Swine Influenza Update #3 Updated 12:00 p.m. April 30, 2009 Introduction: This document revises our last update which was sent April 28th, 2009. The most important revisions include the following: 1. The duration of prophylaxis has been increased from 7 days to 10 days to be 2. The CDC has recently approved the use of Oseltamivir for treatment and prophylaxis for infants less t
- A |
J |K |
U |V |
Microsoft word - smoking - final completed moduleSmoking
Edith Okola with Holly Halstead
These resources are freely available to be copied and used for teaching and public health studies. Please acknowledge author and LTPHN for publication. SMOKING
Why is smoking important?
Approximately 10 million adults currently smoke in the UK.1 In London a person is
admitted to hospital every 10 minutes due to causes related to smoking, around
55,000 people each year. It is estimated that approximately 12,000 people in the
Capital are killed by tobacco annually - 18% of all deaths.2
Smoking impacts on health within every clinical specialty, and is the responsibility of
every healthcare professional. Identifying people who smoke and offering them help
to stop will reduce premature morbidity and mortality, and is also important in
reducing health inequalities.
The Public Health white paper published in 2004 Choosing Health: Making Healthier
Choices states that ‘every member of the NHS staff has the potential to increase their
role in raising people’s awareness of the benefits of healthy living – as part of the
NHS responsibility to patients to improve health, not just provide healthcare for the
Smoking prevalence has decreased over the last 20 years in both men and women.
(51% to 26% of men and 41% to 23% of women in Great Britain from 1974 to
The General Household Survey in 2004 demonstrated that 25% of adults smoked.
Figure 1 shows the highest prevalence was in the 20-24 age group and the lowest in
the 60 years and over group. The prevalence is thought to be lowest in the over 60
group because many people stop smoking in middle age, whilst a quarter of smokers
die before their 70 birthday.1,4
Figure 1: Prevalence of smokers in Great Britain in 2004 5
Original Author: Edith Okola with Holly Halstead Figure 2: Cigarette smoking status of men in Great Britain in 2004 5
Figure 3: Cigarette smoking status of women in Great Britain in 2004 5
The survey found that 31% of people in manual socio-economic groups smoked compared to 18% in non-manual groups. Men had a higher prevalence for smoking than women in all socio-economic classifications as shown in figure 4. Original Author: Edith Okola with Holly Halstead Figure 4: Prevalence of smoking among adults aged 16+ years by National
Statistics Socio-economic classification (NS-SEC) in Great Britain in 2004 5
The managerial and professional group had a higher percentage of smokers wanting to quit than the routine and manual group, which is shown in the chart below.5 Figure 5: The percentage of adult smokers who would like to stop by gender
and socio-economic classification 5
In 1974 the mean number of cigarettes smoked daily by men was 18 and women 13. In 2004 it had decreased to 15 for men and stayed at 13 for women.5 In 1999 the Health Survey for England found that self reported smoking was higher in Bangladeshi, Irish and Black Caribbean men and Irish women than for the general population as shown in table 1.6 However, the survey did not include the African population. It also should be noted that in some cultures it is more common to chew tobacco rather than smoke. Original Author: Edith Okola with Holly Halstead Table 1: Percentage of self-reported smokers by ethnicity and gender
Many people start smoking and become addicted to nicotine as teenagers. A series of surveys at secondary schools in 2004 showed 7% boys and 10% girls aged 11-15 smoked regularly. 7 Smoking regularly was defined as at least one cigarette a week. Figure 6 shows the prevalence of smoking by age and gender. Figure 6: Prevalence of regular smokers among secondary school children in
England in 2004 7
The prevalence of smoking increases with age. A higher percentage of girls smoke
than boys, from ages 12-15 with the percentage gap widening from 1% more girls at
age 12 to 10% more at age 15.
31% of men and 26% of women in London smoke, about 2 million people.8 The
highest percentage of smokers is found amongst the 25-34 age group. Men have a
higher prevalence of smoking in all ages under 75 years old, as shown in figure 7.
Original Author: Edith Okola with Holly Halstead Figure 7: Prevalence of smoking in London between 1998-2001
Smoking prevalence has had a larger decrease in London from 34% to 28% in men
and 24% to 20% in women when compared with a fall nationally from 29% to 27% in
men and 26% to 24% in women between 1998 and 2003.9
What’s in a cigarette?
Over 4000 chemicals are found in tobacco smoke, which include tar, nicotine, benzene, benzopyrene, carbon monoxide, ammonia, dimethylnitrosamine, formaldehyde, hydrogen cyanide, sulphur dioxide and acrolein.10,11 Of these, nearly 70 are known or suspected carcinogens and the World Health Organisation (WHO) has classified secondhand smoke as a carcinogen.8, 12 Why do people smoke?
Nicotine is contained in the moisture of tobacco leaf and is an addictive substance.13,14
It is a stimulant, entering the blood via several routes including the lungs and mucous
membranes, and quickly crosses the blood-brain barrier to reach the brain within 15
seconds. Nicotine enhances the release of neurotransmitters including dopamine,
acetycholine, norepinephrine and serotonin.15 This experience for smokers is
pleasurable, and when repeated becomes physically and psychologically addictive.15
Evidence shows the effect on the dopamine system in the brain is similar to that of
heroin and cocaine.16 A study in the late 1980s showed people who had alcohol,
cocaine or heroin dependence found cigarettes as hard to give up as their other
Further information about the physiology of smoking can be found in ‘Nicotine
Addiction in Britain’ at http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm
Original Author: Edith Okola with Holly Halstead Smoking and health
It has been estimated that 1000 people a day are admitted to an NHS hospital with a
smoking related problem.15 Each year approximately 114,000 smokers die from a
smoking related illness in the UK,19 and smoking related diseases cost the NHS £1.5
billion annually.20 Ref 20 onwards
In London between 1998-2002 the percentage of smoking related deaths ranged from
under 14% in Barnet and Kingston, more affluent areas, to 23% in Tower Hamlets.
