Rewards of Smoking Cessation By Dr. Ashraf El-Adawy By Dr. Ashraf El-Adawy Consultant Chest Physcian Consultant Chest Physcian TB TEAM Expert - WHO

Rewards of Smoking Cessation

By

Dr . Ashraf El-Adawy

Consultant Chest Physcian

TB TEAM Expert - WHO

In the past century smoking was common as a symbol of simple pleasures

Times have changed

Smoking is less socially acceptable now than ever...

Growing Recognition of Value of Smoking Cessation

Smoking’s bad for your health, but exactly how does quitting make life better?

The American Heart Association

• Smoking cessation intervention is one of the most cost-effective interventions in medicine

• Compared with other preventive interventions, smoking cessation is extremely cost-effective.

• Smoking cessation has been called the 'gold standard' of health care cost effectiveness, producing additional years of life at costs that are well below those estimated for a wide range of healthcare interventions.

World Health Organization 2003

Smoking and Life span

On average, each cigarette shortens a smoker's life by around 11 minutes

BMJ. 2000 January

Finally, here’s a nice example of what stopping smoking can offer.Richard Doll (1912-2005), who stopped smoking cigarettes at age 37,

photographed aged 91 at the 2004 BMJ press conferenceon the 50-year results from his study of British doctorsMichael Crabtree, copyright Troika

Photos

Study of smoking and death in male British doctors

• Recorded all deaths for 50 years (1951-2001)

• Main findings (for men born in the 20th century)– Smokers lose, on average, 10 years of healthy life

• Asked all UK doctors in 1951, and periodically thereafter, what they themselves smoked

– Stopping smoking at any age will add years to a persons life

– Those who stop smoking before 35 years of age avoid almost all of the excess risk will have a life expectancy no different from that of a nonsmoker.

Ag

e 40

A Study of Male Physicians Showed Quitting at Any Age Increases Life Expectancy

35-44 years

Patients were studied over the period of 1951-2001.Adapted from Doll R et al. BMJ. 2004;328:1519-1527.

Years

Nonsmokers Cigarette Smokers

Stopped Age

% S

urv

ival

Fro

m M

ean

Qui

t at a

ge 3

5-44

Additional9-yearlife expectancy

13

N=34,439 British male physicians.



Years

% S

urvi

val F

rom

Mea

nAg

e 50

Qui

t at a

ge 4

5-54


45-54 years

14


Stopped Age




Years

% S

urvi

val F

rom

Mea

nAg

e 60

Qui

t at a

ge 5

5-64


55-64 years

15


Stopped Age


Tobacco is the single largest preventable cause of cancer in the world today

Nonsmokers 1-14 cigs 15-24 25 +

Smoking habit

0.0

4.0

8.0

12.0

16.0

20.0

Rate

per

100

0 pe

rson

yea

rs

CPS2

0.00.6 0.6

1.1

45-54

0.1

1.72.7

3.9

55-64

0.3

4.5

7.1

9.265-74

0.6

7.0

13.2

17.9

75-84

Lung cancer risk by age and smoking habit

40 50 60 70 80Age

0

500

1000

1500

Lung

can

cer d

eath

s pe

r 100

,000

Currentsmokers

Neversmokers

quit 30-39

quit 40-49

quit 50-54

quit 55-59

quit 60-64

Halpern JNCI 1993: CPS2 data

Lung cancer risk by age of quitting

Stopping smoking: avoiding lung cancer

% dead fromlung cancer

Continued smoking: 16% dead from lung cancer

Stopped age 50: 6%

Stopped age 30: 2%

Never smoked: <1%

15

10

5

0

45 55 65 75Age

Cumulative risk at UK male 1990 ratesBMJ 2000; 321: 323-9

The benefits of quitting

Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk

5 yearsThe risk of cancer of the mouth, throat, esophagus, and bladder are reduced by half Cervical cancer risk falls to that of a non-smoker.

10 years The risk of lung cancer halved

Within years .......

