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To the Editor.—Dr Hemmelgarn and colleagues¹ studied injury rates associated with motor vehicle crashes and benzodiazepine use. Tobacco use is also associated with automobile crashes, as well as industrial accidents, poisonings, burns, occupational injuries, fire deaths, suicides, and violence.^2-3 While the causal mechanism of these relationships is not currently well understood, several plausible mechanisms have been postulated by us and others.^2-4 This risk may stem from the cognitive or neuromuscular effects of carbon monoxide, nicotine or nicotine withdrawal, or an association with risk-taking behavior. Tobacco use could also increase the risk of cumulative trauma disorders resulting from impaired tissue-repair processes. While the mechanism is unknown, smoking is a potentially important confounder in injury research, and one that would have been helpful to assess in this study.

Paul J. Amoroso, MD, MPH; Katy L. Reynolds, MD
US Army Research Institute of Environmental Medicine

Nicole S. Bell, ScD, MPH
SSDS Inc
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