SMOKING

BY DR PRAYTHIESH BRUCE CRRI SMIMS, KULASEKHARAM

.

SEMINAR PRESENTATION

• We’re Creatures of Habit• “Form good habits…be a good person” is the universal

motherly advice every one• of us can recall when we scratch the realm of our

memories. • Tiny tots and youngsters are forever bound, protected

and guided by their seniors and elderly• in order to help them on to tread the path laid on time

tested principles of honesty and good behavior. • Yet sometimes unknowingly they take the forbidden• route just to prove things for the heck of it.• Due to the extreme stress, strain and stretch of the

competitive world around any• person today is more susceptible to succumb to

pressure and buckle under it.• Here’s where the need for addiction in any form arises

which however provides

• only temporary solace rather than erasing the real cause. We sometimes latch on

• to it and slowly get further and further suck into its false whirlpool leading us to

• lose our will power.• An addiction simply adheres itself to our self-belief eroding it gradually

by• digging into it. We just remain a shade of our previous selves hereby

taking a• short cut to a track that leads us to more acute physical and mental

problems.• Any addiction can be overcome, any bad patch overridden if only we

could• endure it by facing it head-on keeping the following lines from Kipling

in mind –• If you can fill the unforgiving minute• With sixty seconds worth of distance run• Yours is the earth and everything that’s in it• And – which is more – you’ll be a MAN!

WHAT IS SMOKING?

• smoking refers to the inhalation and exhalation of fumes from burning tobacco in cigars,cigarettes and pipes

• A smoker is someone who smokes at least one cigarette a week.

• The Ugly Truth• Tobacco usage causes more than 430,000 adult deaths per year in the

• United States.

• Around 5 million under 18 years will die prematurely from smoking-related

• diseases.

• More than 4,000 chemicals have been identified in tobacco smoke of which

• at least 43 cause cancer in humans and animals

• Exposure to passive smoking, 3,000 nonsmokers die of lung cancer every

• year.

• 150,000 to 300,000 infants and children less than 18 months experience

• lower respiratory tract infections. Asthma and other respiratory conditions

• often are triggered or worsened by tobacco smoke.

• Smoking among 8th, 10th, and 12th graders varies between 18% to 40%

• (including 9% to 13% females)

• Tobacco use is linked with numerous adverse health outcomes, disability,

• and death across a spectrum, including heart disease, cancer, and chronic

• lung disease.

• 10 Reasons for Picking the Habit Up• A sudden rise of energy level to combat stress, stretch and strain of

our daily• schedule• A concentration pill• To overcome frustration due to the indomitable desire of achieving the

very• best even beyond our limits• To bridge the gap between our desired aspirations and hard core

reality• Already Addicted and finds no valid reason to quit• A style in the society• The additional energy level for repeated sexual interaction in a row• To avoid boredom• Its a tradition and doctor's advise is a foolish notion• Just to enjoy• The smokers treat all the above as valid points and the non-smokers

feel these to• be• Smoking Ain’t Cool

• Diabetes

• People with diabetes are three times more likely to have a heart attack if they smoke. Older

• smokers with diabetes are much more likely to need insulin than those who do not smoke.

• Chest conditions

• Smoking causes chronic inflammation and irritation of the respiratory tract, leading to destruction

• of the air sacs (emphysema) and introduction of excess mucus with obstruction or narrowing of

• the small airways (bronchitis). The onset of respiratory disease is gradual. Breathlessness only

• becomes troublesome when about half the lung has been destroyed. Many of these changes

• are irreversible, and some become progressive.

• Women

• When female smokers use the contraceptive pill they are at

• increased risk from heart attacks and strokes. Osteoporotic

• bone loss is much more common in women who smoke.

• Women who smoke are twice as likely to develop cervical

• cancer and are likely to start their menopause two to three

• years earlier than non-smokers

• Smoking in pregnancy • The evidence is quite clear that smoking during pregnancy • harms the baby. Nicotine and carbon monoxide can retard • foetal growth so that the child is born below normal weight. • Babies born to mothers who smoked in pregnancy are more • likely to be premature, stillborn or die shortly after birth. • A baby exposed to tobacco smoke has a higher risk of dying

from cot death. • Fertility and childbirth • Smoking can affect fertility both in men and women. Women

who smoke take longer to conceive • and are more likely to have a miscarriage

• Other conditions • Cigarette smoking depresses the immune defence

mechanism and may contribute to increased • liability to infection. • Appearance • Smoking affects the blood vessels in the skin, which

damages facial colour and complexion. • Wrinkles around the eyes and mouth develop much

earlier and the tar stains the teeth and • fingers.

