1. Smoking and health
Dr. Ashok Kumar Kapoor
MBBS, MD (Med.), DM (Car.), F.Card (Germany), FCCP (US),
Chairman
Getwell Medical Center & Curewell Diagnostic Center,
www.getwelluae.com
2. Smoking as nicotine dependence
• Nicotine the driving force
• As with other drugs, complex interplay
between pharmacology, learning
mechanisms, social and economic
influences in determining patterns of
use
http://www.getwelluae.com
3. The major health consequences of
smoking
• Cancer
– lung
– mouth, larynx, throat, oesophagus
– bladder, cervix, kidney, pancreas
• COPD
• Coronary heart disease
• Stroke
• Peripheral vascular disease
• Pregnancy and birth complications
http://www.getwelluae.com
4. Mortality associated with smoking
• At least 320 deaths every day from smoking in
the UK, 120,000 per year
• 1/5 all deaths across all ages
• 1/4 all deaths in age group 35-64 years
• 1 in 2 lifetime risk for smokers
• 7.5 years average loss of life expectancy
• Over half of the difference in risk of death in
middle age between professional and unskilled
men
• 4 million deaths worldwide http://www.getwelluae.com
5. Scenarios for future deaths from tobacco
Cumulative deaths from tobacco (millions)
520
500
Trend
400
300
220
200
100 70
0
1950 1975 2000 2025 2050
Year
http://www.getwelluae.com
Source: Peto et al
6. Smoking is highly addictive
• At least 70% of smokers want to give up
• Less than half succeed before age 65
• 40% of heart attack smokers relapse while still
in hospital within 2 days of intensive care
• 50% of patients with laryngectomies try
smoking again
• 50% of patients with lung removed for lung
cancer smoke again
• More than half of heroin and cocaine users and
alcoholics rate smoking harder to quit
http://www.getwelluae.com
8. Starting point - the cigarette
“The cigarette should be conceived not as a
product but as a package. The product is
nicotine. Think of the cigarette pack as a
storage container for a day’s supply of
nicotine….Think of the cigarette as the
dispenser for a dose unit of nicotine…..Smoke
is beyond question the most optimised vehicle
of nicotine and the cigarette the most
optimised dispenser of smoke”.
William Dunn, Philip Morris, 1972
http://www.getwelluae.com
9. Schematic Diagram
of Arterial vs Venous
40 Nicotine Levels
Nicotine Concentration (ng/ml)
35
30 Arterial
25
20
Venous
15
10
5
0
-10 0 10 20 30 40 50 60 70
Time (mins)
c i ga r e tte
http://www.getwelluae.com
smoked
10. Nicotine Addiction in Britain
Royal College of Physicians Feb 2000
Central conclusion: smoking is best
understood as nicotine seeking
behaviour
• “Nicotine delivered rapidly to the brain in
cigarette smoke should be recognised as a
powerfully addictive drug on a par with
heroin and cocaine, and tobacco products
should be recognised as nicotine delivery
systems.” http://www.getwelluae.com
11. Rating IV nicotine and cocaine:
Jones et al (1999)
• Compared 3 doses of cocaine and
nicotine given IV double-blind + saline
placebo
• Nicotine ‘high’ and ‘rush’ rated stronger
than cocaine, also ‘jittery’
• Nicotine frequently misidentified as
cocaine, and, at highest dose, an opiate
http://www.getwelluae.com
12. Prevalence of regular drug use:
adults aged 16-64, GB 1993-1994
Cigarette smoking % 32
Drinking above
22
recommended limits
Marijuana 2
Tranquillizers
0
sleeping pills
Amphetamines 0
Opiates 0
Cocaine 0
Psychedelics 0
hallucinogens
0 10 20 30 40
Regular drug user = every day for 2 weeks or more in past 12 months
http://www.getwelluae.com
OPCS Psychiatric Morbidity Survey: Meltzer et al 1995 Base n=9792
13. Neurotic disorder % by drinking habits
GB 1993-1994
45
40
35
Neurotic disorder %
30
25
20
15
10
5
0
Abstainer Occasional Light Moderate Fairly heavy Heavy Very heavy
Alcohol drinking habits
http://www.getwelluae.com
15. Nicotine as a drug of dependence
• Blood nicotine from cigarettes, snuff
(oral and nasal) and cigars very similar
• IV nicotine suppresses smoking
• Nicotine intakes from different brands of
cigarette very similar
http://www.getwelluae.com
16. Nicotine as a drug of dependence
• Nicotine withdrawal syndrome
• Effect of nicotine replacement on
successful quitting
http://www.getwelluae.com
17. Self-assertion . . .
“To account for the fact that the beginning
smoker will tolerate the unpleasantness
we must invoke a psychosocial motive.
