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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5536_Библиотеки_им_академика_М_И_Перельмана.pdf
Tobacco
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When companies sell more than they spend, they make a profit. Selling their products
to other countries is called exporting. The product that is sold is called an export.
Buying from other countries is called importing, and what U.S. companies buy is
called an import. For example, if Ford Motor Company buys steel from Japan to
make a car, it is importing a product. Steel is the import. When Ford sells its cars
to Brazil, it is exporting. Cars are the exports.
When companies or governments export more than they import, they have a trade
surplus. A trade surplus is another way of saying a profit. On the other hand, when
they import more than they export, they have a trade deficit. A deficit means a
debt or money owed to someone else.
Throughout history, tobacco companies have had a trade surplus. That is one big
reason why they have been important to the economy of the U.S. In 1992 the
tobacco industry reported a $5.65 billion dollar trade surplus. In the first half
of 1992, tobacco exports were $2 billion more than imports. The taxes that the
tobacco companies pay provide a lot of money for the U.S. government. In 1992,
Philip Morris alone paid $4.5 billion in taxes. This makes it the largest tax payer
in the U.S.
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
Tobacco companies export their products (cigarettes, cigars, chewing tobacco) to
at least 146 countries around the world. They sell to Hong Kong, Saudi Arabia,
United Arab Emigrates, Turkey, South Korea, Singapore, China, Russia, and many
more countries. In 1992 Philip Morris sold 11 billion cigarettes to Russia alone.
One of the reasons tobacco growing is so profitable is because its costs are so
low. There are only about 800,000 people working in the tobacco industry. There
are 136,000 tobacco farms in more than 16 states.
Tobacco Acres Harvested by
State in 1991
State 1991 Acres
Connecticut 1,750
Florida 6,700
Georgia 40,000
Indiana 7,200
Kentucky 223,150
Maryland 7.400
Massachusetts 480
Montana 3.000
North Carolina 274,000
Ohio 1,0,500
Pennsylvania 10,500
South Carolina 51,000
Tennessee 61,700
Virginia 53,600
West Virginia 1,800
Wisconsin 7,400
United States 761,080
The making or manufacturing of cigarettes is almost completely automated. It is
done by machines without people. Machines crush and clean tobacco leaves and
add chemicals like nicotine. They also roll cigarettes, put on filters, cut them to
length, and then package them.
Tobacco
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171
All of the six U.S. companies producing cigarettes are large and powerful. They are
so strong that not even all the medical reports of the health dangers of smoking and
all the laws restricting smoking and advertising have been able to weaken them.
They are still able to make big profits by buying up other non-tobacco companies
in the U.S. and by selling and making cigarettes outside the country. For example,
Philip Morris bought Miller Beer and Kraft General Foods, and R.J. Reynolds bought
the Nabisco Food Group and General Entertainment Corporation.
Tobacco Companies: The Companies They Own & The Products They Make
Philip Morris
Bird’s Eye Louis Kemp
Seafood
Louis Rich
Meats
Crystal Light Lender’s
Minute Rice Oscar
Post Cereals Claussen
Stove-Top Log Cabin Country
Millers Beers Maxim
Shake and
Bake
Light ‘n
Lively
Bagels
Mayer
Pickles
Coffee
Baboli
Bread
Jello
Kool-Aid
Kraft
Tang
Lowenbrau
Time
Maxwell
House
Seven Seas
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
Miracle Whip Louis Rich Cool Whip
Milwaukee’s
Best Beer
Knudson Meister
Capri Sun DiGiorno
Entenmanns Sealtest Ice
Chiffon Richmix
Brooke Group (formerly Liggett & Myers)
MAI (computers,
information
systems)
Basic Four LineDrive Pre-
Distributor of
football & hockey
cards
GI Joe cards World Championship
Terminator II
movie cards
NFL Proline
Portraits
Star Trek X-men
Full House Perfect Strangers
Family Matters DC comic book
Sharp’s Beer Bulls Eye
Sauce
Parkay
Brau Beer
Pasta
Cream
Candy
NBA Hoops (baseball
cards)
rookie(baseballcards)
Marvel superhero cards
Wrestling cards
Disney cards
1992 Olympic cards
characters
Margarine
Food Club
Bakers
Chocolate
Breyer’s
IceCream
The Greg Louganis Story
The U.S. government and the tobacco companies help each other. Since 1964 all
the Surgeon Generals of the U.S. have talked and written about the health dangers
of cigarettes. Still, cigarettes are made, advertised, and sold. The tobacco industry
gives thousands of dollars to help cover the costs of political campaigns of people
running for political office. These are people who want to be elected or reelected
as Senators, Representatives, Vice-President, and President. In turn the politicians
help the tobacco industry.
