The Painless Stop Smoking Cure

Smoke Free In One Hour

Joan Chionilos is the person behind the smoke free in one hour program. She has been a hypnotherapist for more than 18 years. She has been certified by the National Guild of Hypnotherapists, which is the oldest and largest association of hypnotherapists you can find in the world, so she can be trusted. She has dedicated her entire career to helping people quit smoking for good with the use of hypnosis. With her expertise in hypnotherapy, you should expect nothing but results when you purchase her product. Her methods has helped lots of people all around the world quit smoking for good, your case will not be different. This is a digital product that contains one hour of professional hypnosis recording. Smoke free in one hour is an effective one-hour stop smoking hypnosis session. This hypnosis session works to eliminate your cigarette cravings at the same time it increases your willpower. It is available online for download for you to use at home. It is very easy to use. This program has been designed for anyone who is ready to quit smoking once and for all. All you need to do is to get comfortable, sit back, relax and listen to this recording. You will not regret your decision. Read more here...

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Physiciandelivered smoking cessation programs

In 1991,70 of smokers in the United States had at least one outpatient visit with a physician or other health professional during the previous year (59). Sixty to 70 of current smokers want to stop 70 to 80 feel that a physician intervention would help them in quitting. There is a natural window of opportunity for physicians to intervene with smok ers, and the effectiveness of physician advice is cost-effective and has been examined in trials of smokers in general practice (60). However, simple advice by the physician to quit smoking compared to no advice, results in only an additional 5 of smokers quitting in 1 year. Physicians are not unaware of this low rate of success, and unfortunately it has resulted in many physicians not systematically addressing smoking with their patients. Having a more effective yet practical smoking cessation protocol is likely to increase physician attention to this issue. The following clinical practice guideline for smoking cessation is based on the...

Step 3 Assist Smokers Willing to Quit Within the Next 30 Days

Find other ways to accomplish the positive things that smoking does for the patient, such as provide relief from stress and boredom, keep weight down, aid in socializing with friends who smoke, etc. d. Based on past experience and the patient's self-knowledge, discuss challenges to staying smoke-free and how the patient will overcome them. Discuss specific issues such as using alcohol without smoking or quitting while other smokers are in the house. 4. Recommend use of approved pharmacotherapy to reduce symptoms of withdrawal and increase smoking cessation success, except when con-traindicated by the patient's medical condition. There are five first-line approved medications b. Nicotine replacement therapy in the form of the patch, gum, nasal spray, or inhaler. Generally used for 3-6 months. Initiate dose of nicotine replacement therapy at approximately the level of the smoker's current daily nicotine consumption. Note that nicotine replacement, in particular the nicotine patch, is...

Step 4 Provide a Motivational Intervention for Smokers Currently Unwilling to Quit

With smokers unwilling to quit, have a brief discussion following the 5 Rs relevance, risks, rewards, roadblocks, and repeat as necessary at future clinic visits. 2. Risks. Ask the patient to identify potential negative health consequences of tobacco use. Discuss acute, long-term, and environmental risks. c. Environmental risks increased risk of heart disease and lung cancer in spouses higher rates of smoking in children of smokers sudden infant death syndrome, asthma, middle ear disease, respiratory infections in children of smokers.

Step 5 For Former Smokers Assist in Preventing Relapse

Prolonged conditioned cravings or difficulty withdrawing from nicotine replacement therapy In regards to keeping a lapse from becoming a relapse, patients should be specifically told that if circumstances lead them to smoke one or two cigarets, they have not failed and can choose to go back being smoke-free. The worst situation is for them to smoke a single cigaret, decide they have failed, and resume smoking at their previous level. An effective analogy to use is as follows If circumstances lead you to say something you wish you hadn't said to a person, you don't need to go on saying it. The same thing applies if circumstances lead you to smoke one or two cigarets. Simultaneously with this message, however, patients should be explicitly told that this does not imply that they are being given permission to smoke one or two cigarets occasionally their health does not benefit if they become occasional smokers, and their risk of complete relapse rises substantially.

Step 6 If Necessary Refer Patient to a Professional Smoking Cessation Program

Structuring a clinic to provide patients with an effective and comprehensive smoking cessation program may not always be possible. However, we contend that it is always possible to provide a referral to such services when smokers have been identified and the risks of continuing to smoke have been discussed with them. Smoking cessation programs are available throughout the United States from the American Lung Association, the American Cancer Society, and the Seventh-Day Adventist Church. The American Heart Association also offers a self-help program. Many national and local commercial programs are also available. Developing a comfortable referral relationship with programs in your area can improve the care you provide for your smoking patients.

Patient Education and Smoking Cessation

Patient education is an important part in the management of COPD. The patient should be educated about the disease and encouraged to take an active role in its management (2). Cigarette smoking is the most significant cofactor in the etiology of COPD. Consequently, cessation of smoking is the single most important therapeutic intervention in the management of COPD patients. This can reduce the progressive reduction in FEV1 in smokers with established COPD (3). Moreover, it is the only therapeutic intervention that can lessen or stop the rate of progression of COPD. Smoking cessation can be achieved by patients with the advice and support of their physician. If this is unsuccessful, other methods should be attempted, including nicotine replacement (in the forms of gum, transdermal patch, spray, or inhaler), bupropion, and or professional counseling. Smoking cessation is crucial in the management of all stages of COPD, and patients should be encouraged to quit as soon as possible. It...

Case 62 Lung Cancer With Lymphangitis Carcinomatosis

Chemical Inhalation

The CXR shows a left upper lobe mass and mid-zone infiltrates with a normal heart size. In addition, there are Kerley B lines (Fig. 62.2) in the periphery of the left mid zone, suggestive of lymphatic distension. These features are consistent with the advanced lung cancer metastasizing to the lymphatics. The prognosis is extremely poor.

Do You Really Want To Start Smoking

Another area in which hypnotic strategies are utilized, but the concepts of hypnosis are not mentioned, is in the 3-minute smoking cessation interaction. At the conclusion of the oral examination and cancer screening, if there is an indication by the patient that there is a desire to 'quit', the following sample script is useful. doctor So you had your last cigarette at three o'clock, on 6, May 1997. Do you really want to start smoking again patient (Pause). I get it. Each time I burn the tobacco and inhale the smoke, I start smoking. It was not pleasant when I started at 18. Knowing what I know now, I have no desire to start today. Rarely do people feel comfortable in labeling themselves as quitters. The focus is changed from quitting to starting. This strategy eliminates the fear of failure at 'quitting', and does not strain the doctor-patient relationship. If more intense interaction is indicated, an appropriate referral is made to a mental health practitioner or smoking cessation...

Divergent Expression of Caveolin1 in Human Cancer The Case of Lung Cancer

The divergent pattern of caveolin-1 in human cancer is well represented in studies of lung cancer tumors and cell lines. Human lung adenocarcinoma- and small cell carcinoma-derived cell lines exhibited little or no caveolin-1 expression, in contrast to high levels of caveolin-1 expression observed in CaLu-1 lung squamous carcinoma cells 59 . However, when compared with normal human lung epithelia, four other lung squamous cell carcinoma lines expressed reduced levels of cav-eolin-1 60 . In another study, low-level caveolin-1 expression was similarly found in cell lines derived from two lung adenocarcinomas, a bronchioalveolar carcinoma and a large-cell lung carcinoma, whereas non-small-cell lung carcinoma cell lines (Hop-62, Hop-92) highly expressed caveolin-1 61 . More recently, it was found that about 95 of small-cell lung cancer (SCLC) cell lines exhibit low or no caveolin-1 expression, whereas a majority (76 ) of non-SCLC lines retained high caveolin-1 expression 62 . Furthermore,...

Weight Differences Between Smokers And Nonsmokers

It is well established that middle-aged and older smokers weigh less than comparably aged non-smokers. In a review of 29 cross-sectional studies evaluating weight and smoking status, smokers weighed an average of 3.4 kg less than non-smokers (1,20,21). Weight differences between smokers and non-smokers tended to be greater for moderate smokers (compared to light or heavy smokers), older smokers, and women (20). Although most studies have been conducted in American populations, similar weight differences between smokers and non-smokers (as well as a more pronounced weight-control effect for women compared to men) were reported from the World Health Organization MONICA project, which assessed weight and smoking status in 69 000 individuals from 42 populations (22). non-existent in adolescent and young adult smokers. In a biracial sample of 6751 seventh grade students (average age of 13 years), daily smokers had a significantly higher body mass index (BMI) than non-smokers (21.61 vs....

