Why to Quit Smoking Dr Abhay Nigam MBBS MD (Medicine) Senior Specialist – Internal Medicine RAK Hospital Ras Al Khaimah

About 4.9 million die each year WW. By 2020 – 10 million SMOKING FACT SHEET About 4.9 million die each year WW. By 2020 – 10 million Annually, smoking kills more people than a combined mortality from AIDS, alcohol, drug abuse, car crashes, murders, suicides, and fires

SMOKING FACT SHEET Globally, 1 person dies every 6 seconds from smoking related diseases A smoker loses an average of 13.8 years of life One out of every five deaths is caused by tobacco The term diabesity was coined by Shape Up America Founded in 1994, Shape Up America! is a not-for-profit organization committed to raising awareness of obesity as a health issue and to providing responsible information on healthy weight management

Tobacco use costs the United States billions of dollars each year. Cigarette smoking costs more than $193 billion (i.e., $97 billion in lost productivity plus $96 billion in health care expenditures).1 Secondhand smoke costs more than $10 billion (i.e., health care expenditures, morbidity, and mortality).

Thousands of young people begin smoking every day Each day, more than 3,800 persons younger than 18 years of age smoke their first cigarette. Each day, about 1,000 persons younger than 18 years of age begin smoking on a daily basis.

Many adult smokers want to quit smoking Approximately 69% of smokers want to quit completely. Approximately 52% of smokers attempted to quit in 2010.

Types of Tobacco – Smokeless Tobacco Smokeless tobacco snuff: Nicotine + Carcinogens + other toxins Gutkha is basically a sweetened mixture of tobacco, betel, lime and catechu chewed together. 7

Types of Tobacco – Smokeless Tobacco Khaini: is basically a preparation made from tobacco leaves when they are mixed with lime and ready to be chewed. Zarda: Chewing tobacco mostly added to betel leaves 8

Types of Tobacco Smoking 9

CIGARETTES: 20th Century phenomenon – Epidemic after 2nd world war CIGARS :A cigar is a tightly rolled bundle of dried and fermented tobacco. The wrapper determines much of the cigar's character and flavor. 6

Types of Tobacco Smoking - Pipes A "Bulldog" style pipe made of Briar wood Meerschaum (hydrated magnesium silicate), a mineral found mainly in central Turkey CALABASH GOURDS (usually with meerschaum or porcelain bowls set inside them) are quite expensive. “CORNCOB" pipes made from maize cobs are cheap

Types of Tobacco Smoking Egyptians call it Shisha, Lebanese refer to it as Nargile, in English, it is Hookah or hubble-bubble Obesity significantly increases the risk of a number of health problems, some of them debilitating or even life threatening. Obese individuals have a 50–100 percent increased risk of death from all causes. Obese people have twice the risk of CHD, HTN, knee arthritis and gout. Obesity doubles the risk of breast, Uterine and colon cancer, as well as hormone abnormalities, fertility problems and fetal defects. The risk of diabetes and gallbladder disease is three times greater for obese people. Deep abdominal fat—as opposed to fat concentrated in the hips, buttocks and thighs—adds to the risk of both heart disease and diabetes. Physical inactivity, independent of body fat, increases the risk of diabetes, heart attacks and strokes, high blood pressure and cancers of the cervix, ovaries, vagina and colon.

Types of Tobacco Smoking - BIDIS Bidis – common in south asia Concentrations of nicotine, tar and other toxic agents in the smoke are much higher for bidi than for cigarettes. Since bidi is hand-rolled, workers employed in bidi factories are at risk of developing cancerous conditions due to exposure to tobacco dust and flakes Associated with obesity is a cascade of metabolic and cardiovascular disorders often referred to as Syndrome X, the metabolic syndrome, or the insulin resistance syndrome. There is no doubt, however, that excess weight gain is the primary cause of all of these disorders, including hypertension and kidney disease, the topic I will focus on today. The importance of obesity as a cause of hypertension has been well established from animal studies showing that weight gain raises blood pressure, from clinical studies showing that weight loss reduces blood pressure in most hypertensive patients, and from population studies showing that excess weight is one of the best predictors we have for subsequent development of hypertension.

