Difficult to treat asthma

1
??T????? ?????S??
?a?as?e?? ?atsa????? ???t??a? ??e?µ???????a? ?at??
?? S???? ?????? G? ???GG???S??S
2
??T????? ?????S??

• Environmental tobacco smoke (ETS)
• second-hand smoke
• involuntary smoking
• The smoke inhaled by the smoker first, and then
  exhaled, is called mainstream smoke. The smoke
  that goes directly into the air from the end of a
  burning cigarette is called sidestream smoke. ETS
  is composed of side-stream smoke from smouldering
  cigarettes and from mainstream smoke exhaled by
  smokers.

3
??T????? ?????S??- ??S

• ?p?te?e? s?µa?t??? ?a? ap???ta a?a?????sµ???
  ??p? t?? es?te????? ?????.
• 4.000 ??µ???
• 100 t?????
• 50 ?a????????a
• ? ???es? e??? µ? ?ap??st? p?? s?µί???e? µe
  ?ap??st? e??a? ?s?d??aµ? pe??p?? µe t? 1 t??
  ???es?? e?e???t???? ?ap??st? 20 ts?????? t??
  ?µ??a.

4
??T????? ?????S??-???????

• T? 2004 e?t????a? se pa??t??? ??p??sµa
• 40 t?? pa?d???.
• 33 t?? µ? ?ap??st?? a?t???.
• 35 t?? µ? ?ap??st?? ???a????.

5
??T?S? S? ETS S?? ???????
6
??T?S? S? ETS S?? ???????

• 17 st?? ????pa??? ???s?
• 60 st?? ????da
• 47 st? ?????a??a
• 41 st? ?????a??a, ??p??
• lt10 st?? ?????a, Ga???a, S???d?a
• S????te?a se -??t?e?
• -?aµ??? e?pa?de?s?
• - e???te?
• - ?????a ??? t?? 54
• - a?t?apas?????µe???

7
??T?S? S? ETS S?? S????
8
??T?S? S? ETS S?? S????
9

??T?S? S? ETS S?? S????
10
??T????? ?????S?? ??? ??????

• ???µ??e?? ?at?te??? a?ap?e?st???? (LRI)
• S????? se pa?d?? 0-2 et??
• ί?????t??, ί????????t??, p?e?µ???a
• S????? e?sa????? st? ??s???µe?? ??a LRI

11
??T????? ?????S?? ??? ??????
12
(No Transcript)
13
??T????? ?????S?? ??? ?????? S?µpt?µata

• S????µ??
• ???a?
• ?p???eµ??
• ??sp???a
• ? ??R
• At?p?a

14
??T????? ?????S?? ??? ?????? ??S?? ??S?? O??S

• ??e?a µ?s? ?t?t?da
• ?p?t??p?????sa µ?s? ?t?t?da
• S??????? µ?s?? ?t??

15
??T????? ?????S?? ??? ?????? S?????? ??F??????
T?????? ???FO?- SUDDEN INFANT DEATH SYNDROME

• Kat? t? d????e?a t?? ???s?? ?a? µet?.
• ?a?a??te?? p??sf?s? t?? ???e??d?? st???
  ae?a??????, µe ap?t??esµa pe??ss?te?? e???d?t???
  ae?a??????, ?d?a?te?a µet? ap? ???es? se
  e?e??sµata p?? p???a???? e??tt?s? t?? d?aµ?t???
  t???.
• ?e??ss?te?a ap????? ep?s?de?a ??????
  ap?f?a?t???? t?p?? ?a? p??a??? ?????te?? ??d?
  af?p??s?? µet? ta ap????? ep?s?de?a.

16
?ST?? ???????S ??????S ??? ??T????? ?????S??

• ??????s? ί???????? ?s?µat??
• ?p?de???s? t?? s?ίa??t?ta? ?a? t?? p?????s?? t??
  ί???????? ?s?µat??
• ?e??ss?te?a s?µpt?µata ?a? pa?????se??.
• ??? s?ίa??? pa????sµ?? p?? µp??e? ?a ?d???s???
  ?a? se ???at?

