Joy Linn, BSN

• Tobacco smoking is a global pandemic, affecting an estimated 1.2 billion people.
• With nearly 6 million deaths annually, smoking is the single most important cause of avoidable premature mortality in the world.
• Lung cancer, coronary heart disease, chronic obstructive pulmonary disease and stroke are the most common causes of death related to smoking according to the World Health Organization (Alberg, 2014).
• In the United States nearly 42 million adults and 3.5 million middle and high school students continue to smoke cigarettes (Rollins, 2014).
• It is estimated there will be more than 8 million smoking related deaths every year by 2030. Smoking induced deaths during the 21 st century will reach one billion (Kusel, 2013).

• Most smokers start before the age of 18 years. One report from the Surgeon General places the blame on tobacco industry advertising and promotional activities as a cause to start smoking. This, in turn, causes a nicotine addiction that keep people smoking well into adulthood and later life (Rollins, 2014).
• It has been shown that approximately 80% of smokers who attempt to quit on their own relapse within the first month, and only 5% achieve long term abstinence.
Nicotine addiction alters the brain structure and function that impairs the ability to achieve and sustain abstinence. Some changes may not be entirely reversible.
Cigarette smokers will keep smoking because of their addiction and when given the options of smoking or completely giving up nicotine, many will not give it up.
• “There is little doubt that if it were not for the nicotine… people would be little more inclined to smoke than they are to blow bubbles or light sparklers” (Polosa, 2013).

• Traditional cigarettes contain: nicotine, benzene, formaldehyde, lead, tar, methanol, hydrogen cyanide, butane, ammonia, chloroform, carbon monoxide, acetone, nitrosamines, aluminum, carbon dioxide, cadmium, arsenic, ethanol, vinyl chloride, radon.
• An additional 3500 more chemicals can be included.
• 50 known carcinogens are also present

• Dissolvable tobacco: Comes in tablet or strips that look like candy.
• Bidis: Small, thin, hand-rolled cigarettes of tobacco wrapped in a tenchi leaf and secured with colored string. They are chocolate, cherry and mango flavored.
• Kreteks: Clove cigarettes containing a mixture of tobacco, cloves and other additives. Kreteks and Bidis have higher levels of nicotine, tar and carbon monoxide than cigarettes manufactured in the United States. (Rollins, 2014)
• E-cigarettes: Contains propylene glycol, glycerin, nicotine, and food flavoring (Polosa, 2013).

• Passive smoking is defined as an involuntary environmental exposure to cigarette side-stream smoke plus exhaled smoke from smokers. Side-stream smoke is a combination of gas and particulate matter that comes from the smoldering end of the cigarette while the smoker is not puffing. This smoke consists of cytotoxic substances much higher than those found from cigarette mainstream smoke.
Exposure can occur at home or in other enclosed spaces such as motor vehicles
• Secondhand smoke was responsible for an estimated 600,000 deaths of non-smokers in 2011, the majority of which were women and children.
• Secondhand smoke is one of the world’s most critical environmental hazards and there is no reported safe level of exposure (Kusel, 2013).
• ETS has been classified as a class I carcinogen by the Internal Agency for Research on Cancer (Cobanoglu, 2007).
• Apart from containing all of the chemicals, the particle size in the ETS is much smaller than main stream smoke and has greater penetrability in the airways of children.

• Chronic diseases causally linked to smoking: stroke, blindness, cataracts, macular degeneration, congenital defects of orofacial clefts, periodontitis, aortic aneurysm, early abdominal aortic atherosclerosis in young adults, coronary heart disease, pneumonia, atherosclerotic peripheral vascular disease, chronic obstructive pulmonary disease, tuberculosis, asthma, diabetes, reproductive effects in women including reduced fertility, hip fractures, ectopic pregnancy, male sexual function and erectile dysfunction rheumatoid arthritis, immune function and overall diminished heath.
• Cancers causally linked to smoking: oropharynx, larynx, esophagus, trachea, myeloid leukemia, acute myeloid leukemia, stomach, liver, pancreas, kidney and ureter, cervix, bladder and colorectal.