Types of Tobacco Smoking Kreteks:are cigarettes made with a complex blend of tobacco, cloves and a flavoring 'sauce'. Kreteks are by far the most widely-smoked form of cigarettes in Indonesia. We should also keep in mind that it is not just the total amount of fat, but also the distribution of fat that is important. Visceral obesity carries a much greater risk for hypertension and metabolic disorders compared to lower body or subcutaneous obesity. Unfortunately, the distribution of fat and the duration of obesity are often not taken into account in most human studies. Also, there are many individuals, especially older sedentary people, who have a normal BMI but who are metabolically obese, with increased adiposity, especially visceral adiposity. Although it is clear that excess body weight is the major cause of human essential hypertension, the mechanisms by which obesity raises are not as well understood. The development of new animal models of obesity, both genetic and dietary, has allowed mechanistic insights on obesity and hypertension.

Passive Smoking Passive or involuntary smoking occurs when the exhaled and ambient smoke from one person's cigarette is inhaled by other people. Passive smoking involves inhaling carcinogens, as well as other toxic components, that are present in secondhand tobacco smoke. Circling back to the discussion of abdominal adiposity, data regarding waist circumference and diabetes illustrate its health impact. These are age-adjusted data from the Nurses’ Health Study, analyzing responses from 43,581 subjects who provided information on weight and body measurements in 1986. These subjects had no history of cancer, heart disease, stroke, or any type of diabetes. An 8-year follow-up in this population showed a strong positive association between waist circumference and the incidence of diabetes. At the far end of the spectrum, women with a waist circumference >38 inches had a diabetes risk of 22.4, relative to women in the normal waist circumference range of <28 inches. Other obesity measures studied included body mass index and waist-to-hip ratio; both of these were also found to be independent determinants of type 2 diabetes in this population. The sharpest risk gradient was documented with waist circumference, indicating that it is a powerful independent predictor of type 2 diabetes in women. (WC was measured at the high point of the iliac crest at minimal respiration to the nearest 0.1 cm.) Carey VJ, Walters EE, Colditz GA, et al. Body fat distribution and risk of non-insulin-dependent diabetes mellitus in women: the Nurses’ Health Study. Am J Epidemiol. 1997;145:614-619.

How Many Cigarettes Have You Smoked Without Knowing It? If you have been. . . it’s like you’ve smoked. . In a smoky bar for 2 hrs = In a nonsmoking section for 2 hrs = In a car with someone, windows closed for 1 hr = source: breathe easy Springfield, www.breatheeasymo.org There is an epidemic of obesity and diabetes in the United States. The Centers for Disease Control conducts the Behavioral Risk Factor Surveillance System (BRFSS) as a cross-sectional telephone survey of adults 18 years or older in the United States. Among other data, the BRFSS has been collecting data on obesity and diabetes in the United States. As shown in these maps based on BRFSS results, the prevalence of obesity and of diabetes has increased dramatically from 1991 to 2001. The prevalence of obesity in the United States in 2001 was 19.8%, an increase of 74% from the 1991 prevalence of 12%. That prevalence rate represents an estimated 21.4 million obese men and 22.9 million obese women in 2001. The prevalence of diabetes in 2001 was 7.9%, an increase of 61% since 1990 when the prevalence was 4.9%. In 2001, an estimated 16.7 million US adults could have been diagnosed as having diabetes (6.9 million men and 9.8 million women). The maps show the prevalence by state. 17 Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76-79.

Passive Smoking Exposure to secondhand smoke occurs anywhere smoking is permitted: homes, workplaces, and other public places. According to the WHO, some 200,000 workers die each year due to exposure to smoke at work,  About 700 million children, around half the world's total, breathe air polluted by tobacco smoke, particularly in the home Based on the evidence of three recent comprehensive reports on May 29, 2007, the WHO called for a global ban on smoking at work and in enclosed public places.

Passive Smoking Secondhand smoke is known to harm children, infants and reproductive health Acute lower respiratory tract illness, Asthma induction and exacerbation, Chronic respiratory symptoms, Middle ear infection, Lower birth weight babies, Sudden Infant Death Syndrome, or SIDS. Low-level exposure to secondhand smoke has a clinically important effect on susceptibility to cardiovascular disease,

What is third-hand smoke, and why is it a concern? Definition: A term used to describe the gases and small particles in cigarette smoke that are deposited on every surface they come in contact with. From the smoker's hair and clothing, to the environment the cigarette was smoked in, these toxic particles remain long after the cigarette has been put out and any secondhand smoke has been removed from the area.

