Smoking & liver

2. Dr. Ashraf El Adawy
Consultant Chest Physician
TB TEAM EXPERT – WHO
Smoking & liver
Mansoura - Egypt

3. Most people are well aware of effects of smoking on the heart and lungs. However, what you may not know that smoking cigarettes can also severely affect the liver . Smoking has numerous detrimental effects on the liver , It induces three major adverse effects :
1.Direct or indirect toxic effects
2.Immunological effects
3.Oncogenic effects
World J Gastroenterol 2006

4. 1.Toxic effect: Though cigarette smoke does not directly come into contact with the liver, it does indirectly affect the liver. The chemicals that are present in cigarette smoke prevent the liver from performing its main function. Over time, the liver becomes less efficient at removing the toxins from your body.
World J Gastroenterol 2006

5. Direct toxic effect: Smoking increases the production of pro-inflammatory cytokines IL-1, IL-6 and TNF-α that would be involved in liver cell injury. Smoking yields chemical substances with cytotoxic potentials , These chemicals induce oxidative stress associated with lipid peroxidation which leads to activation of stellate cells and development of fibrosis.
World J Gastroenterol 2006

6. Direct toxic effect: Heavy smoking yields toxins which induce : Necroinflammation and increase the severity of hepatic lesions (histological activity index and fibrosis score) when associated with hepatitis C virus (HCV) or hepatitis B virus (HBV) infection.
World J Gastroenterol 2006

8. A French study published in the January 2003 edition of Gut found that smoking, independent of alcohol, could aggravate the histological activity of chronic Hepatitis C. In the June 2006 issue of Clinical Gastroenterology & Hepatology, California researchers found that smokers with chronic Hepatitis C may be more likely than non-smokers to develop liver fibrosis.

9. Smoking increases serum and hepatic iron which induce oxidative stress and lipid peroxidation that lead to activation of stellate cells and development of fibrosis . Heavy smokers accumulate excess iron in hepatocytes which induces fibrosis and favours development of HCC
World J Gastroenterol 2006

10. Indirect toxic effects (Concomitant polycythemia)

11. Indirect toxic effects (concomitant polycythemia)
Heavy smoking is associated with increased carboxy HB and decreased oxygen carrying capacity of RBCs leading to tissue hypoxia. Hypoxia stimulates erythropoetien production which induces hyperplasia of the bone marrow. The latter contributes to the development of secondary polycythemia and in turn to increased red cell mass and turnover , which might be a contributing factor to secondary iron overload promoting oxidative stress of hepatocytes.

12. Smoker’s syndrome is a clinico-pathological condition reported in patients smoking more than 40 cigarettes or 10 stones of popular shisha per day, over a long time Patients complain of episodes of facial flushing, warmth of the palms and soles of feet, throbbing headache , fullness in the head, dizziness, lethargy, prickling sensation, pruritus and arthralgia .
World J Gastroenterol 2006

13. 2. Immunologic effect:
Smoking in adults have negative influence on the efficacy of hepatitis B vaccination. Smoking significantly affected their antibody titre responses.
World J Gastroenterol 2006

14. Smokers suffering from chronic hepatitis C tend to have a lower response rate to interferon-α compared to non-smokers. It is recommended that chronic hepatitis C patients should be advised to avert smoking before embarking on IFN .
World J Gastroenterol 2006

16. Although smoking has long-term adverse effects; cessation of smoking reversed these effects, such as :
1.Elevation of NK activity which is detectable within one month of smoking cessation.
2.Elevation of both antibody and cell-mediated immune responses.
3.Decreased proinflammatory cytokines.
4.Increased antioxidant activity.
World J Gastroenterol 2006

17. 3. Oncogenic effect : Smoking could favor the occurrence of clinical decompensations in patients with established cirrhosis and is associated with an increased incidence of hepatocellular carcinoma. Tobacco smoking is associated with reduction of p53 a tumour suppressor gene which is considered “the genome guardian
Herrero JI. Liver Transpl. 2011

