidis 9, 11 of bidis and conventional  Bidis are also typically flavored. Are small, hand-rolled cigarettes cigarettes, the nicotine  These products typically have comprised of tobacco wrapped content in bidis was typically more tar, nicotine, and carbon in tendu or temburni leaf. They around 21.2mg/g. monoxide than conventional are made mostly in India and U.S. cigarettes. Southeast Asian countries. SMOKELESS TOBACCO Moist and Dry Snuff12, 13 Nicotine content in snuff  This has not been found to be a Comes in teabag-like pouches. ranges from 8 mg/g – safe substitute for smoking. Moist snuff has high nicotine 23.1mg/g.  There are efforts being made to content, whereas dry snuff has come up with herbal chews as lower nicotine content. alternatives. Chewing tobacco12, 13 Can be in twist or plug form; mostly inserted inside cheeks and called spitting tobacco.

DISSOLVABLE TOBACCO12, 13

These are tobacco products that Nicotine content: 3.9mg/g – Although initial estimates suggest are placed in the mouth or on 8.2 mg/g these products may reduce health the tongue. They typically come risks associated with typical packaged as sticks, strips, or tobacco use, they also increase orbs. interest in nicotine use, particularly among younger demographics.

E-Cigarettes & Related Products “E-cigarette use may surpass consumption of conventional cigarettes within the next decade (by 2023).”1 Electronic Nicotine Delivery Systems (ENDS) encompass all electronic devices on the market today, such as e-cigarettes, e-hookahs, vape pens, etc. Initial estimates suggest e- cigarettes are the most commonly used products. They are relatively new in the U.S. (2007), and as such, the research is in its early stages and lacks longitudinal perspectives. There are many questions regarding their safety, their effects on initiation of tobacco use among youth, and their use as a cessation aid. Regardless, their use is on an exponential rise throughout the U.S. — particularly among youth, who seem to enjoy vaping competitions and the variety of flavors available. Specifically, ever use of e-cigarettes tripled among youth from 2013 to 2014, suggesting that these products are now more commonly used among youth than are tobacco products.7

WHAT ARE E-CIGARETTES? E-cigarettes are battery-operated devices generally containing cartridges filled with nicotine, flavored “juice,” and other chemicals. This liquid or oil mixture is vaporized, then

WHAT IS IN THE E-CIGARETTE “JUICE”?4  Nicotine (extracted from tobacco leaves)

 Large variation in nicotine content between and within brands

 Lethal if ingested (60mg adult; 6mg children)

 Tobacco specific nitrosamines (TSNAs) = Carcinogenic compounds

 Propylene Glycol (the vapor/fog), Glycerin, Metals, Flavorants (including Menthol and Candy/Sweet flavors)

WHAT ARE THE POTENTIAL NEGATIVE UNLIKE CIGARETTES, E-CIGARETTES DO NOT NEGATIVELY AFFECT: 5 EFFECTS?  Heart rate, carbon monoxide (CO) level, or plasma nicotine level

 Complete blood count (CBC) indices  Mouth and throat irritation, and  Lung function

dry cough at initial use—  Cardiac function as measured with echocardiogram

complaints generally decrease  No increase in inflammatory markers with continuing use

 Increase in respiratory impedance and flow resistance (restricted airways) — similar to cigarette use

IS THERE SECONDHAND SMOKE WITH E-CIGARETTES?6 No secondhand “smoke,” but e-cigarettes produce secondhand aerosol vapor containing small amounts of potentially harmful chemicals.

 In a room of five or more e-cigarette users, nicotine and particulate matter levels are above healthy levels.

CAN E-CIGARETTES BE USED AS A CESSATION TOOL?3

What should healthcare providers say to patients about e-cigarettes for cessation?3 Most importantly, support their decision to make a quit attempt! Then, with permission, provide the following information:

 There are multiple, effective cessation aids available that have been approved by the FDA: NRT, varenicline, & bupropion!

 Free telephone quit counseling is available through 1-800-QUIT NOW.

 Although e-cigarettes are likely much less toxic than cigarette smoking, these products DO contain toxic chemicals, are NOT regulated by the FDA, and have NOT been

Health Effects of Smoking Tobacco Tobacco use is currently the leading preventable cause of death and disease in the U.S.; however, many smokers aren’t aware of what specifically makes tobacco use dangerous. It is essential to inform patients and create widespread awareness of what happens to the body after repeated tobacco usage. This brief fact sheet was compiled from the 50th Surgeon General’s Report on Smoking,1 and equips providers with current information and statistics on the health risks of smoking tobacco.

WHY IS SMOKING SO HARMFUL? The dangers of smoking result from inhaling chemical compounds. Some of these chemical compounds are found in tobacco, while others are manifested when tobacco is burned.1 Over 7,000 chemicals and chemical compounds have been found in tobacco smoke; around 70 of these have been found to cause cancer.1 What makes smoking so harmful to the lungs? The chemicals in cigarette smoke damage cells and tissue on the path from the mouth to the lung’s air sacs. Lung tissue is delicate and doesn’t get the chance to heal if it is constantly exposed to these chemicals, resulting in a wide range of deadly lung conditions.1

WHAT ARE THE HEALTH EFFECTS OF SMOKING? Smoking causes many types of cancer and leads to the development of several chronic diseases. Below is a graphic displaying all cancers and chronic diseases that have been causally linked to smoking tobacco. Those highlighted in red were released in the 50th Surgeon General’s Report. 1

CHRONIC DISEASES CHRONIC

CANCERS

CANCER  Lung cancer is the leading cause of cancer death for both men and women. Smoking is the principal cause of lung cancer; nearly 9 out of 10 lung cancers are caused by smoking.1  Evidence now demonstrates that smoking is associated with colorectal cancer, the second deadliest cancer after lung cancer, as well as liver cancer.1  If no one in the U.S. smoked, we could prevent 1 out of every 3 cancer deaths. 1 How does smoking cause cancer almost anywhere in the body? Tobacco smoke damages DNA, causing cells to grow abnormally. The toxic chemicals in tobacco smoke also weaken the body’s response to these abnormal cells, allowing them to keep growing and dividing.1

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 Nearly 8 out of 10 deaths from WHAT IS COPD? COPD are the result of smoking, COPD is an incurable disease primarily caused by smoking, and it and there is no cure for COPD.1 includes several underlying lung diseases, including emphysema and chronic bronchitis. COPD occurs when the airways are damaged and  Women smokers are up to 40 never completely heal, causing the lungs to lose their elastic properties. Air becomes trapped in the lungs, which complicates breathing and times more likely to develop induces coughing. Eventually scar tissue is formed and the oxygen COPD than women who have supply in the body diminishes. Additionally, COPD puts individuals at never smoked.1 high risk for lung cancer, heart disease, and other serious conditions.