Further information on London boroughs can be found from the London Health
Below are examples of the effects smoking has on most clinical specialties. 21 The
WHO has also produced a poster called The Smoker’s Body, which demonstrates
some of the effects of smoking.22
The relevance of smoking to different clinical specialties 15
Smoking is relevant to most clinical specialties: it both causes disease and makes
treatment more difficult. The examples here are not intended as an exhaustive list.
• Surgery – all sub-specialties
− increases the risk of postoperative complications, including respiratory, − increases the risk of poor wound healing − increases average lengths of stay − increases the likelihood of admission to an intensive care unit − increases the risk of postoperative death Smoking also damages skin flaps used in reconstructive and cosmetic surgery often causing failure or subsequent breakdown • Obstetrics and gynaecology
Antepartum bleeding and abruptio placentae has been linked directly with smoking23 Smoking during pregnancy induces fetal hypoxia and, because of the vasoconstrictive effect of nicotine, also causes uteroplacental underperfusion – both contribute to prematurity and low birth weight (maternal smoking cessation in the first trimester eliminates the excess risk of low birth weight)24,25,26,27,28,29,30,31,32,33 Smoking has been associated with a 29% increase in fetal malformations, including hare lip, cleft palate and abnormalities of the central nervous system, heart and digestive system Original Author: Edith Okola with Holly Halstead • Orthopaedics
Smoking is associated with delayed bone healing: the average length of time for a non-smoker to form 1 cm of new bone is 69.6 days, but it takes 89.4 days in a smoker.34,35 Women who smoke have a lower bone mass and are more likely to have a premature menopause – in combination, these two factors significantly increase the risk of osteoporosis and fracture.36 Men who smoke are also at increased risk of osteoporosis because smoking affects the production of bone cells.14 Smokers are 70% more likely than non-smokers to suffer hearing loss.37,38 Non-smokers living with smokers are twice as likely to have hearing problems.29,30
Smoking increase the risk of developing age-related macular degeneration and smokers are up to four times more likely to go blind in old age.39,40,41 • Dentistry
There is a direct relationship between smoking and bone resorbtion – smokers are
more likely to lose their teeth, and have a high risk of dental implant
Periodontal disease is 2-3 times commoner in smokers.48
Smokers are twice as likely to develop peptic ulcers, and gastroesophageal reflux is more common in smokers.49,50,51,52 Smokers are more likely to develop Crohn’s Disease.53 Current and former smokers have been found to have more hepatic inflammation and scarring than non-smokers and, independent of the effect of alcohol, smoking can aggravate the effects of hepatitis C infection.54,55 Smoking increases the risk of developing alcoholic liver cirrhosis – smoking 20 cigarettes a day trebles the risk compared to that of a lifelong non-smoker.56 Smoking increases the hepatotoxicity of some drugs, e.g. paracetamol.57 • Cardiovascular medicine
Smoking causes peripheral vascular disease. Original Author: Edith Okola with Holly Halstead • Respiratory medicine
Smoking causes chronic obstructive pulmonary disease. People with chronic obstructive pulmonary disease who give up smoking halve their likelihood of hospital admission because of an exacerbation, whilst merely cutting down has no benefit at all. People with cystic fibrosis who smoke (actively or passively) have much poorer respiratory function. • Endocrinology
Smoking affects pituitary, thyroid, adrenal, testicular and ovarian function, calcium metabolism and the action of insulin. Smokers are more likely to develop:58,59 − insulin resistance − Grave’s Disease (thyroid eye disease is also commoner) − and irregular menstrual cycle and a premature menopause (in women) − osteoporosis (in men and women) Smoking is an independent risk factor for diabetes.60,61,62 Smoking increases the risk of complications and premature death in people with diabetes.63,64 Nephropathy is commoner in people with diabetes who smoke.65,66 Smoking is an independent risk factor for pancreatitis.67,68 • Renal medicine
Smoking is nephrotoxic in people with renal disease.69,70 Smokers have a higher risk of end-stage renal failure.71 • Dermatology
Smoking leads to premature ageing of the skin – the effects are permanent.72,73,74 There is a significant relationship between smoking and hair loss and baldness.75 • Neurology
Older people who smoke are at greater risk of developing dementia.76 Smoking is a risk factor for multiple sclerosis and its progression (smokers are three times more likely to have rapid progression of MS than non smokers).77,78 • Haematology
Chronic exposure to cigarette smoke or nicotine causes T cell unresponsiveness – smoking reduces the effectiveness of the body’ immune system.79 Smoking is thrombogenic – it increases platelet stickiness Smoking reduces the oxygen carrying capacity of red blood cells.80 Original Author: Edith Okola with Holly Halstead • Paediatrics
Children living with smokers are more likely to develop meningitis.81 Babies living with two or more smokers are 30 per cent more likely to need hospital treatment than those who live in smoke-free homes.82 Babies of mothers who smoke have five times the risk of dying of sudden infant death syndrome.83,84,85 Passive smoking by children has been shown to cause bronchitis, pneumonia, coughing and wheezing, asthma attacks and middle ear infections.86 • Genitourinary medicine
Smoking causes erectile dysfunction – 40% of male smokers are affected compared with 28% of the general population.87 Smoking reduces the total sperm count and sperm motility – it is a significant cause of male infertility.88,89,90,91 Smoking has been directly linked with infertility in women.92,93,94,95,96 • Oncology
Active and passive smoking causes cancer of the respiratory tract. Smoking increases the risk of pancreatic cancer by 70%. Smoking causes nasal, sinus and throat cancer. Smoking is also associated with cancers of the oesophagus, stomach, kidney, bladder and cervix, and with myeloid leukaemia. • Psychiatry
People with mental health problems are much more likely to smoke – their general health is poorer and they are more likely to die prematurely (this likelihood is in addition to an increased risk of death from suicide). People with mental health problems are much more likely to smoke – people with schizophrenia are ten times more likely to die of respiratory disease. People with mental health problems who smoke are much more likely to require higher doses of neuroleptic drugs because of enzyme induction by nicotine.
