Microsoft word - smoking - final completed module

Smoking 
Tutor’s Notes 
Edith Okola with Holly Halstead 
 
Ann Wylie 
These  resources  are  freely  available  to  be  copied  and  used  for  teaching  and  public  health  studies.  Please acknowledge author and LTPHN for publication.  SMOKING

Why is smoking important?

Approximately 10 million adults currently smoke in the UK.1 In London a person is
admitted to hospital every 10 minutes due to causes related to smoking, around
55,000 people each year. It is estimated that approximately 12,000 people in the
Capital are killed by tobacco annually - 18% of all deaths.2
Smoking impacts on health within every clinical specialty, and is the responsibility of
every healthcare professional. Identifying people who smoke and offering them help
to stop will reduce premature morbidity and mortality, and is also important in
reducing health inequalities.
The Public Health white paper published in 2004 Choosing Health: Making Healthier
Choices states that ‘every member of the NHS staff has the potential to increase their
role in raising people’s awareness of the benefits of healthy living – as part of the
NHS responsibility to patients to improve health, not just provide healthcare for the
sick.’3
Epidemiology

Nationally
Smoking prevalence has decreased over the last 20 years in both men and women.
(51% to 26% of men and 41% to 23% of women in Great Britain from 1974 to
2004.3)
The General Household Survey in 2004 demonstrated that 25% of adults smoked.
Figure 1 shows the highest prevalence was in the 20-24 age group and the lowest in
the 60 years and over group. The prevalence is thought to be lowest in the over 60
group because many people stop smoking in middle age, whilst a quarter of smokers
die before their 70 birthday.1,4
Figure 1: Prevalence of smokers in Great Britain in 2004 5
Original Author: Edith Okola with Holly Halstead Figure 2: Cigarette smoking status of men in Great Britain in 2004 5
Figure 3: Cigarette smoking status of women in Great Britain in 2004 5
The survey found that 31% of people in manual socio-economic groups smoked compared to 18% in non-manual groups. Men had a higher prevalence for smoking than women in all socio-economic classifications as shown in figure 4. Original Author: Edith Okola with Holly Halstead Figure 4: Prevalence of smoking among adults aged 16+ years by National
Statistics Socio-economic classification (NS-SEC) in Great Britain in 2004 5
Socio-economic classification
The managerial and professional group had a higher percentage of smokers wanting to quit than the routine and manual group, which is shown in the chart below.5 Figure 5: The percentage of adult smokers who would like to stop by gender
and socio-economic classification 5
Socio-economic classification
In 1974 the mean number of cigarettes smoked daily by men was 18 and women 13. In 2004 it had decreased to 15 for men and stayed at 13 for women.5 In 1999 the Health Survey for England found that self reported smoking was higher in Bangladeshi, Irish and Black Caribbean men and Irish women than for the general population as shown in table 1.6 However, the survey did not include the African population. It also should be noted that in some cultures it is more common to chew tobacco rather than smoke. Original Author: Edith Okola with Holly Halstead Table 1: Percentage of self-reported smokers by ethnicity and gender
Ethnicity
Many people start smoking and become addicted to nicotine as teenagers. A series of surveys at secondary schools in 2004 showed 7% boys and 10% girls aged 11-15 smoked regularly. 7 Smoking regularly was defined as at least one cigarette a week. Figure 6 shows the prevalence of smoking by age and gender. Figure 6: Prevalence of regular smokers among secondary school children in
England in 2004 7

The prevalence of smoking increases with age. A higher percentage of girls smoke
than boys, from ages 12-15 with the percentage gap widening from 1% more girls at
age 12 to 10% more at age 15.
London
31% of men and 26% of women in London smoke, about 2 million people.8 The
highest percentage of smokers is found amongst the 25-34 age group. Men have a
higher prevalence of smoking in all ages under 75 years old, as shown in figure 7.
Original Author: Edith Okola with Holly Halstead Figure 7: Prevalence of smoking in London between 1998-2001
rcentage 15

Smoking prevalence has had a larger decrease in London from 34% to 28% in men
and 24% to 20% in women when compared with a fall nationally from 29% to 27% in
men and 26% to 24% in women between 1998 and 2003.9
What’s in a cigarette?
Over 4000 chemicals are found in tobacco smoke, which include tar, nicotine, benzene, benzopyrene, carbon monoxide, ammonia, dimethylnitrosamine, formaldehyde, hydrogen cyanide, sulphur dioxide and acrolein.10,11 Of these, nearly 70 are known or suspected carcinogens and the World Health Organisation (WHO) has classified secondhand smoke as a carcinogen.8, 12 Why do people smoke?