HEART DISEASE  Smoking causes CVD (Cardiovascular Disease), PAD (Peripheral Arterial Disease), and CHD (Coronary Heart Disease). 1  The global rates of CVD declined sharply in the later half of the 20th century, largely due to the reduction in smoking occurring during the same period.  However, CVD continues to be an epidemic; CVD is the single largest cause of death in the U.S., killing over 800,000 people a year. How does smoking cause heart disease? Smoking clogs and narrows your arteries by causing deadly plaque buildup. The toxins in tobacco smoke also damage blood vessels and block blood flow, leading to a wide range of heart diseases.1

DIABETES MELLITUS  The risk of developing diabetes is 30-40% higher among current smokers than among nonsmokers. The more cigarettes a person smokes, the higher their risk for diabetes.  For those already diagnosed with diabetes, smoking can aggravate insulin resistance. Diabetics who smoke often require a larger dose of insulin to manage their diabetes as compared to diabetics who do not smoke. How does smoking cause diabetes? Research suggests that smoking disrupts glucose regulation and other metabolic processes that can ultimately lead to the development of diabetes.

Benefits of Quitting WHY QUIT SMOKING?1 Today, most people, including current smokers, can articulate some awareness that smoking or using tobacco negatively affects health. It is important to also increase awareness of the kinds of benefits that come from quitting smoking. Many immediate health benefits result from quitting smoking, which may help to encourage smokers to maintain their quit attempt. Current smokers and tobacco users need to know that regardless of their history of tobacco use, they can experience short and long term health benefits by quitting today. These same benefits have been experienced by many others before them, as evidenced by the fact that in the U.S. there is now a higher ratio of former smokers as compared to current smokers. WHAT SHORT-TERM BENEFITS CAN YOU EXPECT? The short-term benefits of tobacco cessation can be observed rather immediately; improvements appear within minutes to hours to weeks.2

 Abstaining from smoking can quickly lead to reductions in respiratory difficulties (e.g., coughing) and circulation problems (e.g., high blood pressure), allowing an individual to participate in different kinds of activities without any hesitations or restrictions. Increased activity further results in improvements in lung functioning and blood circulation.  With respect to mental health, individuals who quit smoking typically report being happier, feeling healthier, and experiencing improved quality of life.  Quitting can also help with everyday memory retention, allowing an individual to retain essential information as well as social and emotional memories.  Because smoking can severely affect oral hygiene, quitting can lead to reduction or elimination of oral problems, teeth stains, and/or dental expenses.  Aesthetically, quitting can quickly result in reversal of pre-mature aging (e.g., wrinkles).  Most individuals who quit also experience immediate financial benefits by no longer purchasing tobacco.

WHAT LONG-TERM BENEFITS CAN YOU EXPECT?  According to the National Research Council, the life expectancy of a smoker will increase after quitting. A longitudinal study in the United Kingdom found that women who quit smoking before middle age tend to live 10 years longer than those who do not quit.

 Smoking has been found to be related WHAT IS CHD? to the development of coronary heart CHD is a heart disease that results from the buildup of disease (CHD). According to the U.S. plaque in the walls of coronary arteries, which provide Surgeon General’s Report (2010), after oxygen rich blood to the heart. Chemical compounds one year smoke-free, the risk of present in tobacco damage blood cells and result in many severe life-threatening problems, including heart developing CHD is decreased by 50%. attacks, cardiac arrest, heart failure and potentially Fifteen years after quitting, CHD risk is death. the same as an individual who has never smoked.3

 According to the American Cancer Society, risks of lung, larynx, and pancreatic cancers significantly decrease 10 years after quitting.4

 As a member of the community, one can become a role model or have a positive impact on others. This can enhance his/her confidence and self-esteem over time.

BENEFITS OF QUITTING4

Stress & Withdrawal Tobacco smoking has been proven to cause many harmful health effects, one of which is increased stress. While quitting is the surest way to mitigate health risks and reduce stress, many find the withdrawal period too difficult to overcome, and relapse is common. Withdrawal occurs when an individual becomes physically dependent on nicotine, and it induces many unpleasant side effects as they quit. This brief fact sheet aims to inform providers on the relationship between smoking and stress, and additionally on the nature of the withdrawal process. HOW ARE SMOKING AND STRESS RELATED? Although individuals who smoke often cite smoking as a “stress reliever,” smokers actually report higher rates of stress than non-smokers.1 This is likely a result of the recurring mood fluctuations that are associated with regular tobacco use.2,3  Nicotine is classified as a “stimulant” because it activates the body’s stress response, also known as the “fight-or-flight” response. Upon entering the body, nicotine causes the release of adrenaline, resulting in: increased blood pressure, increased heart rate, and release of the stress hormone, cortisol.1 HOW DOES NICOTINE WITHDRAWAL PRODUCE STRESS? In the absence of cigarettes, individuals who smoke frequently report feelings of anxiety, stress, and low mood. While most smokers attribute relief of these feelings to cigarettes serving as a “stress reliever,” these feelings they are experiencing are actually a result of nicotine deprivation.2  Daily smokers perceive nicotine to be relaxing and stress relieving; however, as the day goes on they are usually smoking to avoid withdrawal symptoms. 5  Smoking induces a restoration to “normal” after periods of nicotine deprivation between cigarettes.5

 The initial boost after Graph: Benowitz, 1992 smoking typically lasts no more than 10 minutes, before the levels of nicotine in the body begin to decrease.10

WHAT IS NICOTINE WITHDRAWAL? Withdrawal occurs during the abstinence from or reduction in tobacco use following a period of prolonged use.5 The severity of withdrawal is typically dependent on quantity and frequency of past use—individuals who smoke more cigarettes per day tend to experience worse withdrawal symptoms. What should you know about withdrawal symptoms? Withdrawal symptoms can occur in just one hour without a cigarette.6 Although there is significant variability among individuals in the experience and time course of withdrawal symptoms, tobacco withdrawal typically begins with 24 hours of quitting (or cutting back), and peaks within 2-3 days. Most symptoms subside within 2-3weeks of quitting.2,7 Common withdrawal symptoms include:2,3,5,6

Irritability, frustration, anger WHAT ELSE CAN YOU EXPECT? Anxiety Other symptoms that are commonly associated with tobacco withdrawal are: Depressed mood  Cravings for sweet foods  Reduced attention Difficulty concentrating  Constipation, nausea  Coughing Restlessness  Dizziness  More frequent dreams/nightmares Insomnia  Weight gain (average is 4-7 lbs over 1 year) 5

Individuals with mood disorders, substance use disorders, and attention-deficit/ hyperactivity disorder have more severe withdrawal symptoms when quitting.5 Withdrawal symptoms can also depend on the environment—smokers report fewer withdrawal symptoms while in a restricted environment (e.g., an inpatient facility, or prison) but more symptoms in their natural environment (e.g., around smokers, within sight of smoking paraphernalia).8 WHAT DOES QUITTING SMOKING DO FOR STRESS? Although overcoming the initial withdrawal period can be difficult, individuals who quit smoking report significant decreases in stress, accompanied by a decrease in irritability and negative affect.1,2,3,9 In fact, reductions in stress are reported shortly after the quit attempt despite the initial period of withdrawal.10 Various research studies demonstrate that with continued abstinence, former smokers experience a steady decrease in their ratings of stress, whereas the number of stressful life events that occur during this time does not change.10 Smoking cessation is associated with a reduction in stress ratings, while relapse to smoking is associated with increased feelings of stress.10 Individuals who successfully remain abstinent from cigarettes report an overall improvement in well- being.9