Lifestyle Modifications Smoking Cessation And Exercise

Much of the work documenting the impact of smoking on health does not discuss results on subsets of subjects with diabetes, suggesting that the identified risks are at least equivalent to those found in the general population. Other studies of individuals with diabetes consistently report a heightened risk of morbidity and premature death associated with the development of macrovascular complications among smokers. Although smokers have repeatedly heard of the pulmonary effects of smoking, the cardiovascular burden of diabetes, especially in combination with smoking, has not been communicated effectively to either people with diabetes or health care providers. Despite demonstrated efficacy of smoking cessation counseling, only about 50 of patients with diabetes are advised to quit smoking by their health care providers (12). Treatment characteristics that have been identified as critical to -o achieving cessation include counseling by multiple health care providers, use of individual...

Weight Change After Smoking Cessation

Smoking cessation reliably produces weight gain in both women and men, although the magnitude of this gain, and the mechanisms involved are less clear (20,27). In the 1970s, a commonly reported but empirically unsupported estimate was that one-third of quitters gain weight, one-third remain the same, and one-third lose weight (28). Based on a review of 43 longitudinal studies, conducted primarily during the 1970s and 1980s, the average weight gain was estimated at 2.8 kg (0.8 to 8.2 kg) during the first year after cessation, with women tending to gain more than men (21). Another review around this time estimated post-cessation weight gain using only methodologically rigorous studies (1). Fifteen longitudinal investigations which included a control group of continuing smokers, a minimum follow-up length of 1 month, and a sample size of at least 10 quitters were examined. The average sample size of the reviewed studies was 1348 subjects with an average follow-up length of 2 years. The...

Step 2 Advise All Smokers to Quit

All smokers should be advised to quit in a clear, strong, and personalized manner. At the same time, acknowledge that it is up to the patient to make the decision to quit. Ask the patient what their personal reasons for quitting might be. Look for reasons that are concrete, specific, and personal such as, I want to be able to keep up with my grandchildren when we go to the zoo. Theoretical, vague, and impersonal reasons may sound like the right answer (I want to quit for my health), however, they are less likely to motivate behavior.

Benefits of smoking cessation

Smoking cessation significantly improves cardiovascular health. According to the World Health Organization, within 1 year of quitting the risk of CHD decreases by 50 , and within 15 years (and often less) the relative risk of dying of CHD for an ex-smoker approaches that of a long-time nonsmoker (8,52). Therefore, smoking cessation is more beneficial in reducing mortality in the aggregate of smokers with coronary artery disease than medical therapy, (3-blockers with bypass surgery, or coronary angioplasty (53,54).

Lung cancer screening

Lung cancer is the leading cause of cancer death in the United States. Yet unlike breast, prostate, and colon cancer, there is not currently a widely accepted screening protocol for lung cancer. Studies of chest radiography and sputum cytology conducted in the 1970s did not reveal a decrease in mortality that justified the expense and complications of widespread lung-cancer screening.22 However, interest in lung-cancer screening was reinvigorated in 1999 with a report by Henschke et al. on the Early Lung Cancer Action Project (ELCAP), which is studying the use of low-dose helical CT in 1,000 volunteers age 60 or greater with at least a 10 pack-year history of smoking.23 The authors have thus far concluded that low-dose CT can greatly improve the likelihood of detection of small non-calcified nodules, and thus of lung cancer at an earlier and potentially more curable stage. Despite the lack of long-term mortality data for these patients, the preliminary ELCAP results were so promising...

Pharmacology of Nicotine and Tobacco Relevance to Schizophrenia

There has been an increasing understanding of the neurobiology of both schizophrenia and nicotine addiction in the past 20 years. For the purposes of this discussion, nicotine is assumed to be the active ingredient in tobacco and cigarette smoking that exerts psychopharmacological effects, though other components of tobacco smoke may also be active in this respect (Fowler et al. 1996a, 1996b). There are three possible reasons for the high comorbidity rates of nicotine addiction in schizophrenia 1) self-medication of clinical and cognitive deficits associated with schizophrenia by tobacco use, 2) abnormalities in brain reward pathways in schizophrenia that make these patients Table 5-1. Prevalence of cigarette smoking in individuals with schizophrenia vulnerable to tobacco (and other drug) use, and 3) common genetic and environmental factors that are independently associated with smoking and schizophrenia. We briefly describe next the pharmacological effects of nicotine and how such...

Effects of Nicotine and Smoking on Clinical and Cognitive Deficits Associated With Schizophrenia

Several cross-sectional studies have examined the effects of cigarette smoking on psychotic symptoms in schizophrenic patients (Goff et al. 1992 Hall et al. 1995 Ziedonis et al. 1994). Goff and colleagues found that schizophrenic smokers had higher Brief Psychiatric Rating Scale (BPRS) total scores than schizophrenic nonsmokers, and higher subscale scores for both positive and negative symptoms. Ziedonis and colleagues found increased positive symptom scores and reduced negative symptom scores in smoking versus nonsmoking schizophrenic patients, with heavy smokers having the highest positive and lowest negative symptom scores. Hall and colleagues noted that schizophrenic patients who were former smokers had fewer negative symptoms than current schizophrenic smokers, yet a recent study by our group found that schizophrenic former smokers had more negative symptoms than current smokers after adjustment for differences in age, depressive symptoms, and education (George et al. 2002a)....

Smoking Cessation

The majority of COPD is caused by smoking. Cigarette smoking has been shown to be as addictive as alcohol or narcotic agents (15). This addictive power of tobacco explains the tendency of individuals to continue to smoke, even in the face of pulmonary disease. Because of this, it is crucial for interventions aimed at smoking cessation to be initiated and maintained. Quitting smoking is clearly in the patient's interest, and performing surgery or other therapeutic interventions in the face of continued smoking is self-defeating the patient must actively participate in his or her care by not smoking. Direct confrontation and insistence on the cessation of smoking by the entire staff are critical components in the management of individuals with COPD in pulmonary rehabilitation. The involvement of the referring physician is important, as the physician's counseling and warning are important predictors of compliance with the program (16,17). The individuals who are to start a program of...

Nicotine

Likewise dopaminergics, nicotine can have specific vascular effects most notably vasodilation. However, much of the observed vasodilatory effects appear to be mediated via NO 44 . Intravenous administration of nicotine to human subjects leads to increased BOLD signal in the nucleus accumbens, amygdala, cingulate, and frontal lobes, all areas associated with reward circuitry 14 . In addition, the primary sites of activation appear to correspond well with the distribution of nicotine cholinergic binding sites seen using nC-nicotine binding 163 . The highest concentration of sites are seen in the frontal, cingulate, and insular lobes of the cortex and in the thalamus and basal ganglia. These results are somewhat different from those obtained using PET measurements of changes in regional CBF. Nicotine reduced rCBF in the left anterior temporal cortex and in the right amygdala. Increases were noted in the right anterior thalamus 164,165 . In the case of the MRI study nicotine was...

Lung Cancer

Lung cancer is the leading cause of cancer-related deaths in both men and women. The incidence of this form of cancer has increased steadily over the past 50 years, especially in women. Cigarette smoking is a major risk factor in this as well as other forms of cancer. The most common form of lung cancer is squamous carcinoma, originating in the lining of the bronchi (bronchogenic). Lung cancer usually cannot be detected early, and it metastasizes rapidly. The overall survival rate is low. Methods used to diagnose lung cancer include radiographic studies, computed tomography (CT) scans, and examination of sputum for cancer cells. A bronchoscope can be used to examine the airways and to collect tissue samples for study. Surgical or needle biopsies may also be taken.

Nicotine Abuse

Tobacco consumption has been estimated to cause nearly 20 of deaths in developed countries, and smokers are more than 20 times more likely to develop lung cancer than individuals who do not smoke (Peto et al, 1992). Despite being aware of its harmful effects, most smokers find it extremely difficult to give up tobacco. Current evidence suggests that the addictive effects of tobacco are principally due to nicotine. It is likely that neuronal nAChRs are the principal target for the drug and that their activation stimulates dopaminergic neurones of the mesolimbic system which mediate 'reward' pathways in the brain. Dani and Heinemann (1966) have suggested a simple model to explain nicotine addiction. They argue that smoking a cigarette delivers sufficient nicotine to active nAChRs that, directly or indirectly, stimulate dopamine release within the mesolimbic system and thereby induce a pleasurable effect. With continued use, nicotine builds up to a low steady-state level that causes...

