Smoking has been practiced by humans since at least 5000 BCE as part of offerings to divine beings or as a cleansing ritual. Most of these early forms of smoking used herbs, incense, or hallucinogens. Tobacco smoking appears to have started among the Maya and Aztecs of Mexico and Central America, first as a practice used by the priests to make contact with the spirit world, and later as a recreational activity among the Aztec nobles. By the time the Spanish conquistadors arrived in the 1520s, recreational smoking was widespread among wealthy Aztecs. Smoking quickly spread around the world in the sixteenth and seventeenth centuries, as European traders brought tobacco from the Americas to China and Ottoman Turkey as well as to Europe itself. Nicotine, the addictive chemical in tobacco, takes its name from Jean Nicot (1530–1600), a French diplomat who introduced tobacco to the French court. One of the historical ironies of tobacco use is that smoking was originally thought to be beneficial to health. Some European doctors claimed that smoking could sober up alcoholics and cure sexually transmitted diseases like syphilis. Although Benjamin Rush (1745–1813), a signer of theDeclaration of Independence, as well as a physician, argued that tobacco smoke is harmful to health as early as 1798, it was not until 1948 that a British researcher named Richard Doll (1912–2005) published proof that smoking increases the risk of lung cancer and heart disease.
In spite of antismoking campaigns since the 1970s, smoking remains a difficult habit to break. One reason is the addictive nature of nicotine itself; it is considered even more addictive than cocaine. When inhaled in tobacco smoke, nicotine reaches the brain within seconds. It stimulates the release of dopamine, a brain chemical that causes most people to feel good. Nicotine is also a stimulant—a drug that makes people feel more alert and awake. Thus people smoke in order to relieve stress, to wake up in the morning, to stay alert when tired, or as part of social get-togethers. The habits that build up around tobacco use are another reason why people find it hard to quit smoking.
Smoking is harmful to health partly because of nicotine itself and partly because of the other chemicals contained in tobacco smoke along with nicotine. Nicotine increases a person’s risk of heart disease because it raises blood pressure and speeds up the heart rate. It doubles a person’s risk of stroke. Because the tobacco in a cigarette or cigar does not burn completely, the smoke contains carbon monoxide. It also contains arsenic, cyanide, and at least sixty chemicals known to cause cancer. In addition to causing 90 percent of deaths from lung cancer, smoking also causes cancers of the bladder, oral cavity, pharynx, larynx (voice box), esophagus, cervix, kidney, lung, pancreas, and stomach. Women who smoke have an increased risk of giving birth prematurely or having the baby die before birth. They are also at increased risk of osteoporosis after menopause.
Cigarette smoking is considered the leading cause of preventable illness and premature death worldwide. As of 2008, it is estimated that about 1.1 billion people around the world are smokers, more of them in the developing countries than in the West. The rates of smoking are increasing rapidly in China and India but decreasing in the United States. As of 2008, about 28 percent of American males and 24 percent of females smoke, down from 52 percent of males and 34 percent of females in 1965.
Cigarette smoking costs the United States about $195 billion in health care costs each year, or an average of $4,300 per adult smoker. About 438,000 Americans die each year from smoking-related diseases. More deaths are caused each year by tobacco use than by all deaths from AIDS, illegal drug use, alcoholism, motor vehicle injuries, suicides, and murders combined. In addition to the death toll, about 8.6 million people in the United States as of 2008 had at least one serious illness caused by smoking.
Risk factors for becoming a smoker include:
• Low levels of education. Forty percent of men who did not complete high school smoke, compared to 17 percent of college graduates.
• Low income.
• Race. Forty percent of African American men and 30 percent of Hispanics smoke compared to 27 percent of Caucasian men.
• Age at which a person starts smoking. People who begin to smoke before age eighteen are far more likely to be heavy smokers as adults than those who started after age twenty-one. As of 2008, the average age of first-time smokers had dropped to 14.5 years.
• Having parents who smoke. Teens with parents who smoke are twice as likely to start smoking.
• Depression. Depression is a common symptom of nicotine withdrawal. People who have become depressed may start smoking in order to soothe their feelings and then find themselves unable to quit.
• Genetic factors. Recent research indicates that some people have a gene that influences the production of an enzyme that clears nicotine from the bloodstream fairly rapidly. These people tend to smoke more heavily and find it harder to quit.
