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date: 30 June 2022

• Mansoo YuMansoo YuSchool of Social Work, University of Missouri
•  and Rachel FischerRachel FischerDepartment of Public Health, University of Missouri, Mizzou

### Summary

Tobacco use is a major public-health concern in the United States. Intervention and prevention strategies for tobacco use are an urgent public-health priority because tobacco use is the single most preventable cause of death. To help social workers better understand tobacco use problems, this entry presents an overview, including definitions of terms, the scope and impact of tobacco use problems in terms of different segments of the population (that is, age, gender, race or ethnicity, geographic location, and education level or socioeconomic status), etiology of tobacco use (for example, biological or genetic; psychiatric; psychosocial; or environmental or sociocultural factors), policy history, tobacco prevention, clinical issues (such as cessation desire, treatment and success, or screening tools for tobacco use disorder and tobacco withdrawal), and practice interventions for tobacco use problems. Based on the information, the roles of social workers will be addressed.

### Subjects

• Health Care and Illness
• Mental and Behavioral Health

### Updated in this version

Updated with diagnostic criteria and terminology from the DSM-V.

### Definition of Terms

Federal law (section 5702(c) of Title 26 of the U.S. Code) defines tobacco products as cigars, cigarettes, smokeless tobacco, pipe tobacco, and roll-your-own tobacco. The definition of cigar is any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco, other than cigarettes, whereas cigarettes are any roll of tobacco wrapped in paper or in any substance not containing tobacco. Both types of tobacco exist in small (weighing not more than three pounds per thousand) and large sizes (weighing more than three pounds per thousand). Smokeless tobacco consists of snuff (any finely cut, ground, or powdered tobacco that is not intended to be smoked) and chewing tobacco (any leaf tobacco that is not intended to be smoked). Pipe tobacco includes any tobacco that, because of its appearance, type, packaging, or labeling, is suitable for use and likely to be offered to, or purchased by, consumers as tobacco to be smoked in a pipe. Roll-your-own tobacco includes any tobacco that, because of its appearance, type, packaging, or labeling, is suitable for use and likely to be offered to, or purchased by, consumers as tobacco for making cigarettes (Alcohol and Tobacco Tax and Trade Bureau, 2012).

Consistently, the Family Smoking Prevention and Tobacco Control Act of 2009 defined the term “tobacco product” as any product made or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, among other products, cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco (U.S. Food and Drug Administration [FDA], 2009). Additionally, the National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), which is an annual nationwide survey involving interviews with approximately 70,000 randomly selected individuals aged 12 and older, includes information about tobacco products including cigarettes, chewing tobacco, snuff, cigars, and pipe tobacco.

In 2010, an estimated 69.6 million Americans aged 12 or older used had a tobacco product in the past month (SAMHSA, 2011). Of all adults aged 18 years or older, an estimated 45.3 million people, or 19.3%, smoke cigarettes (Centers for Disease Control and Prevention [CDC], 2011). Cigarette smoking is more common among men (21.5%) than among women (17.3%). Smokeless tobacco rates are as low as 1.3% and as high as 9.1%, varying by state (McClave, Thorne, & Malarcher, 2010). An additional 14% and 8.9% of high school–age students report smoking cigars and using smokeless tobacco, respectively (CDC, 2012a). Although the percentage of adolescent smokeless tobacco users is lower than that of cigarette or cigar smokers, smokeless tobacco serves as an indicator for future likelihood of becoming an adult cigarette smoker (CDC, 2012b). Refer to the section entitled “Prevalence of Tobacco Use among Different Segments of the Population” for details.

Hookahs (also known as water pipes) are another popular form of tobacco used primarily among 18- to 24-year-old young adults (American Lung Association [ALA], 2011). Water pipe and hookah use is also gaining popularity among youth, with 4% of middle school and 11% of high school students reporting having used hookah (ALA, 2011). Estimates indicate that approximately 48% of college students have used hookah at some point in their lives, with up to approximately 20% having used it in the past month (ALA). Similar to smokeless tobacco, hookah can serve as a pathway to other tobacco products such as cigarettes (ALA). Last, e-cigarettes, or electronic nicotine delivery systems (ENDS) have gained popularity in the United States within recent years. Reports indicate that approximately 4% of current smokers and 0.5% of former smokers are current e-cigarette users (Pearson, Richardson, Niaura, Vallone, & Abrams, 2012). Lifetime usage of ENDS is around 11% for smokers, 2% for former smokers, and less than 1% for nonsmokers (Pearson et al., 2012).

The 2013 American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) uses the term tobacco-related disorders. Tobacco-related disorders are 1 of 10 classes of the substance-related disorders including alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics or anxiolytics; stimulants; tobacco; and other substances. These 10 classes are not fully distinct. Tobacco-related disorders include mainly two categories: tobacco use disorder and tobacco withdrawal, which is a classification of tobacco-induced disorder.

The diagnostic criteria for a substance use disorder can be applied to tobacco use disorder (APA, 2013, p. 571): a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1.

Tobacco is often taken in larger amounts or over a longer period than intended.

2.

There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.

3.

A great deal of time is spent in activities necessary to obtain or use tobacco.

