The musculoskeletal effects of cigarette smoking

It has been well-established that cigarette smoking is the leading cause of preventable mortalities worldwide (Abate et al., 2013), but what is the most important implication of cigarette smoking on morbidity and quality of life? You most likely focused on the effects of smoking on the cardiovascular system, but have you looked beyond the cardiovascular dimension? A large quantity of experimental research indicates that cigarette smoking is a prominent contributor to morbidity through its effects on the musculoskeletal system. A recent review by Abate and colleagues (2013) investigated the effects of cigarette smoking on the musculoskeletal system and the musculoskeletal benefits associated with smoking cessation.

Cigarette smoking has been shown to decrease bone density through both direct and indirect pathways (Abate et al., 2013). In vitro experiments have demonstrated that at concentrations comparable to levels found in regular smokers, nicotine directly suppresses bone metabolism (Abate et al., 2013). Cigarette smoking has also been found to exhibit anti-estrogenic properties, which is relevant to bone health because estrogen is known to contribute to maintaining bone health in post-menopausal women (Abate et al., 2013). It was previously discovered that smoking patients receiving estrogen-replacement therapy required a greater dose of the hormone to achieve similar clinical results to non-smoking patients receiving the standard dose of estrogen (Abate et al., 2013).

The negative impact of cigarette smoking on bone density has numerous implications for one’s quality of life. Some of the downstream outcomes of decreased bone density include an increased risk of fractures, poorer prognosis following fractures, and an increased risk of back pain (Abate et al., 2013). Moreover, meta-analyses have suggested that up to 25% of the burden of rheumatoid arthritis in the population can be attributed to smoking (Abate et al., 2013). Finally, studies have consistently found that cigarette smoking is linked to muscle and tendon atrophy, with a dose-response relationship observed between the daily number of cigarettes smoked and the severity of tendon atrophy (Abate et al., 2013).

The good news is that smoking cessation has been linked with noticeable short- and long-term musculoskeletal benefits. In the long-term, smoking cessation has been associated with increased bone metabolism and a decreased risk of fractures (Abate et al., 2013). The short-term benefits include improved prognosis following orthopaedic surgery, reduced frequency of musculoskeletal complication, and reductions in the length of hospital stays (Abate et al., 2013).  All the evidence presented supports one of the main messages of Leave the Pack Behind, which is that it is never too late to think about smoking cessation.   

References

Abate M, Vanni D, Pantalone A, Salini V. (2013). Cigarette smoking and musculoskeletal disorders. Muscles, Ligaments and Tendons Journal, 3(2), 63-9.

Smoking up... what's the harm?

Almost all young adults are aware of the consequences of smoking cigarettes on health. However, the risks associated with smoking marijuana and the effects it has on social smoking of tobacco products are far less known.

Marijuana is an illegal tobacco alternative that is used by some university students. Like cigarettes, marijuana contains many chemicals – specifically, up to 400 different chemicals can be found in marijuana.

Compared to smoking cigarettes, smoking a marijuana joint:

• Puts 5 times more carbon monoxide in your bloodstream

• Puts 3 times more tar in your lungs

In addition, smoking one joint is the equivalent to smoking 2.5-5 cigarettes with respect to decreased lung function and obstructing airflow. The smoke from marijuana joint contains 50-70% higher levels of cancer causing chemicals.

Compared to a cigarette smoker, someone who smokes five joints a week would be taking in as many cancer causing chemicals as a cigarette smoker who smokes a pack a day! People who use marijuana regularly are also more likely to become dependent on marijuana, and may experience irritability, anxiety, cravings, and sleep disturbances when they try to quit using marijuana. Since smokers are more likely to also become dependent on marijuana, avoiding the use of marijuana products when you are trying to quit smoking can increase your chance of success!


Do you want to try quitting, cutting back, or eliminating marijuana use when you drink alcohol? Register for the wouldurather... contest by January 27, 2014 and you could win $750!

References: Aldington et al. (2008). Cannabis use and risk of lung cancer: A case-control study. Eur Respir J, 31(2):280-286.