Nursing Care Plan Signs and SymptomsPeople start smoking as a result of a combination of social and individual psychological factors. They then become dependent on smoking because of the addictive qualities of nicotine and possible genetic factors that increase their dependency on nicotine.
The symptoms of nicotine dependence include:
• Inability to quit smoking in spite of one or more serious attempts.
• Craving for a cigarette at certain times of day or in specific situations.
• Continuing to smoke in spite of lung disease, heart disease, or other smoking-related health problems.
• Withdrawal symptoms when trying to quit smoking. These may include anxiety, depression, headache, drowsiness, difficulty concentrating, diarrhea, irritability, insomnia, and weight gain.
Nursing Care Plan DiagnosisMost visits to doctors about smoking are usually to ask for help with quitting rather than diagnosing that a person smokes, though nicotine withdrawal can be diagnosed on the basis of the patient’s smoking history and the presence of withdrawal symptoms. Doctors and dentists are, however, in a good position to give their patients the facts about the harmful effects of smoking and offer encouragement and advice about quitting.
Nursing Care Plan TreatmentTreatment of smoking is called smoking cessation. The goal is to help the smoker quit smoking permanently. There are a number of different approaches to smoking cessation:
• Quitting cold turkey. This term refers to stopping without medications or other helps and relying on will power alone. About 90 percent of smokers try to stop cold turkey on their first attempt; however, only about 10 percent are able to stop for as long as six months this way.
• Counseling and psychotherapy. This approach attempts to help smokers understand their reasons for smoking and identify situations or other triggers that increase the urge to smoke. It helps about 25 percent of smokers stay smoke-free for six months.
• Antismoking medications. These include nicotine replacement gums, patches, and inhalers that work to reduce cravings for tobacco by supplying the body with nicotine in other forms. A newer drug called Chantix works by occupying the nicotine receptors in the brain even though it is not nicotine itself. Chantix reduces withdrawal symptoms and the satisfaction people get from smoking. Doctors usually suggest that smokers combine these medications with support group meetings, smoking cessation programs, or ongoing guidance from a health professional rather than relying on the drugs alone.
• Antidepressants. A drug called Zyban is sometimes prescribed to help smokers quit. It helps some people stop smoking by increasing the level of dopamine in the brain.
• Group therapy and support groups. Many smokers find support group meetings helpful in dealing with the social triggers of cigarette smoking.
• Complementary and alternative treatments. Some smokers report that hypnosis, acupuncture, and massage therapy are useful in helping to quit.
Quitting smoking is very difficult; it is much better never to start in the first place. According to the Surgeon General, only about 30 percent of attempts to quit last longer than six months. The average person who does succeed in quitting takes between seven and fifteen attempts to do so. The benefits of quitting at any age, however, make the effort worthwhile. A person who quits smoking before age thirty-five will avoid 90 percent of the health risks associated with smoking. A person who succeeds in quitting between the ages of thirty-five and fifty cuts his or her risk of dying before age sixty-five in half compared to people who continue smoking. Even someone who quits at age sixty-five will increase his or her lifespan by an average of three years.
Nursing Care Plan PreventionMany programs to prevent smoking in the United States are aimed at teenager, on the grounds that more than 90 percent of first-time tobacco use occurs before high school graduation, and about 40 percent of teenagers who smoke become addicted to nicotine. Among the specific measures to lower the rate of smoking among young people are:
• Imposing legal penalties for food stores or supermarkets that sell tobacco products to anyone under 18.
• Education programs in schools, patient handouts in doctors’ and dentists’ offices, and personal counseling by health care professionals about the dangers of smoking.
• Limiting or forbidding smoking in restaurants, offices, stores, and other public places.
• Limiting the advertising of cigarettes and other tobacco products.
• Taxing tobacco products heavily.
As of 2008 there were several nicotine vaccines undergoing clinical trials as aids to smoking cessation. One is called NicVAX and is thought to work by stimulating the body to produce antibodies against nicotine. The antibodies block nicotine from reaching the brain, thus interfering with the pleasurable effects of smoking. Other nicotine vaccines being studied include one called TA-NIC and another called Nicotine-Qbeta. Both of these work like NicVAX in producing antibodies against nicotine.