The Primary Care Physician’s Guide
to the Systemic Effects of Smoking
and the Benefits of Cessation
Overview

Smoking and
– Malignancy
– Renal disease
– Dermatologic effects
– Effects on the oral cavity
– Endocrinologic effects
Smoking and Malignancy

Malignancy
– Lung
– Pancreas
– Esophagus
– Kidney
– Bladder
– Gastric
Risk of Lung Cancer
 Current smokers have a higher risk of developing lung cancer than exsmokers or nonsmokers
18
Hazard Ratio (95% CI)a
16
14
12
10
8.4
8
6
3.6
4
2
1.0
0
Never Smokers
aThe
Ex-smokers
Current Smokers
relative likelihood of experiencing a particular event or the effect of an explanatory variable on the hazard
or risk of an event.
Mannino et al. Arch Intern Med. 2003;163:1475-1480.
Risk of Lung Cancer
 The risk of developing lung cancer is directly related to the amount
Hazard Ratio (95% CI)a
smoked
40
35
30
25
19.9
20
15
9.0
10
5
1.0
0
Never Smokers
2.9
30
30 to 60
60
Pack/Years
Pack/year was calculated by multiplying the average number of cigarettes smoked daily by the number of years
smoked and dividing the product by 20.
aThe relative likelihood of experiencing a particular event or the effect of an explanatory variable on the hazard
or risk of an event.
Mannino et al. Arch Intern Med. 2003;163:1475-1480.
Risk of Pancreatic Cancer
Relative Risk (95% CI)a
10.0
8.0
6.0
4.0
2.0
3.3
1.7
1.6
1.0
0.0
Nonsmokers
aThe
Female
Smokers
Male
Smokers
Males Smoking
40 Cigarettes
per Day
probability of an event (developing a disease) occurring in exposed people compared with the probability of
the event in nonexposed people.
Lin et al. Cancer Causes Control. 2002;13:249-254.
Risk of Pancreatic Cancer
 Former smokers reduced their risk of developing pancreatic cancer by
Relative Risk (95% CI)a
almost 50% within 3-10 years of quitting, compared with the risk in current
smokers
1.2
1.0
0.8
0.6
0.4
0.2
0.0
aThe
Current
2
3-10
11-15
16
Never
Time Since Quitting Smoking (years)
probability of an event (developing a disease) occurring in exposed people compared with the probability of
the event in nonexposed people.
Relative risk measured with reference to current smokers. Reference RR of 1 refers to current smokers.
Fuchs et al. Arch Intern Med. 1996;156:2255-2260.
Risk of Esophageal Cancer