17
???S? ??? ?????S??

• ? ????t??? ep?d?? a???t??? st?? ?????f???a
  p?a????ta-µ?t?a?
• ? d?af???p???s? eµί??ο??? ?a?d?a??? s????t?ta?
• ? a?t?stas? ?µf???a? a?t???a?
• ?? ??p??sµa s?et??eta? µe
• ? d?ast?se?? a??e??? p?a????ta
• ? a?t?µate? ap?ί????
• ? e?d?µ?t??a a??pt???
• ? ???d???? ??t?p?? ???s?? (d?s?e?a?t?µe???)
• ? ???d??? ap??????s?? p?a????ta
• ?a??ste??µ??? e?d?µ?t??a a??pt???
• ??t?µat? ap?ί??? 1?? t??µ????
• ?µί??ο?? ???s?µ?t?ta
• ????µ? ???? ?µ????
• ???οµ?? t??et??
• ???d??µ?? p?a????ta?
• ?ht eµί????
• ?a?d??? ?s?µa
• ??ata?a??? a??pt???? ??S

18
EN???????? ??T?S? S? ????? ?S?G????

• ??t???? ??p??sµa s?et??eta? µe a???µ???
  o?e?d?t??? stress st? 3 µ???? ?e???? (Noakes P.
  et al, ?horax 2007).
• E?d?µ?t??a ???es? se ?ap?? ep?te??e? t??
  a??e????? ap????s? se a??e???????a se p??t???a
  (Penn A. et al, Env Heal Perc 2007).
• ??t???? ??p??sµa (?at? t?? ???s? ?a? st?
  s????e?a) s?et??eta? µe wheezing OR1.24
  1.1-1.56 ?a? ?s?µa OR1.22 1.04-1.66(Raheri
  son C et al, Resp Med 2006).
• Guilliand FD, AJRCCM 2003

19
?????S?? S??? ???S? ??? ?ST?? S??? ??????? ??????

• ?? ??p??sµa ?at? t?? eµί????? ?????a s?et??eta?
  µe ?????te?? ep?pt?s? ?s?µat?? sta pa?d??.
• ?????s? 60 µe?et?? a??de??e ?t? ? ???d????
  eµf???s?? ?s?µat?? st?? pa?d??? ?????a e??a?
  a???µ???? ?ta? ?? ???e?? ?ap??????. Odds Ratio
  (OR)a1.21 (95 CI, 1.10-1.34).
• ?? ??p??sµa t?? µ?t??a? e??e µe?a??te?? ep?pt?s?
  ap? t? ??p??sµa t?? pat??a sta pa?d??.

aThe ratio of the odds of development of disease
in exposed persons to the odds of development of
disease in nonexposed persons. Cook et al.
Thorax. 199752(12)1081-1094 www.worldofstock.co
m/closeups/PHE1195.php..
20
?????S?? S??? ???S? ??? ?ST?? S??? ??????? ??????

• ? ???es? se ?ap?? ts?????? p??? ?a? µet? t?
  ?????s? s?et??eta? µe a???µ??? ???d??? ?s?µat??.

?O??S ??T?S? S? ?????
??T?S? S? ????? ??GO ??????S
Odds Ratio (95 CI)a
???? ?? G????S?
???? ?? G????S?
???? ??? ???? ?? G????S?
Adjusted for sex, age, educational level, active
smoking in terms of both smoking habits and
pack/years, occupational exposure, and hay fever.
In addition, when estimating the ORs for the 3
maternal smoking variables, adjustment was made
for exposure to smoking from other household
members. Skorge et al. Am J Resp Crit Care Med.
2005172(1)61-66.
21
??T????? ?????S?? ??? ??????

