1. Medicine, Nursing and Health Sciences Smoking and its effects Ian Davis Professor of Medicine, Monash University and Eastern Health Head, Eastern Health Clinical School Medical oncologist, Eastern Health

2. What you see …  Over 4000 chemicals: –CO, HCN, formaldehyde, benzene, phenols, radioactive isotopes  Nicotine: highly addictive  Carcinogens (>60 known): –Poly aromatic hydrocarbons, N-nitrosamines, benzene, aldehydes, nickel, arsenic, chromium, cadmium  Chemical additives (not regulated or declared): –Flavour; numbing (less irritant); alter nicotine PK; bronchodilators and what you get… chathamcommunitylibrary.com www.quit.org.au

3. Nicotine  Nicotine is highly addictive  Withdrawal syndrome: –Dizziness (which may last 1 to 2 days after quitting) –Depression –Feelings of frustration, impatience, anger, irritability –Anxiety –Irritability –Sleep disturbance –Trouble concentrating –Restlessness or boredom –Headaches –Tiredness –Increased appetite and weight gain –Constipation and flatulence –Cough, dry mouth, sore throat, and nasal drip –Chest tightness –Slower heart rate

4. How big is the problem?  Smoking is the leading cause of preventable death in Victoria  Of every 1000 deaths: –119 are caused by smoking –24 are caused by alcohol; 12 are caused by road deaths (overlapping) –3 are caused by other drugs, including heroin  The most preventable cause of death in Western countries –USA: Causes more than 1 in 5 deaths (~440,000/year) 14 million smoking-attributable conditions in 2009 –Australia: Direct cause of death in 12% (15,000/yr); indirect up to 50% Annual cost: $31.5 billion www.health.gov.au/tobacco; www.quit.org.au Rostron BL et al. JAMA ePub October 13 2014

5. Impact of smoking  Cancer –90% of lung cancer in men, 80% in women –Non-lung cancers: Head and neck, oesophagus, stomach, colon, breast, bladder, kidney, pancreas, ovary, cervix, leukemia, liver, others  Non-cancer –Smokers average 13-14 years shorter life span –Cardiovascular, cerebrovascular, respiratory –Osteoporosis –Cataracts, macular degeneration –Infertility, impotence, early menopause –Type 2 diabetes –Autoimmune disorders eg rheumatoid arthritis www.myclevelandclinic.org; www.cdc.org; www.quit.org.au

6. US cancer deaths 1930-2010 Siegel R et al. CA: A Cancer Journal for Clinicians 64:9-29, 2014 US cancer incidence 1975-2010

7. Estimated deaths from cancer in 2014 (USA) Siegel R et al. CA Cancer J Clin 64: 9-29, 2014           

8. Incidence: 14.1 million new cases worldwide (both sexes) (6.1 in more developed regions, 8.0 in less developed regions) 57% in less developed regions Global Burden of Cancer (2012) IARC. World Cancer Report 2014. http://www.iarc.fr/en/publications/pdfs-online/wcr/

9. Projected cancer incidence by more and less developed regions 2012 to 2025 More Developed Less Developed 8.0M → 11.5M 44% increase 8.2 6.1M → 7.3M 20% increase

10. Australian data  Smoking rates are slowly declining: –1940s: 72% of males, 26% of females smoked –Almost halved since 1980 –Australia:17.5% in 2010 –Victoria:13.3% in 2012 (16.1% males, 10.6% females) –Victorian students aged 12-17:7.0%  Indigenous Australians: 38% smokers cf 18% –1.9 x risk of lung cancer; 3.8 x head and neck; 1.4 x leukemia; 3.3 x liver –1 in 5 indigenous deaths –Earlier uptake of smoking, smoke for longer, smoke more cigarettes daily, less likely to attempt to quit –Similar data for non-indigenous lower socioeconomic groups  20 year lag in change in lung cancer mortality www.aihw.gov.au; www.quit.org.au

