Effects of Smoking on Health Quiz 1

Clinician-Assisted Tobacco Cessation

• Presenter: Kelly Orr, PharmD, AE-C, Clinical Professor at the University of Rhode Island College of Pharmacy.
• Topic overview includes: Epidemiology of Tobacco Use, Nicotine Pharmacology & Principles of Addiction, Drug Interactions with Smoking, Forms of Tobacco, Medications for Cessation (Part 2), and Assisting Patients with Quitting (PHC 415).

Epidemiology of Tobacco Use

• Cigarette smoking is the leading, preventable cause of death in society.
• All forms of tobacco are harmful.
• Trends in adult cigarette consumption (1900-2002) show a peak in the mid-1960s, declining thereafter.
• The Surgeon General's Report (1964) was a key event in linking smoking to health risks.
• Smoking prevalence in adults (since 1955) has decreased in both males and females.
• In 2021, US adult smoking rates were 11.5% for cigarettes and 13.1% overall for commercial tobacco products.
• Current adult use of any form of tobacco (2021): 11.5% for cigarettes, showing a downward trend over time; 3.4% used more than one type; and 14.5% used a "combustible" product.
• Current use of e-cigarettes and nicotine pouches among US middle and high school students (2024): 5.9% for e-cigarettes, 1.8% for nicotine pouches.

State-Specific Prevalence of Smoking (2014-2015)

• Map showing geographic variations in adult smoking prevalence.
• High rates are concentrated in specific regions.

Prevalence of Adult Cigarette Smoking, by Race/Ethnicity (2021)

• Rates varied by race/ethnicity. White adults had the highest rate (12.9%), followed by Black or African American (11.7%), Hispanic (7.7%), and Asian (5.4%).

Prevalence of Adult Cigarette Smoking, by Education (2021)

• Individuals with no high school diploma had the highest rate (20.1%), followed by those with a GED (30.7%).
• Rates decreased with increasing educational attainment. Highest rate among high school graduate (17.1%).

Trends in Teen Smoking by Ethnicity (1977-2021)

• Trends in cigarette smoking (30-day prevalence) among 12th graders by ethnicity (White, Hispanic, Black) showed a downward trend overall.

Marketing Strategy: "Light" Cigarettes

• Marlboro Lights marketed with ventilation holes, promoting a perception of reduced harm compared to regular Marlboro cigarettes.
• Advertisements used to portray cigarettes as positive and safe.

FDA Regulation of Tobacco Products

• FDA Center for Tobacco Control Products regulates cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco, and e-cigarettes.

Compounds in Tobacco Smoke

• An estimated 8,700 chemicals in tobacco smoke, including 72 proven/suspected carcinogens.
• Nicotine is the addictive substance but not the driver of all illnesses.

Annual U.S. Deaths Attributable to Smoking (2005-2009)

• Summary of deaths attributed to smoking across different disease categories, with percentages of the total.

Annual Smoking-Attributable Economic Costs

• Significant costs were assigned, including healthcare expenditures and lost productivity.

2014 Report of the Surgeon General: Health Consequences of Smoking

• Cigarette smoking causes diseases of all body parts, reduced health status, and harms to the fetus.
• Exposure to secondhand smoke jeopardizes the health of infants and children.

Health Consequences of Smoking (2014)

• Comprehensive summary of diseases linked to smoking, including cancers (bladder, kidney, acute myeloid leukemia, cervix, colon/rectum, esophagus/stomach, liver, lung, oropharynx/larynx, pancreatic), pulmonary diseases (asthma, COPD, pneumonia/tuberculosis, chronic respiratory symptoms), cardiovascular diseases (aortic aneurysm, coronary heart disease, cerebrovascular disease, peripheral vascular disease), and reproductive effects (reduced fertility, poor pregnancy outcomes, infant mortality).

Health Consequences of Smokeless Tobacco Use

• Periodontal effects (gingival recession, bone attachment loss, dental caries), oral leukoplakia, oral cancer and pharyngeal cancer.

