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Cigarette smoking and health

by D. P. Atukorale

Cigarette smoking is the greatest epidemic facing humanity and use of tobacco is the second major cause of death in the world.

Cigarette smoking is currently responsible for the death of one in ten adults worldwide (about 5 millions deaths each year according to World Health Organisation (WHO) website 2002).

Every eight seconds, someone dies from tobacco use. If current smoking pattern continues it will cause some 10 million deaths each year by year 2020.

Half the people that smoke today, that is, about 650 million people will eventually be killed by tobacco. 15 billion cigarettes are sold daily or 16 million every minute and the total number of cigarettes is enough to send 3 million smokers to the grave annually.

This includes both passive and active smoking. Smoking is becoming one of the important risk factors not only in the industrialised countries but also in the developing countries such as Sri Lanka.

In 1974, N. J. Wallooppillai and D. P. Atukorale carried out a research project (sponsored by Sri Lanka Science Council) to find out the common causes of myocardial infraction (heart attacks) among the young Sri Lankans (i.e. those below the age of 40 years) and we came to the scientific conclusion that smoking is the commonest coronary risk factor in the young infarcts.

I have come across thousands of young widows (and their school going children) thanks to the good work of the cigarette industry. Like other more developed countries, these widows should take legal action against the cigarette companies for the damages.

About 12 times more British people have died from smoking than from World War II. Cigarettes cause more than one in five Americans deaths. Great effort has been made to reduce the number of smokers in the developed countries, for example the percentage of the population that smokes in England has been reduced to 9% and in United States to 25%.

However, the number of smokers has been increasing in developing countries. The percentage of population who are smokers is about 22% in the Asiatic countries, and 42% in the African Countries.

The economic costs of tobacco use are equally devastating. In addition to high public health costs of treating tobacco caused diseases, tobacco kills people at the height of their productivity, depriving families of breadwinners and nations of a healthy workforce.

Tobacco users are also less productive while they are active due to increased sickness.

In 1994, W.H.O. report estimated that the use if tobacco resulted in an annual global net loss of U.S. 200 billion dollars, a third of the loss being in developing countries. (Reference B. M. J. 1994, 309, 901-911).

Mortally in relation to long term smoking: 40 years observation of male British Doctors by R. Doll, R. Peto, K. Wheatley, I. Sutherland.

A prospective study of mortality in relation to smoking habits was assessed for male British doctors from 1951-1991.

A large regiment of 34,439 British male doctors who replied to a postal questionnaire in 1951 of whom 10,000 had died during the first 20 years and another 10,000 died during the second 20 years.

The death rate ratio during 1951-1991 (comparing continuing cigarette smokers with life long non-smokers) was approximately threefold at age group 45-54 and twofold at ages 65-84. The excess mortality was chiefly from diseases that can be caused by smoking.

Positive association with smoking was confirmed for death from cancers of mouth, esophagus, pharynx, larynx, lung, pancreas and larynx, bladder, from chronic obstructive pulmonary disease, from vascular diseases; from peptic ulcer and (perhaps because of confounded by personality and alcohol use) from cirrhosis, suicide and poisoning.

Those who stopped smoking before middle age subsequently avoided all the excess risk that they would otherwise have suffered and even those who stopped smoking in middle age were subsequently at less risk than those who continued to smoke. It now seems that about half of all regular cigarette smokers will eventually be killed by their habits.

Pipe and cigar smokers

Mortality of pipe and cigar smokers who had never regularly smoked cigarettes has been found to be higher than the nonsmokers but less than cigarette smokers.

The causes of death in pipe and cigar smokers are cancer of lung and other respiratory sites (such as pharynx and larynx), cancer of oesophagus, chronic obstructive lung disease, pulmonary tuberculosis, pulmonary heart diseases, non-syphilitic aortic aneurysms. But these were less than in cigarette smokers though greater than non-smokers, while their mortality from other causes was similar to that of non-smokers. Upper respiratory cancers include cancer of mouth (other than salivary gland), pharynx (other than nasopharynx) and larynx, cancer of lung; esophagus, bladder and pancreas were all clearly related to smoking.

Out of above, mortality rates of cancers of upper respiratory sites, lung and esophagus were at least 15 times that of non-smokers.