4.

Craving, or a strong desire or urge to use tobacco.

5.

Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interfere with work).

6.

Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use).

7.

Important social, occupational, or recreational activities are given up or reduced because of tobacco use.

8.

Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed).

9.

Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.

10.

Tolerance, as defined by either of the following:

a.

A need for markedly increased amounts of tobacco to achieve the desired effect.

b.

A markedly diminished effect with continued use of the same amount of tobacco.

11.

Withdrawal, as manifested by either of the following:

a.

The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for tobacco withdrawal below).

b.

Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

DSM-IV nicotine dependence criteria (APA, 2000) can be used to estimate the prevalence of tobacco use disorder, but because the nicotine dependence criteria are a subset of tobacco use disorder criteria, the prevalence of tobacco use disorder will be somewhat higher. Both tobacco use disorder and tobacco withdrawal symptoms are common among individuals who use cigarettes and smokeless tobacco daily and uncommon among individuals who do not use tobacco daily or who use nicotine medications (APA, 2013).

Tobacco withdrawal usually begins within 24 hours of stopping or cutting down on tobacco use, peaks at two to three days after abstinence, and lasts two to three weeks. Tobacco withdrawal symptoms can occur among adolescent tobacco users, even prior to daily tobacco use. Prolonged symptoms beyond one month are uncommon (APA, 2013). The DSM-V diagnostic criteria for tobacco withdrawal include the following:

A.

Daily use of tobacco for at least several weeks.

B.

Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms: 1) irritability, frustration, or anger, 2) anxiety, 3) difficulty concentrating, 4) increased appetite, 5) restlessness, 6) depressed mood, 7) insomnia.

C.

The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D.

The signs or symptoms are not attributed to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. (APA, 2013, p. 575)

In terms of diagnostic features, withdrawal symptoms impair the ability to stop tobacco use. Heart rate decreases by 5 to 12 beats per minute in the first few days after stopping smoking, and weight increases an average of four to seven pounds (two to three kilograms) over the first year after stopping smoking. Tobacco withdrawal can produce clinically significant mood changes and functional impairment (APA, 2013). This entry does not include information about tobacco intoxication because it is not included in DSM-V.

### The Scope and Impact of Tobacco Use Problems

Tobacco use is the leading preventable cause of morbidity and mortality in the United States, accounting for approximately 443,000 deaths, or 1 of every 5 deaths each year (CDC, 2011). According to another CDC report (CDC, 2008), the three leading specific causes of smoking-attributable death are lung cancer, ischemic heart disease, and chronic obstructive pulmonary disease (COPD). Smoking during pregnancy resulted in an estimated 776 infant deaths annually during 2000 to 2004, the most recent years for source data available. An estimated 49,400 lung cancer and heart disease deaths annually were attributable to exposure to secondhand smoke. The average annual smoking-attributable mortality estimates also included 736 deaths from smoking-attributable residential fires. Tobacco use is the most common cause of cancer-related deaths in the United States, including deaths from laryngeal cancer, esophageal cancer, oral cancer, and bladder cancer, as well as lung cancer (CDC, 2008). As mentioned, tobacco use is a leading cause of heart disease, stroke, and COPD (U.S. Department of Health and Human Services [USDHHS], 2013).

Tobacco use results in more than $157 billion in annual health-related costs. Tobacco use is also related to approximately 5.1 million years of potential life lost (YPLL) consisting of 3.1 million YPLL for males and approximately 2.0 million YPLL for females annually, as well as$96.8 billion in productivity losses, consisting of $64.2 billion for males and$32.6 billion for females annually in the United States during 2000 to 2004 (CDC, 2008).

### Prevalence of Tobacco Use Among Different Segments of the Population

Prevalence of tobacco use varies according to age, gender, race or ethnicity, geographic location, and education or socioeconomic status (SES).

#### Tobacco use by age.

In 2010 approximately 27% of individuals age 12 and older and 19% of adults age 18 and older were current tobacco users, meaning they had used some form of tobacco at some point in the past month (CDC, 2012c; SAMHSA, 2011). In that same time, 23% of the population identified as current cigarette smokers, 5.2% identified as cigar smokers, 3.5% identified as smokeless tobacco users, and 0.8% identified as pipe smokers (SAMHSA). The highest rates of tobacco use in 2010 were among young adults, ages 18 to 25, 41% of whom were current tobacco users (SAMHSA). Adults aged 26 years or older were the next highest tobacco-using age group at 27%. Youths, ages 12 to 17, had the lowest prevalence, with approximately 10% being current tobacco users (SAMHSA). Cigarettes were the most commonly used tobacco product among all age groups, with 34% of young adults, 8% of youths, and approximately 9% of older adults age 65 and older smoking cigarettes within the past month (SAMHSA). Approximately 11% of young adults smoke cigars, 6% use smokeless tobacco, and nearly 2% smoke tobacco pipes (SAMHSA).

