Since it was first suggested in 1898 that smoking may result in lung cancer, many
studies have examined the effect of tobacco smoke on active and passive smokers. As the
social and economic costs of tobacco-related problems are enormous, medical practitioners
and health workers play an important role in educating smokers of the risks and promoting
the health benefit of quitting.
- Although initial inhalation of cigarette smoke can produce palpitations, dizziness,
sweating, nausea, and vomiting, tolerance to these symptoms develops rapidly but can take
up to 3 years.
- Physical dependence on nicotine, and even more important, psychological dependence to
cigarettes, soon develops.
- 'Smokers cough' (a manifestation of bronchitis) typically occurs early in the smoker's
- Physical problems occurring later are numerous lung cancer, respiratory diseases
and problems, cardiovascular diseases including stroke and peripheral vascular disease.
- Fertility difficulties may occur in both males and females.
- Family history of smoking especially young children of smokers, and other first
- People (usually younger persons) susceptible to peer group pressure. Influences may
- friends who smoke
- spouse/partner smokes
- image and social acceptability
- co-workers who smoke.
- People with extroverted personalities: impulsive, arousal-seeking, risk-taking.
- People prone to the effects of stress and tension.
Tobacco smoke contains over 4000 compounds, many of which have been linked to human
- Nicotine a highly toxic chemical which primarily acts on the nervous system and
- increases in heart rate
- increases in blood pressure
- constriction of blood vessels
- increased blood fatty acids and platelet stickiness.
- Carbon monoxide as it avidly displaces oxygen from haemoglobin it produces a
relative hypoxia that is particularly dangerous to those with precarious tissue
oxygenation: eg in IHD (ischaemic heart disease) and PVD (peripheral vascular disease),
especially in diabetics. It also has psychomotor performance effects.
- Tar a carcinogenic substance containing more than a dozen cancer producing
- Glycoprotein acts as an allergen.
- Nitrosamines carcinogenic in animals and suspected to be so in humans.
- Benzo(a)pyrene and phenols known human carcinogens.
- Oxides of nitrogen may induce and worsen emphysema.
- Hydrogen cyanide a particularly toxic agent in cigarette smoke which can impair
Complications related to pregnancy
Traumatic and accidental
- Ischaemic heart disease
- Myocardial infarction
- Heart failure
- Cerebral vascular events
- Cardiac arrythmias and conduction disorders
- Pulmonary circulation disorders
- Aortic and aneurysms, peripheral vascular disease
- Trachea, bronchus and lung
- Oral cavity: tongue, gums, floor of mouth
- Pharyngeal cancers
- Renal pelvis and parenchyma
- Salivary glands
- Nasal cavities, middle ear and sinuses
- Breast cancer
- Uterine cervix
- Ovary and adnexae
- Prepuce and penile cancer
- Chronic obstructive airways disease
- Asthma; especially in children (passive smoking effect)
- Sudden Infant Death Syndrome
- Neonatal respiratory disorders
- Pneumonia, influenza
- Low birth weight
- Placental abruption and premature labour
- Amenorrhoea, ovulation, fertilisation and implantation defects
- Impotence, decreased sperm count
- Peptic ulceration
- Ulcerative colitis
- Parkinson's disease
- Premature aging of the skin
- Each year, more than 30 fire-related casualties are caused by smoking and matches.
- 53% of domestic fires are related to smoking.
- Toddlers and children are particularly susceptible to burns from cigarettes and ash,
especially ocular burns.
- Toxic ingestion butts are particularly toxic.
Most psychological and behavioural difficulties occur with the cessation of smoking and
in the ambivalent phase leading up to the decision to quit. However, most withdrawal
phenomena are short lived, and with continual abstinence, ex-smokers enjoy many positive
Common psychological presentations of nicotine withdrawal:
- anxiety and tension
- difficulties with concentration and restlessness
- increased appetite.
- Legal liability associated with passive smoking.
- Financial strain 1 packet per day ($4.80) = $33.60 per week = $1752 per year.