Passive smokers inhale sidestream and mainstream smoke. Mainstream smoke has
been inhaled and exhaled from a smoker. Sidestream smoke is emitted from the
burning tip of a cigarette, contains higher concentration of potential toxic gases
and composes 85% of a smoke-filled room.97,98
It was first recognised that passive smoking damaged health in 1981, and there is now
plenty of evidence to support this.99 In November 2004 the Scientific Committee on
Tobacco and Health, which advises the Government, showed that the risk of lung
cancer and heart disease was increased by one quarter in adult non-smokers exposed
to passive smoke.100 Within 30 minutes of exposure to passive smoke there is a
Original Author: Edith Okola with Holly Halstead reduction in coronary blood flow.101 A non smoker has a 23% increased risk of heart
disease when living with a smoker.102
Other recent reviews of the effects of passive smoking have been carried out by the
International Agency for Research on Cancer (IARC), the California Environmental
Protection Agency and the WHO.
The impact of passive smoking on children103
Cotinine is a metabolite of nicotine. It is excreted in urine, saliva, and blood and can
be found in hair. It is specific to nicotine and is a measure of the persons’ intake of
tobacco smoke.104,105,106 Its half-life is approximately 24 hours. Studies have found
cotinine in the urine and saliva of children exposed to passive smoking.107,108 From
this it is reasonable to infer that children exposed to passive smoking are at risk of all
smoking related illnesses. As many as up to half the children in Britain are exposed to
A cross sectional survey of 3531 children aged 4-11 years old showed an association between exposure to passive smoke and risk of dental caries.110
• Ear nose and throat (ENT)
A systematic quantitative review shows a likely a causal relationship between passive smoking and acute and chronic otitis media in children.111
Passive smoking increases the risk of children developing invasive meningococcal disease.112
• Respiratory diseases
Passive smoking is a contributor to chronic cough in children113 and increases the risk of children succumbing to acute lower respiratory tract infections.114 A systematic quantitative review showed passive smoking:115 - Is a co factor for provoking wheezing attacks in 5 year olds and under - Increases the symptom score of patients with asthma - Is associated with more severe disease in established asthma Prevalence surveys conducted amongst school-age children suggest wheeze and diagnosed asthma are more common in those exposed to passive smoke.116 It has also been demonstrate that children whose mothers smoke have a decrease in their lung function.117 Children with cystic fibrosis exposed to passive smoke have an increased number of hospital admissions compared with those who are not.118
• Sudden infant death syndrome
A systematic quantitative review of the epidemiological evidence relating parental smoking to sudden infant death syndrome concluded that maternal smoking doubles the risk of sudden infant death syndrome.119 Original Author: Edith Okola with Holly Halstead
Along with evidence showing the detrimental effect passive smoking has on
children’s health, there is also evidence to demonstrate that it adversely affects
different treatment regimes.
• Drug regimes
Tobacco smoke induces CYP1A2 enzymes found primarily in the liver.120 This speeds the metabolism of drugs induced by CYP1A2 leading to the patient requiring larger doses to obtain therapeutic levels. Drugs induced by this are: theophylline 121 Evidence also shows that insulin resistance increases with exposure to nicotine123, which leads to diabetics requiring more insulin.124
Exposure to passive smoke affects children undergoing general anaesthesia. The risk of perioperative respiratory complications125 and incidence of postoperative hypoxaemia are both increased in children exposed to passive smoke.126 A retrospective cohort study showed there was a ten-fold increase risk of laryngospasm in children exposed to environmental tobacco smoke who underwent anaesthetic.127
• Ear nose and throat
The effects of passive smoking on ENT conditions have been discussed above. However, there is evidence to show that passive smoking effects the treatment of secretory otitis media. A prospective study of 606 children undergoing bilateral myringotomy with insertion of grommets showed passive smoking:128 - Increases the chance of an ear infection post grommet insertion - Adversely affects the length of time grommets are in situ post operatively. The median survival rate of grommets in children exposed to passive smoking was 59 weeks compared to 86 weeks in non exposed children - Increases the risk of myringosclerosis of the tympanic membrane after the - Increases the risk of permanent perforation of the tympanic membrane Endoscopic sinus surgery is used in children with chronic sinusitis in whom medical treatment has failed. Evidence shows that exposure to passive smoking predisposes children who are having endoscopic sinus surgery to a poorer outcome. At 12 months non exposed children had a success rate of 90% compared to 70% in children who were exposed to cigarette smoke.129 Original Author: Edith Okola with Holly Halstead • Respiratory
As discussed above passive smoking contributes to many respiratory problems in children. It also interferes in the treatment of many respiratory illnesses. Asthmatic children exposed to household smoke were more likely to have: - Increased attack frequency - Increased use of medication - Increased hospital attendance - Increased life threatening attacks A prospective cohort study showed asthmatic children exposed to passive smoke were less likely to have good peak flow and symptom control than non exposed children.130
Smoke Free Legislation
Comprehensive legislation banning smoking in public places, including places of
work and enclosed public areas such as pubs and clubs, was introduced in England in
July 2007. Previously, it was estimated that 8% (2,182,000) of people employed in
Great Britain worked in places with ‘no restrictions on smoking at all’ and 38%
(10,366,000) in places where smoking occurs in ‘designated areas.’131
Smoke free legislation is a huge public health issue, because it is known that passive
smoking is a risk to non-smokers. It is hoped that it will also reduce health
inequalities by effectively decrease smoking rates, which are higher amongst people
in manual work.132
Evidence from other countries demonstrates that a complete ban can decrease smoking prevalence by 4 %; this is assuming there are no smoking restrictions initially.133 New York went smoke free in 2003 and Ireland in 2004. In New York, an 85% drop in cotinine levels was seen in non-smoking staff working in restaurants and bars after the introduction legislation.134 In Ireland almost one in five smokers decided not to smoke whilst out socialising since the introduction of the ban there.135 Tobacco Advertising
