Smoking

Aztec women are handed flowers and smoking tubes before eating at a banquet, Florentine Codex, 1500

The history of smoking dates back to as early as 5000 BCE for shamanistic rituals.[4] Many ancient civilizations, such as the Babylonians, Indians and Chinese, burnt incense as a part of religious rituals, as did the Israelites and the later Catholic and Orthodox Christian churches. Smoking in the Americas probably had its origins in the incense-burning ceremonies of shamans but was later adopted for pleasure, or as a social tool.[5] The smoking of tobacco, as well as various hallucinogenic drugs, was used to achieve trances and to come into contact with the spirit world.

Substances such as cannabis, clarified butter (ghee), fish offal, dried snake skins and various pastes molded around incense sticks dates back at least 2000 years. Fumigation (dhupa) and fire offerings (homa) are prescribed in the Ayurveda for medical purposes, and have been practiced for at least 3,000 years while smoking, dhumrapana (literally "drinking smoke"), has been practiced for at least 2,000 years. Before modern times these substances have been consumed through pipes, with stems of various lengths or chillums.[6] Archaeological findings also show the existence of pipes to smoke opium in Cyprus and Crete as soon as the Bronze Age.[7]

Cannabis smoking was common in the Middle East before the arrival of tobacco, and was early on a common social activity that centered around the type of water pipe called a hookah. Smoking, especially after the introduction of tobacco, was an essential component of Muslim society and culture and became integrated with important traditions such as weddings, funerals and was expressed in architecture, clothing, literature and poetry.[8]

Cannabis smoking was introduced to Sub-Saharan Africa through Ethiopia and the east African coast by either Indian or Arab traders in the 13th century or earlier and spread on the same trade routes as those that carried coffee, which originated in the highlands of Ethiopia.[9] It was smoked in calabash water pipes with terracotta smoking bowls, apparently an Ethiopian invention which was later conveyed to eastern, southern and central Africa.

Reports from the first European explorers and conquistadors to reach the Americas tell of rituals where native priests smoked themselves into such high degrees of intoxication that it is unlikely that the rituals were limited to just tobacco.[10]

A Persian girl smoking by Muhammad Qasim, 17th century.

In 1612, six years after the settlement of Jamestown, John Rolfe was credited as the first settler to successfully grow tobacco as a cash crop. The demand quickly grew as tobacco, referred to as "golden weed", revived the Virginia Company from its failed expeditions in search for gold in the Americas.[11] In order to meet demands from the old world, tobacco was grown in succession, quickly depleting the land. This became a motivator to settle west into the unknown continent, and likewise an expansion of tobacco production.[12] Indentured servants became the primary labor force up until Bacon's Rebellion, from which the focus turned to slavery.[13] This trend abated following the American Revolution as slavery became regarded as unprofitable. However the practice was revived in 1794 with the invention of the cotton gin.[14]

A Frenchman named Jean Nicot (from whose name the word nicotine is derived) introduced tobacco to France in 1560. From France tobacco spread to England. The first report documents an English sailor in Bristol in 1556, seen "emitting smoke from his nostrils".[15] Like tea, coffee and opium, tobacco was just one of many intoxicants that was originally used as a form of medicine.[16] Tobacco was introduced around 1600 by French merchants in what today is modern-day The Gambia and Senegal. At the same time caravans from Morocco brought tobacco to the areas around Timbuktu and the Portuguese brought the commodity (and the plant) to southern Africa, establishing the popularity of tobacco throughout all of Africa by the 1650s.

Soon after its introduction to the Old World, tobacco came under frequent criticism from state and religious leaders. Murad IV, sultan of the Ottoman Empire 1623–40 was among the first to attempt a smoking ban by claiming it was a threat to public morality and health. The Chongzhen Emperor of China issued an edict banning smoking two years before his death and the overthrow of the Ming dynasty. Later, the Manchu rulers of the Qing dynasty, would proclaim smoking "a more heinous crime than that even of neglecting archery". In Edo period Japan, some of the earliest tobacco plantations were scorned by the shōgun as being a threat to the military economy by letting valuable farmland go to waste for the use of a recreational drug instead of being used to plant food crops.[17]

