H2 Smoking

AS Level and A Level Biology Chapter 12 Pages 150-164

Learning outcomes
Candidates should be able to: (e) describe the effects of tar and carcinogens in tobacco smoke on the gas exchange system; (f) describe the signs and symptoms of lung cancer and chronic obstructive pulmonary disease (emphysema and chronic bronchitis); (g) describe the effects of nicotine and carbon monoxide on the cardiovascular system;

(h) explain the link between smoking and atherosclerosis, coronary heart disease and strokes;
(i) evaluate the epidemiological and experimental evidence linking cigarette smoking to disease and early death; (j) discuss the difficulties in achieving a balance between preventions and cure with reference to coronary heart disease, coronary by-pass surgery and heart transplant surgery; (k) use the knowledge gained in this section in new situations or to solve related problems.

Introduction
The World Health Organisation (WHO) considers smoking to be a disease. Each day, 1200 young boys, and as many young girls, take up smoking.

1. Tobacco smoke
There are over 4000 different chemicals in cigarette smoke, many of which are toxic. Tobacco smoke consists of:
mainstream smoke (from the filter or mouth end), sidestream smoke (from the burning tip).

About 85% of smoke released from smoking is sidestream smoke. Many of the toxic ingredients are in higher concentration in this smoke.

 Breathing someone elses smoke is called passive smoking and can be harmful.

Three main components of cigarette smoke that can cause damage either to the gaseous exchange or cardovascular systems are:
tar which settles on lining of airways in lungs and can cause obstructive lung diseases and lung cancer, carbon monoxide forms the stable compound carboxyhaemoglobin, putting a strain on the heart and damaging the lining of arteries, nicotine increases heart rate and blood pressure and decreases oxygen supply to bodys extremities. Also increases stickiness of blood platelets.

 Both carbon monoxide and nicotine increase the risk of developing cardiovascular disease. Link was discovered in latter half of twentieth century.

2. Lung disease
Despite the filtering system of the lungs, very small particles (<2m in diameter) can reach the alveoli and stay there. Allergens (substances that can cause allergies) trigger a defence mechanism in the cells lining the airways. If this is severe, it may cause an asthmatic attack in which the smooth muscles of the airways contract, obstructing the flow of air and making breathing difficult.

 Severe coughing, in response to production of mucus in lungs, can damage alveoli.

Continuous damage can lead to replacement of thin alveolar surface with scar tissue, so reducing surface area for diffusion.
Chronic (long-term) obstructive lung diseases such as asthma, chronic bronchitis and emphysema are now the most common cause of illness and death in the UK after heart disease and strokes.

Chronic bronchitis
Tar in cigarette smoke stimulates goblet cells and mucous glands to enlarge and secrete more mucus.

It also destroys many cilia lining the epithelium and weakens the action of those that remain. This leads to smokers cough and thickening of airways.

 Trapped bacteria and viruses can cause infections such as pneumonia. Infection then leads to linings becoming inflamed, further narrowing the airways. This is chronic bronchitis, characterised by large quantities of phlegm and severe coughing.

Emphysema
With smaller quantities of elastin in the alveolar walls, some alveoli may burst during exhalation. This reduces surface area for gaseous exchange, i.e. emphysema.

 People with emphysema do not oxygenate their blood very well and have rapid breathing rate.

As the disease progresses, blood vessels in lungs become more resistant to blood flow so blood pressure increases to compensate and right side of heart enlarges.
People with severe emphysema often need a continuous supply of oxygen to stay alive.

Chronic obstructive pulmonary disease

Chronic bronchitis and emphysema often occur together. The term chronic obstructive pulmonary disease refers to the overall condition which is progressively disabling.

Only in rare cases is this reversible and can only happen in young people if smoking is given up.

Lung cancer
Tobacco smoke contains carcinogens. These react with DNA in epithelial cells to produce mutations and eventually a malignant tumour.

The cancer can then spread (metastasis) to other organs via the lymphatic system.

 Lung cancer takes 20-30 years to develop. The most common symptoms are coughing up blood due to tissue damage. Tumours in lungs can be located by:
bronchoscopy, chest X-ray, CT scan.

Treatments include chemotherapy with anti-cancer drugs or radiotherapy with Xrays.

3. Providing the links between smoking and lung disease

In 1912, there were 374 cases of lung cancer, now there are over 35 000 deaths a year in the UK from the disease.

 Different epidemiological data link smoking and lung diseases, including lung cancer (see pages 154-155). Conclusions drawn from these data can be criticised because they only show that there is an association and not a causal link. But smoking is the common factor in all cases.