The Tobacco Advertising and Promotion Act 2002 came into effect in the UK on 14th February 2003. This bans any advertising which has the purpose or effect of promoting a tobacco product, including: • adverts in print and billboards; • internet; • direct mail; • promotions; • free gifts; and • sponsorship.136 Tobacco sponsorship was banned from domestic sport in 2003 and, at an international level, from World Snooker and Formula One in 2005. Exemptions from this ban include advertising at the point of sale. Original Author: Edith Okola with Holly Halstead Tobacco advertising increases tobacco consumption, and countries who have imposed a ban on advertising have also demonstrated a drop in consumption.137,138 A report by the US Surgeon General about tobacco advertising acknowledged the following points: - Tobacco advertising increases the use of tobacco in children and young - It increases the consumption of smokers - It lowers smokers’ motivation to stop smoking - It ensures tobacco remains acceptable and health warnings are
A European Union (EU) directive in 2001 regulated certain components of cigarettes,
stating that any cigarettes sold in Europe can have a maximum 10mg tar, 10 mg
carbon monoxide and 1 mg nicotine.140 The directive also regulates the health
warnings on cigarette packets, which must cover 30% of the surface area on the front
of the packet, and 40% of the back. Use of words such as ‘light’ or ‘mild’ in the brand
name was also banned.141
In 2004/2005 the treasury earned £8,013 million (excluding VAT) from tobacco
duties.141 About 80% of the cost of a packet of cigarettes constitutes tax.142 The NHS
spends approximately £1.5 billion a year on treating smoking related diseases, which
does not include invalidity or sickness benefits.143 In England and Wales
approximately 34 million days are lost each year due to absence because of a smoking
Increasing the price of cigarettes does decrease consumption, but 16% of cigarettes
consumed in the UK are smuggled, reducing the effect of the policy. 145
Original Author: Edith Okola with Holly Halstead
At least 70% of adult smokers would like to quit smoking and one of the main reasons
is for their health.146,147 The table below illustrates the benefits of stopping
Table 2: Health benefits of stopping smoking
Beneficial health changes
Blood pressure and pulse rate return to normal. Nicotine and carbon monoxide levels in blood reduce by Carbon monoxide will be eliminated from the body. Lungs start to clear out mucus and other smoking debris. Ability to taste and smell is greatly improved. Bronchial tubes begin to relax and energy levels increase. 2-12 weeks
Coughs, wheezing and breathing problems improve as 3-9 months
lung function is increased by up to 10%. Risk of a heart attack falls to about half that of a smoker. Risk of lung cancer falls to half that of a smoker. Risk of heart attack falls to the same as someone who has As nicotine is an addictive substance when smokers quit they experience withdrawal symptoms which are shown in table 3.149,150 Table 3: Withdrawal symptoms
Proportion of those trying
to quit who are affected
Irritability / aggression
Original Author: Edith Okola with Holly Halstead NHS smoking cessation services
NHS Stop Smoking Services were established in 1998 to offer support for smokers
wanting to quit based on best available evidence. Behavioural support, nicotine
replacement therapy (NRT) or bupropion are offered along with advice. There is
evidence to show that providing smokers with help to quit is effective. Specialist
intensive support quadruples the chance of quitting. 151 However, to stop one person
smoking, twenty people need to be advised to quit.
In 2004/2005 around 530,000 people in England set a quit date with NHS stop
smoking services, and at four weeks follow up 56% were not smoking.152
There are three levels of intervention for stopping smoking and are outlined below. 153
• Level 1: Brief opportunistic advice to stop from a health care professional
The main aim of the intervention is to trigger an attempt to stop smoking. Brief advice to all smokers to encourage them to make an attempt to stop is effective in promoting smoking cessation. Ask – if they are a smoker Advise – to stop smoking and reasons why Assist – explain different options for stop smoking services Arrange – to see a stop smoking advisor either level2 or 3 Recent NICE Public Health Intervention Guidance makes nine recommendations for brief interventions and referral for smoking cessation in primary care and other settings.154 The recording of smoking status should also be readily accessible in both primary and secondary care so that patients can be regularly asked and advice given is recorded.
• Level 2: Behavioural support to aid attempts to stop smoking
The main aim of the intervention is to respond to smokers requests for help with an attempt to stop smoking. The programme runs for 12 weeks with the clients being seen weekly for the first 4 weeks. Advice is given on the use of NRT or bupropion and behavioural advice and support is given.
• Level 3: Specialist services
This service provides intensive behavioural support in groups for smokers over a 6-7 week period. All healthcare professionals involved in smoking cessation to encourage the smokers to use bupropion or NRT where appropriate. Pregnant women and inpatients at hospital who smoke who wish to stop should have behavioural support provided by specialist counsellors. Original Author: Edith Okola with Holly Halstead Clients accessing Level 2 or 3 support will be asked the following questions to assess nicotine addiction and enable NRT to be tailored to their needs. - What time do you have your first cigarette of the day? - Do you smoke more in the morning? - Do you smoke when you are ill? - Do you have difficulty not smoking in a non-smoking area? - Number of cigarettes smoked a day - Which cigarette would be the hardest to give up?
NICE Guidance on NRT and bupropion
NRT and bupropion (Zyban) are recommended for smokers who want to quit
smoking. It should normally be prescribed as part of an abstinent-contingent treatment
which is when the client commits to stopping smoking on a certain date known as
their quit date. Behavioural support is available from trained advisors to aid in the
clients quit attempt.
What is nicotine replacement therapy (NRT)?
NRT works by reducing the severity of the withdrawal symptoms and reduces
cravings and the desire to smoke. It provides a temporary nicotine substitution at a
lower level (a third to a half) and slower delivery than nicotine from an inhaled
cigarette. It helps smokers to quit in a two stage approach, firstly by behaviour change
and then the drug. The nicotine replacement therapy is weaned during the programme
and is available in a variety of preparations, such as gum, patches and inhalers.
What is bupropion (Zyban)?
Initially buproprion was used as an antidepressant in the US, known as Wellbutrin,
but anecdotal reports demonstrated that it also aided people trying to stop smoking.
The mechanism of action is not fully known. It may act as a nicotine acetylcholine
receptor, inhibit dopamine reuptake or decrease activity of noradrenaline-releasing
One 150mg tablet is taken daily for the first six days and the client still smokes. At
day 7 the dose is increased to two tablets a day taken 8 hours apart. A quit date is set
for between 8-14 days after starting bupropion.
