Download 21-SMOKING

‫باتل الطريقي‬
‫فارس الرحيلي‬
‫ياسر بخش‬
‫حسام الحميدي‬
‫سعد الشمري‬
‫عمار الشهري‬
Smoking ‫التدخين‬

Smoking epidemic is one of the biggest public health
threats the world has ever faced.

It is the leading preventable cause of death in many
countries.

Every Day 13,000 people die .

It kills nearly six million people each year.
more than 5 million are users and ex users and more
than 600.000 are nonsmokers exposed to secondhand smoke.
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1 Billion Man in the world smoke !!
About 35% of men in developed countries and
50% of men in developing countries .
250 Million woman in the world smoke !!
About 22% of women in developed countries
and 9% of woman in developing countries .

It caused 100 million deaths in the 20th century. If current
trends continue, it will cause up to one billion deaths in the
21st century.
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Nearly 80% of the more than one billion smokers worldwide
live in low- and middle-income countries, where the burden
of tobacco-related illness and death is heaviest.
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95 % of the global population is unprotected by laws
banning smoking.
Mechanism of addiction
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Nicotine Multiplies the effect of various
neurotransmitter
Dopamine
Noradrenaline
Chronic nicotine administration develop
tolerance .
Causes of the withdrawal
symptoms :
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State of nicotine deprivation
Altered level of dopamine
Noradrenaline
Other neurotransmitter
Hussam Alhamidi
Effects on body system
caediovascular
Heart rate ,BP
Vasoconstriction
Vasodilatation
skin
Skletale muscle
Coronary artery
Chronic effects
on CVS
HR, BP,
contractility
Myocardial O2
consumption
Demand for
blood flow
Coronary blood
flow (coronary
spam )
Metabolic
BMR
Appetite
suppressio
n
VLDL/LDL
HDL
Catecholamines
Libolysis
Free faty acid
Synthesis of VLDL

Major factor in many diseases and adverse
health events .
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There is sufficient evidence that smoking
causes the following conditions :
Cancers :
lung,
oral (laryngeal)
GI (esophageal, stomach, liver, pancreatic)
GU (bladder, kidney, cervical)
hematologic (myeloid leukemia)
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•
•
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Cardiovascular disease:
atherosclerosis
cerebrovascular
coronary heart disease(CHD)
abdominal aortic aneurysm
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Respiratory disease:
•
chronic obstructive pulmonary disease(COPD)
•
•
increased susceptibility to pneumonia
impaired lung growth during childhood and
adolescence
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o
o
o
o
o
o
o
o
Reproductive effects:
decreased fertility in women,
complications of pregnancy:such as
premature rupture of the membranes
placenta previa
placental abruption
miscarriage
still birth
low birth weight
reduced lung function in infants
sudden infantdeath syndrome (SIDS)
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Other:
hip fractures
low bone density
peptic ulcer disease
cataracts
diminished health
status
50000
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
269,000 deaths among men
age 35-69
age 70+
60000
243,000 deaths among women
50000
40000
30000
20000
10000
0
age 35-69
age 70+
For smoker
chronic bronchitis
emphysema
for former smoker
chronic bronchitis
emphysema
previous heart attack
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Lung cancer represents the biggest cause of
smoking-related cancer mortality.
According to the (CDC), smoking-related lung
cancer accounts for more than 10 times the
number of years of potential life lost (YLL) in
the United States compared with any other
smoking-related cancer
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Difference in lung cancer risk between
smokers and former smokers is not to be
expected before around 2 years after
quitting.
Because of the time lag between mutation,
and disease detection.
Most of the increased risk is avoided by those
who stop smoking before middle age
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A systematic review found that smoking
cessation was associated with a reduction in
the risk of all the major histologic types of
lung cancer.
the risk for adenocarcinoma and large cell
carcinoma fell off less rapidly than for small
cell lung cancer and squamous cell
carcinoma.
Cancer type
Disease burden from smoking, additional risk factors,
and health
benefits
from
cessation compared with current smokers
evidence
of reduced
risk
for ex-smokers
Esophageal
cancer
for squamous cell esophageal cancer and an increased risk was probably
Second biggest cause of
maintained for at least 20 years risk among ex-smokers was still twice the
(YLL)
among
risk
of from
never smoking
smokers after
10 men (101,100 YLL), and the
Oral cancer
Third biggest cause of years of life lost Among men and
the fifth among women Strong interaction between
alcohol and smoking risk remained elevated compared
with never smokers up to 20 years after cessation
Pancreatic
cancer
Second biggest cause of smoking-related years of life
lost among women There is good evidence of risk
reduction following cessation The risk is likely to
remain elevated for at least 15 years after
cessation.
third amongwomen (25,000 YLL)
Urinary tract
cancer
There is good evidence of reduced risk among former
the risk remained elevated for at least 25 years after
cessation.
Cervical cancer
Following cessation, the relative risk returned rapidly
to the level of never smokers.
Stomach cancer
Smoking has recently been found to be causally
associated with stomach cancer Reduced relative risk
compared with persistent smokers but no evidence
for non smoker
Laryngeal
cancer
Rapid reduction in risk (about 60% at 10 to 15 years
compared with smokers), and continuing to fall,
although an elevated risk remains compared with
never smokers for at least 20 years
Myeloid
leukemia
No enough evidence

