Tobacco and lung health – a global view

Dr Vinayak Prasad leads the World Health Organisation’s (WHO) Tobacco Free Initiative and is a world authority on the damage caused to health by smoking.  To mark World No Tobacco Day 2019, which this year focuses on lung health, we spoke to him about the impact of tobacco smoking globally.

 Does the impact of tobacco on lung health vary greatly across different countries?

The tobacco smoking risks are the same or similar across all countries. But the cause of death or disease patterns differ according to the way tobacco is used. For instance, in Southern Asia, there is a far greater use of smokeless tobacco, in other words chewing tobacco. So, in that part of the world diseases caused by chewing tobacco such as oral cancer are becoming predominant. It is also affected by which health conditions are more common in certain regions.

What are the links between smoking and tuberculosis?

Tuberculosis is a big problem in some countries and there a greater risk of mortality among those with TB who smoke. It is a cause of mortality that has been well established for more than a decade.  Smoking also more than doubles the risk of developing tuberculosis.

How big a threat is smokeless tobacco to global health?

Smokeless tobacco is used in over 80 countries and that’s huge. There are a lot of challenges in Sri Lanka for example, where smoking rates are still high but declining and smokeless tobacco use is rising. It is popular because it’s cheaper and it’s easily accessible for young people to consume and to use without being noticed in school.  80% of oral cancer deaths in that part of the world are because of one single product, smokeless tobacco.

Is there sufficient awareness globally about the harms caused by tobacco smoking?

Lung health and lung disorders are the most common disease factors in the world. This can come from multiple factors, whether it’s air pollution or tobacco. Interestingly in more than 30 countries where surveys have been carried out, 90% of people know that tobacco causes cancer, even in countries with a less literate population. However, it’s not the same story for  other conditions such as cardiovascular disease and COPD. Only 60 per cent know about these risks to lung health because of smoking.

How big is the impact of secondhand smoke globally?

The global picture is that more than 60% of secondhand smoke exposure affects women and children, which is a concern because they are not smokers but they are being affected. Children are hugely prone to asthma and to respiratory diseases from their parents smoking.

Most people don’t smoke in the workplace because of legislation but they go home and they tend to smoke.  The law of the land doesn’t prevent them from smoking at home at all. It’s more and more important to raise awareness of the harms of second-hand smoke.  And that cannot be imposed by law, it requires more community engagement and literacy. It’s very important, for instance, to teach children that it’s risky so they can go home and tell their parents that if they want to smoke they can go outside and smoke.

What should governments do to reduce the impact of tobacco on lung health globally?

World Tobacco Day 2019 is focused on tobacco and lung health to raise awareness of the negative impact of tobacco use on people’s health ranging from cancer to chronic respiratory diseases . And for us at this stage it’s important to raise awareness among all stakeholders. Tobacco control is the key factor to reducing NCDs (non-communicable diseases). Governments must prioritise tobacco control as part of their policies.

The WHO has a package of measures which we call MPOWER which are key demand reduction measures such as graphic warning labels on the products, banning tobacco advertisements and raising taxes. The UK has done extremely well in raising tobacco taxes.  Tax is the best instrument. That is the best levy.  It makes it difficult for the poor, the vulnerable, even the rich to consume so much tobacco. And it provides the government has additional revenue with which they could then help tobacco smokers to quit and launch awareness campaigns.

A classroom full of children still start smoking in Wales every day with the poorest teens most likely to take up the habit

New figures released today reveal the gap in smoking rates amongst Wales’ richest and poorest teenagers has widened.

According to the latest Health Behaviour in School-aged Children Report, youngsters from the most deprived families in Wales are now twice as likely to smoke compared to their affluent counterparts.

The survey of over 100,000 students, carried out by researchers at Cardiff University, showed 9% of 15-16-year-olds smoke at least once week, a figure that despite concerted efforts, has remained unchanged since 2013/14. More than 11,000 children still take up smoking every year in Wales

Differences in smoking rates across social classes remain a major concern as smoking is more than twice as common in adults in the most deprived areas of Wales (28%) compared to the least deprived (13%).

Across Wales smoking is a leading cause of death and ill health and a major driver of health inequalities.

Among those from the least affluent families, 6% of secondary school aged children now smoke at least weekly, compared to just 3% of those from the most affluent families.  This compares to 4% of the least affluent and 3% of the most affluent as reported in 2013/14.