Nicotine is contained in the moisture of tobacco leaf and is an addictive substance.13,14
It is a stimulant, entering the blood via several routes including the lungs and mucous
membranes, and quickly crosses the blood-brain barrier to reach the brain within 15
seconds. Nicotine enhances the release of neurotransmitters including dopamine,
acetycholine, norepinephrine and serotonin.15 This experience for smokers is
pleasurable, and when repeated becomes physically and psychologically addictive.15
Evidence shows the effect on the dopamine system in the brain is similar to that of
heroin and cocaine.16 A study in the late 1980s showed people who had alcohol,
cocaine or heroin dependence found cigarettes as hard to give up as their other
drugs.17,18
Further information about the physiology of smoking can be found in ‘Nicotine
Addiction in Britain’ at http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm
Original Author: Edith Okola with Holly Halstead Smoking and health
It has been estimated that 1000 people a day are admitted to an NHS hospital with a
smoking related problem.15 Each year approximately 114,000 smokers die from a
smoking related illness in the UK,19 and smoking related diseases cost the NHS £1.5
billion annually.20 Ref 20 onwards
In London between 1998-2002 the percentage of smoking related deaths ranged from
under 14% in Barnet and Kingston, more affluent areas, to 23% in Tower Hamlets.
Further information on London boroughs can be found from the London Health
Observatory. 7

