Most Important Health Informations For All: Cigarette Smoking

AUTHOR INFORMATION

Author: Steven L Bernstein, MD, Vice-Chair, Academic Affairs, Department of Emergency Medicine, Newark Beth Israel Medical Center; Assistant Professor, Department of Emergency Medicine, Mt Sinai School of Medicine

Steven L Bernstein, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Editor(s): Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; John A Calomeni, MD, JD, Consulting Staff, Department of Emergency Medicine, Seton Medical Center; Jonathan Adler, MD, Instructor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital; and Anthony Anker, MD, Emergency Department, Mary Washington Hospital

INTRODUCTION

Cigarette smoking remains the leading cause of death and illness among Americans. Every year, roughly 430,000 Americans die from illnesses caused by tobacco use, accounting for one-fifth of all deaths. Tobacco use costs the nation about $100 billion each year in direct medical expense and lost productivity.

About 25% of all American adults, 46.3 million people, smoke. This number has remained constant for several years despite government efforts through Healthy People 2000 and Healthy People 2010 to lower those percentages. Slightly more men (28.1%) smoke than women (23.5%). Hispanics (20.4%) smoke less than whites (25.3%) or African Americans (26.7%).

Nevertheless, significant progress has been made since 1964, when the Surgeon General issued the first report outlining the health dangers of smoking. Since that time, the prevalence of smoking has dropped from 42.4% among adults to 25%.

Both lung cancer and emphysema would become quite rare if people would stop smoking. Compared to a nonsmoker, a smoker faces these risks:

14 times greater risk of dying from cancer of the lung, throat, or mouth
4 times greater risk of dying from cancer of the esophagus
2 times greater risk of dying from a heart attack
2 times greater risk of dying from cancer of the bladder

Use of other tobacco products such as pipes, cigars, and snuff is less common, comprising less than 10% of use of all tobacco products. But the health effects of these products are similar to those of tobacco — particularly their association with cancers of the mouth, throat, and esophagus.

Increasing attention has been devoted to publicizing the dangers of second-hand (environmental) smoke, the association between tobacco marketing and initiation of smoking among youth, and the development of strategies and medications to help smokers quit. Cigarette smoking has been linked strongly to the following illnesses:

Stroke

Other diseases of blood vessels (such as poor circulation in the legs)

Respiratory illness, including the following:
- Lung cancer
- Emphysema
- Bronchitis
- Pneumonia

Cancers, including:
- Lip or mouth
- Pharynx or larynx (voice box)
- Esophagus (food pipe)
- Pancreas
- Kidney
- Urinary bladder
- Cervix

Peptic ulcer disease
Burns

SIGNS AND SYMPTOMS

Signs and symptoms of tobacco use depend on the specific illnesses they cause.

Shortness of breath may be a sign of emphysema or heart disease.
Chest pain may signal angina pectoris caused by insufficient blood flow to the heart or a heart attack.
Difficulty swallowing, or persistent hoarseness, may signal a cancer in the mouth or larynx.
Painless bloody urination may mean bladder cancer.
Common signs and symptoms of diseases associated with tobacco use follow. The presence of any of these symptoms should prompt a visit to the doctor or hospital's Emergency Department:

Chest pain
Shortness of breath
Persistent cough
Coughing up blood
Frequent colds and upper respiratory illness
Persistent hoarseness
Difficulty or pain on swallowing
Change in exercise capacity
Sudden weakness on one side of the face or body, or difficulty speaking
Leg pain while walking that goes away when you rest
Unexplained weight loss
Persistent abdominal pain
Bloody urine

HOME CARE

Home treatment of the various conditions caused by smoking is complex and may involve many different kinds of medicines.

Treatment of respiratory diseases, for example emphysema, involves taking aerosol sprays by mouth. These medicines are called beta-agonists and are related to epinephrine (Adrenaline, Bronitin, Primatene, Vaponefrin).

The medicines may be taken by metered-dose inhalers (pumps) or through nebulizer (cloud) machines.
They dilate the air passages in your lungs known as bronchi and bronchioles.

Additional medicines that may help treat emphysema include:

Corticosteroids, which reduce swelling and airway obstruction

Leukotriene inhibitors such as zileuton (Zyflo), zafirlukast (Accolate), montelukast (Singulair), which help prevent airway narrowing

Cromolyn sodium (Crolom, Intal, Nasalcrom), another anti-inflammatory agent

Theophylline (Hydrophed, Marax, Tedral), which helps widen airways

Oxygen is available at home for people with severe emphysema.

For people with heart disease, a variety of medicines are available.

Aspirin
Antiplatelet agents
Beta-blockers
Calcium channel blockers
Angiotensin converting enzyme inhibitors
Cholesterol-lowering agents

. WHEN TO CALL THE DOCTOR

If you are interested in quitting smoking, call your doctor.

It is never too early to think about quitting.

Every encounter with a doctor, whether in the office, the hospital, the Emergency Department, or clinic, is a good time to talk about smoking and the possibility of quitting.

WHEN TO GO TO THE HOSPITAL

Anyone with unexplained or sudden onset chest pain or difficulty breathing should go to the nearest hospital's Emergency Department, probably by ambulance. These conditions may be symptoms of a heart attack, which can be life threatening if not recognized and treated promptly. Tobacco use may cause shortness of breath or chest pain that may be life threatening along with these symptoms:

Pneumonia

Acute attack of emphysema

Pulmonary embolism (blood clot in the lung)

Aortic aneurysm - A football-shaped widening of the main artery leaving the heart, caused by a weakening in the wall of the artery

Aortic dissection - A tearing of the wall of the aorta, which, if it ruptures, bleeds profusely

PHYSICIAN DIAGNOSIS

Diagnosing tobacco use or tobacco-related illness is not difficult.