Bonsack's cigarette rolling machine, as shown on U.S. patent 238,640

Religious leaders have often been prominent among those who considered smoking immoral or outright blasphemous. In 1634, the Patriarch of Moscow and all Rus' forbade the sale of tobacco and sentenced men and women who flouted the ban to have their nostrils slit and their backs whipped until skin came off their backs. The Western church leader Pope Urban VII likewise condemned smoking in a papal bull of 1590. Despite many concerted efforts, restrictions and bans were almost universally ignored. When James VI and I, a staunch anti-smoker and the author of A Counterblaste to Tobacco, tried to curb the new trend by enforcing a whopping 4000% tax increase on tobacco in 1604, it proved a failure, as London had some 7,000 tobacco sellers by the early 17th century. Later, scrupulous rulers would realise the futility of smoking bans and instead turned tobacco trade and cultivation into lucrative government monopolies.[18]

By the mid-17th century every major civilization had been introduced to tobacco smoking and in many cases had already assimilated it into its culture, despite the attempts of many rulers to stamp the practice out with harsh penalties or fines. Tobacco, both product, and plant followed the major trade routes to major ports and markets, and then on into the hinterlands. The English language term smoking was coined in the late 18th century; before then the practice was referred to as drinking smoke.[15]

Tobacco and cannabis were used in Sub-Saharan Africa, much like elsewhere in the world, to confirm social relations, but also created entirely new ones. In what is today Congo, a society called Bena Diemba ("People of Cannabis") was organized in the late 19th century in Lubuko ("The Land of Friendship"). The Bena Diemba were collectivist pacifists that rejected alcohol and herbal medicines in favor of cannabis.[19]

The growth remained stable until the American Civil War in the 1860s, from which the primary labor force transition from slavery to sharecropping. This compounded with a change in demand, lead to the industrialization of tobacco production with the cigarette. James Albert Bonsack, a craftsman, in 1881 produced a machine to speed the production of cigarettes.[20]

An illustration of an opium den on the cover of Le Petit Journal, 5 July 1903

In the 19th century, the practise of smoking opium became widespread in China. Previously, opium had only been ingested via consumption, and then only for its medicinal properties (opium was an anaesthetic). The narcotic was also outlawed in China sometime in the early 18th century due the societal issues it caused. Due to a massive trade imbalance, however, foreign merchants started to smuggle opium into China via Canton, to the chagrin of the Chinese authorities. Attempts by Chinese official Lin Zexu to eliminate the trade led to the outbreak of the First Opium War. The Chinese defeat in the First and Second Opium Wars resulted in the legalization of the importation of opium into China.[21][22]

Opium smoking later spread with Chinese immigrants and spawned many infamous opium dens in Chinatowns around South and Southeast Asia, Europe and the Americas. In the latter half of the 19th century, opium smoking became popular in the artistic community in Europe, especially Paris; artists' neighborhoods such as Montparnasse and Montmartre became virtual "opium capitals". While opium dens that catered primarily to emigrant Chinese continued to exist in Chinatowns around the world, the trend among the European artists largely abated after the outbreak of World War I.[21] The consumption of Opium abated in China during the Cultural Revolution in the 1960s and 1970s.[21]

Many people have been critical about tobacco use since it gained popularity. In 1798, Dr. Benjamin Rush (early American physician, signer of the Declaration of Independence, Surgeon General under George Washington, and anti-tobacco activist) was "against the habitual use of tobacco" because he believed it (a) "led to a desire for strong drink," (b) "was injurious both to health and morals," (c) "is generally offensive to" nonsmokers, (d) "produces a want of respect for" nonsmokers, and (e) "always disposes to unkind and unjust behavior towards them."[23][24]

With the modernization of cigarette production compounded with the increased life expectancies during the 1920s, adverse health effects began to become more prevalent.[1] In Germany, anti-smoking groups, often associated with anti-liquor groups,[25] first published advocacy against the consumption of tobacco in the journal Der Tabakgegner (The Tobacco Opponent) in 1912 and 1932. In 1929, Fritz Lickint of Dresden, Germany, published a paper containing formal statistical evidence of a lung cancer–tobacco link. During the Great Depression, Adolf Hitler condemned his earlier smoking habit as a waste of money,[26] and later with stronger assertions. This movement was further strengthened with Nazi reproductive policy as women who smoked were viewed as unsuitable to be wives and mothers in a German family.[27]