• ????? a??? stat?st??? s?µa?t??? ep?d?as? st??
  a??pt??? t?? p?e?µ??a, ?p?? a?t? e?f???eta? ap?
  t??? sp???µet?????? de??te? FEV1, FVC, MEFR.
• ???a??sµ?? ???OS
• ??e??sµ?? ?p?d?????
• ??d?µa ί?e????????
• ?ί?e??????ss?t? ???a?s?
• ?pe?t??f?a ?a????e?d?? ??tt????
• ?pe??????s? ί????a?
• ?pe?p?as?a ade??e?d?? e?ί?ast?se??
• F?e?µ??? ί???????? ί?e????????
• ?p?ί??d??s? t?? a??pt???? t?? p?e?µ??a ?at? t?
  ?????s?
• ?????OS
• - ?p?ί??d??s? eµί?????? a??pt????

22
S??????? ??F?????? T?????? ?O? ???FO?- SUDDEN
INFANT DEATH SYNDROME

• ??s?e?a?t?µe?? s?s??t?s? µeta?? ?ap??sµat?? t??
  µ?t??a? ?a? ίef???? ?a??t??, t?s? ?at? t?
  d????e?a t?? ???s??, ?s? ?a? µet? t?? t??et?.
• ?a? µ??? µet? t?? t??et? ?? ???d??? ??a SIDS.
• t? ??p??sµa µ??? t?? pat??a ????d??? ??a SIDS.

23
?????S?? ??? ???S?

• ? ????t??? e??a? ??p?d?a??t? ?a? d?a??eta? e????a
  µ?s? t?? ί????????? µeµί?a???.
• ?at? t? d????e?a t?? ???s?? µetaf??eta? µ?s? t??
  p?a????ta ?a? e?ap?t??eta? st??? eµί??????
  ?st???.
• ?? ep?pt?se?? t?? ????t???? st?? ???s? ?fe????ta?
  ?????? sta pa?a??t?
• - a??e??d?asta?t???? ?d??t?t?? t?? ????t????
• - ? ep?peda ?ate???aµ???? ?a?
  ?a?ί???a?µ?-sfa?????? eµί????.
• - ? ?a?d?a?? s????t?ta ?a? a?t???a?? p?es?

24
??????? ????????S S?? ??????? ?G??

• ? ???es? st? ????t??? µp??e? ?a µet???e? ?µµesa
  µe t? µ?t??s? t?? ??t??????.
• ? ??t????? e??a? ?a??te??? de??t?? ???es?? st??
  ?ap?? ap ?t? ? ????t???.
• ? ??t????? e?ap?t??eta? ?d? ap? t?? 7? eίd?µ?da
  st?? ?????f?-??a t?? eµί????.
• ?p???e? ??aµµ??? s????t?s? µeta?? t?? ep?p?d??
  ??t?????? t?? µ?t??a? ?a? t?? eµί????.

Jauniaux et al. Obstet Gynecol. 199993(1)25-29
http//www.lennartnilsson.com/child_is_born.html.
25
? ??????S? ??S ????????S S??? ???????? ?????F????

• ? a?µat??? ??? p?a????ta-µ?t?a?.
• ?a?t?stas? st?? a?µat??? ??? µ?s?? e??efa?????.
• ? d?af???p???s? eµί??ο??? ?a?d?a??? s????t?ta?
  (?ST)

?µί????? ?????f???a (Directional Color Doppler)
Oncken et al. Obstet Gynecol 200299751-755.
Albuquerque et al. Early Hum Dev. 20048031-42.
26
? ??????S? ??? ?????S????S S??? ?????F???? ???
?????????
?????? ???S??????? ???? ???????S ?????S Notch
Plt.05
Umbilical S/D (Median)a
?? ?????S??S
??? ?????S??S
aS/Dsystolic/diastolic ratio, the ratio of
time-averaged maximal systolic and diastolic
blood flow velocities. Albuquerque et al. Early
Hum Dev. 20048031-42.
Plt.05
Number of Patients
?? ?????S??S
??? ?????S??S
27
????G????????S ????????S S??????????S ?? ?? ???S?
??????

