Slide 1: By
Dr.Ashraf Sobhy Al-Abasiry.MBBCh.MSc Internist,Primary Care Department
Saad Specialist Hospital
( The illusion and reality) Smoking Global impact : Smoking Global impact ►Smoking is the world’s leading preventable cause of premature death (1) .
► There are more than 1.3 bilion smokers worldwide.(1)
► About 5 million people die from smoking-related disease each year.(2)
► Every 8 seconds a person dies of smoking –related disease.
► Tobacco use will Kill 1 billion people in the 21 st century if current smoking trends continue.(3)
. 1-. The Health Report 2003.Chapter 6. www.who.int/whr/2003
2- WHO. Tobacco Free initiative. www.who.int/tobacco
3- Mackay j et al. The Tobacco Atlas .second edition ,2006.American cancer society Slide 3: ► The CDC estimates that in recent years, the number of Americans who smoke has consistently dropped, down from a high of more than 50 percent in the 1960s to less than 25 percent of Americans today.
► Much of this progress may be due to extensive public education campaigns that seek to educate people about the dangerous toxins in tobacco smoke and prevent young people from becoming smokers. Cigarette smoking in KSA : Cigarette smoking in KSA Prevalence rate of smoking:
► 21% among male population 20 years old & above (1)
► 9% among female (1)
► About 20,000 people die from smoking-related disease each year
► Estimated current smokers are:
◙ 2.4 million males ◙ 1.7 million females
► The average age of smokers is 32.1 years (2)
► The average duration of smoking was 12.1 years (2)
. 1- jamal s jarallah.et.al.prevalence and determinants of smoking in 3 regions of saudi arabia.tobacco control1999:8:53-582- salma siddiqui.et.al.smoking in a saudi community.prevalence.influncing factors.and risk perception.Fam Med 2001:33(5):367-70 World Map of Male Smoking : World Map of Male Smoking World Map of Female Smoking : World Map of Female Smoking Slide 7: ► Researchers have estimated that smoking cuts an average of 10 years off a person's life expectancy.
► (CDC) in the late 1990s estimated that adult male smokers lost an average of 13.2 years of life and female smokers lost 14.5 years of life because of smoking.
► However, by quitting early these “lost” years can be regained.
► A person who quits at age 35 can live as long as nonsmokers, according to recent studies. Smoking Reduces Survival an Average of 10 Years : Results From a Study of Male Physician Smokers in the United Kingdom 1. Doll R, et al. BMJ. 2004;328:1519–1527. Smoking Reduces Survival an Average of 10 Years 10 years 24 4 26 59 81 94 100 80 60 40 20 0 40 50 60 70 80 90 100 97 91 81 59 2 Age (Years) Survival At
Point (%) Physician Nonsmokers Physician Smokers Slide 9: What are The Health Consequences of
Smoking ? Effect of smoking on the body : Effect of smoking on the body ► Harms nearly every organ in the body.(1)
► Smoking can result in a wide variety chronic conditions that affect the heart, circulatory and respiratory systems, contributing or causing more than 25 specific diseases.
► Smokers face a much higher risk of life-threatening events such as heart attack and stroke.
. 1- ASH.factsheet no 2.smoking statistics:illness and death. 2006.www.ash.org.uk How Smoking Causes Disease : How Smoking Causes Disease Lung cancer
Direct respiratory cell exposure to potent mutagens and carcinogens in tobacco smoke
Ischemic heart disease
Toxic products in the bloodstream create a pro-atherogenic environment.