The movement in Nazi Germany did reach across enemy lines during the Second World War, as anti-smoking groups quickly lost popular support. By the end of the Second World War, American cigarette manufacturers quickly reentered the German black market. Illegal smuggling of tobacco became prevalent,[28] and leaders of the Nazi anti-smoking campaign were assassinated.[29] As part of the Marshall Plan, the United States shipped free tobacco to Germany; with 24,000 tons in 1948 and 69,000 tons in 1949.[28] Per capita yearly cigarette consumption in post-war Germany steadily rose from 460 in 1950 to 1,523 in 1963.[30] By the end of the 20th century, anti-smoking campaigns in Germany were unable to exceed the effectiveness of the Nazi-era climax in the years 1939–41 and German tobacco health research was described by Robert N. Proctor as "muted".[30]

A lengthy study conducted in order to establish the strong association necessary for legislative action (US cigarette consumption per person blue, male lung cancer rate green)

In the UK and the US, an increase in lung cancer rates, formerly "among the rarest forms of disease", was noted by the 1930s, but its cause remained unknown and even the credibility of this increase was sometimes disputed as late as 1950. For example, in Connecticut, reported age-adjusted incidence rates of lung cancer among males increased 220% between 1935–39 and 1950–54. In the UK, the share of lung cancer among all cancer deaths in men increased from 1.5% in 1920 to 19.7% in 1947. Nevertheless, these increases were questioned as potentially caused by increased reporting and improved methods of diagnosis. Although several carcinogens were already known at the time (for example, benzo[a]pyrene was isolated from coal tar and demonstrated to be a potent carcinogen in 1933), none were known to be contained in adequate quantities in tobacco smoke.[31] Richard Doll in 1950 published research in the British Medical Journal showing a close link between smoking and lung cancer.[32] Four years later, in 1954 the British Doctors Study, a study of some 40 thousand doctors over 20 years, confirmed the link, based on which the government issued advice that smoking and lung cancer rates were related.[33][34] In 1964 the United States Surgeon General's Report on Smoking and Health demonstrated the relationship between smoking and cancer.[35] Further reports confirmed this link in the 1980s and concluded in 1986 that passive smoking was also harmful.[36]

As scientific evidence mounted in the 1980s, tobacco companies claimed contributory negligence as the adverse health effects were previously unknown or lacked substantial credibility. Health authorities sided with these claims up until 1998, from which they reversed their position. The Tobacco Master Settlement Agreement, originally between the four largest US tobacco companies and the Attorneys General of 46 states, restricted certain types of tobacco advertisement and required payments for health compensation; which later amounted to the largest civil settlement in United States history.[37]

From 1965 to 2006, rates of smoking in the United States have declined from 42% to 20.8%.[38] A significant majority of those who quit were professional, affluent men. Despite this decrease in the prevalence of consumption, the average number of cigarettes consumed per person per day increased from 22 in 1954 to 30 in 1978. This paradoxical event suggests that those who quit smoked less, while those who continued to smoke moved to smoke more light cigarettes.[39] This trend has been paralleled by many industrialized nations as rates have either leveled-off or declined. In the developing countries, however, tobacco consumption continues to rise at 3.4% in 2002.[40] In Africa, smoking is in most areas considered to be modern, and many of the strong adverse opinions that prevail in the West receive much less attention.[41] Today Russia leads as the top consumer of tobacco followed by Indonesia, Laos, Ukraine, Belarus, Greece, Jordan, and China.[42]

