The Effects of Tobacco Use

Housed within our pulmonary system is an innate immunological defense system. The system aims to identify foreign cells or organisms and produce an innate immune response. When smokers inhale tobacco smoke, this defense is compromised, making people more susceptible to injury and illness (CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010; National Center for Chronic Disease Prevention and Health Promotion, 2012).

Smoking cigars carries many of the same risks as smoking cigarettes. An aging process is used to make cigars, causing them to have higher concentrations of nitrates. Once smoked, these compounds produce some of the most potent carcinogenic substances known to experts (ACS, 2020).

Smokeless tobacco products are nicotine-containing substances placed into the mouth or nose and, therefore, not burned like traditional tobacco products. Smokeless tobacco products are often called snuff or chewing tobacco. Like any tobacco product, these also cause many types of cancer, particularly oral and mouth cancers, as the chemicals are absorbed through the mouth during use (ACS, 2020).

Second-hand smoke has been a long-standing issue, as it has been responsible for more than 40,000 adult and 400 infant deaths per year. The same disease caused by smoking can also be caused by second-hand smoke exposure. Infants and children exposed have demonstrated a higher risk of developing asthma, ear conditions, recurrent respiratory illness, and sudden infant death syndrome, better known as SIDS (CDC, 2020c).

For decades, experts have warned of the dangers of second-hand smoke. Individuals who may have never smoked a day are being diagnosed with lung conditions seen in smokers, all because they were exposed to it (CDC, 2020d).

Second-hand smoke exposure can also cause heart attacks, strokes, and other forms of heart disease. Annually, more than 8,000 stroke deaths are caused by individuals exposed to second-hand smoke (CDC, 2020d).

Long before it had a name, experts hypothesized that cigarette smoke toxins lingered on car, home, and room surfaces long after the smoke dissipated. Studies have shown that nicotine has been found in the dust in the homes and cars of smokers, increasing the potential exposure to others. The term "third-hand smoke (THS)" was first heard in 2006, but it was not until 2009 that it was used by a Harvard professor stating they believed THS would be harmful to children, prompting home smoking bans (Burton, 2011).

The longer you inhale tobacco smoke, the lungs, trachea, and larynx become damaged and irritated. The process causes the lungs' ability to exhale harmful substances to diminish, resulting in poisonous substance buildup. Ultimately, the alveoli become permanently scarred, placing individuals at a higher risk for lung infections. Alveolar scarring is also the cause of increased sputum, coughing, and wheezing, often seen or heard in long-term smokers (Better Health Channel, 2019).

The respiratory system is not the only system affected by smoking. Inhaling tobacco smoke causes the following issues in the circulatory system (Better Health Channel, 2019):

• Decreased oxygen exchange during activity and exercise
• Hypertension and tachycardia
• Decreased skin temperature because of vascular constriction
• Hypercoagulability
• Atherosclerosis
• Peripheral vascular constriction
• Higher risks of myocardial infarction (MI) and cerebrovascular accident (CVA)

Inhaling tobacco smoke causes the following problems with the immune system (Better Health Channel, 2019):

• Diminished immunity; decreased antioxidants
• Higher infection risks, especially pneumonia and flu
• Longer lasting infections

Smoking can affect the musculoskeletal system, causing decreased bone density and muscle tightening (Better Health Channel, 2019).

Tobacco use can also affect both the male and female reproductive systems. Males may experience decreased sperm count, sperm damage, or lead to a high percentage of deformities. Impotence is also a potential effect. Females may experience irregular menstrual cycles, decreased fertility, earlier menopause, and increased cervical cancer risk. In females older than 35, if they are on oral contraceptives and a smoker, the risk of stroke or heart attack is substantially higher (Better Health Channel, 2019).

Women who are pregnant or are thinking of becoming pregnant may experience difficulty if they are active smokers. For those already pregnant, evidence has suggested for years that a strong correlation exists between smoking during pregnancy and damage to the unborn baby. Smoking is known to damage the tissue in the brain and lungs during fetal development. Congenital disabilities and miscarriages are also linked to smoking during pregnancy (CDC, 2020f).