- With increasing community disapproval of smoking, many workers report being ostracised
at social events, restaurants, relatives and even at home especially where there are
- At work impaired job performance secondary to illness, increased absenteeism and
sick leave, psychological consequences of restlessness and impaired concentration as
nicotine levels fall before cigarette breaks.
Ex-smokers live longer than those who continue to smoke. The extent to which life span
improves depends on the length of time since quitting, number of cigarettes smoked over
how many years and the health status of the ex-smoker.
However, quitting is beneficial even in the presence of disease, eg patients with
chronic obstructive airways disease will have improved lung function and symptomatology.
Even lung cancer patients can help avoid second cancers and terminal respiratory
infections. Of course, early cessation, with the support of education from health
professionals and stop smoking programmes, will have greater health benefit by preventing
the development of disease rather than its progression.
Although health issues are often given as the main reason for stopping smoking, for
those who have yet to develop disease these events may be far less relevant than social or
financial issues, or the health of their family.
Medical practitioners and other health care workers can help by emphasising the
positive benefits of quitting. Discussion of withdrawal symptoms with the patient can also
help them prepare for the process of quitting. It may be worthwhile for health
professionals to think about their own behaviour and attitudes to smoking and how this
affects their advice to patients.
- Increased life expectancy
- Improved health of family
- Improved physical fitness and appearance
- Improved sense of well being
- Positive psychological changes; enhanced self esteem and sense of self control
- Improved social standing and finances
- Restoration of sense of taste and smell
- Better work performance.
It should be emphasised that most of these are short lived when discussing them with
the patient (eg symptoms usually peak about 3 days after cessation and the withdrawal,
usually mild, is over within 7-10 days for most people). Discussion of withdrawal symptoms
is not to discourage the uncommitted from the attempt, but rather to help the patient be
better prepared for quitting, especially if it is his or her first attempt.
- Psychological symptoms
- Physical symptoms
- How medical practitioners and other health care workers can help
- Individual approaches
- General and community approaches
- Intense cravings for cigarettes they are usually brief (10-15 minutes) and tend
to recede with time
- Irritability and restlessness
- Dejection and sorrow it is not uncommon to report a sense of grief and mourning
for a 'lost companion'
- Difficulty in concentrating
- Anxiety and tension
HOW MEDICAL PRACTITIONERS AND OTHER HEALTH CARE WORKERS CAN HELP
A good start is to document each patient's smoking history as part of general
history-taking on initial presentation. When time allows, the patient can be encouraged to
talk about their smoking using a non-judgemental question such as, 'How do you feel about
your smoking?' A helpful model to use when assessing the smoker's readiness to quit
identifies three stages:
- Not ready They are likely to become defensive and resistant to simple advice to
stop. Gentle encouragement of the patient to think about their habit and making it clear
that you are available for further support is the most effective approach.
- Unsure The advantages of continuing to smoke are still as important as the
advantages of quitting. Discussion can focus on weighing up the pros and cons and any
other specific concerns.
- Ready They will respond positively to advice to stop and can be given more
specific help on how to deal with withdrawal symptoms. Provide follow-up to encourage
their efforts and deal with continuing difficulties (Mendelssohn and Richmond, 1992).
It is therefore useful to identify how ready the patient is to change in order to
provide the most appropriate individual assistance. An approach that helps the patient to
take control and responsibility for the problem is more likely to be successful than
systematically giving advice to stop or telling the patient what to do.
Many ex-smokers relapse, especially in the setting of social events, peer pressure and
alcohol. Patients should be encouraged to view these as learning experiences, and to learn
from there how to avoid future relapses when they try again. Subsequent attempts are often
easier for this reason.
- Nicotine chewing gum useful for the very physically dependent. The chewing
tablets can prevent withdrawal symptoms. The patient should follow the enclosed
instructions carefully to avoid unpleasant side effects.
- Nicotine patches useful for very physically dependent but motivated patients.
Manufacturers emphasise the need for concomitant support from the medical practitioner.
