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Nicotine and related disorders Synopsis:Tish Davidson, AM Emily Jane Willingham, PhD Kristin Key Source Citation: "Nicotine

and related disorders." Tish Davidson, AM. and Emily Jane Willingham, PhD. The Gale Encyclopedia of Mental Health. Ed. Kristin Key. 3rd ed. Detroit: Gale, 2012. 2 vols.

DefinitionNicotine is the main psychoactive ingredient in tobacco. It is a physically and psychologically addictive drug. Nicotine is the most influential dependence-producing drug in the United States and worldwide, and its use is associated with many serious health risks.

DemographicsAlthough the prevalence of smoking has gradually decreased in the United States and many other industrialized countries since the 1970s, the use of tobacco products is rapidly increasing in developing nations, where approximately 80% of current smokers live. Younger populations may be particularly vulnerable. For example, a CDC survey from 2003 found that almost 42% of teenaged boys in one city in Mali were cigarette smokers. The World Health Organization currently attributes more than five million deaths per year globally to tobacco use among the estimated one billion smokers worldwide, a death total expected to increase to eight million by 2030. Another 600,000 deaths occur in nonsmokers as a result of exposure to secondhand smoke. Use of tobacco products in developing countries is of particular concern, because these countries often lack adequate healthcare resources to treat smokingrelated diseases, let alone support smoking cessation programs.

In the United States, men are more likely to smoke than women (33.7% to 21.5%). In developing countries, male smokers outnumber women smokers, but among adolescent populations, girls and boys are becoming more equal in their rates of smoking. In the United States, people who smoke tend to have less formal education than those who do not, with the lowest smoking rates in persons with college degrees. At least 50% of patients diagnosed with psychiatric problems are smokers, while more than three-quarters of those who abuse other substances also smoke.

According to the National Survey on Drug Use and Health, from 1997 to 2010, smoking among U.S. middle- and high-school students had declined after increasing dramatically in the 1990s. Smoking is most prevalent among adults aged 18 to 25, with an estimated 40.8% of all smokers falling within this age group. Among different ethnic groups, the highest rates of smoking resided in American Indian or

Alaskan Native populations (35.8%), followed by persons who were two or more races (32%), Caucasians (29.5%), and African Americans (27.3%).

Recent research suggests that there may be a genetic component to nicotine dependence, just as there is for alcohol dependence. Studies show that girls (but not boys) whose mothers smoked during pregnancy are four times more likely to smoke than those whose mothers were tobacco-free during pregnancy. Other research suggests that the absence of a certain enzyme in the body protects the body against nicotine dependence.


Nicotine is the most addictive and psychoactive chemical in tobacco, a plant native to North America. Early European explorers learned to smoke its leaves from indigenous peoples who had been using tobacco for hundreds of years. They took tobacco back to Europe, where it became immensely popular. Tobacco became a major source of income for the American colonies and later for the United States. Advances in cigarette-making technology caused a boom in cigarette smoking in the early 1900s. Before the early twentieth century, most people who used tobacco used pipes, cigars, or chewing tobacco.

In the 1950s, researchers began to link cigarette smoking to certain respiratory diseases and cancers. In 1964, the Surgeon General of the United States issued the first health report on smoking. Cigarette smoking peaked in the United States in the 1960s, then began to decline as health concerns about tobacco increased. In 1971, cigarette advertising was banned from television, although tobacco products are still advertised in other media today. There were about 69.6 million adult smokers in the United States in 2010, and approximately 2.4 million people had smoked their first cigarette in the previous month. Most active smokers are addicted to nicotine.

Pure nicotine is a colorless liquid that turns brown and smells like tobacco when exposed to air. Nicotine can be absorbed through the skin, the lining of the mouth and nose, and the moist tissues lining the lungs. Cigarettes are the most efficient nicotine delivery system. Once tobacco smoke is inhaled, nicotine reaches the brain in less than 15 seconds. Because people who smoke pipes and cigars do not inhale, they absorb nicotine more slowly. Nicotine in chewing tobacco and snuff is absorbed through the mucous membranes lining the mouth and nasal passages. There are also several "hard snuff" and other new tobacco products being produced and marketed as alternative to traditional tobacco products. At least one study of the nicotine content of these products has found that some have lower levels of nicotine than regular tobacco products, but others contain comparable levels.