• ?p??????s? p?a????ta
• ?a??ste??µ??? e?d?µ?t??a a??pt???
• ??t?µat? ap?ί??? 1?? t??µ????
• ?µί??ο?? ???s?µ?t?ta
• ????µ? ???? ?µ????
• ???οµ?? t??et??
• ???d??µ?? p?a????ta?
• ?ht eµί????
• ?a?d??? ?s?µa
• ??ata?a??? a??pt???? ??S (e??efa???? ?e?t?????a,
  s?µpe??f???, ???s?)

Andres et al. Semin Neonatol. 20005231-241
Cnattingius. Nicotine Tob Res. 20046(suppl
2)S125-S140.
28
????????S? ?????????

• ????µ? ap??????s? f?s???????? eµf?teµ????
  p?a????ta p??? t?? t??et?.
• 0.8-1.0 t?? ???se??.
• ????t??? epape??e? t?? ??? eµί????-µ?t??a?.
• ?p??e? ?a ?d???se? se p???µ? t??et?, µe ί?a?? ?a?
  µa????????e? s???pe?e?.

Abruption
FH
Bl
FB
FBfetal body Blbladder FHfetal head Health
Education Assets Library. http//www.healcentral.o
rg/healapp/showMetadata?metadataId217. Accessed
October 19, 2007 Cunningham et al. In Williams
Obstetrics. 19th ed. 1993819-851 Ananth et al.
Obstet Gynecol. 199993622-628.
29
?????S?? ??? ????????S? ?????????
?? ?ap??st??e? ????? d?p??s?? ???d??? ??a
ap??????s? p?a????ta
S?et???? ???d???? OR
??? ?????S??S
?? ?????S??S
????????S? ?????????
Ananth et al. Am J Epidemiol. 1996144(9)881-889.
30
?????S?? ??? ????????S? ????????? S?S????S? ??
??S????? ??????
Odds Ratio (95 CI)a
?? ?????S??S b
1-9
?10
?S?G??? / ???????? ?????S??S
Cnattingius. Am J Epidemiol. 1997145(4)319-323.
31
?????S?? ??? ????????S? ?????????
15- 25 t?? ap??????se?? t?? p?a????ta ?a
e??a? ap?fe???e? e?? ?? ???a??e? d????pta? t?
??p??sµa ?at? t? d????e?a t?? ???s??.
???????????S S?? ?????S??
????????S? ?????????
Ananth et al. Obstet Gynecol. 199993622-628.
32
?????S?? ??? ???????? ??????? 1?? ????????

• 9 t?? a?t?µat?? ap?ί???? µp??e? ?a ap?d????? st?
  ??p??sµa

P for trend lt.001
Odds Ratio (95 CI)a
0
?10
?S?G??? / ????? T? 1? ??????? ??S ???S?S
Logistic regression estimates include the
following covariates center, age, marital
status, maternal family history of spontaneous
abortion, education, history of miscarriages,
nausea, and alcohol and coffee intake in the
first trimester of pregnancy. Chatenoud et al.
Ann Epidemiol. 19988(8)520-526.
33
??????S? ??? ?????S????S S??? ?????????
Cigarette smoking during pregnancy
Reduced dimensions of the fetal capillaries in
villi
Modify placental blood flow
Diminish the area for exchange of gasses and
nutrients between the mother and the fetus
Reduction in birth weight of infants delivered by
smoking mothers
Adapted from Larsen et al. Am J Obstet Gynecol.
2002186531-537.
34
??????S? ??? ?????S????S S??? ???????? ????????

• ??s?e?a?t?µe?? s??s? µeta?? µ?t????? ?ap??sµat??
  ?a? ?aµ???? ί????? eµί???? ??a t?? ?????a t??.

Odds Ratio (95 CI)a
?? ?????S??S
?10 ?S?G??? / ?????
??? ?????S??S
Cnattingius. Am J Epidemiol. 1997145(4)319-323.
35
???????S ??????S ???S? ??? ?????S??

