Smoking. NT version

Malignancies associated with smoking?

A. 400 000 Europeans die from cancers related to smoking every year, (1). The best known link between smoking and malignancy is lung cancer, the evidence for this is overwhelming, (2). Smoking causes 9 out of 10 deaths from lung cancer, (3)

Carcinogens are absorbed from the lungs into the bloodstream, (4) and can lead to the other carcinomas listed in table 1. In addition sites such as the liver and cervix may be effected, (5). Cigarette smoking increases the risk of gastric carcinoma and there is a strong association between smoking and carcinoma of the pancreas, (6).

The risk of upper airway tract and oesophogeal carcinomas grows substantially when smoking is combined with heavy alcohol consumption. This principle of "multiplication" of cancer risk factors is also seen in individuals exposed to ionising radiation and asbestos, (7).

Consumption of other tobacco products which are not smoked, eg. snuff and chewing tobacco are also closely associated with malignant disease. 210 suspect compounds have been identified in unburnt tobacco, (7).

Effects on the respiratory system

A. There is no doubt that cigarette smoking is a major factor in the development of bronchitis and emphysema. These conditions are virtually confined to smokers and there is a strong correlation with the number of cigarettes smoked. Risk of death from these diseases is 20 times that of non-smokers in individuals who smoke 30 a day, (8).

The carbon monoxide in smoke binds in a stable way to haemoglobin in red blood cells forming carboxyhaemoglobin. This reduces the oxygen carrying capacity of the blood resulting in breathlessness.

Effects does smoking have on the heart?

A. Smoking is a major risk factor in the development of atherosclerosis, and subsequent ischaemic heart disease, (IHD). Levels of the protective high-density lipoproteins in the blood are lowered, altering the ratio with the harmful

low-density lipoproteins. Triglycerides are also slightly raised, (9). Nicotine raises systolic blood pressure, increases heart rate and induces platelet activation making thrombosis formation more likely, (10)

If people in the UK did not smoke cigarettes, about 10 000 fewer men and women of working age would die from myocardial infarction each year, (11). Smoking is particularly dangerous in people with other IHD risk factors such as a family history, high serum cholesterol, diabetes and hypertension.

Q. What effect does smoking have on the circulatory system?

A. Peripheral vascular disease (PVD) is a chronic disabling illness causing ischaemia and necrosis of the legs. It is caused by atherosclerosis of the arterial supply. Although it seldom causes death it often leads to the loss of a limb. The most significant single factor contributing to both the onset and the progression of PVD is smoking. 70-90% of patients are smokers at the time of diagnosis, (12). The risk increases with the intensity of smoking, the risk is 2 to 9 times greater in smokers compared to non smokers, (13).

The occurrence of arterial disease also makes cerebrovascular accident more likely.

Q. Are there any effects on the gastrointestinal system?

A. Smoking increases the secretion of hydrochloric acid in

the stomach, thereby making peptic ulcers more likely to occur and harder to treat. The association between smoking and the prevalence of both gastric and duodenal ulcers has been known for some time, smokers have been shown to suffer from more pain and to have delayed ulcer healing rates. (14) Reflux will also exacerbate conditions involving the oesophagus such as hiatus hernia.

Q. Are there any other effects of smoking?

A. More adverse effects of smoking are discovered the more the subject is researched. It causes decreased fertility in women and there is an increased prevalence of impotence in smoking men, (11). It also causes nicotine stains on the fingers and face, orangeing of hair, and of course halitosis.

In several ways smoking seems to accelerate the ageing process. This is expressed in wrinkles on the face, osteoporosis and in females early menopause, (15).

Q. Why stop smoking when I could be knocked over by a bus?

A. Out of 1 000 young men who smoke a packet of cigarettes a day, 6 will be killed on the roads but 250 will die from their smoking, (3). Of course some would die prematurely anyway, but others will be dying 10, 20 or even 30 years "before their time".

Smoking is the single most important cause of avoidable illness and premature death in the UK. The government accepts that smoking causes at least 50 000 premature deaths per year (3).

"Cigarette smoking is now as important a cause of death as were the great epidemics diseases such as typhoid, cholera and tuberculosis that effected previous generations of this country", (16).

Q. What are the effects of passive smoking.

A. Initial work carried out in Japan and Greece indicated that non-smoking women married to smokers were at increased risk of developing lung cancer, (17). The recent case of Roy Castle has also raised awareness of the dangers. A clear correlation has been demonstrated between parental smoking and the levels of cotinine, (a metabolite reflecting exposure to tobacco smoke) in non-smoking children, (18).

Children of smoking parents are at greatly increased risk of hospital admissions suffering from bronchitis and pneumonia, (19). Associations have also been demonstrated between passive smoking and impairment of lung function and glue ear, (otitis media) in seven year olds, (20).

Mothers smoking while pregnant may be considered as a form of passive smoking. This increases the incidence of spontaneous abortion and low birth weight babies, (under 2.3 Kg), (15). Children born to smoking mothers are liable to a measurable delay in their physical and mental development up to the age of 11 years, (11).

Parents often act as a role model for their children, this is important because the younger an individual starts smoking the greater their risk of smoking related disease, (11).

A review of 13 studies by Jarvis, (21) concluded that the risk of major coronary events, including death from IHD and lung cancers are about 25% greater in the spouses of smokers. It has been estimated that passive smoking causes some 37 000 deaths per year in the USA from cardiovascular disease, (22).