Contraindications include seizures, eating disorder, CNS tumours, bipolar disorder,
severe hepatic cirrhosis, use of MAOIs. Common side effects include insomnia,
headache, and a dry mouth; rarely it can cause seizures, severe allergic reactions, and
Original Author: Edith Okola with Holly Halstead
For further information/Resources
Action on Smoking and Health
Fact sheets available covering:
Guidance on smoking cessation, including bupropion and nicotine replacement
therapy (No. 39), as well as brief interventions and referral for smoking cessation in
primary care and other settings.
Department of Health
Relevant online documents include:
• Smoking Kills: A White paper on tobacco 1998 • The NHS Plan: 2000 • Choosing Health: Making healthy choices easier 2004 www.dh.gov.uk
World Health Organisation
• International consultation on environmental tobacco smoke (ETS) and child www.who.int/tobacco/en/
The Royal College of Physicians
Information about nicotine addiction in Britain.
Original Author: Edith Okola with Holly Halstead References
1 Action on smoking and Health. Smoking statistics Basic Facts 1. August 2008
2 London Health Observatory www.lho.org.uk (Accessed 11/10/08)
3 Department of Health. Choosing health. Making healthy choices easier.
London: Stationery Office, 2004.
4 Peto R. Mortality in relation to smoking:40 years’ observation on male British doctors. BMJ
5 Office for National Statistics. General Household Survey 2004/2005 Available at:
6 Department of Health. Health Survey for England: The Health of Minority Ethnic Groups
1999. London, The Stationary Office,2002.
7 National Centre for Social research (NaTCen) and the National Foundation for Educational
Research (NFER). Smoking, drinking and drug use among young people in England in 2004.
London, The Stationary Office, 2005.
8 LHO. Tobacco in London: The preventable burden. London 2004. Available at:
http://www.lho.org.uk/viewResource.aspx?id=8716 (Accessed 11/10/08)
9 LHO. Choosing Health: a briefing on Tobacco in London. London: LHO, December 2004.
10 Respiratory health effects of passive smoking. EPA/600/6-90/006F United States
Environmental Protection Agency, 1992
11 Action on Smoking and Health Smoking at Work
http://old.ash.org.uk/html/factsheets/html/onsworkplacefigures2004.html (Accessed 11/10/08)
12 World Health Organization International Agency for Research on Cancer (2004). Tobacco
smoke and involuntary smoking. IARC Monographs on the Evaluation of Carcinogenic Risks
to Humans 83. Summary available at: www.iarc.fr
13 Action on smoking and health. What’s in a cigarette fact sheet no:12. August 2001
14 Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal
College of Physicians, February 2000.
http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm (Accessed 11/10/08)
15 Nicotine actions and the physiology of smoking
16 Pich E M, Pagliusi S R, Tessari M et al. Common neural substrates for the addictive
properties of nicotine and cocaine. Science 1997; 275:83-6.
17 Kozlowski L T, Wilkinson A, Skinner W et al. Comparing tobacco cigarette dependence
with other drug dependencies. JAMA 1989; 261:898-901.
18 Report of the scientific committee on tobacco and smoking
19 Peto R et al. Mortality from smoking in developed countries 1950-2000 (2nd edition)
Oxford: Oxford University Press, 1994.
20 Action on smoking and Health. Smoking statistics Basic Facts 3. November 2007
21 Bhatti, M, Saker L, Burnett A. The relevance of smoking to different clinical specialties.
Barnet PCT. June 2005
22 The Smoker’s Body
23 Goujard S, Rumeau C, Schwartz N: Smoking during pregnancy, stillbirth and abruptio
placentae. Biomedicine 1965; 23:20-22.
24 Kelly J, Mathews KA, O'Connor M: Smoking during pregnancy: effects on mother and the
fetus. Br J Obstet Gynaecol 1984; 91:111-117
25 Lehtovirta P and Forss M The acute effects of smoking on intravillous blood flow of the
placenta. Br J Obstet Gynaecol 1978; 85:729-731
Original Author: Edith Okola with Holly Halstead 26 Naeye RL Effects of maternal cigarette smoking on the fetus and placenta. Br J Obstet Gynaecol 1978; 85:732-737 27 Himmelberger DV, Brown BW, Cohen EN:Cigarette srnoking during pregnancy and the occurrence of spontaneous abortion and congenital malformation. Am J Epidemiol, 1978; 108:470-479 28 Kelsey JL, Theodore RH, Bracken MB: Maternal smoking and congenital malformations: An epidemiological study. J Epidem Community Health 1978; 32:103-107, 29 Tuula E. Tuormaa.The adverse effects of smoking on reproduction. Nutr Health. 1995;10(2):105-20. 30 Frazier TM, Davis GH, Goldstein H et al.: Cigarette smoking and prematurity: A predictive study. Am J Obstet Gynecol, 1961; 81:988-996 31 Frederick J, Anderson A: Factors associated with spontaneous pre-term birth. Br J Obstet Gynaecol, 1976; 83:342 32 Simpson WJ and Linda L: A preliminary report on cigarette smoking and the incidence of prematurity. Am J Obstet Gynecol, 1957; 73:808-815 33 Naeye RL and Peters EC: Mental development of children whose mothers smoked during pregnancy. Obstet Gynecol, 1984; 64(5):601-607 34 Martino J A, Galante A, Smoking-can it affect bone healing. HH, 1994. 