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Tobacco and its hazards

Smoking Tobacco of all types whether cigarette, bidi or hooka carries a high degree of morbidity and mortality. Almost all major organs of the body bear brunt of smoking whether it be heart (coronary heart disease), lungs (cancer, chronic bronchitis, asthmatic bronchitis), nervous system (cerebrovascular accidents), G. I. Tract (gastritis, peptic ulcer, oesophagitis, carcinoma mouth) and genital organs. There is enough evidence to show the hazards of smoking Tobacco.

Very few people appreciate that every puff smoked takes them much faster towards various ailments and shortens their life span. Though the mortality rates in smokers show a number of variations, yet there is consensus on one point and that is the increased risk of mortality amongst smokers as compared to non-smokers.

Depending on the number of cigarettes smoked per day, one may classify smokers into moderate and’ heavy smokers. Thus a moderate smoker pays with 12.7 minutes of life for each cigarette he smokes: the heavy smokers pays with 34.6 minutes of life and pack a day smoker pays with 11.1/2 hours of life for each packet of cigarette he smokers.

The morbidity associated with smoking depends on a number of factors. Thus in men who started smoking Tobacco before the age of 20, the mortality is higher as compared to those starting late in life.

People who smoke cigarettes as compared to bidis, hooka, cigar, pipes: those who smoke their cigarettes to the end and do not leave much of bull and smoke cigarettes having a higher tar and nicotine content and inhale smoke deeply all portend increased hazards to a person’s life and longevity.

Tobacco

When one considers the overall picture of increased mortality and morbidity associated with the habit then only one can really gauge the harmful effects of tobacco smoking. Hardly any system in the body escapes from its ravages.

Most of the smokers suffer from a chronic irritant cough often referred to as smoker’s cough which is more troublesome in the early hours of morning. With constant smoking lung functions are impaired and chances of developing chronic bronchitis with emphysema are sky rocketed. Similarly air pollution will have adverse effects on smokers.

Smoking Tobacco may interfere with recovery in patients of pulmonary tuberculosis.

Chronic bronchitis is a disabling and distressing disease and takes away a greater chunk of a person’s life span if the process is not halted in time. But the major risk associated with Tobacco smoking is the increased risk of cancer of the lung. The overall picture of lung cancer in most countries is related to the amount and duration of cigarette smoking.

Smokers often complain of chronic irritation and dryness of the throat, their voice becoming husky. Teeth become discolored and the breath becomes offensive. There is formation of dark calcified particles around teeth and more chances of loosing teeth since enamel has been damaged. Again heavy smokers suffer from sudden black outs, especially in middle aged and elderly males who smoke strong pipe tobacco.

Accumulation of fluid secretions in the pipe stem whether inhaled or swallowed may be a factor. And this condition is called ‘Tobacco ambylopia’. Clinical features consist of gradual development of bilateral visual failure sometimes asymmetrical in the two eyes. The pathognomonic sign is the presence of bilateral centroceacal scotomota, horizontally oval with sloping edges.

Nicotine is generally regarded as the toxic agent but one of the more volatile decomposition products of tobacco such as collidine or lutidine may be involved. The incidence of cancer of the lips, mouth and larynx is higher among the smokers.

Next to respiratory system, cardiovascular, system bears a bigger brunt due to Tobacco smoking. Cigarette smokers have more incidence of coronary heart disease as compared to non-smokers and this increases their risk for sudden and unexpected deaths.

Cigarette smoking may act alone or in combination with other major risk factors in causing hypertension. Nicotine increases liberation of epinephrine and norepinephrine from stores in or near the blood vessels and the heart and thus exerts its harmful effects on the heart by increasing its work load and a decreased oxygen supply to it.

People with impaired cardiac function are at more risk because of Tobacco smoking. People who suffer from angina or have had a myocardial infarction and those who continue to smoke, not only angina attacks increase but also chances of sudden death loom large in the horizon.

Cardiac irregularities, increased stickiness of platelets and increase in levels of total cholesterol, triglycerides and at the same time decrease in HDL levels are going to be other risk factors in smokers.

Raynaud’s disease and phenomenon are closely related. The higher incidence of cerebrovascular accidents and strokes in smokers can not be ignored, the death rate increasing with the amount of smoking of Tobacco.