Tobacco
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173
One way politicians help is continuing the tobacco price support system. Under
the price support system, tobacco can only be grown on a certain number of
government-approved farms. The government gives farms special, low interest loans
to help cover the costs of growing tobacco. The U.S. Department of Agriculture
allows a certain amount of tobacco to be grown each year. This is called a quota.
It also sets a minimum price for tobacco. When the farmer takes his/her tobacco to
the market, any tobacco not sold one cent above the government price is bought
by grower cooperatives and stored to be sold another year.
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
PHARMACOLOGY
To understand the pharmacology of varenicline, it is necessary to understand the
pharmacology of nicotine and its addiction. Nicotine is distilled from the cigarette as
it is smoked and readily absorbed through the alveolar surface of the lung, rapidly
reaching circulation through the extensive capillary network within the lung. It is
estimated that nicotine rapidly reaches the brain within 11 seconds after inhalation.
Nicotine is the primary chemical in tobacco that contributes to tobacco dependency.
Nicotine affects many neurotransmitters, but dopamine seems to be most responsible
for the major addictive properties of nicotine. Nicotine from tobacco directly
stimulates the acetylcholine receptors on dopamine-containing neurons, which are
involved in the reinforcing centers of the brain, as a part of the mesolimbic system.
The stimulation of these acetylcholine receptors is responsible for the overflow of
dopamine in the reward centers of the brain, resulting in extracellular dopamine
within the nucleus accumbens and an increased firing of dopaminergic neurons.
Many subtypes of acetylcholine receptors are associated with nicotine addiction.
Acetylcholine-receptor subtypes, such as →4ß2, are ligand-gated ion channels found
on the dopaminergic neurons and on the →-aminobutyric acid (GABA)-containing cells.
These receptors are thought to play a principal role in the mediation of nicotine
addiction. Unlike acetylcholine, which is degraded quickly by acetylcholinesterase,
nicotine remains active at the →4ß2 receptor sites for a prolonged period of time.
While prolonged stimulation by most entities usually causes receptor down-regulation,
nicotine stimulation at the acetylcholine receptors causes receptor up-regulation. This
up-regulation desensitizes acetylcholine receptors, resulting in physical dependence,
tolerance, and withdrawal symptoms, thereby adding to the propensity for nicotine
addiction. Smokers who try to quit unaided experience symptoms of withdrawal,
such as depression, insomnia, irritability, anxiety, difficulty concentrating, restlessness,
weight gain, increased appetite, and decreased heart rate.
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Tobacco
Use of nicotine sustains tobacco addiction, which in turn causes devastating
health problems, including heart disease, lung disease, and cancer, and increased
susceptibility to a variety of infectious diseases. Smoking harms almost every organ
of the body (1). Quitting smoking at any age leads to significant reductions in
the risks associated with it, and the vast majority of smokers in the United States
indicate an interest in quitting (2). Despite these facts, however, approximately
80% of smokers who attempt to quit on their own relapse within the first month
of abstinence, and only approximately 3% remain abstinent at six months.
Although most of the toxicity of smoking is related to other components of
cigarette smoke, it is primarily the pharmacologic effects of nicotine that produce
the addiction to tobacco. An understanding of how nicotine produces addiction
and influences smoking behavior provides a necessary basis for optimal smoking
cessation intervention. This article reviews the neurobiology of nicotine addiction
and withdrawal, as well as the implications for nicotine addiction therapy.
Tobacco contains about 4,000 chemicals including:
■ nicotine
■ a number of known carcinogens (e.g. nitrosamines, toluidine, nickel,
benzopyrene, cadmium and polonium 210)
■ 2–6% carbon monoxide
■ hydrogen cyanide
■ various nitrogen oxides
■ tar
■ Toba
Nicotine is the agent responsible for physical dependence. It is a toxic alkaloid,
with a half life of 1–2 hours, that rapidly crosses the blood brain barrier to stimulate
both the dopaminergic and noradrenergic pathways in the brain.
Nicotine effects on the cardiovascular system are mediated by sympathetic neural
stimulation together with an increase in levels of circulating catecholamines. It
has the apparent paradoxical effect of being both a stimulant (at low doses) and a
relaxant (at high doses). Nicotine produces a range of toxic effects.
175
At-Risk Groups
Sub-groups of the Australian population have smoking rates much higher than that
of the general population. As the level of disadvantage increases, so do smoking
rates. In addition, people from these groups often smoke more cigarettes and for
more years than the general population. As a result, many people that are already
experiencing disadvantage carry an unequal share of death and disease caused by
smoking.
Smokers from at risk groups face many barriers to quitting. However, when asked
the majority of people from disadvantaged groups do want to quit smoking. By
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
supporting people from at risk groups to quit, you will also help to reduce the
health inequalities they experience from smoking, and give them the opportunity
to experience real health and material benefits.