Descriptive epidemiology

As far as time trends are concerned, incidence rates tended to increase in both sexes in the United States between 1969 and 1990, whereas mortality tended to decline, particularly in men.4 In Europe, mortality rates increased in southern and eastern Europe between the mid-1950s and late 1980s, while a decline has been observed in several northern European countries over the last two decades. This pattern was similar to that of lung cancer, and underlines the importance of tobacco-smoking as an etiologic factor.13

Predispositions to atherosclerosis

The prevalence and extent of atheromata is increased by cigarette-smoking 37 , hypertension, diabetes, and specific genetic diseases 4 . In carotid atherosclerosis, cigarette-smoking has been shown to increase intralesional macrophage content, with an associated increase in intralesional inflammatory enzymes (i.e., macrophage-derived metalloelastase) which degrade vascular tissue.

Contributors to Medical Morbidity in Schizophrenia

Ranking high among the causes of poor physical health in schizophrenic patients are the unhealthy lifestyle practices so prevalent in this disorder. The fact that 70 -80 of patients with schizophrenia are chronic smokers has been extensively documented (Davidson et al. 2001), and studies of individuals with schizophrenia living in the community have also found a high prevalence of sedentary habits and poor dietary choices (Brown et al. 1999 Davidson et al. 2001). Comorbid substance use disorders have been There are ample data suggesting that, overall, the quality of preventive care received by patients with schizophrenia is inferior to that of other groups, including those with other mental disorders. Druss and colleagues studied a database comprising 88,241 Medicare patients age 65 years and older hospitalized with clinically confirmed acute myocardial infarction (MI) to examine the quality of follow-up care for persons with mental disorders (Druss et al. 2001a). In their model...

Preventive Implications For The 21st Century

Has set the stage for opportunities in the next century to direct research and public health activities that can substantially reduce the risk and impact of cardiovascular disease. Foremost among those opportunities is implementation of comprehensive preventive programs of government regulation, health education, and preventive medicine designed to control the major identified cardiovascular risk factors. This includes exploring further the underlying basis for clustering of atherogenic risk factors and the prevalence and impact of insulin resistance, promoting cardiovascular risk profiles to more efficiently target high-risk cardiovascular disease candidates for preventive measures, and finding better ways to implement preventive measures against obesity, insulin resistance, and cigarette smoking. The potential is large if physicians can be induced to more aggressively implement the proven measures recommended to prevent cardiovascular disease.

Inferences From Epidemiologic Research

Extrapolation of findings to previously unstudied populations, by definition, goes beyond the available data, and is thus vulnerable to error in addition to whatever error is contained in the studies that provide the basis for the extrapolation. Universal causal relations (Smoking causes lung cancer.) reflect the ultimate extrapolation, synthesizing a series of individual studies into the untestable assertion about what exposure would do to disease risk in all possible past, present, and future populations. Nonetheless, when we use epidemiologic evidence to guide decisions about individual behavior and public policy, we are implicitly

Ivepidemiology A Hepatitis A Virus

Considerably less virus, up to 105 particles per mL, is found in the blood, and the viremic stage coincides largely with the period that the virus is excreted into the feces. This may now explain the increasing finding of bloodborne hepatitis A infections (17). Virus is also excreted into the saliva, although it has not been established whether saliva plays any role in hepatitis A virus transmission (18). There is, for example, no evidence that sharing eating utensils, cigarettes, or kissing can transmit hepatitis A infection.

Metabolism as Deduced from the Genome Sequence

The complete metabolic pathways for biotine, riboflavin, folate, nicotine amine and heme are present. However, the ubiquinone biosynthesis pathway in L. pneu-mophila is different to the one described for E. coli and may correspond to an uncharacterized biosynthetic pathway also present in P. aeruginosa.

Implications for prevention

Cigarette-smoking is the major identified cause of bladder cancer. The proportion of cases attributable to tobacco was about 80 in men and 30 in women in a study in the UK, about 50 in men and 30 in women in a study from the United States, around 70 in men and 30 in women in a study from Italy, and more than 70 in men (but very low in women) in Alexandria, Egypt.15,87-9 Thus, reducing cigarette-smoking is an imperative for prevention.

Human In Vitro Studies

Recently, using a new investigative tool (chemilu-minescence technique by means of a tonometric balloon), some authors detected higher rectal luminal levels of NO in IBD patients compared to IBS and healthy controls 53 . Nicotine appears to reduce circular muscle activity, predominantly through the release of NO that appears to be upregulated in active ulcerative colitis 54 .

Economic Growth and Modernization

In many populations undergoing rapid modernization and economic growth, high levels of obesity are associated with high rates of NIDDM, hypertension, dyslipidaemia and CVD as well as alcohol abuse and cigarette smoking. This has been de-scibed as the 'New World syndrome' and is responsible for the disproportionately high rates of mortality in developing nations and among the dis-advantaged ethnic minority groups in developed countries.

Other Possible Explanations

Smoking Cessation and Increasing Obesity Rates It has been suggested that the fall in smoking rates observed over recent years in many industrialized countries has made a significant contribution to the rises in mean body weight and rates of obesity. Studies have shown that smokers have significantly lower mean BMI than those who have never smoked and that male ex-smokers tend to have the highest level of BMI (29). Mean weight gain attributable to smoking cessation in a nationally representative cohort of smokers and non-smokers in the USA was 2.8 kg in men and 3.8 kg in women, with heavy smokers (> 15 cigarettes per day) and younger people at higher risk of weight gain (> 13 kg) on cessation (30). However, analyses of the contribution of smoking cessation to population weight gain have been equivocal. One study suggested that smoking cessation may account for up to 20 of the increase in overweight adults in the USA but other studies have indicated that the contribution may be...

Contribution Of Epidemiology To Policy Decisions

Viewing causal inference in epidemiology as falling on a continuum of certainty, never reaching a clearly defined point of resolution, may sound like a formula for inaction. If tobacco use has not actually been proven, beyond all possible doubt, to cause disease based on epidemiologic studies, then how can actions to curtail or eliminate use of tobacco be justified In fact, the spectrum of scientific certainty has been used cynically at times to argue that control of tobacco or other hazards should await definitive proof, quite possibly with the knowledge that such proof will never come. It would be much easier to explain and market epidemiologic evidence to outsiders if we set a quantitative threshold for proven as is done in court (more probable than not). In opposition to such an approach is the inability to measure certainty in such formal, quantitative terms, the incentive it would create to understate or exaggerate the certainty of epidemio-logic evidence, and the real...

How is Used Blood Containing Carbon Dioxide Refreshed With Oxygen

The transfer of carbon dioxide out of the capillaries and the entry of oxygen into the blood stream is called gas exchange. It is the main function of the lungs. Smokers get breathless because the chemicals in the tobacco damage the lungs, reducing the amount of lung tissue (emphysema) and the ability of the lungs to exchange gas. Any lung condition that reduces the ability of the lung to exchange oxygen for carbon dioxide will cause breathlessness.

Cardiovascular Function In Severe Emphysema

Patients with end-stage obstructive lung disease who qualify for lung transplantation commonly have only mild-to-moderate pulmonary hypertension, producing variable degrees of RV dysfunction. Causes of pulmonary hypertension in these patients include destruction of pulmonary vascular space, with or without associated chronic hypoxemia and hypercapnia. Keller et al. (67) studied the hemodynamic profile at rest and during maximum exercise in 30 patients listed for lung transplantation, 15 chronic smokers and 15 with -1-antitrypsin deficiency ( -1-ATD). Pulmonary function tests in both groups showed severe airflow obstruction (mean FEV1 < 25 predicted) and hyperinflation with impaired diffusion capacity. Both groups showed resting pulmonary hypertension, which was more severe with -1-ATD (in COPD, PA systolic pressure 33 + 5 mmHg, in -1-ATD PA systolic pressure 43+ 13 mmHg p < 0.01) . With exercise, both groups showed similarly significantly increased PA pressures. Both groups also...

Need For Objective Assessment Of Epidemiologic Evidence

For example, advocates of restrictions on exposure to environmental tobacco smoke may be inclined to interpret the evidence linking such exposures to lung cancer as strong whereas the same evidence, viewed by those who oppose such restrictions, is viewed as weak. A recent review of funding sources and conclusions in overviews of the epidemiologic evidence on this topic finds, not surprisingly, that tobacco industry sponsorship is associated with a more skeptical point of view (Barnes & Bero, 1998). Whereas judgment of the epidemiologic evidence is (or should be) a matter for science, a position on the policy of restricting public smoking is, by definition, in the realm of advocacy public policy decisions require taking sides. However, the goal of establishing sound public policy that advances public health is not well served by distorting the epidemiologic evidence. Fallible epidemiologic evidence on the health effects of environmental tobacco smoke may well be combined with other...

But Some People Get Coronary Heart Disease And Have No Risk Factors

Coronary heart disease is very uncommon in people who have no risk factors. The risk factors listed above account for the vast majority of cases of coronary heart disease. Smokers often know of someone who smoked all his life and lived to a ripe old age Maybe so, but he (or she) may have had a bad chest with bronchitis and emphysema and may have died from his lung problems or cancer of the lung or another part of the body, before dying from a heart attack. Most smokers know that if they continue, it will catch up with them sooner than they would like.

