World No-Tobacco Day on May 31:

Kicking the smoking habit

By Carol Aloysius

In spite of repeated calls and regulations being introduced to curb smoking, it is still widely prevalent in Sri Lanka and worldwide. True, there has been a decline since especially in Sri Lanka, but studies have shown that those who are newly introduced to the habit could become addicted to it - unless they are weaned away from it right from the start. School boys and school leavers as well as young men are specially vulnerable due to peer pressure ...

Consultant Physician, Sri Jayewardenepura Hospital, Dr Shyama Subasinghe who has made a personal study of smoking habits among her patients shares her views on the subject.

Excerpts…

Q. Smoking is still widely prevalent both in Sri Lanka and abroad, in spite of steps being taken to curb the practice. Why?

A. Because of addictive properties of nicotine. This leads to nicotine withdrawal syndrome if appropriate pharmacological treatment is not given.

Also easy availability, advertising, stress, depression and personality disorders, socio-economical issues, all play a role.

Q. Who are those who are most likely to become smokers? Those who start early as school boys and adolescents? Or those who start in their 20s or middle aged persons? Which of these age groups are at highest risk and why?

A. The earlier age at which a person begins smoking, the more likely he or she will continue into adulthood. Within a year of smoking initiation, children inhale the same amount of nicotine per cigarette as adults, and experience the craving and withdrawal symptoms; tobacco dependence can develop very quickly in children.

Risk factors for an adolescent becoming a smoker include having parents or friends who smoke, living with a smoker, having a strained relationship with a parent and/or single parent at home, low level of self-esteem and self-worth, poor academic performance, increased perception of parents’ approval of one's smoking, co-morbid psychiatric disorders, and the availability of cigarettes.

An additional risk factor for boys is high levels of aggression and rebelliousness.

Twin studies have shown a significant genetic link to both smoking initiation and dependence, although it is likely that they involve different genes.

Q. What are the substances found in tobacco smoke that undermine health?

A. Nicotine, Tar (the aggregate of particulate matter, after subtracting nicotine and moisture is referred to as tar, it contains more than 4,000 various carcinogens). The vapour contains carbon monoxide, respiratory irritant and ciliotoxins (toxins that damage the cilia).

Q. What are the other products of tobacco apart from cigarette?

A. Cigarettes are not the only tobacco product. Cigars and pipes are older forms of smoked tobacco.

The smoke of these products is not typically inhaled as deeply into the lungs as cigarette smoke is, and for this reason, the health risk of smoking cigars and pipes is lower than the risk of smoking cigarettes, but higher than the health risk of a non smoker.

Q. What are the respiratory health risks smokers face?

A. COPD(Chronic Obstructive Pulmonary Disease) - cigarette smoking is responsible for more than 90 percent COPD. Within 1-2 years of beginning to smoke regularly, many young smokers develop inflammatory changes in their small airways.

Smoking affects heart and blood vessels in the following ways:

• Cigarette smoking activates the sympathetic nervous system, producing an increase in heart rate and blood pressure, and this leads to hypertension.

• Also it causes cutaneous and perhaps coronary vasoconstriction leading to IHD.

• Smoking enhances the prothrombotic (blood clotting) state via inhibition of tissue plasminogen activator release from the endothelium, and elevation in the blood fibrinogen concentration, increased platelet activity (possibly due to enhanced sympathetic activity). This also contributes to the development of heart attacks.

• In patients with advanced lung disease, elevated whole blood viscosity due to secondary polycythemia (high red blood cells) in smokers can lead to hypoxia (lack of oxygenation to the tissues) and tissue damage.

• Smoking is an independent major risk factor for CHD(coronary heart disease), cerebrovascular disease, and total atherosclerotic cardiovascular disease. The incidence of a MI is increased six fold in women and threefold in men who smoke at least 20 cigarettes per day compared to subjects who never smoked. In the worldwide INTERHEART study of patients from 52 countries, smoking accounted for 36 percent of the population attributable risk of a first MI.

•Aortic aneurysm. - Smoking can damage the vascular wall, possibly leading to impaired prostacyclin production and enhanced platelet-vessel wall interaction.

This can reduce the elastic properties of the aorta, resulting in stiffening of and trauma to the wall.

• Peripheral vascular disease.

• (approximately 90 percent of peripheral vascular disease in the non-diabetic population can be attributed to cigarette smoking, as can 50 percent of aortic aneurysms.)

