Tobacco smoking

The cigarette is the most common method of smoking tobacco.

Tobacco smoking is the act of burning the dried or cured leaves of the tobacco plant and inhaling the smoke for pleasure, for ritualistic or social purposes, self-medication, or simply to satisfy addiction. The practice was common among Native Americans throughout North and South America, and was later introduced to the rest of the world, via trade, following European exploration of the Americas.

Tobacco smoke contains nicotine, an addictive stimulant. The effect of nicotine in first time or irregular users is an increase in alertness and memory, and mild euphoria. In chronic users, nicotine simply relieves the symptoms of nicotine withdrawal: confusion, restlessness, anxiety, insomnia, and dysphoria. Withdrawal symptoms in chronic users begin to appear approximately 30 minutes after every dose . Nicotine also disturbs metabolism and suppresses appetite. This is because nicotine, like many stimulants, increases blood sugar.

It has been determined that all forms of tobacco smoking including cigarettes, cigars, pipes, bidis, hookahs, Chillums, Ritual Smudging, Kreteks, and other forms of tobacco use such as chewing tobacco and snuff are addictive. In fact, some news organizations compare the addiction potential of tobacco with that of heroin.

Medical research has determined that chronic tobacco smoking is a major contributing factor towards many health problems, particularly lung cancer, emphysema, and cardiovascular disease. Many countries regulate or restrict tobacco sales and advertising and require warnings to be placed prominently on the product packaging. Many governments now restrict or ban smoking in a variety of public venues over concerns of second-hand smoke, and possibly also to discourage tobacco use in general.

Methods of smoking

Various smoking equipment including different pipes.

Cigarette

Main article: Cigarette

Cigarette smoking is the most common form of tobacco consumption. It leads all other methods by more than a factor of 10. A cigarette is a product manufactured from cured and cut tobacco leaves, which are rolled and/or stuffed into a paper-wrapped cylinder. The cigarette is lit, usually with a match or lighter at one end and allowed to burn for the purpose of inhalation of its smoke from the other (usually filtered) end, which is inserted in the mouth. "Roll Ups" are also very popular, particularly in European countries; these are prepared from loose tobacco, cigarette papers and filters all bought separately by the consumer. Cigarettes are smoked by some with a cigarette holder. (See also Beedi). Cigarette smoke contains a number of artificial additives, particularly to enhance taste, and also several carcinogens.

Main article: List of additives in cigarettes

Cigar

Main article: Cigar

A cigar is a cylinder of tobacco rolled in tobacco leaves for smoking. They come in many shapes and sizes, the most common being the "Corona", "Cigarillo" and "Blunt". The tobacco used is grown throughout the Caribbean in places such as the Dominican Republic, Honduras, Jamaica, and Cuba. A popular light colored "shade" wrappers is from Connecticut whereas darker Maduro wrappers come from the Caribbean. Cigars manufactured in Cuba have historically been considered to be without peer, though today some aficionados consider the relative quality of Cuban cigars has diminished with the Cuban government’s mismanagement of cigar production, as well as the increasing quality of non-Cuban cigars, such as the Rocky Patel, Arturo Fuente, Punch, Bolivar and Padron labels.

Pipe

Main article: Smoking pipe (tobacco)

A pipe for smoking typically consists of a small chamber (bowl) for combustion of the substance to be smoked and a thin stem (shank) that ends in a mouthpiece (also called a bit). Pipes are made from a variety of materials (some obscure): briar, corncob, meerschaum, clay, wood, glass, gourd, bamboo, and various other materials, such as metal. Tobacco used for smoking pipes is often chemically treated and altered to change smell and taste (both functions are affected negatively in humans by smoking) not available in other tobacco products sold commercially. Many of these are mixtures using staple ingredients of variously cured Burley and Virginia tobaccos which are mixed with tobaccos from different areas, such as Oriental or Balkan locations. Latakia (a fire-cured tobacco of Cypriot or Syrian origin), Perique (only grown in St. James Parish, Louisiana) or combinations of Virginia and Burley tobaccos of African, Indian, or South American origins. Traditionally, many U.S. tobaccos are made of American Burley with artificial sweeteners and flavorings added to create an artificial "aromatic" smell, whereas "English" blends are based on natural Virginia tobaccos enhanced with Oriental and other natural tobaccos. There is a growing tendency towards "natural" tobaccos which derive their aromas from blending with spice tobaccos alone and historically-based curing processes.

Pipes can range from the very simple machine-made briar pipe to handmade and artful implements created by pipemakers which can be very expensive collector's items. The popularity of pipe smoking in Western countries has declined in recent years. However, it has also enjoyed a resurgence of late among younger and middle aged smokers who find its contemplative nature and age-transcendent status as "hobby not habit" to be both thoroughly enjoyable and stress-relieving. Due to the wide availability of high quality mass-produced and custom smoking pipes as well as a myriad of pipe tobaccos to suit any taste, the hobby is likely to persist for years to come despite growing anti-smoking sentiment.

Hookah

Main article: Hookah

A hookah (or sheesha) is a type of traditional Middle Eastern and South Asian water pipe, a pipe which operates by water-filtration and indirect heat. Hookahs are most popular in the Middle East, and is a niche market in many other places. In Muslim countries, where cannabis products smoking occupies a social niche analogous to that of alcohol drinking in the West, hookahs are sometimes loaded with hashish or opium. In the Far East opium and cannabis are also among the traditional drugs used, and today is often a complement to tobacco.

Typically, tobacco is smoked from a hookah by placing richly flavored tobaccos in the smoking bowl, covering it with foil, and placing a coal on top of the foil. This keeps the tobacco from burning, and allows it to bake. The resulting vapors are further cooled by the hookah water, resulting in a moist, warm smoke and a pleasant aroma. The Al-Waha, Al Fakher, and Nakhla tobacco companies compete for market share in the Middle East by producing increasingly luxurious flavored tobaccos for use in the hookah. Currently available flavors include the traditional apple, grape, double apple, orange, strawberry, cherry, mango, vanilla, and melon flavors; as well as the modern cola, coconut, cappuccino, and banana milk flavors.

Popular myth suggests that hookah smoking is considered to be safer than other forms of smoking. However, water is not effective for removing all relevant toxins, e.g. the carcinogenic aromatic hydrocarbons are not water-soluble. Several serious negative health effects are linked to hookah smoking and studies indicate that it is likely to be more harmful to health than cigarettes, due in part to the volume of smoke inhaled. One study found hookah smoke to be both clastogenic and genotoxic for human beings, while another study showed that the CO hazard is as high with hookah smoking as with cigarette smoking. In addition to the cancer risk, there is some risk of infectious disease resulting from pipe sharing, and other risks associated to the common addition of other psychoactive drugs to the tobacco.