Physiological mechanisms increasing risk of cardiovascular disease from smoking

There are strong plausible hypotheses for the relation between exposure to tobacco and vascular disease. In animal and human studies, endothelial injury has been associated with carbon monoxide and nicotine. In contrast to healthy individuals, those with ischemic heart disease are affected by carbon monoxide during submaximal exercise, in part because carbon monoxide reduces the ability of hemoglobin to combine with oxygen and diminishes oxygen transport from the lungs to the tissues. Levels as low as 2.5 to 3 carboxyhemoglobin (COHb ) have been found to decrease exercise time before the onset of angina and prolong the duration of ischemia. For maximal exercise, the critical level is approximately 4.5 COHb. Above this level, both exercise and V02max are inversely related to CO concentration. Additionally, cigaret smokers may have baseline COHb in the 4 to 8 range (23). Platelet and clotting factors predisposing to formation of thrombus, as well as vascular smooth muscle cell...

Aging and the Elderly

More recent studies that examined the effect of age on the BMI-mortality association have controlled for smoking. In a Finnish cohort of 17 000 women followed for 12 years, there was a U-shaped BMI-all-cause mortality relation among non-smokers 25 to 64 years of age. Among women aged 65 or greater, mortality varied little according to BMI (52). Among white women from the Seventh Day Adventist cohort who never smoked, the RR of death associated with elevated BMI was lower among 55- to 74-year-olds than for 30- to 54-year-olds. For these older women, the minimal mortality was in the group with BMIs from 23 to 24.8 (53). Although the nadirs of the curves were much higher, a recent study by Seccareccia et al. (54) of over 60 000 Italian subjects again shows the increase in the nadir with age. In one of the largest studies, Stevens et al. (34) investigated mortality over 12 years as a function of BMI across six age groups (30-44, 45-54, 55-64, 65-74, 75-84, and > 85) among 324 135...

Esophageal Adenocarcinoma

There is a strong and probable causal relationship between GERD symptoms and esophageal adenocarcinoma. A case control study from Sweden showed that among individuals with recurrent symptoms of reflux, the odds ratios were 7.7 for esophageal adenocarcinoma (95 CI 5.3-11.4).70 It was also shown that the more frequent, and more severe the symptoms of reflux, the more pronounced the risk of adeno-carcinoma.70 Although Barrett's esophagus is the most widely accepted risk factor for adeno-carcinoma, other risk factors exist as well such as tobacco use, increasing age, male gender, diets high in fats and low in fruits and vegetables, and obesity. A recent population-based study showed a strong correlation between increased body mass index (BMI) and esophageal adenocarcinoma individuals in the highest quarter of BMIs measure had an adjusted odds ratio 7.6 (95 CI 3.08-15.2) compared with those with the lowest BMIs.71

Assess Rates for Diseases Known Not to Be Affected by the Exposure

For most exposures of possible health relevance, we have sufficient background knowledge to delineate some health outcomes that are likely to be affected (typically the ones that motivate the study and similar diseases) and other health outcomes that are highly unlikely to be affected. The conventional wisdom is fallible, of course. There are notable historical examples of erroneous assumptions about health outcomes that were certain to be unaffected by a given exposure. For example, men with chronic bronchitis were selected as controls in early case-control studies of lung cancer because chronic bronchitis was believed to be unaffected by tobacco smoking. Humans have a way of surprising epidemiologists with unanticipated associations, but in general, we can specify some diseases that are very likely to be affected by the exposure of interest based on current knowledge and diseases that are very unlikely to be affected by that exposure. Within the bounds of random error, and in the...

Disease Type and Stage

In some patients, clinical onset of CD occurs with subocclusive symptoms secondary to inflammatory strictures. In naive patients, infliximab probably induces rapid anti-inflammatory effects with symptomatic improvement, reducing the need for resec-tive surgery. There are no studies confirming this hypothesis but a top-down therapy has been recently proposed 16 and, probably, in the near future, this may be an appropriate initial treatment 44 . However, concomitant therapy with immunomodulators increases the rate of clinical response and clinical remission, and smoking seems to be a negative predictor of response to infliximab therapy 45, 46 . Therefore, an initial therapeutic approach with steroids and immunosuppressants followed by infliximab is suggested, as well as smoking cessation.

Notes Electron Transfer

Of course, if energy is dissipated as heat or light, no manufacture occurs. In order for the energy that is trapped when light shines on chlorophyll to become available for carbohydrate manufacture, it must be harvested in certain energy-rich molecules. Two such molecules are nicotine amide dinucleotide phosphate (NADPH) and adenosine triphosphate (ATP). Noncyclic electron transfer produces other energy-rich molecules. This pathway is more complicated than is cyclic transfer and is, therefore, presumed to have evolved later than the more primitive cyclic method. As in the cyclic pathway, an electron moves from the chlorophyll molecule to other intermediate molecules and energy is harvested in certain molecules. Nicotineamide adenine dinucleotide phosphate (NADP) acts as an electron acceptor, becomes negatively charged (is reduced), and, thus, can receive a positive charge in the form of a proton. The proton (which is also a hydrogen nucleus) that attaches to NADP comes from the...

Control of Airway Secretions

Diminishing airway secretion is the avoidance of inhaled irritants, the most important of which is cigarette smoking. Use of air conditioners and air cleaners may also help reduce the effects of environmental air pollution. Various forms of chest physiotherapy are also effective in the mobilization and clearance of airway secretions. These techniques include proper controlled coughing, postural drainage, chest wall percussion, and vibration. Mucus clearance devices, such as the Flutter device and vibration vest, may be helpful (18). There are also several mucoactive or mucolytic agents available to help diminish or clear airway secretions in patients with COPD.

Epidemiology and Significance of the Problem

Several epidemiological and clinical studies since the 1980s have documented the high rates of cigarette smoking in psychiatric patients, particularly those with schizophrenia-related disorders (Chong and Choo 1996 de Leon et al. 1995 Diwan et al. 1998 el-Guebaly and Hodgins 1992 George et al. 1995 Goff et al. 1992 Hughes et al. 1986 Kelly and Mc-Credie 1999 Masterson and O'Shea 1984 McEvoy and Brown 1999 Menza et al. 1991 O'Farrell et al. 1983 Ziedonis et al. 1994). Although smoking rates in the general population have substantially declined from 45 in the 1960s to about 25 currently (Vocci and DeWit 1999), rates of smoking in chronic psychiatric patients, especially those with schizophrenia, continue to be very high. In fact, one recent community-based study suggested that nearly 45 of all cigarette consumption in the United States is by individuals with mental disorders (Lasser et al. 2000). Surveys of cigarette smoking in schizophrenia in a myriad of inpatient and outpatient...

Summary Of General Approach To Medical Management Of Copd

After the diagnosis of COPD is established, education about the disease should be undertaken, so that the patient has a better understanding of the illness and can take an active role in its management. Smoking cessation should be emphasized and demanded. Pharmacotherapy is recommended in patients who are symptomatic. It should be instituted in a

Most cancers are caused by genetic mutations

As we saw in Chapter 12, spontaneous mutations arise because of chemical changes in the nucleotides. In addition, certain mutagens, called carcinogens, can cause mutations that lead to cancer. Familiar carcinogens include the chemicals that are present in tobacco smoke and meat preservatives, ultraviolet light

So How Do Doctors Find Out If People Have Coronary Heart Disease

GPs are encouraging their patients to visit them for checks on blood pressure, weight, cholesterol, and blood sugar. Doctors and nurses help patients stop smoking and give advice about diet, exercise, and lifestyle. These checks help identify patients at risk. Patients with chest pain, who may have ignored their symptoms, have the opportunity to tell the doctor about their symptoms.

Pharmacokinetic Implications of Smoking for Psychotropic Drug Use in Schizophrenia

The metabolism of antipsychotic drugs such as haloperidol, chlorpromazine, olanzapine, and clozapine (George and Vessicchio 2001 Perry et al. 1993). Accordingly, smoking cessation may be expected to lead to increases in plasma concentrations of antipsychotic drugs metabolized by the 1A2 system, a finding demonstrated in both prospective and retrospective studies using both between-subject (Perry et al. 1993, 1998 Seppala et al. 1999) and within-subject (Meyer 2001) designs. Such an increase in circulating levels would be expected to increase the likelihood of extrapyramidal reactions and other antipsychotic drug side effects. A nomogram has been developed for clozapine in an attempt to aid clinicians in adjusting clozapine doses in smoking compared with nonsmoking schizophrenic subjects (Perry et al. 1998). Although no smoking cessation study in schizophrenics to date has prospectively measured antipsychotic plasma levels before and after smoking cessation, Meyer (2001) reported on...

