5. Tobacco

Since it was first suggested in 1898 that smoking may result in lung cancer, many studies have examined the effect of tobacco smoke on active and passive smokers. As the social and economic costs of tobacco-related problems are enormous, medical practitioners and health workers play an important role in educating smokers of the risks and promoting the health benefit of quitting.

• Although initial inhalation of cigarette smoke can produce palpitations, dizziness, sweating, nausea, and vomiting, tolerance to these symptoms develops rapidly but can take up to 3 years.
• Physical dependence on nicotine, and even more important, psychological dependence to cigarettes, soon develops.
  
• 'Smokers cough' (a manifestation of bronchitis) typically occurs early in the smoker's career.
• Physical problems occurring later are numerous – lung cancer, respiratory diseases and problems, cardiovascular diseases including stroke and peripheral vascular disease.
  
• Fertility difficulties may occur in both males and females.

• Family history of smoking – especially young children of smokers, and other first degree relatives.
• People (usually younger persons) susceptible to peer group pressure. Influences may include:
  
  • friends who smoke
    
  • spouse/partner smokes
    
  • image and social acceptability
    
  • co-workers who smoke.
    
• People with extroverted personalities: impulsive, arousal-seeking, risk-taking.
• People prone to the effects of stress and tension.

Tobacco smoke contains over 4000 compounds, many of which have been linked to human disease.

• Nicotine – a highly toxic chemical which primarily acts on the nervous system and causes :
  • increases in heart rate
    
  • increases in blood pressure
    
  • constriction of blood vessels
    
  • increased blood fatty acids and platelet stickiness.
    
• Carbon monoxide – as it avidly displaces oxygen from haemoglobin it produces a relative hypoxia that is particularly dangerous to those with precarious tissue oxygenation: eg in IHD (ischaemic heart disease) and PVD (peripheral vascular disease), especially in diabetics. It also has psychomotor performance effects.
• Tar – a carcinogenic substance containing more than a dozen cancer producing chemicals.
  
• Glycoprotein – acts as an allergen.
• Nitrosamines – carcinogenic in animals and suspected to be so in humans.
  
• Benzo(a)pyrene and phenols – known human carcinogens.
• Oxides of nitrogen – may induce and worsen emphysema.
  
• Hydrogen cyanide – a particularly toxic agent in cigarette smoke which can impair cardiac function.

• Hypertension
• Ischaemic heart disease
  
• Myocardial infarction
• Heart failure
  
• Cerebral vascular events
• Cardiac arrythmias and conduction disorders
  
• Pulmonary circulation disorders
• Aortic and aneurysms, peripheral vascular disease

• Trachea, bronchus and lung
• Oral cavity: tongue, gums, floor of mouth
  
• Pharyngeal cancers
• Oesophagus
  
• Larynx
• Stomach
  
• Pancreas
• Bladder
  
• Renal pelvis and parenchyma
• Salivary glands
  
• Nasal cavities, middle ear and sinuses
• Breast cancer
  
• Uterine cervix
• Ovary and adnexae
  
• Prepuce and penile cancer

• Malignancies
• Chronic obstructive airways disease
  
• Asthma; especially in children (passive smoking effect)
• Sudden Infant Death Syndrome
  
• Neonatal respiratory disorders
• Pneumonia, influenza
  
• Tuberculosis
• Pneumoconioses

• Low birth weight
• Miscarriage
  
• Placental abruption and premature labour
• Amenorrhoea, ovulation, fertilisation and implantation defects
  
• Impotence, decreased sperm count

• Peptic ulceration
• Ulcerative colitis

• Parkinson's disease
• Osteoporosis
  
• Premature aging of the skin

• Each year, more than 30 fire-related casualties are caused by smoking and matches.
• 53% of domestic fires are related to smoking.
  
• Toddlers and children are particularly susceptible to burns from cigarettes and ash, especially ocular burns.
• Toxic ingestion – butts are particularly toxic.
  

Most psychological and behavioural difficulties occur with the cessation of smoking and in the ambivalent phase leading up to the decision to quit. However, most withdrawal phenomena are short lived, and with continual abstinence, ex-smokers enjoy many positive psychological effects.

Common psychological presentations of nicotine withdrawal:

• anxiety and tension
• irritability
  
• frustration
• anger
  
• difficulties with concentration and restlessness
• depression
  
• fatigue
• increased appetite.

• Legal liability associated with passive smoking.
• Financial strain – 1 packet per day ($4.80) = $33.60 per week = $1752 per year.
  