Health effects

Main article: Health effects of tobacco smoking

History

As the use of tobacco became popular in Europe, some people became concerned about its possible ill effects on the health of its users. One of the first was King James I of Great Britain. In 1604, he wrote A Counterblaste to Tobacco in which he asked his subjects

You have not reason then to be ashamed, and to forbeare this filthie noveltie, so basely grounded, so foolishly received and so grossly mistaken in the right use thereof? In your abuse thereof sinning against God, harming your selves both in persons and goods, and raking also thereby the marks and notes of vanitie upon you: by the custome thereof making your selves to be wondered at by all forraine civil Nations, and by all strangers that come among you, to be scorned and contemned. A custom loathsome to the eye, hateful to the Nose, harmful to the brain, dangerous to the Lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stigian smoke of the pit that is bottomelesse.

In 1761, English doctor John Hill published "Cautions against the Immoderate Use of Snuff" in which he warned snuff users that they were vulnerable to cancers of the nose. In 1795, American Samuel Thomas von Soemmering reported on cancers of the lip in pipe smokers. The late-19th century invention of automated cigarette making machinery in the American South made possible mass production of cigarettes at low cost; the profits endowed Duke University, and cigarettes became elegant and fashionable among society men as the Victorian era gave way to the Edwardian. In 1912, American Dr. Isaac Adler was the first to strongly suggest that lung cancer is related to smoking. In 1929, Fritz Lickint of Dresden, Germany, published a formal statistical evidence of a lung cancer–tobacco link, based on a study showing that lung cancer sufferers were likely to be smokers. Lickint also argued that tobacco use was the best way to explain the fact that lung cancer struck men four or five times more often than women (since women smoked much less). Many American and other servicemen began smoking during World Wars I and II when cigarettes were included in military rations and distributed by charitable organizations.

In 1950, Dr. Richard Doll published research in a 1950 issue of the British Medical Journal showing a close link between smoking and lung cancer. Four years later, in 1954 the British Doctors Study, a study of some 40 thousand doctors over 20 years, confirmed the suggestion, based on which the government issued advice that smoking and lung cancer rates were related. The British Doctors Study lasted till 2001, with result published every ten years and final results published in 2004. Reader's Digest was a major crusader and for decades published many anti-smoking articles. In 1964, Luther L. Terry, M.D., Surgeon General of the United States, released the report of the Surgeon General's Advisory Committee on Smoking and Health. It was based on over 7000 scientific articles that linked tobacco use with cancer and other diseases. This report led to laws requiring warning labels on tobacco products and to restrictions on tobacco advertisements. As these began to come into force, tobacco marketing became more subtle, with sweets shaped like cigarettes put on the market, and a number of adverts designed to appeal to children, particularly those featuring Joe Camel resulting in increased awareness and uptake of smoking among children. However, restrictions did have an effect on adult quit rates, with its use declining to the point that by 2004, nearly half of all Americans who had ever smoked had quit. In the 1950s, manufacturers began adding filter tips to cigarettes to remove some of the tar and nicotine as they were smoked. "Safer", "less potent" cigarette brands were also introduced. They were so popular that, as of 2004, half of Americans preferred them in spite the fact that the idea of a "safer" cigarette is a myth. Cigarettes that offer, "low tar and nicotine" simply cause the smoker to smoke more or to inhale more deeply to get the same level of nicotine. According to The Federal Government’s National Cancer Institute (NCI), light cigarettes provide no benefit to smoker's health.

Health Risks of Smoking

Because of their nicotine addiction, many smokers find it difficult to cease smoking despite their knowledge of ill health effects.

The health effects of tobacco smoking are related to direct tobacco smoking, as well as passive smoking, inhalation of environmental or secondhand tobacco smoke. A 50 year study of over thirty-thousand British physicians showed that nonsmokers lived about 10 years longer than smokers. For those born between 1920 and 1929 the standardized mortality rate between the ages of 35 and 69 for nonsmokers was 15% and for smokers was 45% —nearly three times as great. Claims that personalities of smokers account for these differences are not convincing in light of the fact that the heavy smokers were about 25 times more likely to die of lung cancer or chronic obstructive pulmonary disease than the nonsmokers. Another source claims smoking is responsible for 87% of lung cancer deaths.

The main health risks in tobacco pertain to diseases of the cardiovascular system, in particular smoking being a major risk factor for a myocardial infarction (heart attack), diseases of the respiratory tract such as Chronic Obstructive Pulmonary Disease (COPD), asthma, emphysema, and cancer, particularly lung cancer and cancers of the larynx and tongue. Prior to World War I, lung cancer was considered to be a rare disease, which most physicians would never see during their career . With the postwar rise in popularity of cigarette smoking, however, came a virtual epidemic of lung cancer.

A person's increased risk of contracting disease is directly proportional to the length of time that a person continues to smoke as well as the amount smoked. However, if someone stops smoking, then these chances gradually decrease as the damage to their body is repaired. A year after quitting, the risk of contracting disease is half that of a smoker.

The health risks of smoking are not uniform across all smokers. Risks vary according to amount of cigarettes smoked, with those who smoke more cigarettes at greater risk. Light smoking is still a health risk. According to the Surgeon General of The United States, mortality rates for pipe smokers and cigar smokers that smoke less than five cigars per day are roughly the same as for non-smokers. The data regarding smoking to date focuses primarily on cigarette smoking, which even by conservative estimates increases mortality rates by 40%. Men who smoke 10-19 cigarettes a day have a 70% increase in mortality rates, men who smoke 20-39 cigarettes a day have an increase in mortality rate by 90%, for men smoking two packs a day or more, their mortality rates increased 120%. According to the Canadian Lung Association, tobacco kills between 40,000–45,000 Canadians per year, more than the total number of deaths from AIDS, traffic accidents, suicide, murder, fires and accidental poisoning. The United States' Centers for Disease Control and Prevention describes tobacco use as "the single most important preventable risk to human health in developed countries and an important cause of premature death worldwide".

Infant mortality

Tobacco smoke reduces the delivery of oxygen to the fetus through the presence of carbon monoxide, cyanide, and aromatic hydrocarbons. Nicotine and other substances in tobacco smoke cause reduction in placental blood flow, creating further reductions in oxygen delivery as well as reductions in nutrients to the unborn baby. Secondhand smoke exposure during pregnancy produces twice the risk of low birth weight babies. Smoking is the single largest modifiable risk factor in intrauterine growth retardation.

Carcinogenicity

The incidence of lung cancer is highly correlated with smoking.

Smoke, or any partially burnt organic matter, is carcinogenic (cancer-causing). Lung cancer rates are linked to the number of people who smoke. It is noted that an increase in deaths from lung cancer appeared 20 years after an increase in cigarette consumption. The damage a continuing smoker does to their lungs can take up to 20 years before its physical manifestation in lung cancer. Women began smoking later than men, so the rise in death rate amongst women did not appear until later. More men than women smoke. More men than women die of lung cancer. The male lung cancer death rate decreased in 1975 — roughly 20 years after the fall in cigarette consumption in men. Fall in consumption in women also began in 1975 but by 1991 had not manifested in a decrease in lung cancer related mortalities amongst women.

Some commentators however question the claims that lung cancer trends are closely related to smoking trends due to the fact that figures from other parts of the world where smoking rates have been as high or higher over many decades do not support this hypothesis

An extremely carcinogenic (cancer-causing) metabolite of benzopyrene, a polynuclear aromatic hydrocarbon, produced by burning tobacco.

