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smoking; cigarette smoking; tobacco smoking

Etiology: -> smoking may be a sign of mental illness [4] Epidemiology: - cigarette smoking among U.S. high school students has dropped to the lowest level in more than 20 years (16%) [37] - hispanic youth most susceptible to smoking [49] - smoking during pregnancy [57] - most common among women age 20-24 - most common among Native Americans (17%) - least common among Asian women (< 1%) - most common in West Virginia > Kentucky, Montana, Missouri, & Vermont -least common in California, Connecticut, & Texas [57] Pathology: Some known carcinogens in smoke - polycyclic aromatic hydrocarbons - benzo[a]pyrene - aromatic amines - 4-aminobiphenyl - nitrosamines - 4-(methylnitrosoamino)-1-(3-pyridyl)-1-butanone - benzene & benzene metabolites - acrylamide - acrylonitrile Genetics: - AZGP1 may reduce body fat in smokers - associated with mosaic loss of chromosome [39] Laboratory: 1) decrease in HDL cholesterol 2) increase in plasma fibrinogen 3) decrease in plasma plasminogen 4) increase in blood carboxyhemoglobin Special laboratory: - spirometry alone is insufficient to rule out lung disease in smokers & former smokers [42] Radiology: - chest X-ray - low-dose spiral CT anually for high-risk patients (see screening for lung cancer) - abdominal ultrasound: selective screening for men aged 65-75 who have never smoked [43] (USPSTF) Complications: 1) pulmonary disease a) chronic obstructive pulmonary disease (COPD) b) pneumonia c) idiopathic pulmonary fibrosis d) 50% of smokers with preserved pulmonary function on spirometry are symptomatic [46] - respiratory exacerbations - shorter mean 6-minute walk distance - increased mean airway wall thickening 2) atherosclerosis (cardiovascular disease) a) coronary artery disease (CAD) [19] - epicardial coronary endothelial dysfunction [22] - smokers < 50 years have 8X risk for myocardial infarction as people same age who've never smoked or quit smoking [50] b) congestive heart failure secondary to CAD c) abdominal aortic aneurysm - screening for older men who have ever smoked (USPSTF) d) ischemic stroke e) peripheral arterial disease f) cardiovascular risk from 1 cigarette/day about 1/2 that of 20 cigarettes/day [55] g) cardiovascular risk appears to remain elevated well beyond 5 years in heavy smokers after they quit [59] 3) cancer [41] (mostly carcinoma) of the a) lung cancer# b) oral cancer, pharyngeal cancer, laryngeal cancer c) esophageal cancer (squamous cell carcinoma & adenocarcinoma) d) bladder cancer & cancer of the renal pelvis e) pancreatic cancer f) nasal cavity & nasal sinus g) gastric cancer h) liver cancer, intrahepatic biliary carcinoma [41] i) kidney cancer (renal cell carcinoma) j) cervical cancer k) breast cancer [40], not included in [41] l) prostate cancer [40], not included in [41] - smoking increases prostate-specific mortality [46] m) bone marrow - myeloid leukemia 4) impotence 5) mortality [13,18] a) 1 in 2 smokers will die from smoking [29] b) shortens life expectancy by 8-11 years [30,31] c) smoking cessation by age 35-45 cuts most excess mortality [30,31] d) even light smoking increases risk of death [32] e) 15-20 years after smoking cessation, risk of death declines to that of non-smokers [32] f) excess mortality in current smokers [56] - cigarette smoking (RR=4.1) - cigar smoking (RR=1.6) - pipe smoking (RR 1.6) 6) diabetes mellitus type 2 (see CARDIA study) 7) chronic pancreatitis 8) bone fractures [35] 9) smoking during pregnancy associated with - birth defects [28] - 50% increased risk for schizophrenia & bipolar disorder in offspring [47,53] - may not be directly caused by smoking, but related to mental health disorder in mother [53] - white-matter changes in infants [51] * Unfiltered high-tar cigarettes associated with greatest risk Amount of tar in filtered cigarettes has little effect on risk [11] # 26-fold increase risk of lung cancer for 1 pack/day relative to non-smoker reduction in smoking reduces lung cancer risk [16] even consistent smoking < 1 cigarette/day is associated with excess mortality relative to never smokers (RR=1.6) [52] Diseases associated with or aggravated by smoking: 1) asthma 2) pulmonary fibrosis 3) calcification of pleural plaques in asbestosis 4) alveolar proteinosis 5) Langerhans cell granuloma 6) Goodpasteur's syndrome (lung hemorrhage) Other increased risks: 1) infections of the lower respiratory tract - includes Mycoplasma pneumonia 2) fluid collection in the middle ear 3) decreased lung function 4) increased risk of developing asthma 5) cataracts [3] 6) increased risk of post-operative complications [6] Pipe & cigar smoking also associated with COPD [25] Water pipe smoking with pulmonary effects similar to cigarettes [27] 2nd hand smoke or passive smoking: 1) increases risk of lung cancer (30%) 2) increases risk of coronary artery disease (30%) 3) increased bronchial hyperreactivity & risk of asthma [5] 4) diminishes FEV1 [5] 5) may increase risk of sudden infant death syndrome (SIDS) [8] 6) risks may be overestimated [10] 7) increases risk of mortality (15%) [12] Management: - PPSV23 - see smoking cessation Notes: - menthol cigarettes* - increase initiation of smoking by youth - increase dependence - reduce likelihood of successfully quitting smoking - do not increase smoke toxicity - do not increase risk for disease [33] - smoking bans in US prisons reduces smoking-related mortality by 9% [38] - FDA announces plans to reduce nicotine levels in combustible cigarettes to nonaddictive levels [54,58] * comparisons relative to non-menthol cigarettes

Interactions

disease interactions

Related

inhalation injury second hand smoke (passive smoking) smokeless tobacco smoking cessation tobacco

Specific

electronic cigarette; e-cigarette; juul; electronic nicotine delivery system (ENDS) Hookah pipe (water pipe)

General

tobaccoism

References

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