• With increasing community disapproval of smoking, many workers report being ostracised at social events, restaurants, relatives and even at home especially where there are children.
• At work – impaired job performance secondary to illness, increased absenteeism and sick leave, psychological consequences of restlessness and impaired concentration as nicotine levels fall before cigarette breaks.

Ex-smokers live longer than those who continue to smoke. The extent to which life span improves depends on the length of time since quitting, number of cigarettes smoked over how many years and the health status of the ex-smoker.

However, quitting is beneficial even in the presence of disease, eg patients with chronic obstructive airways disease will have improved lung function and symptomatology. Even lung cancer patients can help avoid second cancers and terminal respiratory infections. Of course, early cessation, with the support of education from health professionals and stop smoking programmes, will have greater health benefit by preventing the development of disease rather than its progression.

Although health issues are often given as the main reason for stopping smoking, for those who have yet to develop disease these events may be far less relevant than social or financial issues, or the health of their family.

Medical practitioners and other health care workers can help by emphasising the positive benefits of quitting. Discussion of withdrawal symptoms with the patient can also help them prepare for the process of quitting. It may be worthwhile for health professionals to think about their own behaviour and attitudes to smoking and how this affects their advice to patients.

• Increased life expectancy
• Improved health of family
  
• Improved physical fitness and appearance
• Improved sense of well being
  
• Positive psychological changes; enhanced self esteem and sense of self control
• Improved social standing and finances
  
• Restoration of sense of taste and smell
• Better work performance.

It should be emphasised that most of these are short lived when discussing them with the patient (eg symptoms usually peak about 3 days after cessation and the withdrawal, usually mild, is over within 7-10 days for most people). Discussion of withdrawal symptoms is not to discourage the uncommitted from the attempt, but rather to help the patient be better prepared for quitting, especially if it is his or her first attempt.

• Psychological symptoms
  
• Physical symptoms
  
• How medical practitioners and other health care workers can help
  
• Individual approaches
  
• General and community approaches

• Intense cravings for cigarettes – they are usually brief (10-15 minutes) and tend to recede with time
• Irritability and restlessness
  
• Impatience
• Dejection and sorrow – it is not uncommon to report a sense of grief and mourning for a 'lost companion'
  
• Depression
• Difficulty in concentrating
  
• Anxiety and tension
• Frustration
  
• Anger
• Fatigue.

• Sore throat
• Dizziness
  
• Headache
• Coughing – often productive, as the respiratory cilia are no longer paralysed and can clear the lungs of accumulated debris
  
• Tremor, perspiration
• Floating feeling – distance judgement may be affected
  
• Increased effect of caffeine
• Sleep disturbance
  
• Increased appetite – 'looking for the cigarette in the fridge'.

  Weight gain should be brought up specifically as it is often an unspoken fear in women. Only half of smokers will gain weight of which the average is 2.3 kg. It is said that a weight gain of 30 kg is needed to offset the health benefits of quitting. Positive changes in lipid profile and body fat distribution also occur. The patient can be encouraged to avoid weight gain with an exercise programme and have low kilojoule prepared snacks at hand.

HOW MEDICAL PRACTITIONERS AND OTHER HEALTH CARE WORKERS CAN HELP

Individual approaches

A good start is to document each patient's smoking history as part of general history-taking on initial presentation. When time allows, the patient can be encouraged to talk about their smoking using a non-judgemental question such as, 'How do you feel about your smoking?' A helpful model to use when assessing the smoker's readiness to quit identifies three stages:

1. Not ready – They are likely to become defensive and resistant to simple advice to stop. Gentle encouragement of the patient to think about their habit and making it clear that you are available for further support is the most effective approach.
2. Unsure – The advantages of continuing to smoke are still as important as the advantages of quitting. Discussion can focus on weighing up the pros and cons and any other specific concerns.
3. Ready – They will respond positively to advice to stop and can be given more specific help on how to deal with withdrawal symptoms. Provide follow-up to encourage their efforts and deal with continuing difficulties (Mendelssohn and Richmond, 1992).

It is therefore useful to identify how ready the patient is to change in order to provide the most appropriate individual assistance. An approach that helps the patient to take control and responsibility for the problem is more likely to be successful than systematically giving advice to stop or telling the patient what to do.

Relapses

Many ex-smokers relapse, especially in the setting of social events, peer pressure and alcohol. Patients should be encouraged to view these as learning experiences, and to learn from there how to avoid future relapses when they try again. Subsequent attempts are often easier for this reason.