Unique Challenges for Smoking Cessation People with substance abuse and mental health concerns consume tobacco products at a much higher rate than other groups of people. As a result, these at-risk populations are particularly vulnerable to smoking-related illness and mortality.1 It is important to consider unique challenges for smoking cessation among mental health and substance abuse clients. Brief interventions have been shown to help the general public, but individuals with mental health and substance abuse problems may require more in depth discussion around smoking cessation.2 For example, the following topics should be addressed more intensively: Need for extra coping skills training around anxiety and stress Management of depressive moods Assertiveness training for refusal skills Increase in number of social supports Anger management HOW CAN YOU PREVENT RELAPSE ? A client who has started to quit smoking should check-in with their provider often to reinforce quit attempts and prevent relapse. Discussions with a provider should include:  Celebration of the duration of abstinence and the reduction in withdrawal symptoms  Potential health benefits resulting from quitting (e.g., improved circulation, enhanced lung function)  Improved concentration and sleep, and/or decreased irritability and restlessness  Brainstorming solutions for any current issues that may threaten abstinence, including weight gain, ongoing withdrawal symptoms, and decreased motivation3 WHAT CAN YOU DO TO COPE WITH TRIGGERS? It is important to specify triggers and cues, such as “people, places, and things,” that tempt people to smoke. Triggers might be different for the specific substances abused and for the individuals involved. You can cope with triggers by remembering the 3 A’s: Avoid, Alter, and Alternative. When people who smoke cigarettes are looking to exert “stimulus control,” they need to avoid triggering situations where smoking is more likely to occur. If the client is unable to avoid the situation, help them to alter their thoughts or behaviors related to the event. Ultimately, you want to choose alternative strategies that lead to healthier behaviors.

Examples of the 3 A’’s in action include:

AVOID TRIGGERING SITUATIONS:  You can benefit from quickly getting up from the table after a meal is complete to avoid the post-meal cigarette.  Smoking and alcohol have been found to be strongly linked, and early quitters may have a difficult time coping with this trigger.5 We encourage avoiding drinking situations, while those behaviors are still closely linked together.

ALTER YOUR ROUTINE:  Since nicotine levels are low when first waking up, alter your typical morning routine, such as drinking coffee. Instead, drink something else, like orange juice, that is not associated with smoking. You could also try drinking your coffee in a place where smoking is prohibited, such as at the kitchen table (if you have a smokefree home) or at your desk at work.

FIND ALTERNATIVES TO SMOKING:  Many people smoke when faced with negative emotions; instead, find alternative strategies to help you cope. When stressed, rather than smoking, you could practice a deep breathing exercise, call a friend, or listen to music.

WHAT ARE HEALTHY ALTERNATIVES TO SMOKING? An additional element to consider is the type of alternative activities available to quitters when triggered to smoke.4 This “counterconditioning” change strategy is effective, needs to be customized to the individual, and can be integrated into a successful smoking cessation plan.

TAKE HEALTH BREAKS: If your treatment groups have breaks scheduled within programming, this is a strong trigger for behavioral health clients to smoke. Individuals should find an enjoyable, alternative activity that can replace smoking. Taking a 5 minute walk with a friend, eating an apple, or listening to music are all much healthier options.

CONSIDER THE ENVIRONMENT: Clients may work in the restaurant business or other industries where cigarette smoking is rampant. Discuss with your clients various activities that are available and appealing to them that they can engage in during breaks from work.

URGE-SURFING: Be sure to explore additional interests with your clients that can be used when cravings hit, and remind clients that most cravings are short-lived. By being able to stay strong when cravings arrive for the short-term (i.e., “riding them out”), your clients will be enjoying a longer life away from nicotine’s control.

Special Populations MDQuit’s Breaking the Habit in Behavioral Health (BH2) smoking cessation intervention is targeted at individuals with mental health and/or substance use concerns. However, you will likely encounter clients who belong to other special population groups. The purpose of this fact sheet is to provide you with basic information about smoking and cessation among individuals belonging to these special populations.

PREGNANT WOMEN FAST FACTS:

 Cigarette smoking during pregnancy is the most critical and preventable cause of pregnancy- related illness and death in the U.S.1  About 23% of women smoke during the 3 months before pregnancy, and 10% smoke during the last 3 months of pregnancy. 2  Smoking increases risk of miscarriage, and babies born to women who smoke during pregnancy are more likely to be born premature, to have a low birth weight, and to die from Sudden Infant Death Syndrome (SIDS) than those born to women who do not smoke.2 SPECIAL CONSIDERATIONS:

 Women are more likely to quit smoking during pregnancy than at any other time in their lives.1  Although abstinence from cigarettes in early pregnancy is best, quitting smoking at ANY point during pregnancy is beneficial to both the mother and the child.1  During pregnancy, nicotine replacement therapy (NRT) is typically NOT recommended, although it may be discussed on a case-by-case basis with a physician, as NRT can reduce the risk of pregnancy-related complications in comparison to sustained smoking.1  Of women who quit smoking during pregnancy, 47% to 63% return to smoking during the postpartum period, so it is critical to follow-up with new mothers to support continued abstinence.3  As of 2015, the Maryland Tobacco Quitline (1-800-QUIT NOW) currently offers 10 free counseling calls (pre- and post-partum) and up to $90 in gift cards to pregnant women and new mothers who utilize this cessation resource. INDIVIDUALS LIVING WITH HIV FAST FACTS:

 Smoking rates are twice as high among individuals living with HIV than in the general U.S. population.4  HIV+ individuals who smoke have higher mortality rates and report lower quality of life than nonsmokers who are HIV+.1

 Smoking is especially dangerous to the health of people living with HIV:4  Individuals living with HIV are more likely to develop the harmful consequences associated with smoking (e.g., cancers, heart disease, and stroke) than those without the disease.5  HIV+ individuals who smoke are also more likely to develop potentially deadly HIV-related infections than are nonsmokers with HIV.5 SPECIAL CONSIDERATIONS:  Addressing common smoking myths with HIV+ individuals is important! Research suggests that many HIV+ individuals who smoke underestimate the impact that smoking has on their health, or believe that they will not live long enough to experience smoking-related illnesses.1  Stress management strategies may be critical for cessation: Some HIV+ individuals report that smoking helps to relieve the stress associated with their HIV+ status.1 LESBIAN, GAY, BISEXUAL, AND TRANSGENDER (LGBT) FAST FACTS:  Individuals in the LGBT community are more likely to smoke cigarettes (1 in 4) than heterosexual/straight individuals (1 in 6).6  Tobacco companies target their advertising at individuals in the LGBT community.6  LGBT individuals are more likely to experience daily stress related to prejudice and stigma, which increases the risk for smoking.1 SPECIAL CONSIDERATIONS:  Given higher reported daily stress levels among LGBT individuals, it may be especially helpful to incorporate stress management strategies into cessation interventions. Teaching these strategies can provide individuals with an effective alternative to smoking as a means to cope with stress. ADOLESCENTS FAST FACTS:  In 2013, 16.9% of Maryland high school youth reported using any tobacco product in the past month.7  Adolescents in Maryland now smoke cigarettes and cigars at similar rates.  In 2013, 11.9% of high school youth reported smoking cigarettes, while 12.5% reported smoking cigars in the past 30 days.7 SPECIAL CONSIDERATIONS:  Though nicotine replacement therapy (NRT) has been shown to be safe for adolescents, NRT has not been found to support long-term cessation among adolescent smokers. Thus, NRT is NOT recommended for adolescents who smoke.1  Adolescents are not typically as nicotine-dependent as adults, so using NRT may have the negative effect of increasing the level of nicotine dependence in this group.  The Maryland Tobacco Quitline (1-800-QUIT NOW) offers 5 free and confidential tobacco cessation counseling calls to 13-17 year olds. They do NOT offer NRT to individuals under the age of 18.