When mothers smoke during pregnancy, there is a higher risk of preterm delivery, which comes with complications. Experts state that one in every five babies born to mothers who smoked during pregnancy experience a low birth weight. Several health concerns relate to babies being born too early and too small. Babies born with low birth weight due to smoking are at higher risk for hypertension, diabetes, and heart disease in adulthood. Babies born to mothers who smoked during pregnancy are also at higher risk of being born with a cleft lip or palate and attention deficit hyperactivity disorder (ADHD) as they get older (Better Health Channel, 2019).

SIDS has been linked to maternal smoking over the years; studies show the risk of SIDS increases three-fold when the mother smoked during pregnancy (CDC, 2020f). Once born, a baby exposed to second-hand smoke during their first year is at a much higher risk of ear infections, respiratory infections, and meningitis (Better Health Channel, 2019).

Experts have discouraged smoking during pregnancy or around babies for quite a while. Some of the harmful effects experienced by babies due to smoking are relatively common knowledge, and others may not be well understood.

Chronic bronchitis has been linked to long-term smoking and is described as a chronic cough and sputum production. To receive an official diagnosis of chronic bronchitis, one must have experienced these symptoms for at least three months (most days each month) in two consecutive years without any other identifiable cause (National Center for Chronic Disease Prevention and Health Promotion, 2012).

A collective of conditions affecting the respiratory system is how COPD is identified. COPD affects people differently and at different points in life, ultimately causing issues with airflow and breathing. Emphysema, asthma, and bronchitis make up the diagnosis of COPD(CDC, 2020b).

In the beginning stages of COPD, people may not exhibit any signs or symptoms; or they may be so mild they are difficult to identify. Symptoms may include (CDC, 2020b):

• Wheezing
• Chest tightness
• Shortness of breath (this worsens with exertion)
• Frequent cough (may be referred to as a "smokers cough")

As the disease progresses, symptoms last longer and may become worse. What initially begins as shortness of breath with exertion may progress into difficulty talking or moving due to the inability to catch their breath. Other later symptoms include the following (CDC, 2020b): 

• Blue-gray discoloration to the lips and nails
• Weight loss (individuals may become so short of breath that even eating is difficult)
• Tachycardia
• Mental status changes

The overall type, amount, and progression of symptoms will vary from person to person. These factors will also be determined by an individual's willingness to quit smoking. According to the CDC, 39% of Americans with COPD continue to smoke cigarettes (CDC, 2020b).

Emphysema is one of the diseases that make up COPD and results from gradual lung tissue damage. Alveoli are often described as "tiny air sacs" and often rupture in emphysema, creating a larger air pocket. The process reduces surface area within lung tissues and diminishes the ability for oxygen to flow through the bloodstream as expected. More than three million people have an emphysema diagnosis in the United States. Smoking is the primary cause of emphysema, making it a highly preventable respiratory disease (American Lung Association [ALA], n.d.).

Smoking is one of the number one causes of stroke and heart disease in America, resulting in one in four deaths. Smoking is known to cause the following (CDC, 2020d):

• High cholesterol
• Increases atherosclerosis
• Damage to the lining of blood vessels
• Decreases the "good" cholesterol
• Smoking makes blood more susceptible to clotting

Individuals are at an increased risk of developing coronary artery disease and having a stroke if any combination of these occurs (CDC, 2020d).

Aside from specific system damage, there are other generalized effects caused by smoking. Smokers may experience:

• Higher rates of gastritis
• Premature skin aging
• Increased rate of periodontitis
• Increased rate of vision problems and blindness
• Decreased sense of taste and smell
• Increased risk of stomach ulcers

Cancer occurs when cells begin to multiply uncontrollably. When this process begins in the lungs, it is termed lung cancer. The location within the body where cancer originates is known as primary cancer; if it migrates to other organs, it is best known as metastases. A lung cancer diagnosis can be further broken down into small-cell or non-small-cell (CDC, 2022b).

Risk factors: The number one risk factor for lung cancer is cigarette smoking. Up to 90% of all lung cancer deaths are attributed to smoking. Of the 7,000 chemicals in tobacco smoke, most are poisonous, and many are known to cause cancer.