Excessive deaths from cancer of the lip, mouth, esophagus in cigarette, pipe and cigar smokers are being identified. Gastric secretions increase remarkably after cigarette smoking. Gastritis has been found to be commoner among heavy cigarette smokers and so has been peptic ulcer which is about twice as high in smokers than in non-smokers.

Smoking negativities the healing of gastric ulcer and has a role to play in its non-healing. It has been found to be responsible for 16 per cent of colon cancer deaths and 22 per cent of rectal cancer deaths in the United States.

Deaths from liver cirrhosis are more common in smokers than in non-smokers but this may be due to strong association between heavy drinking and smoking which are commonly seen in the same person. Almost every system of the body suffers because of heavy smoking of Tobacco. Cancers of the urinary bladder and prostate have been found to be higher in smokers.

It has been observed that women are much more sensitive to nicotine and other tobacco products as compared to men and this explains why women who enjoy it become habituated to it and find it hard to stop.

Women who are heavy smokers have menstrual problems like painful and frequent menstruation and they reach menopause earlier. Late fetal and neonatal deaths are higher among women who smoke during pregnancy.

In a nutshell smoking of any kind (cigarettes, bidi, hooka, cigar, pipe etc) has not only immediate ill effects but carries a high degree of morbidity and mortality in the long run.

How to stop smoking Tobacco

Tobacco smoking is a form of habit and addiction from which the patient has to be weaned off. Many people derive a form of psychological satisfaction in view of its supposed relaxing or stimulant effect on the mind.

It may be a difficult habit to give up because to some it satisfies a variety of pleasures – basic oral pleasure in holding a cigarette between the lips, savoring smoke on the tongue and palate thus deriving a sense of oral gratification.

What is required to break the habit, is to convince the patient about the hazards and ill effects of it. Cooperation of the patient, his/her friends and family members in this regard is very essential. Many persons would like to play at the game of giving up Tobacco smoking and then say at the end. “I tried hard, but could not give it up.” Such a case is naked failure of will power on the part of smoker.

The only and sensible method is to quit it with a bang. In this family and friends can provide invaluable support by encouraging the patient to stick to his decision. If there are other members in the family who smoke they must also be asked to quit it simultaneously.

All cigarettes etc. should be removed from the surroundings both at work place and home and the person must avoid the company of smokers whether friends or family members and avoid visiting places where a large number of smokers are present.

Many times it is used as a crutch or a fashion to show off. This requires explaining to the patient. Psychosocial and psychological problems like depression must be handled properly.

A patient must be made to understand that total abstinence is very essential and not even a single puff is to be indulged after he/she quits smoking Tobacco. Again it is observed that in most people drinking of alcohol and smoking go side by side. Such people must review their alcohol consumption since it also increases intake of cigarettes consumption. So it would be better if alcohol consumption is also curtailed.

Drinking of large amounts of fluids and fruit juices during the first few days after cessation of it is desirable since it helps in the excretion of nicotine. Once the person stops it he/she may get an urge to eat more. The best way to avoid further putting on weight shall be to avoid fat producing foods.

Drugs

During the last few years, a number of drugs have been introduced to help the patient in cessation of smoking of Tobacco. There is no doubt that of the various methods available, the cessation of it is best achieved by sell motivation and will power on the part of patient, doctor, family members and friends.

In some cases help of psychiatrist may be sought because many times some hidden/subconscious frustration might have led the patient to smoke. Further help can be obtained by hypnosis or acupuncture. Patient should be encouraged to change his/her previous life style and divert his attention to more pleasurable hobbies and activities.

No doubt the withdrawal period is difficult but once the patient overcomes this, half the battle is won. At the same time it must be understood that even a single puff of smoke after quitting may bring back the habit again. As the smoke free period time increases, the patient shall definitely experience a sense of well being.

For help in the quitting of Tobacco smoking, various medicine replacement therapies have been tried and these are:

1. Nicotine patch (trans-dermal nicotine)

2. Nicotine gum

3. Nicotine nasal spray

Miscellaneous

1. Clonidine

2. Bupropion hydrochloride (zyban)

Nicotine Patch (transdermal nicotine)

It is a significant cessation treatment which is found to be quite effective and efficacious. Commonly used dugs in this group are:

Nicoderm and Habitrol

During the first 4 weeks (21 mg/24 hrs) then in next 2 weeks (14 mg/24 hrs) and further 2 weeks (7 mg / 24 hrs).

