Dr. M. Uwais AshrafDepartment of Medicine

Centre of CardiologyJ N Medical College

AMU, Aligarh

Introduction:

5 million people in the world die of active smoking and more than600000 nonsmokers die from exposure to passive smoke annually [1].

Smoking is recognised as one of the major preventable causes of death.

It significantly increases the chances of developing a respiratorydisorder and over half of respiratory disease related deaths are due tosmoking [2,3].

The risk of serious disease diminishes rapidly after quitting and life-long abstinence is known to reduce the risk of lung cancer, heart disease, strokes, chronic lung disease and other cancers [4].

1. World Health Organization. Tobacco Factsheet. Fact sheet Nu339. Date last accessed: July 7th, 2014. Date last updated: May 14, 2014.

2. Gibson GJ, Loddenkemper R, Sibille Y, et al., eds. European Lung White Book. 2nd Edn. Sheffield, European Respiratory Society, 2013.

3. Ward B. www.smokehaz.eu – a review of the evidence on smoking and lung health. Eur Respir J 2014; 44: 20–22.

Health effects of smokingEyes Macular degeneration

Hair Hair loss

Skin Aging, wrinkles, wound infection

Brain Stroke

Mouth and

pharynx

Cancer, gum disease

Lungs Cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis),

pneumonia, asthma

Heart Coronary artery disease, raised blood pressure

Stomach Cancer, ulcer

Pancreas Cancer, increase blood glucose levels and less control over blood glucose levels

Bladder Cancer

Women Cervical cancer, early menopause, irregular and painful periods, infertility

Men Impotence

Arteries Peripheral vascular disease

Bone Osteoporosis

Smoking Kills More Americans thanAll of these Combined

AIDS

Car crashes

Heroin

Homicide

Alcohol

Fires

Cocaine

Suicide

Each day, 1,200 Americansdie from smoking

Each smoker who dies isreplaced by 2 young smokers

90% of all smokers start before age 18

99% of all smokersstart before age 26

The Dirty DozenAcetone (solvent and paint

stripper)

Ammonia (poisonous gas and toilet bowl cleaner)

Arsenic (potent ant poison)

Benzene (poisonous toxin)

Butane (flammable chemical in lighter fluid)

Cadmium (carcinogenic chemical in batteries; lung & intestinal irritant)

Carbon monoxide (poisonous

gas in auto exhaust)

Formaldehyde (dead frogs love it)

Hydrogen cyanide (deadly ingredient in rat poison)

Methanol (jet engine and rocket fuel)

Polonium-210 (radioactive element and spy-killer)

Toluene (poisonous industrial solvent)

Health benefits of quitting

12 hours Blood levels of carbon monoxide are significantly decreased

5 days Improvements in the sense of taste and smell

6 weeks Risk of wound infection after surgery substantially reduced

3 months Lung function is improving as cilia recover

1 year Risk of coronary heart disease is halved after one year compared to

continuing smokers

10 years Risk of lung cancer is halved and continues to decline

15 years All cause mortality falls to the same level as for those who have never

smoked

Stages of change in smoking cessation

Adapted from Prochaska and DiClemente, 1983.

Stage Behaviour Intervention Questions to ask

Precontemplation – no

thoughts about changing

behaviour

Not considering stopping

smoking in the next 6 months

Discuss negative consequences

of smoking. Provide information

rather than be judgmental.

Are you thinking of quitting

in the near future?

Contemplation –

thoughts about the need

to change but no action

taken yet

Considering quitting in the

next 6 months but no action

taken yet

Raise patient's consciousness

of smoking through information;

give emotional support and

assist in identifying people who

will be supportive (eg. offer Quit

kit literature)

Why do you want to quit?

What things have stopped

you from trying to quit?

How confident are you that

you can quit?

Who can you ask to support

you during this time?

Action – attempts made

to change behaviour and

avoid environmental

'triggers'

Attempt made to quit smoking

in the last 6 months

Provide emotional support and

encouragement; help identify

triggers for smoking and

promote new behaviours to take

the place of smoking

Are you confident you can

continue not smoking?

What situations make you

feel like smoking?

How do you deal with these

situations?