Causes and symptoms

How nicotine works

Nicotine is the main addictive drug among the 4,000 compounds found in tobacco smoke. Other substances in smoke as tar and carbon monoxide present documented health hazards, but they are not addictive and do not cause cravings or withdrawal symptoms to the extent that nicotine does. Neuroimaging technology has shown that levels of monoamine oxidase, the enzyme responsible for boosting mood-enhancing molecule levels in the brain, increase in response to smoking, even though nicotine does not affect levels of this enzyme. Thus, some other compound in cigarette smoke must be acting to exert this effect. In addition, a compound in cigarette smoke called acetaldehyde may contribute to tobacco addiction and may have a stronger effect in adolescents.

Nicotine is both a stimulant and a sedative. It is a psychoactive drug, meaning that it works in the brain, alters brain chemistry, and changes mood. Once tobacco smoke is inhaled, nicotine passes rapidly through the linings of the lungs and into the blood. It quickly circulates to the brain where it stimulates release of dopamine, a neurotransmitter (nerve signaling molecule) that affects mood. Drugs that elicit an increase in dopamine influence the brain's "reward" pathway, causing the user to turn again to the drug for another pleasurable, rewarding dopamine response. This release accounts for the pleasurable sensation that most smokers feel almost as soon as they light a cigarette. Nicotine also decreases anger and increases the efficiency of a person's performance on long, dull tasks.

As nicotine affects the brain, it also stimulates the adrenal glands. The adrenal glands are small, peasized organs located above each kidney that really act as two different endocrine organs. The adrenal gland produces several hormones in the medulla, or inner layer, including epinephrine, also called adrenaline. Under normal circumstances, adrenaline is released in response to stress or a perceived threat. It is sometimes called the "fight or flight" hormone, because it prepares the body for action. When adrenaline is released, blood pressure, heart rate, blood flow, and oxygen use increase. Glucose, a simple form of sugar used by the body, floods the body to provide extra energy to muscles. The overall effect of the release of the stress hormones is strain on the cardiovascular (heart and blood vessels) system. This response to stress produces inflammation in the blood vessels that ultimately results in buildup of plaque, which can block the vessels and cause stroke or heart attack.

Most people begin smoking between the ages of 12 and 20. Few people start smoking as adults over 21. Adolescents who smoke tend to begin as casual smokers, out of rebellion or a perceived need for social

acceptance. Dependence on nicotine develops rapidly, however; one study suggests that 85%-90% of adolescents who smoke four or more cigarettes become regular smokers. Nicotine is addictive, so being tobacco-free soon feels uncomfortable for users. In addition, smokers quickly develop tolerance to nicotine. Tolerance is a condition that occurs when the body needs a larger and larger dose of a substance to produce the same effect. For smokers, tolerance to nicotine means more frequent and more rapid smoking. Soon most smokers develop physical withdrawal symptoms when they try to stop smoking. Users of other forms of tobacco experience the same effects; however, the delivery of nicotine is slower and the effects may not be as pronounced.

Nicotine dependence

In addition to the physical dependence caused by the actions of nicotine on the brain, there is a strong psychological component to the dependency of most users of tobacco products, especially cigarette smokers. Most people who start smoking or using smokeless tobacco products do so because of social factors. These include:

desire to fit in with peers acceptance by family members who use tobacco rebelliousness association of tobacco products with maturity and sophistication positive response to tobacco advertising Such personal factors as mental illness (depression, anxiety, schizophrenia, or alcoholism), the need to reduce stress and anxiety, or a desire to avoid weight gain also influence people to start smoking. Once smoking has become a habit, whether physical addiction occurs or not, psychological factors play a significant role in a person's continuing to smoke. People who want to stop smoking may be discouraged from doing so because:

they live or work with people who smoke and who are not supportive of their quitting they believe they are incapable of quitting they perceive no health benefits to quitting they have tried to quit before and failed

they associate cigarettes with specific pleasurable activities or social situations that they are not willing to give up they fear gaining weight Successful smoking cessation programs must treat both the physical and psychological aspects of nicotine addiction.