35 Polito.J.R.How smoking destroys blood circulation.BHF.2005 36 The musculoskeletal effects of smoking.J Am Acad Orthop Surg. 2001; 9(1):9-17. 37 Cruickshanks K, Klein R et al. Cigarette Smoking and Hearing Loss -The Epidemiology of Hearing Loss Study JAMA. 1998;279:1715-1719 38 Nondahl D, Cruickshanks K et al. Serum Cotinine Level and Incident Hearing Loss: A Case-Control Study. Arch Otolaryngol Head Neck Surg. 2004;130:1260-1264. 39 Cheng AC, Pang CP, Leung AT, Chua JK, Fan DS, The association between cigarette smoking and ocular diseases. Hong Kong Med J. 2000; 6(2):195-202. 40 Kelly S P, Thornton J, Lyratzopoulos G, Edwards R, Mitchell P. Smoking and blindness. BMJ, 2004;(328) 7439: 537 41 http://my.webmd.com/content/article/98/104876.htm?src=rss_cbsnews (Accessed 11/10/08) 42 Lindblad BE, Hakansson N, Svensson H, Philipson B, Wolk A. Intensity of smoking and smoking cessation in relation to risk of cataract extraction: a prospective study of women. Am J Epidemiol. 2005; 162(1):73-9 43 A prospective 15-year follow-up study of mandibular fixed prostheses supported by osseointegrated implants. Clinical results and marginal bone loss Clin Oral Implants Res 1996; 7(4):329-36. 44 Tonetti. Ann. Cigarette smoking and periodontal diseases: etiology and management of disease. Periodontol 1998; 3(1):88-101.\ 45 Sennerby, R. Surgical determinants of clinical success of osseointegrated oral implants: a review of the literature. Int J. Proshtodont 1998; 11(5):408-20. 46 Esposito, Hirsch, Lekholm, Thomsen. Biological factors contributing to failures of osseointegrated oral implants. (II) Etiopathogenesis. Eur J Oral Sci 1998; 106(3):721-64. 47 Influences of smoking on the periodontium and dental implants. Dent Update 1997; 24(8)328-30. 48 Wilson, Higginbottom. Periodontal diseases and dental implants in older adults. J Esthet Dent 1998; 10(5):265:71. 49 Facts & Fallacies About Heartburn And GERD. American College Of Gastroenterology.MSIACG015 50 Smoking and Your Digestive System Fact sheet, National Digestive Diseases Information Clearinghouse, NIH Publication No. 95-949, October 1991. 51 Cigarette smoking and peptic ulcer, http://my.webmd.com/hw/health_guide_atoz/hw216734.asp (Accesssed 11/10/08) 52 Smoking and Your Digestive System, National Centre for Chronic Disease Prevention and Health, Promotion NIH Publication No. 02–949, March 2002 Original Author: Edith Okola with Holly Halstead
53 Smoking and Your Digestive System - Crohn's Disease, NIH Publication No. 02–949March
54 Pessione F, Ramond MJ, Njapoum C, Duchatelle V, Degott C, et al. Cigarette smoking and
hepatic lesions in patients with chronic hepatitis C. Hepatology 2001;34(1):121-5
55 Hézode C, Lonjon I, Roudot-Thoraval F, Mavier J-P, Pawlotsky J-M, et al. Impact of
smoking on histological liver lesions in chronic hepatitis. Gut 2003;52:126-129
56 Klatsky AL, Armstrong MA. Alcohol, smoking, coffee, and cirrhosis. Am J Epidemiol
57 Palmer M. Tobacco and Liver Disease. In Palmer M. Guide of Hepatitis and Liver Disease.
New York: Penguin Putnam, 2004
58 Kapoor D, Jones TH. Smoking and hormones in health and endocrine disorders. Eur J
Endocrinol. 2005; 152(4):491-9.
59 Windham GC, Mitchell PR, Fenster L, Lasley BL, Waller K, et al. Effects of tobacco
smoke exposure on hormones and fertility. Am J Epidemiol 2001; 153
60 Rimm EB et al. Cigarette smoking and the risk of diabetes in women. Am J Public Health
1993; 83:(2) 211-214
61 Kawakami, N. et al. Effects of smoking on incidence of non-insulin dependence diabetes
mellitus. Am J Epdemiol 1997; 145(2):103 – 109.
62 Rimm EB et al. Prospective study of cigarette smoking, alcohol use, and the risk of
diabetes in men. BMJ 1995; 310: 555-559.
63 Suarez L, Barrett-Connor E. Interaction between cigarette smoking and diabetes mellitus
in the prediction of death attributed to cardiovascular disease. Am J Epdemiol 1984; 120:
64 Al-Delaimy WK et al. Smoking and mortality among women with type 2 diabetes: The
Nurses’ Health Study cohort. Diabetes Care 2001; 12: 2043-8.
65 Mehler P, Jeffers B, Biggerstaff S, Schrier R. Smoking as a risk factor for nephropathy in
non-insulin-dependent diabetics. J Gen Intern Med. 1998;13:842-5
66 Pinto-Sietsma S, Janssen W, de Jong P, Smoking and Abnormalities in Renal Function.
Annals of Internal Med 2001; 135(1):68
67 Morton C, Klatsky A L, Udaltsova N, Smoking, Coffee, and Pancreatitis, Am J Gastro
2004; 99(4): 731
68 Imoto M, DiMagno EP. Cigarette smoking increases the risk of pancreatic calcification in
late-onset but not early-onset idiopathic chronic pancreatitis. Pancreas. 2000; 21(2):115-9
69 Orth SR. Effects of smoking on systemic and intrarenal hemodynamics: influence on renal
function. J Am Soc Nephrol. 2004; 15 Suppl 1:S58-63.
70 Orth SR, Viedt C, Ritz E. Adverse effects of smoking in the renal patient. Tohoku J Exp
Med. 2001; 194(1):1-15.