Cancer of bladder and pancreas were about 3 times more common in heavy smokers than in non-smokers. Cancer of stomach showed a marginally significant relation with the amount smoked.

Chronic obstructive lung disease which includes chronic bronchitis and emphysema showed a relation almost as strong as that for cancer of the lung. Pulmonary tuberculosis shows a moderately close relation with smoking.

A statistically highly significant relation with smoking was observed for pancreas. Asthma mortality was more than double that of non-smokers.No death was observed in men under 25 years of age. Total number of deaths observed at 25-34 years was small.

Under 35 years, the mortality was higher in current smokers than in non-smokers. Overall mortality was twice as great in continuing cigarette smokers compared to life-long non-smokers throughout middle and early old age.

Passive smoking

Active smoking is a well established major preventable risk factor for coronary heart disease (C.H.D.). Many studies have reported that passive smoking is also associated with increased risk of C.H.D. (Law MR et al, B. M. J., 1997, 315, 315-80).

Generally such studies have compared the risks of non-smokers who do or do not live with cigarette smokers (Hirayama T, N. Z. Med J. 1990, 103, 5) though few have also considered occupational exposure. Passive smoking may also be related to risk of stroke (Bonita R.et al, Tob. Control, 1998, 8, 156-60).

Living with someone who smokes is an important component of exposure to passive smoking. A person may also get exposed to passive smoking in work places and public places such as restaurants.

Thirty years ago scientific committees and national organisations concluded that exposure to environmental tobacco smoke (also called passive smoking) is a cause of lung cancer. A woman who has never smoked has an estimated 24% greater risk of developing lung cancer if she lives with a smoker.

There is a dose response relation between a non-smoker's risk of getting a lung cancer and the number of cigarettes and years of exposure to the smoker. Tobacco specific carcinogens are found in the blood and serum of non-smokers exposed to environmental tobacco smoke. All the available evidence confirms that exposure to environmental tobacco smoke causes lung cancer.

I have come across a significant number of young wives who have developed heart attacks and angina following passive smoking (second - hand smoke) due to their husbands smoking at home. I always advise young women to get married to smokers if they want to be young widows!

British heart study

This is a prospective study of cardiovascular disease in 7735 men aged 40-49 years selected from 24 towns in England, Wales and Scotland. According to above study passive smoking is associated with an increase in risk of coronary heart disease. (C. H. D.) of 20-25%. Passive smoking may also increase the risk of stroke though information is limited.

According to above study, high concentrations of cotinine (which is a nicotine product) among non-smokers are associated with excess risk of coronary heart disease of about 50-60%.

High overall exposure to passive smoking seems to be associated with a greater excess risk of C. H. D. than partner smoking and widespread in non-smokers that the effects for passive smoking have been under-estimated in the past.

Weight of evidence using serum nicotine concentrations suggests that exposure to passive smoking is a public health hazard and should be minimized (Peter H. Whincup et al, B. M. J. 2004, 329, 200-205).

School students

Among young teens (aged 13 to 15) about one in 5 smokes worldwide. Between 80,000 and 100,000 children worldwide start smoking everyday, roughly half of whom live in Asia. Evidence shows that 50% of those who start smoking in adolescence go on to smoke for 15 to 20 years. Peer-reviewed studies show that teenagers are heavily influenced by tobacco advertising.

The number of smokers among school students in still high. There are many factors influencing, these students to start smoking; for example socio-economic status, parents, friends and siblings who smoke and social environment. In developing countries like Sri Lanka, smoking among children and adolescents has not yet received much attention.

It has been found that most common age for starting smoking was between 15 years and 19 years. The main sources of the first cigarette were relative or neighbour (25% school friend). Close relative i.e. father or sibling accounted for 20.9%, and friend outside school (18.9%).

The first cigarette for those who smoked before 10 years of age was predominantly given by a relative or neighbour followed by close relatives (mainly father). For those who started smoking between 10 years and 14 years the main sources were relatives or neighbours, school friend or close relative (father or sibling). For those who smoked between 15 years and 19 years the main sources were friends.

The first cigarette was usually smoked at home, followed by on the way to or from school and these at the house of a friend or relative.

The reason of starting smoking was usually to see what it was like i.e. curiosity followed by to imitate others and because of encouragement by others. The idea that smoking makes people elegant was not a common reason given for starting smoking.