Acetylcholine as a Neurotransmitter

The stimulatory effect of ACh on skeletal muscle cells is produced by the binding of ACh to nico-tinic ACh receptors, so named because they can also be activated by nicotine. Effects of ACh on other cells occur when ACh binds to muscarinic ACh receptors these effects can also be produced by muscarine (a drug derived from certain poisonous mushrooms).

Sampling Distributions

Example 4.1 Consider a population consisting of six subjects (this small size is impractical, but we need something small enough to use as an illustration here). Table 4.1 gives the subject names (for identification) and values of a variable under investigation (e.g., 1 for a smoker and 0 for a nonsmoker). In this case the population mean m (also the population proportion p for this very special dichotomous variable) is 0.5 ( 3 6). We now consider all possible samples, without replacement, of size 3 none or some or all subjects in each sample have

Determine Whether Exposure Prevalence Varies as Expected Among the Controls

An aberration in the manner in which controls are selected may manifest itself as an unusual pattern of exposure among subsets of controls if the faulty selection does not apply equally to all segments of the study base. Often we know from previous research that exposure prevalence varies by subgroup, e.g., men tend to drink more alcohol than women, White smokers tend to smoke more heavily than African-American smokers, leisure-time physical activity is greater among persons of higher socioeconomic status. If some erroneous method of selection has been applied that is similarly problematic for all subgroups of controls, defined by gender, race, age, etc., then the pattern of exposure prevalence across those markers of exposure may be as expected. If, however, the problems in selection are more extreme for some groups than others, or simply affect subgroups differentially, we will observe patterns of exposure comparing subsets of controls that deviate from those that would normally be...

Case Study for Chapter

A 27-year-old accountant recently drove cross-country to start a new job in Denver, Colorado. A week after her move, she started to experience chest pains. She drove to the emergency department after experiencing 24 hours of right-sided chest pain, which was worse with inspiration. She also experienced shortness of breath and stated that she felt warm. She denied any sputum production, hemoptysis, coughing, or wheezing. She is active and walks daily and never has experienced any swelling in her legs. She has never been treated for any respiratory problems and has never undergone any surgical procedures. Her medical history is negative, and she has no known drug allergies. Oral contraceptives are her only medication. She smokes a pack of cigarettes a day and consumes wine occasionally. She does not use intravenous drugs and has no other risk factors for HIV disease. Her family history is negative for asthma and any cardiovascular diseases.

Dietary lipids and cancer

As reviewed above, the evidence is strong for a link between adiposity and breast cancer and for endometrial cancer, both in post-menopausal women. The most consistent theory implicates the production of oestrogens by the excess adipose tissue. Adipose tissue is an important site for the conversion of androgens (particularly androstene-dione, secreted from the adrenal cortex) to oestrogens, oestradiol and oestrone. The development of some forms of breast and endometrial cancer is stimulated by oestrogens, and hence the association with dietary fat or obesity. The intake of some antioxidants, including tocopherols and lycopene (the red carotenoid pigment of tomatoes), has been linked to protection against certain cancers, including prostate. Even if these findings should be confirmed, it should be emphasized that cancer prevention may not be as simple as supplementation with the antioxidant vitamins at high doses. A number of supplementation studies has been carried out, none so far...

Relationship Between Obesity And Type 2 Diabetes Mellitus

Trowell and Burkitt's studies of epidemiological changes in modernizing societies showed that obesity is the first of the 'diseases of civilization' to emerge in the longitudinal picture (78). As such obesity is clearly the earliest target for intervention to halt a wide range of non-communicable diseases of modern and modernizing societies. Gracey has termed this defined cluster of diseases the New World syndrome (79), and has included within its sphere obesity, type 2 diabetes, hypertension, dys-lipidemia, and cardiovascular disease (also termed the metabolic syndrome X (80)) (with the addition of cigarette smoking and alcohol abuse).

Mr Hyde Tumor Glycolipids

GD2 is aberrantly expressed in small cell lung cancer and is considered to be a key factor in cancer cell proliferation and invasion. Upregulated expression of GD3 in melanomas has been reported to enhance phosphorylation of two adaptor molecules, p130Cas and paxillin, which regulate cell growth and cell adhesion 104 . Similarly, polysialic acid (polySA) is involved in cell-cell interactions and cell migration 105 . Based on its large size and negative charge of the carbohydrate side chain, polySA has an inhibitory effect on cell adhesion and thus promotes cell motility 106 . This has been confirmed in animal studies, where its expression correlated with tumor invasiveness, metastases, and increased growth rate 107 .

Profiling Gene Expression At The Rna And Protein Levels

Although several technologies are currently available for global profiling of gene expression at the RNA level, the DNA microarray approach has had the most impact on biomedical research. Applications of DNA microarrays include uncovering unsuspected associations between genes and specific biological or clinical features of disease that are helping devise novel molecular-based disease classifications. In relation to cancer, most published studies of tumor analysis using DNA microarrays have either examined a pathologically homogeneous set of tumors to identify clinically relevant subtypes e.g., responders vs. nonresponders, or pathologically distinct subtypes of tumors of the same lineage e.g., high-stage vs. low-stage tumors to identify molecular correlates, or tumors of different lineages to identify molecular signatures for each lineage. Very few studies have analyzed microarray data primarily from a functional pathway point of view. An important challenge for microarray analysis...

Cancers Linked To Hpv Infections

Besides anogenital cancers, approx 20 of oropharyngeal cancers have been found to contain anogenital high-risk HPV types (39). Particularly frequent are HPV findings in cancers of the tonsils (40,41) and the tongue (42). Occasional HPV positivity has also been reported for other cancers, such as cancer of the larynx (43,44), hypopharynx (45), nasal cavity (46), palatine, buccal mucosa, lips (45), and even for a few lung cancer biopsies (47). Since HPV-positive oral cancers, to the extent they have been investigated, express the viral oncoproteins E6 and E7 (48,49), it is likely that the virus plays a causal role in these tumors.

Dose Response Gradients and Potential for Confounding

Depending on the reasons for the exposure-confounder association, confounding that exaggerates or masks dose-response gradients may require increasingly implausible scenarios. For example, in the case of silica exposure and lung cancer being confounded by cigarette smoking, a global comparison of foundry workers and the general population may suffer from positive confounding if cigarette smoking is not carefully controlled. On the other hand, assume we now have information on levels of silica exposure, based on job activity and years of employment. The hypothesis that those individuals who have accrued greater amounts of silica exposure are heavier smokers, accounting for age, seems less plausible. That is, the sociological basis for foundry workers being more likely to smoke does not extend to an expectation that more heavily exposed foundry workers would be more likely to smoke than less heavily exposed foundry workers. The association of smoking with exposure only applies to...

Integrated Assessment Of Potential Confounding

In order to evaluate the extent to which confounding may have biased the results of an epidemiologic study, the conceptual basis for confounding must first be examined. The question of exchangeability of exposed and unexposed needs to be posed for the specific research question under consideration Do nonsmokers have the risk of lung cancer that smokers would have had if they had not smoked Do women with low levels of calcium intake have the same risk of osteoporosis that women with high levels of calcium intake would have had if their intakes had been low This question, posed in the grammatically awkward but technically correct counterfactual manner serves to focus interest on the phenomenon of confounding rather than available covariates, which are at best, a means of addressing and mitigating the lack of comparability of the groups. The goal is not to achieve statistical control of covariates or to consider the longest possible list of potential confounders but rather to reduce or...

We Are Living Longer With Coronary Heart Disease And After Heart Attacks

Because medical care and treatment have improved. We understand more about how these conditions develop and what things really work in reducing our risk of getting them. Fewer adults smoke due to anti-smoking publicity, smoking clinics, help lines and medications (although smoking among children, teenagers and the twenty-year-olds, particularly females, may be increasing).

Measurement And Classification Of Exposure

Or hair color physiologic characteristics such as blood pressure behaviors such as physical exercise mental states such as stress or depression the social environment, including poverty and discrimination and participation in health care, such as disease screening and receipt of immunizations. As a consequence of this remarkable range of interests that fall within the scope of epidemiology, there is a corresponding diversity of methods for measuring exposure (Armstrong et al., 1992). Tools include biological assessment based on specimens of blood or urine, physical observation, assessment of the social and physical environment, review of paper or computerized records and a broad array of tools based on self-report and recall, including instruments to evaluate stress, diet, and tobacco use. The distinctive features of the exposure of interest pose specific challenges to accurate measurement, and thus there are many different strategies for evaluating exposure accuracy and...

