Paul Pomrehn, MD, MS and Christopher Squier, PhD, D.Sc.
Division of Community and Behavioral Health
University of Iowa Hospitals and Clinics

Creation Date: June 2000
Last Revision Date: June 2000
Peer Review Status: Internally Peer Reviewed

Dr. Squier: I am an oral pathologist at The University of Iowa. I am interested in diseases of the mouth and, in particular, in oral cancer. Most oral cancers are caused by tobacco use. This brings us to the topic today of our chat. Before we entertain any questions, perhaps we should just give our listeners/viewers a little bit of information about tobacco use world wide since it is World No Tobacco day. About 1.1 billion people aged 15 years or older now smoke in the world. There are 4 million deaths a year from tobacco. As we move further into the 21st century more than 100 million people will die from tobacco-related illnesses. That total will exceed the total from AIDS, tuberculosis, automobile accidents, maternal mortality, homicide, and suicide combined.

What is tobacco and global health?

Dr. Squier: Why global? Tobacco is an enormous problem across the world. It is very much a problem as a result of export of tobacco from the developed world to the developing world. There is a strong economic influence on what is happening. Increasingly, we are realizing that problems of health cannot be looked upon in isolation in terms of individual countries, they have an impact on everyone, and hence we use the term global.

What are some problems smoking can cause that aren't as publicized, other than lung cancer for instance?

Dr. Pomrehn: I am a physician in the University of Iowa College of Public Health. I am particularly interested in studies to help people quit smoking and issues on the health effects from using tobacco. With regard to the question about what other problems are caused or associated with smoking--lung cancer is certainly the most well known. Coronary artery disease caused by cigarette smoking results in many more deaths than lung cancer. Then we need to add chronic lung diseases such as emphysema and chronic bronchitis to the list of smoking-caused illnesses. There are several other cancers.

Dr. Squier mentioned oral cancer. We should mention cancer of the bladder, esophagus, throat, cervix as well as other cancers that are caused by smoking. The effects of smoking on a growing fetus do not get enough attention. Smoking during pregnancy causes increased risk of spontaneous abortion, a much greater risk of premature delivery, and all of the complications associated with prematurity. Smoking during pregnancy causes an increase in birth defects, particularly cleft palate/lip. Children whose mothers smoke during and after pregnancy are at greater risk for ear infections and sudden infant death syndrome.

Is it possible to reverse the damage caused by smoking?

Dr. Squier: There is evidence that if you quit, you will then reverse some of the effects of smoking, for example, decrease in life span. There will be some recovery of lost function such as lung function. It is important also to mention that if you have initiated a cancer, then you may not be able to reverse the progression of cancer.

What is the relationship between smoking and stroke?

Dr. Pomrehn: Smoking promotes a process called atherosclerosis, or hardening of the arteries, and this is one of the causes of stroke. Smokers are several times more likely to have a stroke than non- or ex-smokers.

What does smoking do to your teeth and gums?

Dr. Squier: Smoking, and, in fact, tobacco use generally, will cause staining of teeth. There is a tendency to increase tooth loss and that is probably because the major effect is on the gum. A recent study indicated that smoking could contribute as much as 50 percent of the risk of periodontal (or gum) disease.

Are the numbers of new smokers going down?

Dr. Pomrehn: It depends on the community. In the world as a whole, there is a big increase going in tobacco use, in particular, cigarettes. That is true as well in the United States, but in some places, some states/communities where they are taking actions to reduce smoking, the rates are actually going down.

What happens to your body after you stop smoking?

Dr. Squier: Most people smoke because they are addicted; there are receptors that are being stimulated by the nicotine in the tobacco. The first thing that happens with any addictive drug is that you get some degree of withdrawal. The first symptoms are behavioral or neurological and psychological, then gradually the body will try to repair the tissues that have been damaged and regenerate lost tissues. However, there is a limit to that process. As I said earlier, some processes, such as cancer, are not easy to reverse once started.

Does smoking affect young adolescents more than adults?