The primary carcinogens are the pyrolysis products of tobacco leaves. Any partially burnt material, tobacco or not, contains polycyclic aromatic hydrocarbons, particularly benzopyrene. The mechanism of their carcinogenity is well-known: oxidation produces an epoxide, which binds to DNA covalently and distorts it. If the cell cannot repair its DNA damage prior to undergoing mitotic division, the daughter cells carry a greater risk becoming tumorgenic. DNA damage is one of the causes of cancer, because if the poison damages the programmed cell death system severely enough (usually requiring more than one mutation), damaged cells cannot kill themselves and begin to divide uncontrollably. This results in the formation of tumors that have the potential of becoming cancerous. The DNA oxidative damage is non-specific, so oncogenes and tumor suppressor genes (both genes associated with tumorgenicity) aren't always targeted. This results in an essentially random occurrence of cancer, where the probability increases with increasing exposure. In this respect, the mechanism of carcinogenicity closely resembles that of mustard gas, aflatoxin and other DNA alkylating agents.

Tobacco smoke also contains various carcinogens other than polynuclear aromatic hydrocarbons, such as traces of radioactive elements. Smoking is therefore an important route of exposure to the dangerous ionizing radiation. The carcinogenity of tobacco is aggravated by the delivery of the carcinogens, namely direct inhalation. Radioactive and carcinogenic particles would not find their way by itself to the lungs, but a smoker inhales them repeatedly over a long period of time.

For example, smoke from tobacco grown with phosphate fertilizers contains polonium 210. Polonium 210 is an emitter of alpha particles, which cannot penetrate skin and are harmless outside the body, but destructive when present in the lungs. Some researchers have estimated that polonium 210 carries a cancer risk of 4 per 10000 smokers, while others have estimated the mortality rate to be 18 per million.

The carcinogenity of tobacco smoke is not explained by nicotine per se, which is not carcinogenic or mutagenic. However, it inhibits apoptosis, therefore accelerating existing cancers. Also, NNK, a nicotine derivative converted from nicotine, can be carcinogenic.

Tobacco disease

Chronic obstructive pulmonary disease (COPD) caused by smoking, known as tobacco disease, is a permanent, incurable reduction of pulmonary capacity characterized by shortness of breath, wheezing, persistent cough with sputum, and damage to the lungs, including emphysema and chronic bronchitis. Smokers have a 25% risk of developing COPD.

The chronic cough associated with smoking is largely due to paralysis of the small hairs which sweep mucus and debris out of the lungs (the mucociliary escalator) and up the windpipe to the back of the mouth, from where they are swallowed. Impairment of this system means that mucus collects in the lung bases, and the "smoker's cough" is an attempt to clear this. It cannot be treated, but tends to resolve if the smoker can quit.

Effects on the heart

Smoking contributes to the risk of developing heart disease. All smoke contains very fine particulates that are able to penetrate the alveolar wall into the blood and exert their effects on the heart in a short time.

Inhalation of tobacco smoke causes several immediate responses within the heart and blood vessels. Within one minute the heart rate begins to rise, increasing by as much as 30 percent during the first 10 minutes of smoking. Carbon monoxide in tobacco smoke exerts its negative effects by reducing the blood’s ability to carry oxygen.

Smoking tends to increase blood cholesterol levels. Furthermore, the ratio of high-density lipoprotein (the “good” cholesterol) to low-density lipoprotein (the “bad” cholesterol) tends to be lower in smokers compared to non-smokers. Smoking also raises the levels of fibrinogen and increases platelet production (both involved in blood clotting) which makes the blood viscous. Carbon monoxide binds to haemoglobin (the oxygen-carrying component in red blood cells), resulting in a much stabler complex than haemoglobin bound with oxygen or carbon dioxide--the result is permanent loss of blood cell functionality. Blood cells are naturally recycled after a certain period of time, allowing for the creation of new, functional erythrocytes. However, if carbon monoxide exposure reaches a certain point before they can be recycled, hypoxia (and later death) occurs. All these factors make smokers more at risk of developing various forms of arteriosclerosis. As the arteriosclerosis progresses, blood flows less easily through rigid and narrowed blood vessels, making the blood more likely to form a thrombosis (clot). Sudden blockage of a blood vessel may lead to an infarction (e.g. stroke). However, it is also worth noting that the effects of smoking on the heart may be more subtle. These conditions may develop gradually given the smoking-healing cycle (the human body heals itself between periods of smoking), and therefore a smoker may develop less significant disorders such as worsening or maintenance of unpleasant dermatological conditions, e.g. eczema, due to reduced blood supply. Smoking also increases blood pressure and weakens blood vessels.

Nicotine

Nicotine is a powerful, addictive stimulant and is one of the main factors leading to the continued tobacco smoking. Although the amount of nicotine inhaled with tobacco smoke is quite small (most of the substance is destroyed by the heat) it is still sufficient to cause physical and/or psychological dependence.

Smokers' attitudes

Prior to habituation, tobacco smokers often focus on the reinforcing properties of smoking rather than the associated health risks. The diseases caused by smoking surface relatively later in life. As a result, they do not serve to deter smoking given the immediate gratification offered by smoking.

Some smokers claim that the depressant effect of smoking allows them to calm their nerves, often allowing for increased concentration. This, however, is only partly true. According to the Imperial College London, "Nicotine seems to provide both a stimulant and a depressant effect, and it is likely that the effect it has at any time is determined by the mood of the user, the environment and the circumstances of use. Studies have suggested that low doses have a depressant effect, whilst higher doses have stimulant effect." However, it is impossible to differentiate a drug effect brought on by nicotine use, and the alleviation of nicotine withdrawal.

Passive smoking

Main article: Passive smoking

This photo illustrates smoke in a pub, a common complaint from those concerned with passive smoking

Passive or involuntary smoking occurs when the exhaled and ambient smoke (otherwise known as environmental or secondhand smoke) from one person's cigarette is inhaled by other people. Passive smoking involves inhaling carcinogens, as well as other toxic components, that are present in secondhand tobacco smoke. Carcinogens that occur in secondhand tobacco smoke include benzene, 1,3-butadiene, benzo[a]pyrene, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, and many others.

It is confirmed that, in adults, exposure to secondhand smoke causes lung cancer, nasal sinus cancer, breast cancer in younger women, heart disease, heart attacks, and asthma induction, where the risk increases with increasing exposure. Secondhand smoke is also known to harm children, infants and reproductive health through acute lower respiratory tract illness, asthma induction and exacerbation, chronic respiratory symptoms, middle ear infection, lower birth weight babies, and Sudden Infant Death Syndrome. In a study released February 12, 2007 warning signs for cardiovascular disease are higher in people exposed to secondhand tobacco smoke, adding to the link between "passive smoke" and heart disease. "Our study provides further evidence to suggest low-level exposure to secondhand smoke has a clinically important effect on susceptibility to cardiovascular disease," said Dr. Andrea Venn of University of Nottingham in Britain, lead author of the study.

