Smoking a Public and Community Health issue. (by Dr Rizwan Saeed) Professor of Community Medicine. ANMC, Superior University, Lahore. Pakistan.

1. Smoking
(2021)
1
Prof. Dr Rizwan Saeed

2. Smoking is a practice in which a substance is burned
and the resulting smoke is breathed in to be tasted and
absorbed into the bloodstream
• Cannabis
• Opium
• Den
• Opiate
• Opioid
• Papaver somniferum (opium poppy)
• Psychoactive drug
Crack
• Cocaine
Other
• Heroin
• Narcotics
2
Poppy seeds (dried latex)  Opium
Vapours from heating the flower
Narcotic = medically to any psychoactive compound with numbing or paralysing properties.
https://en.wikipedia.org/wiki/Smoking

3. Why tobacco is a Public
Health priority ?
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4. • Tobacco use kills more than 7 million people / year.
including some 890,000 from breathing in second-
hand smoke.
• 1.1 Billion users worldwide (2021) https://ourworldindata.org/smoking
• It is responsible for 1 in 10 adult deaths. (2014)
• Among the five greatest risk factors for
mortality, it is the single most preventable cause
of death.
• 11% of deaths from IHD, the world's leading killer, are
attributable to tobacco use.
• More than 70% of deaths from lung, trachea and
bronchus cancers are attributable to tobacco use.
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5. • Tobacco use and poverty are inextricably
linked. Many studies have shown that in the poorest
households in some low- and middle-income
countries, more than 10% of total household
expenditure is on tobacco. This means that these
families have less money to spend on such basic
items as food, education and health care.
• In addition to its direct health effects, tobacco use
leads to increased health-care costs. It contributes
to higher malnutrition and illiteracy rates, since
money that could have been used for food and
education is spent on tobacco.
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7. WHAT YOU NEED TO KNOW
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• More than 400,000 deaths in the U.S. each
year are from smoking-related illnesses.
• Smoking kills an estimated 120,000 people
each year in the UK. It is a major cause of
illness and premature death – on average,
persistent smokers die 10 years younger than
non-smokers.

8. Tobacco contains 4000 - 7,000
chemicals (200 compounds), 60 are
known cancerous. These include:
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• Benzene - solvent used in fuel and chemical manufacture
• Formaldehyde - highly poisonous, colourless liquid used to
preserve dead bodies
• Ammonia - chemical found in cleaning fluids. Used in
cigarettes to increase the delivery of nicotine
• Hydrogen cyanide - poisonous gas used in the manufacture of
plastics, dyes, and pesticides. Often used as a fumigant to kill
rats
• Cadmium - extremely poisonous metal found in batteries
• Acetone - solvent found in nail polish remover
• Arsenic - ingredient in rat poison

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10. The three main components of
inhaled smoke are :
• Nicotine (↑Blood pressure & heart rate)
• Carbon monoxide
• Tar ( can narrow arteries and damage blood vessels)
all of which can cause disease.
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11. It is absorbed into the bloodstream and effects
the brain within 10 seconds. If you are a regular
smoker, when the blood level of nicotine falls,
you usually develop withdrawal symptoms such
as craving, anxiety, restlessness, headaches,
irritability, hunger, difficulty with concentration,
or just feeling awful. These symptoms are
relieved by the next cigarette. So, most smokers
need to smoke regularly to feel 'normal', and to
prevent withdrawal symptoms.
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12. Carbon monoxide
Carbon monoxide is a poisonous gas found in
car fumes, which reduces the amount of
oxygen carried in the blood. Oxygen is vital for
the body’s organs to function efficiently. The
reduction in oxygen changes the consistency
of the blood, making it thicker and putting the
heart under increased strain as it pumps blood
around the body.
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13. Tar
Tar contains many substances proven to cause
cancer. Irritants found in tar damage the lungs
causing narrowing of the tubes (bronchioles)
and damaging the small hairs (cilia) that protect
the lungs from dirt and infection.
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15. • Bronchitis
• Emphysema
• Heart disease
• Cancer
• TB