Below are examples of the effects smoking has on most clinical specialties. 21 The
WHO has also produced a poster called The Smoker’s Body, which demonstrates
some of the effects of smoking.22
The relevance of smoking to different clinical specialties 15
Smoking is relevant to most clinical specialties: it both causes disease and makes
treatment more difficult. The examples here are not intended as an exhaustive list.
• Surgery – all sub-specialties
− increases the risk of postoperative complications, including respiratory, − increases the risk of poor wound healing − increases average lengths of stay − increases the likelihood of admission to an intensive care unit − increases the risk of postoperative death Smoking also damages skin flaps used in reconstructive and cosmetic surgery often causing failure or subsequent breakdown • Obstetrics and gynaecology
Antepartum bleeding and abruptio placentae has been linked directly with smoking23 Smoking during pregnancy induces fetal hypoxia and, because of the vasoconstrictive effect of nicotine, also causes uteroplacental underperfusion – both contribute to prematurity and low birth weight (maternal smoking cessation in the first trimester eliminates the excess risk of low birth weight)24,25,26,27,28,29,30,31,32,33 Smoking has been associated with a 29% increase in fetal malformations, including hare lip, cleft palate and abnormalities of the central nervous system, heart and digestive system Original Author: Edith Okola with Holly Halstead • Orthopaedics
Smoking is associated with delayed bone healing: the average length of time for a non-smoker to form 1 cm of new bone is 69.6 days, but it takes 89.4 days in a smoker.34,35 Women who smoke have a lower bone mass and are more likely to have a premature menopause – in combination, these two factors significantly increase the risk of osteoporosis and fracture.36 Men who smoke are also at increased risk of osteoporosis because smoking affects the production of bone cells.14 Smokers are 70% more likely than non-smokers to suffer hearing loss.37,38 Non-smokers living with smokers are twice as likely to have hearing problems.29,30
• Orthopaedics
Smoking increase the risk of developing age-related macular degeneration and smokers are up to four times more likely to go blind in old age.39,40,41 • Dentistry
There is a direct relationship between smoking and bone resorbtion – smokers are
more likely to lose their teeth, and have a high risk of dental implant
failure.43,44,45,46,47
Periodontal disease is 2-3 times commoner in smokers.48
• Gastroenterology
Smokers are twice as likely to develop peptic ulcers, and gastroesophageal reflux is more common in smokers.49,50,51,52 Smokers are more likely to develop Crohn’s Disease.53 Current and former smokers have been found to have more hepatic inflammation and scarring than non-smokers and, independent of the effect of alcohol, smoking can aggravate the effects of hepatitis C infection.54,55 Smoking increases the risk of developing alcoholic liver cirrhosis – smoking 20 cigarettes a day trebles the risk compared to that of a lifelong non-smoker.56 Smoking increases the hepatotoxicity of some drugs, e.g. paracetamol.57 • Cardiovascular medicine
Smoking causes peripheral vascular disease. Original Author: Edith Okola with Holly Halstead • Respiratory medicine
Smoking causes chronic obstructive pulmonary disease. People with chronic obstructive pulmonary disease who give up smoking halve their likelihood of hospital admission because of an exacerbation, whilst merely cutting down has no benefit at all. People with cystic fibrosis who smoke (actively or passively) have much poorer respiratory function. • Endocrinology
Smoking affects pituitary, thyroid, adrenal, testicular and ovarian function, calcium metabolism and the action of insulin. Smokers are more likely to develop:58,59 − insulin resistance − Grave’s Disease (thyroid eye disease is also commoner) − and irregular menstrual cycle and a premature menopause (in women) − osteoporosis (in men and women) Smoking is an independent risk factor for diabetes.60,61,62 Smoking increases the risk of complications and premature death in people with diabetes.63,64 Nephropathy is commoner in people with diabetes who smoke.65,66 Smoking is an independent risk factor for pancreatitis.67,68 • Renal medicine
Smoking is nephrotoxic in people with renal disease.69,70 Smokers have a higher risk of end-stage renal failure.71 • Dermatology
Smoking leads to premature ageing of the skin – the effects are permanent.72,73,74 There is a significant relationship between smoking and hair loss and baldness.75 • Neurology
Older people who smoke are at greater risk of developing dementia.76 Smoking is a risk factor for multiple sclerosis and its progression (smokers are three times more likely to have rapid progression of MS than non smokers).77,78 • Haematology
Chronic exposure to cigarette smoke or nicotine causes T cell unresponsiveness – smoking reduces the effectiveness of the body’ immune system.79 Smoking is thrombogenic – it increases platelet stickiness Smoking reduces the oxygen carrying capacity of red blood cells.80 Original Author: Edith Okola with Holly Halstead • Paediatrics
Children living with smokers are more likely to develop meningitis.81 Babies living with two or more smokers are 30 per cent more likely to need hospital treatment than those who live in smoke-free homes.82 Babies of mothers who smoke have five times the risk of dying of sudden infant death syndrome.83,84,85 Passive smoking by children has been shown to cause bronchitis, pneumonia, coughing and wheezing, asthma attacks and middle ear infections.86 • Genitourinary medicine
Smoking causes erectile dysfunction – 40% of male smokers are affected compared with 28% of the general population.87 Smoking reduces the total sperm count and sperm motility – it is a significant cause of male infertility.88,89,90,91 Smoking has been directly linked with infertility in women.92,93,94,95,96 • Oncology
Active and passive smoking causes cancer of the respiratory tract. Smoking increases the risk of pancreatic cancer by 70%. Smoking causes nasal, sinus and throat cancer. Smoking is also associated with cancers of the oesophagus, stomach, kidney, bladder and cervix, and with myeloid leukaemia. • Psychiatry
People with mental health problems are much more likely to smoke – their general health is poorer and they are more likely to die prematurely (this likelihood is in addition to an increased risk of death from suicide). People with mental health problems are much more likely to smoke – people with schizophrenia are ten times more likely to die of respiratory disease. People with mental health problems who smoke are much more likely to require higher doses of neuroleptic drugs because of enzyme induction by nicotine.
Passive smoking

Passive smokers inhale sidestream and mainstream smoke. Mainstream smoke has
been inhaled and exhaled from a smoker. Sidestream smoke is emitted from the
burning tip of a cigarette, contains higher concentration of potential toxic gases
and composes 85% of a smoke-filled room.97,98
It was first recognised that passive smoking damaged health in 1981, and there is now
plenty of evidence to support this.99 In November 2004 the Scientific Committee on
Tobacco and Health, which advises the Government, showed that the risk of lung
cancer and heart disease was increased by one quarter in adult non-smokers exposed
to passive smoke.100 Within 30 minutes of exposure to passive smoke there is a
Original Author: Edith Okola with Holly Halstead reduction in coronary blood flow.101 A non smoker has a 23% increased risk of heart
disease when living with a smoker.102
Other recent reviews of the effects of passive smoking have been carried out by the
International Agency for Research on Cancer (IARC), the California Environmental
Protection Agency and the WHO.
The impact of passive smoking on children103

