Substance use like cigarettes is addiction

Psychology

Sigmund Freud, whose doctor assisted with his suicide because of oral cancer caused by smoking[91]

Most tobacco smokers begin during adolescence or early adulthood. Smoking has elements of risk-taking and rebellion, which often appeal to young people. The presence of high-status models and peers may also encourage smoking. Because teenagers are influenced more by their peers than by adults,[92] attempts by parents, schools, and health professionals at preventing people from trying cigarettes are not always successful.

Smokers often report that cigarettes help relieve feelings of stress. However, the stress levels of adult smokers are slightly higher than those of nonsmokers. Adolescent smokers report increasing levels of stress as they develop regular patterns of smoking, and smoking cessation leads to reduced stress. Far from acting as an aid for mood control, nicotine dependency seems to exacerbate stress. This is confirmed in the daily mood patterns described by smokers, with normal moods during smoking and worsening moods between cigarettes. Thus, the apparent relaxant effect of smoking only reflects the reversal of the tension and irritability that develop during nicotine depletion. Dependent smokers need nicotine to remain feeling normal.[93]

In the mid-20th century psychologists such as Hans Eysenck developed a personality profile for the typical smoker of that period; extraversion was associated with smoking, and smokers tended to be sociable, impulsive, risk taking, and excitement-seeking individuals.[94] Although personality and social factors may make people likely to smoke, the actual habit is a function of operant conditioning. During the early stages, smoking provides pleasurable sensations (because of its action on the dopamine system) and thus serves as a source of positive reinforcement. After an individual has smoked for many years, the avoidance of withdrawal symptoms and negative reinforcement become the key motivations. Like all addictive substances, the amount of exposure required to become dependent on nicotine can vary from person to person.

In terms of the Big Five personality traits, research has found smoking to be correlated with lower levels of agreeableness and conscientiousness, as well as higher levels of extraversion and neuroticism.[95]

Prevention

Education and counselling by physicians of children and adolescents has been found to be effective in decreasing the risk of tobacco use.[96] Systematic reviews show that psychosocial interventions can help women stop smoking in late pregnancy, reducing low birthweight and preterm births.[97] A 2016 Cochrane review showed that the combination of medication and behavioural support was more effective than minimal interventions or usual care.[98] Another Cochrane review "suggests that neither reducing smoking to quit nor quitting abruptly results in superior quit rates; people could therefore be given a choice of how to quit, and support provided to people who would specifically like to reduce their smoking before quitting."[99]

• Average price of a pack of 20 cigarettes, measured in international dollars in 2014[100]

• Taxes as a share of cigarette price, 2014[101]

• Types of bans on tobacco advertising, 2014[102]

• Support to help quit tobacco use, 2014[103]

Prevalence

Further information: Prevalence of tobacco consumption

Prevalence of daily smoking in 2012[104]

Share adults who smoke any tobacco product on a daily or non-daily basis in 2016[105]

Smoking, primarily of tobacco, is an activity that is practiced by some 1.1 billion people, and up to 1/3 of the adult population.[106] The image of the smoker can vary considerably, but is very often associated, especially in fiction, with individuality and aloofness.[citation needed] Even so, smoking of both tobacco and cannabis can be a social activity which serves as a reinforcement of social structures and is part of the cultural rituals of many and diverse social and ethnic groups. Many smokers begin smoking in social settings and the offering and sharing of a cigarette is often an important rite of initiation or simply a good excuse to start a conversation with strangers in many settings; in bars, night clubs, at work or on the street. Lighting a cigarette is often seen as an effective way of avoiding the appearance of idleness or mere loitering. For adolescents, it can function as a first step out of childhood or as an act of rebellion against the adult world. Also, smoking can be seen as a sort of camaraderie. It has been shown that even opening a packet of cigarettes, or offering a cigarette to other people, can increase the level of dopamine (the "happy feeling") in the brain, and it is doubtless that people who smoke form relationships with fellow smokers, in a way that only proliferates the habit, particularly in countries where smoking inside public places has been made illegal.[citation needed] Other than recreational drug use, it can be used to construct identity and a development of self-image by associating it with personal experiences connected with smoking. The rise of the modern anti-smoking movement in the late 19th century did more than create awareness of the hazards of smoking; it provoked reactions of smokers against what was, and often still is, perceived as an assault on personal freedom and has created an identity among smokers as rebels or outcasts, apart from non-smokers:

The importance of tobacco to soldiers was early on recognized as something that could not be ignored by commanders. By the 17th century allowances of tobacco were a standard part of the naval rations of many nations and by World War I cigarette manufacturers and governments collaborated in securing tobacco and cigarette allowances to soldiers in the field. It was asserted that regular use of tobacco while under duress would not only calm the soldiers but allow them to withstand greater hardship.[108] Until the mid-20th century, the majority of the adult population in many Western nations were smokers and the claims of anti-smoking activists were met with much skepticism, if not outright contempt. Today the movement has considerably more weight and evidence of its claims, but a considerable proportion of the population remains steadfast smokers.[109]