2006 Report of the Surgeon General: Involuntary Exposure to Tobacco Smoke

• Secondhand smoke causes premature death and disease in nonsmokers, especially children (SIDS risk, respiratory infections, ear infections, severe asthma, slowed lung growth.)
• There's no safe level of secondhand smoke. Indoor spaces are safer without it.

Quitting: Health Benefits

• Benefits of quitting smoking over time, such as improved circulation, easier walking, increased lung function, reduced risk of cardiovascular disease, similar lung cancer death rates to never smokers, and reduced stroke risk.

Beneficial Effects of Quitting: Pulmonary Effects

• Quitting smoking improves lung function even after starting smoking at a later age.

Reduction in Cumulative Risk of Death from Lung Cancer in Men

• Demonstrates how stopping smoking at different ages significantly reduces the risk of lung cancer death compared to continued smoking.

Smoking Cessation: Reduced Risk of Death

• Smoking cessation is linked to a gain in life expectancy.
• Smokers, on average, die approximately 10 years younger than nonsmokers. At least half of smokers who continue will die from a tobacco related illness.

Financial Impact of Smoking

• Costs associated with smoking are considerable ($3,069 annual cost for a smoker + additional costs for healthcare related to those illnesses.)

Epidemiology of Tobacco Use: Summary

• Fewer than one in five adults is a current smoker in the US.
• Nearly half a million US deaths are attributed to smoking annually.
• Annual cost for smoking is over $288.9 billion.

Nicotine Addiction: U.S. Surgeon General's Report

• Cigarettes and other tobacco products are addictive.
• Nicotine is the substance that causes addiction; addiction from nicotine shares similarities with heroin and cocaine addiction.

Chemistry of Nicotine

• Nicotine is a natural liquid alkaloid, colorless, and volatile. Its pK2 is 8.0.

Pharmacology (Pharmacokinetics)

• Effects of the body on the drug; includes absorption, distribution, metabolism, and excretion.

Nicotine Absorption

• Absorption through intact skin is straightforward.
• Well absorbed in the small intestine.
• Low bioavailability (~20-45%) due to first-pass hepatic metabolism.

Nicotine Absorption: Buccal (Oral) Mucosa

• Oral pH (7.0) is alkaline, supporting significant nicotine absorption.
• Beverages can change factors affecting absorption.

Nicotine Absorption: Skin and Gastrointestinal Tract

• Nicotine readily absorbs through skin. Well absorbed in the small intestine.
• Low bioavailability (20–45%) due to first-pass hepatic metabolism.

Nicotine Absorption: Lung

• Nicotine is "distilled" from the burning tobacco to the lungs in tar droplets and rapidly absorbed across the respiratory epithelium from the alveoli.
• The large alveolar surface area and extensive capillary network also influence this process.
• Approximately 1 mg of nicotine is absorbed per cigarette.

Nicotine Distribution

• Reaches the brain within 10-20 seconds.

Nicotine Metabolism

• 70-80% is metabolized to cotinine and then eliminated.
• 10% are other metabolites.
• 10-20% is excreted in urine unchanged.

Nicotine Excretion

• Half-life of nicotine (t1/2): ~2 hours; cotinine t1/2 = ~16 hours.
• Elimination primarily through the kidneys; affected by pH, with higher excretion when acidic urine.
• Nicotine can also be present in breast milk.

Nicotine Pharmacodynamics

• Nicotine's effects are predominantly stimulatory, affecting the central nervous system (pleasure, arousal, vigilance), cardiovascular system (heart rate, cardiac output, blood pressure, coronary vasoconstriction), gastrointestinal system, neuromuscluar junction, sensory receptors, and other organs.