Second & Thirdhand Smoke

WHAT IS SECONDHAND SMOKE? Secondhand smoke (SHS), is often referred to as environmental or passive smoke, and describes any smoke that comes from burning tobacco, including:1  Sidestream smoke- smoke that comes from the actual burning of tobacco  Mainstream smoke- smoke that is exhaled by the individual smoking tobacco As a result of SHS, individuals who choose not to smoke, will end up ingesting the same harmful chemicals and can experience many of the same health consequences. While any exposure to SHS is dangerous, sidestream smoke contains higher concentrations of carcinogens, often in smaller particles which can make it easier to be ingested.

WHAT IS IN SHS? The composition of SHS is not that different from what is inhaled by smokers. SHS contains over 7,000 chemicals—almost 70 of these are known cancer causing compounds.2

WHAT ARE THE HEALTH EFFECTS OF SECONDHAND SMOKE? Bottom line, there is no safe amount of exposure to SHS. SHS exposure can lead to early death and disease among children and adults who do not smoke3. The most recent Surgeon General’s Report (see image at left; 2014), described a direct link between SHS exposure and cancer, cardio-vascular and respiratory diseases, and other negative health consequences3. Among pregnant women, SHS can lead to low birth weight and can cause sudden death among infants.4 Each year over 600,000 premature deaths are attributed to SHS. Of these, 28% are among children.4

HOW ARE YOU EXPOSED TO SECONDHAND SMOKE? Unfortunately, cleaning, ventilation, and separation do not eliminate SHS exposure; completely removing smoking from the environment is the only way to protect against exposure.2 The vast majority of people are exposed to SHS in their homes, at work, or in a vehicle.2,3 However, despite smokefree policies and legislation, people continue to be exposed to SHS in public places, particularly outdoors. Children are at higher risk for exposure to SHS.2 According to the World Health Organization, over 40% of children are exposed to SHS in the home due to having at least one parent who smokes; whereas over 50% of children are exposed to SHS in public places outside of the home.4

WHAT IS THIRDHAND SMOKE? Thirdhand smoke (THS), or residual smoke, refers to tobacco smoke particles that remain on indoor surfaces or in dust after the smoke itself is gone.1 Even if you are not smoking in or near your home, you can carry these dangerous chemical residues into the home on your skin, hair, and clothes. THS can stay on furniture, clothes, walls, etc. for up to several months,5 and during this time chemical reactions can occur that produce secondary pollutants, some of which increase in toxicity over time.6,7 Generally, less is known about THS, particularly surrounding its health impacts.6 In fact, heavy smokers are less likely to identify THS as being harmful to nonsmokers. Beliefs in the harm of THS are associated with enforcement of a smokefree policy in the home.

WHAT ARE THE HEALTH EFFECTS OF THIRDHAND SMOKE? Individuals may be at risk of THS exposure and subsequent health consequences even if not otherwise exposed to SHS.8 THS exposure can affect multiple organ systems including the lungs, liver, and skin, and can lead to higher lipid levels and non-alcoholic liver disease, which may later develop into cirrhosis or liver cancer.7 Additionally, THS exposure has been associated with COPD, asthma, poor wound healing, and behavioral problems. The Surgeon General’s Report also documents additional conditions related to THS exposure (see graphic to the right).3

HOW ARE YOU EXPOSED TO THIRDHAND SMOKE? Exposure to THS can be through involuntary inhalation, ingestion, and dermal uptake.9 Infants and toddlers are at greater risk for exposure to THS, largely due to the greater amount of time spent in the home and their proximity to the floor. Additionally, their mouthing behaviors and more rapid respiration can increase their rate of ingestion and inhalation of THS.6

WHAT ABOUT YOUR PETS? Just like us, our furry, feathery, and scaly friends can be exposed to tobacco smoke in the environment by either SHS or THS, and they are also susceptible to many tobacco related illnesses, including cancer.10,11 Given that pets spend most, if not all, of their time in the home, they have a particularly elevated risk of environmental tobacco smoke exposure.

Smoking & Social Justice When people think about the negative impact of the tobacco industry, they often mainly consider health and environmental impacts. However, the tobacco industry is implicated in several social justice issues, in addition to the more well-known problems of tobacco use. These social justice issues include exploitation of youth in several different ways, exploitation of minorities and people of lower SES, damaging labor and environmental practices, and corruption.

WHAT ABOUT TOBACCO COMPANIES?  Tobacco companies have long lobbied to minimize tobacco regulation and use their influence to distort scientific research and findings.1  As recently as 1994, tobacco industry executives have testified before Congress, under oath, that nicotine is not addictive.2  Tobacco company advertising often specifically targets youth, minorities, and low income communities.3,4  Companies strategically pursue those with the least information, fewest resources and social supports, and least access to tobacco cessation services.5

SMOKING-RELATED DISPARITIES  There are strong links between smoking and low income and lower levels of education.6  27.9% of adults in the U.S. below the federal poverty line smoke, compared with 17% of those above the poverty line.  24% of adults without a high school diploma smoke, compared to 9.1% of adults with a college degree.  Sexual and gender minorities often have higher rates of smoking and exposure to secondhand smoke.7  White collar workers are TOBACCO IMPACTS SOME OF US more likely to be covered MORE THAN OTHERS by smoke-free work 30 policies than blue-collar workers.8 25 20  Minorities, low income individuals, and 15 medically underserved 10 women are often 5 diagnosed later for cancer 0 and heart disease,and Below P overty Less than High Multi-racial National receive fewer Level School Average interventions than well- Education off white men.9,10,11, 12 CDC, 2014

WHAT ARE THE IMPACTS OF THE TOBACCO INDUSTRY’S PRACTICES?

