‫بسم هللا الرحمن الرحيم‬

‫قتلوـا أـنـفسكمـ (‬
‫وـالـ تــــ‬
‫ان الله كان‬
‫) بكم رحيما‬
‫صدق هللا العظيم‬
‫)ا لنساء ‪(29 -‬‬
TOBACCO
SMOKING
AN OVERVIEW
By
Dr. Mahmoud Alsalahy
Assist. Prof of chest Medicine
Banha
• What is tobacco ?
■ Processed leaves of Nicotiana plant,
Nightshade (Tree Tobacco.)

■ Origin : Arizona and parts of New Mexico

■ Contains: Nicotine, anabasine and harmane

■ Types : Black and Brown

 Exposure :
Active consumption:
Tobacco smoking:
Cigarettes, Cigars, Pipes, Shisha
• Smokeless tobacco:
Chewing, Buccal, Wet snuff

Passive exposure:
2nd hand & 3rd hand smokers
!!!!!! DANGEROUS
Burnet tobacco smoke contains more
than 4000 toxic substances including
oxides, aldehydes, heavy metals,
oxygen radicals, radioactive
intermediates, ….
 Why is tobacco smoked ?
How initiated:
How initiated:
1. Curiosity WHO:
EVERY DAY: 80-
2. Imitating a role or model 100 THOUSANDS
3. Rebelling from adult warnings CHILDREN START
SMOKING
4. Gaining acceptance from peers
5. Projecting an image of
confidence
6. The most common: Social
stresses
7. Information systems
 Why
Whymaintained:
maintained:
Although 1st cigarette is unpleasant,
smokers continue to smoke.. Why?
Pharmacologic effects of nicotine
1. Effects on nucleus ceruleus :
Enhanced vigilance, arousal and decrease
fatigue
2. Effects on mesolimbic dopaminergic system :

Feeling of reward, pleasure, perservation and

improve fine motor activity
Later: obliged by withdrawal symptoms
LANDMARKS
LANDMARKSIN
INTOBACCO
TOBACCOHISTORY
HISTORY: :
● 5000-3000 BC: Tobacco consumption by
native south Americans
● Late 15th century: Columbus finds tobacco
in the "New World" and takes it back
to Europe. 
● In 16th century: European Occupants took
it to their colonies
● In the middle of 19th century: Matches
were introduced, making smoking
more convenient and spread widely. 
 HISTORY OF TOBACCO (contd.)

● 1939 German researchers found a statistical

link between lung cancer and smoking. 
● 1950 Journal of the Amer . Med . Assoc .
Published its first major study definitively
linking smoking to lung cancer. 
● 1953 The first definitive biological link between
smoking and cancer was uncovered. 
● 1957 The first official statement on smoking by
the Public Health Service in USA
Since that time, research was
centered on health hazards
of tobacco smoke and the
cardiovascular and
other systems damage
were discovered
THE MAGNITUDE OF THE PROBLEM

● Consumption peaked in 60 s of 2oth century

● In 90 s, marked drop in western world and
marked rise in 3rd world (3.4 %/yr)
● 90 % of smokers are between 14 and 25 yrs old
● Most pts with smoking induced disease are
above 40
● An average smoker has 30% risk of having fatal
disease and 30% risk of non fatal disease
● 20% of worldwide deaths are related to SID
 2 GREAT ALARMS !!!!!!
1. The world burns > 500
billion $ of tobacco/year
2. Expected that :
> 10% of the 6 billions living
in the world now will die
due to SID
(WHO, 2009)
 HEALTH
HEALTH HAZARDS
HAZARDSOF
OF
TOBACCO
TOBACCO SMOKING
SMOKING
3 MAIN PATHOGENETIC MECHANISMS
1. INFLAMMATION

2. CARCINOGENESIS
3. VASCULOPATHY
INFLAMMATION

1. Direct irritation

2. Auto-immunity

3. Vasculopathy
(ischemia)
CARCINOGENESIS
1. Impairedimmune
surveillance

2. Oncogene mutations

3. Direct irritation
VASCULOPATHY
1. Atherosclerosis
▪ Endothelial injury :
■ Direct toxic effect ■ Tachycardia
■ Neutrophilia ■ Platelets cytokines
▪ Dyslipidemia :
Increase in LDL cholesterol
2. Thrombogenesis
Most evident in micro vessels
■ Platelet activation
■ Increased fibrinogen
■ Atheroma formation
CCO SMOKE RELATED DISEASE
1. CARDIOVASCULAR:
● Atherosclerotic disease
- Coronary artery disease
- Carotid vascular disease
- Mesenteric, renal, iliac
- Abdominal aortic aneurysm
● Peripheral vascular disease
- Thromboangiitis obliterans (Buerger’s)
- Deep venous thrombosis
- Pulmonary embolus
● Cardiac disease
- Angina pectoris
- Myocardial infarction
- Coronary artery spasm
- Arrhythmia
2. Malignancy
● Respiratory tract
- Lung cancer - Laryngeal cancer - Oral cancer
● Other tissues
- Esophagus - Pancreas - Bladder - Uterine cervix
- Kidney - Anus - Penis - Stomach
- Liver - Leukemia