Rickert, Robinson & Rogers. (1982). A comparison of tar, carbon-monoxide and ph levels in smoke from marijuana and tobacco cigarettes. Can J Public Health, 73:386-391.


Swift et al. (2008). Adolescent cannabis users at 24 years: trajectories to regular weekly use and dependence in young adulthood. Addiction, 103:1361-1370.


Vandrey et al. (2008). A within-subject comparision of withdrawal symptoms during abstinence from cannabis, tobacco, and both substances. Drug Alcohol Depend, 92:48-54.


Wu et al. (1988). Pulmonary hazards of smoking marijuana as compared with tobacco. New Engl J Med, 318:347-352. 

The role of friend selection in smoking initiation

How does your selection of friends influence your likelihood of taking up cigarette smoking? A recent study by Delay and colleagues investigated the relationship between cigarette smoking and the selection of friends. The authors suggested that the choice of friends greatly impacts one’s attitude towards smoking prior to the initiation of smoking, but once an individual has begun smoking and is addicted, the influence of friends on smoking behaviour is dramatically reduced (Delay et al., 2013).

One of the main concepts investigated was the idea of selection, a process by which people choose to establish friendships with those who are similar to themselves in attitudes and beliefs (Delay et al., 2013). As a result, those with a more positive attitude towards smoking tend to be friends, increasing the likelihood of the initiation of smoking among members of the group (Delay et al., 2013).

            

The study found that once a group of adolescents has taken up smoking, deselection (or ‘dropping’ friends because of dissimilarities in attitudes and beliefs) was more likely to occur than selection (Delay et al., 2013). This frequently occurs to non-smoking members in a group comprised predominantly of smokers, because smoking is often considered a salient behaviour within the group (Delay et al., 2013). A concern with adolescents is that in response to the fear of being ‘deselected’, some will choose to take up smoking to ‘fit in’ and avoid being rejected from the group (Delay et al., 2013).

            

Among non-smokers, selection is practiced more frequently than deselection (Delay et al., 2013). The authors suggest that the main reasons for non-smokers to avoid establishing friendships with smokers include aversion to smoking behaviour and the negative health consequences associated with exposure to second hand smoke (Delay et al., 2013). Also, it is common for non-smokers to seek avoidance of other risky behaviours associated with smoking including illicit drug use and general deviance (Delay et al., 2013).

            

The findings of this study provide important implications for the question of whether the difficulty of ignoring peer pressure to smoke is equal in all adolescents simply because it is a ‘choice’. The evidence indicates that adolescents in a predominantly smoking group are faced with much greater peer pressure in that they risk rejection if they do not take up smoking, and at the same time they are more susceptible to succumbing to peer pressure because their initial decision to establish friendships with to-be smokers generally means their attitude towards smoking is more positive relative to that of a non-smoker.

References

Delay D, Laursen B, Kiuru N, Salmela-Aro K & Nurmi J-E. (2013). Selecting and retaining friends on the basis of cigarette smoking similarity. Journal of Research on Adolescence, 23(2), 464-473.   

Weight Gain Following Smoking Cessation: Inevitable or Not?

Weight Gain Following Smoking Cessation: Inevitable or Not?

Countless myths surrounding smoking cessation have been accurately addressed, but the one concerning smoking cessation and weight gain is not one of them. In fact, weight gain following smoking cessation may not be a myth, as there is evidence supporting the tendency to see minor increases in weight post-cessation, which is plausible when considering that cigarette smoking increases resting metabolic rate and ultimately energy expenditure at rest (Filozof et al., 2004). In one study, it was found that over the course of four years, the net weight gain on average totaled less than 2 kilograms (Clair et al., 2013). When considered in conjunction with the array of health risks that accompany sustained smoking behaviour, one ought to reconsider the significance of such a minor increase in weight.