Tobacco use in middle and high school students has declined since the beginning of the 21st century. As of 2011, 7.1% used any form of tobacco (including cigarettes, cigars, smokeless tobacco, tobacco pipes, etc.) compared with a decade prior, when 14.9% used tobacco of some kind. Particularly, current cigarette use dropped from 10.7% in 2000 to 4.3% in 2011 (CDC, 2012a). The most commonly used forms of combustible tobacco in 2011 among middle school students were cigarettes (4.3%), cigars (3.5%), and pipes (2.2%) (CDC, 2012a). Additionally, up to 4% reported smoking a hookah (ALA, 2011).

Similar to use among middle school students, use of any tobacco product among high school students declined from 34.4% in 2000 to 23.2% in 2011 (CDC, 2012a). Particularly, current cigarette use dropped from 27.9% in 2000 to 15.8% in 2011 (CDC). The most commonly used forms of combustible tobacco in 2011 were cigarettes (15.8%), cigars (11.6%), and pipes (4%). Additionally, up to 11% reported smoking a hookah (ALA, 2011).

#### Tobacco use by gender.

Globally, cigarette usage is higher among men than among women, with 48% of men worldwide smoking compared with 12% of women (World Health Organization [WHO], 2013). In the same trend as that seen in the rest of the world, among individuals aged 12 and older in the United States, approximately 34% of males were tobacco users compared with approximately 22% of females in 2010 (SAMHSA, 2011). Males have higher rates of usage for all tobacco products. Over 25% of U.S. males smoke cigarettes compared with nearly 21% of females (SAMHSA). U.S. adults aged 18 and older had similar rates in 2010, with greater than 21% of adult males and greater than 17% of adult females smoking (CDC, 2012b). Similarly, greater than 8% of males smoke cigars, nearly 7% use smokeless tobacco, and greater than 1% smoke pipes compared with approximately 2% of females reporting smoking cigars and less than 1% reporting smokeless tobacco or pipe use (SAMHSA).

However, among youth, rates of smoking and use of other tobacco products such as chew and water pipes are nearly equivalent between the two genders (WHO, 2013). Similar to global tobacco rates, U.S. youth ages 12 to 17 report similar smoking rates among male and females, with nearly 9% of male and greater than 8% of female youth smoking cigarettes in 2010 (SAMHSA, 2011). In general, females tend to smoke less, use lower nicotine cigarettes, and inhale less deeply than males (National Institute on Drug Abuse [NIDA], 2012a). However, use of tobacco products may impact genders differently.

The lesbian, gay, bisexual, transgender, and queer (LGBTQ) population is a special population with disproportionately high rates of smoking and general tobacco use (National LGBT Tobacco Control Network, 2013). Smoking rates within the LGBTQ community range from 50% to 200% higher than that of the general heterosexual population (National LGBT Tobacco Control Network). A 2004 study found that compared with straight women, lesbian women are approximately 70% more likely to smoke and compared with straight men, gay men are greater than 55% more likely to smoke (Tang et al., 2004). LGBTQ youth follow similar tobacco use trends, with gay, lesbian, or bisexual adolescents smoking at much higher rates than their heterosexual peers (Easton, Jackson, Mowery, Comeau, & Sell, 2008). Compared with the heterosexual adolescent population, in which approximately 29% smoked cigarettes, up to 47% of lesbian or same sex–attracted adolescent females and 37% of gay or same sex–attracted adolescent males reported smoking (Easton et al., 2008). Smoking rates among those who identify as bisexual are high as well, around 39%, with bisexual males more than twice as likely to smoke as straight or gay males (ALA, 2010).

#### Tobacco use by race or ethnicity.

Smoking rates tend to differ among different racial and ethnic groups. In the United States, the American Indian (AI) or Alaskan Native (AN) population had the highest rates of both adult and youth smokers. More than 32% of the adult AI/AN population were current smokers in 2010 (CDC, 2012c). Additionally, more than 55% of AI/AN youth have ever used tobacco products, with cigarette smoking being the most common form of tobacco use (Yu, 2011). In rural areas, the rates are even higher, with AI smoking rates at greater than 45% (ALA, 2012). Overall, 19% of U.S. adults ages 18 or older were current smokers in 2010. Specifically, 32% of those who reported being AI/AN were current smokers, as were more than 27% of multiple-race, more than 20% of White, approximately 19% of Black, nearly 13% of Hispanic, and nearly 10% of Asian adults in 2010 (CDC, 2012c). Among individuals ages 12 and older, nearly 36% of AI/AN, 32% of individuals reporting multiple races, more than 29% of Whites, approximately 27% of Blacks, nearly 22% of Hispanics, and over 12% of Asians reported being current tobacco users in 2010 (SAMHSA, 2011).

Nearly 15% of AI/AN youths, ages 12 to 17, smoke compared with 10% of White youths, 8% of Hispanic youths, approximately 5% of Black youths, and greater than 4% of Asian youths (SAMHSA, 2011). Similar trends are seen among young adults, ages 18 to 25, with approximately 39% of White young adults smoking compared with approximately 27% of Hispanic young adults, 26% of Black young adults, and 21% of Asian young adults (SAMHSA).

#### Tobacco use by geographic location.

Tobacco use varies by geographic location as well as by population density. In 2010 the midwestern United States had the highest rates of smoking, at approximately 25%, compared with the South at 24%, the Northeast at 22%, and the West at 20% (SAMHSA, 2011). However, smokeless tobacco use was actually highest in the South at greater than 4% compared with the Midwest at approximately 4%, the West at 3%, and the Northeast at approximately 2% (SAMHSA).