16. Cancers
• Lung cancer (About 30,000 people in the UK die
from lung cancer each year. More than 8 in 10
cases are directly related to smoking).
• Mouth, throat and nose cancer
• Cancer of the larynx
• Oesophageal cancer
• Pancreatic cancer
• Bladder cancer
• Stomach cancer
• Kidney cancer
• Leukaemia
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18. Heart and circulatory diseases
• Heart attacks and Heart disease (is the
biggest killer illness in the UK. About 120,000
people in the UK die each year from heart
disease).
• Arteriosclerosis - build up of fatty deposits in
the blood vessels. Causes loss of elasticity in the
artery walls, which can lead to diseases such as
stroke, gangrene and aortic aneurysms.
• High blood pressure
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19. Respiratory disease and Other illnesses
• Asthma.
• Chronic Polmunary
(About 25,000 people in the UK die each year from this serious
lung disease. More than 8 in 10 of these deaths are directly
linked to smoking).
• Increased frequency of colds, particularly chest colds
and bronchitis.
• Shortness of breath.
• Headaches.
• Stained teeth, fingers, and hair
• Insomnia.
• Diarrhea and colitis.
• Arthritis.
• Decreased sexual activity
• Mental depression. 19

20. • Blood flow to the extremities is decreased (cold hands and
feet).
• Smoking decreases the oxygen supply, requiring a higher
blood pressure, thus causing extensive circulatory problems
and premature heart attacks. Smokers have difficulty running
and exercising.
• Air pollution (auto exhausts, industry wastes, etc.) increases
the lung cancer rate of the smoker, but not of the non-smoker.
• The time to recover from any specific ill, whether caused by
smoking or not, is much longer for the smoker. Often, a non-
smoker will survive a sickness from which he would have died
had he smoked.
• The smoker's body requires more sleep every night. This
extra sleep must come from his spare time. Besides needing
more sleep, smokers don't sleep as well.
• Smokers are sick more often, Smoking destroys vitamins,
particularly vitamin C and the B's. Lower intelligence has been
related to smoking. In fact, smoking is both a cause and an
effect of lower intelligence, just as smoking is both a cause and
effect of lower income. 20

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22. Smoking in PAKISTAN
• The Prohibition of Smoking and Protection of
Non-Smokers Health Ordinance-2002 came
into effect on June 30, 2003. The law had the
following aspects:
• Ban on tobacco use in public buildings and
transportation,
• Limiting tobacco advertising,
• banning tobacco sale within 50 meters from
educational institutions,
• and requiring “no smoking” signs displayed in public
places.
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23. • According the study conducted by Sustainable
Development Policy Institute (SDPI)
on national treasury versus public health
2018-19, it was learned that there are above
23.9 million tobacco users in the country, out
of which 125000 are dying every year because
of tobacco inducted diseases. 40% smokers
are children 10 yr or above age.
79% of smokers used to buy loose
cigarettes banned
Annual cigarette consumption in Pakistan is around
86.7 billion sticks (57B local production)
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24. • 24 % of male and 16 % of female
college students were regular
smokers in Karachi.
• The prevalence of smoking in the
youth of Islamabad is even higher at
28 %
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25. • 40% OF MEN AND 8% FEMALE ARE REGULAR
SMOKERS IN PAKISTAN
• In Pakistan, about 1200 children take up
smoking every day.
• 51% of the children do not have enough to
eat and are moderately under weight. We
should create a world that allows the children
to choose not to smoke.
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26. • In Pakistan, there are 31 tobacco companies having
38 cigarette manufacturing factories with an installed
capacity of 126,853 million pieces per annum on
three shifts. Of these,
• 25 factories are located in N.W.F.P. with installed
capacity of 53,755 million pieces per annum.
• 9 factories with an annual installed capacity of
25,010 million pieces are located in Sindh
• and 4 factories are located in Punjab with an
installed capacity 48,088 million pieces per annum.
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27. • Smokable and chewing
tobacco is on the rise in rural
areas of Pakistan
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28. SOME MORE FACTS
• In most countries around the world, the legal
age for the purchase of tobacco products is
now 18, raised from 16, while in Japan the
age minimum is 20 years old.
• According to the World Health Organization,
approximately 25% of cigarettes sold around
the world are smuggled.
• ‘Toppings’ are added to the blended tobacco
mix to add flavor and a taste unique to the
manufacturer.
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29. • Approximately 5.5 trillion cigarettes are
produced globally each year and are smoked
by over 1.1 billion people or greater than one-
sixth of the world population.
(2010)
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Fewer than 10% of lung cancer patients
survive five years after diagnosis.
Smokers who smoke between 1 and 14 cigarettes
a day have eight times the risk of dying from lung
cancer compared to non-smokers. Smokers who
smoke more than 25 cigarettes a day have 25
times this risk compared to non-smokers.
Smoking leads to an earlier menopause:
on average women smokers go through the
menopause up to 2 years earlier than non-
smokers and are at a greater risk of
developing osteoporosis. Smoking has been
associated with increased sperm
abnormalities and with impotence in men.