Commenting on the latest figures, Suzanne Cass, CEO of ASH Wales, said: “It is shocking to discover that despite efforts to curb smoking among young people in Wales, a classroom’s worth of children continue to take up the habit every single day.

“Meanwhile the differences in the smoking rates between our richest and poorest youngsters are actually getting worse.

“Among the adult population of Wales, it is those people from the deprived areas that are the most likely to smoke. It is essential that we take action to prevent young people from those areas from becoming the next generation of adult smokers in Wales and from perpetuating the health inequalities that continue to blight our most deprived communities.”

Those who start smoking earlier in life are likely to become the heaviest smokers later in life as well as the least likely to quit. Research has shown the earlier children start smoking then carry on into adulthood, the greater their risk is of developing lung cancer or heart disease in later life.

The report also reveals the following differences in smoking prevalence and exposure to smoking between the most and the least affluent youngsters in Wales:

  • 46% of Year 11 students from the most deprived families first tried a cigarette at 13 or younger compared to 34% of the most affluent. In 2013/14, 61% of those from the least affluent families had tried at cigarette at 13 or younger, compared to 38% from the most affluent families.
  • 8% of young people were exposed to smoking during their most recent car journey – a significant decrease compared to 13% in 2013/14. This figure rises however depending on the young person’s background with 5% of those from a more affluent background having been exposed to smoke during their last car journey, compared to 14% from the most deprived families.  In 2013/14 23% of youngsters from a deprived background said someone was smoking the last time they were in a car, compared to 10% of youngsters from a more affluent background.
  • E-cigarette use has not been shown to vary greatly depending on a child’s background. 28% of those from the least affluent families said they had tried an e-cigarette, compared to 24% from the most affluent.  The figure was the same for both groups in 2013/14 at 12%. Only 4% of those from the least affluent backgrounds and 3% from the most affluent said they used e-cigarettes regularly.

Following the release of the figures, ASH Wales is calling for a more targeted approach to reducing youth smoking prevalence, with prevention and cessation work provided in those areas where it is most needed.

Suzanne Cass, CEO of ASH Wales, said: “It is clear from these figures that tobacco control policies designed to restrict young people’s access to cigarettes are not working, with no change in the number of pupils lighting up.

“Tobacco companies want nothing more than to trap these youngsters into a cycle

of addiction that will see them become their customers for life. The only way to break that cycle is to identify those most at risk of smoking and arm them with the tools they need to resist temptation or to quit.”

“We would like to see prevention and cessation support for young people available in both community and educational settings and families provided with the support they need to quit together. In addition, we believe smoking prevention work should form part of the new National Curriculum for Wales 2022.”

Currently 19% of the adult population in Wales smoke. There are around 5,388 smoking related deaths and 26,489 smoking related hospital admissions in Wales every year and the cost of this to NHS Wales is around £302 million a year.

Student Health and Wellbeing In Wales: Report of the 2017/18 Health Behaviour in School-aged Children Survey and School Health Research Network Student Health and Wellbeing Survey, was compiled by Cardiff University’s Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer).

Editor’s Notes

Enquiries: Diana Milne | PR Officer  | diana@ashwales.org.uk |

Or Beth Mahoney | marketing and communications manager | Beth@ashwales.org.uk |

Interviews available. Please contact using the details above.

Mental Health, Smoking and Me?

Charlotte Harding, author of Welsh Mummy Blogs overcame the challenge of giving up smoking, despite suffering from mental health problems. To mark Mental Health Awareness Week, she tells us her story.

Can you tell us about your experiences of mental health issues?

I have suffered ill mental health from a young age. I first started seeing a psychiatrist at 14 years old when I was suffering from anorexia. From there I was diagnosed with an anxiety and panic disorder. I suffer with depression at times and I was diagnosed with a more severe mental health illness years later.

When did you start to smoke?

I started to smoke on and off around 15 years old, I was smoking full time at 16.

Did you smoke to relieve symptoms of your mental health issues?

100% yes! I found smoking stopped me eating. I also found that I smoked more when my anxiety was high. Smoking in a way regulated my breathing and this would help with my panic attacks, or so I thought.

Do you think suffering from mental ill health made it more challenging for you to give up smoking?