Maintenance –

behaviour has been

changed and person is

adjusting to these

changes and working to

prevent relapse

Has not smoked for at least 6

months; the person is

adjusting to change and

working to prevent relapse

Continue supportive approach;

discuss possible problems that

may lead to relapse

Do you see yourself as a

nonsmoker?

What do you do when you

feel like smoking?

What have been the benefits

of quitting?

Fagerstrom Nicotine Dependence Questionnaire

Questions Answer Score

1. How soon after you wake up do you smoke your first cigarette?

Within 5 min

6–30 min

31–60 min

after 60 min

3

2

1

0

2. Do you find it difficult to refrain from smoking in public? Yes

No

1

0

3. Which cigarette would you hate to give up most? The first one in the morning

Any other

1

0

4. How many cigarettes a day do you smoke? 31 or more

21–30

11–20

10 or less

3

2

1

0

5. Do you smoke more frequently during the first hours after waking than during the rest of the day?

Yes

No

1

0

Total_____

8–10 = high dependence; 5–7 moderate dependence; 1–4 = low dependence

Coping with cravings – the 4 Ds

Delay Delay acting on the urge to smoke. After 5 minutes, the urge to

smoke weakens and your resolve to quit will come back

Deep breathe Take a long slow breath in and slowly release it out again. Repeat

three times

Drink water Drink water slowly holding it in your mouth a little longer to savour

the taste

Do something

else

Do something else to take your mind off smoking. Exercise is a good

alternative

Nicotine replacement therapy • The aim of NRT is to replace nicotine from cigarettes without other harmful components of

tobacco smoke

• Reduces withdrawal symptoms.

Nicotine transdermal patch• Usually first choice, simple to use

• Can be combined with an intermittent form of NRT

• Initial recommended dosage:

Patient group Initial dose Duration

>10 cigarettes/day or weight

>45 kg

21 mg/24 hour patch or 15 mg/16

hours

At least 8

weeks

<10 cigarettes/day or weight

<45 kg or cardiovascular

disease

14 mg/24 hour patch or 10 mg/16

hours

At least 8

weeks

•

Most common adverse effects: skin irritation

and sleep disturbance.

INHALER• Useful for patients who miss the ‘hand to mouth’

action of smoking

• Initial recommended dosage: 6–12 cartridges/day for

12 weeks followed by 3–6/day for 2 weeks and 1–

3/day for 2 weeks

• Most common adverse effect: throat irritation.

Gum

• Useful for those who cannot tolerate patches or who require

combination therapy

• Initial recommended dosage:

•

Most common adverse effects: gastrointestinal disturbances,

dyspepsia, nausea and hiccups, occasional headache if the gum

is chewed too quickly, jaw pain and dental problems.

Patients who smoke <20

cigarettes/day

2 mg Use one piece of gum/hour. Should be tapered

over 3 months

Patients who smoke >20

cigarettes/day

4 mg Use one piece of gum/hour. Should be tapered

over 3 months

Lozenge

• Useful for patients who cannot use patches, need combination therapy

or do not wish to use nicotine gum

• Initial recommended dosage:

•

Most common adverse effects: gastric and throat irritation.

Patients who smoke their first

cigarette >30 minutes after waking

2 mg

lozenge

One lozenge can be used every 1–2

hours to a maximum of 15 20 or 4mg

lozenges/day

Patients who smoke their first

cigarette within 30 minutes of waking

4 mg

lozenge

One lozenge can be used every 1–2

hours to a maximum of 15 20 or 4mg

lozenges/day

Microtabs

• Also known as sublingual tablet

• Useful for patients who cannot use patches or those needing

combination therapy; may be particularly useful for mothers who

are breastfeeding

• Initial recommended dosage:

• Most common adverse effects: mouth and throat irritation,

gastrointestinal upset and cough.