Symptoms: Not everyone with lung cancer will exhibit the same symptoms. Symptoms may begin as respiratory, or if the cancer has spread to other organs, symptoms may be based on the affected organs. Some more common symptoms include the following:

• Chest pain
• Worsening cough
• Hemoptysis
• Wheezing
• Weight loss without trying
• Fatigue
• Shortness of breath or difficulty breathing
• Lymphadenopathy
• Recurrent pneumonia

Lung cancer types: The non-small cell is the more common of the two types. Once an official diagnosis is given, further diagnostics are performed to determine which stage the cancer has progressed to. The process allows medical professionals to identify which treatment regimen would work best.

Treatment: Treatment selection will depend upon the cancer's location and staging. Treatment could include a combination of the following (CDC, 2022a):

• Surgery
• Chemotherapy
• Radiation
• Targeted therapy

Experts are still studying the long-term effects of e-cigarette use, though the harmful effects of nicotine are not new. E-cigarettes contain multiple chemicals, metals, and other dangerous particles that have been shown to cause unintended lung and other injuries.

There have been reports of defective e-cigarettes that cause explosions and fires, which can cause various amounts of injury. Lung injuries have also been linked to e-cigarettes (CDC, 2023).

No tobacco products are considered safe because they pose multiple health-related risks. The Food and Drug Administration [FDA] has also had to warn the general population about other safety concerns related to e-cigarettes, including:

• Vape-induced lung injuries
• Explosions and fires
• Neurological symptoms, such as seizures

Healthcare providers and regulatory agencies, such as the FDA and CDC, have noticed many respiratory illnesses linked to e-cigarettes (vapes). Despite medical providers educating teens and young adults against using e-cigarettes, respiratory illnesses continue to occur, though they seem to have been on the decline. According to the CDC, 2800 hospitalizations or deaths have been reported in the U.S. The total death count in 2020 was reported at 68 within 29 U.S. states (CDC, 2020e).

There are specific e-cigarette contents that have been found harmful. Vitamin E acetate is a well-known vitamin found in many foods and supplements. Vitamin E supplements are in pill or capsule form and can be found in most pharmacies, drug stores, and major grocery stores. Vitamin E is also found in many cosmetic products, particularly skin creams. Food high in vitamin E content includes fruits, vegetables, meats, and oils. However, many THC-containing e-cigarette products contain vitamin E acetate as an additive. Evidence supports that when vitamin E acetate is inhaled into the lungs, our lung function may be impacted, placing us at risk for respiratory illness and other complications (CDC, 2020e).

Researchers have enough evidence to support a likely link between tetrahydrocannabinol (THC)-containing e-cigarettes and chemicals containing vitamin E as potential contributors to adverse health effects. Data from state public health departments and emergency rooms showed a shift in cases of vape-induced lung injuries after a rapid increase in e-cigarette use in 2019. Since then, there have been multiple interventions that have promoted a decrease in severity, such as:

• Vitamin E has been removed from some chemicals used in e-cigarettes
• Law enforcement has increased their response related to e-cigarette usage
• Public health officials have enhanced educational and awareness efforts in the community

Laboratory analyses have occurred over the years on patients, vaping devices, packaging, and other products containing cartridge liquor or packaging. More than 1300 samples were submitted from more than half of U.S. states containing varied amounts of liquid for sampling ability. Findings demonstrated that although not one chemical was found in each sample, THC was present in most submitted samples. Half of the samples containing THC also contained vitamin E acetate. Persistent research and identifying chemical compounds found in e-cigarettes are vital to determine the root cause of vape-induced lung injuries and associated respiratory illnesses (FDA, 2020).

Though it is unlikely to end all e-cigarette usage, the CDC and FDA have developed recommendations (CDC, 2020e).

1. People should be cautious about where they purchase e-cigarette products and who they get them from. Just like medication, purchasing products online, from unknown sources, or using products belonging to others is discouraged.
2. There are already enough harmful chemicals in nicotine-containing products, and people should avoid additional additives, especially vitamin E acetate.
3. Adolescents, young adults, and pregnant women should avoid using nicotine-containing products, including e-cigarettes.
4. It is not a good time to start if you are an adult who does not currently use nicotine-containing products.
5. If you have used e-cigarettes to quit smoking, do not go back to smoking. Speak to your healthcare provider about safer smoking cessation options available.
6. Concerns about using THC-containing products and their potential health effects have been raised. Side effects and complications have been linked to prolonged use of these products.
7. If you or someone you know is or becomes addicted to substances, consider seeking help from a trusted source who can provide safe and evidence-based treatment options.