Q. Can smoking cause cancers?

A. Yes. It causes cancer of the lung, Kidney, Liver, Lower urinary tract, including renal pelvis and bladder, Mesothelioma, Pancreas, Nasal cavity and para-nasal sinuses, Stomach,Upper aero-digestive tract, including oral cavity, pharynx, larynx, nasopharynx, and oesophagus, Uterine cervix.

Q. Does smoking cause DM and high blood Cholesterol?

A. Yes. Smoking is associated with an adverse effect on serum lipids (elevated low density lipoproteins and triglycerides and reduced high density lipoproteins).

Diabetes - Smoking is a risk factor for developing type 2 diabetes, and smoking cessation appears to decrease this risk.

Q. What are the other health hazards of smoking.

A. Peptic ulcer disease,

• Cataract and macular degeneration.
• Osteoporosis- Smoking accelerates bone loss and is a risk factor for hip fracture in women. Smoking cessation begins to reverse this excess risk after approximately 10 years. Accelerated bone loss has also been noted in male smokers, but the magnitude of resultant excess fracture risk is less well defined.

• Gall stone and cholecystitis(inflammation of the gall bladder).
• Male impotence.
• Premature menopause.
• Wrinkling of the skin and premature ageing.

Q. Can cigarette smoking affect already existing diseases?

A. Cigarette smoking increases the risk of several types of infection and the chance of dying from it and is an important risk factor for the development of invasive pneumococcal disease in immunocompetent non-elderly adults.

In addition, smoking appears to increase the risk of developing (and dying from) pulmonary tuberculosis; this is a particular problem in areas where tuberculosis is endemic.

Q. What are the symptoms of Chronic Obstructive Pulmonary disease (COPD?)

A. Cough, difficulty in breathing, sputum production

Q. Will patients with NCDs such as diabetes, hypertension, IHD etc be at greater risk to their diseases if they smoked?

A. Yes.

• E.g. Patients who continue to smoke in the presence of established CHD have an increased risk of re-infarction (second heart attack) and an increased risk of death, including sudden cardiac death.

• Persistent smokers after CABG (Coronary Artery Bypass Graft) have a greater relative risk of all-cause mortality (relative risk 1.68), cardiac death (relative risk 1.75), and need for repeat revascularisation (relative risk 1.41) compared to those who stopped smoking for at least one year.

• After angioplasty, persistent smokers have a greater relative risk of death (1.76) and Q wave myocardial infarction (2.08) compared to non-smokers, and a higher relative risk of total and cardiac mortality (relative risk 1.44 and 1.49, respectively) when compared to those who quit smoking.

• Worsening of asthma, and frequent exacerbations and hospital admissions in smokers.

Q. What about those in their vicinity such as spouses, children, colleagues etc? Are they even more affected because they don’t have the protection which smokers get from the filter of the cigarette filter?

A. Yes. It is estimated that exposure to second-hand smoke (ie, passive smoking) causes almost 40,000 deaths from heart disease each year in the United States, increasing the risk in non-smokers of coronary disease and coronary death by approximately 20 percent in large epidemiological studies.

Q. How does passive smoking affect women and pregnant women?

A. Smoking is associated with increased risks for infertility, spontaneous abortion, ectopic pregnancy, placenta previa (low lying placenta), placental abruption(detachment of the placenta from the uterus.), premature rupture of membranes.(rupture of water bag),

Q. If a woman smoked, will it affect her baby if she smokes while nursing the infant?

A. Delivered babies are more prone to develop respiratory distress, infant death, small for gestational age, developmental delay. Cessation during pregnancy could prevent

• 10 percent of perinatal deaths
• 35 percent of low birth weight births
• 15 percent of pre-term deliveries

Q. What is nicotine withdrawal syndrome

A. Nicotine is a psychoactive drug capable of causing tolerance, physical dependence, and when smokers quit, the symptoms of nicotine withdrawal. These include irritability, anger, restlessness, difficulty concentrating, insomnia, anxiety, and depressed mood, which may be severe. Nicotine withdrawal symptoms generally peak in the first three days and subside over the next three to four weeks.

Q. What are the new techniques introduced to stop or discourage smoking e.g. patches? Pills? How effective are these? Are they available in Sri Lanka?

A. Nicotine patches, nicotine chewing guns, inhalers, clonidine, bupropion. They are available in SL and effective if combine with proper advice and counselling.