Leads to endothelial injury and dysfunction, thrombosis, inflammation, and adverse lipid profiles
Chronic Obstructive Pulmonary Disease (COPD)
Accelerated decline in respiratory function. 1. Surgeon General’s Report. The Health Consequences of Smoking; 2004. Smoking: Leading Preventable Cause of Disease and Death1 : Smoking: Leading Preventable Cause of Disease and Death1 Top 3 Smoking-Attributable Causes of Death in US
#1 Lung cancer
#2 Ischemic heart disease#3 COPD Cancer
Lung (#1)* Leukemia
(AML, ALL, CLL)2-4
Oral cavity/pharynx Laryngeal
Bladder Cervical Cardiovascular
Ischemic heart disease (#2)*Stroke – Vascular dementia5
Peripheral vascular disease6
Abdominal aortic aneurysm Respiratory
Poor asthma control Reproductive
Sudden Infant Death Syndrome Other
Adverse surgical outcomes/wound healing
Peptic ulcer disease† *Top 3 smoking-attributable causes of death. †
1. Surgeon General’s Report. The Health Consequences of Smoking; 2004. 2. Sandler DP, et al. J Natl Cancer Inst. 1993;85(24):1994-2003. 3. Crane MM, et al. Cancer Epidemiol Biomarkers Prev. 1996;5(8):639-644. 4. Miligi L, et al. Am J Ind Med. 1999;36(1):60-69. 5. Roman GC. Cerebrovasc Dis. 2005;20(Suppl 2):91-100. 6. Willigendael EM, et al. J Vasc Surg. 2004;40:1158-1165. US Mortality From Smoking-Related Disease* : US Mortality From Smoking-Related Disease* Approximately 438,000 annual US deaths attributable to cigarette smoking
between 1997 and 2001 † † *Percentage of deaths attributable to specific smoking-related diseases, 1997–2001.
†Includes secondhand smoke deaths.
1. CDC. MMWR. 2005;54:625–628. Secondhand smoke : Secondhand smoke Environmental tobacco smoke (ETS) is also known as secondhand smoke.
Passive smoking (inhaling secondhand smoke) happens when non-smokers breathe other people’s tobacco smoke.
. Health effects of second hand smoke exposure in adults : Health effects of second hand smoke exposure in adults ►There is strong evidence that ETS causes serious damage to human health.
► Each year about 49,400 non-smoking adults die of lung cancer or heart disease as a result of breathing secondhand smoke.
► Estimated lung cancer risk increased by 20%–30%1.
► Believed to cause and worsen diseases such as asthma, COPD, and emphysema2.
► Increases risk for developing heart disease by 25%–30%1. 1. News release, June 27, 2006; US Department of Health & Human Services. Available at: http://www.hhs.gov/news/press/2006pres/20060627.html. 2. Mackay J, et al. The Tobacco Atlas. World Health Organization; 2002. 3. Teo KK, et al. Lancet. 2006;368:647-658. Slide 17: The copy says “Second Hand Smoke Kills” and the poor horse of Marlboro man has to pay the price of his master’s smoking. Slide 18: due to Smoking Illustration of Health Effects Smoking &EYE : Smoking &EYE cataract Acute macular degeneration Smoking & Mouth : Smoking & Mouth Cancer tongue Cancer lip Oral cancer gum disease, tooth decay Oral cancer : Oral cancer This patient is a 87 year old who used to smoke 1 pack per day for many years. She was not sure how long she smoked.
This patient has a tumor on both her tongue and right floor of the mouth. Slide 22: Rick Bender was a Major League baseball player who lost half of his face due to chewing tobacco. Smoking & LARYNX : Smoking & LARYNX After removal of cancer larynx Smoking & Lung : Smoking & Lung Smoker’s lung Normal Lung Smoker’s lung specimen : Emphysema Bronchiectasis Normal Lung Smoker’s lung specimen Lung Cancer : Lung Cancer Peripheral vascular disease : Buerger’s Disease Gangrene Peripheral vascular disease Amputation Skin damage : Smoking also causes premature wrinkling of the skin, dry skin, psoriasis, yellow fingers and stained fingernails Skin damage Cancer of cervix : Cancer of cervix Cancer of cervix No.2 killer in women So Why Do People Smoke? : So Why Do People Smoke? Slide 33: Varied names and the poison one Smokeless Tobacco Shisha Cigar Pipe Cigarettes What’s in a Tobacco smoke? : What’s in a Tobacco smoke? Chemicals in Tobacco Products: : Chemicals in Tobacco Products: Nicotine ► Cigarettes contain over 4 000 chemicals including tar, nicotine, carbon monoxide, radioactive compounds, irritant substances (for example, hydrogen cyanide, acetone, ammonia, arsenic, phenol, naphthalene).