 Smokers have an approximately
3-fold increased risk of
esophageal squamous cell cancer
 Ex-smokers have a lower risk of
squamous cell esophageal cancer
than current smokers
 Ten years after cessation of
smoking, ex-smokers still have a
2-fold increased risk
Nature Clinical Practice. http://www.nature.com/ncpgasthep/journal/v2/n1/fig_tab/ncpgasthep0072_ft.html.
Accessed September 19, 2007. Bosetti et al. Oral Oncol. 2006;42:957-964; Wu et al. Cancer Causes Control.
2001;12:721-732.
Risk of Esophageal and Gastric Cancer
 Smokers have an increased risk of developing esophageal, gastric, and
distal gastric cancer
Odds Ratio (95% CI)a
4.5
Never Smokers
4.0
Current Smokers
3.5
2.80
3.0
2.5
2.12
2.0
1.5
1.50
1.00
1.00
1.00
1.0
0.5
0.0
aThe
Esophageal
Adenocarcinoma
(n=222)
Gastric Cardia
Adenocarcinoma
(n=277)
Distal Gastric
Adenocarcinoma
(n=443)
ratio of the odds of development of disease in exposed persons to the odds of development of disease in
nonexposed persons. Adjusted for age, sex, race, birthplace, and education.
Wu et al. Cancer Causes Control. 2001;12:721-732.
Risk of Esophageal and Gastric Cancer
 Increased risk of developing GI cancers is dependent upon the number
of years smoked
4.0
Odds Ratio (95% CI)a
3.5
Esophageal
adenocarcinoma
(n=222)
Gastric cardia
adenocarcinoma
(n=277)
Distal gastric
adenocarcinoma
(n=443)
3.0
2.5
2.09
2.0
1.5
2.16 2.26
1.61
1.36 1.50
1.40
1.10
0.84
1.0
0.5
0.0
20
21-40
≥41
Years of Smoking
aThe
ratio of the odds of development of disease in exposed persons to the odds of development of disease in
nonexposed persons. Adjusted for age, sex, race, birthplace, and education.
Wu et al. Cancer Causes Control. 2001;12:721-732.
Risk of Bladder Cancer
 Smoking is one of the most
important risk factors associated
with bladder cancer
 Prevention of cigarette smoking
would result in 50% fewer men
and 23% fewer women with
bladder cancer
 Current cigarette smokers have
an approximately 3-fold
greater risk of bladder cancer
than nonsmokers
Zeegers et al. World J Urol. 2004;21:392-401; Urology channel.
http://www.urologychannel.com/bladdercancer/index.shtml. Accessed September 20, 2007
Risk of Renal Cancer
 Relative risk for developing renal cancer is increased with greater
cigarette consumption
Relative Risk (95% CI)a
3.0
2.5
2.03
2.0
1.60
1.58
1.5
0.98
1.0
0.5
0.0
Cigarettes/Day
20
1-9
Men
aThe
20
1-9
Women
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people.
Hunt et al. Int J Cancer. 2005;114:101-108.
Risk of Renal Cell Cancer Decreases With
Longer Duration of Abstinence
 Relative risk for developing renal cell cancer decreases with length
of time from smoking cessation
Relative Risk (95% CI)a
3.0
2.5
2.0
b
1.75
c
1.5
1.21
1.0
0.5
0.0
Short-term
Long-term
Male Ex-smokers
aThe
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people. bShort-term ex-smokers were those who had quit smoking <10 years before
diagnosis. cLong-term ex-smokers were those who had quit smoking >10 years ago (reported categories).
Hunt et al. Int J Cancer. 2005;114:101-108.
Summary: Smoking and Cancer

Smoking is associated with an increased risk of
developing the following cancers:
– Lung
– Pancreatic
– Esophageal
– Gastric
– Bladder
– Renal

The risk of developing some cancers may be related to
the duration and amount smoked

Ex-smokers may have a reduced cancer risk compared
with current smokers
 Risk of developing cancer may decrease with longer
duration of abstinence
Endocrine Effects of Smoking
 Osteoporosis
 Thyroid disease
 Insulin resistance/diabetes
Osteoporosis Risk and Smoking
Epidemiology of Hip Fracture in Smokers

Smoking is a risk factor for hip fracture in postmenopausal
women
 In current postmenopausal smokers relative to
nonsmokers, the risk of hip fracture is 17% greater at age
60, 41% greater at age 70, and 71% greater at age 80