smoking was associated with pulmonary
complications during and following surgery

poorer wound healing

increased complications from radiation
therapy

Other studies have associated smoking cessation with
increased survival times in breast cancer and non-small cell
lung cancer
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Smoking operates at different stages in the
development of coronary heart disease (CHD):
reduces the ability of the blood to carry
oxygen
causes progressive atherosclerosis
endothelial injury
thrombotic processes
acute infarction
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The evidence is less good than for
cardiovascular disease .
The RR decreases with cessation and may
reach that of never smokers following 5 to 10
years of abstinence,
depends on past smoking habits, with light
smokers (< 20 cigarettes/day) reaching the
risk of never smokers within 5 years, whereas
heavier smokers may never reach it.
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Smoking is the dominant risk factor for (PAD).
RR is slower than for cerebrovascular and
CHD, with elevated risk observed even after
20 years.
smoking increased graft failure 3.09-fold in
people with PAD who were undergoing
arterial reconstructive surgery in the lower
extremities
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The strongest evidence for benefit is in
people with mild COPD.
One RCT, the Lung Health Study, which
included people with mild to moderate COPD,
found :
an increase in FEV1 in the first year following
smoking cessation.
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Is a significant health risk for nonsmokers,
especially those with pre-existing respiratory and
cardiac conditions.
Is now a recognized carcinogen .
containing over 50 harmful chemicals, such as :
Formaldehyde
benzene
vinyl chloride
arsenic
ammonia
hydrogen cyanide.
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Concentrations of many harmful chemicals
are higher in secondhand smoke than in that
inhaled by smokers.
Found to be immediately detrimental to the
cardiovascular system.
There is a prothrombotic effect with
increased platelet stickiness
decreased coronary flow reserves
Reduced heart rate variability.
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•
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Pooled evidence has indicated a causal
relationship between secondhand smoke and
both lung cancer and CHD.
Nonsmokers exposed to secondhand smoke
at home or at work have about :
25% to 30% increased risk of heart disease
20% to 30% increased risk of lung cancer.

•
Meta-analysis found that :
RR increased on average by 24%, with people
in the highest workplace exposure categories
being twice as likely to develop lung cancer
compared with nonexposed people .
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Infants and young children are considered
especially vulnerable .
Maternal exposure during pregnancy is
associated with
Small decrease in birth weight
Persistent adverse effects on lung function
throughout childhood.
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Parental smoke is linked to ever having
asthma,
exposure in children has been associated
with increased risk for
Sudden infant death syndrome (SIDS)
Acute respiratory infections
Ear problems
Increased severity of asthma.
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The Surgeon General has concluded that there is
no safe level for secondhand smoke Exposure .
Mechanical ventilation or separation of smokers
does not fully eliminate the risk.
Air cleaning systems leave behind small particles.
Heating and cooling systems may distribute
smoke throughout a building.
Smoking is the biggest preventable cause of
premature mortality
Faris Awadallah AlRehaili
QUITTING PLAN
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Support group vs Self monitoring
Cold turkey vs Nicotine fading
Use of medications vs Non use of medication
Set a quitting day
QUIT DAY
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Sitting the quit after 7 to 14 days.
Quitting on Saturday vs Quitting Wednesday.
Mark the date on your calendar.
Be determined to quit on that day.
Don’t quit before your Quit Day.
PREPARE FOR YOUR QUIT DAY
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stop smoking relating to external and internal
triggers
wait 10-15 minutes after the trigger is done.
Be consistent.
Don’t try to quit smoking or even cut down
yet.
AT THE QUIT DAY
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Get rid of all cigarettes, ashtrays, lighters,
and matches.
Have creative alternatives available, such as :
Using “meswak”
Sugarless gum
Sugarless candy
A ball to squeeze
Rubber bands
Tell a lot of people that you’ve quit smoking.
AFTER QUIT DAY
Irritability, Fatigue, Insomnia, Cough, Dry throat,
Nasal drip, Dizziness, Constipation, Gas, Hunger.
 most symptoms pass within two to four weeks.
Craving for a cigarette.
1-Urges only last a few minutes.
2-Find out your personal reason and remembering
them when things get a little tough
3-Do something to take your mind off smoking.
4-Don’t ever take a cigarette from your friend not
even a puff.

