CLINICAL | SMOKING CESSATION
It is never too early or too late to stop smoking
Prof James Ker
ERADICATE TOBACCO TO PROTECT HUMAN RIGHTS TO HEALTH
Cardiovascular disease remains the leading cause globally for premature mortality and morbidity.
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HERE ARE A number of well-known cardiovascular risk factors including hypertension, dyslipidaemia, elevated blood glucose, lack of physical exercise, obesity (especially central obesity) and poor diet. A major modifiable cardiovascular risk factor is smoking. The known effects of smoking on cardiovascular disease and the reports about the effect of smoking is mainly based on investigations of coronary artery disease. It is however, recognised that smoking is a particular strong risk factor for peripheral arterial disease (PAD). Despite this recognition there are relatively few studies done prospectively comparing PAD and coronary heart disease (CHD) as complications of current smoking status. The objective of this study was to quantify the long-term association of cigarette smoking and its cessation with the incidence of the three major atherosclerotic diseases namely coronary heart disease, cerebrovascular disease and peripheral artery disease.1 This study used data from the ARIC study (Atherosclerosis Risk in Communities) and patients were followed up for nearly 30 years. A total of 13 355 people aged between 45 and 64 years of age were examined between 1987 and 1989 and then followed up for a median period of 26 years. A comprehensive surveillance of hospitalisations and deaths from coronary heart disease, cerebrovascular disease and peripheral artery disease were conducted by the authors. In this period of 26 years there were 492 cases of PAD, 1798 CHD cases and 1106 cases of stroke. The findings overall confirmed that smoking is a major cardiovascular risk factor increasing substantially the risk of developing all three atherosclerotic outcomes. The increased risk was consistent for both the duration of smoking and the intensity of smoking (number of cigarettes smoked per day).
24 MAY 2020 | MEDICAL CHRONICLE
After adjustment for other risk factors, smoking risk had a hazard ratio of 5.36 for PAD, Hazard Ratio 2.37 for heart attack and Hazard Ratio 1.92 for stroke. Thus, there were a much higher risk of PAD than the two other atherosclerotic outcomes. After smoking cessation, the reduction of risk for all atherosclerotic outcomes of all three vascular beds were within five years but to reach such a low risk as those of never-smokers took a much longer time. The reduction of the risk of PAD was also higher than for any of the two other atherosclerotic outcomes. After quitting, more time was needed for the risk of PAD to reach the level of risk of a never-smoker (more than 30 years was necessary) as compared to about 20 years for the risk of coronary heart disease to reach the level of CHD risk of a never-smoker. The findings of this study are also consistent with the hypothesis that traditional cardiovascular risk factors have distinct effects on different arterial beds suggesting that atherosclerosis is not a homogenous process.2 The composition of atherosclerotic plaques also differ between the different vascular beds with the femoral artery having more fibrosis and the coronary and cerebral arteries more lipid and more inflammatory cells. CONCLUSION 1. Smoking is significantly associated with a substantial increased risk of atherosclerotic disease events in all three vascular beds: coronary, cerebral and peripheral. 2. Smoking cessation is associated with significant reduction in the risk of atherosclerotic disease events. 3. It is never too late to stop smoking because of the relative rapid reduction of cardiovascular events (within five years). 4. It is never too early to stop smoking because it takes several decades to reach the risk level of a never-smoker (20-30 years).
Savera Kalideen, Executive Director of the National Council Against Smoking (NCAS), on behalf of NCAS, The Heart and Stroke Foundation, CANSA. In the grip of the COVID-19 pandemic, we are seeing governments all over the world, including our own, act to protect public health. We are in full support of this action to protect public health. There are other epidemics that we live with every day. Tobacco harm is one of them, causing 115 deaths each day in South Africa. We call for bold action on tobacco control, as the protection of public health through tobacco control is inextricably linked with human rights to life, health and a healthy environment. This Human Rights month, we call on our leaders to recognise that halting the spread of the tobacco epidemic is an obligation as South Africa is a signatory to the World Health Organisation Framework Convention on Tobacco Control (FCTC). Passing South Africa’s Control of Tobacco and Electronic Delivery Systems Bill, for which the public consultation ended more than 18 months ago, would be a good step in the direction of the ‘right to health’. PROTECTING CHILDREN FROM SECOND-HAND SMOKE Exposure to second-hand smoke, particularly for children, leads to middle ear infections, respiratory diseases including asthma, the worsening of serious conditions such as cystic fibrosis and asthma, and in some cases, death. The dangers posed by second-hand smoke violate the rights of non-smokers and children, affecting their rights to life, health and a clean and safe environment. The Bill requires that any enclosed public area is 100% smoke-free and will make certain outdoor public places smoke-free too. It removes the current requirement to provide for smoking areas in all enclosed public places, workplaces and on public conveyances and applies the 100% smoking ban to common areas of multi-unit residences. It further bans smoking in private dwellings used for commercial childcare/ education and in cars carrying children under 18. People caught smoking or vaping or using e-cigarettes in no-smoking zones could face a hefty fine and/or up to three months in prison. PROTECTION FROM ACTIVE SMOKING AND ADDICTION Human rights principles also justify protecting individuals from the harms of smoking and nicotine addiction. We have a right to enjoy the highest attainable standard of physical and mental health, including the prevention, treatment and control of epidemic, endemic, occupational and other diseases. Tobacco products are the only legally available consumer products that kill over 50% of users when used exactly as intended. Many adolescents are tempted into experimentation with cigarette smoking, and now e-cigarettes, at a fragile time when they can’t fully grasp the addictive grip of nicotine and the health impacts, they will later experience. The body of research showing the health harm arising from e-cigarette use, which are popular among young people, continues to expand. The Bill introduces uniform plain packaging for all brands and pictorial warnings on all packages. The Bill bans cigarette advertising at tills, removing the loopholes in existing provisions for advertising displayed at points of sale. It further bans the sale of cigarettes through vending machines. Current tobacco control legislation predates the introduction of e-cigarettes and needs to be urgently updated to include the regulation of e-cigarettes. The Bill does include regulation of e-cigarettes and when passed, e-cigarettes will finally fall under the same regulations as cigarettes. REFERENCES 1. Ding N, Sang Y, Chen J et.al. Cigarette smoking, smoking cessation and long-term risk of 3 major atherosclerotic diseases. J Am Coll Cardiol 2019; 74(4):498-507. 2. Rigotti NA, McDermott MM. Smoking cessation and cardiovascular disease: It’s never too early or too late for action. Editorial comment J Am Coll Cardiol 2019;74:508-511.