The Fabric And The Chain

Dorothy Wrinch, the first woman to receive a doctorate in science from Oxford, was in many ways ahead of her time. She spoke her mind (often with an acid tongue), smoked cigarettes, believed in independent careers for married women, and forcefully pursued her own. Trained as a mathematician, Wrinch believed that all scientific progress grew directly out of pure logic she found her greatest success applying that approach to biology.

Reducing blood pressure through lifestyle changes

Therapeutic lifestyle changes focusing on weight reduction, exercise, and healthy eating (restricted sodium intake, the dietary approaches to stop hypertension DASH eating plan, and moderate alcohol consumption) is the foundation of hypertension management in persons with metabolic syndrome (Table 3) (16). Individuals should also be counseled to stop smoking to reduce their overall CVD risk. A realistic weight loss target is 10 of initial weight over 6 mo. Losing 22 lbs (10 kg) reduces SSP by 5-20 mmHg in a large proportion of overweight individuals (16).

Patients Unsuitable For Strict Control

In practice, however, there are patients in whom attempts to achieve a near normal glycated haemoglobin are not appropriate (Box 8.2). Patients with advanced complications, especially retinopathy, have not been shown to benefit and a sudden improvement in glycaemic control may cause acceleration in severity of pre-proliferative or early proliferative retinopathy (Hanssen et al., 1986). Although some authorities claim that this should not be a contraindication to improving glycaemic control (Chantelau and Kohner, 1997), as yet there is no real evidence for benefit in advanced cases and the retinopathy should be treated appropriately before glycaemic control is intensified. Similarly, in patients with established renal impairment and severe macrovascular disease, attempts to treat elevated blood pressure and plasma lipids and to encourage patients to stop smoking may be more beneficial than targeting glycaemic control alone. As intensive insulin therapy is aimed at achieving benefit...

Testing For Differences Between Two Proportions

The foregoing chi-square tests also may be considered tests of proportion and may be used as an alternative to the binomial test of proportions (Chapter 10). Tests for differences among groups are based on whether or not the proportions are equal. So a test of independence between gender and smoking is the same as testing that the proportion of male smokers equals the proportion of female smokers. The binomial test is called an exact test of significance, whereas the chi-square test is an approximate test of the comparison of two or more proportions. The chi-square test statistic under the null hypothesis has an approximate chi-square distribution based on asymptotic theory, but the exact probability distribution is not a chi-square. Hence, the significance level based on the table of the chi-square distribution is only an approximation to the true significance level. On the other hand, the binomial distribution is the exact probability of the test statistic and so an exact...

Optimal Level of Exposure Aggregation

Nutritional epidemiology provides an abundance of opportunities for creating exposure indices and demands clear hypotheses about the effective etiologic agent. Much research has been focused on specific micronutrients, such as beta-carotene or dietary fiber, and with such hypotheses, the goal is to comprehensively measure intake of that nutrient. An alternative approach is to acknowledge the multiplicity of constituents in foods, and develop hypotheses about fruit and vegetable intake, for example, or even more holistically, hypotheses about different patterns of diet. A hypothesis about beta-carotene and lung cancer is distinct from a hypothesis about fruit and vegetable intake and lung cancer, for example, with different demands on exposure assessment. Exposure indices must be defined with sufficient precision to indicate which potential components of exposure should be included and which should be excluded, and how the measure should be defined.

Problems in Classification

* Notes of chemical taxonomy, plants are grouped according to common chemical substances. The plants of the Cruciferae family, for example, all have mustard oils. Even the presence of common chemicals, however, does not guarantee kinship. Nicotine, for example, occurs in some widely separated families and not just in tobacco. Substances called tropolones occur in fungi (P nicillium) and also in certain conifers. The mention of these exceptions is not meant to entirely invalidate chemical taxonomy or other attempts at classifying organisms. Rather, it is meant to illustrate the importance of considering a collection of information when attempting to identify relationships between organisms. The computer is being used as a tool to this end.

Operational Measures of Exposure

A variety of biochemical markers of tobacco use, for example, urinary or salivary cotinine, or carboxyhemoglobin, are precise indicators that are reflective of hours or at most a day of exposure. The alternative approach to assessing tobacco exposure is the ostensibly cruder measure of self-report, subject to the ability and willingness of respondents to recall their smoking behavior. If the ideal measure is lifetime (or long term) exposure, however, self-report is likely to be superior even to a series of biochemical measures only because the latter cannot integrate over time the way the participants' memories can. If the ideal exposure measure were lifetime inhalation of tar from tobacco combustion, the operational definition based on self-report of cigarettes smoked daily over specified periods of life is likely to be far more strongly correlated with that ideal measure than any present or recent biochemical markers of recent exposure. If our gold standard definition were...

Arousal And Attention

Similar to hypocretin, nicotine excites high-affinity nicotinic acetylcholine receptors on thalamocortical terminals and results in a large increase in glutamate release onto prefrontal layer V pyramidal neurons.32 Interestingly, nicotine has repeatedly been shown to enhance attention. While this effect has mainly been demonstrated with systemic administration of nicotine, a recent study showed that direct infusion of nicotine into prefrontal cortex improves performance of rats on a task of divided attention.33 It would be fascinating to study the effect of hypocretin infused into prefrontal cortex in this manner.

Contraindications Precautions And Interactions

When xanthine bronchodilators are administered with sympathomimetic drugs (see Chap. 22), additive CNS and cardiovascular effects may occur. If a patient eats large amounts of charcoal-broiled foods while taking the xanthines, a decrease in the therapeutic effect of the xanthines may occur. Certain foods contain xan-thine (eg, coffee, colas, or chocolate) and may increase the risk of cardiac and CNS adverse reactions. Cigarettes, nicotine gum and patches, barbiturates, phenytoin, loop diuretics, isoniazid, and rifampin may decrease the effectiveness of the xanthines. There is an increased risk of xanthine toxicity when the drugs are administered with influenza vaccination, oral contraceptives, glucocorticoids, p-adrenergic blockers, cimeti-dine, macrolides, thyroid hormones, or allopurinol.

The Immune System and Cancer

Our thinking about cancer has changed remarkably in recent years. Bone cancer still looks different from brain cancer skin cancer is still treated differently than lung cancer. But the current focus is on understanding what causes cancer in the first place, and here the emphasis is on what cancers have in common, rather than on what makes them different. Cancer can be contributed to by external agents radiation, chemicals, and some viruses or by mistakes made within a cell when it reproduces its DNA. And indeed, any cell or tissue in the body can give rise to a tumor. But ultimately every cancer is a disorder of DNA. All cancer cells share one single, common feature they have their lost ability to regulate DNA synthesis and cell division. And the regulatory elements governing these processes lie in the DNA itself in our genes.

Examine Multiple Indicators of Exposure

For example, in measuring exposure to environmental tobacco smoke over long periods of time, there are two basic strategies available biochemical markers of short-term exposure and self-reported information on proximity to active smokers. The biochemical markers are precise indicators over short periods of time. Assuming that the measurement period represents a sample from the long-term period of etiologic interest, the accurate short-term measure has some value as a marker of long-term exposure. The self-report of proximity to smokers is capable of integration over the extended time period of etiologic interest, given that questions can be focused on specific periods of interest and the respondent can presumably reflect on and recall the period of interest. Self-report is vulnerable to the uncertainties of perception and recall, however, including potential biases in perceiving the presence of tobacco smoke and faulty memory in recalling those experiences. What type of association...

Acute and Chronic Complications

The chronic complications of diabetes are microvascular disease (neuropathy, nephropathy, retinopathy), macro-vascular disease (ischemic heart disease, cerebrovascular disease, peripheral vascular disease), and poor growth and development. Many of the chronic complications can be prevented or delayed with optimal blood glucose control, management of dyslipidemia and hypertension, proper weight management, and smoking cessation.

Oligonucleotide Delivery By Cationic Liposomes

Another vector for oligonucleotide delivery is influenza virus envelopes reconstituted in DOTAP liposomes (105). This system was used to deliver an oligonucleotide antisense to L-myc in human small cell lung cancer cells and resulted in inhibition of thymidine incorporation in the picomolar range, whereas micromolar concentrations of free oligonucleotides were necessary to achieve inhibition in previous studies (106). Antisense oligonucleotides can also be delivered via the hemagglutinating virus of Japan (HVJ)-liposome'' method, in which the oligonucleotides are first encapsulated in PS PC Chol (1 4 8 2) liposomes, and the liposomes are allowed to interact with UV-inactivated HVJ (Sendai virus) (107,108). HVJ-liposomes-mediated delivery of antisense oligonucleotides against cyclin B1 and CDC2 kinase-encoding genes into cells lining the rat carotid artery mediated partial inhibition in neointima formation (107). Systemic delivery of antiapolipopro-tein E oligonucleotides in these...