• ?? ??p??sµa a????e? s?µa?t??? t? ???d???
  ??t?p?? ???s?? d?s?e?a?t?µe?a

3.9
3.1
Odds Ratio (95 CI)a
1.7
1.5
1.0
?? ?????S??S
?20
??O?? ?????S??S
1-9
10-19
??? ?????S??S (?S?G??? / ?????)
Adjusted for age (the category 25-29 years was
taken as the reference because this corresponds
to the mean age for delivery in France at the
time of the study). bP for trend .001.Bouyer.
Am J Epidemiol. 2003157(3)185-194.
36
????G????S ???????? G?? ?????? ???S?
???????????S ???????S

• ? ep?d?as? t?? ?ap??sµat?? st? ??t?p?
  ???s? ?p?t?µ?ta? e?? e??a? a?????? t?? ???µ??e??.

??p??sµa 35
???µ??e??, ?e??????e?? 33
???a 32
Bouyer. Am J Epidemiol. 2003157(3)185-194.
37
?????S?? ??? ???????S ????????? T??????
?? ??p??sµa s?et??eta? µe a???µ??? ???d???
eµί??ο??? ?a??t??
Relative Risk (95 CI)
?? ?????S????S
??? ?????S??S
Yuan et al. Am J Obstet Gynecol. 2005193489-495.
38
??OΟ?? ???? ????O? (PPROM) ??? ?????S??
Rate of PPROM (per 1000)
?? ?????S??S
?10
1-9
?S?G??? / ????? ??? ?????S??S
Kyrklund-Blomberg et al. Am J Obstet Gynecol.
19981791051-1055.
39
??OΟ?? ???? ????O? (PROM)

• 5 -15 ???? t?? ???se??
• ????µ? (lt37 w.) ???? ?µ???? (PPROM) p????pte? se
  0.7-2.0 ???? t?? ???se??
• PPROM ap?d?deta? t? 30 ???? t?? p???µ?? ???se??

Andres et al. Semin Neonatol. 20005231-241
http//www.lennartnilsson.com/child_is_born.html.
Accessed October 12, 2007.
40
?????S?? ??? ??Oο??S ??????S (lt32 ????????)
Odds Ratio (95 CI)a
?? ?????S??S
?10
1-9
?S?G??? / ????? ??? ?????S??S
Adjusted for maternal age, marital status,
educational level, employment, prepregnancy body
mass index, previous induced or spontaneous
abortion, and parity. Burguet et al. Br J Obstet
Gynaecol. 2004111258-265.
41
????????S ?????????S

• 0.3 -0.5 t?? ???se??
• ???d?a?es???? pa?????te?
• ???????µe?? ?a?sa????
• ??t??s?
• ?e??????e?? ???????
• ??p??sµa
• ? ?????a
• ????t??e?
• ???s? ???a????
• ????d?µ? ???s?

Complete
Partial
Marginal
Low lying
Oyelese et al. Obstet Gynecol. 2006107(4)927-941
.
42
????????S ?????????S ??? ?????S????S??????O????
S?S????S?
Plt.00001
Incidence per 1000 Births
G??????S ?????S????S ?1 pa??t?/?µ??a
G??????S ?????S????S lt1 pa??t?/?µ??a
?? ?????S??S
?S?G??? / ????? ???
?????S??S
Meyer et al. Am J Obstet Gynecol.
1977128(5)494-502.
43
??????S? ??? ?????S????S S??? ??????????? ???
???????
?ht eµί??? p??a?? ?a ?fe??eta? st? ?????a
?p??a?µ?a
P.05a
Ht ()
?? ?????S????S
??? ?????S????S (packyears)
??? ?????S????S (??????? ????????S)
Bush et al. Placenta. 200021824-833.
44
??????? ?????S????S S? G????S

• ? ???es? st?? ?ap?? t?? ts?????? µet? t? ?????s?
  e???e? S??????S, ??????? ???????O?????S ???d?????
  ??a t? ?e????, ί??f?? ?a? pa?d?, a?t?st?????? µe
  a?t??? t?? ???es?? t?? eµί???? ?ap??st??a?
  µ?t??a? st? d????e?a t?? ???s??.
• ?? ??p??sµa t?? ?????? ap?te?e? p??t?p? ??a
  ??a??? ?ap??sµat?? sta pa?d??, s???e???µ??a
  d?p?as???e? t?? ???d??? t?? ?ap??st???? s????e?a?
  sta pa?d??.
• ?? 1/3 pe??p?? t?? pa?d??? p?? ?ap?????? µp??e?
  ?a aap?d??e? st?? ?ap??st??? s????e?a t?? ??????.