Of all hip fractures in women, 1 in 8 may be attributable
to smoking

Smoking increases the lifetime risk of postmenopausal hip
fracture by about half, from an estimated 12% to 19% in
women up to the age of 85, and from 22% to 37% up to
the age of 90
Law et al. BMJ. 1997;315:841-846.
Bone Mineral Density (BMD):Similar in
Premenopausal Smokers and Nonsmokers
 In premenopausal women, there is little difference in BMD between
smokers and nonsmokersa
Differences in
Bone Density (SD)a
1.0
0.5
0
(0.5)
(1.0)
20
aBMD
30
Age
40
50
55
differences were recorded as a proportion of 1 standard deviation (SD), because absolute bone density
units varied among studies. White circles refer to 2 studies and yellow circles to 10 studies.
Differences are recorded as a proportion of 1 SD in BMD. The regression line is drawn through the data points
to estimate the average values for the variable on the vertical scale (y) according to values of the variable on
the horizontal scale (x).
Law et al. BMJ. 1997;315:841-846.
Bone Mineral Density: Differences Between
Postmenopausal Smokers and Nonsmokers
 Postmenopausal bone loss is greater in current smokers than nonsmokers
 Bone density diminishes by about an additional 2% for every 10-year
increase in age, with a difference of 6% at age 80
Differences in
Bone Density (SD)a
1.0
0.5
0
(0.5)
(1.0)
45
aBone
50
60
Age
70
80
mineral density (BMD) differences were recorded as a proportion of 1 standard deviation, because
absolute bone density units varied among studies. White circles refer to 2 studies and yellow circles refer to 22
studies.
The regression line is drawn through the data points to estimate the average values for the variable on the
vertical scale (y) according to values of the variable on the horizontal scale (x).
Law et al. BMJ. 1997;315:841-846.
Bone Mineral Density in Elderly Women
 Heavy smokers have an increased reduction in bone mineral density
(BMD) compared with light and nonsmokers
Total Body
0.84
1.02
0.82
1.00
0.80
0.78
a
BMD (g/cm2)
BMD (g/cm2)
Total Femur
0.98
a
0.96
0.76
0.94
0.74
0.00
0.00
Nonsmokers 1 ≥1 Pack/Day
Nonsmokers 1 ≥1 Pack/Day
Cigarettes/Day
Cigarettes/Day
Current Smokers
Current Smokers
aP<.05 compared with nonsmokers. Values are adjusted means and standard error of adjusted means. Means
are compared by adjusted covariance for alcohol intake, total body BMD, height, weight, dietary calcium, and
caffeine intake.
Rapuri et al. Bone. 2000;27(3):429-436.
Relation of Smoking to
Thyroid Disease
Smoking as a Risk Factor for Thyroid
Dysfunction in Women
Disease State
Attributable Riska
Graves’ disease
45%
Nodular goiter
28%
Autoimmune hypothyroidism
23%

Female smokers have an increased risk of Graves’ disease,
toxic nodular goiter, and autoimmune hypothyroidism
aAttributable
risk is used to quantify risk in the exposed group that is attributable to the exposure.
Vestergaard et al. Thyroid. 2002;12(1):69-75.
Smoking and Graves’ Disease
 Increased susceptibility to Graves’
disease
 Increased incidence and clinical
severity of ophthalmopathy
 Smoking abstinence may result in
a decrease in morbidity in women
http://db2.photoresearchers.com/cgi-bin/big_preview.txt?image_iid=10791029. Accessed October 23, 2007;
Vestergaard. Eur J Endocrinol. 2002;146:153-161.
Smoking as a Predictor of Graves’ Disease
4.5
Hazard Ratio (95% CI)a
4.0
3.5

Women who smoke 25 cigarettes daily have the greatest risk of
Graves’ disease

Among women who previously smoked, risk of Graves’ disease
decreases with prolonged smoking cessation
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Nonsmokers
Ex-smokers
Current Smokers
1-14
15-24
25
Cigarettes/Day
Current Smokers
aThe
relative likelihood of experiencing a particular event or the effect of an explanatory variable on the hazard or risk of an event.
Adjusted for age, duration of oral contraceptive use, age at menarche, parity, recent pregnancy, menopausal status, body mass
index (BMI), alcohol intake, and physical activity level.
Holm et al. Arch Intern Med. 2005;165:1606-1611.
Smoking: A Risk Factor for
Hypothyroidism
 Nystrom et al
– 12-year follow-up of 1462
randomly selected women
in 5 age strata, evaluated
longitudinally
– Strong association found
between smoking at time of
initial screening and later
development of
hypothyroidism
– Relative riska for woman
smoker to develop
hypothyroidism is 3.9
(95% CI, 1.6-9.1)
aThe
relative likelihood of experiencing a particular event or the effect of an explanatory variable on the
hazard or risk of an event.
Nyström et al. J Endocrinol Invest. 1993;16:129-131.
Insulin Resistance and Smoking
Insulin Resistance Syndrome in Male
Smokers

A syndrome in which endogenous insulin fails to produce
an adequate physiologic response from fat, muscle, and
liver cells