Q. The Court of Appeal recently approved graphic health warnings covering 50-60 percent of cigarette packs. Do you think this will be an effective deterrent to smokers or would be smokers?

A. Yes. But other measures also should go in hand to hand.

Q. As a Consultant physician you see many young and old patients with smoking related problems. How do you organise cessation of smoking in them?

A. It is a stepwise management process. There are five stages. We need to gradually take the patient from stage 1 to 5.

• Pre-contemplation - The patient states he/she is not ready to quit. We should educate and motivate him first.

• Contemplation - The patient is considering smoking cessation at some point. The patient at this stage should be encouraged to select a specific quit date and to engage in preparation toward that date.

• Determination - The patient is actively considering cessation soon and is engaging in some quit-oriented behaviour as we advised earlier.

Treatment for nicotine withdrawal is given at this stage.

• Action - The patient is actively involved in a quit attempt and has quit smoking.
• Maintenance - The patient has quit for at least six months. Give continuous encouragement and support.

Q. Any advice you can offer the public based on your own hands on experiences in dealing with such patients (who are in pre-contemplation stage)? For example, the impact it has on the patient and the family? The costs involved in indulging in this habit on a daily basis? Etc.

• We explain the health Risks - The acute and long-term risks of smoking should be stressed. It is most effective if smoking can be tied to the patient's current health or illnesses.

For the healthy patient, environmental risks, such as exposing spouses and children to smoking and thereby increasing their risk of ill-health should be included. Smokers should also be made aware that children of smokers are more likely to smoke.

• Rewards - Encourage the patient to identify potential benefits of smoking (such as saving money, performing better in sports, improving the health of children and other household members, etc).

• Roadblocks - Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers.

Sense of taste may affect length of life

Perhaps one of the keys to good health isn't just what you eat but how you taste it.

Taste buds - yes, the same ones you may blame for that sweet tooth or French fry craving - may in fact have a powerful role in a long and healthy life - at least for fruit flies, say two new studies that appear in the Proceedings of the National Academy of Sciences of the United States of America.

Researchers from the University of Michigan, Wayne State University and Friedrich Miescher Institute for Biomedical Research in Switzerland found that suppressing the animal's ability to taste its food - regardless of how much it actually eats - can significantly increase or decrease its length of life and potentially promote healthy ageing.

Bitter tastes could have negative effects on lifespan, sweet tastes had positive effects, and the ability to taste water had the most significant impact - flies that could not taste water lived up to 43 percent longer than other flies. The findings suggest that in fruit flies, the loss of taste may cause physiological changes to help the body adapt to the perception that it's not getting adequate nutrients.

In the case of flies whose loss of water taste led to a longer life, authors say the animals may attempt to compensate for a perceived water shortage by storing greater amounts of fat and subsequently using these fat stores to produce water internally. Further studies are planned to better explore how and why bitter and sweet tastes affect ageing. “This brings us further understanding about how sensory perception affects health. It turns out that taste buds are doing more than we think,” says

senior author of the University of Michigan-led study Scott Pletcher, associate professor in the Department of Molecular and Integrative Physiology and research associate professor at the Institute of Gerontology.

“We know they're able to help us avoid or be attracted to certain foods but in fruit flies, it appears that taste may also have a very profound effect on the physiological state and healthy ageing.”

Pletcher conducted the study with lead author Michael Waterson, a Ph.D graduate student in U-M's Cellular and Molecular Biology Program. “Our world is shaped by our sensory abilities that help us navigate our surroundings and by dissecting how this affects ageing, we can lay the groundwork for new ideas to improve our health,” says senior author of the other study, Joy Alcedo, assistant professor in the Department of Biological Sciences at Wayne State University, formerly of the Friedrich

Miescher Institute for Biomedical Research in Switzerland. Alcedo conducted the research with lead author Ivan Ostojic,of the Friedrich Miescher Institute for Biomedical Research in Switzerland.

Recent studies suggest that sensory perception may influence health-related characteristics such as athletic performance, type II

diabetes and ageing. The two new studies, however, provide the first detailed look into the role of taste perception.

“These findings help us better understand the influence of sensory signals, which we now know not only tune an organism into its environment but also cause substantial changes in physiology that affect overall health and longevity,” Waterson says.

“We need further studies to help us apply this knowledge to health in humans potentially through tailored diets favouring certain tastes or even pharmaceutical compounds that target taste inputs without diet alterations.”

- MNT