Both cigarette and smokeless tobacco use were highest in nonmetropolitan areas, at 26% and greater than 6%, respectively (SAMHSA, 2011). Similarly, cigarette and smokeless tobacco use were both lowest in large metropolitan areas, at nearly 22% and approximately 2%, respectively (SAMHSA). These trends hold for both males and females up to age 64 (ALA, 2012). Although rural rates of tobacco use are higher in all areas, certain populations within metropolitan areas have higher smoking rates than their urban counterparts. Studies have indicated that lifetime smoking rates of African American adolescents living in large metropolitan public housing units are high, approximately 46%, and recent cigarette usage within the past year was approximately 20% (Yu et al., 2012). These smoking rates of African American youths living in urban public housing are more than double the national rates of smoking for adolescent African Americans, both for lifetime and for recent smoking rates (Yu et al.).

Yet, rural rates of tobacco use are the highest in the county. Rural youth are up to three times more likely to smoke than their urban or suburban peers (ALA, 2012). Young adults from rural areas, ages 18 to 34, have some of the highest smoking rates in the United States and are 27% more likely to smoke than urban young adults (ALA). At all ages, rural men are two times as likely to use smokeless tobacco as are men from urban areas (ALA). Those in rural areas have greater chances of being exposed to secondhand smoke but are also less likely to have access to smoking cessation programs (ALA). Not only do residents of rural areas have higher rates of cigarette and smokeless tobacco use, but also they typically start using tobacco at a young age and tend to use it more heavily than suburban or urban individuals (ALA). Dual use of both cigarettes and smokeless tobacco is twice as high in rural areas, at 2.5%, compared with national rates of dual usage of only 1.4% (ALA). Additionally, the rate of rural women who smoked during the duration of their pregnancy (greater than 27%) is similar to the smoking rate of nonpregnant urban women (ALA). Smoking and tobacco education and cessation programs implemented in culturally appropriate ways could have large impacts on improving the health of rural communities.

#### Tobacco use by education level and socioeconomic status.

In general, smoking and tobacco use are correlated negatively with education levels and SES. In 2010, more than 45% of adults with a general education development degree were current smokers compared with only approximately 24% of adults with a high school diploma, less than 10% of adults with an undergraduate college degree, and approximately 6% of adults with a postgraduate degree being current smokers (CDC, 2012b). Similarly, of adults who lived below the poverty line in 2010, nearly 29% were current smokers compared with approximately 18% of adults who lived at or above the poverty level (CDC).

### Etiology of Tobacco Use

There is no single etiological factor that accounts for why some people use tobacco (or develop nicotine dependence) and others do not.

#### Biological and genetic factors.

There are a variety of different biological and genetic factors associated with tobacco use. The body’s biological response to nicotine can often lead to addiction and nicotine dependence over time. The nicotine from cigarettes and other tobacco products increases the levels of dopamine in the reward circuits of the brain, which is what leads to the pleasure and buzz so many tobacco users report experiencing (NIDA, 2012b). Over time, tobacco use will result in a neural sensitization, which makes each smoke or use of tobacco result in a stronger dopamine release (Lochbuehler, Otten, Voogd, & Engels, 2012). This continued use is capable of changing the user’s brain chemistry, resulting in nicotine addiction or dependence (NIDA, 2012b). All regular tobacco users, regardless of potential genetic factors, risk nicotine addiction simply by using tobacco products.

Various research has demonstrated, however, that there is in fact a genetic component to tobacco use. Genetics can impact all three stages of smoking and tobacco use: initiation, current usage, and cessation (Amos, Spitz, & Cinciripini, 2010). A longitudinal study, using a nationally representative sample of sibling pairs, reported that genes are an important etiological factor in nicotine dependence (Haberstick et al., 2007). The study has shown that genetic factors account for approximately 60% of the variance in smoking rates. Another study, using 32,359 California twins, reported that 32% of the variance in smoking initiation and 55% of the variance in smoking persistence are attributable to genetic factors (Hamilton et al., 2006). With genetics playing a large role in all aspects of nicotine dependence and tobacco use, genetics should also be considered when attempting to develop and implement tobacco prevention, education, and cessation programs.

#### Psychiatric factors.

Smoking and tobacco use are often comorbid with other psychiatric disorders, such as alcoholism, schizophrenia, depression, and anxiety disorders, among others (NIDA, 2012c). Although it is difficult to discern a direction concerning the link between psychiatric factors and tobacco use, studies have indicated that a psychiatric disorder may precede tobacco use (Griesler, Hu, Schaffran, & Kandel, 2008). Early onset of a psychiatric disorder has been found to increase the odds of adolescents becoming nicotine dependent (Griesler et al., 2008). Panic disorders such as panic attacks and panic-specific vulnerabilities have also been shown to influence tobacco use, with smoking and nicotine delivery as a potential means of coping with panic (Zvolensky & Bernstein, 2005). For many psychiatric disorders, tobacco use may serve as a self-medicated coping mechanism to help curb the symptoms of the illness.