Compared with nonsmoking men of similar age and BMI,
smokers had
– Insulin resistance
• Higher fasting levels of triglycerides
• Lower HDL-C
• Elevated C-peptide levels, consistent with compensatory
increase in insulin release as a result of insulin resistance
• Larger adipose mass at the expense of lean body tissue
without increased weight
• Lipid intolerance
Eliasson et al. Atherosclerosis. 1997;129:79-88.
Type 2 Diabetes Mellitus
Risk of Type 2 Diabetes Mellitus: Men
 History of current or past smoking is associated with an elevated
risk of diabetes mellitus
Relative Risk (95% CI)a
2.0
b
1.5
1.49
c
1.31
1.00
1.0
0.5
0.0
Nonsmokers
Ex-smokers
Current Smokers
Aged 20-69 Years
aThe
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people; bP=.0383; cP=.0043.
Adjusted for ex-and current smokers, age, BMI, waist/hip ratio, alcohol consumption (yes/no).
Beziaud et al. Diabetes Metab. 2004;30:161-166.
Risk of Developing Type 2 Diabetes: Men
 Smoking is associated with an increased risk of diabetes
Relative Risk (95% CI)a
3.0
2.5
2.0
1.79
1.71
1.5
1.00
1.0
0.5
0.0
Nonsmokers
Light Smokers
(1-19/Day)
Moderate/Heavy Smokers
(20/Day)
Cigarettes/Day
Current Smokers
aThe
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people. Adjusted for age and BMI.
Wannamethee et al. Diabetes Care. 2001;24(9):1590-1595.
Smoking Cessation and Risk of Type 2
Diabetes
 Risk of developing diabetes decreases with increased duration of
cessation
Relative Risk (95% CI)a
3.5
3.0
2.5
1.89
2.0
1.5
1.20
1.42
0.95
1.0
0.5
0.0
5
5-10
11-19
20
Time Since Quitting (Years at Screening)
aThe
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people. Adjusted for age and BMI.
Wannamethee et al. Diabetes Care. 2001;24(9):1590-1595.
Smoking-Associated Hyperglycemia:
Pathophysiology

Increase in free fatty acids might be cause of insulin
resistance

Cigarette smoking may release free radicals that could
reduce insulin sensitivity

Tobacco use can stimulate epinephrine and
norepinephrine

Direct toxic effect on pancreatic cells has been
suggested
Beziaud et al. Diabetes Metab. 2004;30:161-166.
Summary: Smoking and the Endocrine
System

Postmenopausal bone loss is greater in smokers than in
nonsmokers

Women who smoke have an increased risk of developing
Graves’ disease

Smoking is associated with an increased incidence and
clinical severity of Graves’ ophthalmopathy

Male smokers have a higher incidence of insulin
resistance than male nonsmokers


Smokers are at increased risk of developing diabetes
Risk of type 2 diabetes decreases with increased duration
of smoking abstinence
Smoking and Renal Disease
 Chronic kidney disease (CKD)
 Decreased renal function
 Decreased glomerular filtration rate (GFR)
 Increased relative risk of proteinuria
Smoking and Risk of Chronic Kidney Disease