Nicotine withdrawal

The American Psychiatric Association first recognized nicotine dependence and nicotine withdrawal as serious psychological problems in 1980. Today nicotine is considered an addictive drug, although a common and legalized one.

Quitting nicotine can be difficult. Among people who try, between 75% and 80% relapse within six months. Because of this rate, research has found that smoking cessation programs that last longer than six months can greatly enhance quit rates, achieving rates as high as 50% at one year. Combining a nicotine-withdrawal product with a behavioral-modification or support program has produced the greatest success rates.

The combination of physiological and psychological factors make withdrawal from nicotine very difficult. Symptoms of nicotine withdrawal include:

irritability restlessness increased anger or frustration sleep disturbances inability to concentrate increased appetite or desire for sweets depression anxiety

constant thoughts about smoking cravings for cigarettes decreased heart rate coughing Withdrawal symptoms are usually more pronounced in smokers than in those who use smokeless tobacco products, and heavy smokers tend to have more symptoms than light smokers when they try to stop smoking. People with depression, schizophrenia, alcoholism, or mood disorders may find it especially difficult to quit, as nicotine offers temporary relief for some of the symptoms of these disorders.

Symptoms of nicotine withdrawal begin rapidly and peak within one to three days. Withdrawal symptoms generally last three to four weeks, but a significant number of smokers have withdrawal symptoms lasting longer than one month. Some people have strong cravings for tobacco that last for months, even though the physical addiction to nicotine is gone. These cravings often occur in settings in which the person formerly smoked, such as at a party, while driving, or after a meal. Researchers believe that much of this extended craving is psychological.


Smokers usually self-diagnose their nicotine dependence and nicotine withdrawal. Such questionnaires as the Fagerstrom Test for Nicotine Dependence (FTND), a short six-item assessment of cigarette use, help to determine the level of tobacco dependence. Physicians and mental health professionals are less concerned with diagnosis, which is usually straightforward, than with determining the physical and psychological factors in each patient that must be addressed for successful smoking cessation.

The Diagnostic and Statistical Manual of Mental Disorders , the handbook used by medical professionals in diagnosing mental health conditions, recognizes two smoking-related disorders: tobacco use disorder and tobacco withdrawal disorder. The criteria for diagnosing a tobacco use disorder is the same for any substance abuse disorder. Specific criteria include experiencing symptoms of tolerance or withdrawal, unsuccessful attempts at quitting, and smoking for longer or more often than was originally intended. Criteria for tobacco withdrawal include experiencing withdrawal symptoms within 24 hours after quitting (or reducing intake).


Most people do not decide to stop smoking all of the sudden. Instead, they go through several preparatory stages before taking action. First is the precontemplation stage, in which the smoker does not even consider quitting. Precontemplation is followed by the contemplation stage, in which the smoker thinks about quitting, but takes no action. Contemplation eventually turns to preparation, often when counselors or family members encourage or urge the smoker to quit. Now the smoker starts making plans to quit soon. Finally the smoker arrives at the point of taking action.

Having decided to stop smoking, a person has many choices of programs and approaches. When mental health professionals are involved in smoking cessation efforts, one of their first jobs is to identify the physical and psychological factors that keep the person smoking. This identification helps to direct the smoker to the most appropriate type of program. Assessment examines the frequency of the person's smoking, his or her social and emotional attachment to cigarettes, commitment to change, available support system, and barriers to change. These conditions vary from person to person, which is why some smoking cessation programs work for one person and not another.


Before 1984, there were no medications to help smokers quit. In that year, a nicotine chewing gum (Nicorette) was approved by the U.S. Food and Drug Administration (FDA) as a prescription drug for smoking cessation. In 1996, it became available without prescription. Nicorette was the first of several medications used for nicotine replacement therapy, intended to gradually reduce nicotine dependence to prevent or reduce withdrawal symptoms. This approach, called tapering, is used in withdrawal of other addictive drugs. Studies indicate that people using these replacement therapies do not become addicted to them.