71 Orth SR, Schroeder T, Ritz E, Ferrari P. Effects of smoking on renal function in patients
with type 1 and type 2 diabetes mellitus. Nephrol Dial Transplant. 2005 20(11):2414-2419
72 Mosley JG, Gibbs AC: Premature grey hair and hair loss among smokers: a new
opportunity for health education? BMJ 1996; 313(7072): 1616
73 Freiman A, Bird G, Metelitsa AI, Barankin B, Lauzon GJ. Cutaneous Effects of Smoking. J
Cutan Med Surg 2005; 8(6):415-23
74 Yin L, Morita A, Tsuji T. Skin premature aging induced by tobacco smoking: the objective
evidence of skin replica analysis. J Dermatol Sci. 2001; 27 Suppl 1:S26-31
75 TrüebR.M .Association between Smoking and Hair Loss: Another Opportunity for Health
Education against Smoking? Dermatology 2003; 206:189-191
76 A. Ott, K. Andersen, M. E. Dewey, L. Letenneur, C. Brayne, et al. Effect of smoking on
global cognitive function in nondemented elderly. Neurology 2004;62:920-924
77 Riise, T. News release, American Academy of Neurology. Neurology, Oct. 28, 2003; vol
61: pp 1122-1124. (Warner J. Smoking Raises Multiple Sclerosis Risks, WebMD 2003)
http://my.webmd.com/content/article/76/89951.htm (Accessed 11/10/08)
Original Author: Edith Okola with Holly Halstead 78 Hernan, M. Brain, March 9, 2005. Miguel A. Hernan, MD, DrPH, department of epidemiology, Harvard School of Public Health, Boston. Nicholas LaRocca, PhD, director of health care delivery and policy research, National MS Society. 79 Sopori ML, Kozak W. Immunomodulatory effects of cigarette smoke. J Neuroimmunol. 1998;83(1-2):148-56 80 Cigarette smoking and coronary artery disease, WebMD 2004 http://my.webmd.com/hw/health_guide_atoz/hw79682.asp (Accessed 11/10/08) 81 Kriz P, Bobak M, Kriz B. Parental smoking, socioeconomic factors, and risk of invasive meningococcal disease in children: a population based case-control study Arch Dis Child 2000;83:117-121 82 Lam T, Leung GM and Ho LM. The effects of environmental tobacco smoke on health services utilization in the first eighteen months of life. Pediatrics 2001; 107(6) :e91 83 Anderson M. E, Johnson D. C, Batal H. A Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleep era BMC Medicine 2005, 3:4 84 E.A Mitchell, Smoking and Sudden Infant Death Syndrome., University of Auckland, Auckland, New Zealand; Milerad, Department of Women and Child Health, A. Lindgren, Children Hospital at Karolinska Institute, Stockholm, Sweden. 85 International Consultation on Environmental Tobacco Smoke (ETS) and Child Health, 11-14 January 1999.Geneva, Switzerland. http://old.ash.org.uk/html/passive/html/who-ets.html (Accessed 11/10/08) 86 International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. Consultation Report, WHO 1999 http://old.ash.org.uk/html/passive/html/kidsbrief.html (Accessed 11/10/08) 87 Tengs TO, Osgood ND. The link between smoking and impotence: two decades of evidence. Prev Med. 2001; 32(6):447-52. 88 Viczian M: Ergebnisse von Spermautersuchungen bei Zigarettenrauchen. Z Haut Geschlectskr, 44:183-187, 1969 89 Kulikauskas V, Blaustein D, Ablin RJ: Cigarette smoking and its possible effect on sperm. Fertil Steril, 1985; 44:526-528 90 Rantala ML, Koskimies AI. Semen quality of infertile couples - comparison between smokers and non-smokers. Andrologia 1986; 19:42-46 91 Saaranen M, Suonio S, Kauhanen O, Saarikoski S: Tupakka ja siemennesteen laatu. Suomen Laakarilehti, 1986; 36:3466-3470 92 Wynn M, Wynn A: The Prevention of Handicap of Early Pregnancy Origin. London: Foundation for Education and Research in Childbearing, 1981. pp28-33 93 Bernard P. Die Wirkung des Rauchens auf Frau and Mutter. Munch Med Wochenschr, 1962; 104:1826 94 Jick H, Porter J, Morrison AS. Relation between smoking and age of natural menopause. The Lancet 1977; 1:1354-1355, 1977 95 Linquist O, Bengtsson C: Menopausal age in relation to smoking. Acta Med Scand, 1979; 205:73-77 96 Campbell AM. Excessive cigarette smoking in women and its effect upon their reproductive efficiency. J Mich Med Soc, 1935; 34:146-151 97 Action on smoking and health. Secondhand smoke Factsheet no 8 March 2006 http://www.ash.org.uk (Accessed 11/10/08) 98 US Surgeon General. The health consequences if smoking:chronic obstructive lung disease. USGPO, 1984. 99 Hirayama T. Non-smoking wives of heavy smokers have a higher risk of lung cancer:a study from Japan. BMJ 1982;282:183- 100 Scientific committee on tobacco and health. Second hand smoke review of evidence since 1998 http://www.dh.gov.uk/assetRoot/04/10/14/75/04101475.pdf (Accessed 11/10/08) 101 Otsuka R. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441 Original Author: Edith Okola with Holly Halstead 102 Law MR, Morris JK Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ 1997; 315: 973-80 103 Halstead H. The impact of passive smoking on children and their treatment regimes. Barnet PCT 2005 104 Oddoze C, Dubus JC, Badie M, Thirion X, Pauli AM, Pastor J, Bruguerolle B. Urinary cotinine and exposure to parental smoking in a population of children with asthma. Clinical Chemistry 1999;45:505-9 105 Chilmonczyk BA, Salmun LM, Megathlin KN, Neveux LM, Palomaki GE, Knight GJ, Pulkkinen AJ, Haddow JE. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. NEJM 1993;328:1665-9 106 Wald NJ, Boreham JBailey A, Ritchie CR, Haddow JE, Knight GJ. Urinary cotinine as marker of breathing other people's tobacco smoke. Lancet 1984;1:230-231 107 Irvine L, Crombie IK, Clark RA, Slane PW, Goodman KE, Feyerabend C, Cater JI. What determines levels of passive smoking in children with asthma? Thorax 1997;52:766-9 108 Matt GE, Wahlgreen DR, Hovell MF, Zakarian JM, Bernert JT, Meltzer SB, Pirkle JL, Caudill S. Measuring environmental tobacco smoke exposure in infants and young children through urine cotinine and memory-based parental reports:empirical findings and discussion. Tobacco Control 1999;8:282-9 109 Jarvis MJ et al. Children’s exposure to passive smoking in England since the 1980s: cotinine evidence from population surveys. BMJ 2000; 321: 343-345 110 Aligne CA, Maoo ME, Auinger P, Weitzman M. Association of paediatric dental caries with passive smoking. JAMA 2003;289:1258-1264 111 Strachan DP, Cook DG. Health effects of passive smoking.4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax 1998;53:50-6 112 Kriz P, Bibak M, Kriz B. Parental smoking, socio-economic factors, and risk of invasive meningococcal disease in children: a population based case control study. Archives of disease in childhood 2000;83:117-121 113 de Jongste JC, Shields MD. Chronic cough in children. Thorax 2003;58:998-1003 114 Strachan DP, Cook DG. Health effects of passive smoking.1.Parental smoking and lower respiratory illness in infancy and early childhood. Thorax 1997;52:905-14 115 Strachan DP, Cook DG. Health effects of passive smoking. 