45
??T????? ?????S?? ??? ???????G???S ???S?

• Ca p?e?µ???? (a???s? ???d???? ?at? 20-3-)
• t? 1/3 t?? ?a?????? se µ? ?ap??st?? ap?d?deta?
  se pa??t??? ??p??sµa.
• Ca pa?a??????? ???p??
• Ca t?a????? µ?t?a? (?)
• ?e??a?µ?a (?)
• Ca µast?? (?)
• Ca e??ef???? sta pa?d?? (?)

46
??T????? ?????S?? ??? ???????S ???G???? ?ST??

• ?p?de???s? ί???????? ?s?µat??
• ??????s? pa?????se??.
• ?a?????ta? ???d???? ??a ft??? p?????s? ?a? ?a??
  ??e??? t?? s?µpt?µ?t??.
• ?? pa??t??? ??p??sµa ep?de????e? t? ?s?µa t??
  e??????? ?at? 20

47
??T????? ?????S?? ??? ???????S

• ??e??sµ? sta µ?t?a 20
• ???a 21
• ?a?t?a 8
• ?efa?a???a 6

48
(No Transcript)
49
ASTHMA AND ENVIRONMENTAL TOBACCO SMOKE (ETS)

• ETS aggravates asthma in childhood
• Asthmatic children whose mothers smoke have more
  severe cases of asthma compared with those whose
  mothers dont smoke
• Prenatal smoking is causally associated with
  increased prevalence of asthma in children

Chan-Yeung et al. Respirology. 20038131-139
Courtesy of Getty Images. http//delivery.gettyima
ges.com/xc/BB6074-001.jpg?v1cCFWk2d2EA4B0C5
9585DB42C1FF2DD0E5B2E618EC7C5022FB410D56.
Accessed October 12, 2007.
50
PRENATAL SMOKING AND ASTHMA IN CHILDREN

• Analysis of 60 studies revealed that the risk of
  asthma in school- aged children is increased if
  either parent smokes Odds Ratio (OR)a1.21 (95
  CI, 1.10-1.34)
• Maternal smoking did have a greater effect than
  paternal smoking, yet the effect of the father
  only was clearly significant
• Results suggest postnatal effect is also important

aThe ratio of the odds of development of disease
in exposed persons to the odds of development of
disease in nonexposed persons. Cook et al.
Thorax. 199752(12)1081-1094 www.worldofstock.co
m/closeups/PHE1195.php. Accessed October 12, 2007.
51
ASTHMA EFFECTS OF ENVIRONMENTAL TOBACCO SMOKE IN
UTERO OR EARLY CHILDHOOD

• Exposure to pre- and postnatal smoking carries a
  substantial risk for developing adult asthma

No exposure to maternal smoking
Exposure to maternal smoking
Odds Ratio (95 CI)a
Prenatal
Postnatal
Pre- and Postnatal
aThe ratio of the odds of development of disease
in exposed persons to the odds of development of
disease in nonexposed persons. Adjusted for sex,
age, educational level, active smoking in terms
of both smoking habits and pack/years,
occupational exposure, and hay fever. In
addition, when estimating the ORs for the 3
maternal smoking variables, adjustment was made
for exposure to smoking from other household
members. Skorge et al. Am J Resp Crit Care Med.
2005172(1)61-66.
52
E?????S??S ETS S?? ??????GG?????