Smoking a cigarette for the beginner is a
symbolic act. The smoker is telling his
world, 'This is the kind of person I am.'
Surely there are variants of this theme, 'I
am no longer my mother's child,' 'I am
tough,' 'I am not a square.' Whatever the
individual intent, the act of smoking
remains a symbolic declaration of
personal identity . . .” Philip Morris (Bates no. 1003287836)
http://www.getwelluae.com
18. . . . and addiction
“ . . . As the force from the
psychosocial symbolism subsides,
the pharmacological effect takes
over to sustain the habit . . .”
Philip Morris 1969 document (Bates no. 1003287836)
http://www.getwelluae.com
20. Factors favouring study of smoking as
compared with other drug taking
behaviours
• High prevalence
• Legal
• Little stigma, so self-reports largely
accurate
• Unlike alcohol, excellent biomarker
of intake available
http://www.getwelluae.com
21. Cotinine as a biomarker of nicotine
intake
• Main nicotine metabolite (70-80%
converted)
• Half-life 16-20 hours
• Measurable in saliva, blood or urine
• Quantitative measure of nicotine intake:
10ng/ml cotinine in blood ~ 1mg nicotine
daily
http://www.getwelluae.com
22. Brief dependence scale
1. How soon after waking do you smoke your
first cigarette of the day?
Less than Between Between Between Between Longer
5 minutes 5 and 15 15 and 30 30 min. 1 and 2 than 2
minutes minutes and 1 hr hours hours
2. How easy or difficult would you find it to go
without smoking for a whole day?
Very easy Fairly easy Fairly difficult Very difficult
3. How many cigarettes do you usually smoke
each day?
1-10 11-20 21-30 31+
http://www.getwelluae.com
23. DISTRIBUTION OF TIME TO FIRST CIGARETTE
IN SMOKERS IN PRIMARY CARE
30
"How soon after waking do you smoke
your first cigarette of the day?"
25
Percentage of smokers
20
15
10
5
0
Less than 5-15 15-30 30 min 1 to 2 More than
5 minutes minutes minutes to 1 hr hours 2 hours
450
400
Saliva cotinine (ng/ml)
350
300
250
200
150
Mean + 95% CI
100 -
50
Less than 5-15 15-30 30 min 1 to 2 More than
5 minutes minutes minutes to 1 hr hours 2 hours
n=260 n=322 n=205 n=214 n=182 n=307
TIME TO FIRST CIGARETTE OF THE DAY http://www.getwelluae.com
24. SALIVA COTININE BY DEPENDENCE IN
SMOKERS IN PRIMARY CARE
550
Saliva cotinine (ng/ml)
440
330
220
110
Mean + 95% CI
0
0 1 2 3 4 5 6 7 8 9 10 11
N= 130 108 96 99 120 149 136 143 160 108 73 38
DEPENDENCE SCALE SCORE http://www.getwelluae.com
25. 3
2
Plasma cotinine (ng/ml)
1
0 .5
Geometri c mean ± 95%CI
0
0 1 -4 5 -9 1 0 -1 4 1 5 -1 9 2 0 -2 4 2 5 -2 9 30+
P ar tner 's daily cigar ette consum ption
http://www.getwelluae.com
26. PASSIVE SMOKING: COTININE IN ADULTS
BY PARTNER'S CIGARETTE CONSUMPTION
2.5
Health Survey for England
Plasma cotinine (ng/ml)
1994 &1996
2.0
1.5
1.0
0.5
Geometric mean + 95%CI
0.0
0 1-4 5-9 10-14 15-19 20-24 25-29 30+
Partner's daily cigarette consumption
http://www.getwelluae.com
n= 8328 234 231 259 155 294 60 79
27. CIGARETTE SMOKING 1972-1998:
GB: General Household Survey
60
50 Men
% prevalence
40
30 Women
20
10
0
1972 1976 1980 1984 1988 1992 1996
http://www.getwelluae.com
28. Disadvantage and Smoking
• A whole range of indicators of
disadvantage predict who smokes
• Cigarette smoking prevalence tightly
linked to deprivation, mainly because of
low rates of quitting in disadvantaged
groups
http://www.getwelluae.com
29. Indicators of socio-economic
status
• Occupational class
• Educational level
• Housing tenure
• Car ownership
• Unemployment
• Living in crowded accommodation
• Single parenthood
• Divorced or separated
http://www.getwelluae.com
30. Disadvantage and smoking
• Poor people are:
– More likely to take up smoking
– Less likely to quit
– More heavily exposed to other people’s
smoke
– Become more nicotine dependent
– Much more likely to die prematurely
from smoking
http://www.getwelluae.com
31. CIGARETTE SMOKING BY DEPRIVATION
IN GREAT BRITAIN: GHS 1973 & 1998
80
70
60
% prevalence
50
1973
40
1998
30
20
10
0
0 1 2 3 4 5
Most affluent Poorest
DEPRIVATION SCORE
http://www.getwelluae.com
32. SMOKING CESSATION BY DEPRIVATION
IN GREAT BRITAIN: GHS 1973 & 1998
80
70
60
50
% quit
1973
40
1998
30