#### Psychosocial factors.

Research has shown that low achievement motivation, rebelliousness, and thrill seeking are all psychological traits that influence smoking behaviors (Bricker et al., 2009). The presence of these traits and their level of intensity are shown to ultimately contribute to the likelihood that individuals will initially try smoking, as well as the probability of increasing smoking to a monthly or daily habit (Bricker et al.). Stress has been shown to be a factor in adolescent smoking, with personal and school-related stress linked to increased lifetime smoking and smoking intentions in multiethnic adolescents (Booker et al., 2008). Similar results concerning stress and smoking habits have been found in adults, with links existing between stressful life events and smoking status. Studies have found that stressful life events such as financial concerns or changes in residence may result in failure to quit smoking or relapse among women (McKee, Mciejewski, Falba, & Mazure, 2003). Individuals who have been trauma exposed and exhibit higher levels of posttraumatic stress symptoms are more likely to report smoking as a means to reduce symptoms, irrelevant of their actual smoking levels (Feldner et al., 2007). Smoking may be used as a means to relieve stress or symptoms of posttraumatic stress disorder and alleviate symptoms of stress and trauma. Low levels of self-worth, self-image, and self-esteem have also been shown to be factors that impact tobacco use, particularly in adolescent populations (CDC, 2012d). Perceived discrimination has been found to have different effects on adolescent males and females, with adolescent males increasing smoking rates and adolescent females decreasing smoking rates in discriminatory settings (Wiehe, Aalsma, Liu, & Fortenberry, 2010). Further research is needed to more fully understand the effects of stigma and discrimination on smoking habits so proper interventions and cessation treatments can be implemented. Historically marginalized and minority populations, such as the LGBTQ community, may be influenced by these factors. With the potential stigma and stress associated with being a minority, individuals may turn to smoking as a coping mechanism, which may help to explain high rates of smoking in minority populations (The DC Center for the LGBT Community, 2013).

#### Environmental and sociocultural factors.

In addition to genetic and psychosocial factors, environment and sociocultural factors can play a large part in tobacco use initiation and habits. As shown previously, low SES has been shown to impact smoking rates, with those with lower SES having higher rates of tobacco use than those with higher SES and education (CDC, 2012b). Additionally, the use and approval of tobacco by peers, parents, guardians, siblings, or the community can impact tobacco use and acceptance, as can exposure to smoking in movies or advertisements and the accessibility and cost of tobacco products (CDC, 2012d).

Various studies have demonstrated that children of smoking parents tend to view smoking more favorably and are more likely to indicate a desire to smoke than their peers whose parents do not smoke (Kobus, 2003; Lochbuehler et al., 2012). One study found that children whose parents smoked were more innately attuned to smoking cues than their peers whose parents did not smoke (Lochbuehler et al.). This finding could indicate that children of smoking parents may unconsciously be more aware and focused on smoking behaviors, even prior to their understanding of tobacco use, including smoking (Lochbuehler et al.). The impact of peers on smoking has also been well documented. Many studies have shown that youth who have smoking friends are more likely to smoke than their peers who have nonsmoking friends (Kobus). Social relationships, such as friends, romantic interests or partners, and social groups, can all impact smoking behavior in adolescents and youth; they can promote or discourage smoking, depending on the perspective of the influence (Kobus). Adolescents whose parents or peers smoke are more likely to try smoking compared with adolescents whose peers and parents do not smoke or view smoking negatively, who may be less likely to smoke or use tobacco (Kobus). Last, one study found that schools that incorporated tobacco education and prevention into their curriculum and schools that had policies that prohibited tobacco use on campus had lower rates of smoking then schools that did not incorporate tobacco education or policies (Lovato et al., 2010). The same study also found that the local price of cigarettes was inversely related to student smoking; the higher the cost of cigarettes in the community, the fewer students smoked.

#### Interplays among multiple factors.

Although genetics, psychiatry, psychosociology, and environment all are related to tobacco use, there are interplays among these factors for tobacco use. For example, psychosocial factors such as novelty seeking predict tobacco use through social environmental factors such as tobacco advertising and media (Audrain-McGovern et al., 2006). In the study, novelty-seeking personalities have been shown to have a significant indirect effect on smoking habits; with novelty seekers being more likely to be receptive to tobacco advertising and therefore more likely to either start or continue smoking. The researchers found that individuals who are receptive to tobacco advertising are up to three times more likely to smoke.

#### Associations between tobacco use and other risk behaviors.

Adolescent tobacco use has been shown to be related to a variety of other risk behaviors, such as alcohol consumption and drug usage, delinquent behaviors (for example, carrying weapons and fighting), dropping out of school, early sexual intercourse, not using seat belts, failure to exercise, and eating fewer than five daily servings of fruits and vegetables (Brener & Collins, 1998; CDC, 2012d; Escobedo, Reddy, & DuRant, 1997).

