tobacco smoking: an overview

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بسم الله الرحمن الرحيم ( ولا تقتلوا أنفسكم ان الله كان بكم رحيما ) صدق الله العظيم (النساء - 29)

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TOBACCO SMOKING AN OVERVIEW By Dr. Mahmoud M. Alsalahy Assist. Prof of chest Medicine Banha University, Egypt

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What is tobacco ? ■ Processed leaves of Nicotiana plant, Nightshade ( Tree Tobacco.) ■ Origin : Arizona and parts of New Mexico ■ Contains: Nicotine, anabasine and harmane ■ Types : Black and Brown

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Active consumption : • Tobacco smoking: Cigarettes, Cigars, Pipes, Shisha Smokeless tobacco: Chewing, Buccal, Wet snuff Passive exposure: 2 nd hand & 3 rd hand smokers Exposure :

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!!!!!! DANGEROUS Burnet tobacco smoke contains more than 4000 toxic substances including oxides, aldehydes, heavy metals, oxygen radicals, radioactive intermediates, ….

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1 . Curiosity 2. Imitating a role or model 3. Rebelling from adult warnings 4. Gaining acceptance from peers 5. Projecting an image of confidence 6. The most common: Social stresses 7. Information systems WHO: EVERY DAY: 80-100 THOUSANDS CHILDREN START SMOKING Why is tobacco smoked ? How initiated:

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Although 1 st cigarette is unpleasant, smokers continue to smoke.. Why? Pharmacologic effects of nicotine 1. Effects on nucleus ceruleus : Enhanced vigilance, arousal and decrease fatigue 2. Effects on mesolimbic dopaminergic system : Feeling of reward, pleasure, perservation and improve fine motor activity Later: obliged by withdrawal symptoms Why maintained:

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● 5000-3000 BC: Tobacco consumption by native south Americans ● Late 15 th century: Columbus finds tobacco in the "New World" and takes it back to Europe. ● In 16 th century: European Occupants took it to their colonies ● In the middle of 19 th century: Matches were introduced, making smoking more convenient and spread widely. LANDMARKS IN TOBACCO HISTORY :

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HISTORY OF TOBACCO (contd.) ● 1939 German researchers found a statistical link between lung cancer and smoking. ● 1950 Journal of the Amer . Med . Assoc . Published its first major study definitively linking smoking to lung cancer. ● 1953 The first definitive biological link between smoking and cancer was uncovered. ● 1957 The first official statement on smoking by the Public Health Service in USA

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Since that time, research was centered on health hazards of tobacco smoke and the cardiovascular and other systems damage were discovered

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● Consumption peaked in 60 s of 2o th century ● In 90 s, marked drop in western world and marked rise in 3 rd world ( 3.4 %/yr ) ● 90 % of smokers are between 14 and 25 yrs old ● Most pts with smoking induced disease are above 40 ● A n average smoker has 30% risk of having fatal disease and 30% risk of non fatal disease ● 20% of worldwide deaths are related to SID THE MAGNITUDE OF THE PROBLEM

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1. The world burns > 500 billion $ of tobacco/year 2. Expected that : > 10% of the 6 billions living in the world now will die due to SID (WHO, 2009) 2 GREAT ALARMS !!!!!!

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3 MAIN PATHOGENETIC MECHANISMS 1. INFLAMMATION 2. CARCINOGENESIS 3. VASCULOPATHY HEALTH HAZARDS OF TOBACCO SMOKING

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Direct irritation Auto-immunity Vasculopathy (ischemia) INFLAMMATION

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1. Impaired immune surveillance 2. Oncogene mutations 3. Direct irritation CARCINOGENESIS

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Atherosclerosis 2. Thrombogenesis ▪ Endothelial injury : ■ Direct toxic effect ■ Tachycardia ■ Neutrophilia ■ P latelets cytokines ▪ Dyslipidemia : Increase in LDL cholesterol Most evident in micro vessels ■ Platelet activation ■ Increased fibrinogen ■ Atheroma formation VASCULOPATHY

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CARDIOVASCULAR: ● Atherosclerotic disease - Coronary artery disease - Carotid vascular disease - Mesenteric, renal, iliac - Abdominal aortic aneurysm ● Peripheral vascular disease - Thromboangiitis obliterans ( Buerger’s ) - Deep venous thrombosis - Pulmonary embolus ● Cardiac disease - Angina pectoris - Myocardial infarction - Coronary artery spasm - Arrhythmia TOBACCO SMOKE RELATED DISEASES

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2. Malignancy ● Respiratory tract - Lung cancer - Laryngeal cancer - Oral cancer ● Other tissues - Esophagus - Pancreas - Bladder - Uterine cervix - Kidney - Anus - Penis - Stomach - Liver - Leukemia 3. Lung disease ● COPD - Emphysema - Chronic bronchitis - Asthma ● Other lung diseases - Idiopathic pulmonary fibrosis - Histiocytosis X - Respiratory bronchiolitis - Goodpasture’s syndrome - Sleep apnea - Pneumothorax