Your Role as a Friend
1) Don’t nag, insult, or try to shame the smoker
into quitting.
2) Let the smoker know that he is valued as
a person.
3) Listen non-judgmentally, Try to see the
problem through the smokers’ eyes.
4) Praise the smoker for even the smallest
efforts to quit.
Saad Ibraheem AlShammeri
‫عند حضور المراجع للعيادة يتم تعريفه بالحكم الشرعي للتدخين‬
‫وبأخطار التدخين الصحية والنفسية من خالل جلسة مع المشرف‬
‫االجتماعي ومن خالل المعرض الذي يحتوي على بعض‬
‫المعروضات و المجسمات ‪.‬‬
‫‪-Then the phusician should take the following:‬‬‫‪1-Body weight and height‬‬
‫‪2-CO level‬‬
‫)‪1-2 ??(normal‬‬
‫)‪3-7??(mild smoking‬‬
‫)‪8-22(severe smoking‬‬
‫‪- Peak flow meter‬‬
By :
Yaser Yousef Bakhsh

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Pharmacological
treatment .
Non pharmacological
treatment ( behavioral
therapy ).
1.
2.

Nicotine based therapy
Non nicotine based therapy
Both nicotine and non nicotine based therapy
can increase the chances of successful
smoking cessation.

Nicotine replacement therapy (NRT) :
are available as transdermal patch,
gum, nasal spray, inhaler, or
iozenge.

Reduces the withdrawal symptoms associated
with smoking cessation such as anger,
anxiety, craving, difficulty concentrating,
hunger, impatience or restlessness.
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There
are
two
recent
high-quality
systematic reviews found all forms of NRT
to be effective.
In this study observed that the main factor
determining the effectiveness of NRT was
the level of the nicotine dependence.
Anther study found little good evidence that
NRT was effective for people who smoke
fewer than 10-15 cigarettes daily . An
additional cohort study found that nicotine
patches were more effective in achieving
long term cessation (52 weeks) in smoker
with moderate dependence compared with
those with mild to high dependence.
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The review found on evidence that one form of
NRT is preferable.
Anther study found that positive predictors for
the patch were different compared with the nasal
spray : low to moderate dependency smokers
with white ancestry and a BMI less than 30 kg\m²
were more successful with the patch where as
highly dependent obese people from a nonwhite
background had higher cessation rates with the
spray.
Another trail compared four different formats of
NRT and found that women were more successful
with inhaler compared with gum and men vice
versa .
forms
Overthe
counter
gum
patch
Prescriptio
n only
Dose*
Side effects
yes
2mg if < 25 cigarette per day
4 mg if ≥ 25 cigarette per day
•1 every 1-2 hours for 6 week
or 1 every 2-4 hours for 7-9
weeks or 1 every 4-8 hours for
10-12 weeks
Bad test,
mouth
irritation, jaw
pain,
orodental
problem, GI
disturbances,
cough
yes
•>10 cigarette per day: 21mg
Skin irritation,
per day for4-6 weeks or 14mg or sleep
for 2 weeks or 7mg for 2 weeks disturbances.
•≤10 cigarette\day 14mg \day
for 6 weeks or 7mg\day for 2
weeks
forms
Overthe
counte
r
lozeng
e
yes
Prescript Dose*
ion only
Side effect
2mg if smokes 1st cigarette>30
min.
4mg if smokes 1st cigarette within
30 min.
1 every 1-2H for 6W, 1 every 24H for 7-9W, 1 every 4-8H for
10-12 W
Mouth
irritation, bad
taste, nausea,
dyspepsia,
hiccups
Nasal
spray
yes
1or2 doses\H for 6-8W but at
least 8 doses \day.
Gradually reduce over 9-14W.
Nasal/sinus
irritation,
runny nose
Oral
inhaler
yes
One-10mg cartridge deliver 4mg
nicotine.
6-16 cartridge\day for 1-12W.
Gradually reduce over next 6-12W
Throat
irritation,
cough, oral
burning,
dyspepsia
*dosing in this table is based on manufacturers’ recommendations.
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Side effects of NRT
include local irritation
depends on the route of
administration.
NRT is generally safe in
patients
with
stable
cardiovascular disease.
Patient preference, cost,
and side effect may be
consideration
when
choosing NRT.
1.
Antidepressants .
2.
Nicotine partial receptor agonists .
3.
Other drug therapy .
1.
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Antidepressants: such as
Bupropion is a selective
serotonin\norepinephrine
uptake inhibitor(SSNRI)
Nortriptyline is a tricyclic
antidepressant(TCA)
But anther antidepressant
like SSRI and MAO inhibitor
have not been shown to
help smoking cessation.