Nicotine Pharmacodynamics (cont'd)

• Nicotine affects CNS by: Pleasure, Arousal, vigilance, Improved task performance, and Anxiety relief.
• Nicotine affects the Cardiovascular system by Increased heart rate, Increased cardiac output, Increased Blood pressure, and Coronary and Cutaneous vasoconstriction.
• Nicotine affects Other by: Appetite suppression, Increased metabolic rate, Skeletal muscle relaxation

Neurochemical Effects of Nicotine

• Nicotine affects neurochemicals like dopamine, norepinephrine, acetylcholine, glutamate, serotonin, beta-endorphin, and GABA.

What is Addiction?

• Addiction is defined as compulsive drug use without medical justification in the face of negative consequences.

Dopamine Reward Pathway

• Nicotine's effects involve stimulation of the dopamine reward pathway, linking to pleasure and reinforcing behavior.

Chronic Administration of Nicotine: Effects on the Brain

• Chronic nicotine exposure results in increased nicotine receptors in the prefrontal cortex.

Nicotine Withdrawal Symptoms: Time Course

• Withdrawal symptoms, including irritability, anxiety, difficulty concentrating, restlessness, depressed mood, insomnia, impaired task performance, increased appetite, weight gain, and cravings, peak within the first 1-2 days and usually subside 2-4 weeks following quitting.

Nicotine Addiction Cycle

• Nicotine concentrations fluctuate to maintain a critical serum level, preventing withdrawal and rewarding the user.

Nicotine Addiction

• Tobacco users maintain a threshold serum nicotine concentration to ward off withdrawal symptoms, pleasure/arousal, and mood regulation.
• Users adapt/increase their smoking/vaping frequency/intensity.

Assessing Nicotine Dependence (FTND)

• Fagerström Test for Nicotine Dependence (FTND) is common, assessing nicotine dependence; scores above 5 indicate substantial dependence.

Nicotine Pharmacology and Addiction: Summary

• Summarizes that nicotine is highly addictive and requires multifaceted treatment.

Drug Interactions with Tobacco Smoke

• Summary of drugs affected by smoking and quitting (induces CYP1A2 enzymes and results in needing higher doses prior to quitting).

Drug Interactions: Tobacco Smoke and Caffeine

• Caffeine levels increase significantly (~56%) upon quitting smoking.

Pharmacodynamic Drug Interactions with Tobacco Smoke

• Smokers using combined hormonal contraceptives have an elevated risk of serious cardiovascular issues, such as stroke, myocardial infarction, and thromboembolism.

Drug Interactions with Tobacco Smoke: Summary

• Clinicians must consider patient smoking status while prescribing medications; the combustion products of tobacco smoke, not nicotine, are typically involved in these effects.

Factors Contributing to Tobacco Use

• Individual factors (sociodemographics, genetics, coexisting medical conditions) and environmental factors (tobacco advertising, conditioned stimuli, social interactions) drive tobacco use, as does nicotine and its pharmacological effects.

Tobacco Dependence: A 2-Part Problem

• Tobacco dependence is biologically motivated and behaviorally driven and requires targeting both.

Forms of Tobacco

• Different ways people ingest or use tobacco, including cigarettes, chewing tobacco, snuff, snus, cigars, pipes, hookah, and electronic nicotine delivery systems.

Cigars

• Categorizes cigars as traditional, cigarillos, or filtered cigars and considers their prevalence in the Unites States.

Electronic Nicotine Delivery Systems

• Summarizes issues related to inconsistency in e-cigarette regulation, variability in nicotine delivery due to product differences and puff variations, and imprecise nicotine labeling/content.

Electronic Cigarettes: Potential Health Risks

• Propylene glycol, glycerin, nicotine, and carcinogens in e-cigarette aerosols may lead to respiratory irritation, asthma, lipoid pneumonia, poisoning risks, and long-term health issues are possible.

Plasma Nicotine Concentrations: Cigarettes and JUUL

• Graphic demonstrating nicotine concentration differences between cigarette and JUUL use

Tobacco Harm Reduction

• Describes the concept of minimizing harms and decreasing total morbidity/mortality from tobacco and nicotine use through harm reduction strategies.

Forms of Tobacco: Summary

• Cigarettes remain the most common, but other forms exist and are growing in popularity.