Representative other applications

Several studies have been carried out to obtain proteomic profiles in human lung cancer cell lines. Proteomic signatures were obtained for different histological types of lung cancer. Hierarchial clustering analysis and principal component In cell line studies, an 11 kDa protein was identified by MALDI-MS and database search as S100C (calgizzarin) which is significantly downregulated in bladder cancer and is associated with poor survival loss of S100C which was also significantly associated with poor survival in patients 135 . Two downreg-ulated proteins, identified as isocitrate cytoplasmic and peroxiredoxin-II, were identified in both bladder cancer cell lines and human biopsies. Loss of these proteins marked the progression of malignancy 136 . In a study of tumor subsets in lung cancer, 15 1600 separated peaks provided a call-prediction model to distinguish primary tumors from metastasis and to distinguish between patients with resected nonsmall-cell lung cancer and poor prognosis...

Evaluate Known Predictors of Exposure

In a study of the potential association between serum selenium and the risk of lung and prostate cancer among cigarette smokers, Goodman et al. (2001) provided a rather detailed analysis of predictors of serum selenium concentrations (Table 8.5). In addition to addressing concerns with the comparability of collection and storage methods across study sites, they were able to corroborate the expected reduction in serum selenium levels associated with intensity and recency of cigarette smoking. Even though the background knowledge is limited to help anticipate what patterns to expect, confirming the inverse association with smoking adds confidence that the measurements were done properly and are more likely to be capturing the desired exposure. Heavy smokers *Adjusted means from model including all variables with p < 0.1 except years quit smoking for the *Adjusted means from model including all variables with p < 0.1 except years quit smoking for the

Kenneth D Ward Robert C Klesges and Mark W Vander

The health consequences of cigarette smoking are well established (1). Smoking has been linked to many serious health problems including cancer, coronary heart disease, stroke, and chronic obstructive pulmonary disease (2). As a result, smoking has been determined to be the single most preventable cause of death in Western society (3). Each year, an estimated 419 000 people in the United States die from smoking-related diseases (4), making it responsible for approximately one in every five deaths (2). Although overall smoking rates have declined over the past 30 years in the United States, nearly 26 of the population continue to smoke (5), including 3.1 million adolescents (6). One of the many factors which may encourage smoking, despite health risks, is the influence of smoking on body weight. There is considerable evidence that the weight-controlling properties associated with cigarette smoking influence decisions to smoke. For example, the relationship between smoking and weight...

Surgical Planning

On the day before the operation the surgeon discusses with the patient in detail which changes he or she wants and how this will be achieved. The areas to be removed by suction and the tumescence borders are marked exactly. In order to keep the operation risk as low as possible the patient should be made aware that he or she should not take any anticoagulants such as acetylsalicylic acid before the operation. The patient should also not smoke before the operation as this causes a reduction in perfusion. The risk of blood clots forming in the body also increases if the patient is taking contraceptives. In such cases the patient should stop smoking 2 weeks before the procedure and for the duration of the wound-healing period at the very least.

Mechanisms Of Postcessation Weight Gain

The exact mechanisms underlying post-cessation weight gain still are not well understood. According to the principles of energy balance, smoking cessation must lead to either an increase in energy intake, and or a decrease in energy expenditure (viz., metabolic rate, physical activity) to promote weight gain (33). The available data indicate that physical activity does not play a role in the relationship between smoking and body weight (20,33,34). Cross-sectional studies comparing activity levels in smokers and non-smokers have failed to find discrepancies that would account for the difference in body weight between the two groups (20,35). In fact, studies finding a relationship between smoking status and physical activity have typically found smokers to be less active than non-smokers (36-38). Additionally, physical activity does not appear to decrease following smoking cessation (33,39-41). Those studies finding changes following smoking cessation have reported increases in physical...

Changing demographics of the elderly in the general population

At the same time, there has been a 17 increase in age-adjusted death rates from malignancies, an increase (100-200 in males and over 400 in females) largely due to respiratory cancer death rates and clearly reflecting the timing and development of smoking habits.7 The same may become true of bladder cancer, given its strong association with cigarette-smoking, and may well account for an increasing risk as the population ages, particularly in younger cohorts, unless smoking habits change.

Gastric Adenocarcinoma

Gastric cancer is the second most frequent cancer worldwide, representing almost 10 of all new cancers and surpassed only by lung cancer (1). It is also the 14th most common cause of death and the second most common cause of cancer death (2). Since the beginning of the century, however, gastric cancer incidence has been declining at a rate of 20-50 per decade (3). In the United States, for example, it has gone from, in 1940, the leading cause of cancer death to, in 1998, the ninth and tenth leading cause of cancer death in men and women, respectively (Fig. 1). Today, the incidence of gastric cancer in the United States is on the order of eight per 100,000 persons, although rates are higher among men than women and vary substantially across various racial and ethnic groups (4).

Organ system function and ageing

Chronic obstructive pulmonary disease is the fourth leading cause of death in the elderly.11 Risks are increased by co-morbid diseases, cigarette-smoking, decreased ventilatory responses to hypoxia and hypercapnia, and a decreased perception of dyspnea. Smoking is associated with a fourfold increase in post-operative pulmonary complications.12 Risks of pulmonary complications can be significantly reduced by cessation of smoking, and this is mandatory before any major surgery. Indeed, significant reduction of such risks can be achieved with cessation of smoking as early as four to eight weeks before surgery.

Factors Contributing To Malignancy

The effects of other known risk factors for gastric cancer could be modified by the concurrent presence of H. pylori. For example, it appears that diets high in salt and nitrates increase cancer risk while diets rich in fresh fruits and vegetables protect against gastric cancer (123). Because H. pylori both induces nitric oxide formation (potentially fostering the formation of A-nitroso compounds from intraluminal nitrites) and destroys mucosal ascorbate, the interaction of infection with diet may have an effect far greater than each alone in causing cancer. In the same way, cigarette smoking potentially alters the outcome of H. pylori infection (171,172), again via the nitric oxide pathway (173). Also of interest, some gastric adenocarcinomas have clonal integration of Epstein-Barr virus (174,175), although a relationship with H. pylori remains unclear.

Cardiovascular Disease

The Framingham Study showed in 2005 men and 2521 women that the 28-year age-adjusted rates (per 100) of CHD was 26.3 for a mean BMI of 21.6kg m2 and 42.2 for a mean BMI of 31 in men, and 19.5 for a BMI of 20.4 and 28.8 for a BMI of 32.3 in women, respectively (82). The 28-year age-adjusted relative risks and their 95 confidence intervals for the highest quintile compared to the lowest were 1.9 (1.4-2.5) for CHD and 1.8 (1.4-2.4) for CHD excluding angina pectoris for men and 1.7 (1.3-2.3) and 1.6 (1.2-2.3) for women, respectively. The Gothenburg study, in a 12-year incidence period, showed in a multivariate analysis, that the WHR was the strongest predictor (84) of myocardial infarction in 1462 women. In 1990, the Nurses Health Study, during an 8-year observation, clearly showed in a population of 121700 females that obesity is a determinant of CHD after control for cigarette smoking, which is essential to assess the true effect of obesity, even mild-to-moderate overweight increased...

Prevention Of H Pylorirelated Gastric Cancer

Alternative targets for gastric cancer prevention involve environmental cofactors. As mentioned previously, dietary supplementation with antioxidants, or diets rich in fresh fruit have been associated with a decreased gastric cancer risk and are beneficial for many reasons (198,199). Cigarette smoking has also been linked to gastric tumors, among many other conditions (171).

Experiments with Plant Animal Interaction

Research has also successfully analyzed how certain plants have been able to develop toxins as chemical defenses against animals. These protective devices include such poisons as nicotine and rotenone that help prevent insect and small mammal attacks. A more remarkable group of protective compounds recently isolated from some plants are known as juvocimines. These chemicals actually mimic juvenile insect hormones. Insect larvae feeding on leaves containing juvocimines are prevented from undergoing their normal development into functional, breeding adults. Thus, a specific insect population that could cause extensive plant damage is locally reduced.

The Ecology of Interaction

Burned and blighted areas through their seed dispersal strategies. The plant horticulture and floral industries also are developing an appreciation of specific plant-animal interactions that produce more viable natural strains of flowers and ornamental shrubbery. The study of natural chemical defenses produced by some plants against animal invasions is most promising. The renewed interest in earlier efforts to extract such plant products as nicotine, rotenone, pyrethrum, and caffeine may produce natural compounds that can be effective insecticides without the long-term, environmental hazards associated with such human-made pesticides as malathion, chlordane, and dichloro-diphenyl-trichloroethane (DDT).