Nicotrol

First 4 weeks (15 mg / 16 hrs) then 2 weeks (10 mg/ 16 hrs) and further 2 weeks (5 mg / 16 hrs).

Prostep. Four weeks 22 mg/24 hrs and then next 4 weeks (11 mg/24 hr).

Start with 30 sq cm or 20 sq cm patch depending on the number of cigarettes smoked per day, usually in an average adult 30 sq cm/day patch is used.

During the period of use of the nicotine patch no Tobacco smoking is permitted. At the start of each day the patient should place a new patch on a relatively hairless area between the neck and waist. Patient should apply these patches as soon as he/she gets up in the morning. There are no restrictions to the patients activities while using the patch.

Special precautions should be employed in pregnant women and those suffering from cardiovascular diseases. Avoid using it in those with recent myocardial infarction, cardiac arrhythmias, unstable, angina. Recent cerebrovascular accident, active peptic ulcer,Local skin reactions are usually mild but may worsen in some over the course of therapy. Local treatment with hydrocortisone cream and rotating sites of applying patch may help.

On average trans-dermal nicotine treatment is carried out for a period of 6-8 weeks and is complied with by most of the patients. Side effects include erythema or pruritis at the site of application, headache, flu like symptoms, nausea, dizziness, myalgia, sleeplessness, dyspepsia, dry mouth, diarrhea, sweating and angioneurotic oedema.

Nicotine Gum (Nicotine Polacrilex)

It is again an efficacious smoking cessation treatment but the problems are with compliance. It is easy to use but social acceptability and unpleasant taste are the things to be considered.

Dosage of nicotine gum varies from 2-4 mg. Most side effects of gum use are relatively mild and transient and many can be resolved by simply correcting the user’s chewing habits. Many people use it on average for a year or so.

Nicotine gum (Nicorette) is available in 2 mg and 4 mg (per piece) doses. Patients are usually prescribed 2 mg gum for the first few months and should not use more than 30 pieces/day. In resistant and difficult cases 4 mg strength piece may be used and should not exceed 20 pieces / day.

Gum should be chewed slowly until a peppery taste emerges. It is parked between cheek and gum to facilitate nicotine absorption through the oral mucosa. Nicotine gum should be slowly and intermittently chewed and parked for about 30 minutes.

Special precautions about acidic beverages (coffee, juices, soft drinks) have to be employed while using nicotine gums since these shall interfere with the buccal absorption of nicotine. So eating and drinking anything except water should be avoided for 15 minutes before and during chewing.

To see that the patient complies with the use of gum and gets maximal benefit the smoker be advised to chew the gum on a fixed schedule (at least one piece every 1-2 hours) for at least 1-3 months. It may be quite beneficial and then once a beginning has been made for further period the patient shall be able to follow the instructions. Special precautions have to be employed for use in pregnant females and those with serious cardiac ailments like myocardial infarction, cardiac arrhythmias etc.

Common side effects of chewing nicotine gum include mouth soreness, Hiccups, dyspepsia and jaw ache. These effects are generally mild and transient.

Nicotine Nasal Spray

Like the gum, nasal spray of nicotine is used instead of Tobacco smoking when the desire to smoke is bothersome. The dose is one spray (1 mg) in each nostril and no more than five times per hour or 40 times in 24 hours. Use of nicotrol nasal spray is not recommended in patients with known chronic nasal disorders like, allergy. Rhinitis, nasal polyps and sinusitis. Precautions are also required in patients with cardiovascular ailments.

Side effects include a hot peppery sensation in the nose or throat, sneezing, coughing, watery eyes or rhinorrhea.

Although nicotine spray appears to be safe and effective for highly dependent smokers, but rapid nicotine absorption may lead to dependence on the spray in upto 30 per cent of users. Like the gum, the spray is used instead of it when the desire to smoke can not be controlled.

Success of Nicotine Replacement Therapy

Whatever evidence is available so far, nicotine replacement therapy has been found to be quite effective in achieving success of its cessation. In patients on nicotine gum treatment 4 mg gum is used in patients who are highly dependent on nicotine (more than 20 cigarettes/ day). Less than 10 per cent of patients will become dependent on the gum though many will require, long term use (one to two years) to maintain abstinence.