What is third-hand smoke, and why is it a concern? Residual nicotine and other toxic chemicals - indoor surfaces Potential health hazard to nonsmokers (especially children.) Third-hand smoke clings to hair, skin, clothes, furniture, drapes, walls, bedding, carpets, dust, vehicles and other surfaces, even long after smoking has stopped Third-hand smoke residue builds up on surfaces over time and resists normal cleaning. Can't be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas of a home. Third-hand smoke remains long after smoking has stopped

Tobacco Addiction Motivated by the desire for nicotine. Smokers regulate their nicotine intake and blood levels by adjusting the frequency and intensity of their smoking both to obtain psychoactive effects and avoid withdrawal. Smokeless tobacco contains nicotine, carcinogens and other toxins capable of causing gum and oral disease mainly. When tobacco is burned resultant smoke contains Nicotine, CO + 4000 other toxic compounds.

Effects of Smoking on Health Nicotine is absorbed into pulmonary circulation, brain nicotinic cholinergic receptors Smokeless tobacco is absorbed more slowly and results in less intense pharmacologic effects. With long term use of tobacco, physical dependence develops as a result of an increased number of nicotinic cholinergic receptors in the brain.

Effects of Smoking on Health The acidic pH of smoke generated by cigarettes dramatically reduces nicotine absorption in oral mucosa, necessitating inhalation of smoke deep into lungs. Alkaline pH of smoke from tobacco utilized in cigars, pipes and smokeless tobacco allows absorption from oral mucosa to satisfy the smokers need for this drug.

Effects of Smoking on Health ORAL Staining and shifting of teeth Oral cancers Mouth sores Root caries (cavities) Sinusitis Hairy tongue Smoker’s lip Leukoplakia Snuff Dipper’s lesions Smoker’ palate Periodontal diseases which includes bone and tooth loss, if unchecked, it can lead to complete destruction of the tooth’s supporting tissues, abscesses and, ultimately, loss of the tooth. Dangerous gum diseases Loss of taste sensation Halitosis (Bad breath)

Effects of Smoking on Health NON MALIGNANT Gastrointestinal Respiratory Cardiovascular Ocular Sexual Dysfunction & Infertility Pregnancy related Skin wrinkling Osteoporosis

SMOKING HAZARDS – PEPTIC ULCER

SMOKING HAZARDS - COPD Increased incidence of Asthma Chronic obstructive pulmonary disease (COPD) is a permanent, incurable reduction of pulmonary capacity characterized by shortness of breath, wheezing, persistent cough with sputum, and damage to the lungs, including emphysema and chronic bronchitis

SMOKER’S LUNG

SMOKING HAZARDS - LARYNX Larynx – Supraglottic Squamous Cell carcinoma Anterior Left Vocal Cord Polyp

SMOKING HAZARDS - VASCULAR CVA CARDIAC - CAD & MI OCULAR HYPERTENSION THROMBOANGITIS OBLITERENS (BURGER’S DISEASE)

SMOKING HAZARDS - VASCULAR

SMOKING HAZARDS - EYE Smoking doubles the risk of nuclear cataract.   cataracts are more serious in heavy smokers than in light smokers. Age related macular degeneration (AMD) risk among smokers is 2 to 3 times higher. Smoking may accelerate the development of, or worsen diabetic retinopathy,

Anterior ischaemic optic neuropathy is an eye disease that results in a sudden, painless loss of vision, often leading to permanent blindness.  Smokers are at a 16-fold increased risk

SMOKING HAZARDS - SEXUAL Smoking increases the risk of erectile dysfunction because blood flow into the penis is blocked by atherosclerosis. Smoking also causes Abnormal sperm shape, Impaired sperm motility Damaged sperms, Oligospermia Reduced ejaculate volume 

Smoking and Pregnancy Smoking causes delivery complications, (Fetal tobacco syndrome) Increases risk of pre-term delivery (premature rupture of membrane) Abortions : 2 - 3 times Abruptio placentae & Placenta previa Giving birth to low-birth weight baby : 4 times Slows fetal growth Smoking also increases risk of serious health problems to the newborn such as:  Cerebral palsy Mental retardation : 1.5 times Learning disabilities  Sudden Infant Death Syndrome (SIDS)

Smoking and Oral Hygiene After: After quitting and a thorough cleaning, this smoker's teeth were restored to their original whiteness. Failure to remain tobacco-free will cause the staining to recur in weeks Before: 37-year-old heavy smoker with a heavy build up of dental calculus, stains, and severely offensive tobacco breath.