Patient Selection And Preoperative Assessment

Operative candidates were selected on the basis of hyperinflation, heterogeneity of disease, pulmonary perfusion and ventilation deficits, and significant functional disability. Patients with morbid obesity, chronic bronchitis and or excessive sputum production, metastatic cancer, continued or recent cigarette smoking, or less-than-severe functional disability were excluded from consideration.

Overcoming Tolerance Leads to Tumor Immunity

Tregs have been shown to limit the efficacy of vaccine-induced tumor responses. Many tumors, both human and experimental, have been demonstrated to recruit Tregs to both the draining lymph nodes and tumor bed (Curiel et al. 2004). Murine studies have demonstrated that depletion of Tregs can enhance immunotherapy directed toward tumor antigens. In these tumor models, injection of an anti-CD25 monoclonal antibody to deplete Tregs was shown to significantly enhance vaccine efficacy to a variety of tumors, including mammary adenocarcinoma (Comes et al. 2006) and melanoma (Sutmuller et al. 2001). Even in the absence of vaccination, intratumoral depletion of accumulating CD4+ Tregs in a murine fibrosarcoma model also led to tumor rejection (Yu et al. 2005). Interestingly, Sharma and colleagues (2005) demonstrated that Cox-2 inhibitors, which can block accumulation of tumor-induced Tregs, can enhance the immune response in non-small cell lung cancer. The ability to deplete Tregs in humans...

Ischemic heart disease

The risk of pulmonary complications can be attributed to various factors, both pulmonary and nonpulmonary. Minor pulmonary complications (atelectasis, bronchitis) are increased in patients who smoke or who have chronic cough or abnormal spirometry values. However, the risk for severe postoperative pulmonary complications (pneumonia, respiratory failure) is increased mainly in those patients with marked impairment in lung function (FEV-i < 1.5 L). Among the nonpulmonary factors that contribute to the risk for postoperative complications are age, obesity, longer duration of anesthesia, excessive sedation, poor patient effort, and the type of surgery. Respiratory dysfunction is less severe after orthopedic than after intraabdominal or thoracic surgery.

Occupational Carcinogens

Although only 2 to 8 of human cancers are of occupational origin, the risks are high for specific populations of exposed workers. For example, employment in the rubber industry has been strongly associated with bladder, stomach, and lung cancers and leukemia. The following are manufacturing production environments in which there is exposure to known human carcinogens (IARC Group I) aluminum production, auramine manufacture, boot and shoe manufacture and repair, coal gasification, coke production, furniture and cabinet making, hematite mining, iron and steel founding, isopropanol and magenta manufacturing, painting, the rubber industry, and heavy exposure to sulfuring acid mists. Probable human carcinogen exposure (Group 2A) occurs for hairdressers and barbers. Possible human carcinogens (Group 2B) affect workers in the carpentry and textile industries. The types of occupation-related epidemiology studies include case reports, sentinel events, ecologic investigations, and analytic...

Adverse Events From Cannabis Administration

One of the most reliable effects of acute cannabis administration is the impairment of memory processes. Numerous studies have found that smoked marijuana decreased the number of words or digits recalled and or increased the number of intrusion errors in either immediate or delayed tests of free recall (9,53,55,60). Using an extensive battery of cognitive tests, Block et al. (51) found that cannabis slowed response time for producing word associations, slowed reading of prose, and impaired tests of reading comprehension, verbal expression, and mathematics. Heishman et al. (31) also found that simple addition and subtraction skills were impaired by smoking one, two, or four cannabis cigarettes. 2. NIDA cigarettes can be ordered in writing from the Chemistry & Physiological Systems Research Branch, Division of Neuroscience & Behavioral Research, 6001 Executive Boulevard, MSC 9555, Bethesda, MD 20892-9555 (301 443-6275). US investigators must hold a valid Schedule I research...

Imaging Techniques for Studying Neuronal Activity

Autoradiographic and PET studies have also examined metabolic changes (both blood flow and glucose utilization) after neurotransmitter stimulation using, for example, amphetamine 4 . While PET is the gold standard tool for measurement of regional changes in glucose utilization in vivo, the same cannot be said for PET studies of metabolic activation using CBF. A number of studies used PET to assess changes in CBF after drug stimulation. These studies suffer from the fact that, with PET, CBF is usually only measured once after administration of the drug whereas with MRI one can obtain the entire hemodynamic time course with temporal resolution on the order of 1 sec. The technique of fMRI is well suited to study these metabolic changes 5 . Several reports using MRI to study the acute effects of amphetamine 5-7 , cocaine or cocaine analogs 5,8-10 , apomorphine or L-dopa 11-13 , nicotine 14 , heroin 15 , and serotonin ligands 16 have appeared. Nonetheless, there is a number of issues that...

What About Women And Smoking

Smoking increases the risk of blockage in the leg arteries (peripheral vascular disease) sevenfold and increases the potential of coronary artery disease and myocardial infarction fivefold (Chapter 10). Even passive smoking is dangerous. Although the proportion of male and female adult smokers has decreased over the last three decades, smoking has increased among girls. Twenty-five percent of women smoke, and many of these are very young, damaging their heart and lungs, sometimes irreversibly, at an early age. Many women get angina and heart attacks for no other reason than smoking. Women who smoked more than 15 cigarettes per day and used high-dose estrogen oral contraceptives (now rarely prescribed) were found to have a 20-fold increase in coronary heart disease risk. Passive smoking increases coronary risk in men and women by 30 .

What Are Inflammatory Markers In The Blood

There is a protein in the blood called C reactive protein. High levels are found in the blood in people with infection or inflammation. The levels ofC reactive protein increase with age and are higher in smokers. High levels may predict a future heart attack or episodes of angina. Levels are high in patients who have had attacks of angina. It is probable that the high levels reflect the general inflammatory process that occurs inside the heart arteries. Levels are also high in women after the menopause, but it is not known why. At this moment, we do not check this in the blood as a screening test.

Lipid Lowering After Revascularization

Rosis progression in saphenous vein grafts in patients in the post-CABG trial identified current smoking, male sex, hypertension, elevated triglycerides, and low HDL as independent predictors of graft worsening (85). The importance of vein graft atherosclerosis in the diabetic population was graphically emphasized in BARI where the 7-year survival of diabetic patients treated with CABG using only saphenous vein grafts was only 54 compared to 83 for patients receiving at least one LIMA graft (see Fig. 6). It is clear, based on BARI and previously reported work (22,34), that diabetics after CABG have a reduced longevity compared to nondiabetics, especially when dependent on saphenous vein grafts. Aggressive measures are indicated in all post-CABG patients to reduce serum LDL, elevate HDL, control blood pressure, lower triglycerides, and strongly encourage smoking cessation. The effects of rigorous glycemic control on cardiac events post-CABG have not been carefully studied.

What About The Birth Control Pill Is It Safe In Women With Cardiovascular Risk Factors

Yes, the Pill is safe in women who do not have any risk factors and so is almost always safe in young women. But in women who have risk factors, for example, women who smoke, are fat, have high cholesterol, are diabetic, or have high blood pressure, the Pill may not be safe because it adds to the risk of heart attacks. A woman with more than one risk factor should probably not take the Pill and may need another form of contraception. who have any cardiovascular risk factor, particularly smokers Therefore, a woman who smokes is at greater risk from developing coronary heart disease than a nonsmoker. A woman with several risk factors is at much greater risk, and the risks of the Pill may be too high. The greater the number of risk factors, the greater the risk of cardiovascular problems. Women who smoke or have high blood pressure, should either not take the Pill or should stop smoking.

Consideration Of Random Error And Bias

Observational studies are rarely if ever true replications of one another. The populations in which the studies are conducted differ, and thus the presence of potential effect-modifiers differs as well. The tools of measurement are rarely identical, even for relatively simple constructs such as assessment of tobacco use or occupation. Exact methods of selecting and recruiting subjects differ, and the extent and pattern of nonparticipation varies. Susceptibility to confounding will differ whenever the underlying mechanism of exposure assignment differs. Thus, the opportunity to simply integrate results across a series of methodologically identical studies does not exist in observational epidemiology. Glossing over these

Toxic Compounds in Food

Plant and animal tissues contain nutrients, but as we have seen in other chapters of this book, they can also contain toxic compounds. Some plants produce toxic secondary metabolites as defenses against herbivores. One example is the nicotine in tobacco. Animals may use toxins for capturing prey as well as for self-defense (Figure 50.22). Ingesting many plant and animal tissues, therefore, can be dangerous. Human activities add millions of tons of synthetic toxic com-

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