Nicotine gum comes in two strengths, 2 mg and 4 mg. Lozenges (Commit, Nicorette lozenge) are also available in the same doses. As the gum is chewed, nicotine is released and absorbed through the lining of the mouth. Over a 6- to 12-week period, the amount and strength of gum chewed can be decreased until the smoker is weaned away from his or her dependence on nicotine. People trying to quit smoking are instructed to use the gum when they feel a craving. Products with caffeine may limit nicotine absorption and should be avoided in a window of time around the gum "dose." Some people may not like the taste of the gum, and other common side effects include burning mouth and sore jaw. Pregnant

or lactating women and persons with heart problems, diabetes, or ulcers should consult with a doctor before beginning any nicotine-replacement product.

Nicotine transdermal patches have been available without prescription since 1996. They are marketed under several brand names, including Habitrol, Nicoderm, NicoDerm CQ, Prostep, and Nicotrol. All but Nicotrol are 24-hour patches; Nicotrol is a 16-hour patch designed to be removed at night. The patches are worn on the skin between the neck and the waist and provide a steady delivery of nicotine through the skin. Patches like Nicoderm come in varying strengths, and after several weeks, users can move down to a patch that delivers a lower dose. With the Nicotrol patch, a user simply ceases use after six weeks. Some people using the 24-hour patches experience sleep disturbances, and a few develop mild skin irritations, but generally side effects are few. Doctors recommend not smoking while using the patch.

Two other nicotine delivery devices are available by prescription only. One is a nicotine nasal spray. It has the advantage of delivering nicotine rapidly, just as a cigarette does, but it delivers a much lower dose than a cigarette. Treatment with nasal spray usually lasts four to six weeks. Side effects include cold-like symptoms (runny nose, sneezing, etc.). A nicotine inhaler is also available that delivers nicotine through the tissues of the mouth. A major advantage of the inhaler is that it provides an alternative to having a cigarette in one's hands while still delivering nicotine. It delivers less nicotine in cold weather (under 50F). Recommendations for both the spray and the inhaler are that they be used at least hourly at first.

Prescription drugs outside of nicotine replacement therapy have been approved for the treatment of nicotine dependence. The first-approved drug was bupropion (Zyban), an antidepressant that acts to cut down withdrawal symptoms. This drug may be used in combination with a nicotine-replacement therapy and behavioral therapy.

A newer drug is varenicline (Chantix), which was developed to help people stop smoking. This drug acts directly on the proteins in the brain that recognize and bind nicotine. Interfering with their action not only stops the brain from sending the pleasurable message of nicotine but also reduces the feelings of nicotine withdrawal. Some studies indicate that this drug can double a person's chances of quitting smoking. Side effects of this drug can include headache, nausea, vomiting, sleep problems, gas, and changes in taste sensation.

Other drugs used in some smoking cessation programs include nortriptyline (Pamelor), a tricyclic antidepressant, and clonidine (Catapres), a high blood pressure medication. Side effects of these drugs include dry mouth and drowsiness. Both of these drugs are second-line treatments (used only when other treatments have shown no results) and are considered off-label uses(not approved by the FDA for this purpose).

Behavioral treatments

Behavioral treatments are used to help smokers learn to recognize and avoid specific situations that trigger desire for a cigarette. They also help the smoker learn to substitute other activities for smoking. Behavioral treatments are almost always combined with smoker education, and they usually involve forming a support network of other smokers who are trying to quit.

Behavioral treatments often take place in support groups either in person or online. They are most effective when combined with nicotine reduction therapy. Other supportive techniques include the use of rewards for achieving certain goals and contracts to clarify and reinforce the goals. Aversive techniques include asking the smoker to inhale the tobacco smoke deeply and repeatedly to the point of nausea, so that smoking is no longer associated with pleasurable sensations. Overall, quit rates are highest when behavior modification is combined with nicotine replacement therapy and tapering. Behavior modification once was conducted in person, but with the advent of a telephonic and virtual world on the Internet, behavioral approaches are also available via mail, telephone, and the Web for greater access and flexibility. The U.S. Department of Health and Human Services sponsors a toll-free number for people who want to quit: 800-QUIT-NOW (800-784-8669). This number serves as the point of contact for smokers who want information and help.