• What smoking can do to the non-smoker

• Cigarettes give off two types of smoke. The first is mainstream smoke, which is filtered by the

• cigarette and inhaled by the smoker. The other type is side stream smoke, which goes directly

• from the end of the cigarette into the air. As it is not filtered, it contains higher concentrations of

• harmful substances than the mainstream smoke. It is therefore potentially more dangerous to

• non-smokers, especially when they are exposed to it for long periods of time.

• Children who are exposed to a large amount of side-stream smoke are more prone to chest

• infections, glue ear, asthma attacks, hospital admissions, and irritation to the eyes, throat and

• respiratory tract.

• Half the children in the UK live in homes in which at least one parent smokes and are more likely

• to become smokers if their parents smoke. Up to two-thirds of cot deaths might be avoided if

• babies were not exposed to tobacco smoke before and after birth.

What is Second Hand Smoke

• Second-hand smoke: that is inhaled involuntarily or passively by someone who is not smoking.

• Second-hand smoke is also called involuntary smoking or passive smoking

Second hand smoke causes serious Health Hazards

– Lung cancer -risk up 24%– Heart diseases -risk up 25%– Asthma attacks– Sudden Infant Death

Syndrome (cot death)– Childhood respiratory diseases– Chronic cough, phlegm, and

wheezing – Chest discomfort– Lowered lung function

Smoking and Second-Hand Smoke Damage Virtually Every Part of the Body

Smoking

Second-Hand Smoke

Think what you are

breathing

200 poisonous, 60 carcinogens

What is in tobacco and cigarettes?Lots of toxic chemicals!

Carbon Monoxide-auto exhaust, gas chambers Carbon Dioxide Carbonyl Sulfide Benzene (1) Toluene-industrial solvent, in explosives Formaldehyde (2)- body tissue preserver Acrolein-aquatic herbicide=burned glycerol Acetone-poisonous solvent, nail polish remover Pyridine-poisonous solvent Methylpyridine-insecticide solvent Vinylpyridine Hyrogen Cyanide-rat poison, gas chambers Hydrazine-rocket fuel chemical

Ammonia-poisonous, cleaning agent for toilets and floors Methylamine-tanning agent Dimethylamine-tanning accelerator Nitrogen Oxides Nitrosodimethylamine Nitrosodiethylamine Nitrosopyrrolidine Formic Acid-caustic solvent Acetic Acid-caustic solvent Methyl Chloride-poisonous refrigerant Butadiene Particulate Matter-animal carcinogen Nicotine-insecticide, cockroach killer Anatabine Phenol-toilet bowl disinfectant

Catechol-tanning, dyeing agent Hydroquinone-photographic developing agent Aniline-industrial solvent Toluidine-agent in dye manufacture Napthalamine-mothballs Aminobiphenyl Benz(a)anthracene Benzo(a)pyrene Cholesterol Butyrolactone Quinoline-specimen preservative Harman Nitrosonornicotine NNH Nitrodiethanolamine Cadmium Nickel Zinc-anti-corrosion coating for metals Aluminum-metal Titanium-metal Copper-metal Mercury-metal

Silicon-metal Silver-metal Gold-metal Polonium-210-radioactive element Benzoic Acid-tobacco curing agent Lactic Acid-caustic solvent Glycolic Acid-metal cleaning agent Succinic Acid-agent in Lacquer manufacture PCDDs and PCDFs –dioxins, dibenzofurans Hexamine-barbecue lighter Stearic Acid-candle wax Cadmium-rechargeable batteries Arsenic-poison Butane-cigarette lighter fluid Propylene Glycol-antifreeze

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Unless urgent action is taken, tobacco will kill 1 billion people this century

World Health Organization

Tobacco Is Now the World’s Leading Single Agent of Death

Hatched areas indicate proportions of deaths related to tobacco use.

Tobacco Is a Risk Factor for 6 of the World’s 8 Leading Causes of Death

THE MAJOR HEALTH CONSEQUENCES OF SMOKING• State that tobacco smoking can cause-

Emphysema, bronchitis, cancer and heart disease.

