2. Rewards of Smoking Cessation

3. By Dr. Ashraf El-Adawy By Dr. Ashraf El-Adawy Consultant Chest Physcian Consultant Chest Physcian TB TEAM Expert - WHO

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

5. Times have changed Smoking is less socially acceptable now than ever...

6. 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

7. 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

8. Smoking and Life span

9. On average, each cigarette shortens a smoker's life by around 11 minutes BMJ. 2000 January

11. 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 conference on the 50-year results from his study of British doctors Michael Crabtree, copyright Troika Photos

12. Study of smoking and death in male British doctors Recorded all deaths for 50 years (1951-2001) Main findings (for men born in the 20 th 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.

13. Age 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 % Survival From Mean Quit at age 35-44 Additional 9-year life expectancy 13 N=34,439 British male physicians.

14. A Study of Male Physicians Showed Quitting at Any Age Increases Life Expectancy Patients were studied over the period of 1951-2001. Adapted from Doll R et al. BMJ. 2004;328:1519-1527. Years % Survival From MeanAge 50 Quit at age 45-54 Additional 6-year life expectancy 45-54 years 14 Nonsmokers Cigarette Smokers Stopped Age N=34,439 British male physicians.

15. A Study of Male Physicians Showed Quitting at Any Age Increases Life Expectancy Patients were studied over the period of 1951-2001. Adapted from Doll R et al. BMJ. 2004;328:1519-1527. Years % Survival From MeanAge 60 Quit at age 55-64 Additional 3-year life expectancy 55-64 years 15 Nonsmokers Cigarette Smokers Stopped Age N=34,439 British male physicians.

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

18. Nonsmokers1-14 cigs15-2425 + Smoking habit 0.0 4.0 8.0 12.0 16.0 20.0 Rate per 1000 person years CPS2 0.0 0.6 1.1 45-54 0.1 1.7 2.7 3.9 55-64 0.3 4.5 7.1 9.2 65-74 0.6 7.0 13.2 17.9 75-84 Lung cancer risk by age and smoking habit

19. Lung cancer risk by age of quitting

20. Stopping smoking: avoiding lung cancer % dead from lung cancer Continued smoking: 16% dead from lung cancer Stopped age 50: 6% Stopped age 30: 2% Never smoked: <1% 15 10 5 0 45556575 Age Cumulative risk at UK male 1990 rates BMJ 2000; 321: 323-9

21. The benefits of quitting Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk 5 year s The 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.......

22. 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

23. Smoking Cessation &Cardiovascular Diseases Smoking Cessation & Cardiovascular Diseases

24. 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 The American Heart Association

25. The benefits of quitting Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk 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 year The excess risk of a heart attack reduces by half

26. The American Heart Association 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

27. Insulin action Smoking Oxdative stress Diabetes mellitus Bridges AB. et al., 1993 Paolisso G, et el., 1993 Smoking and Diabetes

28. The American Heart Association 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 Smoking and Diabetes

29. The American Heart Association 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. Smoking and Diabetes

30. The American Heart Association 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

31. The American Heart Association Increases LDL Decreases HDL Slightly increases triglycerides More LDL in plasma leads to more modified LDL Smoking and hypercholestorlemia

32. The American Heart Association 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

33. 2.4 2.5 2.6 2.7 2.8 2.9 Postbronchodilator FEV1 Sustained quitters depqumch.tc Continuing smokers Screen 1234 5 Years of follow-up JAMA 1994;272(19):1497-505 CHANGE IN FEV1 BY SMOKING STATUS The Lung Health Study

34. 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.

35. 1990 2020 Ischaemic heart disease Cerebrovascular disease Lower resp infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road Traffic Accidents Lung Cancer Stomach Cancer HIV Suicide 6th 3rd Future Mortality Worldwide Source: Murray & Lopez. Lancet 1997

36. Am. J. Respir. Crit. Care Med. 2002; 166: 675-679 Years FEV 1 (L) 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 01234567891011 Continuous smokers Disease Progression in COPD Lung Function

37. Smoking cessation decreases mortality in patients with COPD 1.00 0.95 0.90 0.85 0.80 Proportion of patients with no event 0123456789101112131415 Time since LHS baseline (years) Special intervention group Usual 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

38. 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 value at age 25) 25 50 75 100 0 Age (years) 255075

39. 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 2001 CRJ. 10;(Suppl A). 2003

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

41. 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

42. 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 FEV 1 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)

43. 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

44. Smoking and TB Form a Deadly Combination

45. 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”

46. 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

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

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

49. 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

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

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

52. Danish study (Lancet 2002;359:114) Randomised Cessation 6-8 weeks before surgery Fewer wound-related complications, reduced cardiovascular complications and secondary surgery Overall complication rate was 18% in the smoking intervention group and 52% in controls Shorter hospital stay Postoperative complications

53. 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.

54. 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

55. Adolescents Grimshaw GM, et al. Tobacco cessation interventions for young people. Cochrane Database Systematic Reviews. 2006 Teenagers care about the immediate benefits to 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

56. 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.”

57. You’ll Save Money Smoking is expensive - multiply how much money you spend on tobacco every day by 365 (days per year).

58. 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!

59. 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

60. 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!

61. Be good role model by either not smoking, or quitting

62. You’ll Protect Those You Love

63. The benefits of quitting Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk 8 hours Nicotine and carbon monoxide levels halved, Blood oxygen levels return to normal 24 hours Carbon monoxide eliminated from the body 48 hours Nicotine eliminated from the body, Taste buds start to recover Within hours.......

64. The benefits of quitting Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk 1 month Appearance improves skin loses greyish pallor, less wrinkled Regeneration of respiratory cilia starts Withdrawal symptoms have stopped 3-9 months Coughing and wheezing decline lung function increased by 10% Within months.......

65. IT’S NEVER TOO LATE TO QUIT

68. The Role of Health Professionals In Tobacco Control

69. 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

71. 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

72. 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