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All individuals are at-risk from tobacco smoking but some groups are at special risk:
■ socially disadvantaged groups — people of non-English speaking background,
Indigenous Australians, and those with mental illness have higher prevalence
of smoking
■ Pregnant women and unborn babies exposed involuntarily to environmental
tobacco smoke (ETS)
■ Children exposed environmentally to tobacco in ‘smoking’ households and
subject to peer pressure to commence smoking
Factors associated with likelihood to smoke or use tobacco
Numerous factors influence adolescents’ decisions to start smoking or to use other
tobacco products. These factors include some individual characteristics, such as
stress and low self-esteem, but also social characteristics, such as having parents,
siblings, or friends who smoke. Exposure and susceptibility to tobacco advertising
can also affect smoking initiation among adolescents.
Certain characteristics increase the likelihood that an adolescent will smoke:
■ Older age. Rates of regular cigarette smoking and other tobacco use are
higher among older adolescents than they are among younger adolescents
[
Tobacco
(although the rate of smoking initiation is higher among younger adolescents).
■ Being male. Females tend to smoke fewer cigarettes a day, use cigarettes
with lower nicotine content, and inhale cigarette smoke less deeply, than
do males. Males are also more likely than females to use e-cigarettes.
■ Being white, multi-ethnic, American-Indian, or Alaska Native. White
adolescents are more likely to smoke cigarettes than black or Hispanic
adolescents (though black adolescents are more likely to smoke cigars).
However, adolescents who are multi-ethnic, as well as American-Indian
and Alaska Natives, are more likely than any other race or ethnic group
to use tobacco.
■ Lacking college plans. Adolescents who plan to attend four years of college
are much more likely to be nonsmokers than are their peers who lack
such plans.
■ Having parents who are not college educated. Adolescents whose parents
had little or no college education are much more likely to smoke than
those whose parents have a college education or more.
■ Experiencing highly stressful events. Having experienced numerous highly
stressful events in childhood is linked with a greater risk of starting smoking
by age 14 and with ever smoking. Among these stressors are being a witness
or victim of abuse, experiencing a parental separation, or growing up in
a household in which a family member is mentally ill or incarcerated.
■ Perception of Risk. The percentage of adolescents who see smoking as posing
a “great risk” to them has steadily increased since the peak of tobacco
cigarette use in the 1990’s. This has helped contribute to the decline in use
seen over the past two decades. Conversely, a low percentage perceive a
“great risk” in using e-cigarettes regularly; in fact, less than 20 percent of
adolescents see a “great risk” in regular e-cigarette use. This is one of the
lowest levels of perceived risk measured across all substance categories.
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
Factors making it difficult to stop smoking
Research points to multiple factors that lead to tobacco addiction in adolescence, from
genetic patterns, to influences of parents and peers, to difficult life circumstances.
First and foremost, nicotine is a highly addictive drug that affects individuals on a
cellular level, meaning addiction is difficult to overcome for adolescents, as well
as adults.
Factors that make it difficult to stop smoking include:
■ Physical effects. The effects of nicotine, including the “reward” feeling,
quickly wear off, motivating the user to keep using tobacco to recapture that
feeling and to prevent withdrawal symptoms. Those withdrawal symptoms
are unpleasant and include irritability, craving, attention problems, disturbed
sleep, and increased appetite.
■ Behavioral factors. In addition to the physical factors that make it harder
for adolescents to quit smoking, behavioral factors also come into play:
adolescents frequently associate smoking, its smell and feel, with a number
of behaviors, including using alcohol and hanging out with friends who
smoke. The influence of peers on adolescents’ smoking behavior seems to
decline with age,
smoking, and whether their smoking escalates to daily use.
■ Smoking early in adolescence. Research shows that the earlier adolescents
begin smoking cigarettes, the more likely they are to become addicted
to nicotine.
survey, nearly 90 percent of adults who smoke became regular smokers
during adolescence or earlier.
■ Concerns about weight gain. For some adolescents, concerns about weight
gain may be associated with the decision to begin smoking or with a
reluctance to quit. Females are less likely to try to quit smoking and are
more likely to relapse if they do quit.
■ Genetics. A half-dozen genes, among the thousands that a person inherits,
can affect how the brain reacts to nicotine, including the likelihood of
becoming addicted.
but is an important factor in whether adolescents begin
According to results from a nationally representative health
Detection and Assessment
Self-report of smoking status is both reliable and valid. Some smokers are sensitive
about enquiry. A non-judgmental approach that also signals that all patients are
asked will help minimise stigma. In assessing and treating smokers, clearly, “one size
does not fit all.” Since no two smokers are the same, it follows that assessment and
treatment must be individualized to take into account the dynamic circumstances
and changing needs of the individual over time. Assessment aims not only to identify
tobacco use and detect dependence, but also to inform individualized and longitudinal
treatment decisions, and finally to measure outcomes over time. Assessment should
also aim to identify and explore factors that potentially impact outcomes. These