smoking and health
TRANSCRIPT
Smoking and health
Dr. Ashok Kumar KapoorMBBS, MD (Med.), DM (Car.), F.Card (Germany), FCCP (US),
Chairman
Getwell Medical Center & Curewell Diagnostic Center,
www.getwelluae.com
Smoking as nicotine dependence
• Nicotine the driving force
• As with other drugs, complex interplay between pharmacology, learning mechanisms, social and economic influences in determining patterns of use
http://www.getwelluae.com
The major health consequences of smoking
• Cancer– lung– mouth, larynx, throat, oesophagus– bladder, cervix, kidney, pancreas
• COPD• Coronary heart disease• Stroke• Peripheral vascular disease• Pregnancy and birth complications
http://www.getwelluae.com
Mortality associated with smoking
• At least 320 deaths every day from smoking in the UK, 120,000 per year
• 1/5 all deaths across all ages• 1/4 all deaths in age group 35-64 years• 1 in 2 lifetime risk for smokers• 7.5 years average loss of life expectancy• Over half of the difference in risk of death in middle
age between professional and unskilled men• 4 million deaths worldwide
http://www.getwelluae.com
1950 1975 2000 2025 2050
Year
0
100
200
300
400
500
Cu
mu
lati
ve d
eath
s fr
om
to
bac
co (
mil
lio
ns)
Scenarios for future deaths from tobacco
Trend
520
70
220
Source: Peto et al http://www.getwelluae.com
Smoking is highly addictive
• At least 70% of smokers want to give up• Less than half succeed before age 65• 40% of heart attack smokers relapse while still in
hospital within 2 days of intensive care• 50% of patients with laryngectomies try smoking
again• 50% of patients with lung removed for lung cancer
smoke again• More than half of heroin and cocaine users and
alcoholics rate smoking harder to quit
http://www.getwelluae.com
Addiction
http://www.getwelluae.com
Starting point - the cigarette
“The cigarette should be conceived not as a product but as a package. The product is nicotine. Think of the cigarette pack as a storage container for a day’s supply of nicotine….Think of the cigarette as the dispenser for a dose unit of nicotine…..Smoke is beyond question the most optimised vehicle of nicotine and the cigarette the most optimised dispenser of smoke”.
William Dunn, Philip Morris, 1972http://www.getwelluae.com
-10 0 10 20 30 40 50 60 70
Time (mins)
0
5
10
15
20
25
30
35
40
Nic
oti
ne C
on
cen
trati
on
(n
g/m
l)
Schematic Diagramof Arterial vs Venous
Nicotine Levels
Venous
Arterial
cigarette
smoked http://www.getwelluae.com
Nicotine Addiction in Britain
Royal College of Physicians Feb 2000
• “Nicotine delivered rapidly to the brain in cigarette smoke should be recognised as a powerfully addictive drug on a par with heroin and cocaine, and tobacco products should be recognised as nicotine delivery systems.”
Central conclusion: smoking is best understood as nicotine seeking behaviour
http://www.getwelluae.com
Rating IV nicotine and cocaine:Jones et al (1999)
• Compared 3 doses of cocaine and nicotine given IV double-blind + saline placebo
• Nicotine ‘high’ and ‘rush’ rated stronger than cocaine, also ‘jittery’
• Nicotine frequently misidentified as cocaine, and, at highest dose, an opiate
http://www.getwelluae.com
0 10 20 30 40
Prevalence of regular drug use:adults aged 16-64, GB 1993-1994
32
22
2
0
0
0
0
0
Cigarette smoking %
Drinking above
recommended limits
Marijuana
Tranquillizers
sleeping pills
Amphetamines
Opiates
Cocaine
Psychedelics
hallucinogens
OPCS Psychiatric Morbidity Survey: Meltzer et al 1995 Base n=9792
Regular drug user = every day for 2 weeks or more in past 12 monthshttp://www.getwelluae.com
Abstainer Occasional Light Moderate Fairly heavy Heavy Very heavy0
5
10
15
20
25
30
35
40
45
Ne
uro
tic
dis
ord
er
%Neurotic disorder % by drinking habits
GB 1993-1994
Alcohol drinking habitshttp://www.getwelluae.com
Never smoker Ex 3-4 5-6 7-8 9-10 11-12 13-140
5
10
15
20
25
30
35
40
45
Ne
uro
tic
dis
ord
er
%Neurotic disorder % by smoking habits
GB 1993-1994
Tobacco dependence scorehttp://www.getwelluae.com
Nicotine as a drug of dependence
• Blood nicotine from cigarettes, snuff (oral and nasal) and cigars very similar
• IV nicotine suppresses smoking
• Nicotine intakes from different brands of cigarette very similar
http://www.getwelluae.com
Nicotine as a drug of dependence
• Nicotine withdrawal syndrome
• Effect of nicotine replacement on successful quitting
http://www.getwelluae.com
Self-assertion . . .“To account for the fact that the beginning smoker will tolerate the unpleasantness we must invoke a psychosocial motive. Smoking a cigarette for the beginner is a symbolic act. The smoker is telling his world, 'This is the kind of person I am.' Surely there are variants of this theme, 'I am no longer my mother's child,' 'I am tough,' 'I am not a square.' Whatever the individual intent, the act of smoking remains a symbolic declaration of personal identity . . .” Philip Morris (Bates no. 1003287836)
http://www.getwelluae.com
. . . and addiction
“ . . . As the force from the psychosocial symbolism subsides,
the pharmacological effect takes over to sustain the habit . . .”