I made the stop smoking Wales service aware of my mental illness before I started the smoking cessation. I explained that I am not good sitting in a group environment and would benefit more if I was having 1:1 meetings. They said it wasn’t a problem, I just had to wait for a space to be available.

Giving up was extremely difficult. I found I was craving a cigarette every time my anxiety played up, which was constant when quitting. I found I had really bad mood swings which played on my mental health.

I also found that I was hungry more often whilst giving up, and I gained around 1st due to snacking. This caused a few problems, I found I tried to restrict calories in my food due to the weight gain. This did resolve itself once the cigarette cravings lessened.

I explained I was finding quitting difficult to my GP and she decided to support me after the smoking cessation finished. I was prescribed my Quick Mist Spray for almost a year. In the end, I decided to go ‘cold turkey’ and I quickly found that I was no longer addicted to nicotine, I just had a habit of reaching for my spray when I felt stressed or anxious.

Would you say there is enough support available for those suffering from mental ill health to give up smoking?

I was lucky, I had a really supportive GP who prescribed me nicotine replacement after the 12 weeks stop smoking service. The GP said she would rather put the nicotine replacement on my repeat than me going back to smoking. If I didn’t have a good GP I would probably had started smoking after the 12 week service.

What advice would you give to anyone with mental ill health who would like to give up smoking?

Go for it! You will feel so much better once you have quit. It may be hard at times but it is so worth it. Be honest with your GP and/or stop smoking adviser, they will help. Most GPs would prefer you on nicotine replacement than smoking.

Mind over matter – why quitting smoking could improve your mental health

Did you know that quitting smoking could improve your mental health? To find out more, we’ve taken a look at how smoking affects your state of mind.

Smoking and stress

It’s a common misconception that smoking helps to relieve feelings of stress and anxiety. Many smokers will automatically reach for a cigarette when the going gets tough.  And while it’s true that puffing on a cigarette will bring a feeling of instant relaxation, in the long term, smoking becomes the cause not the cure for stress.
Once gripped by nicotine addiction, smokers quickly find themselves in a never-ending cycle of smoking to relieve nicotine withdrawal symptoms, experiencing the warmth of a nicotine hit, before the withdrawal symptoms kick in once again. These withdrawal symptoms and cigarette cravings then become the cause of anxiety symptoms which can only be relieved by smoking another cigarette, and so the cycle goes on.

Smoking and depression

It is unclear whether smoking leads to depression or vice versa however, according to the Mental Health Foundation, smoking rates in the UK, are around twice as high among adults with depression as among the general population.    It can be more challenging for people suffering from depression to give up smoking.   Nicotine stimulates the release of dopamine in the brain which is the chemical responsible for triggering positive feelings. Those with depression often have low levels of dopamine. As a result, some people use cigarettes to temporarily increase their levels of dopamine. Regular smoking leads the brain to switch off its own mechanism for making dopamine, meaning that in the long-term supplies decrease, encouraging people to smoke even more.

Medication

Smoking can make prescribed medication for some mental illnesses less effective. This means the smoker would have to take higher doses of their medication in order for it to work effectively. Smoking is known to interfere in particular with the way some antipsychotic medication and antidepressants work.

The benefits of quitting for mental health

According to the NHS quitting smoking can be as effective as antidepressants when it comes to  treating anxiety and depression.   Although coping with cigarette cravings can be tough, those with mental health problems who successfully quit the habit are likely to feel calmer, more positive and have a better quality of life.  Quitting means escaping the cycle of nicotine cravings but also the pressure to fund a habit that costs on average £56 a week and £243 a month for a 20-day smoker.

How to quit

All smokers are different and there is not one quit method or smoking cessation services that suits everybody. To help you find the quit smoking support that is best for you contact Help Me Quit, NHS Wales’ free smoking cessation service.  To get in touch text HMQ to 80818, call 0800 085 2219 or click here to visit the Help Me Quit website.

Depression and smoking – one woman’s journey to a smokefree life

To mark Mental Health Awareness Week we have asked ex-smokers who have experienced mental health problems to tell us their smoking story and how they quit. Today we hear from Tracey Jones *  from North Wales  who suffers from depression and has recently quit smoking.

Can you tell us about your own experiences of mental health issues?

I have experienced depression at low and stressful times of life. The longer the stressful situation, the worse it gets. I’d describe it as like having a very sad stone in your stomach, it’s always there. Sleeping takes away the feeling.