Smoking is associated with an increased risk of chronic kidney disease (CKD)
Compared with current smokers, ex-smokers have a reduced risk of CKD
Odds Ratio (95% CI)a
3.5
3.0
2.5
2.18
2.0
1.5
1.0
1.09
1.0
0.5
0.0
Nonsmokers
Ex-smokers
Current Smokers
CKD=kidney damage for 3 or more months, defined in this study as an estimated GFR of less than 60 mL/minute per 1.73 m2.
Ex-smoker is anyone who smoked >100 cigarettes in his/her lifetime, but had stopped smoking at least 1 year prior to examination.
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Adjusted
for age, sex, education, BMI, current nonsteroidal anti-inflammatory drug (NSAID) usage, hypertension, diabetes, CV disease history, and
heavy drinking.
Shankar et al. Am J Epidemiol. 2006;164(3):263-271.
Risk of Chronic Kidney Disease In Smokers
 There is a dose-response relationship between the quantity and
2.5
2.5
2.0
2.0
1.5
1.0
1.23
1.40
1.00
0.5
0.0
Never
21-40
>40
Smokers
Duration of Cigarette Smoking (y)
aThe
OR (95% CI)a
OR (95% CI)a
duration of smoking and risk of chronic kidney disease (CKD)
1.52
1.32
1.5
1.0
1.00
0.5
0.0
Never
Smokers
16-30
>30
Packs/Year
Current Smokers
ratio of the odds of the development of disease in exposed persons to the odds of development of
disease in nonexposed persons.
Adjusted for age, sex, education, alcohol, and use of paracetamol and salicylates. Analyses of cigarette
smoking also adjusted for pipe smoking, cigar smoking, and snuff use.
Ejerblad et al. J Am Soc Nephrol. 2004;15:2178-2185.
Risk of Proteinuria in Smokers
 Current and ex-smokers have an increased risk of proteinuria
Relative Risk (95% CI)a
7
Nonsmokers
Ex-smokers
Current Smokers
6
P=.0009
5
P=.01
P=.0001
4
2.69
P=.01
3
1.71
3.3
2.4
2
1.00
1.00
1
0
1+ Proteinuria
aThe
2+ Proteinuria
probability of an event (developing a disease) occurring in exposed people compared with the probability
of the event in nonexposed people.
Halimi et al. Kidney Int. 2000;58:1285-1292.
Male Smokers with Type 2 Diabetes: Decline
in Renal Function
Smokers are at increased risk for renal insufficiency. Consequently, significantly
more smokers experience reductions in GFR than nonsmokers.a
22
20
18
16
14
12
10
8
6
4
2
0
20.90
P=.03
12.00
P=.02
4
3
2.20
2
1
1.00
0
Never Smokers
aGFR
5
Adjusted Odds Ratio
(95% CI)b
Patients With a
Low e-GFR (%)a

Current
Smokers
Never Smokers
Current
Smokers
is the volume of fluid filtered from the renal glomerular capillaries into the Bowman's capsule per unit time.
Estimated GFR (e-GFR) was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD)
formula. Low GFR was defined as e-GFR <60 mL/min per 1.73 m2, a value that has been suggested to be the
cutoff point for the definition of CKD. bAdjusted for duration of disease, GHb, albuminuria, and dyslipidemia.
De Cosmo et al. Diabetes Care. 2006;29(11):2467-2470.
Summary: Smoking and Renal Disease

Smokers have a higher risk of
– Decreased renal function
– Decreased glomerular filtration rate (GFR)
– Proteinuria
– Chronic Kidney Disease (CKD)
• Risk of CKD is dose related
Smoking and the Skin
 Characteristic signs
 Cutaneous manifestations
 Squamous cell carcinoma
 Adverse effects on wound healing
Characteristic Signs of Smoking
Clinical Signs
Harlequin nail
Synonyms
Quitter’s nail
Description
Demarcation line in the nail
Smoker’s comedones
Large comedones with furrows and
nodules
Smoker’s face
a) Lines or wrinkles
b) Gauntness
c) Graying of the skin
d) Plethoric complexion
Smoker’s melanosis
Pigmentation of the gingiva
Smoker’s moustache
Moustache discoloration
Smoker’s nail
Nicotine sign
Nail discoloration
Smoker’s palate
Nicotine stomatitis, leukokeratosis
nicotina palati
Coloration of the palatal mucosa
Smoker’s tongue
Leukokeratosis nicotina glossi
Pink-colored depressions
Snuff dipper’s lesion
Smokeless tobacco keratosis,
tobacco pouch keratosis
White lesion in the oral cavity where
smokeless tobacco is held
Freiman et al. J Cutan Med Surg. 2004;8(6):415-423.
Cutaneous Manifestations of Smoking
 Prominent periorbital lines
 Gauntness
 Graying of the skin
 Plethorica complexion
aPlethoric
denotes a red florid complexion.
Freiman et al. J Cutan Med Surg. 2004;8(6):415-423.
Cutaneous Manifestations of Smoking
Freiman et al. J Cutan Med Surg. 2004;8(6):415-423.