• people diagnosed with cancer should quit smoking. For those having surgery, chemotherapy, quitting smoking helps improve the body’s ability to heal and respond to therapy . It also lowers the risk of pneumonia and respiratory failure .

• For people who have already developed cancer, quitting smoking reduces the risk of the cancer returning or developing a second cancer .

The National Cancer Institute

Smoking Cessation & Cardiovascular Diseases

One out of every five smoking-related deaths are caused by cardiovascular disease.

Cigarette smokers are two to four times more likely to develop coronary heart disease than non-smokers.

Cigarette smoking doubles a person's risk of stroke.

Cigarette smokers are more than ten times as likely as non-smokers to develop peripheral vascular disease




5 years The excess risk of a Stroke risk is reduced to that of a nonsmoker

Within years .......

15 years The risk of coronary heart disease is that of a nonsmoker's

1 yearThe excess risk of a heart attack reduces by half


For those smokers with diagnosed CHD, stopping smoking appears to reduce the risk of recurrent infarction and cardiovascular death by 50% or more. Smoking cessation is crucial in the management of many contributors to heart attack e.g atherosclerosis.

Smoking cessation significantly lowers the risk of atherosclerosis

Insulin action

Smoking

Oxdative stress

Diabetes mellitus

Bridges AB. et al., 1993 Paolisso G, et el., 1993

Smoking and Diabetes


Smoking is a risk factor of type-2 diabetes mellitus not only among middle-aged but also among elderly men and women.

Current smokers were 2-3 times more likely than never smokers to develop Type 2 diabetes

It appears to be a modifiable risk factor: the risk of developing diabetes among former smokers was similar to that of never smokers



Type 2 diabetes is a major risk factor for coronary heart disease and stroke. Having diabetes makes you twice as likely as someone who does not to develop cardiovascular disease. Diabetics who smoke have triple the risk of death from heart disease than non-smokers.



Although Smoking increases the cardiovascular risk, at any level of blood pressure, for coronary heart disease, stroke , it is not associated with an increase in the development of hypertension

Drug treatment of hypertension is less effective in smokers Smoking should be avoided in any hypertensive patient

Smoking and hypertension


Increases LDL

Decreases HDL

Slightly increases triglycerides

More LDL in plasma leads to more modified LDL

Smoking and hypercholestorlemia


Smoking has a multiplicative interaction with the major risk factors for coronary artery disease (CAD), to increase disease risk.

For example, if the presence of smoking alone doubles the level of risk for CAD, the presence of another major risk factor in conjunction with smoking results in approximately a 4-fold increase in risk, and the presence of 2 other risk factors together with smoking results in approximately an 8-fold increase in risk.

Multiplicative Risk Factor CAD

2.4

2.5

2.6

2.7

2.8

2.9

Post

bron

chod

ilato

r FEV

1

Sustained quitters

depqumch.tc

Continuing smokers

Screen 1 2 3 4 5Years of follow-upJAMA 1994;272(19):1497-505

CHANGE IN FEV1 BY SMOKING STATUS

The Lung Health Study

Smoking Is the Single Most Important Risk Factor for COPD

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.

1990 2020Ischaemic heart diseaseCerebrovascular diseaseLower resp infectionDiarrhoeal diseasePerinatal disordersCOPDTuberculosisMeaslesRoad Traffic AccidentsLung Cancer

Stomach CancerHIVSuicide

6th

3rd

Future Mortality Worldwide

Source: Murray & Lopez. Lancet 1997

Am. J. Respir. Crit. Care Med. 2002; 166: 675-679

Years

FEV 1 (

L)

2.02.1

2.22.32.4

2.52.62.7

2.82.9

0 1 2 3 4 5 6 7 8 9 10 11

Continuous smokers

Disease Progression in COPDLung Function

Smoking cessation decreases mortality in patients with COPD

1.00

0.95

0.90

0.85

0.80

Prop

ortio

n of

pati

ents

w

ith n

o ev

ent

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time since LHS baseline (years)

Special intervention groupUsual care group

All-cause 14.5 year survival from the Lung Health Study (LHS)

Anthonisen NR, et al. Ann Intern Med. 2005; 142:233-239. Permission granted.