When did you start smoking

I started smoking at around 15 or 16-years-old. At first I just wanted to have a go but I was hooked instantly. Yes, smoking helped to relieve my depression but all it does really is hide issues, and build up a habit at the same time.

In your experience do you think there is enough support out there to help people with mental health issues to stop smoking?

I do think that people with depression and anxiety need much more support, and it’s not out there. Most help is fully booked, and the staff, well meant as they are , don’t really understand. And it’s the dealing with people thing that makes it even more difficult.
Quitting is extra hard I guess for people dealing  with depression and addiction on top of that. The lack of nicotine and habit is extra pressure ( not to mention pressure from other people)

How did you give up smoking?

This my fifth serious attempt at quitting. This time I didn’t tell anyone, and used inhalators bought online. I bought sugar free mints, and used an app to monitor the benefits. To be honest, the hardest thing has been food, and feeling sad.

How has your life changed as a result of giving up smoking?

It’s early days still. But I already have a better sense of taste and smell. My home smells better. My chest is clear, and I have no cough. And I have a lot more time on my hands! And my bank is much healthier.

What advice would you give to anyone who suffers from anxiety or depression and is worried about quitting smoking?

Do it your way. Prepare. Read up. Monitor your progress with an app. Nap when you can ( the body kind of goes into shock when you quit), and empty your house of all smoking paraphernalia!

* Surname changed

Mental health and smoking: My story

Graham Morgan has an MBE for services to mental health and helped to write the Scottish Mental Health Care and Treatment Act. He is also an author, having written a book, Start, about his own personal experiences of mental illness.  We asked him to tell us his story and how he finally found the strength to stop smoking. 

When you start smoking and why?

I first started smoking to fit in, I went to school away from home and was terribly lonely. Anyone who wanted friends and to be even slightly cool smoked. I had never wanted to smoke but it was the ideal way to look slightly rebellious and to make friends. I started at 16 and gave up when I was about 40. In the early years it felt like a great comfort and later, when I experienced sadness and despair, I took an obscure pleasure from the fact that smoking might kill me, which, at the time, was my ambition.

In hospital thirty five years ago smoking was a currency; a form of friendship. Smoking was an excuse to have conversations and to give small gifts, it was a vital way of making a connection with my fellow patients and seemed to be a way of dealing with the pressure, boredom and isolation of being a patient.
For many, many, years I was never without a roll up, always patting my jacket for my tin, my papers, panicking when I frequently lost them. Smoking was a huge part of my life, I didn’t really consider giving up and really struggled during those times when I couldn’t smoke.

Do you think suffering from mental illness made giving up smoking more of a challenge for you?

I think it was, I now know that smoking is bad for your mental and emotional health as well as your physical health but for many years I thought it helped make me happier and calmer. I was very worried about how I would cope if I gave up. As well as being meant to experience Schizophrenia, I also experienced anxiety and depression. I worried that my anxiety would increase dramatically. I also worried that I would no longer have people to talk to and share a cigarette with.
However when I finally decided to give up I found it easy. It was like a key turned in my head and I knew I was going to give up. From then on I just needed to plan my patches, my snacks and so on. I had great support from my then wife and some of my friends, who had mental health problems too, were a great help when I was away with them and thinking of getting a last pack of cigarettes. They refused to let me! After that it all went smoothly, although I felt a desire to smoke for years after I was easily able to resist this.

I used to joke for many years that I was actually a smoker who didn’t smoke. I did worry that if I went into hospital again I would immediately start smoking. In the event I was able to not smoke and even in those times when we still had smoking rooms, which were great hubs of support, I was able to go to them and sit with other people and yet not feel the temptation to ask for a cigarette.

Why do you think there are such high rates of smoking prevalence among people with mental illnesses?

I think there are many, many, reasons. Whether we like it or not it does seem bring a form of pleasure and when you feel miserable any glimpse of pleasure helps. A considerable number of us have nothing to look forward to, have nothing to do, have a lack a belief in ourselves and have no motivation to be healthy, if we are not enjoying our lives then it is hard to look forward to the future, to plan for better times. This might come from the exclusion and stigma we experience, from poverty, from powerlessness, from our illness itself.