• Switching from cigarettes to snuff would significantly reduce the risk of lung cancer, bronchitis, emphysema and possibly coronary heart disease. The cost would be a slight increase in the risk of cancer of the nasal and oral pharynx.
• Nicotine has beneficial effects on attention, concentration, and mood in many smokers. Individuals may be depending on nicotine for self medication.
• Nicotine itself presents little if any cardiovascular risk and is not carcinogenic.
Nicotine may be potentially harmful during pregnancy but probably less harmful than continued smoking. There is some data suggesting nicotine may be treatment for ulcerative colitis, Tourette syndrome, memory impairment, attention deficit disorder, depression and Parkinson’s disease
(Polosa, 2013).

• Since the 1950’s research has been ongoing. One of the earliest projects was by Ernst Wynder who was looking for a link between the upsurge in cigarette smoking and lung cancer in the 1950’s.
• In 1964, a report by the United States Surgeon General stated: “On the basis of prolonged study and evaluation of many lines of converging evidence, the Committee makes the following judgment: Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action” (Alberg, 2014).
• This 1964 report was just the beginning. The Surgeon General’s Report on the health consequences of smoking has been regularly published. The application of causal inference to the evidence has resulted in a lengthy list of disease and health outcomes related to exposure to tobacco smoke.

• Tobacco use has been practiced for centuries. Since the 17 th century tobacco has been used in various forms in America.
• In 1865, Washington Duke rolled cigarettes and sold them to others for profit.
In 1863, James Bonsack invented a cigarette rolling machine to produce thousands per day. In the late 19 th century cigarettes were sold in packs and marketed throughout the United States. Eventually the packs were designed with cards for trading, which boosted their sales. Cigarettes also became blended. Fragrant Rose cigarettes, sold in the 1880’s issued cards with romantic and flowery images to appeal to the feminine market.
Baseball cards were later added to cigarette packs.
• Cigarette usage began as a habit for soldiers. The introduction of the
“Marlboro Man” in 1954 was used to popularize filtered cigarettes, which at the time were considered feminine (Reynolds, 2009).

• The Marlboro advertising campaign is said to be one of the most brilliant advertising campaigns of all time.
Although there were many Marlboro Men, the cowboy proved to be the most popular.
• In 1955, before the Marlboro Man campaign,
Marlboro was less than one percent of the fourth largest selling brand. In 1955, when the Marlboro
Man campaign was started, sales were at $5 million.
By 1957, sales were $20 billion, representing a 300 percent increase within two years (Reynolds, 2009).

• Four men who claimed to have appeared in Marlboro- related advertisements died of smokingrelated diseases.
• In many countries, the Marlboro Man is an icon of the past due to increasing pressure on tobacco advertising.
Death in the West is an expose of the cigarette industry, a powerful antismoking film, aimed at the Marlboro
Man (Reynolds, 2009).

• Cigarette smoke causes an increase in the risk of infection due to several respiratory tract bacterial pathogens including S. pneumonia, Neisseria meningitides, and Legionella pneumophilia. Cigarette smoking is the strongest independent risk factor for invasive pneumococcal disease
(Alberg, 2014).

• For children, exposure to tobacco smoke in the household is associated with an increased risk of certain respiratory tract infections, including otitis media, pneumonia, bronchitis and meningitis.
• Cigarette smoke decreases mucociliary clearance by respiratory epithelium, potentially facilitating bacterial colonization. Increased adherence of bacteria to respiratory epithelial cells is related to smoking. Tobacco smoke causes increased inflammation which leads to epithelial injury leading to bacterial colonization (Murphy, 2006).

• Cigarette smoking is common among adults with asthma.
• Smoking increases the severity of asthma by accelerating the loss of lung function that typically accompanies asthma.
• Cigarette smoking also reduces the responsiveness to inhaled corticosteroids, which are the mainstay of therapy for asthma.
• Cigarettes also induce pro-inflammatory cytokines and alter airway inflammatory cells resulting in poor asthma control (Eisner, 2007).
• Tobacco smoke has been linked with allergic phenomena, such as elevated serum IgE levels (Eisner, 2007).

• Children have a higher internal exposure of environmental tobacco smoke than adults. Passive smoking has a more serious effect on children.
• ETS is associated with an increased risk of lower respiratory tract infections, middle ear effusion, increased episodes and severity of asthma and reduced level of pulmonary function (Cobanoglu, 2007).
• ETS has been shown to increase upper respiratory infections, wheezing, asthma and lower respiratory infections.
• Even developing fetuses who are exposed via the umbilical cord are affected. The placenta does not afford any protection. The immune system in these babies is more deviated toward the allergic and asthmatic inflammatory phenotype and makes them prone to develop asthma later in life (Cheragi, 2009).

