Tc obacco Use Stephen F. Rothemich Tobacco use remains the leading cause of preventable death in the United States, a rank that it has held ever since deaths were first quantified by risk factors in the early 1990s(1, 2). In the United States, cigarette smoking and exposure to tobacco smoke account for approximately one in five deaths (438,000 people)each year, as well as 5.5 million years of potential life lost(3) Although overweight(the product of a combination of poor diet and physica inactivity) runs a close second as a leading cause, tobacco use causes more than twice as many deaths as alcohol consumption, motor vehicle accidents firearm use, unsafe sexual behavior, and illicit drug use combined. In addition to this staggering loss of life as of 2001 tobacco use cost society more than $167 billion per year through smoking-attributable health care expenditures ($76 billion)and adult productivity losses ($92 billion). Helping smokers quit is ranked by the National commission on Prevention Priorities as among the top three most effective and cost effective clinical preventive services that clinicians can offer patients (4) Smoking harms nearly every organ of the body, has been causally linked to dozens of adverse health effects(see Table 9.1), and reduces overall health status(5). Cigarette smoking alone is responsible for more than 30% of U.S cancer deaths(6). Smokeless tobacco use causes oral cancer and other ora lesions. Environmental tobacco smoke, a known human carcinogen, causes premature death and disease in children and in adults who do not smoke; scientific evidence indicates no risk-free level of exposure to secondhand smoke exists (7). Quitting smoking has both immediate and long-term benefits, reducing the risk of diseases caused by tobacco and improving health in general In 2004, 44.5 million Americans, or 20.9%0 of the adult population, smoked cigarettes; 23.4% of men smoked compared with 18.5% of women Among whites, 22. 2% smoked compared with 20.2% of blacks. The highest levels of smoking were among people aged 25-44 years(23.8%); American Indians and Alaskan Natives(33.4%); people who had earned a General Educational Development(GED) but not a standard high-school diploma (39.6%); and people living below the poverty threshold (29. 1%6)(8). Although 235