At the global scale, initial ideas of an international convention towards the prevention of tobacco had been initiated in the World Health Assembly (WHA) in 1996.[43] In 1998, along with the successful election of Dr. Gro Harlem Brundtland as the Director-General, the World Health Organization set tobacco control as its leading health concern and has begun a program known as the Tobacco Free Initiative (TFI) in order to reduce rates of consumption in the developing world. However, it was not until 2003 that the Framework Convention on Tobacco Control (FCTC) was accepted in WHA and entered into force in 2005. FCTC marked a milestone as the first international treaty concerning a global health issue that aims to combat tobacco in multiple aspects including tobacco taxes, advertisement, trading, environmental affects, health influences, etc.[44] The birth of this evidence-based and systematic approach has resulted in the reinforcement of tobacco taxes and the implementation of smoke-free laws in 128 countries that led to the decrease of smoking prevalence in developing nations.[45]

In the early 1980s, organized international trafficking of cocaine grew. However, overproduction and tighter legal enforcement for the illegal product caused drug dealers to convert the powder to "crack" – a solid, smokable form of cocaine that could be sold in smaller quantities to more people.[46] This trend abated in the 1990s as increased police action coupled with a robust economy caused many potential consumers to give up or fail to take up the habit.[47]

Recent years shows an increase in the consumption of vaporized heroin, methamphetamine and Phencyclidine (PCP). Along with a smaller number of psychedelic drugs such as Changa, DMT, 5-Meo-DMT, and Salvia divinorum.

A graph that shows the efficiency of smoking as a way to absorb nicotine compared to other forms of intake

Inhaling the vaporized gas form of substances into the lungs is a quick and very effective way of delivering drugs into the bloodstream (as the gas diffuses directly into the pulmonary vein, then into the heart and from there to the brain) and affects the user within less than a second of the first inhalation. The lungs consist of several million tiny bulbs called alveoli that altogether have an area of over 70 m² (about the area of a tennis court). This can be used to administer useful medical as well as recreational drugs such as aerosols, consisting of tiny droplets of a medication, or as gas produced by burning plant material with a psychoactive substance or pure forms of the substance itself. Not all drugs can be smoked, for example the sulphate derivative that is most commonly inhaled through the nose, though purer free base forms of substances can, but often require considerable skill in administering the drug properly. The method is also somewhat inefficient since not all of the smoke will be inhaled.[76] The inhaled substances trigger chemical reactions in nerve endings in the brain due to being similar to naturally occurring substances such as endorphins and dopamine, which are associated with sensations of pleasure. The result is what is usually referred to as a "high" that ranges between the mild stimulus caused by nicotine to the intense euphoria caused by heroin, cocaine and methamphetamines.[77]

Inhaling smoke into the lungs, no matter the substance, has adverse effects on one's health. The incomplete combustion produced by burning plant material, like tobacco or cannabis, produces carbon monoxide, which impairs the ability of blood to carry oxygen when inhaled into the lungs. There are several other toxic compounds in tobacco that constitute serious health hazards to long-term smokers from a whole range of causes; vascular abnormalities such as stenosis, lung cancer, heart attacks, strokes, impotence, low birth weight of infants born by smoking mothers. 8% of long-term smokers develop the characteristic set of facial changes known to doctors as smoker's face.[78]

Tobacco smoke is a complex mixture of over 5,000 identified chemicals, of which 98 are known to have specific toxicological properties.[79] The most important chemicals causing cancer are those that produce DNA damage since such damage appears to be the primary underlying cause of cancer.[80] Cunningham et al.[81] combined the microgram weight of the compound in the smoke of one cigarette with the known genotoxic effect per microgram to identify the most carcinogenic compounds in cigarette smoke. The seven most important carcinogens in tobacco smoke are shown in the table, along with DNA alterations they cause.

Sigmund Freud, whose doctor assisted with his suicide because of oral cancer caused by smoking[89]

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,[90] 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.[91]

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.[92] 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.[93]

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.[109] 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.[110] 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.[111]

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 artists 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.[112] 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.[113] In his painting "Holy Smokes", artist Brian Whelan pokes fun at the smoking debate and its newly found focus on morality and guilt.

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.[114] Smoking on screen is more common today among characters who are portrayed as anti-social or even criminal.[115]

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.[116] 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."[116]

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

So let us drink
To her, – but think
Of him who has to keep her;
And sans a wife
Let's spend our life
In bachelordom, – it's cheaper.

— Eugene Umberger[117]

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.[118]

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.[119] 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.[120]

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.[121] 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.[122]

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.[123] 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.[124]