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3. GASTO-INTESTINAL DISEASE ● Peptic ulcer disease : Gastric, Duodenal ● Gastroesophageal reflux ● Chronic pancreatitis ● Chron’s disease ● Colonic adenomas 4. DERMATOLOGIC DISEASES ● Skin wrinkling ● Psoriasis 5. REPRODUCTIVE DISEASE ● Fertility related - Ovarian failure - Decreased sperm quality ● Pregnancy related : - Premature rupture of memb . - Spontaneous abortion - Prematurity & Low birth weight

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● Fetal effects - Impaired lung growth - Sudden infant death syndrome - Febrile seizures - Reduced intelligence - Behavioral disorders - Atopic disease/asthma 6. RHEUMATOLOGIC DISEASE ● Osteoporosis ● Rheumatoid arthritis 7. PSYCHIATRIC DISEASE ● Depression ● Schizophrenia

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8. ORAL DISEASE: ● Periodontal disease ● Loss of taste 9. ENT: ● Recurrent infections ● Chronic sinusitis ● Decreased olfaction 10.Infectious diseases: ● Tuberculosis ● Pneumococcal infection ● Meningococcal infection 11.Endocrine disease: ● Altered hormonal secretion ● Graves’ disease & Goiter ● Anti-diuresis

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12. Urinary ● Glomerulonephritis ● Benign prostatic hypertrophy 13.Eyes ● Conjunctivitis ● Cataracts 14. Passive smoking in children ● Asthma ● Rhinitis ● Otitis media ● Pneumonia ● Increased risk to smoke

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■ Mainly a pediatric problem ■ With smoking more than smokeless ■ Has genetic predisposition : ▪ Receptors : alpha 4 & beta 2 ▪ CYP2A6 enzyme ■ Mediated by dopamine & endorphins ■ Pointers for addiction : * ≥ 10 cig/day * keep cigarette in mouth * smokes deep to the end * smoking in closed places * conditioned smoking * Smokes even when ill * Withdrawal symptoms NICOTINE ADDICTION

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Fagerstorm score for quantitative evaluation of addiction: low = 0 ↔ 10 = high

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= Quitters live longer than non quitters = Quitters before 50 have 50% risk of dying before 65 = Simple chronic bronchitis resolves completely = Emphysema progresses slowly = Risk of sudden death due to MI or stroke immediately decreases = Risk of cancer ↓ 50% in a yr Why a smoker must quit ? QUITTING TOBACCO

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● Precontemplation stage : Smoker is enjoying smoking ● Contemplation stage : Smoker thinks in quitting ● Preparation stage: Ask quitters, search for help ● Action stage: Patient start trying to quit Only 5% succeed 1 st trial, most try 5-8 times ● Maintenance: More than 6 months abstinence PSYCHDYNAMICS OF QUITTING

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DYNAMICS OF QUITTING

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● Smokers relationship to cigarettes ● Withdrawal symptoms ● Cigarette cravings ● Smoking associated behavior ● Slips and relapses ● Weight gain FEATURES OF CESSATION PROCESS

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■ Role of primary physician USA NCI 4As : = Ask every patient about smoking = Advice every tobacco user to stop = Assist the cessation effort = Arranging follow up Addressing the subject Always be supportive ● Use multiple strategies at the same time HOW TO ASSISST QUITTING

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■ Explain all to the smoker ■ Let the smoker set a specific quit date ■ Multiple approaches are better than single Group counseling and health education Gradual reduction: ▪ Cold turkey ▪ Tapering of Helping measures: ▪ Hypnosis ▪ Exercises ▪ Acupuncture Specific cessation methods: 1.Non pharmacologic:

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■ NICOTINE REPLACEMENT THERAPY : High success rate if given for 3 months 1. Nicotine gums & lozenges 2. Transdermal patches 3. Nicotine inhalers 4. Nasal spray 5. Sublingual tabs 6. Electronic cigarettes 2. Pharmacologic :

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■ DOPAMINERGIC STIMULANTS : Bupropion : - Antidepressant - Dopaminergic and noradrenergic potentiation - 150 mg starting dose, then twice daily 2. Varenicline : - An alpha4 & beta 2 receptor partial agonist - Has an antagonist action - Very appointing - Dose: 0.5mg/d for 3 days then twice/d for 4 days then 1mg twice daily for 12 wks

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■ Other drugs: 1. CB1 blockers : ( Rimonabant ) - Decrease cravings - Decrease weight gain - Still under investigation 2. Clonidine : an alpha adrenergic agonist 3. Nortriptyline : a tri-cyclic antidepressant 4. Topimerate : an anti-seizure drug 5. Selegiline : anti- parkinsonian drug } Under invest

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● Under investigation ● Distort pharmacokinetics ● Can be used for prevention ● Can prevent long term relapse ■ NICOTINE VACCINES :

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1. Anti-oxidants 2. Low tar cigarettes 3. Efficient filters 4. Smokeless tobacco 5. Electronic cigarettes These methods may help spread tobacco consumption ■ HARM REDUCTION: !!!

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1. Public health campaigns against tobacco: - Mass multimedia: TV, Broadcasts, Cinema - News papers & magazines - Internet & PC 2. School teaching about smoking hazards 3. Tobacco sales restrictions: - Limit sale sites - Increase tobacco taxes - Limit purchase age ■ SMOKING PREVENTION :

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Don’t let it eat you It is eating him

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PLEASE LET US BREATH CLEAN AIR

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THANK YOU