
Cigarette smoking in the United States has fallen more than 70% since the 1940s, but that statistic masks a darker reality. Fueled by generations of new nicotine delivery devices and systems, tobacco use and nicotine dependence are rising, according to the most recent report on tobacco use from the US Surgeon General.
“Combustible tobacco in the form of cigarette use is down substantially compared with the 1940s, ’50s, and ’60s, but there is now a wider variety of tobacco products that makes up for part of that decline,” said Frank Leone, MD, MS, FCCP, Chair of the CHEST Tobacco/Vaping Work Group. “If you broaden the definition of tobacco use to include alternate forms of nicotine delivery—vaping, pouches, etc—the prevalence of tobacco dependence is probably higher now than it has been in the recent past. The trend has been going in the wrong direction.”
Decades of reports from Surgeon Generals have transformed our understanding of tobacco use from an unhealthy lifestyle choice to behavior driven by nicotine dependence. The latest report, Eliminating Tobacco-Related Disease and Death: Addressing Disparities, targets social and environmental influences on the propensity to use tobacco.
The report notes that the advent of e-cigarettes, nicotine pouches, and other noncombustible tobacco products have the potential to undermine progress in younger populations. But the focus remains on smoking and smoking cessation.
“We tend to think about smoking as a unique form of tobacco use, a unique product, and a unique pattern of use,” Dr. Leone said. “But if you don’t use the verb ‘to smoke,’ but rather think about the action of delivering nicotine to the brain, you see a wider variety of use patterns, some of them a little bit scary. Vaping can deliver nicotine aerosol to the lungs 2,000 to 3,000 times a day. That kind of exposure is impossible with cigarettes. Just because it’s not a cigarette doesn’t mean it’s safe.”
The problem for clinicians and people at risk for tobacco use is the decades-old focus on tobacco use as a risk factor for future disease. Dr. Leone suggested the more useful approach is framing tobacco product use as a cardinal sign of an acquired obsessive compulsive-related disorder.
He likened treating tobacco-use disorder to treating type 2 diabetes. Clinicians don’t treat diabetes by lowering hemoglobin A1c; they invoke an ordered process that may include multiple approaches with the desired outcome of reducing A1c. Halting the intake of nicotine from tobacco or any other source is the outcome of treatment; treating nicotine dependence is the process that leads to that outcome.
“We have to start thinking about how the body responds to the delivery of these aerosol mixtures, both in the lungs and in other organ systems downstream,” Dr. Leone said. “That message of tobacco use as an obsessive compulsive-related disorder is an important message for the clinical community and an easy message to translate into lay language.”
The message is straightforward: Everyone knows tobacco is bad, and everyone has their own personal reasons to stop. What has to change, he said, is that “mental tickle,” that internal alarm that makes people uncomfortable or uneasy whenever they think about not using their favorite nicotine product.
“This is not a foreign concept to clinicians: beginning a treatment plan with the expectation that you’re not going to get it 100% correct on the first try,” Dr. Leone said. “The expectation is that you’re going to have to evaluate the impact of your intervention and adjust based on the patient’s experience. The singular focus on the cessation part, on the outcome, can make it so difficult to engage. We clinicians have begun to interpret our effectiveness based on patient behaviors that are outside our locus of control. The best we can do is treat the underlying process that puts the patient at risk and keep working toward the desired outcome.”