Cigarette smoking is also linked with other cancers, i.e. mouth, oesophagus, larynx, bladder, etc.

Experimental evidence
Experimental evidence shows a direct causative link between smoking and lung cancer.
Two lines of evidence exist:
tumours similar to those in humans develop in animals exposed to cigarette smoke. carcinogens have been identified in tar.

4. Cardiovascular diseases
Cardiovascular diseases are degenerative diseases of the heart and circulatory system, e.g. coronary heart disease and stroke. They are responsible for 20% of deaths worldwide and up to 50% of deaths in developed countries. Many factors contribute to the development of these diseases, i.e. they are multifactorial. Smoking is one of these risk factors.

Atherosclerosis
Cholesterol is lipid needed for the synthesis of vitamin D in the skin, steroid hormones in the ovaries, testes and andrenal glands and plasma membranes in all cells. It is insoluble in water so is transported in blood plasma as lipoprotein. There are two types:
HDL remove cholesterol from tissues and transport it to the liver to be excreted, LDL transport cholesterol from liver to tissues, including the artery walls.

 The main process that leads to cardiovascular diseases is atherosclerosis the buildup of an atheroma which contains cholesterol, fibres, dead muscle cells and platelets.
The cholesterol-rich atheroma forms plaques in the lining of arteries making them less elastic and restricting the flow of blood. The restricted blood flow can lead to thrombosis, i.e. the production of a thrombus (blood clot).

Coronary heart disease

Two coronary arteries branch from the aorta to supply all the muscles of the atria and ventricles. Coronary heart disease is a disease of these arteries that causes damage to or malfunction of the heart.

It develops if the blood supply to the heart is reduced, e.g. through atherosclerosis.

 There are three forms of coronary heart disease:

angina pectoris the main symptom is severe chest pain when exercising which goes away when resting. heart attack (myocardial infarction) main symptom is sudden and severe chest pain. heart failure the heart weakens and fails to pump efficiently.

Stroke
A stroke occurs when an artery in the brain bursts so that blood leaks into brain tissue (a brain haemorrhage) or when a blockage occurs in a brain artery due to atherosclerosis or a thrombus.

The brain tissue in the area supplied by the artery is starved of oxygen and dies, i.e. cerebral infarction.
A stroke may be fatal or cause mild or severe disability.

Global distribution of coronary heart disease

Coronary heart disease has mainly been confined to developed countries. It is considered to be a disease associated with affluence but also a degenerative disease. In the developing world, where death rates from infectious diseases is decreasing, death rates from cardiovascular diseases is increasing.

 Death rates from coronary heart disease also differ within countries.

Epidemiological evidence
The evidence for links between smoking and cardiovascular diseases is not as clear cut as it is for smoking and lung cancer. Smoking increases:
the chances of both the development of atherosclerosis and blood clotting, blood pressure (a risk factor for stroke), the concentration of cholesterol in blood (a risk factor for coronary heart disease).

Smoking also increases the risk of developing cardiovascular diseases in passive smokers.

 These factors were identified in long-term epidemiological studies with large groups of participants. To find the reasons for the global distribution of coronary heart disease, the WHO set up a multinational monitoring project, called MONICA, in 1979. Evidence from this study pointed to the importance of blood pressure and blood cholesterol as key factors in predicting whether someone would suffer from heart disease.

 Recent research suggests that genetic factors are important.

Genes can affect blood cholesterol levels, blood pressure and development of diabetes.

The role of diet in coronary heart disease

People with high levels of saturated fat and cholesterol in their diet tend to have high blood cholesterol levels and high incidences of heart disease, e.g. Finland. Red meat and dairy products are especially rich in saturated fats. Mediterranean countries also have high fat intake in their diets, but this is mainly unsaturated fat. Therefore the incidence of heart disease is lower.

In France, there is a high intake of saturated fat but has one of the lowest rates of heart disease. This suggests that saturated fat and cholesterol intake alone are not important.

Prevention and cure of coronary heart disease

Reduction of the incidence and prevalence of heart disease can occur by:
taking more exercise, giving up smoking, decreasing intake of animal fat.

Treatment for coronary heart disease includes drugs to:

lower blood pressure, decrease the risk of blood clotting, prevent abnormal heart rythms, reduce the retention of fluids, decrease blood cholesterol concentrations.

If drug treatments do not work then a coronary artery by-pass operation may be carried out.

 A complete heart transplant is the method of last resort.

Two ways to reduce the cost of treating coronary heart disease include:
identifying and concentrating resources on those in the population at highest risk, encouraging the population to adopt a healthy lifestyle.

Epidemiological evidence suggests that better maternal nutrition better protects against heart disease.