1) Tobacco was introduced to Europe in the 16th century and there are now over 1 billion smokers worldwide. Smoking causes over 8 million deaths per year projected to rise to 12% of all deaths by 2020. 2) Tobacco smoke contains over 500 compounds including nicotine and tars. Cigarette smoke is acidic whereas cigar and pipe smoke is alkaline, affecting how nicotine is absorbed and the associated health risks. 3) Smoking causes diseases of the cardiovascular and respiratory systems as well as various cancers. It is estimated smoking will cause over 450 million deaths between 2000-2050, around half between ages 30-69.

1. By
Dr. Adel Hamada
MD CHEST
EDIC
Tobacco
Smoking

2. Tobacco was introduced to Europe from South
America in the 16th century
there are 1.1 billion smokers worldwide.
In 1990 there were 3 million smoking-related
deaths per year, projected to rise to 8 million
by 2020 (representing 12% of all deaths)
introduction

3. COMPOSITION
The principal components are tar and nicotine, the amounts of
which can vary greatly depending on the country in which cigarettes
are sold.
The composition of tobacco smoke is complex (more than 500
compounds have been identified) and varies with the type of
tobacco and the way it is smoked. The chief pharmacologically
active ingredients are nicotine (acute effects) and tars (chronic
effects).

4. Smoke of cigars and pipes is alkaline (pH 8.5)
and nicotine is relatively un-ionised and lipid-soluble so
that it is readily absorbed in the mouth.
Cigar and pipe smokers thus obtain nicotine
without inhaling (they also have a lower death rate
from lung cancer; which is caused by non-nicotine
constituents).

5. Smoke of cigarettes is acidic and nicotine is Relatively
insoluble in lipids.
Desired amounts are absorbed only if nicotine is taken into the
lungs for compensates for the lower lipid solubility.
Cigarette smokers therefore inhale (and have a high
rate of death from tar-induced lung cancer).

6. Tobacco smoke contains 1-5% carbon monoxide, and habitual
smokers have 3-7% (heavy smokers as much as 15%) of their
haemoglobin as carboxy haemoglobin.
carcinogenic substances (polycyclic hydrocarbons and
nicotine-derived N-nitrosamines) have been identified in tobacco
smoke condensates from cigarettes, cigars and pipes.
Polycyclic hydrocarbons are responsible for the hepatic enzyme
induction that occurs in smokers.

7. Types of Tobacco Smoke Exposure
 First Hand Smoke Exposure
is the smoke inhaled by a smoker.
 Second Hand Smoke Exposure
tobacco smoke inhaled by non-smokers.
I. side stream smoke which is released by the burning end.
II. main stream smoke which is exhaled by a smoker.
 Third Hand Tobacco Exposure
It includes invisible smoke left in the air after a cigarette is
extinguished
This is cigarette smoke deposits on furniture, clothing and other surfaces.

8. Disease Patterns Related to Tobacco
Smoke
Smoking is associated with various diseases of
the cardiovascular and respiratory systems as well
as cancer.
It is estimated that, if current smoking tobacco consumption
patterns are maintained, about 450 million adults will die as a
consequence of tobacco smoke-related diseases between
2000 and 2050. Of the 450 million, about 50% will be between
30 and 69 years of age (Jha, 2009).
three- to four-decade lag between the peak in smoking
prevalence and the subsequent peak in smoking related
mortality (Lopez et al., 1994).

9. Disease Patterns Related to Tobacco Smoke
Smoking is associated with various diseases of the cardiovascular
and respiratory systems as well as cancer.

10. Smoking and cancer

11. Pulmonary Diseases
And Smoking

12. Smoking related ILDs

13. Cardiovascular
Diseases And Smoking

14. Other effects of
Smoking

15. Other
effects
of
Smokin
g

16. Health Hazards of Secondhand
Smoke in Nonsmokers

17. Waterpipe tobacco
smoking

18. The prevalence of waterpipe tobacco smoking has increased
worldwide, in part, because of misconceptions about its safety.
Today, waterpipe smoking typically consists of a combination
of tobacco, water, wood charcoal, and a device known as a
waterpipe, shisha, chica, hookah, hubble-bubble arghileh,
goza, ghalyan, or mada’A (depending on the country).

19. The World Health Organization (WHO) has declared waterpipe
tobacco smoking a new public health problem. (2010)
Although waterpipe smoking is perceived as being less harmful
than cigarettes, evidence suggests that it contains similar
harmful agents and has similar addictive potential as cigarettes
Unlike cigarette smoking, waterpipe smoking has been
associated with infectious diseases, and possibly, a
predisposition toward use of psychoactive substances.