31. Female smokers
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Male smokers

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Maharaja
2000 US $/ cigar

41. Bidi
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< 1 Rs

42. Naswar
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7-15 Rs

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47. Cigars
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50. Vaping
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51. Types of Smokeless Tobacco are Dipping tobacco, Chewing
tobacco, Iqmik, Snuff, Snus, Creamy snuff, Naswār, Gutka,
Dissolvable tobacco and Topical tobacco paste
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52. Evolution From tobacco leaf to electronic cigarette
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Smoking can be dated to
as early as 5000 BCE,
and has been recorded
in many different cultures
across the world.
Religious, recreational,
ceremonial, cultural etc

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Skull with a Burning
Cigarette by Vincent
van Gogh, oil on
canvas, 1885

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LUNG AFTER AND BEFORE SMOKING

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PASSIVE SMOKING
Passive smoking is the inhalation of smoke, called
secondhand smoke (SHS) or environmental tobacco
smoke (ETS), from tobacco products used by others. It
occurs when tobacco smoke permeates any environment,
causing its inhalation by people within that environment.
Scientific evidence shows that exposure to secondhand
tobacco smoke causes disease, disability, and death
The term thirdhand smoke was recently coined to identify
the residual tobacco smoke contamination that remains
after the cigarette is extinguished and secondhand smoke
has cleared from the air

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•Doctor-diagnosed asthma is more
common among non-smoking adults
exposed to ETS than those not exposed.
Among people with asthma, higher ETS exposure is associated
with a greater risk of severe attacks.
In France, passive smoking has been estimated to cause between
3,000 and 5,000 premature deaths per year, "That makes more
than 13 deaths a day. It is an unacceptable reality in our country in
terms of public health .

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The Nicotine Addiction Cycle
Smoking is a true form of drug dependence. Smokers
are physically addicted to the behavioral components
associated with smoking.
For most people, smoking is more than a habit. It’s a
nicotine addiction, and that’s why you probably feel
irritable for anxious when you don’t have a cigarette.
When you smoke nicotine goes to the brain in
seconds. When nicotine is in the brain, it causes the
release of a chemical called dopamine, which gives
the feeling of pleasure and calm.
Your body doesn’t want that feeling to stop. But when
you are between cigarettes, the level of dopamine
drops. That’s what gives the feeling of nicotine
withdrawal.

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Nicotine withdrawal symptoms:
It is the nicotine in cigarettes which causes physical addiction to cigarettes. If
you stop the intake you begin to develop withdrawal symptoms. These will
vary according to the level of dependence on nicotine from person to person.
Symptom can include:
1 Carving for nicotine
2 Irritability, frustration or anger
3 Anxiety
4 Difficulty in concentrating
5 Restlessness
6 Impatience
7 Insomnia
8 Decreased heart rate
9 Increased appetite
10 Depression

64. Effects of quitting
• 20 mins:
• 8 hours:
• 24 hours:
• 48 hours:
• 72 hours:
blood pressure and pulse rate return to normal
blood nicotine & CO halved, oxygen back to
normal
CO eliminated; lungs start to clear mucus etc.
nicotine eliminated; senses of taste & smell much
improved.
breathing easier; bronchial tubes begin to relax;
energy levels increase
Source: Health Education Authority

65. Effects of quitting
• 2-12 weeks:
• 3-9 months:
• 5 years:
• 10 years:
circulation improves.
lung function increased by <10%;
coughs, wheezing decrease
risk of heart attack halved :
• risk of lung cancer halved compared
to continued smoking;
• risk of heart attack equal to never-
smoker’s.
Source: Health Education Authority