Smoking leads to an increase in the contraction frequency of cardiac smooth muscle, increasing heart rate and blood pressure (Clair et al., 2013). These events result in damage to the endothelial lining of blood vessels, increasing susceptibility to atherosclerosis and cardiovascular disease (Clair et al., 2013). Smoking cessation, on the other hand, has been found to reduce a number of risk factors for cardiovascular disease even in spite of small increases in weight (Clair et al., 2013). 

Also noteworthy are the profound health benefits observed immediately following smoking cessation. While cigarette smoking has been shown to reduce insulin sensitivity and increase susceptibility to hyperinsulinemia (Filozof et al., 2004) and hyperglycemia, all of which are predictive of diabetes, refraining from smoking seems to abruptly return insulin sensitivity to higher levels (Clair et al., 2013). Moreover, smoking cessation contributes to improving an individual’s blood lipid profile, particularly through increasing the concentration ratio of high-density lipoprotein cholesterol (the “good cholesterol”) to low-density lipoprotein cholesterol (the “bad” cholesterol) in plasma (Clair et al., 2013). This finding is significant because high-density lipoprotein cholesterol promotes the excretion of excess cholesterol, ultimately improving cardiovascular health (Whiteney et al., 2013).

Lastly, weight gain following smoking cessation does not appear to be inevitable. When smoking cessation is accompanied by a diet intervention and nicotine replacement therapy, particularly the gum, avoidance of post-cessation weight gain seems to be a reasonable expectation (Filozof et al., 2004). A study was conducted on a group of women who attributed their unsuccessful cessation attempts to weight gain (Filozof et al., 2004). This group of women participated in a cessation intervention that included a reduction in caloric intake and assistance from nicotine replacement therapy in the form of the gum (Filozof et al., 2004). The results were promising, as the intervention was found to improve smoking cessation success rates while preventing weight gain (Filozof et al., 2004).

In summary, the health risks of sustained cigarette smoking have been shown to significantly outweigh the risks of a minor weight increase. Furthermore, it was discovered that weight gain is not an inevitable consequence of smoking cessation. The following question should be more easily addressed in light of these findings: Is weight gain a plausible reason for the continuation of cigarette smoking?

Resources & References

More information about quitting and quit aids can be found on the Leave The Pack Behind website.

The QuitRunChill website provides an online program that can increase your success at quitting while avoiding weight gain.

Clair, C., Rigotti, N., Porneala, P., Fox, C.S., D’Agostino, R.B., Pencina, M.J. Meigs, J.B. (2013). Association of Smoking Cessation and Weight Change With Cardiovascular Disease Among Adults With and Without Diabetes. Journal of the American Medical Association, 309(10), 1014-1021. doi: 10.1001/jama.2013.1644.

Filozof, C,. Fernández Pinilla, M.C., Fernández-Cruz A. (2004). Smoking cessation and weight gain. Obesity Reviews, 5(2), 95-103. doi: 10.1111/j.1467-789X.2004.00131

Whitney, E., Rolfes, S, Hammond, G., & Piché, L. (2013). Understanding Nutrition (1st Canadian ed.). Toronto: Nelson

A Revisit: What is the Best Predictor of Smoking Initiation?

It has been well-established that daily smokers most frequently began smoking prior to age 18, and smoking habits in peers are among the greatest predictors in whether or not adolescents will begin to smoke (Mahabee-Gittensa, Xiao, Gordon & Khoury, 2013).  The adolescent years are dominated by emotions centred around social acceptance and the need to fit in with peers (Mahabee-Gittensa et. al, 2013).  With peer influences being so prominently known as the main predictor for smoking initiation, the important role played by parents in protecting against smoking initiation is downplayed.

That is not the sole reason why parents consistently play second fiddle to peers in population-based efforts to prevent smoking initiation.  There is a common belief that rules set by parents are ineffective with respect to regulating behaviours in teens, because adolescence is a period during which individuals are in the pursuit of increasing autonomy (Mahabee-Gittensa et. al, 2013).  Additionally, it would be plausible for some to argue that parents are minimally influential in determining the peer groups their son or daughter tends to associate with.