The evidence that passive smoking causes lung cancer has now been accepted by the Australian, US. and British governments, (21).

Q. What role can nurses play in smoking prevention?

A. A nurse will have little effect advocating that people stop smoking if he or she also smokes, (fig 1). Health education should be tailored to the individual or group the nurse is working with. Often giving the type of information presented in this article is appropriate. Information given in an understandable form allows individuals to make informed choices.

Remind people that two thirds of smokers who have stopped found it "surprisingly easy", if difficult at first, (11). Point out the immediate and longer term advantages.

Calculate the annual expenditure of the individual smoker on cigarettes, (20 a day costs £820 per year). Calcuate how many cigarettes they have smoked all together, eg. 20 a day for 30 years adds up to £24 600.

Aids such as nicotine chewing gum and transdermal patches may be of help in the transition period to becoming a non-smoker. Nurses should explain the correct use of these alternative sources of nicotine to maximise correct compliance. If a patient is using the patches he or she should not chew the gum as well. Neither preparation should be used in pregnancy or during breast feeding. They should not be used by people under the age of 18, and should never be used by non smokers. It should be stressed that nicotine overdosage may occur, which can be life threatening, if gum and patches are incorrectly used. Treatment protocols vary with the preparation, but generally the individual is weaned off nicotine using successively smaller doses over a period of about three months.

In the final analysis the individual must be the one who decides to stop.

Some useful addresses,

Action on Smoking and Health,

109 Gloucester Place,

London,

W1H 3PH.

The Coronary Prevention Group,

102 Gloucester Place,

London,

W1H 3DA.

The Health Education Authority,

Hamilton Place,

Mabledon Place,

London,

WC1H 9TX.

Type of Cancer Per Cent of deaths attributable

to Smoking

Men Women

lung 90 79

lip, oral cavity, 92 61

pharynx

oesophagus 78 75

bladder 47 37

kidney 48 12

larynx 81 87

Table 1. Cancer deaths due to smoking: USA 1985, (23)

Fig. 1 Practice what you teach, (24). (note to artist - can you draw this as a nurse with the cigarette behind her back please, thanks)

References

1. Peto R. (1988) The Future Effects Caused by Smoking, Tobacco or Health: The Way Ahead, WHO Regional Office for Europe, 7-11 Nov

2. International Agency for Research on Cancer, (1982), Cancer Incidence in Five Continents, vol.4, J. IARC. Lyon.

3. Action on Smoking and Health, (1978), Smoking, it effects us all, ASH, London.

4. Doll R. (1989), The Prevention of Cancer, Reducing the Risk of Cancers, Open University Course P578, Hodder and Stoughton, London.

5. The Open University, Current Knowledge about Cancer Prevention, Reducing the Risk of Cancers, Open University Course P578, Hodder and Stoughton, London.

6. Hobsley M. (1982), Disorders of the Digestive System, Edward Arnold, London.

7. Heseltine et al (1992), Tobacco and Cancers,

Reducing the Risk of Cancers, Open University Course P578, The Open University Press.

8. Kumar PJ. Clark ML. (1992), Clinical Medicine, Bailliere Tindall, London.

9. Gotto AM. (1991), Clinician`s Manual on Hyperlipidaemia, Scientific Press, London.

10. Lakier JB. (1992), Smoking and Cardiovascular Disease, American Journal of Medicine, 99 1A-8S to 1A-12S.

11. Smoking and Your Heart, (1992), Health Information Series No.10, The British Heart Foundation,

12. Ronayne R. et al. (1989), Smoking: A Descision-Making Dilemma for Vascular Patients, Journal of Advanced Nursing, 14, 647-652

13. Kannell et al. (1976), A General Cardiovascular Risk profile: the Framingham Study, American Journal of Cardiology, 38, 46-51.

14. The World Health Organisation, (1971), Smoking and Health, Dept of Health and Social Security Publication.

15. Health Education Authority, 1991), Smoking the Facts, HEA. ISBN 1 85448 199 1.

16. Royal College of Physicians, (1978), Smoking, it effects us all, ASH, London.

17. Hirayaman T. (1981), Non-Smoking Wives of Heavy Smokers have a Higher Risk of Lung Cancer, British Medical Journal, 282, 183-185.

18. Jarvis M.J. et al (1984), Biochemical Markers of Smoke Absorption, Journal of Epidemiology and Community Health, 38 335-339.

19. Harlap S. Davies AM. (1974), Infant Admission to Hospital and Parental Smoking, The Lancet, 1, 529-532.

20. Strachan DP. Jarvis MJ. Feyerabend C. (1989), Passive Smoking, Salivary Continine Concentrations, and Middle Ear Effusions in Seven Year Old Children, British Medical Journal 298, 1549-1552.

21. Jarvis MJ. (1992), Passive Smoking, Tobacco and Cancers,

Reducing the Risk of Cancers, Open University Course P578, The Open University Press.

22. Glantz SA. Parmley WW. (1991), Passive Smoking and Heart Disease, Circulation 82, 1-12.

23. Surgeon General, (1989), Reducing the Health Consequences of Smoking, Report of the Surgeon General, U.S. Dept. of Health and Human Services, Maryland.

24. Verner D. (1982), Where there is no Doctor, Teaching Aids at Low Cost.