66. Other benefits of cessation
Reduces risk of:
• bone loss, hip fracture and periodontal
disease
• Rheumatoid arthritis
• Cataract risk
• Aortic aneurysm
• Peripheral arterial disease
• Many others others

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stages of change in smoking cycle

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 An FDA analysis recorded nicotine doses between
26.8 and 43.2 micrograms per puff. It also detected
nicotine in products labeled as nicotine free.
 electronic cigarettes deliver an array of other
chemicals, including diethylene glycol (a highly toxic
substance ??? ), various nitrosamines (powerful
carcinogens found in tobacco), and at least four other
chemicals suspected of being harmful to humans.
E-cigarette

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Tobacco
Harm
Reduction

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1 Cigarette = Life – 11 min
Over 80% of people in the UK
don't smoke.

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Enjoyment
•Company
•Nature
•Society
•Socializing

73. How can I stop smoking?
About 2 in 3 smokers want to stop smoking. Some
people can give up easily. Willpower and
determination are the most important aspects when
giving up smoking. However, nicotine is a drug of
addiction and many people find giving up a struggle.
• Get yourself busy
• Tell everyone that you have stopped smoking
• Change your company
• Chew gum or take mint candy or drink water when craving starts
• Don’t carry cigarette with you.
• Break the habit of early morning smoking
• Do something else after meal
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74. The 6 MPOWER
• Monitor tobacco use and prevention policies
• Protect people from tobacco use
• Offer help to quit tobacco use
• Warn about the dangers of tobacco
• Enforce bans on tobacco advertising,
promotion and sponsorship
• Raise taxes on tobacco.
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https://www.who.int/news-room/fact-sheets/detail/tobacco

75. ESSENTIAL COMPONENTS
The following elements must all be included to
maximize the success of any program to reduce
tobacco use. Conducted in isolation, each of these
elements can reduce tobacco use, but done together
they have a much more powerful impact:
• Public Education Efforts
• Community-Based Programs
• Helping Smokers Quit (Cessation)
• School-Based Programs
• Enforcement
• Monitoring and Evaluation
• Related Policy Efforts

76. • THE FIVE A’S:
ASK
ASSESS
ADVISE
ASSIST
ARRANGE
Promoting Smoking Cessation

78. Smoking Addiction Calculator
• The Fagerström test is a standard questionnaire that is
used to determine if a smoker is addicted to nicotine.
• There are several versions of the Fagerström test. The one
we will use has 6 multiple-choice questions. Each of the
multiple-choice responses has a point score.
• After the person has answered all the questions, you need
to add all points from the individual questions; this should
give an integer between 0 and 10.
• The person is then probably strongly addicted if the total
score is 8 or more; addicted if the score is 6 or 7 ; mildly
addicted if the score is 3, 4, or 5 ; and not addicted if the
score is 2 or less.

79. • Q1: When do you smoke your first cigarette of the day?
Allowed responses: within 5 minutes (3 pt), 6-30 minutes (2 pt); 31-60 minutes
(1 pt); more than 60 minutes after waking up (0 pt)
• Q2: Do you find it hard not to smoke in places where it is forbidden, such as in
a cinema?
Allowed responses: yes (1 pt), no (0 pt)
• Q3: Which cigarette would you most hate to give up?
Allowed responses: the first one in morning (1 pt); any other one (0 pt)
• Q4: How many cigarettes do you smoke in a day?
Allowed responses: 10 or less (0 pt); 11-20 (1 pt); 21-30 (2 pt); 31 or more (3 pt)
• Q5: Do you smoke more after waking up than during the rest of the day?
Allowed responses: yes (1 pt), no (0 pt)
• Q6: Do you still smoke if you are so sick that you're in bed most of the day?
Allowed responses: yes (1 pt), no (0 pt)

80. sisha
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87. Propylene Glycol Electronic Cigarettes
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91. Keep trying
Keep trying. Many
ex-smokers did not
succeed at first,
but they kept
trying.The first few
days after stopping
will probably be
the hardest. Show
yourself and to the
others who you
are. Life's too good
and too short to
waste on that
filthy habit.
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Thank You for your time