18. Tobacco use identified as an independent risk factor for development of hepatocellular carcinoma in patients with cirrhosis

19. Tobacco smoking ‘probably’ increases the risk of primary liver cancer among the Japanese Jon J Clin Oncol 2006
Recent data from China and Taiwan have shown an association of smoking with liver cancer independent of HBV status Int J Cancer 2003

20. Synergistic effect has been established between smoking and HBV or HCV infection on the risk of developing hepatocellular carcinoma (HCC). Chronic carriers of HBV or HCV are recommended to avoid smoking .
Herrero JI. Liver Transpl. 2011

21. Compared with HBV-negative non-smokers, the risk of developing hepatocellular carcinoma : 1.87 times higher for HBV-negative smokers, 15.8 times higher for HBV-positive non-smokers, 21.6 times higher for HBV-positive smokers. The combined effect of cigarette smoking and HBV infection was more than additive effect of the two risk factors.

22. Regarding the risk of developing hepatocellular carcinoma , The synergistic effect between smoking and virus infection was even greater for HCV. The combined effect of cigarette smoking and HCV infection was about 2.5 times greater than the additive effect of the two risk factors

23. In the June 2008 issue of the International Journal of Cancer , researchers from Texas found that : especially in men with Hepatitis C, cigarette smoking can dramatically increase the chance of getting hepatocellular carcinoma. The researchers concluded that there appears to be a synergistic link between smoking and Hepatitis C infection in men, leading to a more than 136-fold increased risk of developing HCC.

24. For men with Hepatitis C who have the intent of preventing their liver disease from progressing to cancer, abstaining from smoking cigarettes should lie at the top of their to-do list. Since increasing the risk of liver cancer by over 100 times is so dramatic, there is no doubt of the evils of cigarettes.

26. •The DHS study estimated 14.7% of the Egyptian population were positive for HCV antibody and 10% positive for HCV RNA
Egypt
14.7%

27. Google Egypt
The prevalence of HCV varies
throughout the country.
The northern Nile Delta appears to have
the highest prevalence ~28 %.

28. • This was published in the Proceedings of the National Academy of Science in August
2010.
• The study included a review of all reports of HCV prevalence in Egypt

29. Egypt has the largest epidemic of HCV in the world. The percentage of Egyptians with HCV is 14.7%. This is ten times greater than any other country in the world. The prevalence of HCV in Western countries is less than 2%.

30. The currect population in Egypt is about 78 to 80 million. 14.7% of this popuation (0.147 X 78 million) is 11,466,000 persons who have been infected with this virus. This number is an underestimate becasue it does not include the number of people who have been infected that are under 15 years of age or over 60 years of age.

31. Hepatitis C infection reaches alarming figures. “Medication cost for every hepatitis C patient stands at an average of 70,000 Pounds [$12,250] and the government has failed to provide this sum for most of the patients.“ Egypt has a very high prevalence of HCV and a high morbidity and mortality from chronic liver disease, cirrhosis, and hepatocellular carcinoma.

32. Smoking Prevalence in Egypt

33.  Reducing NCD risk factors
• Bangladesh
• Brazil
• China
• Egypt
• India
• Indonesia
• Mexico
• Pakistan
Reducing the level of exposure of individuals
and populations to tobacco use
Technical assistance package to implement the
WHO FCTC demand reduction measures
– Monitoring (surveillance and evaluation)
– Protect (second hand smoke)
– Offer help
– Warn against dangers
– Enforce legislation against tobacco
promotion
– Raise taxes
• Philippines
• Russia
• Thailand
• Turkey
• Ukraine
• Vietnam
• Uruguay