Patients who smoke their first cigarette >30 minutes after waking 1 x 2 mg

microtab

1–2 microtabs can be used every 1–2

hours to a maximum of 40 microtabs/day

Patients who smoke their first cigarette within 30 minutes of waking 2 x 2 mg

microtabs

1–2 microtabs can be used every 1–2

hours to a maximum of 40 microtabs/day

Cut down and quit

Step When Goal

Step 1 0–6 weeks Cut down to 50% of baseline cigarette

consumption

Step 2 6 weeks to 6 months Continue to cut down; stop completely by 6

months

Step 3 6–9 months Stop smoking completely, continue NRT

Step 4 within 12 months Stop using NRT by 12 months

Nicotine replacement therapy: cautions and

contraindicationsContraindicated Nonsmokers; those with sensitivity to

nicotine; children aged less than 12

years

Use with caution under medical

supervision in hospital

Dependent smokers with recent

myocardial infarction, severe cardiac

arrhythmias or

with recent cerebrovascular accident

Use with care only when benefits

outweigh risks

Patients who weigh <45 kg; patients

with recent or planned angioplasty,

bypass grafting or stenting; patients

with unstable angina; pregnant or

lactating women

BUPROPION

• Non-nicotine oral therapy

• Unknown mechanism of action

• Helps to reduce withdrawal symptoms

• Recommended dose: 150 mg once per day for 3 days,

increasing to 150 mg twice per day with an 8 hour interval

between doses

• Main adverse effects: insomnia, headache, dry mouth,

nausea, dizziness and anxiety

• Serious adverse events: rare incidences of seizures.

Bupropion: contraindications

• allergy to bupropion

• past or current seizures

• known central nervous system tumours

• patients undergoing abrupt withdrawal from alcohol or

benzodiazepines

• current or previous history of bulimia or anorexia

nervosa

• use of monoamine oxidase inhibitors within the past

14 days.

OTHER OR FUTURE OPTIONS

• Clonidine

• Nortryptiline

• Varenicline.

ENDS

•The electronic-cigarette (e-Cigarette) is a battery-

powered electronic nicotine delivery systems (ENDS)

•Resembles a cigarette designed for the purpose of

nicotine delivery, where no tobacco or combustion is

necessary for its operation.

•The first of these devices was invented by a Chinese

pharmacist, Hon Lik, in 2003.

•Electronic cigarettes (ECs) have been introduced to

the market in recent years as an alternative-to-

smoking habit.

•They are battery-driven devices that vaporise a

liquid containing mainly nicotine, propylene glycol,

glycerine, water and flavourings (according to

manufacturers’ reports). [1]

•By using this device (commonly called ―vaping‖),

nicotine is delivered to the upper and lower

respiratory tract without any combustion involved.

1. Konstantinos E. Farsalinos 1,*, Giorgio Romagna 2, Dimitris Tsiapras 1, et al. Evaluation of Electronic Cigarette Use (Vaping) Topography and Estimation of Liquid Consumption: Implications for Research Protocol Standards Definition and for Public Health Authorities’ Regulation. Int. J. Environ. Res. Public Health 2013,

ENDS, of which electronic cigarettes are the mostcommon prototype, deliver an aerosol by heating asolution that users inhale.

The main constituents of the solution by volume, inaddition to nicotine are propylene glycol, with orwithout glycerol and flavouring agents.

US patent application – an electronic atomizationcigarette that functions as a substitute for quittingsmoking.

E-cigarette products varied from country to country.

WHO framework convention on tobaco control.

•Although some ENDS are shaped to look like their conventional

tobacco counterparts (e.g. cigarettes, cigars, cigarillos, pipes, or

hookahs), they also take the form of everyday items such as

pens, USB memory sticks, and larger cylindrical or rectangular

devices.

•Marketing by multinationals / internet / print advertisement –

•Healthier alternative / Useful for quitting, smoking

?? Really true

The use of ENDS is apparently booming.

It is estimated that in 2014 there were 466 brands [1] and that in 2013 US$ 3 billion was spent on ENDS globally.

Sales are forecasted to increase by a factor of 17 by 2030.

Unanswered question about safety, efficacy for harm reduction/smoking cessation/impact of public health.

1. Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette” in the USA. Tob Control. 2013;22:19–23.

E-Cigarette E-Fluid and Vapor Simulated e-cigarette use revealed that individual

puffs contained from 0 to 35 μg nicotine per puff [1].

A puff of the e-cigarette with the highest nicotinecontent contained 20% of the nicotine containedin a puff of a conventional cigarette.