### Policy History

The Family Smoking Prevention and Tobacco Control Act of 2009 is the most recent national policy to work toward regulating tobacco manufacturing, distribution, and marketing (USDHHS, 2013). The Tobacco Control Act allots this power of regulation to the U.S. FDA, under the understanding that these regulations will lead to better national and public health (USDHHS). In addition to restricting marketing and advertising toward youth and adolescents by regulating packaging and advertisements and banning sponsorships and free samples or promotional items from certain situations, the act also puts regulations on harm claims made by the tobacco companies concerning various products. The act requires all tobacco companies to submit all marketing research to the FDA (USDHHS). The Tobacco Control Act also mandates warning-label changes to cigarettes and smokeless tobacco, including that warning labels are required to cover 50% of the front and rear of cigarette packages, and all packages must have one of nine specific warning messages and include color graphics that show the negative health effects of smoking. However, because of ongoing court appeals concerning the legality and effectiveness of these changes, the implementation date of the label changes remains unspecified (USDHHS).

### Tobacco Prevention

Many of the tobacco prevention programs and campaigns are aimed at youths. With the large majority of new tobacco users being under the age of 18, prevention programs targeted toward youth will likely be most effective (USDHHS, 2013). National as well as state and local campaigns that work to counteradvertise any pro-tobacco marketing, such as the national truth campaign, which uses media such as television commercials and an interactive web site to engage their audience, are working toward preventing first-time and occasional tobacco users (American Legacy Foundation, 2013; CDC, 2012f). The national Drug Abuse Resistance Education (D.A.R.E.) program is currently implemented in over 75% of U.S. school districts and uses local police officers to teach school-age children to resist alcohol and drugs, including tobacco (D.A.R.E., 2012). In addition, tobacco prevention policies such as smoke-free or tobacco-free campuses are being implemented in schools (CDC, 2012f). For example, the University of Missouri, located in Columbia, Missouri, banned all smoking on campus starting in January 2014 (University of Missouri, 2011). Until that point, smoking was banned on campus with the exception of specifically designated smoking areas located around the campus. Many college campuses either are moving toward being smoke free or are already smoke free, such as the University of Colorado–Boulder and all University of California campuses (University of California, 2012; University of Colorado–Boulder, 2013). State-, local-, and community-level prevention campaigns exist as well, with communities passing restrictions and policies concerning tobacco advertising and availability especially aimed toward youth (CDC, 2012g).

### Clinical Issues

Although previous studies were based on DSM-IV nicotine dependence, they can be applied to estimate clinical issues related to DSM-V tobacco use disorder because the DSM-IV criteria for nicotine dependence are a subset of the DSM-V criteria for tobacco use disorder (APA, 2000, 2013).

#### Cessation desire, treatment, and success.

With the most common form of chemical dependence in the United States being tobacco use disorder, treatment is often required for successful tobacco cessation (CDC, 2013). Although 69% of smoking U.S. adults wish to quit entirely, only 52% of adult cigarette users attempted to quit in 2010 (CDC, 2012c). Approximately 50% of youth ages 14 to 17 wish to quit smoking, with approximately 62% of young adults ages 18 to 24, 57% of adults ages 25 to 44, and up to 46% of older adults ages 45 and older wishing to quit cigarettes as well (CDC, 2013). However, fewer than one third (31%) of smokers who attempted to quit received cessation treatment (Malarcher, Dube, Shaw, Babb, & Kaufmann, 2011). Nearly 75% of adult smokers seeking cessation treatment are highly nicotine dependent (Zoler, 2008). Perhaps because of the lack of treatment among tobacco users who wish to quit, the overall rate of successful tobacco cessation among the smoking population is currently only approximately 6.2%, despite much higher percentages wishing to quit (Malarcher et al., 2011). In fact, more than 85% of smokers who attempt cessation without assistance end up relapsing, with many relapsing within a week of attempting to quit (NIDA, 2012b).

#### Tobacco use disorder and comorbid psychiatric disorders.

Nicotine is highly addictive, which leads to most tobacco users being nicotine dependent (CDC, 2013). Tobacco use disorder has been found to be comorbid with other psychiatric disorders in both adults and youths. Studies have indicated that adolescents with a depressive disorder were nearly five times as likely to have nicotine dependence compared with their nondepressive disorder peers (Fergusson, Lynskey, & Horwood, 1996). Other studies have identified that psychiatric disorders tend to precede nicotine dependence, as opposed to nicotine dependence triggering psychiatric illnesses (Griesler et al., 2008). An early onset of a psychiatric disorder was found to increase the risks of developing nicotine dependence in adolescents.

Similarly, adults with nicotine dependence have been shown to have increased chances of having other substance use disorders (for example, alcohol abuse), anxiety disorders, somatoform disorders, or affective disorder (Ulrich, Meyer, Rumpf, & Hapke, 2004). Estimates indicate that approximately 80% of alcoholics and as many as 90% of those with schizophrenia are regular smokers (NIDA, 2012c). In 2010, up to 23% of current smokers ages 12 and older reported using illicit drugs compared with fewer than 5% of their nonsmoking peers (SAMHSA, 2011). The report shows that rates of comorbidity are even higher among youths, with more than 50% of current smoking youth ages 12 to 17 using illicit drugs compared with only approximately 6% of their nonsmoking peers. Other comorbid factors may contribute to the relationship between nicotine dependence and psychiatric disorders. In some cases, smoking or tobacco use may serve as a form of self-medication for psychiatric illness, such as major depressive disorder or anxiety disorders. This may be brought on by a third variable, which could impact the relationship between psychiatric disorders and nicotine dependence (Ulrich et al., 2004). In total, approximately 44% of all cigarettes sold in the United States are purchased by people with psychiatric disorders (NIDA, 2012c).