The tobacco industry often purchases tobacco produced with child labor and high levels of deforestation.13

 Children working on tobacco farms, both in the U.S. and abroad, are exposed to nicotine, toxic pesticides, and other dangers.14

 Children as young as 7 years old work on tobacco farms in the U.S., often experiencing symptoms consistent with nicotine poisoning, such as: nausea, vomiting, loss of appetite, headaches, dizziness, skin rashes, difficulty breathing, and irritation to their eyes and mouths.14

 The annual total costs of tobacco-related deforestation are estimated at $160 million worldwide.13

THE SINS OF THE TOBACCO INDUSTRY

There are numerous examples of tobacco companies using bribery and other corrupt practices to shape governmental policies and maximize profits.

 As recently as 2006, several major transnational tobacco companies were found guilty of racketeering, conspiracy, and fraud. Several instances described in the suit include:

 deceptively refuting the negative health impacts and addictive potential of tobacco products;

 denying that the nicotine levels in cigarettes have been altered;

 inaccurately portraying “light” cigarettes as less harmful;

 targeting marketing campaigns to underage smokers — viewing them as “replacement smokers”; and

 manipulating scientific research regarding the harmful effects of tobacco smoke.15

 In 2010, the U.S. Securities and Exchange Commission claimed that Universal Corporation and Alliance One International, a tobacco leaf purchaser for Philip Morris and BAT (two large, multinational tobacco companies) paid bribes in excess of $5 million to government officials in China, Greece, Indonesia, Kyrgyzstan, Malawi, and Mozambique.13

The Cost of Tobacco on Society The tobacco industry spends $8.4 billion each year on cigarette advertising and promotional materials.1 In addition to the money spent by the tobacco industry, tobacco use results in additional financial burden to smokers, non-smokers, and society as a whole. Costs include healthcare and health related spending, loss of workplace productivity, and environmental expenses.

WHAT ARE THE COSTS TO SOCIETY? The costs of smoking to society are staggering: $298 billion in annual smoking- attributable economic costs.2  Workplace productivity losses of approximately $67.5 billion.2  Premature death losses of $117 billion.2  Direct medical expenditures of $116 billion.2  The $116 billion dollars spent on tobacco-related illnesses is a missed opportunity for needed social services and programs. If this money was not spent on healthcare, it could instead be used for transportation, public safety, education and rural development, among other needs.  Tobacco is a drain on the healthcare system: 4.9% of all healthcare expenditure in the United States is used to treat tobacco-related illnesses.6 Among non-smoking adults, secondhand smoke causes premature death annually, including:5 Medicaid.gov  33,950 deaths due to heart disease  7,330 deaths due to lung cancer  Secondhand smoke is a common trigger for asthma7  About 7 million children had asthma (1 in 11 kids) in 2010  10.5 million school days were missed due to asthma in 2008  Each year, secondhand smoke contributes to:8  150,000–300,000 new cases of pneumonia and bronchitis in children 18 months or younger  7,500-15,000 hospitalizations among children

WHAT ARE THE COSTS TO THE INDIVIDUAL?

The dollar amount of the health damage caused by a single pack of cigarettes is $35 to the average American smoker.3

Smokers have a reduced quality of life and shorter lifespan—smokers have an average life expectancy that is over 10 years shorter than non-smokers!4,5

WHAT ARE THE COSTS TO THE ENVIRONMENT? TOBACCO LITTER IMPACTS THE LAND, COASTS, AND SEA  Removal/abatement of tobacco product litter can cost cities an average of $0.5 million to $6 million annually for a city the size of San Francisco.9  Cigarettes and cigarette butts are the most prominent litter item on U.S. roads and highways.10  Each year, cigarette butt litter amounts to at least 1.69 billion pounds worldwide. These butts are not biodegradable, and can leach poisons into water and soil. They can also be deadly to fish, other aquatic microorganisms, pets, and small children when ingested.11  In 2010, 1.8 million cigarettes were removed from U.S. beaches and inland waterways.10  In the past century, around ten trillion packs of cigarettes have been smoked, adding up to about 110 billion pounds of packaging waste.11 PESTICIDES Tobacco pesticides harm birds and other small animals, and cause soil and ozone depletion. An estimated 27 million pounds of pesticides are sprayed in U.S. tobacco fields each year.11 DEFORESTATION Deforestation is carried out on a large scale to provide more land to grow tobacco and fuel to cure tobacco leaves. Each year, approximately 20-50 million trees are cut down for these purposes. Deforestation is associated with increasing atmospheric levels of CO2 and other damaging environmental consequences.11 POLLUTION  Air pollution from making cigarettes: The U.S. tobacco industry generates approximately 16 million metric tons of carbon dioxide equivalents. If cigarettes disappeared, the U.S. would experience the carbon benefit equivalent to taking nearly 4 million cars off the road.11  Pollution from tobacco smoke: Tobacco smoke contains at least 172 toxic substances. Pollutants can remain in the environment for months after the act of smoking occurs.12

Tobacco Control & Policy

IS REGULATING TOBACCO LEGAL? Despite efforts of smokers’ rights groups, smoking is not deemed a protected right according to the Constitution.1 All courts, including the U.S. Supreme Court, have determined that smoking is not a protected liberty nor are smokers considered a protected class of people. Therefore, tobacco control policies do not violate a person’s right to privacy, nor do they discriminate against tobacco users.

WHAT ARE SMOKE-FREE POLICIES? Smoke-free policies are some of the most effective strategies to reduce and eliminate the exposure to secondhand smoke (SHS).2 Types of policies include:  Voluntary: implemented by businesses or organizations in their designated settings (e.g., smoke-free Alcoholic Anonymous meetings)  Regulations: issued by agencies of accreditation or boards of health (e.g., smoke- free hospital grounds)  Legislation: enforced by local, state, or federal governments (e.g., Clean Indoor Air Act)

WHY SMOKE-FREE POLICIES? Unfortunately, cleaning, separation, and ventilation do not entirely eliminate SHS exposure. For example, a study examining smoke-permitted and smoke-free units in a multi-unit complex found a significant proportion of SHS found in smoke-permitted units traveled to the building’s hallways and to smoke-free units.3

 29.4 μg/m³ of smoke found in smoke-permitted units  11.9 μg/m³ found in hallways 64.3% of levels found in smoke-permitted units  10.2 μg/m³ found in smoke-free units 34.9% of levels found in smoke-permitted units

WHAT IS THE IMPACT OF SMOKE-FREE POLICIES? A recent study demonstrated that smoke-free policies are helpful for smokers and nonsmokers alike. Following the implementation of a smoke-free policy in multi-unit housing, there was a significant increase in the smoking quit rate and a decrease in the amount of cigarettes consumed on average.4 Additionally, SHS exposure dropped from 41% to 17% during the year-long study. Given the higher rates of smoking among the behavioral health population, implementation of smoke-free policies in treatment settings has been met with significant resistance. However, a review of the literature showed that there is no increase in discharges, aggression, or medication use following the implementation of smoking bans.5

WHAT IS SERUM COTININE? When SHS is inhaled, the body breaks down the nicotine from the smoke into a byproduct called cotinine. Levels of cotinine determine the amount of exposure to SHS. It can be measured by testing saliva, urine, or blood.6

Measures of serum cotinine (see box above) demonstrate that exposure to secondhand smoke has steadily declined in the US over time.6 This is largely due to smoke-free policies that prohibit smoking in public places and workplaces, such as bars and restaurants.