Doctors should ask people about tobacco use at every visit and provide counseling about quitting.

Most people who smoke admit doing so, in part because smoking carries less social stigma than use of other substances, such as alcohol or illicit drugs.

A doctor may find various conditions associated with chronic tobacco use on physical examination.

Nicotine causes a characteristic brown staining of the hard palate, teeth, fingers, and fingernails.

A smoker's skin may wrinkle prematurely.

Smokers will have a typical odor to their hair and clothing.

People with emphysema may have a large, barrel-shaped chest and a chronic cough that brings up thick green sputum

PHYSICIAN TREATMENT

Treating specific illnesses associated with tobacco use is discussed elsewhere in this guide. Treating tobacco use requires integrated steps.

Smokers must partner with their doctors, families, spouses, friends, even employers, to make quitting successful.

Quitting is not easy. Every year, 34% of all smokers try to quit, but only about 2.5% succeed. Nonetheless, 1 million Americans quit smoking each year.

Treatment consists of 2 broad areas.

The medical conditions caused by smoking—respiratory illness, heart disease, circulatory disease, cancer, ulcers—need to be treated.

The nicotine addiction also must be addressed and generally consists of a combination of the following:
- Nicotine replacement therapy (gum, patch, inhaler, or nasal spray). Nicotine patches are available over-the-counter, under several brand names, but are best used in conjunction with a physician.
- Doctors may give you bupropion (Zyban or Wellbutrin), a prescription drug.
- Group or behavioral counseling. The most successful quitting programs use combinations of drug treatment and counseling and have success rates of 5% after 1 year.

Smokers trying to quit need lots of support and encouragement to help handle the inevitable urges to light up.

Physicians, although trained in the diagnosis and treatment of smoking-related illnesses, may be less comfortable in providing the counseling and drug treatment smokers need to quit.

They may be unfamiliar with quit-smoking clinics available in the area.

So call your local chapter of the

American Lung Association

Health insurance plans often fail to pay for smoking cessation services.

This may discourage hospitals, clinics, and other health care settings from establishing stop-smoking programs.
Your employer may reimburse you for some of the cost of a clinic. A typical stop-smoking program costs less than $500, equal to the cost of about 150 packs of cigarettes. When including the gains in productivity caused by fewer missed days of work, and decreased use of health care resources, smoking cessation programs available through your employer can be quite cost-effective.

PROGNOSIS

For smokers, quality and length of life depends on the number and severity of smoking-associated illnesses they may develop and if they have other medical conditions such as diabetes or high blood pressure. Other lifestyle factors—use of alcohol or other drugs, for example—also make a difference in long-term outcomes for smokers. For smokers who quit, projected health and life expectancy improve markedly—at any age of life.

Smokers who quit before age 50 years have half the risk of dying in the next 15 years compared with those who continue to smoke.

Quitting smoking substantially decreases the risk of lung, voice box, esophageal, oral, pancreatic, bladder, and cervical cancers. For example, 10 years after quitting, an ex-smoker has 30-50% of the risk of lung cancer compared to a continuing smoker. Continued abstinence continues to lower the risk.

Quitting lowers the risk for other major diseases including coronary heart disease (CHD) and cardiovascular disease. The increased risk of CHD halves after 1 year of abstinence. After 15 years, the risk of CHD approximates that of someone who never smoked.

Women who stop smoking before pregnancy, or during the first 3 or 4 months of pregnancy, reduce their risk of having a low birthweight baby to that of women who never smoked.

The health benefits of quitting far exceed any risks from the average 5-pound weight gain that may follow quitting.

PREVENTION

Most smokers begin to smoke as teenagers. Every day, 3,000 American youths start smoking.

Despite that fact, the American Lung Association contends that the tobacco industry "aggressively and consistently fights meaningful efforts at the federal, state, and local levels to enact and enforce laws barring sales (of cigarettes) to minors."

Parents still have the biggest impact on their children's decision whether to smoke. The best way to prevent a youngster from taking up smoking likely is to have parents who don't smoke. Children from smoking households are more likely to begin smoking than children from nonsmoking households.

Much attention has been focused in recent years on the influence of tobacco company advertising on encouraging young people to smoke.

Although cigarette commercials have been banned from television for 30 years, the tobacco industry remains the country's largest advertiser. According to the American Lung Association, the tobacco industry spent an estimated $5.7 billion on advertising in 1997, up 10.8% or $552 million from 1996. In 1982, when cigarette sales peaked, the industry spent an estimated $1.8 billion for advertising. Cigarette sales dropped from 632.5 billion in 1982 to 478.6 billion in 1997. Tobacco company ads are everywhere:

Ads are in print media and at sporting and cultural events.

Cigarette use by actors in popular films long has been a means to portray smoking as sophisticated and glamorous.

Tobacco companies sponsor automobile racing and women's tennis.

Although denied by tobacco companies, the use of cartoon animals and the like in advertising campaigns appeals to youngsters.

Counter-advertising by various antismoking advocacy groups may provide some balance, but their advertising budgets pale beside those of tobacco companies.