Dr. Pomrehn: The most severe health effects of smoking are the result of years of smoking. So, if someone smokes daily and for many years, his or her risks of cancer and lung disease and heart disease go up accordingly. For any smoker, be they an adolescent or an adult, the short-term effects are the same. They get the immediate effect of the nicotine and also the short-term effects of toxic chemicals in smoke. So, the short-term effects are the same in adolescents and adults. Carbon monoxide reduces the amount of oxygen available to the brain. Carcinogens begin to damage tissues, etc.

How long does it take the average person to stop smoking?

Dr. Pomrehn: The question is more complicated than it seems. When someone succeeds in quitting smoking, they have often tried to quit on several occasions. If you measure the time from when they first tried to quit to when they succeeded, the process can take years. On the other hand, there are many examples of persons who have made the decision to quit smoking, taken action, and have quit on their first attempt. If you attempt quitting, but are unsuccessful at first, it's important to try again using experience from prior attempts to help you.

Can cigar or pipe smoking cause problems?

Dr. Squier: Both cigars and pipes do have a bad effect. They primarily have an effect in the mouth because many people do not inhale these products. There is a greater amount of nicotine in both cigars and pipe tobacco and a lot of carcinogens, so that there is potential for harm there. For those people who do inhale, the outcome is probably worse than for cigarette smokers.

I am 30 years old and have been smoking on and off for 5 years--I have (maybe) 5 cigarettes a week. How bad is this for me?

Dr. Pomrehn: Smoking a few cigarettes a week, your health risks are less than for someone smoking a pack a day for years and years. The amount of harm done tends to be dose related. We are unable to say whether there is a safe amount to be smoking. Most of us believe that inhaling any of the carcinogens from cigarette smoke is harmful and should be kept to a minimum. You are a bit unusual, as most people who smoke the amount you do go on to become heavier smokers. On the other hand, since you smoke so little, why not stop altogether?

What really is in cigarettes? And is there anything in cigarettes that is not harmful to the body?

Dr. Squier: We don't really know what is in cigarettes. The manufacturers don't tell us. When you burn something, you create thousands of new compounds so even if you knew what was in the tobacco, you don't know what is going into your body. However, we do know that many of these compounds that arise from burning are very dangerous; in fact, these are some of the strongest carcinogens known, so while there may be some substances that are not harmful, it is really an academic point.

What method works best to stop smoking?

Dr. Pomrehn: There are many ways to quit smoking. The best way for any individual is the way they have designed that addresses their specific needs. Some questions to ask in deciding which methods: if you are a heavy smoker smoking 1 to 1 1/2 packs per day and in prior quit attempts you have been very uncomfortable and unable to sustain this quitting, that might indicate a benefit of using nicotine replacement when quitting. Some people are supported in their efforts to accomplish goals by working with others who share the same goal. If you benefit from the social support, then you might want to seek out a group program and work together with others to quit. The point is to reflect on what you think will be successful, then commit to it.

How can some people smoke for 30 years and never get cancer, but others do?

Dr. Squier: This is a very interesting question. We are just beginning to learn that some individuals are able to metabolize or break down the cancer causing agents so they do no damage. It is likely that the ability to do this is genetically linked. As we learn more about gene action, it is possible that we may even be able to influence those effects in the future.

How can you repair the damage done to your mouth and gums?

Dr. Squier: There is very little that you can do. If you have lost teeth, then you will need false teeth. If you have gum disease, a periodontist may be able to help you, but it can involve surgery and expense. However, it is worth noting that people who have quit do show a better response to periodontal therapy. If you get oral cancer, then you have a very small chance of repairing the damage as the lesion often has to be removed by surgery.

What does smoking do to your throat?

Dr. Squier: The throat is one of the risk sites for oral cancer. One of the effects of the constant irritation by tobacco smoke is to cause development of a tumor. This is a very unpleasant disease because it usually involves mutilating surgery to remove it, sometimes with loss of the voice box.

Why do people tend to gain weight after quitting?

Dr. Pomrehn: On the average, when people quit smoking, they may gain 4 to 6 pounds. Not everybody gains, but many do. There are a couple of possible explanations for why this occurs: one is that nicotine or some other chemical in cigarettes increases body metabolism. When that is gone, at a normal resting state the body is not burning as many calories. A second explanation is that nicotine or something else in cigarettes tends to limit one's appetite. When you quit smoking, you lose that effect and your appetite may increase. The increased appetite results in increased intake. A third explanation would be that some people get fatigued when they quit smoking, they may actually decrease their activity level, which would potentially result in some weight gain. When quitting smoking, be mindful of diet and physical activity. There is a recent study that suggests beginning an exercise program while quitting smoking actually increases one's success of quitting.

