Smoking

From Ganfyd

Smoking tobacco is deleterious and addictive. Showing some of these deleterious effects got Richard Doll a knighthood but have still not convinced the vested interests, including those addicted, to do all possible to discourage smoking. It is a multi-billion dollar industry.

UK Warning on cigarette packet (2003)

Smoking History

Age started. Change in numbers. Quantity. Can be used to calculate total pack-years, where one pack year is the exposure equivalent to smoking 20 cigarettes a day for a year. This is rough and ready way of comparing exposure as not all patients smoke cigarette the same way.

12.5g or half an ounce of loose tobacco approximates to one pack.^[1]

Not Starting

Clearly this requires a social approach. The change to Scottish law in 2005-6 and the lesser changes creeping slowly into English law in later years, making smoking in a variety of public spaces unlawful, should help.

Stopping

Nicotine replacement (NRT) works, so does bupropion but not so cost effectively. Varenicline seems more clinically effective than NRT at a cost both in pounds and possibly more significant side-effects. Various approaches have been suggested and publicised, fundamentally, nothing works at the wrong time, and if you are fortunate enough to be consulted at the right time, the smallest of nudges may be of assistance in making the decision to quit. link to discussion of NICE guidance

Psychology

• Understand the model of the process leading to a decision.
• There is no magic psychological technique or tactic which will make people decide.

Drugs

Nicotine, bupropion, varenicline.

Tobacco Control

A complex matter of public policy, tax, criminality and health. (see talk)

Conditions aggravated by/associated with Smoking

(note: some grouping duplication is inevitable and can be resolved by following the links. Some common usage group terms are also added for convenience. For example the popular term lung cancer refers to squamous cell carcinoma of the bronchus, small cell carcinoma of the bronchus, large cell carcinoma of the bronchus and the rarer adenocarcinioma of the lung, all of which are independently associated with increased risk in smokers)

• Abruptio Placentae
• Acute coronary syndrome
• Acute myeloid leukemia
• Adenocarcinoma of kidney; lung; oesophagus; stomach; pancreas;
• Increased mortality without increased incidence of adenocarcinoma of the prostate
• Adverse surgical outcomes related to
  • Delayed wound healing
  • Increased respiratory complications
• Aortic Aneurysm and Ruptured aortic aneurysm
• Angina
• Appearance- Ages collagen so you look older
• Asbestosis
• Asthma - poor control rather than a causal relationship.
• Atherosclerosis
• Buerger's disease
• Cancer of bladder,cervix,kidney,larynx,lung,oesophagus,oral cavity,pancreas,pharynx,stomach,tongue
• Carcinoma of bronchus
• Carcinoma of cervix
• Carcinoma of larynx - combined with alcohol
• Carcinoma of tongue
• Cataracts - nuclear
• Chronic Bronchitis
• Chronic obstructive airways disease
• Cluster headache
• Crohn's disease
• Deep vein thrombosis
• Depression
• Decline in lung function (non specific -seen in all ages and documented in late adolescence and early adulthood of childhood smokers)
• Emphysema
• Fertility- reduced !
• Foetal death
• Fractured neck of femur
• Gastro-oesophageal reflux disease
• Heartburn
• In utero growth retardation
• In utero effects leading to decreased lung function in babies
• Ischaemic Cardiomyopathy
• Ischaemic Heart Disease
• Ischaemic Stroke
• Large cell carcinoma of the bronchus
• Low birth weight
• Meningococcal disease
• Mesothelioma
• Meteorism (smoking in pregnancy)^[2]
• Myocardial infarction
• Osteoporosis
• Peptic Ulcer
  • Gastric ulcer particularily
  • Helicobacter pylori associated ulcers
• Peripheral vascular disease
• Periodontitis
• Pneumonia
• Placenta previa
• Premature rupture of membranes
• Preterm delivery
• Pulmonary embolism
• Respiratory symptoms in all ages exposed to cigarettes including
  • Coughing
  • Phlegm
  • Wheezing
  • Dyspnoea
• Small cell carcinoma of the bronchus
• Squamous cell carcinoma of lung
• Squamous cell carcinoma of oesophagus
• Stillbirth
• Stroke
• Superficial thrombophlebitis
• Thromboembolic Disease
• Transient ischaemic attack
• Transitional cell carcinoma of bladder
• Venous Thromboembolic Disease

Conditions where evidence is suggestive but not definite

• Adenocarcinoma of colon
• Atrophic age-related macular degeneration
• Colorectal adenomatous polyps
• Dental caries
• Erectile dysfunction.
• Exudative age-related macular degeneration
• Hepatoma
• Oral cleft palate - maternal smoking
• Thyrotoxic (Graves) ophthalmopathy

Conditions ameliorated by Smoking

• Alzheimer's Disease (but rather confounded by the much higher incidence of vascular dementia...ie risk of any dementia is increased several fold)
• Endometrial cancer in post-menopausal woman
• Parkinson's Disease

Actual risks

These have been quite well defined for many conditions, particularly acute myocardial infarction (AMI). There is an effectively linear dose response curve up to 21 cigarettes smoked per day with the odds of developing AMI increased by 1.056 (95% CI 1.05-1.06) for every additional cigarette smoked. So at 10 cigarettes a day you double your odds of an AMI, at 20 you quadruple the odds. At 40 or more per day the odds ratio is 9.16 (95% CI 6.79-12.36)^[3].

Type of tobacco

Makes little difference:

Change with risk with age

The relative risk of an acute myocardial infarction for a given amount of smoking is actually far greater the younger you are. This makes sense as the absolute risk of an acute myocardial infarction for reasons over which you have less control increases with age. So a former smoker aged less than 40 has an odds ratio of 2, but if still smoking an odds ratio of 4 if smoking less than 20 a day and an odds ratio of 7 if smoking more than 20 a day. This compares to a smoker aged more than 70 who has only an odds ratio of 2.5 if they are smoking 20 or more cigarettes a day.^[5]

Age standardised mortality risk per 100,000 patient years in current smokers and never smokers illustrating how leaness or obesity compounds the risk^[6]

Financial costs of smoking

According to research by the NHS Smoking Helpline,^[7] the average 20-a-day smoker coughs up an additional £1,824 for cigarettes each year, and an additional £676 on other costs, bringing total spending on their habit to more than £2,500. Additional costs include:

• Tackling burns, stains and odours associated with smoking, including dry cleaning bills, which adds a further £200 to the total spent by smokers.
• Higher energy bills than non-smokers, with estimates suggesting that they pay about ten per cent more for energy due to costs associated with ventilating smoking rooms.
• Health and life insurance: smokers can expect to pay more for health and life insurance, with one insurance company claiming that smokers' life insurance premiums are up to a third higher than those paid by non-smokers.

Change with risk with obesity

There is actually a J shaped curve for risk of death for a given body mass index with smoking grossly enhancing the absolute risk of death if you are too thin or too fat.^[8]

Smoking in pregnancy

Not a good idea for the child to be as it lowers birth weight^[9], is associated with premature birth and of dying of sudden infant death syndrome, reduces cognitive development^[10] and is associated with many childhood medical problems such as diarrhoea, anorexia and meteorism^[2]. The increased relative risk of these conditions is generally between 20% to 50% over non-smoking mothers but some effects are great enough to be detected in passive smoking exposure of non smoking mothers to be^[11].

External links

• Action on Smoking and Health (ASH)
• 2004 Surgeon General's Report: The Health Consequences of Smoking
• Wikipedia:British Doctors Study Description of the landmark study with references.

References