Discoloration of the nail
in smokers

Demarcation line in the nail
Smoking and Cutaneous Squamous Cell
Carcinoma (SCC)

Smokers have a 50%
greater chance of
developing cutaneous
SCC than nonsmokers

Current smokers are at
higher risk for cutaneous
SCC than ex-smokers
Grodstein et al. J Nat Cancer Inst. 1995; 8714:1061–1066; Hertog et al. J Clin Oncol. 2001; 191:231–238.
http://images.google.com/imgres?imgurl=http://www.medscape.com/content/2001/00/41/08/410808/artsmj9406.14.fig4.jpg&imgrefurl=http://www.medscape.com/viewarticle/410808_3&h=291&w=400&sz=24&hl=en&start=0&tbnid=YJS
jToEbzbOMcM:&tbnh=90&tbnw=124&prev=/images%3Fq%3Dsquamous%2Bcell%2Bcancer,%2Blip%26gbv%3D2%26svnum%3D
10%26hl%3Den%26safe%3Dactive%26sa%3DG. Accessed October 19, 2007.
Adverse Effects of Smoking on Wound
Healing

Decreases cutaneous
blood flow

Significantly decreases
immune response, leading
to poor wound healing

Largest risk factor for
complications related to wound
healing in postoperative
arthroplasty study

Delays wound repairs
Freiman et al. J Cutan Med Surg. 2004;8(6):415-423; KCI. http://db2.photoresearchers.com/search/SE6944.
Accessed October 23, 2007.
Smoking: Postoperative Wound
Complications

Manassa et al
– 132 postabdominoplasty
patients evaluated
– Wound-healing
complications assesseda
– Significantly increased
postoperative wound
complications
• Smokers 47.9%
• Nonsmokers 14.8%
(P<.01)
aComplications,
evaluated prior to discharge, were noted when medical intervention such as debridement,
treatment for infection, lavage after fat necrosis, or a secondary skin closure after skin slough was necessary.
Manassa et al. Plast Reconstr Surg. 2003;111(6):2082-2087.
Smoking: Postoperative Wound Infection

Smoking
– Decreases blood flow to damaged skin resulting in the
disruption of repair and response to foreign contaminants
– Independent predictor of wound infection in ventral hernia
repair

Abstinence from smoking reduces incisional wound
infection
– Infection rate 12% (continuous smokers) vs 1%
(abstainers), P<.05
Morecraft. J Hand Surg. 1994;19: 1-7. Finan et al. Am J Surg. 2005;190:676-681;
Sorensen et al. Ann Surg. 2003;238(1):1-5.
Summary: Smoking and Dermatologic
Disease

Smoking
– Causes characteristic skin changes
– Increases the incidence of squamous cell skin cancer
– Delays wound healing and increases risk of wound
infections
Effects of Smoking on the Oral Cavity
 Periodontitis
 Stomatitis
 Oral cancer
Smoking-Attributable Periodontitis

Smoking is a major risk
factor for periodontitis

Current smokers are
approximately 4 times as
likely as persons who have
never smoked to have
periodontitis

Periodontal disease is one
of the main causes of tooth
loss worldwide
Tomar et al. J Periodontol. 2000;71(5):743-751; http://www.cda-adc.ca/en/oral_ health/complications/tobacco/
smokeless.asp. Accessed October 19, 2007.
Smoking: Risk of Periodontitis
 There is a direct dose-response relation between number of cigarettes
smoked and the odds of developing periodontitis
2.79
9 per day
P.000001 for all levels
2.96
10-19 per day
4.72
20 per day
5.10
21-30 per day
5.88
31 per day
0.0
2.0
4.0
6.0
8.0
Odds Ratio Compared With Nonsmokersa
10.0
aThe ratio of the odds of the development of disease in exposed persons to the odds of development of disease
in nonexposed persons. Odds ratio adjusted for sex, age, race/ethnicity, educational attainment, and
income:poverty ratio.
Tomar et al. J Periodontal. 2000;71(5):743-751.
Oral Pathology
Brown Hairy Tongue
Nicotine Stomatitis
Leukoplakia
Necrotizing Ulcerative
Gingivitis
Davis. J Contemp Dent Pract. 2005;6:158-166; Lewin et al. Cancer. 1998;82:1367-1375.
Oral Squamous Cell Carcinoma

Smoking and other types of
tobacco use are associated with
approximately 70% of oral cancer
cases

Symptoms include
– Sores that don’t heal
– A thickening or lump in the
neck, throat, or mouth, that
does not go away
– Persistent white or red patch in
the mouth
– Difficulty chewing or swallowing
– Weight loss