The levels of toxicants in the aerosol were 1 to 2orders of magnitude lower than in cigarette smokebut higher than with a nicotine inhaler [2].

Level of nitrosamine concentration-3 ordermagnitude variation.

1. Goniewicz ML, Kuma T, Gawron M, Knysak J, Kosmider L. Nicotine levels in electronic cigarettes. Nicotine Tob Res. 2013;15:158–166.

2. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska-CzaplaM, Rosik-Dulewska C, Havel C. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014;23:133–139.

E-Smoke Flavoring agents

Along with availability of cigarettes and tobaccoproducts.

Dual smoking

Newer designs not properly tested

Requirement of evidence based regulatory scheme

*WHOFCTC

E-Products (ENDS) Brands:

Disposable – NJOY

Rechargeable – Blue

Pen Style – Vapor King

Tank Style – Volcano

E-Website – Popular Claims Healthier – 95%

Cheaper – 93%

Cleaner – 95%

Smoke anywhere – 88% (before scientific evidence)

* Circulation 2014

Prevalence Doubled in UK, USA – 2008-2012

Korea – 0.5% in 2008 – 9.4% in 2012

Utah Youth – Increase 3 times – 2011-2013

Dual Smoking – 61% increase in US Middle School Students

Highest rate among current smokers and former smokers most appealing in youth

* Chai and Foster (Mid Western Young Adults).

Cytotoxicity Bahl et al screened 41 e-cigarette refill fluids from

4 companies - 3 cell types: human pulmonaryfibroblasts, human embryonic stem cells, andmouse neural stem cells.

Cytotoxicity varied among products from highlytoxic to low or no cytotoxicity.

More cytotoxic on stem cells Farsalino’s – cytotoxicity on cultured rat cardiac

myoblasts. Cytotoxicity was related to the concentration and

number of flavorings used.

Bahl V, Lin S, Xu N, Davis B, Wang YH, Talbot P. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reprod Toxicol. 2012;34:529–537.

The finding that the stem cells are more sensitive thanthe differentiated adult pulmonary fibroblasts cellssuggests that adult lungs are probably not the mostsensitive system to assess the effects of exposure to e-cigarette aerosol.

These findings also raise concerns about pregnantwomen who use e-cigarettes or are exposed tosecondhand e-cigarette aerosol.

*JAMA Intern Medicine - 2014

Secondhand Exposure

E-cigarettes do not burn or smolder the wayconventional cigarettes do, so they do not emit side-stream smoke;

E-cigarette aerosol is not a source of exposure tocarbon monoxide, a key combustion element ofconventional cigarette smoke.

Schripp et al. – Low level of toxins vs. traditional –Formaldehyde / Acetaldehyde – Isoprene/Acetone etal.

Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes [published online ahead of print December 11, 2013]. Nicotine Tob Res. doi: 0.1093/ntr/ntt203.

Particulate Matter The particle size distribution and number of particles

delivered by e-cigarettes are similar to those ofconventional cigarettes, with most particles in the ultrafinerange (modes, ≈100–200 nm). [1]

The thresholds for human toxicity of potential toxicants ine-cigarette vapor are not known.

Serum cotinine level similar in non-smokers

Not a source of carbon-monooxide

Room air contains possible carcinogens – polycyclicaromatic hydrocarbons.

1. Zhang Y, Sumner W, Chen DR. In vitro particle size distributions in electronic andconventional cigarette aerosols suggest comparable deposition patterns. NicotineTob Res. 2013;15:501–508.

Particle number distribution from (A)mainstream aerosol in e-liquid 1 and from (B) conventional cigarette. Reproduced from Fuoco et al55 with permission from the publisher. Copyright © 2013 Elsevier Ltd.

Nicotine Absorption

Early studies of nicotine absorption in 2010 found thate-cigarettes delivered much lower levels of plasmanicotine than conventional cigarettes.[1]

Several studies reported that regardless of nicotinedelivery, e-cigarettes can modestly alleviate somesymptoms of withdrawal, and participantspositively appraised the use of e-cigarettes.[2]

1. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross- over trial. Tob Control. 2010;19:98–103.