• Circulating nicotine decreases the amount of oxygen and nutrients supplying the fetus.
Maternal smoking causes premature delivery, childhood malformations and low birth weight in the third trimester.
• Circulating levels of nicotine have been shown to induce the release of norepinephrine and epinephrine which causes the decreased blood flow to the placenta.
• Carboxyhemoglobin reduces blood flow and nutrients to the placenta.
• There is increased risk for bronchitis and hospitalization among children whose mothers smoked (Cheragi, 2009).

• Out of 100 people who smoke regularly, only 15-20% develop chronic obstructive pulmonary disease, indicating that genetic factors likely play an important part in determining the susceptibility to the harmful effects of tobacco smoke (Cheragi, 2007).
• ETS has been shown to reduce the activity of immune cells and deviate from the responses to those that are normally seen in allergic inflammatory responses (Shiva, 2003).
• The incidence of heart attack is increased sixfold in women and threefold in men who smoke at least a pack per day compared to those who have never smoked (Polosa, 2013).

• E-cigarettes consist of a lithium battery, electric components, an atomizer and a cartridge that hold a liquid solution composed of water, propylene glycol, flavorings and nicotine.
• The popularity of this item relates to the close similarities, that they can be used in smoke free places, the competitive price and the perceived potential for less harm than smoking.
• Evidence shows that e-cigarettes do not raise serious health concerns and can be considered a safe alternative.
• E-cigarette vapor contains a number of potentially toxic compounds generally in low numbers. Contents include: nitrosamines, polycyclic aromatic hydrocarbons, cadmium, lead, nickel, metal, silicate particles.
• One study has shown that each puff from an electronic cigarette delivers approximately 10% of the nicotine found in a regular cigarette (Polosa, 2013).

• Prevention is the key to lowering harm from smoking. This education needs to start when the population is young. One study is shown that if young people do not starting using tobacco by age 26, they almost certainly will never start (Rollins, 2014).
• Tobacco harm reduction is broken into two groups: non-tobacco interventions aimed at decreasing tobacco consumption and alternative tobacco products.
• Most agree that complete cessation is the best outcome for smokers and effort to make available safer products need to be part of a complete strategy .

• Question #1
• How does smoking primarily damage the lungs?
• A. Carbon buildup
• B. Mucociliary damage
• C. Stiffening of lungs
• D. Damage of alveoli
• Question #2
• What common condition does smoking increase the chance of in children?
• A. Pneumonia
• B. Otitis Media
• C. Sore Throat
• D. Rash

• Question #3
• Approximately how many carcinogens are in cigarette smoke?
• A. 2100
• B. 390
• C. 50
• D. 128
• Question #4
• Has environmental tobacco smoke been classified as a Class I carcinogen?
• True
• False
• Question #5
• Does the placenta offer any protection to the developing fetus?
• True
• False

• Alberg, A. S. (2014, January 15). The 2014 surgeon general's report commemorating the 50th anniversary of the 1964 report of the advisory
Epidemiology, 179(4), 403-412.
• Cheragi, M. &. (2009). Environmental tobacco smoke and respiratory health in children. Eur J Pediatr, 168, 897-905. doi:10.1007/s00431-009-
• Cobanoglu, N. K. (2007). Environmental tobacco smoke exposure and respiratory morbidity in children. Inhalation Toxicology, 19, 779-785.
• Eisner, M. D. (2007, January). The influence of cigarette smoking on adult asthma outcomes. Nicotine & Tobacco Research, 9(1), 53-56.
• Kusel, J. T. (2013). The impact of smoking in the home on the health outccomes of non-smoker occupants in the UK. Tobacco Induced
• Murphy, T. F. (2006, April 1). Otitis media, bacterial colonization, and the smoking parent. Clinical Infectious Diseases, 42, 904-906.
• Polosa, R. R. (2013). A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm Reduction Journal, 10(19), 2-11.
• Reynolds, J. A. (2009). A complete social history of cigarettes. Tobacco Research, 1-2.
• Rollins, J. (2014, January-February). 50 years of progress, but still a way to go. Pediatric Nursing, 40(1), 7-8.
• Shiva, F. N. (2003). Effects of passive smoking on common respiratory symptoms in young children. Acta Paediatr, 92, 1394-1397.