Passive smoking has long been known as a risk to the health of people with conditions such as asthma, but as recently as the early 1990s few people believed that it was a killer which had the same effect on non-smokers as it did on smokers. British entertainer Roy Castle, who died of cancer in 1994, blamed his illness on spending years playing the trumpet in smoky jazz clubs.

In June 2006, US Surgeon General Richard H. Carmona called the evidence of the effects of passive smoke "indisputable" and said "The science is clear: secondhand smoke is not a mere annoyance, but a serious health hazard that causes premature death and disease in children and non-smoking adults.". Passive smoking is one of the key issues that have led to introduction of smoking bans, particularly in workplaces.

The composition of environmental tobacco smoke (ETS) is similar to fossil fuel combustion products that contribute to air pollution, and has been shown to be responsible for indoor particulate matter (PM) levels far exceeding official outdoor limits.

A presentation at the American Thoracic Society's 2007 Conference suggested that children of smokers who show no signs of respiratory problems may still be experiencing damaging changes in their airways.

Sudden infant death syndrome

Main article: Sudden infant death syndrome

According to the U.S. Surgeon General’s Report (Chapter 5; pages 180–194), secondhand smoke is connected to SIDS. Infants who die from SIDS tend to have higher concentrations of nicotine and cotinine (a biological marker for secondhand smoke exposure) in their lungs than those who die from other causes. Infants exposed to secondhand smoke after birth are also at a greater risk of SIDS.

Somatic and psychological effects of nicotine

Tobacco smoke contains nicotine. Nicotine acts as an agonist that binds to nicotinic acetylcholine receptor sites in the brain and body. Some of these neurons influence respiration, heart rate, memory, alertness, and muscle movement, and are therefore affected by nicotine.

Nicotine's effect in the body results in desensitization of acetylcholine receptors in the brain and body— a physiological response to excess stimulation of nicotinic acetylcholine receptors. This desensitization can become problematic when a smoker stops smoking, as lower levels of acetylcholine receptor stimulation can affect respiration, heart rate, memory, alertness, and muscle movement until the receptors are resensitized or restimulated.

Recent evidence has shown that smoking tobacco increases the release of dopamine in the brain, specifically in the mesolimbic pathway, the same neuro-reward circuit activated by drugs of abuse such as heroin and cocaine. This suggests nicotine use has a pleasureable effect that triggers positive reinforcement. One study found that smokers exhibit better reaction-time and memory performance compared to non-smokers, which is consistent with increased activation of dopamine receptors. Neurologically, rodent studies have found that nicotine self-administration causes lowering of reward thresholds--a finding opposite that of most other drugs of abuse (e.g. cocaine and heroin). This increase in reward circuit sensitivity persisted months after the self-administration ended, suggesting that nicotine's alteration of brain reward function is either long lasting or permanent. Furthermore, it has been found that nicotine can activate long term potentiation in vivo and in vitro. These studies suggests nicotine’s "trace memory" may contribute to difficulties in nicotine abstinence.

Somatic and psychological addiction

Nicotine, a component of tobacco smoke, is one of the most addictive psychoactive chemicals. When tobacco is smoked, most of the nicotine is pyrolyzed; a dose sufficient to cause mild somatic dependency and mild to strong psychological dependency remains. According to studies by Henningfield and Benowitz, overall nicotine is more addictive than cannabis, caffeine, ethanol, cocaine, and heroin when considering both somatic and psychological dependence. However, due to the stronger withdrawal effects of ethanol, cocaine and heroin, nicotine may have a lower potential for somatic dependence than these substances. A study by Perrine concludes that nicotine's potential for psychological dependency exceeds all other studied drugs - even ethanol, an extremely physically addictive substance with severe withdrawal symptoms that can be fatal. About half of Canadians who currently smoke have tried to quit. McGill University health professor Jennifer O'Loughlin stated that nicotine addiction can occur as soon as five months after the start of smoking.

It can be difficult to quit smoking due to the withdrawal symptoms which include insomnia, irritability, anxiety, decreased heart rate, weight gain, and nicotine cravings. The relapse rate for quitters is high: about 60% relapse within three months. In addition, nicotine users typically do not associate the aversive properties to nicotine as these develop long after the positive associations have been made.

A component of both somatic and psychological addiction is the lowering of reward thresholds associated with nicotine use. Studies from The Scripps Research Institute have shown that acute and chronic nicotine use lowers reward thresholds, sensitizing this neurocircuit. Though nicotinic acetylcholine receptors are being desensitized, the body compensates for the compensatory mechanism by up-regulating the number these receptors. The reason for this is not known, though speculation is that the functionality of NACh receptors is so essential to the body and brain, that it is preferable to have excess stimulation than insufficient activation. As a result, relapse after abstinence can cause an immediate spiral to a physical and psychological state prior to abstinence, even after months of being clean. This would be as if the abstinence never occurred, and might help to explain the high incidence of relapse.

Mood and anxiety disorders

Data from multiple studies suggest that depression plays a role in cigarette smoking. A history of regular smoking was observed more frequently among individuals who had experienced a major depressive disorder at some time in their lives than among individuals who had never experienced major depression or among individuals with no psychiatric diagnosis. Another study found that the average lifetime daily cigarette consumption was strongly related to lifetime prevalence, and to prospectively assessed one year prevalence of major depression. People with major depression are also much less likely to quit due to the increased risk of experiencing mild to severe states of depression, including a major depressive episode. Depressed smokers appear to experience more withdrawal symptoms on quitting, are less likely to be successful at quitting, and are more likely to relapse.

Recent studies have linked smoking to anxiety disorders, suggesting the correlation (and possibly mechanism) may be related to the broad class of anxiety disorders, and not limited to just depression. Current ongoing research are attempting to tweeze apart the addiction-anxiety relationship.

Health benefits of smoking

Some studies have discovered health benefits correlated with smoking. These studies observed a reduction in the occurrence of some diseases, but all such studies stressed that the benefits of smoking did not outweigh the risks.

Several types of "Smoker's Paradoxes", i.e. cases where smoking appears to have specific beneficial effects, have been observed; often the actual mechanism remains undetermined. For instance, recent studies suggest that smokers require less frequent repeated revascularization after percutaneous coronary intervention (PCI). Risk of ulcerative colitis has been frequently shown to be reduced by smokers on a dose-dependent basis; the effect is eliminated if the individual stops smoking. Smoking appears to interfere with development of Kaposi's sarcoma,. a possible reduction in breast cancer among women carrying the very high risk BRCA gene,, although overall risk is increased preeclampsia,

A plausible mechanism of action in these cases may be the nicotine in tobacco smoke acting as an anti-inflammatory agent and interfering with the disease process.

Tobacco smoking has a laxative effect.

In mice, studies have shown nicotine can reduce the amount of DOI-induced head twitches (meant to model tics) related to Tourette's Syndrome .