N=5887

potential effect of stopping smoking early or late

in the course of COPD.

Fletcher CM, Peto R. BMJ. 1977;1:1645-1648. Reproduced with permissions from BMJ Publishing Group.

Smoked regularly and

susceptible to effects of smoke

Never smoked or not susceptible to smoke

Stopped smoking at 45 (mild COPD)

Stopped smoking at 65 (severe COPD)

Disability

Death

FEV 1 (%

of v

alue

at a

ge 2

5)

25

50

75

100

0

Age (years)25 50 75

• Smoking Cessation is Single most effective and cost effective intervention to reduce the risk of developing COPD and stop its progression

Am J Respir Crit Care Med 2001CRJ . 10;(Suppl A). 2003

Corticosteroid resistance

Laboratory Investigation advance online publication 24 July 2006; doi:10.1038/labinvest.3700456

Cigarette smoking in asthma is a risk factor for poor asthma control

Emergency department visits as a result of exacerbations of asthma occur more frequently amongst heavy cigarette smokers with asthma

Every effort should be made to encourage individuals with asthma who smoke to quit.

ERS 2004

Smoking Modulates Outcomes of Glucocorticoid Therapy in Asthma

(SMOG)

• Randomized, double-dummy, crossover trial of treatment with an ICS or an LTRA.

• primary outcome: change in pre-bronchodilator FEV1 • Non-smokers

– increases in FEV1 (170ml)– FEV1% predicted (5%) – PEF (28 L/m) – PC20 (0.63)

• smokers no such effects (except for daily AM PEF) Wechsler (ACRN) ATS 2006 (under review)

Cigarette smoking increases the clearance of theophylline by 60–100% in smokers compared with nonsmokers by induction of several metabolising enzymes

Cytochrome P450-1A2

Smoking cessation for 1 week reduces the elimination of theophylline by 35%.

ERS 2004

Smoking and TB Form a Deadly Combination

• Cigarette smokers may be up to three times more likely to develop latent TB infection than non-smokers

• For a person with latent TB infection, cigarette smoking increases

their risk of developing active TB disease by two to three times, compared to non-smokers

• Smoking reduces the effectiveness of TB treatment which can lead to longer periods of infection and/or more severe forms of the disease

• Smoking is associated with recurrent tuberculosis disease and increase the risk of relapse

• Up to one in every five deaths from tuberculosis could be avoided if the patients were not smokers

“STOP TB” Is Incomplete Without “QUIT SMOKING”

Women who smoke have increased risks for conception delay and for both primary and secondary infertility

Smoking cessation by women during their reproductive years reduces the risk for infertility.

Smoking causes women to reach menopause one to two years early, but former smokers have an age at natural menopause similar to those who have never smoked

AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE 2003 ASH Factsheet: Smoking and reproduction 2008

Impact of cigarette smoking on reproduction in women

Smoking is strongly associated with an increased risk of spontaneous miscarriage and possibly ectopic pregnancy.

Women who smoke during pregnancy are about twice as likely to experience premature rupture of membranes, placental abruption, and placenta previa during pregnancy

Pregnant women who smoke cigarettes run an increased risk of having stillborn or premature infants or infants with low birth weight.


Women who stop smoking before pregnancy or during the first 3 to 4 months of pregnancy reduce their risk of having a low birthweight baby to that of women who never smoked

Reducing the number of cigarettes smoked, rather than quitting completely, does not appear to benefit birthweight of the foetus.


Smoking cigarettes may contribute to inadequate breast milk production In breastfeeding mothers who smoke, milk output is reduced by more than 250 ml per day compared with non-smoking mothers.

Nicotine is rapidly transported from the smoking mother’s blood to her breast milk. The infant may be less willing to feed since the breast milk tastes bad.

ASH Factsheet: Smoking and reproduction February 2011

Impact of cigarette smoking on reproduction in men

Men who smoke cigarettes have a lower sperm count and motility and increased abnormalities in sperm shape and function.

