The modern cigarette is not designed to be recreational, social or even ceremonial. It has evolved into what it is today: a vehicle for addiction, disease and death.
As of 2015, the number of people dying daily from cigarettes in the U.S is around 1500 (1, 2). This is about 15 times greater than the number lost in motor vehicle accidents each day. Most of these deaths are from cancer, coronary heart disease or respiratory disease (3).
This tobacco epidemic is not unleashed by nature. It is funded by the very profitable tobacco industry. In 2013, profits of the top six tobacco companies equaled the combined profits of The Coca-Cola Company, Walt Disney, General Mills, FedEx, AT&T, Google, McDonald's and Starbucks (4).
Nearly 5 percent of the nation's health care budget ($130 billion) is spent taking care of diseases caused by smoking. The overall cost of smoking, including lost productivity, is estimated at between $289 billion and $333 billion (2).
The personal costs of smoking fall more heavily on those who can least afford them. For example, smokers with mental illness smoke more cigarettes (5), and suffer greater medical and financial consequences. Smokers on Social Security disability spend "one-quarter to one-third of their income on cigarettes each month" (6).
Quitting smoking, in contrast, brings significant improvements in mental health for all smokers, with and without diagnosed psychiatric illnesses. A recent review of 26 studies (7) found that quitting smoking "is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke."
Since quitting brings enormous potential benefits to body, mind and bankbook, what explains the persistence of cigarette smoking?
Despite the romance and mythology that has surrounded tobacco over the past few centuries, cigarettes are not a product of nature. The original Native American tobacco plants were not the high-nicotine, "Franken-tobacco" plants bred by today's cigarette makers. Enticing smokers with smoother and more inhalable cigarettes, tobacco companies have made a variety of "innovations" in "smokability" over the past few decades (8). Today's cigarettes are highly efficient at delivering nicotine to the lungs and brain. This makes it easier to become addicted and more difficult to quit (9, 10).
Cigarettes are, in fact, very successful at addicting most people, whether mildly, moderately, or heavily. They are addictive for most people when used under normal conditions.
Smokers' level of addiction is the strongest predictor of whether or not they will quit (11). The stronger the addiction, the harder it is to quit. Demoralization and lack of confidence in a successful outcome are additional barriers to quitting (12, 13).
Science has revealed new insights into addiction, which provide a more complex view of this condition. Brain images featured on the National Institute on Drug Abuse (NIDA) website (14, 15, 16) show impairment and physical damage in areas important to judgment, decision-making, learning, memory, and behavioral control in many types of addiction. When it comes to tobacco, all major scientific and health authorities in the U.S. today recognize nicotine as an addictive drug producing strong dependence and powerful changes in the brain.
Addiction perpetuates itself psychologically as well as biologically. Smokers' confidence in their ability to exert behavioral control over cigarette use breaks down over time. This makes it harder to exercise the freedom of choice and autonomy that most people prize. In this way, addiction acts as a dehumanizing force.
According to a recent Gallup Poll (July 8-12, 2015) 19 percent of a national random sample of U.S. adults said they smoked a cigarette in the past week. 58 percent of smokers in the sample said they would like to give up smoking. 91 percent of smokers said if they had to do it over again they would not have started. And 24 percent of a sample of smokers and non-smokers agreed that smoking should be made totally illegal in this country -- the highest level ever reported. Finally, 58 percent of this sample of smokers and non-smokers said smoking in all public places should be outlawed (17).
The Supreme Court of Florida (December 21, 2006), in the Engle v. Liggett Group legal proceeding, found that cigarettes were "defective and unreasonably dangerous." Selling a cigarette has been compared to selling a car with no or faulty brakes (8, 16).