A protective effect of current smoking has been found in Parkinson's disease, , although the authors stated that it was more likely that the movement disorders which are part of Parkinson's disease prevented people from being able to smoke than that smoking itself was protective, and personality differences may play a role

Evidence on a possible protective effect of smoking on Alzheimer's Disease is mixed, with some studies finding decreased and some increased likelihood of developing the disease. A recent review concluded that the apparent decrease in risk may be simply due to the fact that smokers tend to die before reaching the age at which Alzheimer's normally occurs. "Differential mortality is always likely to be a problem where there is a need to investigate the effects of smoking in a disorder with very low incidence rates before age 75 years, which is the case of Alzheimer's disease", it stated, noting that smokers are only half as likely as non-smokers to survive to the age of 80.

A plausible explanation for these cases may be the effect of nicotine, a cholinergic stimulant, decreasing the levels of acetylcholine in the smoker's brain; Parkinson's disease occurs when the effect of dopamine is less than that of acetylcholine. Opponents counter by noting that consumption of pure nicotine may be as beneficial as smoking without the risk.

Considering the high rates of physical sickness and deaths among persons suffering from schizophrenia, one of smoking's short term benefits is its temporary effect to improve alertness and cognitive functioning in that disease. It has been postulated that the mechanism of this effect is that schizophrenics have a disturbance of nicotinic receptor functioning.

Effects of the habit and industry on society

Link between tobacco use and use of illicit drugs

Tobacco, marijuana, and alcohol are "gateway drugs" according to a 1994 report from the Center on Addiction and Substance Abuse at Columbia University, which stated that there is a consistent relationship between the use of cigarettes and alcohol and the subsequent use of cannabis. Cigarettes, alcohol and cannabis use and the subsequent use of illicit drugs like cocaine is also linked, regardless of the age, sex, ethnicity or race of the individuals involved. This may also be affected by each individual person's personality and or attitude toward their life style. There are many people that smoke marijuana and/or cigarettes without ever becoming addicted or even trying other drugs. The 1994 report also found that when younger children use these gateway drugs, the more often they use them, the more likely they are to use cocaine, heroin, hallucinogens and other illicit drugs. The report concludes that the data is already robust enough to make a strong case to step up efforts to prevent childhood use of cigarettes, alcohol and cannabis and to take firm steps to reduce children’s access to these gateway drugs.

People who abuse drugs are likely to be cigarette smokers also. More than two-thirds of drug abusers are regular tobacco smokers, a rate more than double of that in the general population. National Institute on Drug Abuse researchers have found that craving for nicotine also increases craving for illicit drugs among drug abusers who smoke tobacco, and this suggests that smokers in drug rehabilitation programs may be less successful than nonsmokers in staying off drugs. NIDA is a very controversial organization. Many drug policy organizations, such as the RAND Drug Policy Research Center have released information, on studies performed, in stark contrast to the claims made by NIDA.

The "gateway" theory regarding substance abuse has come under a great deal of criticism. The statistics mentioned above only establish a correlation between tobacco smoking and illicit drug use, and do not establish that one causes the other. For example, it is entirely possible that people who smoke cigarettes have a higher incidence of cocaine use, and that a third variable (such as income) causes both, creating the illusion that smoking cigarettes causes cocaine use. It is commonly known that "correlation does not imply causation", and it is a frequent misconception that correlational evidence is "proof".

In 2002, the RAND Drug Policy Research Center released a paper on one of their studies stating that it "casts doubt on claims that marijuana acts as a "gateway" to the use of cocaine and heroin, challenging an assumption that has guided U.S. drug policies since the 1950s." These findings of the RAND Drug Policy Research Center's study are in contradiction to the claims made by NIDA.

Effect on healthcare costs

In countries where there is a public health system, society pays for the medical care of smokers who become ill through increased taxes. Two arguments exist on this front, the "pro-smoking" argument suggesting that heavy smokers generally don't live long enough to develop the costly and chronic illnesses which affect the elderly, reducing society's healthcare burden. The "anti-smoking" argument suggests that the healthcare burden is increased because smokers get chronic illnesses younger and at a higher rate than the general population.

Data on both positions is limited, although the Centers for Disease Control and Prevention published research in 2002 claiming that the cost of each pack of cigarettes sold in the United States was more than $7 in medical care and lost productivity. The cost may be higher, with another study putting it as high as $41 per pack.

By contrast, some non-scientific studies, including one conducted by Philip Morris in the Czech Republic and another by the CATO institute, support the opposite position. Neither study was peer-reviewed nor published in a scientific journal, and the CATO institute have received funding from tobacco companies in the past. Philip Morris have explicitly apologised for the former study, saying: "The funding and public release of this study which, among other things, detailed purported cost savings to the Czech Republic due to premature deaths of smokers, exhibited terrible judgment as well as a complete and unacceptable disregard of basic human values. For one of our tobacco companies to commission this study was not just a terrible mistake, it was wrong. All of us at Philip Morris, no matter where we work, are extremely sorry for this. No one benefits from the very real, serious and significant diseases caused by smoking."

Tobacco advertising

Main article: Tobacco advertising

Before the 1970s, most tobacco advertising was legal in the United States and most European nations. In the United States, in the 1950s and 1960s, cigarette brands were frequently sponsors of television shows—most notably shows such as To Tell the Truth and I've Got a Secret. One of the most famous television jingles of the era came from an advertisement for Winston cigarettes. The slogan "Winston tastes good like a cigarette should!" proved to be catchy, and is still quoted today. Another popular slogan from the 1960s was "Us Tareyton smokers would rather fight than switch!," which was used to advertise Tareyton cigarettes.

Many nations, including Russia and Romania, still allow billboards advertising tobacco use. Tobacco smoking is still advertised in special magazines, during sporting events, in gas stations and stores, and in more rare cases on television.

In the United States, it was believed by many that tobacco companies are marketing tobacco smoking to minors. For example, Reynolds American Inc. used the Joe Camel cartoon character to advertise Camel cigarettes. Other brands such as Virginia Slims targeted women with slogans like "You've Come a Long Way Baby".

Some nations, including the UK and Australia, have begun anti-smoking advertisements to counter the effects of tobacco advertising. Australia has banned pro-tobacco advertising.

The actual effectiveness of tobacco advertisement is widely documented. According to an opinion piece by Henry Saffer, public health experts say that tobacco advertising increases cigarette consumption and there is much empirical literature that finds a significant effect of tobacco advertising on smoking, especially in children.

Peer pressure

Many anti-smoking organizations claim that teenagers begin their smoking habits due to peer pressure, and cultural influence portrayed by friends. However, one study found that direct pressure to smoke cigarettes did not play a significant part in adolescent smoking. In that study, adolescents also reported low levels of both normative and direct pressure to smoke cigarettes. A similar study showed that individuals play a more active role in starting to smoke than has previously been acknowledged and that social processes other than peer pressure need to be taken into account. Another study's results revealed that peer pressure was significantly associated with smoking behavior across all age and gender cohorts, but that intrapersonal factors were significantly more important to the smoking behavior of 12–13 year-old girls than same-age boys. Within the 14–15 year-old age group, one peer pressure variable emerged as a significantly more important predictor of girls' than boys' smoking. It is debated whether peer pressure or self-selection is a greater cause of adolescent smoking. It is arguable that the reverse of peer-pressure is true, when the majority of peers do not smoke and ostracize those who do.