Society and culture

Smoking has been accepted into culture, in various art forms, and has developed many distinct, and often conflicting or mutually exclusive, meanings depending on time, place and the practitioners of smoking. Pipe smoking, until recently one of the most common forms of smoking, is today often associated with solemn contemplation, old age and is often considered quaint and archaic.[citation needed] Cigarette smoking, which did not begin to become widespread until the late 19th century, has more associations of modernity and the faster pace of the industrialized world. Cigars have been, and still are, associated with masculinity, power and is an iconic image associated with the stereotypical capitalist. In fact, some evidence suggests that men with higher than average testosterone levels are more likely to smoke.[110] Smoking in public has for a long time been something reserved for men and when done by women has been associated with promiscuity. In Japan during the Edo period, prostitutes and their clients would often approach one another under the guise of offering a smoke; the same was true for 19th-century Europe.[17]

Art

An Apothecary Smoking in an Interior by Adriaen van Ostade, oil on panel, 1646

The earliest depictions of smoking can be found on Classical Mayan pottery from around the 9th century. The art was primarily religious in nature and depicted deities or rulers smoking early forms of cigarettes.[111] Soon after smoking was introduced outside of the Americas it began appearing in painting in Europe and Asia. The painters of the Dutch Golden Age were among the first to paint portraits of people smoking and still lifes of pipes and tobacco. For southern European painters of the 17th century, a pipe was much too modern to include in the preferred motifs inspired by mythology from Greek and Roman antiquity. At first smoking was considered lowly and was associated with peasants.[112] Many early paintings were of scenes set in taverns or brothels. Later, as the Dutch Republic rose to considerable power and wealth, smoking became more common amongst the affluent and portraits of elegant gentlemen tastefully raising a pipe appeared. Smoking represented pleasure, transience and the briefness of earthly life as it, quite literally, went up in smoke. Smoking was also associated with representations of both the sense of smell and that of taste.

In the 18th century smoking became far more sparse in painting as the elegant practice of taking snuff became popular. Smoking a pipe was again relegated to portraits of lowly commoners and country folk and the refined sniffing of shredded tobacco followed by sneezing was rare in art. When smoking appeared it was often in the exotic portraits influenced by Orientalism. Many proponents of postcolonialism controversially believe this portrayal was a means of projecting an image of European superiority over its colonies and a perception of the male dominance of a feminized Orient. Proponents believe the theme of the exotic and alien "Other" escalated in the 19th century, fueled by the rise in the popularity of ethnology during the Enlightenment.[113]

Skull with a Burning Cigarette by Vincent van Gogh, oil on canvas, 1885

In the 19th century smoking was common as a symbol of simple pleasures; the pipe smoking "noble savage", solemn contemplation by Classical Roman ruins, scenes of an artist becoming one with nature while slowly toking a pipe. The newly empowered middle class also found a new dimension of smoking as a harmless pleasure enjoyed in smoking saloons and libraries. Smoking a cigarette or a cigar would also become associated with the Bohemian, someone who shunned the conservative middle class values and displayed his contempt for conservatism. But this was a pleasure that was to be confined to a male world; women smokers were associated with prostitution and smoking was not considered an activity fit for proper ladies.[114] It was not until the start of the 20th century that smoking women would appear in paintings and photos, giving a chic and charming impression. Impressionists like Vincent van Gogh, who was a pipe smoker himself, would also begin to associate smoking with gloom and fin-du-siècle fatalism. While the symbolism of the cigarette, pipe and cigar respectively were consolidated in the late 19th century, it was not until the 20th century that artists began to use it fully; a pipe would stand for thoughtfulness and calm; the cigarette symbolized modernity, strength and youth, but also nervous anxiety; the cigar was a sign of authority, wealth and power. The decades following World War II, during the apex of smoking when the practice had still not come under fire by the growing anti-smoking movement, a cigarette casually tucked between the lips represented the young rebel, epitomized in actors like Marlon Brando and James Dean or mainstays of advertising like the Marlboro Man. It was not until the 1970s when the negative aspects of smoking began to appear, yielding the image of the unhealthy lower-class individual, reeking of cigarette smoke and lack of motivation and drive, which was especially prominent in art inspired or commissioned by anti-smoking campaigns.[115] In his painting "Holy Smokes", artist Brian Whelan pokes fun at the smoking debate and its newly found focus on morality and guilt.

Film and TV

Film star and iconic smoker Humphrey Bogart

Ever since the era of silent films, smoking has had a major part in film symbolism. In the hard-boiled film noir crime thrillers, cigarette smoke often frames characters and is frequently used to add an aura of mystique or nihilism. One of the forerunners of this symbolism can be seen in Fritz Lang's Weimar era Dr Mabuse, der Spieler, 1922 (Dr Mabuse, the Gambler), where men mesmerized by card playing smoke cigarettes while gambling.