Alternative treatments

Many alternative therapies have been tried to help smokers withdraw from nicotine. Hypnosis has proved helpful in some cases, but has not been tested in controlled clinical trials. Acupuncture, relaxation techniques, restricted environmental stimulation therapy (REST, a combination of relaxation and hypnosis techniques), special diets, and herbal supplements have all been used to help people stop smoking. Of these alternative techniques, clinical studies of REST showed substantial promise in helping people stop smoking permanently.


Smoking is a major health risk associated with nicotine dependence, with approximately 50% of longterm smokers dying from smoking-related diseases, according to the FDA. It is the top cause of preventable death in the United States and kills an estimated 443,000 U.S. citizens each year--more than alcohol, illegal drug, homicide, suicide, car accidents, and HIV rates combined. Of those 443,000, about 40% will die from cancer, 35% from heart disease and stroke, and 25% from lung disease. Most lung cancers, the leading cause of cancer death in the United States, are linked to smoking, and smoking is linked to about one-third of all cancer deaths. Smoking also causes such other lung problems as chronic bronchitis and emphysema, as well as worsening the symptoms of asthma. Other cancers associated with smoking include cancers of the mouth, esophagus, stomach, kidney, colon, and bladder. Smoking accounts for a large percentage of cardiovascular deaths and significantly increases the risk of heart disease, heart attack, stroke, and aneurysm. Women who smoke during pregnancy have more miscarriages, premature babies, and low-birth weight babies than nonsmokers. In addition, there is an increased risk that a child born to a mother who smokes will die of sudden infant death syndrome (SIDS), making smoking an avoidable factor in this tragic occurrence. Secondhand smoke also endangers the health of nonsmokers in the smoker's family or workplace. Although most of these effects are not caused directly by nicotine, it is the dependence on nicotine that keeps people smoking.

Even though it is difficult for smokers to break their chemical and psychological dependence on nicotine, most of the negative health effects of smoking are reduced or reversed after quitting. Therefore, it is worth trying to quit smoking at any age, regardless of the length of time a person has had the habit.

Mental health problems

Persons with mental health problems, such as depression, anxiety, and schizophrenia, are two to three times more likely to smoke than persons without these conditions. However, smoking has also been associated with the risk of developing mental health problems, which has prompted some researchers to wonder whether smoking is a causal factor in mental illnesses or just prevalent due to effects of nicotine. However, a study published in the Archives of General Psychiatry in 2010 suggested that tobacco smoke may have some implications in the development of mental illness. The study focused on the impact of secondhand smoke on individuals and found that nonsmokers were 1.5 times more likely to develop mental health problems if regularly exposed to secondhand smoke. A similar study focused on children, published in the Archives of Pediatrics & Adolescent Medicine , found that children exposed to secondhand smoke were more likely to develop behavioral problems such as attention deficit hyperactivity disorder (ADHD). Neither study is definitive of smoking's impact on mental health, and

further research is needed, but along with the varied and severe physiological effects of smoking, there is risk of a negative psychological impact, as well.

Cigarette smoking and its health risks.

CareNotes. May 1, 2012 pNA. Full Text:COPYRIGHT 2012 All rights reserved. Information is for End User s use only and may not be sold, redistributed or otherwise used for commercial purposes.