Philip Morris 1969 document (Bates no. 1003287836)
http://www.getwelluae.com
Addiction -
http://www.getwelluae.com
Factors favouring study of smoking as compared with other drug taking
behaviours
• High prevalence
• Legal
• Little stigma, so self-reports largely accurate
• Unlike alcohol, excellent biomarker of intake available
http://www.getwelluae.com
Cotinine as a biomarker of nicotine intake
• Main nicotine metabolite (70-80% converted)
• Half-life 16-20 hours
• Measurable in saliva, blood or urine
• Quantitative measure of nicotine intake: 10ng/ml cotinine in blood ~ 1mg nicotine daily
http://www.getwelluae.com
Brief dependence scale
1. How soon after waking do you smoke yourfirst cigarette of the day?
Less than Between Between Between Between Longer5 minutes 5 and 15 15 and 30 30 min. 1 and 2 than 2
minutes minutes and 1 hr hours hours
2. How easy or difficult would you find it to gowithout smoking for a whole day?
Very easy Fairly easy Fairly difficult Very difficult
3. How many cigarettes do you usually smokeeach day?
1-10 11-20 21-30 31+
http://www.getwelluae.com
0
5
10
15
20
25
30
Per
cen
tag
e o
f sm
oke
rs
DISTRIBUTION OF TIME TO FIRST CIGARETTEIN SMOKERS IN PRIMARY CARE
"How soon after waking do you smokeyour first cigarette of the day?"
Less than
5 minutes
5-15
minutes
15-30
minutes
30 min
to 1 hr
1 to 2
hours
More than
2 hours
50
100
150
200
250
300
350
400
450
Sal
iva
coti
nin
e (n
g/m
l)
Mean + 95% CI-
TIME TO FIRST CIGARETTE OF THE DAY
Less than
5 minutes5-15
minutes
15-30
minutes
30 min
to 1 hr
1 to 2
hours
More than
2 hours
n=307n=182n=214n=205n=322n=260
http://www.getwelluae.com
0 1 2 3 4 5 6 7 8 9 10 110
110
220
330
440
550
Sa
liv
a c
oti
nin
e (
ng
/ml)
SALIVA COTININE BY DEPENDENCE INSMOKERS IN PRIMARY CARE
Mean + 95% CI
DEPENDENCE SCALE SCORE
N = 160 108 381431361491209996108130 73
http://www.getwelluae.com
0 1 -4 5 -9 1 0 -1 4 1 5 -1 9 2 0 -2 4 2 5 -2 9 3 0 +0
1
3
Pla
sma
cotin
ine
(ng/
ml)
P ar tner 's daily cigar ette consum ption
Geometric mean ± 95%CI
0 .5
2
http://www.getwelluae.com
0 1-4 5-9 10-14 15-19 20-24 25-29 30+0.0
0.5
1.0
1.5
2.0
2.5
Pla
sm
a c
oti
nin
e (
ng
/ml)
PASSIVE SMOKING: COTININE IN ADULTSBY PARTNER'S CIGARETTE CONSUMPTION
Partner's daily cigarette consumption
Geometric mean + 95%CI
Health Survey for England
1994 &1996
8328 234 231 259 155 294 79n= 60http://www.getwelluae.com
1972 1976 1980 1984 1988 1992 19960
10
20
30
40
50
60
% p
reva
len
ceCIGARETTE SMOKING 1972-1998:
GB: General Household Survey
Men
Women
http://www.getwelluae.com
Disadvantage and Smoking
• A whole range of indicators of disadvantage predict who smokes
• Cigarette smoking prevalence tightly linked to deprivation, mainly because of low rates of quitting in disadvantaged groups
http://www.getwelluae.com
Indicators of socio-economic status
• Occupational class
• Educational level
• Housing tenure
• Car ownership
• Unemployment
• Living in crowded accommodation
• Single parenthood
• Divorced or separatedhttp://www.getwelluae.com
Disadvantage and smoking