20. Contrary to popular belief, waterpipe and cigarette
smoke contain similar toxic agents and, due to the
longer inhalational puffs required to generate the
smoke with waterpipe smoking, it is believed that up to
100 times more smoke is inhaled, thereby exposing
the individual to large amounts of nicotine, carbon
monoxide, and polyaromatic Hydrocarbons.

21. Compared with cigarettes, waterpipes emit a much greater
amount of ultrafine particles in the size of 0.02-1 μm in size,
particularly from the burning charcoal.
particles that are 0.8-3 μm deposit in the terminal airways and
alveoli or air sacs of the Lungs. Irreversible lung disease, such as
chronic obstructive pulmonary disease, occurs in these terminal
air sacs .
studies investigating the pulmonary function tests of waterpipe
smokers found not only a decrease in the FEV1, but also
decreased values in peak expiratory flow rates

22. Carcinogenic effects
of waterpipe smoking
95% of the polyaromatic hydrocarbons were generated from
the charcoal.
A single session of waterpipe tobacco smoking
produced as much tar as 20 low-tar cigarettes
and waterpipe tobacco mainstream smoke
produced much higher levels of arsenic, chromium,
and lead.
Compared with a single cigarette, waterpipe tobacco smoke
yielded 20 times the total polycyclic aromatic hydrocarbon yield
and 50 times the heavy polycyclic aromatic hydrocarbons.

23. Waterpipe smoking requires larger tidal volumes and longer
inspiratory times. The larger inhaled respiratory volumes expose
the smoker to more carcinogens than cigarette smoking.
Carcinogenic effects
of waterpipe smoking
so
The carcinogenic effect is at least
as ( if not more than) that of
cigarette smoking

24. WHO Study Group on Tobacco Product Regulation
(TobReg) recomendations as regard waterpipe smoking
Waterpipes and waterpipe tobacco should be subjected to the
same regulation as cigarettes and other tobacco products.
 Waterpipes and waterpipe tobacco should include strong
health warnings.
 Claims of harm reduction and safety should be prohibited.
 Misleading labeling, such as “contains 0 mg tar, which may
imply safety, should be prohibited.

25. Waterpipes should be included in comprehensive tobacco control
efforts, including prevention strategies and cessation interventions.
Waterpipes should be prohibited in public places consistent with
bans on cigarette and other forms of tobacco smoking.
Education of health professionals, regulators, and the public at
large is urgently needed about the risks of waterpipe smoking,
including high potential levels of secondhand exposure among
children,pregnant women, and others.
The TobReg recommends that a full document be produced in the
WHO Technical Report Series to evaluate thoroughly the health
effects of waterpipes and to develop recommendations.

27. Smoking cessation

28. An algorithm for treating
tobacco use.

29. The “5 A’s” strategy for helping
patient to quit smoking

30. General Clinical Guidelines for
Prescribing Pharmacotherapy for
Smoking Cessation
five types of nicotine replacement therapy,.
sustained-release bupropion, an antagonist of the nicotinic receptor,.
varenicline, a partial agonist of the nicotinic receptor.
all smokers trying to quit smoking should be offered
pharmacotherapy.
There are seven first-line smoking cessation
medications

31. Second-line therapies include clonidine and
nortriptyline.
These should be reserved for individuals with contraindications to/or
failure of response to first-line medications.
As regard weight gain after smoking cessation:
Bupropion and nicotine replacement therapies may delay but not prevent
weight gain after smoking cessation.
 It is recommended that patients start or increase physical activity, but strict
dieting is discouraged because this appears to increase the likelihood of relapse
to smoking.
Patients should be reassured that weight gain after quitting is self-limited and
poses much less of a risk to health than smoking.

32. As regard safety of medications
Transdermal nicotine (patches), nicotine gum, and bupropion
appear to be safe for patients with chronic cardiovascular disease.
Other medications are likely to be much safer than smoking in the
presence of medical disease, but need further evaluation.

33. long-term therapy with nicotine replacement
medication, bupropion, or varenicline
In those with prolonged withdrawal symptoms or in those who cannot
resist smoking without medication appears to be safe and effective therapy,
Combination therapy is better than monotherapy
Recent research suggests that combining bupropion with nicotine patches
or combining nicotine patches with ad libitum use of nicotine gum or
nicotine nasal spray increases abstinence rates compared with the rates
produced by a single form of therapy.

34. First line pharmacotherapies for smoking
cessation

35. Second line pharmacotherapies for smoking
cessation
Smoking-cessation therapy is far
more cost-effective than almost
any other preventive medicine
intervention.