TOBACCO CONTROL & EMPLOYMENT1  Tobacco users take more sick days, have higher insurance premiums, and exhibit greater healthcare utilization than non-tobacco users, cutting into a company’s bottom line.  As a result, some workplaces are now turning to stricter tobacco policies, including decisions not to hire individuals who use tobacco. Maryland is not currently one of the 30 states that have laws protecting against this discrimination by employers based on off-duty conduct.  An important consideration is that tobacco-free employment policies may disproportionately impact individuals of low socioeconomic status, given that tobacco use is significantly higher among this group.

OTHER TOBACCO POLICIES  Tobacco tax is another incredibly effective method of reducing smoking, particularly among youth.7 Data suggest that for every 10% increase in the price of tobacco, there is a 3-5% decrease in cigarette consumption (6- 7% decrease among youth).  Other federal regulations already in place include: sale of tobacco products to minors is prohibited (under the age of 11); legal ID is required for purchase for anyone under the age of 27; sale of individual and flavored cigarettes is prohibited.8

Creating Your Own Smoke-free Policy: Smoke-free laws do not currently extend to privately owned homes. Since we spend more time in our homes than anywhere else, it is important to make them as safe as possible.9 Insist that all residents and guests do not smoke indoors, and encourage them to smoke a safe distance from the home and away from open doors, windows, or vents.

Use this handbook to help develop a smoke-free policy where you need it: http://www.prevent.org/data/files/initiatives/smokefreepolicies.pdf

References 1References for each individual fact sheet is presented below

TYPES OF TOBACCO PRODUCTS 1. Kozlowski, L. T., Mehta, N. Y., Sweeney, C. T., Schwartz, S. S., Vogler, G. P., Jarvis, M. J., and West, R. J. (1998). Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the United States. Tobacco Control, 7, 369-375. 2. Harris, B. (2011). The intractable cigarette ‘filter problem’. Tobacco Control, 20(Suppl_1), i10-i16. 3. Rigotti, N. A. and Tindle, H. A. (2004). The fallacy of “light” cigarettes. British Medical Journal, 13, 278-279. 4. Kozlowski, L T., and Pillitteri, J. L. (2001). Beliefs about “light” and “ultra light” cigarettes and efforts to change those beliefs: An overview of early efforts and published research. Tobacco Control, 10, i12-i16. 5. Wheeler, M. (2008, September 26). Do ‘light’ cigarettes deliver less nicotine to the brain than regular cigarettes? Retrieved from http://newsroom.ucla.edu/releases/do-light-cigarettes-deliver- less-64109 6. Davies, M. (2014, November 6). Menthol cigarettes could be worse for your health than regular tobacco: Study links them to ‘more severe lung problems’. Daily Mail. Retrieved from http:// www.dailymail.co.uk/health/article-2821738/Menthol-cigarettes-NO-safer-unflavoured-tobacco- lead-severe-lung-problems.html 7. Maryland Resource Center for Quitting Use & Initiation of Tobacco (2012, November 8). Cigars. Retrieved from http://mdquit.org/tobacco-information/cigars 8. American Cancer Society. (2014, February 19). Cigar smoking. Retrieved from http:// www.cancer.org/acs/groups/cid/documents/webcontent/002965-pdf.pdf 9. Center for Disease Control. (2013, July 9). Bidis and kreteks. Retrieved from: http://www.cdc.gov/ tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/index.htm 10. Malson, J. L., Lee, E. M., Murty, R., Moolchan, E. T., and Pickworth, W. B. (2003). Clove cigarette smoking: Biochemical, physiological, and subjective effects. Pharmacology, Biochemistry, and Behavior, 74(3), 739-745. 11. Malson, J. L., Sims, K., Murty, R., Pickworth, W. B. (2001). Comparison of the nicotine content of tobacco used in bidis and conventional cigarettes. Tobacco Control, 10, 181-183. 12. Center for Disease Control. (2014, November 4). Smokeless tobacco: Health effects. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/health_effects/index.htm 13. Center for Disease Control. (2015, April 7). Smokeless tobacco: Products and marketing. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/products_marketing/ index.htm

E-CIGARETTES 1. Herzog, B., Metrano, B., & Gerberi, J. (2012, May 17). Tobacco talk survey- e-Cigarettes a promising opportunity. Retrieved from http://www.stevevape.com/wp-content/uploads/2012/05/E-Cigs-A- Promising-Opportunity.pdf 2. Sutfin, E.L., McCoy, T. P., Morrell, H. E., Hoeppner, B. B., and Wolfson, M. (2013). Electronic cigarette use by college students. Drug and Alcohol Dependence, 131(3), 214-221. 3. Grana, R., Benowitz, N., and Glantz, S.A. (2014). E-cigarettes: A scientific review. Contemporary Reviews in Cardiovascular Medicine, 1972-1986. 4. Wollscheid, K.A. and Kremzner, M. E. (2009). Electronic cigarettes: safety concerns and regulatory issues. American Journal of Health-System Pharmacy, 66(19), 1740-1742. 5. Callahan-Lyon, P. (2014). Electronic cigarettes: Human health effects. Tobacco Control, 23, ii36-ii40. 6. Goniewicz, M.L., Jakub, K., Michal, G., Leon, K., Andrzej, S., Jolanta, K., ...Neal, B. (2014). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control, 23(2), 133-139. 7. Centers for Disease Control and Prevention (2015). E-cigarette use triples among middle and high school students in just one year. Retrieved from http://www.cdc.gov/media/releases/2015/p0416-e- cigarette-use.html.

HEALTH RISKS OF SMOKING TOBACCO 1. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014.

SHORT-TERM & LONG-TERM BENEFITS OF QUITTING 1. Center for Disease Control. (2015, May 21) Quitting smoking. Retrieved from http://www.cdc.gov/ tobacco/data_statistics/fact_sheets/cessation/quitting/ 2. Partnership for a Tobacco-free Maine. (2015). Why Quit? Retrieved from http:// www.tobaccofreemaine.org/quit_tobacco/ 3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014. 4. American Cancer Society. (2014, February 6). When smokers quit – what are the benefits over time? Retrieved from http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide- to-quitting-smoking-benefits

STRESS & WITHDRAWAL 1. Aronson, K. R., Almeida, D. M., Stawski, R. S., Klein, L. C., & Kozlowski, L. T. (2008). Smoking is Associated with Worse Mood on Stressful Days: Results from a National Diary Study. The Society of Behavioral Medicine, 30, 259-69. 2. Parrott, A. C., & Murphy, R. S. (2012). Explaining the stress-inducing effects of nicotine to cigarette smokers. Human Psychopharmacology, 27, 150-55. 3. Parrott, A. C. (1999). Does Cigarette Smoking Cause Stress? American Psychologist, 54(10), 817-20. 4. Benowitz, N. L. (1992). The genetics of drug dependence: Tobacco addiction. New England Journal of Medicine, 327, 881-883. 5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 6. Kassel, J. D., Stroud, L. R., & Paronis, C. A. (2003). Smoking, stress, and negative affect: Correlation, causation, and context across stages of smoking. Psychological Bulletin, 129(2), 270- 304.