• Describe how cigarette smoke effects ciliated epithelial cells and how this is linked to “smoker’s cough”

Facts:• Fewer than 10% of lung cancer patients survive five years after diagnosis.•  Smokers who smoke between 1 and 14 cigarettes a day have eight times the risk of

dying from lung cancer compared to non-smokers.  Smokers who smoke more than 25 cigarettes a day have 25 times this risk compared to non-smokers.

• Smoking leads to an earlier menopause: on average women smokers go through the menopause up to 2 years earlier than non-smokers and are at a greater risk of developing osteoporosis. Smoking has been associated with increased sperm abnormalities and with impotence in men. 

•  Giving up smoking can reduce the risk of developing many of these problems.  Within 10-15 years of giving up smoking, an ex-smoker's risk of developing lung cancer is only slightly greater than that of a non-smoker.  A young smoker suffering from bronchitis or emphysema who gives up may see some improvement in lung function as a result: damage to lungs caused by years of smoking is permanent but quitting smoking prevents it worsening.

• It is estimated that several hundred cases of lung cancer and several thousand cases of heart disease in non-smokers in the UK every year are caused by passive smoking.

•  Tobacco use kills around 120,000 people in the UK every year, about 330 every day - as if a plane crashed every day and killed all its passengers,  around 20% of all deaths.

•  Smoking causes at least 80% of all deaths from lung cancer, around 80% of all deaths from bronchitis and emphysema and around 17% of all deaths from heart disease. About half of all regular cigarette smokers will eventually be killed by their habit.

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Most Recent Scientific Evidence: Active Smoking

Bronchitis

• What is chronic bronchitis?

• Chronic bronchitis is a chronic inflammatory condition in the lungs that causes the respiratory passages to be swollen and irritated, increases the mucus production and may damage the lungs. The symptoms are coughing and breathlessness, which will get worse over the years.

•The definition of chronic bronchitis is chronic cough or mucus reproduction for at least three months in two successive years when other causes have been excluded.

Emphysema

• Effects the alveoli• The smokers cough weekens the walls of

the alveoli, therefore the lungs can not take in enough oxygen which leads to breathlessness.

Cancer

• Increased risk of developing lung cancer

• Number of cigarettes smoked per day Annual death rate per 100,000 men

• 010-14 (8 times that of non-smokers)• 15-25 (13 times that of non-smokers)• 25 or more25 (25 times that of non-

smokers)

Lung Cancer• Lung cancer kills more people than any other type

of cancer and at least 80% of these deaths are caused by smoking. In 1999, 29,406 people in England and Wales died of lung cancer.[

• It is the tar in the `cigarettes which contain the carcinogenic “cancer causing” substances

• Not only are you susceptible to lung cancer, but also: mouth, throat, stomach cancer. Cigarette tars contain some of the most carcinogenic chemicals known to man.  Consider this when watching people smoking and exhaling only 10% of the tars they actually take in.  Not only are these chemicals being painted into the lung, but smoker are also constantly painting them up on their lips, tongue, larynx, swallowing some and thus painting it in the esophagus and throughout the digestive tract.  Smokers have increased incidents of cancer in all of these exposed sites.

Heart Disease

• Smoking tends to increase blood cholesterol levels. 

• Carbon monoxide attaches itself to haemoglobin (the oxygen-carrying pigment in red blood cells) much more easily than oxygen does.  This reduces the amount of oxygen available to the tissues. This again will put pressure on the heart!

CLOGGING CLOGGING OF OF CORONARY CORONARY ARTERIESARTERIES

Heart Disease• The role of smoking in Coronary Heart Disease • Inhaling tobacco smoke causes several immediate

responses within the heart and its blood vessels.  Within one minute of starting to smoke, the heart rate begins to rise: it may increase by as much as 30 percent during the first 10 minutes of smoking.

• Nicotine raises blood pressure: blood vessels constrict which forces the heart to work harder to deliver oxygen to the rest of the body.  Meanwhile,

• carbon monoxide in tobacco smoke exerts a negative effect on the heart by reducing the blood’s ability to carry oxygen.

Healthy Lungs

• You can see how the lung looks without the effects of inhalation of smoke.

• Note black specks throughout indicative of carbon deposits from pollution.

Lung after smoking

• Smokers lung with cancer.  White area on top is the cancer, this is what killed the person.  The blackened area is just the deposit of tars that all smokers paint into their lungs with every puff they take.