34. The Economics of Tobacco andTobacco Taxation in Egypt 2010 International Union Against Tuberculosis and Lung Disease

37. Cigarette smoking is an independent risk factor for onset of non-alcoholic fatty liver disease (NAFLD) Scientists at the University of California, Riverside (UCR) have found that exposure to second-hand tobacco smoke can lead to non-alcoholic fatty liver disease
ScienceDaily September 14th - 2009

38. Cigarette smoking is associated with increased fibrosis severity in human NAFLD, suggesting it may accelerate disease progression. These results may support a formal recommendation of smoking cessation in patients with NAFLD .
J Hepatol. 2011

39. World J Gastroenterol 2009 Fatty liver and smoking had a synergistic effect on metabolic syndrome and its components, especially for hypertriglyceridemia and low serum HDL-C Smoking cessation would have the great benefit of reducing the risk of metabolic syndrome, especially for subjects with fatty liver

40. Finally, patients submitted to liver transplantation are particularly sensitive to the cardiovascular and renal effects of Cigarette smoking Transplanted patients who smoke have an increased risk for vascular complications including hepatic artery thrombosis

41. Herrero JI. Liver Transpl. 2011
Smoking cessation at least 2 years before liver transplantation can significantly reduce the risk for vascular complications. Smoking cessation should be an essential requirement for liver transplantation candidates to decrease the morbidity arising from vascular complications after liver transplantation.

42. After liver transplantation postoperative pulmonary complications (PPC) occur in approximately 35% to 50% of the recipients. Among these PPC, pneumonia is the most frequently encountered Postoperative pulmonary complication is one of the major factors affecting mortality.

43. With regard to preoperative assessment findings, smoking history was found as one of the factors associated with increased postoperative pulmonary complications esp. (pneumonia ) . For this reason, during preoperative assessment, factors should be identified carefully to take the necessary precautions in preparing those patients for LT with the least possible risk .

44. Post–liver transplantation smoking constitutes an early relapse after a brief involuntary hiatus of abstinence caused by the transplantation procedure and associated hospitalization. In a cohort of patients under-going transplantation for alcoholic liver disease, the investigators found that as early as three months after transplantation, 50%of recipients were smoking again.

45. Recurrence of viral hepatitis may be more frequent among liver transplant recipients who are active or former smokers The average "viral hepatitis-free survival time" was less than one year for smokers and close to five years for non-smokers "Encouraging preoperative smoking cessation may be beneficial in improving patient outcomes following transplantation."

46. Other investigators recently reported that smoking was a risk factor in the increased frequency of malignancies after liver transplantation. Smoking cessation after liver transplantation reduced incidence of transplant-related carcinoma

47. Nearly 34 percent of liver transplant recipients were active or former tobacco users The Organs available for transplantation are scarce, with livers particularly in short supply "Transplant centers need to take an active role in identifying and minimizing risks to the success of liver transplantation."

48. Tobacco use is quite prevalent in both pre– and post–liver transplantation patients Nicotine addiction and tobacco use both prior to and after liver transplantation have to be addressed in a proactive and organized manner. Yet, smoking cessation counseling skills are not common in liver transplant centers

49. The Emerging data demonstrating the negative impact of smoking on the short- and long-term outcomes of liver transplantation could lead liver transplant centers to reconsider their position regarding implementation of smoking cessation programs

50. Shisha is less hazardous than cigarette is a misconception According to recent studies the pipe could act as a good medium for conveying bacteria causing infectious diseases like Hepatitis A that can be easily transmitted when shisha pipe is used by multiple smokers

51. Smoking is an underestimated risk factor for liver diseases , it may be an avoidable co-factor in the incidence, progression and clinical course of many types of chronic liver diseases Hepatologists have traditionally paid scant attention to the deleterious effects of CS. Honestly,they are not particularly sensitized to encourage smoking cessation among their patients

52. Patients with chronic liver diseases should be strongly encouraged (and helped) to quit smoking
It is time to seriously take up the cause of banning cigarette smoking in the field of hepatology.

53. IT’S NEVER TOO LATE TO QUIT