- Specialist clinics
- Self-help and GP assistance kits.
Resources available for the cessation of smoking
1. How to help smokers to quit: a guide for the health professional
An easy to use guide to give health professionals tips in counselling smokers with a
brief intervention. The guide also outlines the stages a smoker goes through when quitting
and illustrates how a health professional can help using The Can Quit Book.
2. The can quit book
A book for all smokers. Based on years of research and practical knowledge, it gives
advice on recognising why people smoke, the health facts about smoking and an individual's
health, preparing to quit and techniques to give up smoking and stay stopped.
Both resources are available from:
Victorian Smoking and Health Program (Quit)
PO Box 888Carlton South Vic. 3053
Telephone (03) 663 7777
Fax (03) 663 7761.
Note: No fee for orders in Victoria, small fee for orders interstate.
3. Smokescreen for the 1990s
The stop smoking programme for use by medical practitioners, obtained through the
Prince of Wales Hospital, New South Wales.
There are two kits available:
- one kit for GPs
- self-help kit for smokers that can be displayed in the surgery.
Kits available from:
The Smokescreen Unit
Prince of Wales Hospital
Randwick NSW 203
Telephone (02) 399 4766
Fax (02) 399 2196.
4. Sick of smoking?
A manual for helping patients stop smoking, obtained through the South Australian
Sick of Smoking Officer
College House15 Gover Street
North Adelaide SA 5006
Telephone (08) 267 1249.
General and community approaches
- Assist in educational programmes, especially in schools. Young people and women are
particularly likely to take up smoking.
- If you smoke yourself, try to give up smoking or at least not smoke publicly.
- Have a non-smoking policy in your workplace and other workplaces that you may visit.
- Be aware of the consequences of smoking, and know of the referral agencies available to
- Congratulate people when they finally break the habit.
- Sympathise and offer encouragement to those people who require additional support and
time to give up smoking.
Recent evidence has come to light showing the harmful effects of tobacco smoke on the
health of non-smokers.
Cigarette smoke can be separated into two components, mainstream smoke which is inhaled
by the active smoker, and sidestream smoke, the unfiltered smoke released from the end of
a lit cigarette, which results in passive smoking in non-smokers.
The dangers of passive smoking are highlighted by the knowledge that 85% of cigarette
smoke is released as sidestream smoke. Since the sidestream smoke is unfiltered it
contains higher concentrations of dangerous chemicals. The effects of this harmful smoke
in non-smokers can lead to increased incidence of bronchitis, pneumonia, and other chest
illness in children, Sudden Infant Death Syndrome, lung cancer and lung disease. In
addition, the irritants in tobacco smoke are a major concern to people with asthma and
people with allergies, especially of the eyes, nose and throat.
Recent estimates suggest that annually approximately 150 deaths from lung cancer and
1000 deaths from heart disease in Australia are due to passive smoking (Holman, Armstrong,
Arias et al., 1988).
Health risks of passive smoking
- Higher concentrations of cancer-causing agents in sidestream smoke.
- Aggravation of asthma.
- Aggravation of allergic conditions cigarette smoke results in irritation of the
eyes, nose and throat, and also headaches and coughs in non-smokers.
- Cancer, particularly lung cancer.
- Respiratory illness is increased noticeable in children of active smokers who
suffer from more acute respiratory illness, wheezing, middle ear infections, sore throats
and problems of lung infection.
- Sudden Infant Death Syndrome.
- Growth may be a combination of the mother smoking during pregnancy, and passive
smoking by the child after birth.
- Increased incidence of bronchitis, pneumonia, and chest illness in adults and children.
- Meningitis recent studies indicate a possible association between meningococcal
disease and passive smoking during childhood.
- Heart disease increases the risk of coronary heart disease.
The legal ramifications of smoking in the workplace are now becoming apparent. In
Australia there have been at least 10 cases since 1980 where workers have received
compensation for injuries incurred as a result of passive smoking in the workplace. As a
result increasing numbers of employers are making their workplaces smoke-free.