Cilia and smoking

• The following series of slides illustrate microscopic changes that happen when a person smokes.  The first slide is showing an illustrated blow-up of the normal lining of the bronchus. On the top we see the cilia, labeled (H).  They are attached to columnar cells, labeled (I).  The cilia sweep the mucous produced in the goblet cells, labeled (J) as well as mucous coming from deeper glands within the lungs and the particulate matter trapped in the mucous.  The bottom layer of cells, labeled (L) are the basal cells.

Cilia and smoking

• Below we start to see the changes that occur as people begin to smoke.  You will see that the columnar cells are starting to be crowded out and displaced by additional layers of basal cells. 

• Not only are fewer cilia present but the ones that are still functioning are doing so at a much lower level of efficiency.  Many chemicals in tobacco smoke are toxic to cilia, first slowing them down, soon paralyzing them all together and then destroying them.

Cilia and smoking• As you see with the cilia actions being

diminished, mucous starts to build up in the small airways making it harder for the smoker to breathe and causing the characteristic smokers cough in order to clear out the airways.

• Eventually though, the ciliated columnar cells are totally displaced.  As can be seen below ominous changes have taken place.  Not only is the smoker more prone to infection from the loss of the cleansing mechanism of the cilia, but these abnormal cells (O) are cancerous squamous cells.  These cells will eventually break through the basement membrane wall and invade into underlying lung tissue and often spread throughout the body long before the person even knows they have the disease.

Cilia and smoking

• If a smoker quits before cancer actually starts, even if the cells are in a precancerous state, the process is highly reversible. 

• .  Cilia regeneration starts in about 3 days once smoking stops.  Even if cilia has been destroyed and not present for years, the lining tissue of the windpipe will start to repair. 

• Even the precancerous cells will be sloughed off over time, reversing the cellular process to the point where the lining tissue goes back to normal.  But if a smoker waits too long and cancer starts, it may be too late to save his or her life.

What is Smoke Free Initiative

• Smoke Free Initiative is intended to make all enclosed public places smoke free in order to honour the value of life, and protect present and future generations from the devastating consequences of tobacco consumption and exposure of second hand smoke to non smokers.

Provisions under the tobacco control Act • Ban on smoking in public places;

Section 4• Ban on advertisements of tobacco

products; Section 5 • Prohibition of sale of tobacco products

to and by minors; and Section 6 (a)• Prohibition on sale of tobacco

products within the radius of 100 yards of any educational institutions - Section 6 (b)

• Specified health warning labels on all tobacco products Section -7

Public Place (as per sec.4)• auditorium, • hospital buildings, • railway waiting room,• Officers mess• amusement centres, • bars, restaurants,• discotheques, • refreshment rooms, • banquet halls, • CSD canteen, • Wet Canteen• coffee house,• pubs,• airport lounge (airports can have

a facility of providing separate smoking lounge)

• public offices,

• court buildings, • educational institutions,• libraries, • workplaces (private offices)• banks• shopping malls • cinema halls• open auditorium• historical monuments• stadium• railway station• bus stop• public conveyances• And the like which are visited by

general public

• Article 39 and 47 of the Constitution of India: Duty of Govt. to raise the level of standard of living and to improve the health of its citizens.

• Clean air to breath is the fundamental right of every citizen

• Article 21 the Constitution of India : no body can harm other people to express their liberty.

• The duty of welfare state to protect citizens from all type of harmful exposures like Second Hand Smoke.

Prototype of a challan

Pictorial Health Warnings in India

Pictorial Health Warnings (Globally)

(FOR PREVENTING MOST LIFESTYLE DISEASES)

HEALTHY DIET

•PHYSICAL ACTIVITY

• QUIT SMOKING / TOBACCOUSE

ADOPT HEALTHY LIFESTYLE

• Pharmacotherapy(Medications)For Tobacco Cessation

Nicotine Withdrawal

• Symptoms -anger/irritability -depression/anxiety -insomnia -increased dream activity• Peak in 1st week, last 2-4 weeks• ~50% experience significant withdrawal symptoms• Most patients underestimate withdrawal symptoms

Hughes Nic Tob Res 2007Madden Addiction 1997Stages J Clin Psych 1996

Pharmacotherapy

• Nicotine replacement therapy (NRT)– Gum– Patch– Spray– Inhaler– Lozenge

• Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • Other medications in development

Pharmacotherapy

• Nicotine replacement therapy (NRT)– Gum– Patch– Spray– Inhaler– Lozenge

• Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • Other medications in development