Smoking and Oral Hygiene Smokers can develop a condition called black hairy tongue

Smoking and Periodontitis Roughly half of periodontitis cases are attributed to current or former smoking. Smokers experience widespread periodontal destruction and have significantly greater loss of bone height

Smoker’s Palate Relatively common tobacco related white lesion seen in the palate of a pipe, cigar or a cigarette smoker. Unless the habit is particularly intense or the patient is a reverse smoker, risk for malignancy is quite low. The combination of tobacco smoke and heat combustion is believed to be important for this tissue change.

Smoker’s Melanosis Cigarette smoking in particular may lead to melanin pigmentation of the gums and other mucosal sites in the oral cavity. The process is reversible and improves when the patient quits smoking. It is a harmless condition but needs to be separated from other more serious pigmental disorders

Smoking Stains Smoking wrinkles “For smokers, middle-age starts in their early 30’s as the tell-tale wrinkles around the mouth and eyes begin to appear. Young female smokers are likely to be wasting their money on anti-aging face creams if they continue to smoke.”

SMOKING & ORAL CANCER A large cancer (Squamous CC) is shown growing out of neck of this patient’s neck. The cancer was due to smoking and started in patient’s mouth. The cancer eventually eroded into Carotid Artery causing massive bleeding & death.

Snuff Dipper’s lesions A white or discolored lesion of the oral mucosa occurring at the site at which the powdered tobacco is retained. Malignant transformations are not common but do occur, usually as low-grade VERRUCOUS CARCINOMAS.

New developments Global Treaty 2004 WHO Framework Convention for Tobacco Control (FCTC) Need now to legislate and fund campaigns in accordance with it The Convention entered into force on 27 February 2005 -- 90 days after it had been acceded to, ratified, accepted, or approved by 40 States. ( now 172 countries have ratified – covering 87% world population)

Non Party States Countries those have signed but not yet ratified U.S.A Argentina,  Cuba,  Czech Republic,  El Salvador,   Ethiopia,  Haiti, Morocco,  Mozambique,  Switzerland Countries that have not signed Andorra Dominican Republic,  Eritrea,  Indonesia,  Liechtenstein*,  Malawi,  Monaco,  Somalia, Tajikistan,  Uzbekistan,  Zimbabwe

Monitor tobacco use and prevention polices Monitor tobacco use and prevention polices. Protect people from tobacco smoke. Offer help to quit tobacco use Warn about the dangers of tobacco. Enforce bans on tobacco advertising, promotion and sponsorship. Raise taxes on tobacco.

When it comes to stemming the flow of death and destruction that tobacco use leaves in its wake, it takes a village to effect change -- a global village. If adopted by governments around the world, these simple, yet powerful MPOWER policies could be a life preserver that will save millions and millions of lives.

From WHO: "To sell a product that kills up to half of all its users requires some extraordinary marketing savvy."

Quitting Smoking How to stop smoking … for good!

Benefits of Quitting 20 min. – blood pressure and pulse return to normal, circulation improves to make hands & feet warmer 24 hours – carbon monoxide is eliminated from the body and the lungs start to clear out mucus 72 hours – breathing becomes easier and energy levels increase 2-12 weeks – circulation improves through the body, Your heart attack risk begins to drop, exercise is easier, Your lung function begins to improve 1 to 9 months after quitting: Your coughing and shortness of breath decrease

Benefits of Quitting 1 year after quitting: Your added risk of coronary heart disease is half that of a smoker’s 5 -15 years after quitting: Your stroke risk is reduced to that of a nonsmoker 10 years – risk of lung cancer falls to about half that of a smoker 15 years after quitting: Your risk of coronary heart disease is back to that of a nonsmoker’s source: US Department of Health & Human Services http://www.hhs.gov/ and www.gasp.org.uk

Live longer and healthier 20 minutes after quitting: Your heart rate drops 12 hours after quitting: Carbon monoxide levels in your blood drop to normal

Live longer and healthier 2 weeks to 3 months after quitting: Your heart attack risk begins to drop Your lung function begins to improve 1 to 9 months after quitting: Your coughing and shortness of breath decrease

Live longer and healthier 1 year after quitting: Your added risk of coronary heart disease is half that of a smoker’s 5 -15 years after quitting: Your stroke risk is reduced to that of a nonsmoker

Live longer and healthier 10 years after quitting: Your lung cancer death rate is about half that of a smoker’s
 Your risk of cancers of the mouth, throat, esophagus, bladder, kidney and pancreas decreases