GENERAL INFORMATION: Smoking and your health: Cigarette smoking is the most preventable cause of illness and death in the United States. A large number of Americans smoke cigarettes, and each year more than one million children and adults start smoking cigarettes. Many people die every year from illnesses caused bysmoking. People who smoke die earlier than those who do not smoke. The risk of disease increases if you smoke a lot, inhale deeply, or have smoked many years. Why are cigarettes bad for you? Cigarettes are filled with poison that goes into the lungs when you inhale. Coughing, dizziness, and burning of the eyes, nose, and throat are early signs that smoking is harming you. Smoking increases your health risks if you have diabetes, high blood pressure, or high blood cholesterol. The long-term problems of smoking cigarettes are the following: Cancer: Smoking increases your chances of getting cancer. Cigarette smoking may play a role in developing many kinds of cancer. Lung cancer is the most common kind of cancer caused bysmoking. A smoker is at greater risk of getting cancer of the lips, mouth, throat, or voice box. Smokers also have a higher risk of getting esophagus, stomach, kidney, pancreas, cervix, bladder, and skin cancer. Heart and blood vessel disease: If you already have heart or blood vessel problems and smoke, you are at even greater risk of having continued or worse health problems. The nicotine in the tobacco causes an increase in your heart rate and blood pressure. The arteries (blood vessels) in your arms and legs tighten and narrow because of the nicotine in cigarette smoke. Cigarette smoke increases blood clotting, and may damage the

lining of your heart's arteries and other blood vessels. Carbon monoxide is a harmful gas that gets into the blood and decreases oxygen going to the heart and the body. Cigarette smoke contains this gas. Hardening of the arteries happens more often in smokers than in nonsmokers. This may make it more likely for you to have a stroke (blood clot in your brain). The more cigarettes you smoke, the greater your risk of a heart attack. Lung disease: The younger you are when you start smoking, the greater your risk of getting lung diseases. Many smokers have a cough which is caused by the chemicals in smoke. These chemicals harm the cilia (tiny hairs) that line the lungs and help remove dirt and waste products. Depending upon how much you smoke, your lungs become gray and "dirty" (they look like charcoal). Healthy lungs are pink. Chronic bronchitis is a serious lung infection which is often caused by smoking. Emphysema is a longterm lung disease that may be caused by smoking cigarettes. Cigarette smokingalso makes asthma worse. You are at a higher risk of getting colds, pneumonia, and other lung infections if you smoke. Gastrointestinal disease: Cigarette smoking increases the amount of acid that is made by your stomach, and may cause a peptic ulcer. A peptic ulcer is an open sore in the stomach or duodenum (part of the intestine). You may also get gastroesophageal reflux from smoking. This is when you have a backflow of stomach acid into your esophagus (food tube). Other problems: The following are other problems that smoking may cause: Bad breath. Bad smell in your clothes, hair, and skin. Decreased ability to play sports or do physical activities because of breathing problems. Earlier than normal wrinkling of the skin, usually the face. Higher risk of bone fractures, such as hip, wrist, or spine. Higher risk of starting a fire. This may happen if you fall asleep with a lit cigarette. Men may have problems having an erection.

Sleeping problems. Smoking is an expensive (costly) habit. You will save money if you choose to stop smoking. Sore throat. Staining of teeth. Women and smoking: You may have a higher risk of having a heart attack or stroke if you smoke and use birth control pills. This risk is more serious if you are 35 years or older. The risk of losing your unborn baby or having a stillborn baby is higher if you are pregnant and smoke. Babies born to smoking mothers often weigh less, and are at a higher risk of sudden infant death syndrome (SIDS). You may have a harder time getting pregnant if you are a smoker. Women who smoke may have a higher risk of osteoporosis (also known as "brittle bones"). Women who smoke also have a higher risk of incontinence, which is when you are unable to control when you urinate. Are there risks with smoking cigars or pipes? The risks are the same for people who smoke cigars or pipes as they are for cigarettesmokers. There is a risk of getting cancer of the mouth, lip, larynx (voice box), or esophagus if you smoke a cigar or pipe. What are the risks of using snuff or chewing tobacco ("smokeless tobacco")? People who use snuff or chewing tobacco have an increased risk of getting mouth or throat cancer. The risk of heart disease, stroke, blood vessel disease and stomach problems is the same as it is for cigarette smokers. What is "passive smoking"? Tobacco smoke is dangerous to others. The effect that smoking has on nonsmokers is called "passive smoking". Nonsmokers who breathe tobacco smoke have the same health risks as smokers. Children who are around tobacco smoke may have more colds, ear infections, or other breathing problems. Why should I quit smoking? The benefits from quitting smoking happen right away. Your sense of taste and smell will improve. Your body, clothes, car, and home will not smell of tobacco smoke. Your chance of getting cancer will be reduced as compared to a person who does not quit. As a former smoker, you will live longer than people who continue to smoke. Women who quit smokingbefore getting pregnant have a better chance of having a healthy baby. You will decrease the health risks of nonsmokers if you