20
10
0
0 1 2 3 4 5
Most affluent Poorest
DEPR IVATION SCORE
http://www.getwelluae.com
34. Some implications of nicotine addiction for
cessation and harm reduction
• Ineffective
• cutting down
• switching to cigars or a pipe
• switching to low tar
• Effective
• Nicotine replacement products
http://www.getwelluae.com
35. Predicted and actual nicotine intakes per cigarette
smoked by nominal nicotine yield of usual brand
Nicotine intake per cigarette (mg)
1.6 Health Survey for England 1998
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +
Cigarette nicotine yield (mg)
Predicted
http://www.getwelluae.com
36. Predicted and actual nicotine intakes per cigarette
smoked by nominal nicotine yield of usual brand
Nicotine intake per cigarette (mg)
1.6 Health Survey for England 1998
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +
Cigarette nicotine yield (mg)
Actual Predicted
http://www.getwelluae.com
37. One year success rates by intensity of
intervention:
• Unaided quit attempt …………………...…..….1-2%
• Brief GP advice ……………………………...……5%
• Brief GP advice + NRT ……………………….…10%
• Intensive clinic support ………………………...15%
• Intensive clinic support + NRT……………..20-30%
http://www.getwelluae.com
38. Scenarios for future deaths from tobacco
Cumulative deaths from tobacco (millions)
520
500
Trend
400
300
220
200
100 70
0
1950 1975 2000 2025 2050
Year
http://www.getwelluae.com
Source: Peto et al
39. Scenarios for future deaths from tobacco
Cumulative deaths from tobacco (millions)
520
500 500
Trend
If smoking
uptake halves
400
by 2020
300
220
200
100 70
0
1950 1975 2000 2025 2050
Year
http://www.getwelluae.com
Source: Peto et al
40. Scenarios for future deaths from tobacco
Cumulative deaths from tobacco (millions)
520
500 500
Trend
If smoking
uptake halves
400
by 2020
300 340
220 If adult smoking
200 halves by 2020
190
100 70
0
1950 1975 2000 2025 2050
Year
http://www.getwelluae.com
Source: Peto et al
41. Conclusions
• Nicotine’s legal status and lack of
adverse effects on performance have
hampered recognition of its status as a
drug of dependence
• Nicotine is pharmacologically a hard
drug, on a par with heroin and cocaine
• Cigarette smoking is by far the biggest
problem of drug dependence
http://www.getwelluae.com
Editor's Notes
And here is a quadraplegic who has had all four limbs amputated as a result of smoking induced Beurger’s disease – a type of peripheral vascular disease exclusively brought to you by the tobacco industry - but who still continued to smoke with the aid of this crude device, rigged up for him by ‘friends’. Maybe he had a particularly efficient CYP2A6 gene: research has shown that a defect in this gene, which results in a defective ability to clear the body of nicotine, is associated with a greater chance of not smoking, and among smokers with a lower consumption.
This is how that same document continues. The tobacco companies have become experts on the psychosocial aspects of growing up: so much of their business is bound up in understanding how to motivate children to start smoking. Their researchers wrote: “ To account for the fact that the beginning smoker will tolerate the unpleasantness we must invoke a psychosocial motive. Smoking a cigarette for the beginner is a symbolic act. The smoker is telling his world, 'This is the kind of person I am.' Surely there are variants of this theme, 'I am no longer my mother's child,' 'I am tough,' 'I am not a square.' Whatever the individual intent, the act of smoking remains a symbolic declaration of personal identity . . .”
And they understand that young smokers soon get hooked by the nicotine: “ . . . As the force from the psychosocial symbolism subsides, the pharmacological effect takes over to sustain the habit . . .”
The industry, however, depended for its defence – in law suits and in public debate generally – on the contention that smoking was a free choice made by adults. A US Tobacco Institute paper in 1980 said “We can’t defend continued smoking as ‘free choice’ if the person was ‘addicted’.” They therefore lied about addiction . . . __________ TI quote: Minnesota trial exhibit 14,303.