For me it was getting to an emotional state where I wanted to live, wanted to celebrate my life that enabled me to even consider stopping. However I know for many other people that is not their reality. Smoking can feel like their last pleasure, their last bit of control in unenviable lives. I think many people who feel apart, use drugs and unhealthy lifestyles to cope with life and that smoking is just one element of this. Despite this I also think it is very sad that smoking can represent a form of pleasure when it is one of the reasons we have such reduced life expectancy and poor health, when much to our confusion, what seems to be pleasure is not actually the pleasure we are seeking.

How would you describe the effects of smoking on people’s mental health?

I do not know how to describe it. I am aware of the research that says it is bad for emotional health and I am aware of the fact that smoking often means that we have to take higher doses of anti psychotics than we would normally need but at the time I was smoking I had no idea about this.
It is only many years later that I find myself grateful that I don’t have that clutch of anxiety when waiting on a cigarette, that constant need to make sure I had cigarettes around me. The thought of smoking doesn’t occur to me now; it feels a blessing to be away from all that.

Is there sufficient awareness out there do you think about the effects of smoking on mental health?

No not at all, we all know that it is bad for us and I think feel pretty patronised by people asking us to give up and reminding us of the horrible ways we are likely to die but I think we often feel that other people don’t know or get why we smoke, why it feels sometimes like one of the last pleasures we have.
I first found out about its effect on mental health and our medication from ASH Scotland. I was extremely surprised as many of my friends were convinced that giving up would be bad for their mental health. I still think giving up suddenly if you are a patient in hospital and in crisis would be very difficult and very upsetting but it may also be an opportunity for some people. Knowing that in the long term it will improve our mental health is very helpful to me and I think would be for other people who are trying to decide whether to give up or not.

Based on your personal experience, do you think there is enough smoking cessation support available for people suffering from a mental illness?

No, Speaking purely personally I am very sad at the lack of support patients are given in hospital when they are not allowed to smoke at desperate points in their lives. I cannot understand why vaping is not seen as a viable stop gap measure when you are an inpatient. I know how desperate I have been for the outside world when I have been confined to the ward, not being able to smoke if you are a smoker at these times must be awful, people need all the support that they can get at such times, the end result is people smoke when they are not allowed to the nurses become more like the tobacco police and everyone else suffers. There must be better ways of dealing with such critical times in our lives. It could be a good and positive opportunity to consider our smoking but often seems to become a battleground.

I am idealistic I think smoking cessation involves much more than tips and hints and support to give up. For me smoking comes from inequality and exclusion, it comes from poverty and self loathing. In an ideal world we would address the myriad things that can lead us to think there is no point in us being healthy: that we wouldn’t manage to give up anyway and that we do not really deserve the support that might help us appreciate the lives we have and that we would have nothing in our lives to replace the loss of tobacco. It is not just the support that is given an individual or the wish that people like us would take more responsibility for our health but the support that should be given to a neglected community of people to have a better and more positive place in society. In some strange ways I can see how addressing poverty could be a part of smoking cessation, or that providing community facilities where we can meet our peers and have things to do, food to eat, conversation and support to give each other are also a way of looking at smoking cessation.

What is the best way to start conversations about smoking with people who have a mental health condition?

Try to understand our perspective, don’t preach, don’t force, don’t control, don’t coerce or threaten. Too many of us experience that in our daily lives anyway.
Actions like that will cause us to recoil, become defensive and bloody minded.
So I would say get to know us, our motivations our lives try to see us as people and ask us what we would like. I know most people who smoke wish to stop, so start the conversation but in partnership and with gentleness and sensitivity.
Also help those groups and people who are spokespeople for our community to recognise that smoking is a human rights issue in that far too many of us are hooked on something that kills us, impoverishes us, damages us. Help us recognise that we have been conned by the tobacco lobby and that far from campaigning for us to be able to smoke as much as we want, we would do well to recognise that having the right to find the means to find ways out of smoking will go a long way to eliminating that terrible inequality in health which means so many of us die so much earlier than the rest of the population. Help us realise that the tobacco companies are not allies of any sort in our lives, that we can aspire to more and deserve more.

Help us get to the point where we say our community deserves so much better than this. I don’t know what will make the difference ultimately but I would hope that we would end up trying to reach a place where it is as natural to say we need support if we wish to live smoke free, just as we need support to challenge stigma, support to find hope, support to have community and connection.