Female smokers in film were also early on associated with a type of sensuous and seductive sexuality, most notably personified by German film star Marlene Dietrich. Similarly, actors like Humphrey Bogart and Audrey Hepburn have been closely identified with their smoker persona, and some of their most famous portraits and roles have involved them being haloed by a mist of cigarette smoke. Hepburn often enhanced the glamor with a cigarette holder, most notably in the film Breakfast at Tiffany's. Smoking could also be used as a means to subvert censorship, as two cigarettes burning unattended in an ashtray were often used to suggest sexual activity.

Since World War II, smoking has gradually become less frequent on screen as the obvious health hazards of smoking have become more widely known. With the anti-smoking movement gaining greater respect and influence, conscious attempts not to show smoking on screen are now undertaken in order to avoid encouraging smoking or giving it positive associations, particularly for family films.[116] Smoking on screen is more common today among characters who are portrayed as anti-social or even criminal.[117]

According to a 2019 study, the introduction of television in the United States led to a substantial increase in smoking, in particular among 16–21-year-olds.[118] The study suggested "that television increased the share of smokers in the population by 5–15 percentage points, generating roughly 11 million additional smokers between 1946 and 1970."[118]

Literature

Just as in other types of fiction, smoking has had an important place in literature and smokers are often portrayed as characters with great individuality, or outright eccentrics, something typically personified in one of the most iconic smoking literary figures of all, Sherlock Holmes. Other than being a frequent part of short stories and novels, smoking has spawned endless eulogies, praising its qualities and affirming the author's identity as a devoted smoker. Especially during the late 19th century and early 20th century, a panoply of books with titles like Tobacco: Its History and associations (1876), Cigarettes in Fact and Fancy (1906) and Pipe and Pouch: The Smokers Own Book of Poetry (1905) were written in the UK and the US. The titles were written by men for other men and contained general tidbits and poetic musings about the love for tobacco and all things related to it, and frequently praised the refined bachelor's life. The Fragrant Weed: Some of the Good Things Which Have been Said or Sung about Tobacco, published in 1907, contained, among many others, the following lines from the poem A Bachelor's Views by Tom Hall that were typical of the attitude of many of the books:

The cover of My Lady Nicotine: A Study in Smoke (1896) by J.M. Barrie, otherwise best known for his play Peter Pan

— Eugene Umberger[119]

These works were all published in an era before the cigarette had become the dominant form of tobacco consumption and pipes, cigars, and chewing tobacco were still commonplace. Many of the books were published in novel packaging that would attract the learned smoking gentleman. Pipe and Pouch came in a leather bag resembling a tobacco pouch and Cigarettes in Fact and Fancy (1901) came bound in leather, packaged in an imitation cardboard cigar box. By the late 1920s, the publication of this type of literature largely abated and was only sporadically revived in the later 20th century.[120]

Music

There have been few examples of tobacco in music in early modern times, though there are occasional signs of influence in pieces such as Johann Sebastian Bach's Enlightening Thoughts of a Tobacco-Smoker.[121] However, from the early 20th century and onwards smoking has been closely associated with popular music. Jazz was from early on closely intertwined with the smoking that was practiced in the venues where it was played, such as bars, dance halls, jazz clubs and even brothels. The rise of jazz coincided with the expansion of the modern tobacco industry, and in the United States also contributed to the spread of cannabis. The latter went under names like "tea", "muggles" and "reefer" in the jazz community and was so influential in the 1920s and 30s that it found its way into songs composed at the time such as Louis Armstrong's Muggles, Larry Adler's Smoking Reefers, and Don Redman's Chant of The Weed. The popularity of marijuana among jazz musicians remained high until the 1940s and 50s, when it was partially replaced by the use of heroin.[122]

Another form of modern popular music that has been closely associated with cannabis smoking is reggae, a style of music that originated in Jamaica in the late 1950s and early 60s. Cannabis, or ganja, is believed to have been introduced to Jamaica in the mid-19th century by Indian immigrant labor and was primarily associated with Indian workers until it was appropriated by the Rastafari movement in the middle of the 20th century.[123] The Rastafari considered cannabis smoking to be a way to come closer to God, or Jah, an association that was greatly popularized by reggae icons such as Bob Marley and Peter Tosh in the 1960s and 70s.[124]

Economics

Estimates claim that smokers cost the U.S. economy $97.6 billion a year in lost productivity and that an additional $96.7 billion is spent on public and private health care combined.[125] This is over 1% of the gross domestic product. A male smoker in the United States that smokes more than one pack a day can expect an average increase of $19,000 just in medical expenses over the course of his lifetime. A U.S. female smoker that also smokes more than a pack a day can expect an average of $25,800 additional healthcare costs over her lifetime.[126]