STRESS AND WITHDRAWAL (CONT.) 7. Chassin, L., Presson, C. C., Sherman, S. J., & Kim, K. (2002). Long-term psychological sequelae of smoking cessation and relapse. Health Psychology, 21(5), 438-43. 8. Hughes, J. R. & Hatsukami, D. (1986). Signs and symptoms of tobacco withdrawal. Archives of General Psychiatry, 43, 289-294. 9. Piasecki, T. M., Fiore, M. C., & Baker, T. B. (1998). Profiles in discouragement: Two studies of variability in the time course of smoking withdrawal symptoms. Journal of Abnormal Psychology, 107(2), 238-51. 10. Parrot, A. C. (1995). Smoking cessation leads to reduced stress, but why? The International Journal of the Addictions, 30(11), 1509-1516.

SMOKING CESSATION WITH BEHAVIORAL HEALTH CLIENTS 1. Grant, B. F., Hasin D. S., Chou P. S., Stinson F. S., Dawson D. A. (2004). Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 61(11), 1107-1115. 2. Morris C. D., Waxmonsky J., May M., Giese A. A., & Martin L. (January 2009). Smoking Cessation for Persons with Mental Illnesses: A Toolkit for Mental Health Providers. Tobacco Disparities Initiatives of the State Tobacco Education and Prevention Partnership, Colorado Department of Public Health and Environment, Denver, CO. Retrieved from http:// smokingcessationleadership.ucsf.edu/ 3. US Department of Health and Human Services. (2004). The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 62. 4. Audrain-McGovern, J., Rodriguez, D., Tercyak, K. P., Epstein, L. H., Goldman, P., & Wileyto, E. P. (2004). Applying a behavioral economic framework to understanding adolescent smoking. Psychology of Addictive Behaviors, 18(1), 64. 5. Niaura, R. S., Rohsenow, D. J., Binkoff, J. A., Monti, P. M., Pedraza, M., & Abrams, D. B. (1988). Relevance of cue reactivity to understanding alcohol and smoking relapse. Journal of abnormal psychology, 97(2), 133.

SPECIAL POPULATIONS 1. Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J.,…Wewers, M. E. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/ index.html 2. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update.Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. 3. Harmer, C. & Memon, A. (2013). Factors associated with smoking relapse in the postpartum period: An analysis of the Child Health Surveillance System data in southeast England. Nicotine and Tobacco Research, 15(5), 904-909. 4. Center for Disease Control. (2014, August 5) Information for Health Care Providers and Public Health Professionals: Preventing Tobacco Use During Pregnancy. Retrieved from http:// www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/Providers.html 5. Center for Disease Control. (2015, March 13). People living with HIV. Retrieved from http:// www.cdc.gov/tobacco/campaign/tips/groups/hiv.html 6. Center for Disease Control. (2015, March 13). Lesbian, Gay, Bisexual, and Transgender (LGBT). Retrieved from http://www.cdc.gov/tobacco/campaign/tips/groups/lgbt.html 7. Maryland Department of Health and Mental Hygiene. (2014). 2013 Maryland Youth Risk Behavior Survey. Retrieved from http://phpa.dhmh.maryland.gov/cdp/Documents/MD-YRBS-Report.pdf

SECOND– & THIRDHAND SMOKE 1. American Cancer Society. (2015, March 5). Secondhand Smoke. Retrieved from http:// www.cancer.org/cancer/cancercauses/tobaccocancer/secondhand-smoke 2. Center for Disease Control. (2015, February 6). Secondhand Smoke (SHS) Facts. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm 3. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 4. World Health Organization. (2015, July 6). Tobacco. Retrieved from http://www.who.int/mediacentre/ factsheets/fs339/en/ 5. Singer, B.C., Hodgson, A.T., Guevarra, K.S., Hawley, E.L., and Nazaroff, W.W. (2002). Gas-phase organics in environmental tobacco smoke: Effects of smoking rate, ventilation, and furnishing level on emission factors. Environ Sci Technol. 36(5):846–853. 6. Drehmer, J. E., Ossip, D. J., Rigotti, N. A., Nabi, E., Woo, H., Wasserman, R. C., ...Winickoff, J. P. (2012). Pediatrician interventions and thirdhand smoke beliefs of parents. American Journal of Preventative Medicine, 43(5), 533-536. 7. Matt, G. E., Quintana, P. J., Destaillats, H., Gundel, L. A., Sleiman, M., Singer, B. C., ...Hovell, M. F. (2011). Thirdhand tobacco smoke: Emerging evidence and arguments for a multidisciplinary research agenda. Environmental Health Perspectives, 119(9), 1218-1226. 8. Martins-Green, M., Adhami, N., Frankos, M., Valdez, M., Goodwin, B., Lyubovitsky, J.,...Curras- Collazo, M. (2014). Cigarette smoke toxins deposited on surfaces: Implications for human health. PLoS One, 9(1), Retrieved from http://journals.plos.org/plosone/article?id=10.1371/ journal.pone.0086391 9. Ramírez, N., Özel, M. Z., Alastair, C. L., Marcé, R. M., Borrull, F., and Hamilton, J. F. (2014). Explosure to nitrosamines in thirdhand tobacco smoke increases cancer risk in non-smokers. Environment International, 71, 139-147 10. Bertone, E.R., Snyder, L.A., & Moore, E.S. (2002). Environmental tobacco smoke and risk of malignant lymphoma in pet cats. American Journal of Epidemiology, 156, 268-273. 11. Reif, J.S., Bruns, C., & Lower, K.S. (1998). Cancer of the nasal cavity and paranasal sinuses and exposure to environmental tobacco smoke in pet dogs. American Journal of Epidemiology, 147, 488- 492.

SOCIAL JUSTICE 1. Tan, C. E., Kyriss, T., & Glantz, S. A. (2013). Tobacco Company Efforts to Influence the Food and Drug Administration-Commissioned Institute of Medicine Report Clearing the Smoke: An Analysis of Documents Released through Litigation. Plos Medicine, 10(5), 1-22. doi:10.1371/ journal.pmed.1001450 2. UCSF (2013). Tobacco CEO’s Statement to Congress 1994 News Clip “Nicotine is not addictive.” Retrieved from http://senate.ucsf.edu/tobacco/executives1994congress.html 3. Lovato, C., Watts, A., & Stead, L. F. (2011). Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. The Cochrane Database Of Systematic Reviews, (10), CD003439. doi:10.1002/14651858.CD003439.pub2 4. Widome, R., Brock, B., Noble, P., & Forster, J. L. (2013). The relationship of neighborhood demographic characteristics to point-of-sale tobacco advertising and marketing. Ethnicity & Health, 18(2), 136-151. doi:10.1080/13557858.2012.701273 5. Healton, C., & Nelson, K. (2004). Reversal of misfortune: viewing tobacco as a social justice issue. American Journal Of Public Health,94(2), 186-191. 6. U.S. Centers for Disease Control and Prevention (2014). Adult Cigarette Smoking in the United States: Current Estimates. Retrieved from www.cdc.gov