Cotinine is a metabolite of nicotine. It is excreted in urine, saliva, and blood and can
be found in hair. It is specific to nicotine and is a measure of the persons’ intake of
tobacco smoke.104,105,106 Its half-life is approximately 24 hours. Studies have found
cotinine in the urine and saliva of children exposed to passive smoking.107,108 From
this it is reasonable to infer that children exposed to passive smoking are at risk of all
smoking related illnesses. As many as up to half the children in Britain are exposed to
passive smoke.109
• Dental
A cross sectional survey of 3531 children aged 4-11 years old showed an association between exposure to passive smoke and risk of dental caries.110
• Ear nose and throat (ENT)
A systematic quantitative review shows a likely a causal relationship between passive smoking and acute and chronic otitis media in children.111
• Infection
Passive smoking increases the risk of children developing invasive meningococcal disease.112
• Respiratory diseases
Passive smoking is a contributor to chronic cough in children113 and increases the risk of children succumbing to acute lower respiratory tract infections.114 A systematic quantitative review showed passive smoking:115 - Is a co factor for provoking wheezing attacks in 5 year olds and under - Increases the symptom score of patients with asthma - Is associated with more severe disease in established asthma Prevalence surveys conducted amongst school-age children suggest wheeze and diagnosed asthma are more common in those exposed to passive smoke.116 It has also been demonstrate that children whose mothers smoke have a decrease in their lung function.117 Children with cystic fibrosis exposed to passive smoke have an increased number of hospital admissions compared with those who are not.118
• Sudden infant death syndrome
A systematic quantitative review of the epidemiological evidence relating parental smoking to sudden infant death syndrome concluded that maternal smoking doubles the risk of sudden infant death syndrome.119 Original Author: Edith Okola with Holly Halstead
Along with evidence showing the detrimental effect passive smoking has on
children’s health, there is also evidence to demonstrate that it adversely affects
different treatment regimes.
• Drug regimes
Tobacco smoke induces CYP1A2 enzymes found primarily in the liver.120 This speeds the metabolism of drugs induced by CYP1A2 leading to the patient requiring larger doses to obtain therapeutic levels. Drugs induced by this are: theophylline 121 Evidence also shows that insulin resistance increases with exposure to nicotine123, which leads to diabetics requiring more insulin.124
• Anaesthesia
Exposure to passive smoke affects children undergoing general anaesthesia. The risk of perioperative respiratory complications125 and incidence of postoperative hypoxaemia are both increased in children exposed to passive smoke.126 A retrospective cohort study showed there was a ten-fold increase risk of laryngospasm in children exposed to environmental tobacco smoke who underwent anaesthetic.127
• Ear nose and throat
The effects of passive smoking on ENT conditions have been discussed above. However, there is evidence to show that passive smoking effects the treatment of secretory otitis media. A prospective study of 606 children undergoing bilateral myringotomy with insertion of grommets showed passive smoking:128 - Increases the chance of an ear infection post grommet insertion - Adversely affects the length of time grommets are in situ post operatively. The median survival rate of grommets in children exposed to passive smoking was 59 weeks compared to 86 weeks in non exposed children - Increases the risk of myringosclerosis of the tympanic membrane after the - Increases the risk of permanent perforation of the tympanic membrane Endoscopic sinus surgery is used in children with chronic sinusitis in whom medical treatment has failed. Evidence shows that exposure to passive smoking predisposes children who are having endoscopic sinus surgery to a poorer outcome. At 12 months non exposed children had a success rate of 90% compared to 70% in children who were exposed to cigarette smoke.129 Original Author: Edith Okola with Holly Halstead • Respiratory
As discussed above passive smoking contributes to many respiratory problems in children. It also interferes in the treatment of many respiratory illnesses. Asthmatic children exposed to household smoke were more likely to have: - Increased attack frequency - Increased use of medication - Increased hospital attendance - Increased life threatening attacks A prospective cohort study showed asthmatic children exposed to passive smoke were less likely to have good peak flow and symptom control than non exposed children.130
Tobacco Regulation