#### Screening tools for tobacco use disorder.

Various assessment tools are used in tobacco cessation to screen for tobacco use disorder. The Hooked on Nicotine Checklist is used to assess nicotine dependence in youth (DiFranza et al., 2007). The checklist consists of 10 “yes” or “no” questions, such as “Have you ever tried to quit, but couldn’t?” or “Do you ever have strong cravings to smoke?” (DiFranza et al.). The score is calculated by summing the number of “yes” responses, with higher scores indicating higher nicotine dependence.

The Nicotine Dependence Syndrome Scale (NDSS) and the Fagerström Test for Nicotine Dependence (FTND) are assessments that can be used for both youth and adult screenings (Clark et al., 2005). The NDSS consists of 19 items, each of which has a 5-point Likert-type scale response option ranging from “not at all true” to “extremely true” (Shiffman, Waters, & Hickcox, 2004). Examples of the NDSS questions are “If I wake up during the night, I feel I need a cigarette” and “I smoke consistently and regularly throughout the day.” The FTND is a revision of the 1978 Fagerström Tolerance Questionnaire; it is a shorter assessment than the NDSS, consisting of only 6 items, such as “How soon after you wake up do you smoke your first cigarette?” and “How many cigarettes per day do you smoke?” (Heatherton, Kozlowski, Frecker, & Fagerström, 1991). Higher scores indicate higher nicotine dependence.

#### Screening tools for tobacco withdrawal.

Similar to assessing tobacco use disorder, various assessments are used to screen for tobacco withdrawal, especially in cessation programs or studies. The Nicotine Withdrawal Assessment for Youth (N-WAY) is used to assess adolescent and youth withdrawal (Goldfine, Branstetter, & Horn, 2012). The N-WAY screening is aimed at 13- to 19-year-old youths and uses 39 items to assess the frequency and significance of potential nicotine withdrawal symptoms experienced within the past week. Examples of items include restlessness, anger, headaches, and concentration problems. Each item has a 5-point Likert-type scale response option ranging from “not at all” to “almost always” or “extremely,” with higher scores indicating a higher severity of nicotine withdrawal.

The Minnesota Nicotine Withdrawal Scale (MNWS) is another screening tool for nicotine withdrawal (Hughes & Hatsukami, 1986). The revised version of the scale, the Minnesota Nictotine Withdrawal Scale–Revised (MNWS-R) is now used as well (Shiffman, West, & Gilbert, 2004). The MNWS-R is made up of 15 items that measure eight symptoms of withdrawal such as mood, appetite, and sleep disturbance using a 5-point Likert-type scale response option ranging from “0 or not present” to “4 or severe” (Shiffman, West, et al., 2004; Toll, O’Malley, McKee, Salovey, & Krishnan-Sarin, 2007). Similar to the N-WAY measure, the Wisconsin Smoking Withdrawal Scale (WSWS) is used to screen for nicotine withdrawal (Welsch et al., 1999). The WSWS consists of 28 items that use a 5-point Likert-type scale response ranging from “strongly disagree” to “strongly agree.” Questions range from “I have been impatient” to “I am satisfied with my sleep”; the questions are subdivided into various subscales, which combined measure different aspects of nicotine withdrawal, including anger, anxiety, sadness, concentration, hunger, somatic symptoms, sleep, and cravings (Welsch et al.).

### Practice Interventions

A variety of treatment methods and programs exist for individuals with tobacco use disorder or tobacco withdrawal symptoms. Although a majority of smokers attempt to quit without using evidence-based practices or treatments, incorporating proven cessation practices will help individuals quit long term (CDC, 2013). Effective cessation programs can range from clinical interventions to counseling or behavioral cessation therapy (CDC). Anything from information on how to quit from the doctor to psychiatric therapy has been shown to improve cessation (CDC). Help services such as a quitline that offers free support service over the telephone or group cessation therapy programs at a local hospital can be greatly beneficial.

Various national, state, and local tobacco cessation programs exist across the United States. Free online quit programs such as smokefree.gov and betobaccofree.gov can help individuals quit, as can mobile phone applications such as the National Cancer Institute’s QuitPal, Smokefree Teen QuitSTART, and Smokefree QuitGuide, as well as quit phone lines such as the USDHHS and state-sponsored 1-800-QUIT-NOW (smokefree.gov, 2013; CDC, 2012f). The 1-800-QUIT-NOW program varies its benefits by state, but services such as personalized quit plans, cessation coaching sessions, educational materials, and free or reduced nicotine replacement therapy or prescription nicotine replacement medications are available. The ALA also offers national tobacco quit programs, such as the adult Freedom from Smoking program, including smoking cessation counseling (for example, about managing stress and developing a new self-image), 1-800-LUNG-USA or www.ffsonline.org, and the N-O-T (Not On Tobacco, notontobacco.com) program aimed at teenage smokers (ALA, 2013). In 2004 the CDC published the Youth Tobacco Cessation: A Guide for Making Informed Decisions, which is aimed toward providing tobacco cessation for U.S. youth (Milton et al., 2004). Tobacco cessation programs on the local level exist by the handful as well, with local hospitals or health-care organizations offering unique cessation programs.

