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Cigarette smoking is the leading cause of mortality in the United States, accounting for nearly 445,000 deaths, or one in five deaths per year (Centers for Disease Control and Prevention [CDC], 2009). Tobacco use accounts for more deaths annually than alcohol and drug use, motor vehicle accidents, HIV, suicide and homicide combined (CDC, 2002). Smokers tend to die prematurely, losing an average of about 14 years of life (CDC, 2009). Beyond mortality, smoking is linked to a large range of chronic and severe medical disorders that negatively impact health and function, including heart disease, cancer, pulmonary disease, infertility, sexual dysfunction. Although U.S. smoking prevalence rates have dropped from 50% in 1964 to about 19% currently (CDC, 2012), this still poses a large health and economic burden to smokers and to our society. Smoking prevalence rates are negatively correlated with education and socioeconomic status. Furthermore, smoking prevalence rates in individuals with psychiatric and substance use disorders are more than two to three times greater than rates among the general public (Lasser et al, 2000). Smokers with mental illness are large consumers of cigarettes, accounting for about 44% of all cigarettes smoked (Lasser et al, 2000).


A. Epidemiology

Rates of smoking are calculated based on national survey data collected by the CDC, the Behavior Risk Factor Surveillance System (BRFSS). States use standardized procedures to collect telephone data on a monthly basis. In the United States, 19.3% of all adults (age 18 years or older) smoke cigarettes (defined as persons who reported smoking at least 100 cigarettes during their lifetime and who, at the time of interview, reported smoking every day or some days) (CDC, 2011). These numbers have been continually declining over the past 50 years, which is likely a response to improved education and treatment and higher taxation. However, these numbers do not capture cigarette smokers who are moving to smokeless tobacco (e.g., chew, dip, snuff, snus) and other alternative forms of nicotine intake (e.g., cigars, pipes, hookahs, bidis, e-cigarettes) as regulations (e.g., indoor clean air laws) and taxation on cigarettes have increased. These nicotine users represent a substantial minority of all nicotine users. Of all adults, 3.5% use smokeless tobacco (Substance Abuse and Mental Health Services Administration [SAMHSA], 2010); users are 21 times more likely to be male. However, as the majority of nicotine intake is still accomplished with cigarettes, cigarette smoking is the focus of the bulk of this chapter.

It is important to note that smoking rates are disproportionally stratified and are higher in groups with less education and lower income, as well as those with higher rates of psychiatric and substance diagnoses (Table 52–1 shows the breakdown by age, gender, and race/ethnicity (CDC, 2011). Individuals with a psychiatric diagnosis (including mood, anxiety, psychosis, and substance use diagnoses) are nearly twice as likely to smoke cigarettes (41%) compared to those ...

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