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
9. On average, each cigarette shortens a smoker's
life by around 11 minutes
BMJ. 2000 January
10.
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 doctorsMichael 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 20th 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. Age40
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
%SurvivalFromMean
Quitatage35-44
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
%SurvivalFromMean
Age50
Quitatage45-54
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
%SurvivalFromMean
Age60
Quitatage55-64
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
19. 40 50 60 70 80
Age
0
500
1000
1500
Lungcancerdeathsper100,000
Current
smokers
Never
smokers
quit 30-39
quit 40-49
quit 50-54
quit 55-59
quit 60-64
Halpern JNCI 1993: CPS2 data
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
45 55 65 75
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
5years
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.
10years 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
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
5years The excess risk of a Stroke risk is reduced to that of
a nonsmoker
Within years .......
15years
The risk of coronary heart disease is that of a nonsmoker's
1year
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
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
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.
36. Am. J. Respir. Crit. Care Med. 2002; 166: 675-679
Years
FEV1(L)
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
0 1 2 3 4 5 6 7 8 9 10 11
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
Proportionofpatients
withnoevent
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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
FEV1
(%ofvalueatage25)
25
50
75
100
0
Age (years)
25 50 75
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
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 FEV1
• 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
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
63. The benefits of quitting
Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk
8hours
Nicotine and carbon monoxide levels halved,
Blood oxygen levels return to normal
24hours
Carbon monoxide eliminated from the body
48hours
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
1month
Appearance improves
skin loses greyish pallor, less wrinkled
Regeneration of respiratory cilia starts
Withdrawal symptoms have stopped
3-9months
Coughing and wheezing decline
lung function increased by 10%
Within months .......
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
70.
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