Smoke Free Legislation
Comprehensive legislation banning smoking in public places, including places of
work and enclosed public areas such as pubs and clubs, was introduced in England in
July 2007. Previously, it was estimated that 8% (2,182,000) of people employed in
Great Britain worked in places with ‘no restrictions on smoking at all’ and 38%
(10,366,000) in places where smoking occurs in ‘designated areas.’131
Smoke free legislation is a huge public health issue, because it is known that passive
smoking is a risk to non-smokers. It is hoped that it will also reduce health
inequalities by effectively decrease smoking rates, which are higher amongst people
in manual work.132
Evidence from other countries demonstrates that a complete ban can decrease smoking prevalence by 4 %; this is assuming there are no smoking restrictions initially.133 New York went smoke free in 2003 and Ireland in 2004. In New York, an 85% drop in cotinine levels was seen in non-smoking staff working in restaurants and bars after the introduction legislation.134 In Ireland almost one in five smokers decided not to smoke whilst out socialising since the introduction of the ban there.135 Tobacco Advertising
The Tobacco Advertising and Promotion Act 2002 came into effect in the UK on 14th February 2003. This bans any advertising which has the purpose or effect of promoting a tobacco product, including: • adverts in print and billboards; • internet; • direct mail; • promotions; • free gifts; and • sponsorship.136 Tobacco sponsorship was banned from domestic sport in 2003 and, at an international level, from World Snooker and Formula One in 2005. Exemptions from this ban include advertising at the point of sale. Original Author: Edith Okola with Holly Halstead Tobacco advertising increases tobacco consumption, and countries who have imposed a ban on advertising have also demonstrated a drop in consumption.137,138 A report by the US Surgeon General about tobacco advertising acknowledged the following points: - Tobacco advertising increases the use of tobacco in children and young - It increases the consumption of smokers - It lowers smokers’ motivation to stop smoking - It ensures tobacco remains acceptable and health warnings are
Consumer Protection
A European Union (EU) directive in 2001 regulated certain components of cigarettes,
stating that any cigarettes sold in Europe can have a maximum 10mg tar, 10 mg
carbon monoxide and 1 mg nicotine.140 The directive also regulates the health
warnings on cigarette packets, which must cover 30% of the surface area on the front
of the packet, and 40% of the back. Use of words such as ‘light’ or ‘mild’ in the brand
name was also banned.141
Tobacco economics
In 2004/2005 the treasury earned £8,013 million (excluding VAT) from tobacco
duties.141 About 80% of the cost of a packet of cigarettes constitutes tax.142 The NHS
spends approximately £1.5 billion a year on treating smoking related diseases, which
does not include invalidity or sickness benefits.143 In England and Wales
approximately 34 million days are lost each year due to absence because of a smoking
related illness.144
Increasing the price of cigarettes does decrease consumption, but 16% of cigarettes
consumed in the UK are smuggled, reducing the effect of the policy. 145