A recent study found that while having peers who smoked proved to put one at the greatest risk for smoking imitation, the effect was found to be significant only until mid-adolescence, or around age 15 (Mahabee-Gittensa et. al, 2013).  During those same years, parental monitoring, punishment for smoking, and perceived connectedness to parents also proved to contribute significantly to the risk of smoking initiation (Mahabee-Gittensa et. al, 2013).  Contrary to findings surrounding the temporal effects of peer influences that begin in early adolescence and diminish past mid-adolescence, parental education and monitoring were found to protect against smoking initiation before adolescence and well past the age of 15 (Mahabee-Gittensa et. al, 2013).  This implies a lasting effect of parents on the risk of smoking initiation, while peer influences only appear to showcase their true potential during the critical period from early- to mid-adolescence.

Despite the common belief that adolescents increasingly seek autonomy from their parents, it has been found that parents contribute greatly to a teen’s choice of friends (Mahabee-Gittensa et. al, 2013).  This illustrates that the most powerful predictor of smoking initiation (peer influences) is itself greatly influenced by parents, suggesting that indirectly, parents may actually be the most influential with regards to the risk of smoking initiation.  This phenomenon has been demonstrated through the increased tendency for children of parents with low education, socioeconomic status, and discipline to associate with troubled peer groups who are also much more likely to smoke (Mahabee-Gittensa et. al, 2013).  Also, one may reasonably argue that under certain circumstances, social risk factors could potentially exacerbate or even confound the influences of parenting.

The findings in this study have important implications for public health approaches taken in the prevention of smoking initiation, the most critical of which is that the role of parents should be taken as seriously as the peer groups of teens.  The authors of the article suggest that a successful intervention aimed at preventing smoking initiation should target both parents and peer groups (Mahabee-Gittensa et. al, 2013).  While I agree with the authors, I would also include social risk factors as a third consideration in smoking-prevention interventions, in addition to parents and peer groups.

References

Mahabee-Gittensa, M., Xiao, Y.,  Gordon, J., Khoury, J. (2013). The Dynamic Role of Parental Influences in Preventing Adolescent Smoking Initiation. Addictive Behaviours, 38(4), 1905-1911

Not Just An Addiction - Another Meaning To The Use of Tobacco

With the hard work of many individuals, smoking rates have decreased in Canada. The smoking rate decreased by about 15% from 1980 to 2004 (Wong, 2006)! Although this is good news for Canada as a whole, it appears that the prevalence of First Nations smoking although also decreased, is still quite high with an astounding 59% of Aboriginals on reserve who smoke (Health Canada, 2011).

           

There are many factors that influence the smoking rate of the First Nations in Canada although some factors in this list are not strictly limited to Aboriginals: nicotine addiction, ease of access for aboriginal youths (whether they get it from friends, family, or willing retailers), poverty, poor education, having access to tax-free tobacco on reserves, as well as the cultural meaning of the use of tobacco (Wong, 2006). For this blog entry, I will be focusing on the last point: the cultural meaning of using tobacco among the First Nations in Canada.

For many Aboriginals, smoking is not just a way to relieve stress or to be accepted into a social group. Smoking has a deeper meaning to many where it becomes part of rituals and traditional ceremonies (Wong, 2006). For First Nations, tobacco is vital in ceremonies where it creates a link between the person performing the ceremony and all living things as well as the Creator. This powerful link can be established by smoking a sacred pipe (Godlaski, 2012). 

These spiritual practices have existed for more than 2300 years (Godlaski, 2012) and carry a significant cultural meaning to the First Nations people of Canada. Through stories, it is known that the pipe was a vital part in sacred acts, as described in the passage below:

“What is perhaps most important is that the sacred pipe is a metonymy; it represents itself, the use of tobacco, and the worshipful act. The pipe is a kind of altar or sacrificial vessel, in which the offering of tobacco is burned, sending its smoke to all directions of the cosmos and ultimately to the Great Holy” (Paper, 1987, 1988).