Health

Currently there are more than 70 countries in the world which have official anti-smoking programmes and activities including campaigns to protect individuals from tobacco smokers and promoting a healthy environment.

Work environments and other public places should be tobacco smoke free in order to reduce the adverse effects on people's health. In this respect we should appreciate the good work done by Ministry of Health and Nutrition to make our hospitals and Ministry of Health and Nutrition smoke free areas.

All Sri Lankans should be very grateful to his Excellency the President, the J.H.U. and all other political parties who supported the recent Anti-Smoking and Anti-Alcohol Bill in the Parliament.

Half of long term smokers will die from ill-effects of tobacco. Every cigarette smoked cuts at lest 5 minutes of life on average about the time taken to smoke it.

Smoking is the single largest preventable cause of disease and premature death. It is a prime factor in heart diseases, stroke and chronic lung diseases including lung cancer.

More than 4000 toxic or carcinogenic chemicals have been found in tobacco smoke. Smoking related diseases cost the United States more than 150 billion US$ a year.

Smoking is mainly a problem of young and adult males in Sri Lanka. Fortunately smoking is rare among females in our society. It is likely that social norms and traditions have greater influence on females than males in our society.

Vehicle fumes

There is a misconception among some Sri Lankans that vehicle fumes and other industrial gases contain nicotine and that chemicals present in these fumes cause heart attacks. As far as I am aware to-date there is not a single case of a documented heart attack due to vehicle fumes and industrial gases in Sri Lankan medical literature.

Cigarette smoke contains more than 4000 toxic chemicals which include nicotine which is the most poisonous alkaloid (C10 H14 N2) found in all parts of the tobacco plant, especially in the leaves.

Smoking cigarettes, cigars, beedis, pipes and chewing cigars tobacco (with betel leaves) and inhaling tobacco snuff (which is popular among females in the Western and Southern Province especially in Beruwala) are injurious to health. As far as I am aware only tobacco plant (especially the leaves) contains the very toxic alkaloid nicotine.

"Tobacco companies possess the knowledge that consuming their product is so imminently dangerous that it must in all probability cause death or cause such bodily injury as is likely to cause death and since tobacco companies commit such crimes without any excuse or justification, in all means they are murderous" (Swarna Hansa Foundation).

It is noteworthy that people attached to tobacco industry including those working in their distribution outlets in Sri Lanka, (as far as I am aware) don't smoke cigarettes.

Cigarette smoking should be banned in our 'Big Matches' as these are school events and not adult events.

Anti-smoking campaigns should be started in all our schools and the school syllabus should include ill-effects of smoking and alcohol consumption.

The age-old practice of offering betel leaves with tobacco leaves (Bulat dunkola) to elders during the festive seasons such as April Sinhala and Hindu New Year should be improved and tobacco leaves should never be offered to your elders as these leaves contain nothing but poisons.

Psychological difficulties in motherhood

These days there is no stigma attached to being childless, and many women have other, often very interesting options what females want to do with their lives. But meanwhile, a woman's biological clock is ticking louder than ever.

A study appeared in 2002, in the journal Human Reproduction suggesting that the decline in female fertility starts earlier than previous thought, at age 27. Woman who once put off a decision about children now feel pressure to start at least thinking about it earlier.

In Sri Lanka, the accepted norm is to have a child with in the first two years of getting married. This is the thinking of most Asian countries. The husband's parents and their relations tend to think that there is some fertility problem of the wife, if she does not produce a child within the first two years of married life.

It is complicated for single women, too. In their parent's generation, the choice was pretty much made for them. But these days, even if they decided not to marry - or no one has come along that they want to marry - then in eastern countries like Sri Lanka still it is bit difficult to live a single life. But in western countries like United States or Canada, there is no stigma attached of being single or being a single mother.

There is even a U.S. organisation, Single Mothers by choices, for women having children outside marriage.

Many books have been written both on the joys of motherhood and in support of the child - free choice for those women asking themselves if they want children. But in the last decade there have been very few that take no stand on the subject that simply want to help women think about the question.

At the same time, the reasons to have children - or not have gotten more complicated. Most of the females who are working are living away from their parents. They don't have an extended family to talk to. Their mothers and grandmothers did not think much about whether they would have children or not. That was the married women did.