6. Parental smoking and childhood asthma:longitudinal and case control studies. Thorax 1998;53:204-12 116 Strachan DP, Cook DG. Health effects of passive smoking. 3.Parental smoking and prevalence of respiratory symptoms and asthma in school age children. Thorax 1997;52:1081-9 117 CookDG, Strachan DP, Carey IM. Health effects of passive smoking.9. Parental smoking and spirometric indices in children. Thorax 1998;53:884-893 118 Dunn A, Zeise L, eds. Health effects of exposure to environmental tobacco smoke. Californian Environmental Protection Agency, 1997. 119 Anderson HR, Cook DG. Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax 1997; 52:1003-9 120 Tredger JM, Stoll S. Cytochrome P450-their impact on drug treatment. Hospital Pharmacist 2002; 9:167-173 121 www.hospitalist.net/highligh.htm (Accessed 25.11.2005) 122 Bazire S. Psychotropic Drug Directory 2003/04. Salisbury, UK: Fivepin Publishing 123 Axelsson T, Jansson PA, Smith U, Eliasson B. Nicotine infusion acutely impairs insulin sensitivity type 2 diabetic patients but not in healthy subjects. J Intern Med. 2001; 249:539-44 124 Stockleys drug interaction. https://www.medicinescomplete.com/mc/ (Accessed 11/10/08) 125 Skolnic ET, Vomvolakis MA, Buck KA, Mannino SF, Sun LS. Exposure to environmental tobacco smoke and the risk of adverse respiratory events in children receiving general anaethesia. Anesthesiology 1998; 88(5):1144-1153 126 Lyons B, Frizelle H, Kirby F, Casey W. The effect of passive smoking on the incidence of airway complications in children undergoing general anaesthesia. Anaesthesia 1996; 51:324-326 Original Author: Edith Okola with Holly Halstead 127 Lakshmipathy N, Bokesch PM, Cowan DE, Lisman SR, Schmid CH. Environmental tobacco smoke:a risk factor for pediatric laryngospasm. Anesthetic Analgesia 1996; 82:724-7 128 Praveen C, Terry RM. Does passive smoking affect the outcome of grommet insertion in children? The Journal of Laryngology and Otology 2005; 119:448-455 129 Ramadan HH, Hinerman RA. Smoke exposure and outcome of endposcopic sinus surgery in children. Otolarynology-Head and neck Surgery 2002; 127:546-8 130 Soussan D, Liard R, Zureik M, Touron D, Rogeaux Y, Neukirch F. Treatment compliance, passive smoking, and asthma control:a three year cohort study. Archives of Disease in Childhood 2003; 88:229-233 131 Smokefree Places: the Case for Legislation http://www.ash.org.uk/ (Accessed 11/10/08) 132 Action on smoking and health. Beyond “smoking kills” A submission to the Choosing Health consultation from ASH. May 2004 http://www.ash.org.uk/ (Accessed 11/10/08) 133 West R. Banning smoking in the Workplace BMJ 2002;325:174-175 134 The State of Smoke-Free New York City: A One-Year Review. NYC Department of Finance, NYC Department of Health and Mental hygiene, NYC Department of Small Business Services, NYC Economic Development Corporation. March 2004. 135 Office of Tobacco Control Smoke-Free Workplace Legislation Implementation Progress Report May 2004 136 Action on smoking and health. Tobacco advertising and promotion: Factsheet 19. May 2006 http://www.ash.org.uk (Accessed 11/10/08) 137 Andrews RL, Franke GR. The determinants of tobacco consumption: A meta-analysis. Journal of Public Policy and Marketing. 1991;10:81-100 138 Smee C, Parsonage M, Anderson R, Duckworth S. Effect of tobacco consumption: a discussion document reviewing the evidence. London: Economics and Operational Research Division, Department of Health, 1992. 139 Reducing the health consequences of smoking; 25 years of progress. A report of the surgeon general. USDHH, 1989. 140 Council Directive on the regulation of tobacco products. 141 Tobacco factsheet November 2005. HM Revenue and Customs 142 Action on smoking and health. The economics of tobacco: Factsheet no:16 April 2006 143 Parrott, S et al. Guidance for commissioners on the cost effectiveness of smoking cessation interventions. Thorax 1998; 53: supplement 5, part2:S1 144 Parrott S, Godfrey C. Economics of smoking cessation. BMJ 2004;328:947-949 145 HM Customs and Excise Annual Report 2003-4 146 Lader D, Goddard E. Smoking related behaviour and attitudes, 2004. London, ONS 2005. 147 Statistical Bulletin 2003/21: Statistics on smoking: England, 2003 (Department of Health, Office for National Statistics) 148 The Health Benefits of Smoking Cessation:A Report of the Surgeon General. US DHHS, 1990. 149 West R, Tobacco withdrawal symptoms. St George’s Hospital Medical School, 1996. 150 Action on smoking and health. Stopping smoking: The benefits and aids to quitting. November 2005 151 West R., McNeill A and Raw M. Meeting Department of Health smoking cessation targets:recommendations for primary care trusts. London: Health Development Agency, 2003. 152 Smoking habits in Great Britain. Office for National Statistics http://www.statistics.gov.uk/cci/nugget.asp?id=313 (Accessed 11/10/08) 153 West R, McNeill A, Raw M. Smoking cessation guidelines for health professional:an update. Thorax 2000;55;987-999 154 Brief interventions and referral for smoking cessation in primary care and other settings NICE Public Health Intervention Guidance 1. March 2006 Original Author: Edith Okola with Holly Halstead
2008 112: 3527-doi:10.1182/blood-2008-05-160010 About reporting clinical trials Jean-Louis Bernard, Julie Berbis, Laurent Boyer and Vincent Pradel Updated information and services can be found at: Information about reproducing this article in parts or in its entirety may be found online at: Information about ordering reprints may be found online at: Information about subscriptions an