• Poor people are:– More likely to take up smoking– Less likely to quit– More heavily exposed to other people’s
smoke – Become more nicotine dependent– Much more likely to die prematurely
from smokinghttp://www.getwelluae.com
0 1 2 3 4 50
10
20
30
40
50
60
70
80
% p
rev
ale
nc
e
CIGARETTE SMOKING BY DEPRIVATIONIN GREAT BRITAIN: GHS 1973 & 1998
1973
1998
DEPRIVATION SCOREMost affluent Poorest
http://www.getwelluae.com
0 1 2 3 4 50
10
20
30
40
50
60
70
80
% q
uit
SMOKING CESSATION BY DEPRIVATIONIN GREAT BRITAIN: GHS 1973 & 1998
1973
1998
DEPRIVATION SCOREMost affluent Poorest
http://www.getwelluae.com
0 1 2 3 4
200
250
300
350
Pla
sm
a c
oti
nin
e (
ng
/ml)
Plasma cotinine by deprivationin adult smokers: HSE 1993-1996
1993
1994
1996
DEPRIVATION SCOREhttp://www.getwelluae.com
Some implications of nicotine addiction for cessation and harm reduction
• Ineffective• cutting down• switching to cigars or a pipe• switching to low tar
• Effective
• Nicotine replacement productshttp://www.getwelluae.com
0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +
Cigarette nicotine yield (mg)
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Nic
oti
ne
in
tak
e p
er
cig
are
tte
(m
g)
Predicted and actual nicotine intakes per cigarettesmoked by nominal nicotine yield of usual brand
Predicted
Health Survey for England 1998
http://www.getwelluae.com
0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +
Cigarette nicotine yield (mg)
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Nic
oti
ne
in
tak
e p
er
cig
are
tte
(m
g)
Predicted and actual nicotine intakes per cigarettesmoked by nominal nicotine yield of usual brand
Actual Predicted
Health Survey for England 1998
http://www.getwelluae.com
One year success rates by intensity of intervention:
• Unaided quit attempt …………………...…..….1-2%
• Brief GP advice ……………………………...……5%
• Brief GP advice + NRT ……………………….…10%
• Intensive clinic support ………………………...15%
• Intensive clinic support + NRT……………..20-30%
http://www.getwelluae.com
1950 1975 2000 2025 2050
Year
0
100
200
300
400
500
Cu
mu
lati
ve d
eath
s fr
om
to
bac
co (
mil
lio
ns)
Scenarios for future deaths from tobacco
Trend
520
70
220
Source: Peto et al http://www.getwelluae.com
1950 1975 2000 2025 2050
Year
0
100
200
300
400
500
Cu
mu
lati
ve d
eath
s fr
om
to
bac
co (
mil
lio
ns)
Scenarios for future deaths from tobacco
If smokinguptake halves
by 2020
Trend
520
70
220
500
Source: Peto et al http://www.getwelluae.com
1950 1975 2000 2025 2050
Year
0
100
200
300
400
500
Cu
mu
lati
ve d
eath
s fr
om
to
bac
co (
mil
lio
ns)
Scenarios for future deaths from tobacco
If adult smokinghalves by 2020
If smokinguptake halves
by 2020
Trend
520
70
220
190
500
340
Source: Peto et al http://www.getwelluae.com
Conclusions
• Nicotine’s legal status and lack of adverse effects on performance have hampered recognition of its status as a drug of dependence
• Nicotine is pharmacologically a hard drug, on a par with heroin and cocaine
• Cigarette smoking is by far the biggest problem of drug dependence
http://www.getwelluae.com