Original Author: Edith Okola with Holly Halstead
Smoking cessation

At least 70% of adult smokers would like to quit smoking and one of the main reasons
is for their health.146,147 The table below illustrates the benefits of stopping
smoking.148
Table 2: Health benefits of stopping smoking
Time since
Beneficial health changes
quitting
Blood pressure and pulse rate return to normal. Nicotine and carbon monoxide levels in blood reduce by Carbon monoxide will be eliminated from the body. Lungs start to clear out mucus and other smoking debris. Ability to taste and smell is greatly improved. Bronchial tubes begin to relax and energy levels increase. 2-12 weeks
Coughs, wheezing and breathing problems improve as 3-9 months
lung function is increased by up to 10%. Risk of a heart attack falls to about half that of a smoker. Risk of lung cancer falls to half that of a smoker. Risk of heart attack falls to the same as someone who has As nicotine is an addictive substance when smokers quit they experience withdrawal symptoms which are shown in table 3.149,150 Table 3: Withdrawal symptoms
Proportion of those trying
Withdrawal symptom
Duration
to quit who are affected
Irritability / aggression
Depression
Restlessness
Poor concentration
Increased appetite
Light-headedness
Night-time awakenings
Original Author: Edith Okola with Holly Halstead NHS smoking cessation services
NHS Stop Smoking Services were established in 1998 to offer support for smokers
wanting to quit based on best available evidence. Behavioural support, nicotine
replacement therapy (NRT) or bupropion are offered along with advice. There is
evidence to show that providing smokers with help to quit is effective. Specialist
intensive support quadruples the chance of quitting. 151 However, to stop one person
smoking, twenty people need to be advised to quit.
In 2004/2005 around 530,000 people in England set a quit date with NHS stop
smoking services, and at four weeks follow up 56% were not smoking.152
There are three levels of intervention for stopping smoking and are outlined below. 153
• Level 1: Brief opportunistic advice to stop from a health care professional
The main aim of the intervention is to trigger an attempt to stop smoking. Brief advice to all smokers to encourage them to make an attempt to stop is effective in promoting smoking cessation. Ask – if they are a smoker Advise – to stop smoking and reasons why Assist – explain different options for stop smoking services Arrange – to see a stop smoking advisor either level2 or 3 Recent NICE Public Health Intervention Guidance makes nine recommendations for brief interventions and referral for smoking cessation in primary care and other settings.154 The recording of smoking status should also be readily accessible in both primary and secondary care so that patients can be regularly asked and advice given is recorded.
• Level 2: Behavioural support to aid attempts to stop smoking
The main aim of the intervention is to respond to smokers requests for help with an attempt to stop smoking. The programme runs for 12 weeks with the clients being seen weekly for the first 4 weeks. Advice is given on the use of NRT or bupropion and behavioural advice and support is given.
• Level 3: Specialist services
This service provides intensive behavioural support in groups for smokers over a 6-7 week period. All healthcare professionals involved in smoking cessation to encourage the smokers to use bupropion or NRT where appropriate. Pregnant women and inpatients at hospital who smoke who wish to stop should have behavioural support provided by specialist counsellors. Original Author: Edith Okola with Holly Halstead Clients accessing Level 2 or 3 support will be asked the following questions to assess nicotine addiction and enable NRT to be tailored to their needs. - What time do you have your first cigarette of the day? - Do you smoke more in the morning? - Do you smoke when you are ill? - Do you have difficulty not smoking in a non-smoking area? - Number of cigarettes smoked a day - Which cigarette would be the hardest to give up?
NICE Guidance on NRT and bupropion
NRT and bupropion (Zyban) are recommended for smokers who want to quit
smoking. It should normally be prescribed as part of an abstinent-contingent treatment
which is when the client commits to stopping smoking on a certain date known as
their quit date. Behavioural support is available from trained advisors to aid in the
clients quit attempt.
What is nicotine replacement therapy (NRT)?
NRT works by reducing the severity of the withdrawal symptoms and reduces
cravings and the desire to smoke. It provides a temporary nicotine substitution at a
lower level (a third to a half) and slower delivery than nicotine from an inhaled
cigarette. It helps smokers to quit in a two stage approach, firstly by behaviour change
and then the drug. The nicotine replacement therapy is weaned during the programme
and is available in a variety of preparations, such as gum, patches and inhalers.
What is bupropion (Zyban)?
Initially buproprion was used as an antidepressant in the US, known as Wellbutrin,
but anecdotal reports demonstrated that it also aided people trying to stop smoking.
The mechanism of action is not fully known. It may act as a nicotine acetylcholine
receptor, inhibit dopamine reuptake or decrease activity of noradrenaline-releasing
neurones.
One 150mg tablet is taken daily for the first six days and the client still smokes. At
day 7 the dose is increased to two tablets a day taken 8 hours apart. A quit date is set
for between 8-14 days after starting bupropion.
Contraindications include seizures, eating disorder, CNS tumours, bipolar disorder,
severe hepatic cirrhosis, use of MAOIs. Common side effects include insomnia,
headache, and a dry mouth; rarely it can cause seizures, severe allergic reactions, and
hypertension.
Original Author: Edith Okola with Holly Halstead
For further information/Resources

Action on Smoking and Health
Fact sheets available covering:
NICE
Guidance on smoking cessation, including bupropion and nicotine replacement
therapy (No. 39), as well as brief interventions and referral for smoking cessation in
primary care and other settings.
www.nice.org.uk
Department of Health
Relevant online documents include:
• Smoking Kills: A White paper on tobacco 1998 • The NHS Plan: 2000 • Choosing Health: Making healthy choices easier 2004 www.dh.gov.uk
World Health Organisation
• International consultation on environmental tobacco smoke (ETS) and child www.who.int/tobacco/en/

The Royal College of Physicians
Information about nicotine addiction in Britain.
http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm
Original Author: Edith Okola with Holly Halstead References
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