Smoking addiction is a contagious disease spread by tobacco companies through high-nicotine cigarettes. Evidence suggests that lowering nicotine levels is an important way to give smokers a better chance to escape the trap set for them by addiction (18, 19). The FDA has the authority to regulate and reduce nicotine levels in cigarettes, and they are currently reviewing how to exercise this authority. Although many people, especially when young, choose to experiment with addictive drugs, no one chooses addiction. Selling high-nicotine cigarettes should be illegal.
Dr. Daniel Seidman, a clinical psychologist, is director of smoking cessation services at Columbia University Medical Center. He is author of the book Smoke-Free in 30 Days and of the "Up in Smoke" app from Mental Workout for iPhone, iPad, Android, Mac, and PC. www.Danielfseidman.com.
References:
(1) Brian D. Carter, Christian C. Abnet, Diane Feskanich, Neal D. Freedman, Patricia Hartge, Cora E. Lewis, Judith K. Ockene, Ross L. Prentice, Frank E. Speizer, Michael J. Thun, and Eric J. Jacobs. Smoking and Mortality -- Beyond Established Causes. The New England Journal of Medicine372;7. February 12, 2015
(2) U.S. Department of Health and Human Services. The Health Consequences of Smoking--50 Yearsof 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.
(3) http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/
(7) Taylor, GT, McNeil A, Girling, A., Farley A, Lindson-Hawley N, Aveyard, P (2014). Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ, 348:g115 doi: 10.1136/bmj.g1151
(8) Robert N. Proctor (2012) Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition. University of California Press.
(9) New York Times Editorial: "Even More Addictive Cigarettes" January 23, 2014.
http://www.nytimes.com/2014/01/24/opinion/even-more-addictive-cigarettes.html?_r=0
(10) Daniel F. Seidman. Today's Smokers Are Having a Harder Time Quitting -- What Changed? Huffington Post. June, 2, 2015.
http://www.huffingtonpost.com/daniel-seidman/todays-smokers-are-having_b_7471194.html
(11) Vangeli, E., Stapleton, J., Smit, ES., Borland, R.,West, R. (2011) Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review. Addiction, 106, 2110- 2121
(12) Timea R. Partos , Ron Borland, Hua-Hie Yong, Andrew Hyland, K. Michael Cummings (2013). The Quitting rollercoaster: How recent Quitting History affects Future Cessation Outcomes (Data From the international tobacco Control 4-Country Cohort study). Nicotine & Tobacco Research, volume 15, number 9, 1578-1587.
(13) Hendricks, P.S., Delucchi, K.L., & Hall, S.M. (2010). Mechanisms of change in extended cognitive behavioral treatment for tobacco dependence. Drug and Alcohol Dependence, 109, 114-119.
(14) Fowler JS, Volkow ND, Kassed CA, Chang L. Imaging the addicted human brain. Sci Pract Perspect 3(2):4-16, 2007.
(15) http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction
(16) Nora Volkow. Why Do Our Brains Get Addicted. TedMed 2014. http://www.tedmed.com/talks/show?id=309096
(17) http://www.gallup.com/poll/184397/ban-smoking-public-retains-majority-support.aspx
(18) Michael Fiore and Timothy Baker. Reduced-Nicotine Cigarettes -- A Promising Regulatory Pathway. n engl j med 373;14 nejm.org october 1, 2015
(19) Eric C. Donny, Rachel L. Denlinger, Jennifer W. Tidey, Joseph S. Koopmeiners, Neal L. Benowitz, Ryan G. Vandrey, Mustafa al'Absi, Steven G. Carmella, Paul M. Cinciripini, Sarah S. Dermody, David J. Drobes, Stephen S. Hecht, Joni Jensen, Tonya Lane, Chap T. Le,F. Joseph McClernon, Ivan D. Montoya, Sharon E. Murphy, Jason D. Robinson, Maxine L. Stitzer, Andrew A. Strasser, Hilary Tindle, and Dorothy K. Hatsukami. Randomized Trial of Reduced-Nicotine Standards for Cigarettes. n engl j med 373;14 nejm.org October 1, 2015