SOCIAL JUSTICE (CONT.) 7. Cochran, S. D., Bandiera, F. C., & Mays, V. M. (2013). Sexual Orientation-Related Differences in Tobacco Use and Secondhand Smoke Exposure Among US Adults Aged 20 to 59 Years: 2003-2010 National Health and Nutrition Examination Surveys. American Journal Of Public Health, 103(10), 1837-1844. doi:10.2105/AJPH.2013.301423 8. Shopland, D., Anderson, C., Burns, D., & Gerlach, K. (2004). Disparities in smoke-free workplace policies among food service workers. Journal Of Occupational & Environmental Medicine, 46(4), 347-356. 9. DeSantis, C., Naishadham, D., & Jemal, A. (2013). Cancer statistics for African Americans, 2013. CA: A Cancer Journal For Clinicians,63(3), 151-166. doi:10.3322/caac.21173 10. Smith, C. B., Bonomi, M., Packer, S., & Wisnivesky, J. P. (2011). Disparities in lung cancer stage, treatment and survival among American Indians and Alaskan Natives. Lung Cancer, 72, 160-164. doi:10.1016/j.lungcan.2010.08.015 11. Lewis, D. R., Clegg, L. X., & Johnson, N. J. (2009). Lung disease mortality in the United States: the National Longitudinal Mortality Study. The International Journal Of Tuberculosis And Lung Dis- ease: The Official Journal Of The International Union Against Tuberculosis And Lung Disease, 13 (8), 1008-1014. 12. Coulter, S. A. (2011). Epidemiology of Cardiovascular Disease in Women. Texas Heart Institute Journal, 38(2), 145-147. 13. Otañez, M., & Glantz, S. A. (2011). Social responsibility in tobacco production? Tobacco companies' use of green supply chains to obscure the real costs of tobacco farming. Tobacco Control: An International Journal, 20(6), 403-411. doi:10.1136/tc.2010.039537 14. Human Rights Watch (2014). Tobacco’s Hidden Children: Hazardous Child Labor in United States Tobacco Farming. Retrieved from www.hrw.org 15. Friedman, L. (2009). Tobacco industry use of corporate social responsibility tactics as a sword and a shield on secondhand smoke issues. The Journal of Law Medicine & AMP Ethics, 819-827.

COSTS TO SOCIETY 1. U.S. Centers for Disease Control and Prevention (2014a). Economic Facts About U.S. Tobacco Pro- duction and Use. Retrieved from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/ economics/econ_facts/ 2. Rumberger, J.S., Hollenbeak, C.S., & Kline, D. (2010). Potential Costs and Benefits of Smoking Cessation: An Overview of the Approach to State Specific Analysis. Retrieved from www.lung.org 3. Gruber J. & Koszegi, B. (2008). A Modern Economic View of Tobacco Taxation. Paris: Internation- al Union Against Tuberculosis and Lung Disease. 4. Strandberg, A. Y., Strandberg, T. E., Pitkälä, K., Salomaa, V. V., Tilvis, R. S., & Miettinen, T. A. (2008). The effect of smoking in midlife on health-related quality of life in old age: a 26-year pro- spective study. Archives Of Internal Medicine, 168(18), 1968-1974. doi:10.1001/ archinte.168.18.1968 5. U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Hu- man Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Pre- vention and Health Promotion, Office on Smoking and Health. 6. Eriksen, M., Mackay, J., & Ross, H. (2012). The Tobacco Atlas (4th ed.). The American Cancer Society and World Lung Foundation. Retrieved from http://www.tobaccoatlas.org 7. U.S. Centers for Disease Control and Prevention (2014b). Secondhand Smoke and Asthma. Re- trieved from http://www.cdc.gov/tobacco/campaign/tips/diseases/secondhand-smoke-asthma.html 8. U.S. Centers for Disease Control and Prevention. (2014c). Smoking & Tobacco Use. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/

COSTS TO SOCIETY (CONT.) 9. Schneider, J. E., Peterson, N. A., Kiss, N., Ebeid, O., & Doyle, A. S. (2011). Tobacco litter costs and public policy: a framework and methodology for considering the use of fees to offset abatement costs. Tobacco Control, 20 Suppl 1, i36-i41. doi:10.1136/tc.2010.041707 10. Legacy (2012). Tobacco Factsheet: the Impact of Tobacco on the Environment. Retrieved from www.legacyforhealth.org 11. Portland State University (2013). Factsheet: Environmental Impact of Tobacco. Retrieved from http://www.pdx.edu/healthycampus/sites/www.pdx.edu.healthycampus/files/ Environmental_Impacts.3.7.13.pdf 12. Singer, B. C., Hodgson, A. T., Guevarra, K. S., Hawley, E. L., & Nazaroff, W. W. (2002). Gas- phase organics in environmental tobacco smoke. 1. Effects of smoking rate, ventilation, and furnishing level on emission factors.Environmental Science & Technology, 36(5), 846-853.

TOBACCO CONTROL & POLICY 1. Legal Resource Center for Public Health Policy (2014, March 10). Tobacco free workplaces: Legal issues and implications [powerpoint slides]. Retrieved from http://www.law.umaryland.edu/ programs/publichealth/documents/TobaccoFree Workplace Policy.ppt 2. Partnership for Prevention. (2009, April). Smoke free policies: An action guide. Retrieved from http://www.prevent.org/data/files/initiatives/smokefreepolicies.pdf 3. King, B. A., Travers, M. J., Cummings, K. M., Mahoney, M. C., and Hyland, A. J. (2010). Secondhand smoke transfer in multiunit housing. Nicotine and Tobacco Research, 12(11), 1133- 1141. 4. Pizacani, B. A., Maher, J. E., Rohde, K., Drach, L., and Stark, M. J. (2012). Implementation of a smoke-free policy in subsidized multiunit housing: Effects on smoking cessation and secondhand smoke exposure. Nicotine and Tobacco Research. Retrieved from http://ntr.oxfordjournals.org/ content/early/2012/02/07/ntr.ntr334.short 5. Lawn, S. and Pols, R. (2005). Smoking bans in psychiatric inpatient settings? A review of the research. Australian and New Zealand Journal of Psychiatry, 39, 866-885. 6. Center for Disease Control (2010, September 10). Vital signs: Nonsmokers’ exposure to secondhand smoke—United States, 1999-2008. Morbidity and Mortality Weekly Report, 59(35), 1141-1146. 7. Campaign for Tobacco-free Kids (2012, October 12). Raising cigarette taxes reduces smoking, especially among kids (and cigarette companies know it). Retrieved from http://edsource.org/wp- content/uploads/0146.pdf 8. Legal Resource Center for Public Health Policy (2014, December 5). Regional tobacco enforcement training [powerpoint slides]. Retrieved from http://www.law.umaryland.edu/programs/publichealth/ documents/synar/FederalStateLocalTobaccoControlLaws_Tilburg.pdf