Parental smoking

Children of smoking parents are more likely to smoke than children with non-smoking parents. One study found that parental smoking cessation was associated with less adolescent smoking, except when the other parent currently smoked. A current study tested the relation of adolescent smoking to rules regulating where adults are allowed to smoke in the home. Results showed that restrictive home smoking policies were associated with lower likelihood of trying smoking for both middle and high school students.

Smoking in movies and television

Exposure to smoking in movies has been linked with adolescent smoking initiation in cross-sectional studies. Hollywood movies tend to have a high incidence of smoking behavior. According to a study of movies created between 1988 and 1997, eighty-seven percent of these movies portrayed various tobacco use, with an average of 5 occurrences per film. R-rated movies had the greatest number of occurrences and were most likely to feature major characters using tobacco. Despite the declining tobacco use in the society, the incidence of smoking in 2002 movies was nearly the same as in 1950 movies.

There have been moves to reduce the depiction of protagonists smoking in television shows, especially those aimed at children. For example, Ted Turner took steps to remove or edit scenes that depict characters smoking in cartoons such as Tom and Jerry, The Flintstones and Scooby-Doo, which are shown on his Cartoon Network and Boomerang television channels.

The use of smoking to project an image

Famous smokers of the past used cigarettes or pipes as part of their image, such as Jean Paul Sartre's Gauloise-brand cigarettes, Joseph Stalin's, Douglas MacArthur's or Bertrand Russell's pipes, or the news broadcaster Edward R. Murrow's cigarette. Writers in particular seemed to be known for smoking; see, for example, Cornell Professor Richard Klein's book Cigarettes are Sublime for the analysis, by this professor of French literature, of the role smoking plays in 19th and 20th century letters. The popular author Kurt Vonnegut addresses his addiction to cigarettes within his novels. British Prime Minister Harold Wilson was well known for smoking a pipe in public as was Winston Churchill for his cigars. Sherlock Holmes, the fictional detective created by Sir Arthur Conan Doyle smoked a pipe, cigarettes, and cigars, besides injecting himself with cocaine, "to keep his overactive brain occupied during the dull London days, when nothing happened". The DC Vertigo comic book character, John Constantine, created by Alan Moore, is synonymous with smoking, so much so that the first storyline by Preacher creator, Garth Ennis, centred around John Constantine contracting lung cancer. Professional wrestler James Fullington, while in character as "The Sandman", is a chronic smoker in order to appear "tough".

Genetic correlation

Smoking may have a genetic predisposing factor; one 1990 study posited that 52% of the variance in smoking behaviour is attributable to heritable factors, and another in 1962 on identical twins found that only 21% of participant pairs were discordant (one smoking, one non-smoking), also suggesting a genetic basis or at least a genetic susceptibility or predisposition. This, however, does not demonstrate the genetic susceptibility to smoke, as there may be confounding factors e.g. stronger correlation between personality and smoking would suggest the genetic predisposition is instead towards personality. In addition, most twin studies utilize a small sample size of separated twins--the result is a sample population of twins who lived in the same environment, considerably over estimating the genetic connection. To date, there is no conclusive evidence.

Opinions of society on smoking

Native Americans and smoking

Communal smoking of a sacred tobacco pipe is a common ritual of many Native American tribes, and was considered a sacred part of their religion. Sema, the Anishinaabe word for tobacco, was grown for ceremonial use and considered the ultimate sacred plant since its smoke was believed to carry prayers to the heavens. Smoking was chiefly done after the evening meal, in the sweathouse, and before going to sleep. The tobacco used during these rituals varies widely in potency — the Nicotiana rustica species used in South America, for instance, has up to twice the nicotine content of the common North American N. tabacum. Many Native American tribes operate tobacco stores, including on the Internet, where they are usually exempt from taxes and therefore can sell products cheaper than non-Native American dealers.

Christianity and smoking (arguments against)

In more modern times, even before the health risks of smoking were identified through controlled study, smoking was considered an immoral habit by certain Christian preachers and social reformers. Tobacco was listed, along with drunkenness, gambling, cards, dancing and theatre-going, in J.M. Judy's Questionable Amusements and Worthy Substitutes, a book featuring anti-smoking dialogue which was published in 1904 by the Western Methodist Book Concern of Chicago.

Moral concerns about self-injury are also prevalent in Catholic medical ethics on the grounds that people ought to be responsible stewards of the body as a gift from God; the stewardship argument is also used among Protestant groups as an argument against smoking. However, smoking is seldom considered a sin in Catholicism and many lay, vowed, and ordained faithful smoke. Other Christian denominations, such as the Church of Jesus Christ of Latter-day Saints, doctrinally eschew the use of tobacco to the degree that it does affect one's standing in the faith.

Islam and smoking (arguments against)

“Don't throw yourself into danger by your own hands...” (el-Bakara 2/195)

“You may eat, drink, but not waste” (el-A‘râf 7/31)

In Islam's holy book, the Qur'ān, there's not an exact word against smoking, but some verses contain clues as above. The three main opinions about smoking in Islamic Countries are:

• There is not an exact prohibition word in Qur'ān; so smoking is not forbidden by religion.
• There is not an exact prohibition word in Qur'ān; but it shows that it is a bad habit, coming close to being forbidden.
• The Qur'ān doesn't mention the word "smoking" at all. However it does cover the subject in other indirect ways. There are several verses in Qur'ān that indirectly shows that smoking is forbidden in Islam religion.

Mormonism and smoking (arguments against)

The founder of the Latter Day Saint movement, Joseph Smith, Jr, recorded that on February 27, 1833, he received a revelation which addressed tobacco use. It is commonly known as the Word of Wisdom, and is found in section 89 of the Doctrine and Covenants, a book canonized as scripture by Mormons. (Section 89)

While initially viewed as a guideline, this was eventually accepted as a commandment; consequently, faithful Mormons do not smoke.

Judaism and smoking (arguments against)

File:Chofetzchaim1.jpg

The Jewish leader Rabbi Yisrael Meir Kagan, an anti-smoking advocate.

Main article: Jewish law and history on smoking

The Jewish Rabbi Yisrael Meir Kagan (1838–1933) was one of the first Jewish authorities to speak out on smoking. He considered it a health risk and a waste of time, and had little patience for those who claimed addiction, stating that they never should have started smoking in the first place (Likutei Amarim 13, Zechor le-Miriam 23).

A shift toward health-oriented concerns may be observed in some people's interpretations of Jewish law (halakha). For instance, when the link between smoking and health was still doubted, Rabbi Moshe Feinstein's response stated that smoking was permitted, although still inadvisable..

More recently, rabbinic responsa tend to argue that smoking is prohibited as self-endangerment under Jewish law and that smoking in indoor spaces should be restricted as a type of damage to others.

The verse for this prohibition is a general verse stating that one should watch their health - "ונשמרתם מאד, לנפשתיכם" [Vi'nish'martem Me'od Li'naf'sho'tey'chem] Deut. 04:15 "And you shall watch yourselves very well..."

