Who smokes?The prevalence of tobacco use varies around the world. Of the more than one billion smokers worldwide, 80% live in low and middle income countries, where the burden of tobacco related illness is heaviest.3As smoking rates fall in developed countries, tobacco use is increasingly concentrated in certain groups who have greater difficulty in quitting than other smokers. These include people with mental illnesses, especially schizophrenia, those with substance use problems, people from lower socioeconomic groups, and some indigenous people. There is also some evidence that those who present for treatment have higher levels of nicotine dependence than those presenting 10 or more years ago.4As with other addictions, there is a strong genetic component to smoking behaviour. The estimated mean heritability for starting smoking has been calculated at 50% and for developing nicotine dependence at 56%.5 Genetic factors also have a substantial role in nicotine withdrawal symptoms, cigarette consumption, difficulty in quitting, and response to smoking cessation therapies.6 Most smokers are nicotine dependent and for these people smoking can be thought of as a chronic medical illness that requires ongoing care.7
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