► The main ones that cause problems are: Carbon monoxide ( CO) Tar Nicotine : Nicotine A drug found only in the tobacco plant leaf. Nicotina tabacum
Nicotine was first isolated from the tobacco plant in 1828 by German chemists Posselt & Reimann, who considered it a poison.(1)
It’s highly addictive as heroin or cocaine. Over time, a person becomes physically and emotionally addicted to,or dependent on , Nicotine. Nicotine Effect in the Brain : Nicotine Effect in the Brain ► When a cigarette is smoked nicotine-rich blood passes from the Lung to the brain within 7 seconds and immediately stimulates the release of many messengers including:
Acetylcholine ,epinephrine, norepinephrine,dopamine,arginine, vassopressin,
and beta - endorphin
► Nicotine also activates the sympathetic nervous system, acting via splanchnic nerves to the adrenal medulla, stimulates the release of epinephrine
► This release of messengers and hormones is responsible for most of the nicotine;s effect. ^ Chemically Correct: Nicotine, Andrew Novick 1-
^ 2-Rusted, J; Graupner, O'Connell, Nicholls (1994-05-05
). "Does nicotine improve cognitive function?". Psychopharmacology (Springer-Verlag) (115): 547–549. Nicotine Effect in the Brain : Nicotine Effect in the Brain ► Nicotine appears to enhance concentration and memory due to the acetylcholine of increase
► It also appears to enhance alertness due to the increases of acetylcholine and norepinephrine.
►Nicotine enhances the effect of serotonin and beta-endorphin activity, producing a calming, pain-Killing effect. Slide 39: How Nicotine Hook The Smokers ? Slide 40: How does Tobacco smoking lead to nicotine addiction in some individual?
◘ Part of the answer lies in a common reinforcement pathway in the human brain which drug of abuse stimulate,potentially leading to addiction.
◘ This reinforcement pathway ,which is composed of both centeral nervous system structures and endogenous neurotransmitters communicating between these structures ,has been termed the (reward pathway) Reward Pathway : Reward Pathway ►The core structures of the Reward Pathway is located in the limbic system,a set of primitive structures in the human brain.
► The function of the limbic system is to monitor internal homeostasis, mediate memory, mediate learning. and experience emotion.
► It also drives the aspects of sexual behavior, motivation ,and feeding behavior. www.colorado.edu/cadd1/a_drug/essays/essays4.htm Reward Pathway : Reward Pathway ► This reward system is evolved to respond to the natural activities essential to species survival,such as sexual activity and feeding,drinking behaviors.
► Activities that activate this pathway become associated with ‘ pleasure feeling’
► This ‘pleasure feeling’ will reinforce this behavior to be repeated. www.colorado.edu/cadd1/a_drug/essays/essays4.htm Reward Pathway : Reward Pathway ► The major neurochemical pathway of the reward system in the brain involves the mesolimbic and mesocortical pathway.
► The mesolimbic pathway probably plays the major role,and goes from the ventral tegmental area (VTA) via the medial forebrain to nucleus accumbens,where mainly dopamine is released.