Tobacco control and cessation programs exist for subpopulations, including racial or ethnic minorities. The CDC published an informational guidebook for tobacco cessation and education aimed toward African Americans called Pathways to Freedom: Winning the Fight against Tobacco (CDC, 2003). Other local-level programs directed toward minorities exist, such as the San Francisco Department of Public Health Tobacco Free Project sponsored program The Last Drag (2013), which is aimed toward the LGBTQ community and HIV-positive smokers (http://lastdrag.org). In 2010 the Maryland Montgomery County Department of Health and Human Services sponsored a Latino health initiative smoking cessation program that provided both cultural and linguistically tailored smoking cessation for Latino smokers (Latino Health Initiative, 2010). This program provided individual and group counseling, educational materials, quit kits, and nicotine replacement therapy for Latino individuals wanting to quit smoking.

In 2006 the CDC Office on Smoking and Health (OSH) funded six national tobacco control programs in partnership with the National Tobacco Control Program tailored toward minority and underserved populations (National Network for Tobacco Control and Prevention, 2013). The six networks are the National African American Tobacco Prevention Network (NAATPN), the Asian Pacific Partners for Empowerment Advocacy and Leadership (APPEAL), the Break Free Alliance, the National Latino Tobacco Control Network (NLTCN), the Keep It Sacred National Native Network, and the National LGBT Tobacco Control Network (National Network for Tobacco Control and Prevention). The NAATPN promotes tobacco control and cessation in the African American community (NAATPN, 2011). APPEAL promotes a tobacco-free Asian American, Native Hawaiian, and Pacific Islander community and worked with those community leaders to develop and implement culturally appropriate tobacco control and cessations programs in local communities (APPEAL, 2012). They have also developed the Asian Smokers’ Quitline, a free smoking cessation line available to anyone in the United States, that provides quitline services such as informational materials, support, and nicotine replacement therapy to Cantonese-, Mandarin-, Korean-, and Vietnamese-speaking individuals (Asian Smokers’ Quitline, 2013). The Break Free Alliance, which is administered by the Health Education Council, is targeted toward collaborating with organizations that serve low-SES populations to assist with relevant tobacco control, education, cessation, and policy development (Break Free Alliance, 2009). The NLTCN provides assistance to tobacco control organizations and communities through culturally and linguistically appropriate training services, materials, and cessation practices (NLTCN, 2012). The Keep It Sacred network provides the National Native Commercial Tobacco Abuse Prevention Network, administered by the Inter-Tribal Council of Michigan, that works with over 550 AI/AN tribes to provide culturally relevant interventions and education materials (Keep It Sacred National Native Network, 2013). The final CDC network is the National LGBT Tobacco Control Network, administered by the Fenway Institute in Boston, which is aimed toward the LGBTQ community and works with various quitlines, medical providers, and the ALA to provide relevant cessation and control resources (National LGBT Tobacco Control Network, 2013).

In addition to cessation programs and therapies, medications can also assist in easing the quitting process. Products such as over-the-counter nicotine replacement products (for example, nicotine patches, nicotine lozenges, or nicotine gum), as well as prescription nicotine substances such as nicotine nasal sprays or inhalers, can improve cessation success and ease difficulty (CDC, 2013). Higher nicotine dependence may also be assisted by nonnicotine prescription medications such as bupropion sustained release or varenicline tartrate (CDC). Typically, some combination of medication and therapy is more effective for tobacco cessation.

### Roles of Social Workers

Social workers could play an important role in controlling tobacco. For example, social workers could be tobacco cessation coaches who provide guidance, resources, and treatment options to individual tobacco users. Skills such as communication, screening, assessment, case management, motivational interviewing, and referrals would increase the capacity of social workers in helping tobacco users successfully end their dependence on tobacco.

Social workers could also work as part of an interdisciplinary or a multidisciplinary team consisting of physicians, nurses, social workers, psychologists, and other health-care professionals. Unlike other health-care providers, social workers could help tobacco users quit or stay quitting in both tobacco user levels and system levels around tobacco users (for example, conjunctions with tobacco users’ family, friends, and other significant people). Social-work case managers would be an example of linking tobacco users to system-level interventions. For example, social-work case managers can analyze the strengths and limitations of environments around tobacco users, select tobacco cessation strategies to improve environments, assess the effectiveness of the cessation strategies, and continue to revise the strategies (National Association of Social Workers, 1992).

Furthermore, because tobacco use is a public-health concern, social workers could be involved in all three levels of public-health prevention: the primary level (for example, education about tobacco and medical consequences of tobacco use), the secondary level (for example, screening for tobacco use disorder or tobacco withdrawal), and the tertiary level (for example, helping tobacco quitters minimize tobacco withdrawal symptoms).

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