1.
2.
3.
Mechanism of action :
Improving depressive symptoms precipitated
by quitting smoking.
Substituting for possible antidepressant
effects of nicotine.
Independent neurologic effects such as
nicotine receptor antagonist.
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It decreases depressive symptoms in highly
nicotine dependent smokers, but symptoms
rebound when bupropion is discontinued.
Extended therapy with bupropion to prevent
relapse has not been found to be beneficial.
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Bupropion has been shown to be effective
in in people with or without depression and
in combination with different types of
behavioral support.
A recent trail has shown it to be effective
and safe in people with acute cardiovascular
disease.
bupropion and nortriptyline appear to be
about equally efficacious with NRT

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One small trail found that bupropion was
associated with higher smoking cessation rate
at 6 months compared with nortriptyline or
placebo when each was added to intensive
counseling therapy.
One randomized control trail found that risk
factor for relapse in people treated with
bupropion and counseling were younger age,
female sex, high levels of nicotine dependence
shorter previous quit attempts, previous use of
NRT and self reported depression.
2. Nicotine partial receptor agonists: such as

Varenicline

Cytistine : is the natural chemical from which
varenicline was developed, so it like
varencline but has a low price, is less well
studies but may also aid smoking cessation .
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There have been no quality trails about a
third partial nicotine agonist , (lobeline).

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Varenicline
increases
smoking
cessation
about 3 fold at 1 year
compared
with
placebo.
A systematic review
found that compared
with
bupropion,
varenicline increase the
odds
of
smoking
cessation about 1,7
fold at 1 year.
drugs
FDAapprove
d
dose
Side effects
Bupropion
yes
Set target quit data for during 2nd week
of treatment
150mg ×3 days, then 150mg twice
daily, continue treatment for 7-12W
Dry mouth,
sedation,
seizure
(1\1000)
rare
From 75-100mg daily for 6-12 weeks
Sedation,
constipation
, urinary
retention,
risk of
arrhythmia
Set target quit data for 1 week after
starting treatment
0.5mg once daily for 3 days then twice
daily for 4-7D, increase to 1mg twice
daily from day8 through end of 12
weeks
Nausea,
sleep
disturbance
s, headache
nortriptyline
varenicline
yes
3. Other drug therapies:
 Clonidine a centrally acting antihypertensive
agent, has been studied mostly in
conjunction with behavioral counseling can
increase smoking cessation 2-fold,but had
side effect especially dry mouth and
sedation which limit its use.
Tapering of dosing at the end of therapy is
recommended to avoid withdrawal effect of
clonidine.

Silver acetate gum, lozenge or spray:
causes unpleasant taste when conbined with
cigarette.
Limited data don’t support a role of it, possibly
because of reportedly poor compliance.
Combination NRT:
There is weak evidence that combination NRT
may be more effective than single forms62.
 Combining NRT with other drug treatments:
There is no good evidence about combining
NRT with varenicline, anxiolytics or
clonidine.

Two small studies suggest that adding
mecamylamine(nicotine receptor
antagonist) to NRT may superior to NRT
alone.

Adding NRT to nondrug therapy:
Although the absolute chances of quitting
increase when NRT is used in conjunction
with additional support.
One trail showed that NRT plus physician
training improved quit rates over physiciant
training alone.

Nicotine conjugate
vaccine:
A vaccine currently in
development aims to
induce nicotine-specific
antibodies in order to
prevent nicotine’s
passage into the brain.
CASES
Date
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46 year-old gentleman with a persistent right
lower lobe pulmonary mass after a successfully
treated cavitary pneumonia 5 months ago. At
the time of presentation he was clinically
asymptomatic. The patient worked in the
hospital and smoked one pack of cigarettes a
day. He recently quit.
A chest CT scan revealed a right lower lobe lung
mass and multiple small cavitary nodules.

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What is the most likly diagnosis ?
PRIMARY ADENOCARCINOMA OF LUNG

35 old teacher came up to your clinic for
diabetes follow up .He told you that he is
getting weak last 2 month and he has
shortness of breath in minimal activity , also
he complained of sleep disturbance, and
insomnia . He smokes about 1 pack/day for
18 years and he seems to be upset about his
habit .He is asthmatic and his asthma
exacerbate with seasons .
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Would you prescribe for him broncodilator ?
Would you refill his diabetic medication ?
The patient has good knowledge about the risk
of smoking , would you offer him more
information ?
Would you take advantage of his symptoms
(shortness of breath and and sleep disturbance )
and relate that to years of smoking ?
Would you prescribe for him nicotine patches or
nicotine gums ?
Would you suggest for him to find an alternative
activity instead of smoking ?
What else will you do ?

A 54 years old male present to your clinic
with the complaint of increased sputum
production ,chronic cough ,and shortness of
breath for the last several months , he has
smoked two packs of cigarettes a day for the
last 20 years .


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Whats your most likely diagnosis ?
COPD
Whats is your confirmatory test ?
spirometery , ratio of <0.7
References:
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