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  • Review the epidemiology of patients who smoke tobacco.

  • Describe other types of tobacco used by vulnerable populations.

  • Describe the health consequences of tobacco use and its impact on the health-care system.

  • Describe the challenges that tobacco use poses to patients, clinicians, and communities.

  • Identify strategies to treat tobacco dependence including clinical, policy-level, and systems-level interventions.

Clarence Jones is a 44-year-old man brought to the ­emergency room via ambulance in respiratory distress. He has had five admissions within the past year for chronic obstructive pulmonary disease (COPD) exacerbations and has been intubated during each admission. He has been smoking since he was 8 years old and smokes up to two packs a day.


Cigarette smoking is the leading cause of preventable, premature morbidity and mortality in the United States and in many countries around the world. Smokers, on average, die 10 years earlier than nonsmokers.1 Tobacco use is a major cause of death from cancer, cardiovascular disease, and pulmonary disease. Smoking accounts for 6% or more of total American medical costs.2 Patterns of tobacco use are the result of the complex interactions of a multitude of factors, including socioeconomic status, culture, acculturation, poor access to medical care, targeted advertising, relative affordability of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives. It is clear that helping smokers quit may be the most important act health-care providers do. This chapter reviews the epidemiology, the health effects of cigarette smoking and other tobacco use, and the challenges to treating tobacco dependence, particularly among vulnerable populations where tobacco use is concentrated. It discusses some strategies for confronting these challenges.



In 2012, an estimated 42.1 million Americans were smokers.3 Of these, about three-fourths were daily smokers, and about one-fourth intermittent smokers. Over time, the prevalence of smoking has declined, from a high of 42.7% in 1965 to the current level of 18%. The decrease in male smoking prevalence is even more dramatic, falling from a high of 54% in 1955 to the current level of 20.5%.4 Smoking among women rose to a high of 34% in 1964, before its decline to the current level of 16%.3

It was initially hypothesized that quitting smoking would be easier for light and intermittent smokers, and thus as a result the remaining smokers would be more hardcore. But that has not turned out to be the case. Until 1995, smokers consumed, on average, 20 cigarettes daily. Beginning in 1995 that number began to fall, and today the average smoker smokes about 13 cigarettes per day, with about 22% of all smokers not smoking every day (Figure 40-1). Although 70% of smokers state that they would like to quit, only about 5% are able to ...

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