Additional approaches

• Nicotine chewing gum – useful for the very physically dependent. The chewing tablets can prevent withdrawal symptoms. The patient should follow the enclosed instructions carefully to avoid unpleasant side effects.
• Nicotine patches – useful for very physically dependent but motivated patients. Manufacturers emphasise the need for concomitant support from the medical practitioner.
  
• Acupuncture
• Hypnosis
  
• Specialist clinics
• Self-help and GP assistance kits.
  

Resources available for the cessation of smoking

1. How to help smokers to quit: a guide for the health professional

An easy to use guide to give health professionals tips in counselling smokers with a brief intervention. The guide also outlines the stages a smoker goes through when quitting and illustrates how a health professional can help using The Can Quit Book.

2. The can quit book

A book for all smokers. Based on years of research and practical knowledge, it gives advice on recognising why people smoke, the health facts about smoking and an individual's health, preparing to quit and techniques to give up smoking and stay stopped.

Both resources are available from:

Victorian Smoking and Health Program (Quit)
PO Box 888Carlton South Vic. 3053
Telephone (03) 663 7777
Fax (03) 663 7761.
Note: No fee for orders in Victoria, small fee for orders interstate.

3. Smokescreen for the 1990s

The stop smoking programme for use by medical practitioners, obtained through the Prince of Wales Hospital, New South Wales.

There are two kits available:

1. one kit for GPs
2. self-help kit for smokers that can be displayed in the surgery.
   

Kits available from:

The Smokescreen Unit
Prince of Wales Hospital
High Street
Randwick NSW 203
Telephone (02) 399 4766
Fax (02) 399 2196.

4. Sick of smoking?

A manual for helping patients stop smoking, obtained through the South Australian Health Commission:

Sick of Smoking Officer

College House15 Gover Street
North Adelaide SA 5006
Telephone (08) 267 1249.

General and community approaches

• Assist in educational programmes, especially in schools. Young people and women are particularly likely to take up smoking.
• If you smoke yourself, try to give up smoking or at least not smoke publicly.
  
• Have a non-smoking policy in your workplace and other workplaces that you may visit.
• Be aware of the consequences of smoking, and know of the referral agencies available to help smokers.
  
• Congratulate people when they finally break the habit.
• Sympathise and offer encouragement to those people who require additional support and time to give up smoking.
  

Recent evidence has come to light showing the harmful effects of tobacco smoke on the health of non-smokers.

Cigarette smoke can be separated into two components, mainstream smoke which is inhaled by the active smoker, and sidestream smoke, the unfiltered smoke released from the end of a lit cigarette, which results in passive smoking in non-smokers.

The dangers of passive smoking are highlighted by the knowledge that 85% of cigarette smoke is released as sidestream smoke. Since the sidestream smoke is unfiltered it contains higher concentrations of dangerous chemicals. The effects of this harmful smoke in non-smokers can lead to increased incidence of bronchitis, pneumonia, and other chest illness in children, Sudden Infant Death Syndrome, lung cancer and lung disease. In addition, the irritants in tobacco smoke are a major concern to people with asthma and people with allergies, especially of the eyes, nose and throat.

Recent estimates suggest that annually approximately 150 deaths from lung cancer and 1000 deaths from heart disease in Australia are due to passive smoking (Holman, Armstrong, Arias et al., 1988).

Health risks of passive smoking

• Higher concentrations of cancer-causing agents in sidestream smoke.
• Aggravation of asthma.
  
• Aggravation of allergic conditions – cigarette smoke results in irritation of the eyes, nose and throat, and also headaches and coughs in non-smokers.
• Cancer, particularly lung cancer.
  
• Respiratory illness is increased – noticeable in children of active smokers who suffer from more acute respiratory illness, wheezing, middle ear infections, sore throats and problems of lung infection.
• Sudden Infant Death Syndrome.
  
• Growth – may be a combination of the mother smoking during pregnancy, and passive smoking by the child after birth.
• Increased incidence of bronchitis, pneumonia, and chest illness in adults and children.
  
• Meningitis – recent studies indicate a possible association between meningococcal disease and passive smoking during childhood.
• Heart disease – increases the risk of coronary heart disease.

At work

The legal ramifications of smoking in the workplace are now becoming apparent. In Australia there have been at least 10 cases since 1980 where workers have received compensation for injuries incurred as a result of passive smoking in the workplace. As a result increasing numbers of employers are making their workplaces smoke-free.