Does smokeless tobacco (chew) carry the same risks as smoking?

Dr. Squier: No, it doesn't carry the same risk but has different risks. Those risks are of gum disease, changes to the skin in the mouth, which can develop white patches that may become cancerous. There also will be worse staining of the teeth and some risk of tooth loss from caries because of the sugar in chewing tobacco.

Can anti-depressant medications help with quitting smoking?

Dr. Pomrehn: The antidepressant that has been shown to be effective in quitting smoking is Bupropion. The long-acting form of that drug is known as Zyban. Zyban has been tested in people who are quitting smoking, and it works effectively. There are other antidepressants that have been and are being tested to help people quit smoking, but the data are not as definite about the benefits.

If the smoke is so dangerous why are more people NOT dying from second-hand smoke? Seems like everywhere you go people are still smoking.

Dr. Pomrehn: The environmental tobacco smoke is harmful; it contains the same poisonous substances as in the smoke inhaled by the smoker. For all of us who are inhaling environmental tobacco smoke, the dose is less, so we don't see as many people being harmed by second-hand smoke. Nonetheless, it has been estimated that anywhere from 30,000 to 50,000 people die of heart disease each year as a result of second-hand smoke. Thousands of cases of lung cancer can be attributed to second-hand smoke exposure. Probably most worrisome are the thousands of children who are hospitalized with respiratory infections because of second-hand smoke exposure. Another group especially at risk are people who work where smoking is allowed, particularly restaurants and bars. More work can be done to protect nonsmokers from enviromental tobacco smoke. All of us should be allowed to breath air free of tobacco smoke.

What does smoke do to the heart that causes disease?

Dr. Squier: Smoking does a number of things. First, the nicotine in smoke causes many vessels in the body to constrict, or narrow, so that the heart has to pump harder to get blood around. Secondly, agents in smoke cause narrowing and thickening of a lot of blood vessels, including the vessels that supply blood to the heart itself. This also means the heart has to work harder, does not get the blood supply that it needs, and the result is strain on the heart, which is manifested as heart disease. In addition, there is a tendency to cause thickening and clotting of the blood, which makes the blood stickier and more difficult to move. Finally, there is a lot of carbon monoxide in smoke, which is a highly toxic gas that will shut down a lot of metabolism in body tissue and ultimately kill you.

Do you think if a substance such as tobacco were to come new on to today's market it would be legal to sell to consumers for any reason?

Dr. Squier: I think the answer is very plainly no. It is clear that tobacco is the only legal substance that, when used as intended, inevitably causes some degree of disease and often death. We do not allow such substances to be marketed these days.

Are there any good web-based sources of information on this subject?

Dr. Pomrehn: We would recommend the Centers for Disease Control, which is www.CDC.gov.

Dr. Squier: Since we are talking about global tobacco use, there is the World Health Organization Web page: www.WHO.int.

Dr. Pomrehn: There are a number of sites available for activists. The Campaign for Tobacco Free kids has a great site: tobaccofreekids.org. There is an organization called www.Smokescreen.com, which has a lot of good resources. The CDC website has cataloged the internal documents of the tobacco industry. These documents came to light during litigation.

Dr. Squier: I would like to go back to the data I shared with you at the beginning as a reminder that tobacco use in a global context is potentially the greatest threat to health in the world and that increasingly the burden of this habit will be borne by those least able to deal with it, in other words, the developing nations.

Dr. Pomrehn: Many countries have had success in reducing their cigarette consumption. Success has come about because of activism of concerned citizens. Health professionals have played a role, politicians, and community activists and in general, people who want to improve the health of the public. We need to work together with our like-minded friends/colleagues in our communities and form coalitions that make things happen, such as passing ordinances to make our public places smoke-free, to assure that our health system provides a high standard of care to people who want to quit smoking, and holding politicians accountable so they set policies that are active in reducing tobacco consumption. There is much we can do, and with continued effort, we can make the world tobacco free.