2. Vansickel AR, Eissenberg T. Electronic cigarettes: effective nicotine delivery after acute administration. Nicotine Tob Res. 2013;15:267–270.

Health Effects

Exposure to propylene glycol can cause eye andrespiratory irritation, and prolonged or repeatedinhalation in industrial settings may affect the centralnervous system, behavior, and the spleen [1].

Increase dynamic airway resistance and decrease NO

Increase WBC after smoking

Carcinogenic

PM – 120-165 nm – Alveoli/Arterial Delivery

Airways/Venous Delivery1. Sciencelab.com, Inc. Material Data Safety Sheet: Propylene Glycol. Updated May 21, 2013.

Sciencelab.com, Inc., Houston, TX.

2. Chen IL. FDA summary of adverse events on electronic cigarettes. Nicotine Tob Res. 2013;15:615–616.

Particulate Matter Particle number increase 400 / cm3 < 2 hrs after ENDS

Increase to 49000 – 88000 / cm3 > 2 hrs (Schober etal.)

Polyfil fibres on heating – metals

Tin/Copper – Toxic to human fibroblast

Engineering features influence nature / number / sizeof pm.

Depends on nicotine level in E-liquid not on flavors.

Effects on Cessation of Conventional Cigarettes

E-cigarettes are promoted as smoking cessation aids

Many individuals who use e-cigarettes believe that they will helpthem quit smoking conventional cigarettes [1].

Adkison et al studied current and former smokers in theInternational Tobacco Control study in the United States, Canada,the United Kingdom, and Australia at baseline and 1 year later andfound that e-cigarette users had a statistically significant greaterreduction in cigarettes per day [2].

1. Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction.2011;106:2017–2028.

2. Adkison SE, O’Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH, Cummings KM, McNeill A, Thrasher JF, Hammond D, FongGT. Electronic nicotine delivery systems: international tobacco control four- country survey. Am J Prev Med. 2013;44:207–215.

Clinical Trials Four clinical trials (2 with very small samples) examined

the efficacy of e-cigarettes for smoking cessation.

Taken together, these studies suggest that

e-cigarettes are not associated with successful quitting in general population-based samples of smokers. [1, 2]

1. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronicnicotine delivery device (e-cigarette) on smoking reduction and cessation: a prospective 6-monthpilot study. BMC Public Health. 2011;11:786.

2. Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C, Polosa R. EffiCiencyand Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One. 2013;8:e66317.

Policy Recommendations Prohibit use of E-cigarette similar to traditional.

Prohibit sale of E-Cig to any one who cannot legally buy.

Subject E-Cig to same level of restrictions as conventional.

Prohibit cobranding ENDS with cigarettes.

Prohibits use of E-flavors

Prohibits claims on smoking cessation

Prohibits health claims

Establish standard for regulating product ingredients andfunctioning.

*WHOFCTC

The ultimate effect of e-cigarettes on public health will depend on what happens in the policy environment.

These policies should be implemented to protect public health:

Prohibit the use of e-cigarettes anywhere that use of conventional cigarettes is prohibited.

Prohibit the sale of e-cigarettes to anyone who cannotlegally buy cigarettes or in any venues where sale ofconventional cigarettes is prohibited.

Subject e-cigarette marketing to the same level of restrictions that apply to conventional cigarettes (including no television or radio advertising).

Prohibit cobranding e-cigarettes with cigarettes ormarketing in a way that promotes dual use.

Prohibit the use of characterizing flavors in e-cigarettes,particularly candy and alcohol flavors.

Prohibit claims that e-cigarettes are effective smokingcessation aids until e-cigarette manufacturers andcompanies provide sufficient evidence that e-cigarettescan be used effectively for smoking cessation.

Prohibit any health claims for e-cigarette products untiland unless approved by regulatory agencies to scientificand regulatory standards.

Establish standards for regulating product ingredientsand functioning.

Conclusions Although data are limited, it is clear that e-cigarette

emissions are not merely “harmless water vapor,” as isfrequently claimed.

These can be a source of indoor air pollution.

Introducing e-cigarettes into clean air environmentsmay result in population harm

Premature to lay claims on ENDS

Marketing claims – No scientific evidence.

Long term studies required

Have A Nice Day