No comparative advantage is apparent from either tapering or abruptly discontinuing the use of gum. Of the two therapies, nicotine patch therapy is associated with fewer compliance problems that interferes with its effective use while those using nicotine gum find it probably more easy to use and this is often preferred. Like the gum, the spray is used instead of smoking nicotine when the desire to smoke is troublesome. Although nicotine spray appears to be safe and effective for highly dependent smokers, rapid nicotine absorption may lead to dependence on the spray in up to 30 per cent of users.

There are no two views that nicotine replacement therapy is a good advance in an attempt at cessation of smoking Tobacco and control of withdrawal symptoms.

Other therapies

In addition to nicotine replacement therapy other therapies have also been employed from time to time.

Clonidine was employed as one of the therapies but has not been found to be effective and there is little support for its use as primary or as an adjunctive treatment for smoking cessation.

Bupropion hydrochloride (Zyban)

This is an effective drug and helps reduce nicotine withdrawal symptoms and the urge to smoke presumably through neuro-chemical pathways. Patients start the drug in 2 weeks before their target ‘quit day’ unlike nicotine replacement therapy. For the remainder 7 to 12 weeks of therapy the drug provides pharmacological treatment along with individualized patient support. Dosage 150 mg/day for the first 3 days. Increase dosage to the maximum 300 mg/day (150 mg twice a day) for 7 to 12 weeks.

Allow at least 8 hours between successive doses. The drug is contraindicated in patients with a seizure disorder or with a current or prior diagnosis of anorexia nervosa. The concurrent administration of MAO inhibitors is contraindicated. The use of the drug is associated with a dose dependent risk of seizures so doses above 300 mg/day shall not be prescribed for smoking cessation.

Side effects include dry mouth, hot flushes, arthralgia, insomnia, dizziness, pruritis, and body rash and tastes perversion.

Anti depressants

Most of the smokers suffer from anxiety as well as depressive disorders. Levels of mono amine oxidase A and B are 30-40 per cent in the brains of smokers than in non-smokers. The degree of MAO suppression by cigarette smoking can help to explain the very high smoking rates in patients with depression and the difficulty they have in quitting smoking. In addition to nicotine replacement therapy the problem of anxiety/depression should also be looked into and anti-anxiety/anti-depressant drugs be also employed with usual caution.

Prevention of relapse of smoking habit

Once a patient has been successful in his/her attempt at cessation of smoking habits, the patient should be encouraged to continue with it and reap its benefits. Risks of smoking like shortness of breath, heart attacks and strokes, lung and other cancers (larynx, oral cavity, esophagus, pancreas, bladder, cervix, leukemia). Chronic obstructive pulmonary disease etc. should be highlighted and the benefits achieved after quitting smoking like improved health, improved sense of smell and taste, general improvement and well being as well as pollution free life have to be considered. In addition to the benefits of health and well being, the person shall be also saving lot of money which he/she was earlier on spending on smoking.

Prevention of relapse requires active participation of the treating physician. If the patient reports prolonged craving or withdrawal symptoms, extending nicotine replacement therapy may be considered. Since psychiatric disorders are more common in smokers than in the general population smoking cessation may sometimes exacerbate some of these symptoms especially in those with a prior history of affective disorder so this part of therapy must be paid due attention.

Majority of patients who quit smoking start gaining some weight and this may be caused by increased food intake. But this is not a serious problem and weight gain is not going to be a major problem and can be controlled by adequate diet control.

To summarize smoking of any form (cigarettes, bidis, cigars and hooka) carries with it high degree of morbidity and mortality. Attempts should be made to stop smoking and for this cooperation of the person and desire to quite smoking is essential. In this cooperation of the family and friends is equally important and encouragement is required both from close family friends and physician in charge. Strong will power on the patients part is equally essential.

MAJOR ILL EFFECTS OF SMOKING

Respiratory system: Chronic bronchitis.

Emphysema Bronchogenic carcinoma.

Asthmatic bronchitis, Laryngitis.

Cardiovascular system: Angina, coronary heart disease, hypertension, cardiac arrhythmias, Raynaud’s disease.

GI tract: Oesophagitis, gastritis, peptic ulcer, carcinoma mouth, lips, colorectal cancer.

Nervous system: Cerebrovascular accidents. Stroke tobacco amblyopia.

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