Smoking cessation

Main article: Smoking cessation

File:Easywaytostopsmoking.jpg

The Easy Way to Stop Smoking by Allen Carr, a famous book teaching smoking cessation

Many of tobacco's health effects can be minimised through smoking cessation. The British doctors study showed that those who stopped smoking before they reached 30 years of age lived almost as long as those who never smoked. It is also possible to reduce the risks by reducing the frequency of smoking and by proper diet and exercise. Some research has indicated that some of the damage caused by smoking tobacco can be moderated with the use of antioxidants.

Smokers wanting to quit or to temporarily abstain from smoking can use a variety of nicotine-containing tobacco substitutes, or nicotine replacement therapy (NRT) products to temporarily lessen the physical withdrawal symptoms, the most popular being nicotine gum and lozenges. Nicotine patches are also used for smoking cessation. Medications that do not contain nicotine can also be used, such as bupropion (Zyban or Wellbutrin) and varenicline (Chantix).

Peer support can be helpful, such as that provided by support groups and telephone quitlines. (eg., 1-800-QuitNow in the US, 0800 169 0169 in the UK, and 131 848 in Australia). In addition, there are many self-help books on the market, such as The Stop Smoking Secret by Mark Jordan, and books by Allen Carr and David Marks.

Legal issues and regulation

On February 28 2005, an international treaty, the WHO Framework Convention on Tobacco Control, took effect. The FCTC is the world's first public health treaty. Countries that sign on as parties agree to a set of common goals, minimum standards for tobacco control policy, and to cooperate in dealing with cross-border challenges such as cigarette smuggling. Currently the WHO declares that 4 billion people will be covered by the treaty, which includes 168 signatories. Among other steps, signatories are to put together legislation that will eliminate secondhand smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.

Sale to minors

In many countries, including the United States, most European Union member states, New Zealand, Canada, South Africa, Israel, India, Brazil, Mexico and Australia, it is illegal to sell tobacco products to minors and in the United Kingdom, The Netherlands, Austria, Denmark, Germany, and South Africa it is illegal to sell tobacco products to people under the age of 16. In 46 of the 50 United States, the minimum age is 18, except for Alabama, Alaska, New Jersey, and Utah where the legal age is 19 (also in the Suffolk and Nassau Counties of Long Island, New York). Some countries have also legislated against giving tobacco products to (i.e. buying for) minors, and even against minors engaging in the act of smoking. Underlying such laws is the belief that people should make an informed decision regarding the risks of tobacco use. These laws have a lax enforcement in some nations and states. In other regions, cigarettes are stil sold to minors because the fines for the violation are lower or comparable to the profit made from the sales to minors. However in China, Turkey, and many other countries usually a child will have little problem buying tobacco products, because they are often told to go to the store to buy tobacco for their parents. It is also against the law (in 45 states) for people under the age of 18 to posses any form of Tobacco.

Taxation

File:Cigs high prices.jpg

Cigarettes have become very expensive in places that want to reduce the amount of smoking in public; pictured is the cost of a carton of (200) cigarettes in New Jersey

Many governments have introduced excise taxes on cigarettes in order to reduce the consumption of cigarettes. Money collected from the cigarette taxes are frequently used to pay for tobacco use prevention programs, therefore making it a method of internalizing external costs.

In 2002, the Centers for Disease Control and Prevention said that each pack of cigarettes sold in the United States costs the nation more than $7 in medical care and lost productivity. Another study by a team of health economists finds the combined price paid by their families and society is about $41 per pack of cigarettes.

Substantial scientific evidence shows that higher cigarette prices result in lower overall cigarette consumption. Most studies indicate that a 10% increase in price will reduce overall cigarette consumption by 3% to 5%. Youth, minorities, and low-income smokers are two to three times more likely to quit or smoke less than other smokers in response to price increases.

Many nations have implemented some form of tobacco taxation. As of 1997, Denmark had the highest cigarette tax burden of $4.02 per pack. Taiwan only had a tax burden of $0.62 per pack. Currently, the average price and excise tax on cigarettes in the United States is well below those in many other industrialized nations.

The cigarette taxes vary from state to state in the United States. For example, South Carolina has a cigarette tax of only 7 cents per pack, while Rhode Island has a cigarette tax of $2.46 per pack. In Alabama, Illinois, Missouri, New York City, Tennessee, and Virginia, counties and cities may impose an additional limited tax on a price of cigarettes.

Due to the high taxation, the price of an average pack of cigarettes in New Jersey is $6.35, which is still less than the approximated external cost of a pack of cigarettes.

The average price in New York City has exceeded $7 per pack.

In South Africa, cigarettes are considerably cheaper than in industrialized countries. An average pack (consisting of 20) costs R20 or US$3.50.

In Australia, which has a very high rate of tobacco taxation, the average price of a standard pack (25) is AUD$11.50.

In the United Kingdom, a packet of cigarettes typically costs between £4 and £5.50 depending on the brand purchased and where the purchase was made. The UK has a strong black market for cigarettes which has formed as a result of the high taxation, and it is estimated that one third of all cigarettes smoked in the country avoid UK taxes.

Some nations are reluctant to increase tobacco taxes because they fear the reduction of tobacco tax revenues and increase in smuggling. (thus reducing the small amount of money they take in and increasing difficulties in funding anti-smoking campaigns).

Restrictions on cigarette advertising

Several Western countries have also put restrictions on cigarette advertising. In the United States, all television advertising of tobacco products has been prohibited since 1971. In Australia, the Tobacco Advertising Prohibition Act 1992 prohibits tobacco advertising in any form, with a very small number of exceptions (some international sporting events are excepted, but these exceptions were revoked in 2006). Other countries have legislated particularly against advertising that appears to target minors .

Package warnings

Main article: Tobacco packaging warning messages

Some countries also impose legal requirements on the packaging of tobacco products. For example in the countries of the European Union, Turkey, Australia and South Africa, cigarette packs must be prominently labelled with the health risks associated with smoking. Canada, Australia, Iceland and Brazil have also imposed labels upon cigarette packs warning smokers of the effects, and they include graphic images of the potential health effects of smoking. Cards are also inserted into cigarette packs in Canada. There are sixteen of them, and only one comes in a pack. They explain different methods of quitting smoking. Also, in the United Kingdom, there have been a number of graphic NHS advertisements, one showing a cigarette filled with fatty deposits, as if the cigarette is symbolising the artery of a smoker.

Currently in Australia, almost 70% of the cigarette packet (Including 1/3 of the front, the whole back and both sides) are covered in either graphic imagery or health factoids. These warnings depict images of the effects of smoking (gangrene, children in hospital from passive smoking and browned teeth), name/number of chemicals and annual death rates. Television ads accompany them, involving a doctor amputating a foot and smokers struggling to breathe in hospital. Since then, the number of smokers has been reduced by one quarter. Singapore similarly requires cigarette manufacturers to print images of mouths, feet and blood vessels adversely affected by smoking.