Live longer and healthier 15 years after quitting: Your risk of coronary heart disease is back to that of a nonsmoker’s

Approach to Quitting Counseling Peer support A Word about Cold Turkey Nicotine Replacement Therapy (Patches, chewing gums, Lozenges, Micro-tabs, E cigarettes, Nasal sprays, Mouth sprays) The Downside of NRTs Nicotine-Free Quit Aids

Designing your personal goals Setting your personal goals can be a big help. List the reasons Keep copies of the list in the places - jacket, purse, or car. I will feel healthier and have more energy, whiter teeth, and fresher breath. I will lower my risk for cancer, heart attacks, strokes, early death, cataracts, and skin wrinkling. I will make myself and my partner, friends, and family proud of me. I will no longer expose my children and others to the dangers of my second-hand smoke. I will have a healthier baby (If you or your partner is pregnant). I will have more money to spend. I won't have to worry: "When will I get to smoke next?“

Steps to quitting Get ready Get support Learn new skills and behaviors Get medication – if recommended by your doctor – and use it correctly Be prepared for cravings and withdrawal symptoms

Steps to quitting Step 1: Get Ready Set a quit date Get rid of all cigarettes and ashtrays at home, work, and in your car Keep a diary of when and why you smoke Call 1-800-QUIT-NOW for free materials Tell friends and family you’re going to stop

Steps to quitting Step 2: Get Support Your chances of success increase if you have a support network Ask friends, family, and coworkers for their support in helping you quit Ask others not to smoke around you or leave cigarettes out in the open Talk to your family physician about tobacco’s effects on the body, choosing a quit plan, and dealing with withdrawal Get individual, group, or telephone counseling

Steps to quitting Step 3: Learn New Skills & Behaviors Distract yourself from urges to smoke Talk to someone Go for a walk Get busy with a task Go somewhere you’re not allowed to smoke Change your routine Take a different route to work Drink tea instead of coffee Eat breakfast in a different place Reduce stress – take a hot bath, exercise, or read a book Plan something enjoyable to do every day Drink a lot of water and other fluids

Steps to quitting Step 4: Get Medication Your family physician may recommend one of these to help you quit: Bupropion SR Nicotine gum Nicotine inhaler Nicotine nasal spray Nicotine patch Varenicline

Steps to quitting Step 5: Avoid Relapse Most relapses occur within the first three months Avoid drinking alcohol – drinking lowers your chances of success Avoid being around other smokers – can make you want to smoke Expect a small weight gain (usually less than 10 pounds) Eat a healthy diet Stay active Look for ways to improve your mood other than smoking

Managing withdrawal Symptoms Most intense during the first three to seven days May continue for several weeks but will get less severe Triggers or cues associated with smoking can cause cravings

Managing withdrawal Exercise Reduce or avoid caffeine or other stimulants Relax before going to bed Make your bedroom quiet Keep a bedtime routine Drink plenty of water Use cough drops to relieve throat irritation

Managing withdrawal If you’re having trouble concentrating Adjust your schedule to a lighter workload Lower your expectations on the amount of work you can do Understand the amount of energy and time it takes to stop smoking

Managing withdrawal If your appetite has increased Eat healthy snacks Don’t delay regular meals Drink more water Exercise regularly

Managing withdrawal If you crave a cigarette Wait out the craving (usually less than five minutes) Try deep breathing Use distractions Call someone in your support network Chew gum Brush your teeth

Renew your dedication Reward yourself for resisting urges to smoke Review your reasons for stopping Remind yourself often how well you’re doing

You can do it! Tobacco addiction is a chronic disease – seek advice, support, and care from your family physician to increase your chance of success Quitting smoking can reduce illness, prevent death, and increase your quality of life Quitting can be difficult – remember to ask for help You can do it!

Resources Web Sites with helpful information: familydoctor.org www.smokefree.gov www.surgeongeneral.gov/tobacco http://www.cdc.gov/tobacco/quit_smoking http://www.cancer.org/Healthy/StayAwayfromTobacco/GuidetoQuittingSmoking/index Website: www.abhaynigam.com E Mail: dr@abhaynigam.com

The Fork on Tobacco Road If we act now Result of improved funding can cut smoking rates from present 20% to 10% OR even LESS by 2015 If we do nothing on present global trends, it’s estimated ONE BILLION people will die from smoking this century