3. Lung disease
● COPD
- Emphysema - Chronic bronchitis - Asthma

● Other lung diseases

- Idiopathic pulmonary fibrosis - Histiocytosis X
- Respiratory bronchiolitis - Goodpasture’s syndrome
- Sleep apnea - Pneumothorax
3. GASTO-INTESTINAL DISEASE
● Peptic ulcer disease : Gastric, Duodenal
● Gastroesophageal reflux
● Chronic pancreatitis
● Chron’s disease ● Colonic adenomas
4. DERMATOLOGIC DISEASES
● Skin wrinkling ● Psoriasis
5. REPRODUCTIVE DISEASE
● Fertility related
- Ovarian failure - Decreased sperm quality
● Pregnancy related :
- Premature rupture of memb.
- Spontaneous abortion
- Prematurity & Low birth weight
● Fetal effects
- Impaired lung growth
- Sudden infant death syndrome
- Febrile seizures
- Reduced intelligence
- Behavioral disorders
- Atopic disease/asthma

6. RHEUMATOLOGIC DISEASE
● Osteoporosis
● Rheumatoid arthritis
7. PSYCHIATRIC DISEASE
● Depression
● Schizophrenia
8. ORAL DISEASE:
● Periodontal disease
● Loss of taste
9. ENT:
● Recurrent infections
● Chronic sinusitis
● Decreased olfaction
10.Infectious diseases:
● Tuberculosis
● Pneumococcal infection
● Meningococcal infection
11.Endocrine disease:
● Altered hormonal secretion
● Graves’ disease & Goiter
● Anti-diuresis
12. Urinary
● Glomerulonephritis
● Benign prostatic hypertrophy
13.Eyes
● Conjunctivitis
● Cataracts
14. Passive smoking in children
● Asthma
● Rhinitis
● Otitis media
● Pneumonia
● Increased risk to smoke
NICOTINE ADDICTION
■ Mainly a pediatric problem
■ With smoking more than smokeless
■ Has genetic predisposition :
▪ Receptors : alpha 4 & beta 2
▪ CYP2A6 enzyme
■ Mediated by dopamine & endorphins
■ Pointers for addiction :
* ≥ 10 cig/day
* keep cigarette in mouth
* smokes deep to the end
* smoking in closed places
* conditioned smoking
* Smokes even when ill
* Withdrawal symptoms
Fagerstorm score for quantitative evaluation of addiction: low = 0 ↔ 10 = high
 QUITTING TOBACCO
• Why a smoker must quit ?
= Quitters live longer than non quitters
= Quitters before 50 have 50% risk of dying
before 65
= Simple chronic bronchitis resolves
completely
= Emphysema progresses slowly
= Risk of sudden death due to MI or stroke
immediately decreases
= Risk of cancer ↓ 50% in a yr
PSYCHDYNAMICS OF QUITTING
● Precontemplation stage :
Smoker is enjoying smoking
● Contemplation stage :
Smoker thinks in quitting
● Preparation stage:
Ask quitters, search for help
● Action stage:
Patient start trying to quit
Only 5% succeed 1st trial, most try 5-8 times
● Maintenance:
More than 6 months abstinence
DYNAMICS OF QUITTING
FEATURES OF CESSATION
PROCESS

● Smokers relationship to
cigarettes
● Withdrawal symptoms
● Cigarette cravings
● Smoking associated behavior
● Slips and relapses
● Weight gain
HOW TO ASSISST QUITTING
■ Role of primary physician
• USA NCI 4As:
= Ask every patient about smoking
= Advice every tobacco user to
stop
= Assist the cessation effort
= Arranging follow up
• Addressing the subject
• Always be supportive
● Use multiple strategies at the

same time
Specific cessation methods:
■ Explain all to the smoker
■ Let the smoker set a specific quit date
■ Multiple approaches are better than single

1.Non pharmacologic:
Group counseling and health
education
Gradual reduction:
▪ Cold turkey ▪ Tapering of
Helping measures:
▪ Hypnosis ▪ Exercises
▪ Acupuncture
2. Pharmacologic :
■ NICOTINE REPLACEMENT THERAPY :
High success rate if given for 3 months
1. Nicotine gums & lozenges
2. Transdermal patches
3. Nicotine inhalers
4. Nasal spray
5. Sublingual tabs 6.
Electronic cigarettes
 ■ DOPAMINERGIC STIMULANTS :

1. Bupropion :
- Antidepressant
- Dopaminergic and noradrenergic
potentiation
- 150 mg starting
2. Varenicline : dose, then twice daily
- An alpha4 & beta 2 receptor partial
agonist
- Has an antagonist action
- Very appointing
- Dose: 0.5mg/d for 3 days then twice/d for 4
days then 1mg twice daily for 12 wks
 ■ Other drugs:
1. CB1 blockers : (Rimonabant)
- Decrease cravings
- Decrease weight gain
- Still under investigation
2. Clonidine : an alpha adrenergic agonist
3. Nortriptyline: a tri-cyclic antidepressant
4. Topimerate: an anti-seizure drug
5. Selegiline : anti-parkinsonian } Under invest
drug
■■NICOTINE VACCINES:
NICOTINE VACCINES:
● Under investigation
● Distort pharmacokinetics
● Can be used for prevention
● Can prevent long term relapse
■■HARM
HARMREDUCTION:
REDUCTION:
1. Anti-oxidants
2. Low tar cigarettes
3. Efficient filters
4. Smokeless tobacco
5. Electronic cigarettes

!!!
!!!
These methods may help
spread tobacco consumption
 ■■SMOKING
SMOKINGPREVENTION
PREVENTION: :
1. Public health campaigns against
tobacco:
- Mass multimedia: TV,
Broadcasts, Cinema
- News papers & magazines
- Internet & PC
2. School teaching about
smoking hazards
3. Tobacco sales restrictions:
- Limit sale sites
- Increase tobacco taxes
Don’t let it
eat you

It is
eating
PLEAS
E LET
us
BREAT
H
CLEAN
 A N K
TH
Y O U