stop smoking. By stopping smoking you will also save money. What is the best way to stop smoking? A large percentage of people have tried to quit smoking at least once. Most people who try to quit smoking go through a series of stages. Following are the stages you may go through to stop smoking: Thinking about quitting. Deciding to quit on a certain day. Quitting smoking. Successfully staying an ex-smoker. You must be strong in order to quit smoking. When you decide to quit, you can get help from your caregiver or others. You will learn that there are many ways to stop smoking. Talk to your caregiver about the best method for you when you are ready to quit smoking. Ask your caregiver for more information about how to stop smoking.

Source Citation: "SMOKE INHALATION." SICK! Diseases and Disorders, Injuries and Infections. Online Edition. Detroit: U*X*L, 2008. Updated August 2009.

Table of Contents
Definition | Description | Causes | Symptoms | Diagnosis | Treatment | Prognosis |Preventio n | For More Information

Smoke inhalation is breathing in smoke. Smoke contains many substances that can cause damage to the human body.

The most common cause of smoke inhalation is fire in a structure, such as a home, office, or factory. People trapped in a burning structure as well as firefighters may inhale smoke produced by the fire. Cigarette smoking also produces the effects of smoke inhalation. People who smoke do not get as much smoke into their lungs at once as someone trapped in a structural fire. Over a long period of

time, however, the effects of cigarette smoking can add up. And eventually the effects on a person's lungs from smoking can be as bad or worse than those caused by other forms of smoke inhalation. Smoke inhalation is responsible for a large number of the deaths caused by structural fires each year. In many cases, a person does not show symptoms of smoke inhalation until twenty four to forty eight hours after the fire. Because of this delay, the person may not be diagnosed correctly and his or her medical problem may not be treated soon enough or by the correct methods.

The smoke a person inhales can cause damage to the body in three different ways. First, the smoke may actually cause burns. The smoke is carried in by hot air that can damage or destroy tissues in the mouth, nose, and upper respiratory (breathing) system. Smoke can also cause damage by irritating tissues. The materials found in smoke can be toxic (poisonous) to cells or they can cause physical damage by rubbing across tissues. Finally, smoke can harm the body because it cuts off the supply of oxygen. Cells need oxygen in order to remain alive and function normally. If too much smoke is present in the body, it can prevent oxygen from reaching cells. Cells and tissues then begin to die from oxygen starvation.

Some symptoms of smoke inhalation are visible to the naked eye. For example, nose hairs may be burned and there may be burns on the throat and inside the nose. The throat may also begin to swell up. Smoke inhalation causes other obvious symptoms including noisy breathing, coughing, hoarseness, black or gray saliva (spit), and fluids in the lungs. A person who is not receiving enough oxygen may become short of breath and may develop a bluish-gray or cherry-red skin color. As the condition becomes worse, the patient may lose consciousness or stop breathing.

Diagnosis of smoke inhalation is based on personal history and physical examination. In most cases, the patient will visit a doctor because he or she has been present at a structural fire. The possibility of smoke inhalation will be clear. In the case of a smoker, this connection may not be so obvious. A physical examination may reveal some or all of the symptoms listed above. In addition, the doctor can listen to the patient's chest and take his or her pulse rate. Smoke inhalation may cause abnormal chest sounds and a decreased pulse rate. Blood tests may also be taken. A blood test can show the amount of oxygen in the blood. It can also

show if toxic gases from the smoke are present in the blood. A chest X ray will not show damage to the respiratory system but it may show the presence of fluids in the lungs. Damage to the patient's airways and lungs can be viewed directly with a bronchoscope. A bronchoscope is a device that consists of a long thin tube that can be inserted into the patient's respiratory system. The doctor can look through the tube directly into the windpipe and lungs to see if damage has occurred to tissues.