► All drugs abuse including nicotine Commandeer this reward pathway to promote the continued use of the drug and smoking. mesolimbic pathway www.colorado.edu/cadd1/a_drug/essays/essays4.htm Mechanism of Action of Nicotine in the Reward Pathway : Mechanism of Action of Nicotine in the Reward Pathway Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central nervous system; the primary is the 42 nicotinic receptor in the Ventral Tegmental Area (VTA)
After nicotine binds to the 42 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward The Cycle of Nicotine Addiction : The Cycle of Nicotine Addiction ► The Dopamine decrease between cigarettes leads to withdrawal symptoms of irritability and stress1
► The smoker craves Nicotine to release more Dopamine to restore pleasure and calmness1
► Tolerance typically develops after long-term nicotine use1
► In order to maintain a steady nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and avoid symptoms of withdrawal and craving. 1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125. Nicotine withdrawal : Restlessness or impatience
(<4 weeks)2 Increased appetite or weight gain
(>10 weeks)2 Withdrawal Syndrome Anxiety
(may increase or decrease
with quitting)1,2 Dysphoric or depressed mood
(<4 weeks)2 Irritability, frustration, or anger
(<4 weeks)2 Difficulty concentrating
(<4 weeks)2 Insomnia/sleep disturbance
(<4 weeks)2 1. Diagnostic and Statistical Manual of Mental Disorders, IV-TR. Washington, DC: APA; 2006: Available at http://psychiatryonline.com. Accessed November 7, 2006. 2. West RW, et al. Fast Facts: Smoking Cessation. 1st ed. Oxford, United Kingdom. Health Press Limited. 2004. Withdrawal Syndrome: a Combination of Physical and Psychological Conditions, Making Smoking Hard to Treat1,2 Nicotine withdrawal Slide 47: ► Symptoms of withdrawal and how long they last are different for everyone.
► In general, symptoms begin within hours of stopping smoking and can be worse in the evening.
► Symptoms tend to decrease over the first 4-5 days. Some people have stronger symptoms than others. Slide 48: Benefit of Quitting Smoking Slide 49: (US Surgeon General's Report, 1990, p. vi) Immediate Rewards of Quitting : Immediate Rewards of Quitting Kicking the tobacco habit offers some benefits that you'll notice right away and some that will develop over time. These rewards can improve your day-to-day life a great deal.
► Breath smells better.
► Bad smelling clothes and hair go away.
► Yellow fingers and fingernails disappear.
► Food tastes better.
► Sense of smell returns to normal.
► Everyday activities no longer leave you out of breath (for example, climbing. stairs or light housework). Slide 51: No matter how old you are or how long you’ve smoked,quitting will help you live longer. How to Quit smoking : How to Quit smoking Quitting is very difficult : Quitting is very difficult ► Although quitting smoking has imoprtant health and other benefit.it is extremely difficult for many people.primary because nicotine is so addictive.
► On average, smokers try to quite approximately 5-8 times in a life time.
► Quitting smoking is a process that requires careful planning, courage, discipline, and commitment Role of Primary Care Physicians : Role of Primary Care Physicians Ask each pat about his or her smoking status and record this information
in the patient profile Strongly Advise all smokers to quit Detrmine each patient ‘s desire to quit and therby identify those smokers willing
to attempt cessation (apply the Fagerstrom Tolerance Questionnaire to determine
the level of nicotine dependance) Assist by helping the patient set a target quit date, create a plan of action
And select nicotine-replacement therapy, providing key information and educational
Materials are vital components of the assistance strategy The clinician should also Arrange a follow –up contact idealy after the
first week of cessation Slide 55: Smoking cessation is actually not a single event ,but rather a process that includes. Pre-contemplation contemplation Preparation Action Maintenance Four steps to quitting smoking : Four steps to quitting smoking Pick a quit day Chose one or more Proven methods List reasons for quitting Health,Family, Money Work plan Work your plan : Work your plan It's your quit date.
1-Be firm that you won't smoke.
2-Avoid those people and situations where you will be tempted to smoke.
3-Go for a walk instead of a smoke.
4-Find a hobby that keeps your hands and mind busy.
5-Clean your teeth, your clothes, your house of that stale tobacco smell.