Since many individuals use e-cigarettes to help them quit smoking, researchers decided to perform a literature review to evaluate the numbers and get to the bottom of the e-cigarette debate on using e-cigarettes in cigarette smoking cessation. Researchers reviewed 78 randomized controlled trials that studied more than 22,000 smokers. All studies compared the use of e-cigarettes with other smoking cessation modalities, such as nicotine replacement therapy, medication, therapy, and no support (Hartmann-Boyce et al., 2021).

Findings from the literature reviews included the following:

• E-cigarettes containing nicotine were more successful at helping people to stop smoking than nicotine replacement therapy.
• E-cigarettes helped more people to stop smoking than behavioral-based supportive measures.

All evidence supports that quitting smoking significantly decreases the risk of cancer, heart disease, other smoking-related lung diseases, and other health conditions. Smoking cessation also helps prevent potentially damaging effects on loved ones caused by second-hand smoke exposure (Carabello et al., 2017).

The overall health benefits gained when a person quits smoking are numerous; they include the following (CDC, 2020a):

• It can give you up to 10 years back on your average life expectancy
• Improves the overall quality of life
• Diminishes reproductive risks
• Lowers your risk of developing chronic diseases, such as heart disease, COPD, and cancer
• Can reduce any financial burden felt by a smoking habit
• Improves cholesterol
• Reduces the risk of stroke

Smoking is a massive contributor to various types of cancers. By quitting smoking, individuals reduce their chances of getting the following twelve types of cancer (CDC, 2020a):

• Leukemia
• Lung cancer
• Bladder cancer
• Cervical cancer
• Colon cancer
• Esophageal cancer
• Hepatocellular carcinoma
• Renal cancer
• Oral and throat cancer
• Pancreatic cancer
• Stomach cancer
• Laryngeal cancer

Though e-cigarettes have been largely marketed as a smoking cessation aid, the FDA has not approved them for that purpose. To find an approved smoking cessation method, speak with your primary care provider or a specially trained representative.

Smoking is an addiction because nicotine has addictive properties; like anything else, it is not advised to quit an addictive substance abruptly. Nicotine replacement therapy (NRT) is an approved smoking cessation method. Though various forms can be used, the primary mechanism of action is to give individuals lower levels of nicotine without some harmful chemicals. Quitting an addiction abruptly can lead to unpleasant withdrawal symptoms. These symptoms may vary depending on the substance being withdrawn from.

NRT options can be bought at most grocery stores and pharmacies, in addition to some requiring a prescription from a medical provider. Some NRT therapies may include the following (National Health Service [NHS], 2022):

• Nicotine patches
• Nicotine gum
• Nicotine lozenges
• Oral or nasal spray
• Inhalators

Nicotine patches vary in strength and length of time to be worn. They allow for a slow release of nicotine. Gum, inhalators, and sprays are more rapid-acting and help reduce immediate cravings. Successful NRT treatment may last 8-12 weeks, with the goal being a slow, gradual decrease in use/dose over time (NHS, 2022).

Most people are good candidates for NRT, even pregnant and breastfeeding women. Speaking with a medical provider before using any treatment is always advised to ensure it is safe for their specific use. Side effects of NRT may include nausea, skin irritation, nasal or throat irritation, headaches, or dizziness (NHS, 2022).

Smoking Cessation

Recently, two popular medications were used as prescription options for smoking cessation. Varenicline (Chantix) and bupropion (Zyban) have since been withdrawn from their manufacturers as smoking cessation treatments (NHS, 2022).

Local and state communities can lend a hand in a variety of ways to help reduce the risk of cancer and other illnesses caused by smoking. As one of the biggest concerns in society, community partners can help reduce access to e-cigarettes and tobacco products for minors. Other ways people can help include:

• Promote the avoidance of second-hand smoke
• Help people with smoking cessation endeavors
• Promote regular cancer screenings