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According to data from the National Center for Health Statistics, smoking is the greatest preventable risk factor for morbidity and mortality in the United States, accounting for approximately 467,000 deaths in 2005.1 The Center for Disease Control (CDC) estimates that 20% of the US population over the age of 18 currently smokes. The CDC also estimates that 22% of high school students have used cigarettes within the last 30 days.2 While cigarette smoking remains the most prevalent type of tobacco use, options for nicotine delivery include smokeless tobacco products (chew and snuff) as well as other smoke tobacco products (pipes, cigars, bidis, and hookah pipes).

Nicotine dependence, like any other chemical dependency, is a twofold issue. First is the physiologic dependence a person develops with continued use. Nicotine stimulates the neurotransmitter dopamine and, in turn, activates the dopamine reward pathway in the brain.3 The purpose of this pathway is to reward the body for pleasurable activity, thereby reinforcing an activity with hopes of continued use. Initially, the person using smoke tobacco is rewarded for using the smoke tobacco with pleasure or a perceived relief from stress. However, with continued use of the smoke tobacco, the person is no longer smoking for pleasurable effects, but smoking to avoid the unpleasant effects of nicotine withdrawal. These symptoms, as well as time of presentation and duration, are located in Table 61-1. Most often, these withdrawal symptoms persist for 1 to 2 weeks after quitting the tobacco product.4

TABLE 61-1 Nicotine Withdrawal Symptoms

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