The primary goal in treating smoke inhalation is to make sure that the patient is getting enough oxygen. Two steps may be necessary to achieve this objective. First, the patient's airway has to be kept open. In some cases, the patient may be breathing easily and normally. This condition suggests that the airway is open and functioning normally. In that case, all that may be necessary is to give the patient oxygen through a mask that delivers pure oxygen or air enriched with oxygen to his or her body. If the patient is wheezing, his or her airway may be constricted (narrowed) or blocked. In that case, the first step is to open up the airways. One way to do this is to give the patient a bronchodilator (pronounced brahng-ko-DIE-lay-tor). A bronchodilator is a substance that causes muscles in the respiratory system to relax. As they relax, the tubes through which air gets into the lungs become larger. The patient is able to breathe more easily. At this point, oxygen may also be given. In some cases it may be necessary to insert a tube into the patient's respiratory system through the nose. Oxygen can then be provided through the tube. Other forms of treatment may be necessary also. For example, the smoke inhaled may have contained certain toxic substances. Blood tests will often show the presence of these toxic substances in the blood. They can then be treated with other substances that will react with the toxic materials and make them harmless.

The key to complete recovery from smoke inhalation is often prompt treatment. People with relatively moderate symptoms who receive early treatment tend to recover completely from the experience. In some cases, however, patients may develop chronic respiratory or pulmonary (lung) disorders. Patients most at risk for such disorders are those who had respiratory problems such as asthma before exposure to smoke. Those patients are likely to experience more severe symptoms of their disorder than they did before the smoke inhalation. Prognosis for smoke inhalation among smokers depends on an individual's willingness and ability to stop smoking. A person who is able to stop smoking greatly reduces his or her chances of develop

smoke inhalation problems.

Avoiding smoke inhalation may be difficult because, of course, people usually do not choose to be present in a burning building. The best way to avoid smoke inhalation, then, is to prevent the structural fires that create the problem. Structural fires are best prevented by the use of safe electrical wiring, proper storage of flammable materials, maintenance of clean, well-ventilated chimneys and wood stoves, and other basic fire safety practices. The damage caused by structural fires can often be reduced dramatically by the installation of smoke detectors and sprinkler systems. Studies have shown that more than ninety eight percent of all potentially disastrous fires can be prevented by properly installed sprinkler systems. Finally, fire fighters should be provided with and trained in the use of proper protective gear to avoid the problems of smoke inhalation.

Fire Sprinkler Systems

The first fire sprinkler system was built in 1874 by the American inventor Henry S. Parmalee. He developed the system to protect the factory in which he built pianos. Sprinkler systems soon became popular in large factories and warehouses. But they did not seem to have any use in the large majority of office buildings and other structures. They were much too expensive to build. Attitudes about sprinkler systems began to change in the 1940s. A number of horrible fires were responsible for this change. Perhaps the most important was a fire that struck the Coconut Grove Night Club in Boston in 1942. In that fire, 492 people were killed, many by smoke inhalation. Before long, city governments began to insist on sprinkler systems in all new office and apartment buildings. For example, New York City requires such systems in all high-rise buildings. The city of Chicago requires sprinkler systems in all nursing homes. Some communities even require sprinkler systems in private homes. San Clemente, California, is one such community. Smoke inhalation can also be prevented by reducing or stopping smoking. Many people who suffer from smoke inhalation problems develop those problems because they smoke. The obvious way to prevent smoke inhalation in such cases is to change one's smoking habits. In 2008, the Centers for Disease Control and Prevention reported that the prevalence ofsmoking in the United States fell in 2007 to 19.8 percent, almost a full percentage point decline from 20.8 percent in 2006. Approximately 400,000 to 440,000 Americans die each year from smoking related illnesses.

Words to Know

Bronchodilator: A substance that causes muscles in the respiratory system to relax. Bronchoscope: A device consisting of a long thin tube with a light and camera on the end for looking into a patient's airways and lungs. Pulmonary: Pertaining to the lungs. Respiratory system: The nose, tonsils, larynx, pharynx, lungs, and other structures used in the process of breathing. Toxic: Poisonous.