France has the additional requirement of listing on the side of all packaging the percentages of tobacco present, compared to the weight of the paper and additives present. For one U.S. manufacturer of cigarettes sold in France, the side list indicates only 85.0% is tobacco, 9.0% are the additives, and paper constitutes another 6.0% of the total weight of a cigarette. Filters are not part of the formula. The additives are a syrup sprayed on the chopped tobacco leaf as it rolls down the conveyer belt and is a combination of the 599 additive ingredients as submitted to Member of Congress Henry Waxman in a 50 page list by the five major U.S. tobacco companies during his Congressional Hearings on April 14, 1994.

Smoking bans

Main article: Smoking ban

Some jurisdictions impose restrictions on where smoking is allowed. Several European countries such as the Republic of Ireland, Estonia, Finland, Norway, Sweden, Italy, Lithuania, Spain, Iceland and the United Kingdom have legislated against smoking in public places, often including bars and restaurants. Restaurateurs have been obligated to build designated smoking areas (or to prohibit smoking). A similar ban is coming into effect in France from the 1st of January 2008. In the United States, many states prohibit smoking in restaurants, and some also prohibit smoking in bars. In Canada smoking is illegal in bars and restaurants in certain provinces. In Australia, smoking bans vary from state to state. Currently, Queensland has the strictest laws, with total bans within all public interiors (including workplaces, bars, pubs and eateries) as well as patrolled beaches and some outdoor public areas. There are, however, exceptions for designated smoking areas. In the state of Victoria, smoking is banned in train stations, bus stops and tram stops as these are public locations where second hand smoke can affect non-smokers waiting for public transport. In New Zealand and Brazil, smoking is banned in enclosed public places mainly bars, restaurants and pubs. Hong Kong banned smoking on the 1st of January 2007 in the workplace, public spaces such as restaurants, karaoke rooms, buildings, and public parks. Bars serving alcohol who do not admit under 18's have been exempted till 2009. In Romania smoking is illegal in trains, metro stations, public institutions (except where designated, usually outside) and public transportation.

See the List of smoking bans article for a full list of restrictions in various areas around the world and List of smoking bans in the United States for the United States.

See also

• Other forms of tobacco use:
  • Bidi
  • Chewing tobacco
  • Dipping tobacco
  • Kretek
  • Smoking pipe
  • Snuff
  • Snus
• Other forms of smoking:
  • Cannabis
  • Hashish
  • Cocaine
• Cigarette packet warning signs
• Chemical dependence
• List of iconic smokers
• Pack year
• Smoking ban
• Smoking cessation
• Smoking culture
• Smoking fetish

References

• Boffetta, P., Agudo, A., Ahrens, W., Benhamou, E., Benhamou, S., Darby, S.C., Ferro, G., Fortes, C., Gonzalez, C.A., Jockel, K.H., Krauss, M., Kreienbrock, L., Kreuzer, M., Mendes, A., Merletti, F., Nyberg, F., Pershagen, G., Pohlabeln, H., Riboli, E., Schmid, G., Simonato, L., Tredaniel, J., Whitley, E., Wichmann, H.E., Saracci, R. 1998. Multicenter case-control study of exposure to environmental tobacco smoke and lung cancer in Europe. J. Natl. Cancer Inst. 90:1440–1450.
• Borio, G., 2006. The Tobacco Timeline. Tobacco.org.
• Centers for Disease Control and Prevention (CDC). 2004. History of the 1964 Surgeon General's Report on Smoking and Health. [5]
• James I of England. 1604. A Counterblaste to Tobacco.
• Joint Committee on Smoking and Health. Smoking and health: physician responsibility; a statement of the Joint Committee on Smoking and Health. Chest 1995; 198:201–208
• Osvaldo P. Almeida, Gary K. Hulse, David Lawrence and Leon Flicker, "Smoking as a risk factor for Alzheimer's disease: contrasting evidence from a systematic review of case-control and cohort studies," Addiction, Volume 97, Issue 1, Page 15 - January 2002.
• Smoking cessation methods compared Smoking cessation methods compared. Smokingrelief.co.uk.
• 98. BBC news (2007) Scots 'back smoke ban exemptions'. http://news.bbc.co.uk/1/hi/scotland/6464521.stm

Further reading

• Allan M. Brandt: The Cigarette Century; The Rise and Deadly Persistence of the Product that Defined America, Basic Books, N.Y. (2007), ISBN 0-465-07047-7
• Iain Gately: La Diva Nicotina. The Story of How Tobacco Seduced the World (2001) (ISBN 0-7432-0812-9).
• David Krough: Smoking: The Artificial Passion (Freeman, 1992) (ISBN 0-7167-2347-6).
• G Invernizzi et al., Particulate matter from tobacco versus diesel car exhaust: an educational perspective. Tobacco Control 13, S.219-221 (2004)
• Ian Tyrrell;Deadly Enemies: Tobacco and Its Opponents in Australia (1999)
• John C. Burnham, Bad Habits: Drinking, Smoking, Taking Drugs, Gambling, Sexual Misbehavior, and Swearing in American History, New York University Press, 1993
• Michael Givel and Stanton Glantz (Summer 2001) “Tobacco Lobby Political Influence on U.S. State Legislatures in the 1990s.” Tobacco Control (10) pp. 124-134.
• Jordan Goodman, Tobacco in History: The Cultures of Dependence, Routledge, London, 1993
• Richard Kluger, Ashes to Ashes, 1996, on smoking in U.S.
• Robin Walker, Under Fire: A History of Tobacco Smoking in Australia, Penguin, Ringwood, 1984.
• David Harley, "'The Beginnings of the Tobacco Controversy: Puritanism, James I, and the Royal Physicians'", Bulletin of the History of Medicine, vol. 67, Spring 1993, pp. 28–50
• Hendricks, P.S., et al. (2006). The early time course of smoking withdrawal effects. Psychopharmacology, 187, 385–396.
• Ness, R., Grisso, J., Hirschinger, N., Markovic, N., Shaw, L., Day, N., and Kline, J. (1999). Cocaine and Tobacco Use and the Risk of Spontaneous Abortion. New England J. Med. 340:333–339; Oncken, C., Kranzler, H., O'Malley, P., Gendreau, P., Campbell, W. A. (2002). The Effect of Cigarette Smoking on Fetal Heart Rate Characteristics. Obstet Gynecol 99: 751–755.
• Venners, S.A., X. Wang, C. Chen, L. Wang, D. Chen, W. Guang, A. Huang, L. Ryan, J. O'Connor, B. Lasley, J. Overstreet, A. Wilcox, and X. Xu. (2004). Paternal Smoking and Pregnancy Loss: A Prospective Study Using a Biomarker of Pregnancy Am J Epidemiol 159: 993–1001.
• "Blackwell Synergy - Cookie Absent (See above)". Retrieved 2005-12-18.
• "Health : Young smokers' heart attack risk". BBC. Retrieved 2005-12-18.

External links

• The Social History of Smoking, by G. L. Apperson, 1914, from Project Gutenberg
• The Tobacco Timeline at tobacco.org
• Legacy Tobacco Documents Library at University of California San Francisco
• UCSF Tobacco Industry Videos Collection
• UCSF Tobacco Industry Audio Recordings Collection