Therefore, without the use of the pipe in rituals, there would be no meaning or power associated with the act (Godlaski, 2012).

Interestingly, the tobacco used in such ceremonies actually has more nicotine in it when compared to other tobacco ranging from 3.9- 8.6%. The more common types of tobacco only contain 0.05- 4% nicotine (Godlaski, 2012). This puts individuals at risk of developing an addiction to tobacco and may cause them not only use it ritually but also recreationally.

                                Pipe Bowl                                      Mississippi Style Bowl 

The whole entire ritual from the way the tobacco is put into the pipe to smoking and eventually the end of the ceremony holds significant meaning and requires meticulous preparation. The use of tobacco in such rituals is therefore key to the Aboriginals.

            If you’re interested in reading more about the use of tobacco in Aboriginals, try looking at this pdf: http://www.cps.ca/en/documents/position/tobacco-aboriginal-people

References:

Godlaski, T.M. (2012). Holy Smoke: Tobacco Use Among Native American Tribes in North America. Informa Healthcare, 1-8. doi: 10.3109/10826084.2012.739490

Health Canada. (2011). First Nations & Inuit Health. Retrieved from http://www.hc-sc.gc.ca/fniah-spnia/substan/tobac-tabac/index-eng.php

Wong, S. (2010, June). Use and misuse of tobacco among Aboriginal peoples. Paediatric    Child Health, 11(10), 681-5. Retrieved from http://www.cps.ca/en/documents/position/tobacco-aboriginal-people

The Youth Smoking Paradox

According to the World Health Organization, rates of tobacco-use are decreasing in developed countries and increasing in many developing countries (Kostova, 2013).  Resultantly, it has been projected that on the global scale, developing countries will be burdened with approximately 80% of all cases of tobacco-related deaths (Kostova, 2013).  At the present, a majority of the globe (174 countries) has adopted the World Health Organization’s Framework Convention for Tobacco Control, whose central focus is to control tobacco-use through increasing taxes on cigarettes, leading to increased consumer prices of cigarettes (Kostova, 2013).     

The argument that prices on cigarettes should be increased to prevent the initiation of smoking has received an incredible quantity of exposure in the media, and appears to receive an overwhelming amount of support from the public.  Less widespread however, is the criticism of the idea of raising prices on cigarettes, and opinions questioning whether or not such economic policies truly exert a powerful impact on reducing rates of smoking.

In developed countries including Britain, the United States, and Spain, studies looking at the effect of increasing prices on cigarettes with respect to smoking initiation and cessation in youth have been inconclusive, but the bulk of the cited research indicates that price increases on cigarettes are more likely to reduce rates of initiation as opposed to rates of cessation (Kostova, 2013).  This finding serves as a reminder of just how difficult it is to quit smoking following initiation, and that saving money by not purchasing cigarettes is often not the primary reason smokers choose to quit smoking.

Contrary to the predictable findings in developed countries, the findings for developing countries proved to be surprising and unpredictable.  When results from developed countries were compared with those retrieved from developing countries, it was found (overall) that youth in developing countries appeared to be less responsive to price increases in cigarettes (Kostova, 2013).  It is likely that one would have expected the opposite, because these individuals (on average) have significantly lower incomes than their counterparts in developed countries.  The direct implication of this finding is that increasing prices of cigarettes in developed countries may actually produce a more powerful downward force on smoking initiation and cessation.

In conclusion, the paradox exists in the sense that increasing prices on cigarettes appears to be the least effective in preventing smoking initiation and promoting cessation in those who have the greatest difficulty affording them.  A plausible argument in light of these findings is that raising prices on cigarettes may not actually be the most effective method of reducing rates of tobacco-use.  Perhaps a move towards educating individuals (particularly in developing countries), empowering them to make healthier life choices, may prove to be a greater contributor to tobacco control than economic policies.

References

Kostova, D. (2013). A (nearly) global look at the dynamics of youth smoking initiation and cessation: the role of cigarette prices. Applied Economics. 45(28), 3943-3951. doi: 10.1080/00036846.2012.736947