But today's women are not just considering motherhood in terms of when, but if. Over the past couple of decades, society has grown more accepting of women's choice not to have children. But advances on medicine also have made it possible for older women to conceive, leaving motherhood a question to contemplate much later in life.

In the present society most women have so many questions before becoming a mother. Questions like - Do I want to have a child? - How will children affect my career?

What will pregnancy do to my health? - What does it cost to have a child? How does we raise a good person?

It is feelings of regret that much cross the mind of almost any woman who chooses not have a child. What if? But on the other hand, what if I give up or put on hold, a great career? What if I don't like being a mother? In the end, it may be just a leap of faith.

According to psychologists, motherhood is an automatic response based on millennia of knowing that if you did not have children, something was wrong. Since the advent of the Pill in the early 60s childbearing has been an individual decision.

Most of the psychologists say that it is a good idea for a couple to visit their obstetrician before conceiving. Women also need to think about how motherhood will change their image of themselves. They also should be willing to take a new identity.

Beliefs and attitudes need to be taken into consideration. A couple's differing faiths may become important for the first time, and role changes need to be thought out.

Dr. R. A. R. Perera, Consultant Psychologist, Ontario, Canada.

Emotional recovery helpful to heart attack patients

Emotional recovery from heart attacks is vital to a patient's health, according to a new study published in the Mayo Clinic Women's Health Source.

The study said that people who develop depression after a heart attack are more likely to require hospital care within a year for a heart-related problem than heart attack survivors who aren't depressed.

Heart attack survivors with depression are also three times more likely to die of a future heart attack or other heart problems, the study said.

These differences in health outcomes may be partially due to a lack of follow-up care, the study said, adding that people who are depressed are less likely to take medications and follow the advice of their doctors.

The study said depression, fear and anger are common reactions after a person has had a heart attack, but doctors' follow-up care can ease depression and fear in patients.

The article offered some tips from experts to help heart attack patients with their emotional recovery:

* Discuss your feelings openly and honestly with your doctor, family members and friends;

* If you think you may be depressed, seek treatment; - Talk to your doctor about joining cardiac rehabilitation programs, many of which offer counselling and support groups;

* Get regular exercise as directed by your doctor as exercise not only boosts heart health, it may also help relieve anxiety and depression;

* Try to resume the activities and hobbies you enjoyed before the heart attack so as to keep you in a positive mood.

Doctors ignore sleep problems of elderly

Doctors rarely note the sleep problems of older patients, although two-thirds of them report these complaints, according to a new study.

Researchers at the U.S. Northwestern University studied 1,503 patients aged 60 and older who visited their primary-care doctors.

They surveyed the patients about sleep problems and found that 69 percent of the patients had at least one sleep complaint, and 40 percent had two or more. Forty five percent of the patients said they had "difficulty falling asleep, staying asleep, or being able to sleep."

The study, published in a recent issue of the American Journal of Geriatric Psychiatry, said despite the high rate of sleep complaints among the patients, a sleep complaint was only reported by the doctor in the patient's chart 19 percent of the time, even when the patient indicated sleep problems in all five sleep questions on the survey.

This is important, since previous research has linked sleep disorders in the elderly to poorer mental and physical health and quality of life, the study noted.

"A doctor may not think that it's very important to ask the patient about sleep. We (the researchers) hypothesize that doctors think that sleep problems are a normal part of aging, and there's not much they can do about it," study author Kathryn Reid, a research assistant professor of neurology at Northwestern's Feinberg School of Medicine, said.

But while some sleep problems, including a reduction in deep sleep, tend to occur with age, sleep disturbances are not an inevitable part of aging. In fact, a recent study found that among older people with exceptionally good health, only 1 percent had sleep difficulties.

"Now, a lot of studies show that not getting enough sleep can lower your metabolic function; be associated with cardiovascular problems, cancer and breast cancer in women; and increase our mortality.

Sleep deprivation also increases your sensitivity to pain," Reid said. Treatment options for sleep disorders may include meditation, exercise and bright light or evening activity. Climate crisis: Killer diseases spread North Health officials fear global warming will bring more tropical illnesses, such as West Nile, here to Canada.

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