Prognosis
– Overall 5-year survival rate of
less than 50%
Davis. J Contemp Dent Pract. 2005;6(3):158-166; Oliver et al. J Oral Maxillofac Surg. 1996;54:949-954;
http://www.mediscan.co.uk/cfm/Im_info.cfm?ImageID=000480&mediatype=Image&log=nk. Accessed October
30, 2007.
Summary: Effects of Smoking on the
Oral Cavity
 Major risk factor for periodontitis
 Direct dose-response relationship between smoking and
the odds of developing periodontitis

Smoking is associated with oral pathology
–
–
–
–
Brown hairy tongue
Nicotine stomatitis
Leukoplakia
Necrotizing ulcerative gingivitis
 Most oral cancers are malignant and spread rapidly
 Associated with approximately 70% of oral cancer cases
Presentation Summary

Smoking
– Risk factor for multiple malignancies
– Increases patient risk for
•
•
•
•
•
Osteoporosis
Hip fracture
Thyroid disease
Insulin resistance
Diabetes
– Increases risk of renal dysfunction
– Associated with characteristic skin changes, delayed wound
healing, and increased incidence of wound infection
– Risk factor for various forms of oral pathology
Tobacco: Drug of Abuse
Snus

Moist smokeless tobacco,
snuff

Although used worldwide, the
highest consumption of snus
is in Sweden

Associated with an increased
risk of pancreatic cancer
(RR 2.0; 95% CI, 1.2-3.3a)
aThe
probability of an event (developing a disease) occurring in exposed people compared with the probability of the
event in nonexposed people.
Luo et al. Lancet. 2007. Epub ahead of print;
http://www.arnestadphotography.com/stock_photos/albums/concept/snuff_tobacco_black.jpg. Accessed October 19,
2007.
Hookah: Waterpipe Tobacco Smoking
 Shisha, a mixture of tobacco,
molasses, and fruit flavors used
in the hookah
 Water in the hookah does not
diminish tobacco toxicity
 A 1-hour session of hookah smoking
exposes the user to 100- 200 times
the volume of smoke inhaled from a
single cigarette
 Smoke produced contains high
levels of carbon monoxide, heavy
metals, and other carcinogens
 Delivers significant levels of nicotine
World Health Organization.
http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf; Sajid et al. J
Pak Med Assoc. 1993;43(9):179-182.
Smoking: Addictive Potential
 Smoked tobacco is one of the most addictive commonly used drugs
Tobacco
Cocaine
Prevalence of Dependence
Among Users (%)
50
Alcohol
Psychedelics
Cannabis
Heroin
40
30
20
10
0
15-24
25-34
Age Group
Anthony et al. Exp Clin Psychopharm. 1994;2:244-268.
35-44
45-54
Smoking: Chronic Physical Harm
 When compared with other drugs of abuse, tobacco is associated
with the greatest chronic physical harm
3.5
2.9
Physical Harm
3.0
2.5
2.5
2.4
2.0
2.0
2.1
1.9
1.8
1.6
1.5
1.0
0.5
Nutt et al. Lancet. 2007;369:1047-1053.
co
tas
y
ac
To
b
ph
et
Am
Ec
s
am
ine
bis
na
l
ho
Al
co
Ca
n
Ba
r
bit
ur
ate
s
ain
e
Co
c
He
ro
in
0.0
Smoking: Reduced Life Expectancy
 Long-term cigarette smoking
reduces life expectancy by
approximately 10 years
or 30 years gains
approximately 3, 6, 9,
or 10 years of life
expectancy, respectively
88
Survival From Age 60 (%)
 Cessation at age 60, 50, 40,
100
80
Nonsmokers
71
60
65
Cigarette Smokers
40
26
32
20
2
5
0
40
Doll et al. BMJ. 2004;328:1519-1527.
50
60 70 80
Age (years)
90
100
Summary
Tobacco: Drug of Abuse

Smoked tobacco is one of the most addictive commonly
used drugs

When compared to other drugs of abuse, tobacco is
associated with the greatest chronic physical harm

Long-term cigarette smoking reduces life expectancy
by approximately 10 years