Nicotine replacement therapy

• Replace the nicotine supplied by cigarettes

• Conversion: Each cigarette provides 1 mg of nicotine

• Combination therapy

• Most people underdose NRT, or don’t take it long enough

Bupropion

• Inhibits reuptake of dopamine & norepinephrine• Exact mechanism of action in smoking cessation is not

clear• Initially developed as an antidepressant• Promotes smoking cessation even in the absence of

depression

Nicotine Replacement Therapy (NRT)

• 1mg for each cigarette smoked• 10 cigs=10mg• 20 cigs=20mg• 40 cigs=40mg

• Note: may exceed label recommendations

Varenicline(Chantix)

• A partial nicotine receptor antagonist• Binds to the nicotine receptors in the brain• “Feeds the need” for nicotine at the CNS level• Essentially a “form of NRT”

Varenicline

• Most common side effects

- nausea (16-30%)

- insomnia (18-19%)

- abnormal dreams (9-13%)• Weight-neutral• New FDA warning-monitor for changes in mood/mental

status/behavior

Medications typically will give better results when combined with counseling

Effective Strategies Exist to Assist in Quitting Tobacco

How can I quit?

• First give yourself a pat on the back for wanting to quit. That is the first step.

• Quitting is not easy, remember nicotine is addictive.

• You can do it if you set your mind to it!

Strategies to help you quit

• Get support: ask your parents or friends. If they smoke and are not interested then find a support group in person or online.

• Set a quit date: Mark it on your calendar and tell your friends and family.

• Throw away your cigarettes and chew- ALL of it. Get rid of the ashtrays and lighters too.

• Wash all your clothes. Get rid of the cigarette smell.

• Think about triggers:– Avoid those situations– Substitute something else for cigarettes

Physical symptoms you may have after quitting

• Headaches or stomachaches• Crabbiness, jumpiness, depression• Lack of energy• Dry mouth or sore throat• Desire to pig out

The symptoms will pass so be patient and don’t sneak a smoke or a chew or you will have to deal with the symptoms longer.

More strategies to help you quit

• Keep yourself busy• If you are having trouble with the strategies you may

need to talk to a doctor who can give you some suggestions.

• Don’t give up!• Reward yourself. Use the money that you would have

used to buy cigarettes to buy yourself something special.

                               

Get involved in your community

Join an anti-smoking campaign

Tobacco Quitlines

• Effective Quitlines utilize 5 A’s approach• ASK about tobacco use• ADVISE to quit• ASSESS willingness to make a quit attempt• ASSIST

• those who are ready, with appropriate treatment• those who are not ready, with motivational counseling

• ARRANGE for follow-up• Coupled with Motivational Interviewing (Stages of

Change), a very effective tool

Tobacco Quitlines

• For the Provider (YOU!):

Time saving in the office visit- 3 A’s

• ASK• ADVISE• ASSESS• REFER (pamphlet, fax referral, etc.)

Follow-up…..

QUIT SMOKING ONCE FOR ALL

REDUCING TO 4 PER DAYREDUCING TO 4 PER DAYOROR

EVEN ONE PER DAY WILL EVEN ONE PER DAY WILL NOT HELPNOT HELP

QUIT SMOKING FORTH WITHQUIT SMOKING FORTH WITH

WORLD NO SMOKING DAY 31 MAY 2013

“GENDER AND TOBACCO WITH AN EMPHASIS ON MARKETING TO WOMEN”

LETS LIVE TOBACCO FREE…!

Lets breathe SMOKEFREE

By making INDIA

• References • 1. Consultation on the future of tobacco control:

consultation report: December 2008. • 2. NHS Stop Smoking Services. Service and Monitoring

Guidance 2010/2011. Department of Health• 3. Conroy MB, Majchrzak NE, Silverman CB, et al.

Measuring provider adherence to tobacco • treatment guidelines: A comparision of electronic

medical record review, patient survey, • and provider survey. Nicotine and Tobacco Research

2005; 7(1):S35–S43

References

• www.kidshealth.org• American Academy of Family Physicians

– Smoking: Facts for Teens

• CDC: Tobacco Information and Prevention Source (TIPS)

• www.smokingstinks-aaco.org/horrors.html• www.googleimages.com• www.ottawa.ca

Developed by Bridget Robinson, RN, BSN,SNM

University of Kansas School of Nursing HETC Project