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INTRODUCTION

Cigarette smoking is the leading preventable cause of death in the United States, responsible for an estimated 480,000 deaths per year, or one in every five deaths. Physicians care for the health consequences of their patients’ tobacco use, and it is equally important for them to prevent smoking-related disease. There is no safe level of tobacco use. Smoking as few as one cigarette per day increases the risk of myocardial infarction and stroke. Smoking cessation extends life and treating tobacco use is one of the most cost-effective preventive actions available to clinicians.

The prevalence of cigarette smoking in the United States rose rapidly in the first half of the twentieth century and peaked in 1965, when 40% of adult Americans smoked cigarettes. Since then, smoking prevalence has decreased to 15.5% of adults in 2016. This dramatic decline reflects growing public awareness of the health risks of tobacco and decades of public health efforts to discourage tobacco use. More recently, smoking prevalence has stabilized but the pattern of tobacco use has changed. Nearly a quarter of current smokers do not smoke every day, and the average smoker smokes only 14 cigarettes daily. In addition, an increasing number of cigarette smokers also use other tobacco products such as smokeless tobacco, small cigars, or even newer alternative tobacco products.

Over the past decade, newer products that aim to reduce a smoker’s exposure to the toxins in cigarette smoke have appeared. These so-called alternative tobacco products are expected to reduce the health risks of cigarette smoking because most of the risk is attributable to inhaling the toxins other than nicotine. Electronic cigarettes (e-cigarettes) are the most widespread of the alternative tobacco products. Despite their name, electronic cigarettes (e-cigarettes) are fundamentally different from conventional cigarettes that burn tobacco to generate smoke. E-cigarettes are battery-powered nicotine-delivery devices that heat a solution usually containing nicotine, solvents, and flavors, to create an aerosol that users inhale. E-cigarettes reduce exposure to the many other toxins in cigarette smoke and are therefore likely to have less health risk than smoking cigarettes, but the long-term health effects of e-cigarette use remain unknown.

Cigarette smoking starts during childhood and adolescence. Nearly 90% of smokers begin to smoke before the age of 18 years and 98% start by the age of 26 years. The behavior is sustained due to the addictiveness of nicotine and as a deeply ingrained habitual response to multiple cues. Eventually, most smokes seek to stop smoking, but often struggle to sustain abstinence long term, giving smoking the characteristics of a chronic disease, but one for which sustained remission is possible. In the United States, smoking is concentrated among individuals with lower socioeconomic status, comorbid psychiatric disorders, and other substance use disorders.

HEALTH CONSEQUENCES OF TOBACCO USE

Cigarette smoking increases overall mortality and morbidity rates and is a cause of cardiovascular disease (including myocardial infarction and ...

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