11. Cancer Institute NSW report (October 2014) http://www.cancerinstitute.org.au/

13. Adolescents  Long term nicotine addiction linked to tobacco use during adolescence –Most smokers start in pre-teens or teenage years –Earlier use = increased probability –50% quit failure rate by age 17  Effects on developmental milestones –Establishment of independence and autonomy –Self-identity –Adjustment to physical maturation –Self image, peer pressure, stress, boredom, self- assertiveness, rebellion –Relaxation and pleasure www.myclevelandclinic.org www.heart.org www.cancer.org

14. Second-hand smoke  At least 250 known toxic chemicals, including 50 carcinogens –Relatively more ammonia, acrolein, CO, nicotine –Diluted in air  Linked to 46,000 cardiac deaths and 3400 lung cancer deaths in USA annually –Over 2.5 million deaths in last 50 years  Adult diseases: –Risk of cardiac disease increased by about 25-30% –Risk of lung cancer increased by about 25-30% –Nasal sinus cancer, breast cancer –Stroke –Acute and chronic respiratory illnesses www.heart.org; www.cancer.org; www.quit.org.au

15. Second-hand smoke: other health effects  Children of smokers: –Lower birth weight –More pre-term birth –More respiratory and ear infections –More asthma –Increased risk of cleft lip or palate –Increased risk of SIDS –Increased risk of smoking uptake –Lung and brain injury (foetal exposure) –Increased risk of leukemias, lymphomas, brain cancer –Increased risk of meningococcal disease www.heart.org; www.cancer.org; www.quit.org.au; www.tobaccofreeca.com

16. “Electronic” cigarettes or e-cigarettes  Designed to look like cigarette including glowing tip  Delivers vapour of liquid, flavouring, nicotine – looks like smoke  Efficacy as quit aid?  Can contain toxic chemicals eg diethylene glycol  Some “nicotine-free” cartridges found to contain nicotine  Strong promotional push from tobacco companies  Legal issues: –Devices are legal (not all states) –Illegal to sell liquids containing nicotine –Can import up to 3 months’ worth for personal use

17. Effects of quitting  Within 20 minutes (Mahmud, 2003): –Reduction in HR and BP  12 hours (US Surgeon General, 1988): –Normalisation of blood carbon monoxide levels  2 weeks to 3 months (US Surgeon General, 1990): –Improved circulation and lung function  1-9 months (US Surgeon General, 1990): –Recovery of ciliary function, improved mucus clearance  1 year (US Surgeon General, 2010): –Risk of coronary heart disease reduced by 50% of continuing smoker  5 years (US Surgeon General, 2007): –Risk of stroke equivalent to non-smoker (2-5 years) –50% reduction in risk of cancers of mouth / head and neck / oesophagus / bladder –Risk of cervical cancer equivalent to non-smoker  10 years: –Risk of death from laryngeal cancer 50% of continuing smoker  15 years: –Risk of coronary heart disease equivalent to non-smoker www.healthline.com Centre for Disease Control wwwl.cdc.gov

18. Supports for quitting  “Quitting smoking is easy. I’ve done it a thousand times.” – Mark Twain  Behavioural therapies  Supportive care and counselling  Nicotine replacement therapy: patches, gum, sprays, inhalers, lozenges –Caution if pregnant or if circulatory disease, otherwise safe –Tapering dose –Concomitant behaviour modification  Prescription drugs: –Bupropion –Varenicicline (nicotine antagonist) –Nortryptiline –Clonidine  Non-drug: –Hypnosis –Acupuncture: no evidence

19. KPMG LLP, Illicit tobacco in Australia, 2013, p17

20. Plain packaging of cigarettes in Australia Slide courtesy of Bernard Stewart

21. Major events in tobacco control, price & tobacco products dutied for sale per person 15 +, Australia, 1906 to 2010, (gms per person 15+) Source: Scollo, M Ch 2 Consumption. Tobacco In Australia Facts and Issues 2013 http://www.tobaccoinaustralia.org.au/chapter-2-consumption/2-10-factors-driving-reductions-in-tobacco-consump

22. Cancer prevention works but it takes time…. Lung, men Cervix uteri Slide courtesy of Bernard Stewart

23. Conclusions  Smoking is a health and economic scourge  Social and political pressures make it difficult to eradicate  Certain populations are at significant risk and are specifically targeted –Children and adolescents –Indigenous  Quitting has immediate and late benefits  Public health measures for tobacco control are critical