Significant association between smoking and male sexual impotence with the association increasing with the number of cigarettes smoked per day

There is no “safe” level of smoking , even light smoking is associated with reduced male fertility


Smoking should be discouraged for both male and female partners in couples with a history of infertility or recurrent miscarriage. Smoking cessation may improve natural fertility and success rates with infertility treatment.

Smoking cessation for at least two months before attempting in vitro fertilization (IVF) significantly improved chances for conception.


Danish study (Lancet 2002;359:114)RandomisedCessation 6-8 weeks before surgeryFewer wound-related complications, reduced cardiovascular complications and secondary surgeryOverall complication rate was 18% in the smoking intervention group and 52% in controls Shorter hospital stay

Postoperative complications

Smoking has an inhibiting effect on estrogen,the most important hormone in preventing the loss of bone tissue. Smoking is one of the risk factors for osteoporosis which is a major cause of hip fracture. Postmenopausal women who smoke have lower bone density and an increased risk for hip fracture than women who never smoked. Stopping smoking prevents further excess bone loss.

Smokers have an increased risk of developing duodenal and gastric ulcers. Ulcer disease is more severe, less likely to heal, and more likely to recur in smokers. The increased risk is reduced by stopping smoking.

Risk of periodontal disease minimised by cessation

Cataract risk reduced

Other benefits of cessation

Adolescents

Grimshaw GM, et al. Tobacco cessation interventions for young people. Cochrane Database Systematic Reviews. 2006

Teenagers care about the immediate benefitsto their appearance, well being and financial status

rather more than future health gains

• Address the issues that matter to the teenager

• Brief interventions are likely to be effective

• Pharmacotherapies are not licensed in teenagers

Smoking can prematurely age the skin , Smokers’ skin can be prematurely aged by between 10 and 20 years

The risk of moderate or severe facial wrinkling is 3 times as high for women who smoke than those who have never smoked and twice as high for male smokers

“Tobacco kills beauty and much more.”

You’ll Save Money

Smoking is expensive - multiply how much money you spend on tobacco every day by 365 (days per year).

Your Self Esteem Will Improve

• You will feel more in control of your life.

• Your self esteem will improve by knowing you are doing something positive to help yourself!

You’ll Look Better

• Your clothes and breath will no longer smell like smoke.

• Your teeth will be whiter.

• You’ll lose the yellow nicotine stains on your fingers

Food Will Taste Better

• Your sense of smell and taste will return!

• Your appetite will improve and you’ll get more enjoyment out of eating!

Be good role model by either not smoking, or quitting

You’ll Protect Those You Love



8 hoursNicotine and carbon monoxide levels halved,Blood oxygen levels return to normal

24 hoursCarbon monoxide eliminated from the body

48 hoursNicotine eliminated from the body,Taste buds start to recover

Within hours.......



1 monthAppearance improves skin loses greyish pallor, less wrinkled Regeneration of respiratory cilia startsWithdrawal symptoms have stopped

3-9 monthsCoughing and wheezing decline lung function increased by 10%

Within months .......

IT’S NEVER TOO LATE TO QUIT

The Role of Health Professionals

In Tobacco Control

A smoking aware practice

Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9

Increase in quit rate

GP time

A ‘no-smoking practice’

Brief intervention

Moderate intervention

Intense intervention

>5 mins

<1 mins

2-5 mins

2 fold

3 fold

4 fold

5-7 fold

• Health professionals can make their own organizations’ premises and events tobacco-free

• Include tobacco control in the agenda of all relevant health-related congresses and conferences

• Health institutions and educational centres has to include tobacco control in their health professionals’ curricula

• We must promote and enforce a policy of smoke-free environments for all places

Recommendations

All smokers should be offered brief advice to quit

Making smoking cessation part of your practice At the individual level, health professionals should be tobacco free role models

Recommendations

Documents

Rewards of Smoking Cessation By Dr. Ashraf El-Adawy By Dr. Ashraf El-Adawy Consultant Chest Physcian Consultant Chest Physcian TB TEAM Expert - WHO