6-Be positive. You are choosing to be smoke-free. How to cope with withdrawal symptoms : How to cope with withdrawal symptoms Medicines That Help With Withdrawal : Medicines That Help With Withdrawal There are FDA approved medicines that can help with feelings of withdrawal:
► Nicotine gum , inhaler , lozenge , nasal spray , patch.
► Bupropion SR pills.
► varenicline tartrate. Nicotine Gum, Patch, Inhaler, Spray, and Lozenge (NRT) : Nicotine Gum, Patch, Inhaler, Spray, and Lozenge (NRT) Nicotine gum, patches, inhalers, sprays, and lozenges are called nicotine replacement therapy (NRT).
That's because they take the place of nicotine from cigarettes.
NRT can help with withdrawal and lessen the urge to smoke. Nicotine Patch (transdermal) : Nicotine Patch (transdermal) ► Nicotine patches contain varying amounts of nicotine, usually 21, 14, or 7 mg.
► Different brands of the nicotine patches are intended to be worn from 18 to 24 hours a day.
► Since the adhesives on the patch can cause skin irritation, each day a new patch should be applied to a different area of your body. Nicotine Patch (transdermal) : Nicotine Patch (transdermal) ►Most smokers should start with the highest dose (21 mg/day) for
then one (14 mg/day) patch for 2 wk
then one (7 mg/day) patch for 2 wk
►Those who weigh less than 45 kg or smoke less than 10 cigarettes (one-half pack) per day are advised to begin with:
one 14-mg/day patch qd for 6 wk.
then one 7 mg/d patch qd for 2wk.
then discontinue. Slide 63: Lozenge ( Commit)
Patient who smoke their first cigarette within 30 minute of waking should use the 4 mg strength. Otherwise the 2 mg strength is recommended .
1-6 wk : one lozenge q 1-2 hr
7-9 wk: one lozenge q 2-4 hr
10-12 wk : one lozenge q 4-8 hr
Chewing Gum ( Nicorette)
Chew one piece q 1-2 hr for 6 wk
then One piece q 2-4 hr for 3 wk
then one piece q 4-8 hr for 3 wk
then discontinue Slide 64: Nasal spray (Nicotrol) NS
One dose is 2 sprays ( 1 spray in each nostril).
Initial dose : 1-2 sprays q 1h ,should not exceed 10 sprays (5 doses) / h or 80 sprays (40 doses)/d
Recommended treatment duration 12 weeks.
Inhaler releases 4 mg nicotine ( the equivalent of 2 cigarettes smoked) for 20 min of active inhaler puffing .
Usual dose: 6-16 cartridges/ d for up to 12 wk ,then reduce dose gradually over ensuling 12 wk .
then discontinue. Bupropion ( Zyban) : Bupropion ( Zyban) ► Bupropion available as an antidepressant in the United States since 1989.
► A sustained-release formulation of the drug is licensed as an aid to smoking cessation (Zyban).
► Bupropion significantly decreases the cravings for cigarettes.
► Normally start using bupropion two weeks before target quit date. Bupropion ( Zyban) : Bupropion ( Zyban) ►Bupropion can be used with nicotine replacement therapy to further decrease smoking cessation symptoms.
►The usual dosage is one or two 150 mg tablets per day.
►A meta-analysis of 31 randomized trials of bupropion monotherapy concluded that bupropion SR doubles the likelihood of smoking cessation.
►The most common side effects of Bupropion are insomnia, agitation, dry mouth, and headache. A more serious side effect is seizure. Bupropion ( Zyban) : Bupropion ( Zyban) ► This drug should not be taken if you have ever had seizures, heavy alcohol use, serious head injury, bipolar (manic-depressive) illness, anorexia or bulimia (eating disorders).
► In 2008, the (FDA) reviewed post-marketing reports of suicidal ideation or behavior in smokers taking bupropion, varenicline and suggest a possible association between suicidal events and the use of varenicline and bupropion.
► In 2009, the (FDA) required identical boxed warnings about the risk of serious neuropsychiatric symptoms in patients taking bupropion or varenicline(1). 1-The smoking cessation aids varenicline (marketed as Chantix) and bupropion (marketed as Zyban and generics: suicidal ideation and behavior. FDA Drug Safety Newsletter 2009; 2:1. Varenicline tartrate(Champix ) : Varenicline tartrate(Champix ) In May 2006, (FDA) approved the medication Champix (varenicline tartrate) to help cigarette smokers stop smoking.
Champix received a priority FDA review because of its potential, important benefit to public health. Varenicline tartrate(Champix) : Varenicline tartrate(Champix) Varenicline tartrate is unique in that it mimics the actions of nicotine on the brain and can help both in easing nicotine withdrawal symptoms and blocking the reinforcing effects of nicotine if smoking is resumed.
The researchers report that treatment with varenicline tartrate led to response rates three times higher than placebo in smokers aged 18 to 65 who were attempting to quit smoking. Varenicline: A Highly Selective 42 Receptor Partial Agonist : Varenicline: A Highly Selective 42 Receptor Partial Agonist 1. Coe JW et al. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on Nicotine and Tobacco. 2005. Prague, Czech Republic. 2. Picciotto MR et al. Nicotine Tob Res. 1999; Suppl 2:S121-S125. Binding of nicotine at the 42 nicotinic receptor in the VTA is believed to cause release of dopamine at the nAcc Champix is an 42 nicotinic receptor partial agonist, a compound with dual agonist and antagonist activities. This is believed to result in both a lesser amount of dopamine release from the VTA at the nAcc as well as the prevention of nicotine binding at the 42 receptors. Nicotine Champix Varenicline(Champix) : Varenicline(Champix) Indicated for smoking cessation in adults.
Normally start using Champix one week before target quit date.
Treatment period is 12 weeks
An additional course of 12 weeks of treatment may be considered for patients who have successfully quit at end of 12 weeks
Varenicline is supplied for oral administration in 2 strengths: 0.5 and 1.0 mg; titration is as below: 1. Champix Summary of Product Characteristics. Pfizer Ltd, Sandwich, UK. 2006. Varenicline(Champix) : Varenicline(Champix) ► Reported side effects of varenicline have included headaches, nausea, vomiting, trouble sleeping, unusual dreams, flatulence (gas), and changes in taste.
► There have also been reports of depressed mood, thoughts of suicide, attempted suicide, and changes in behavior in people taking varenicline.
► In 2008, the (FDA) reviewed post-marketing reports of suicidal ideation or behavior in smokers taking bupropion, varenicline and suggest a possible association between suicidal events and the use of varenicline and bupropion.
► In 2009, the FDA required identical boxed warnings about the risk of serious neuropsychiatric symptoms in patients taking bupropion or varenicline(1) 1-The smoking cessation aids varenicline (marketed as Chantix) and bupropion (marketed as Zyban and generics: suicidal ideation and behavior. FDA Drug Safety Newsletter 2009; 2:1. Unproven methods to quit smoking : Unproven methods to quit smoking Acupuncture and related therapies:
Acupuncture traditionally involved inserting needles in the body for about 20 minutes several times a week. Various points on the body are claimed to be related to internal organs and areas of the mind.
Sometimes a small electrical current is applies to the needles.(Electrostimulation )
In some settings needles are replaced by applied pressure and even laser light. The theory is that acupuncture helps release endorphins and enhance neurotransmitters so your smoking cessations symptoms are reduced.
The latest Cochrane Review of acupuncture (October 24, 2005) indicates that this therapy does "not appear to help smokers who are trying to quit." Unproven methods to quit smoking : Unproven methods to quit smoking Hypnosis:
Hypnosis or hypnotherapy is often promoted as a way to help people stop smoking. There are different types of hypnotherapies - some are meant to lessen the desire to smoke and others aim to increase the will to quit.
There is no good evidence to show that hypnotherapy works as a treatment for helping people quit smoking.