• Effects of environmental tobacco smoke
• ? risk of heart disease
• ? platelet and endothelial function
• ? arterial stiffness
• ? atherosclerosis
• ? oxidative stress
• ? inflammation
• ? heart rate variability
• ? energy metabolism
• ? infarct size

American Heart Association. Scientific Position,
Risk Factors and Coronary Heart Disease, 2005.
http//americanheart.org. Accessed February 2007
Barnoya et al. Circulation. 2005 1112684-2698
http//www.istockphoto.com/file_closeup/abuse/smok
ing/tobacco_products/3383715_cigarette_burning.php
?id3383715. Accessed October 11, 2007.
53
??S ??? ???????S ???

• Exposure to environmental tobacco smoke increased
  the risk of non-fatal acute MI in a graded manner

4
Nonsmokers
2
Odds Ratio (95 CI)a
1
Never
1-7
8-14
15-21
?22
0.75
Environmental Tobacco Smoke Exposure (Hours per
Week)
aThe ratio of the odds of development of disease
in exposed persons to the odds of development of
disease in nonexposed persons. Adjusted for age,
sex, region, physical activity, and consumption
of fruits, vegetables, and alcohol. Adapted from
Teo et al. Lancet. 2006368647-658.
54
??T????? ?????S??-???????

• ???e ????? p??? ap? 600.000 (!) µ? ?ap??st??
  pe?a????? ???? pa??t???? ?ap??sµat??.

55
600.000 (!) T?????? ???S?OS ??? ??T????? ?????S??

• ?? ???at?? ap? pa??t??? ??p??sµa e??a?
  pe??ss?te??? st?? ???a??e? ap?t? st??? ??t?e?.
• ?e??p?? µ?s?? ap? a?t??? t??? ?a??t??? (47 ?
  281.000) af????? ???a??e?.
• 166.000 ???at?? (28) af????? pa?d?? µ????te?a
  ap? 5 et??.

56
600.000 (!) T?????? ???S?OS ??? ??T????? ?????S??

• 379.000 ???at?? ap? S?.
• 165.000 ???at?? ap? ???µ??e?? ?at?te???
  a?ap?e?st????.
• 63.900 ???at?? ap? ?s?µa.
• 21.400 ???at?? ap? ?a????? p?e?µ????.

57
DALYs (disability-adjusted life years) KAI
??T????? ?????S??

• 10.9 e?at?µ???a DALYs ?a???a? ???? pa??t????
  ???es??
• se ?ap??.
• DALYs af????? ap??e?e? ???? as???e?a?, a?ap???a?
  ? ???at?.
• 61 t?? DALYS af????? pa?d?? ???? ???µ??e?? t??
  ?at?te??? a?ap?e?st???? (5.939.000) ?a? ?s?µat??
  (651.000).

58
??T????? ?????S?? DALYs
59
?????G???S ?????S??
60
S??????S????

• ?e? ?p???e? asfa??? ???? ???es?? st? pa??t???
  ??p??sµa.
• ?? pa??t??? ??p??sµa s??t??e? p??? ap? 600.000
  a????p??? et?s???.
• ?a???sµ??? ta pa?d?? e?te????ta? pe??ss?te?? st?
  pa??t??? ??p??sµa ap? ?p??ad?p?te ???? ?????a??
  ?µ?da.
• ?? ???at?? ?a? ? ??s???t?ta ???? pa??t????
  ?ap??sµat?? e??a? pe??ss?te??? st?? ???a??e? ?a?
  ta pa?d??.
• ?? ??ίe???se?? ?a p??pe? ?a p??state?s??? t???
  p???te? ap? t??? ???d????? t?? pa??t????
  ?ap??sµat?? µe t? ??sp?s? ??µ?? apa???e?s?? t??
  ?ap??sµat?? st??? ?????? e??as?a? ?a? st???
  d?µ?s???? ??????.

61
S??????S????

• ?? pa??t??? ??p??sµa ί??pte? s?ίa?? t??
  ??e?a.
• ?a???a? p??pe? ?a e?t??eta? se pa??t???
  ??p??sµa µ??? µe d??? t?? ί????s?.

62
????T?S??
63
(No Transcript)
64
Sa? e??a??st? ??a t?? p??s??? sa?
65
(No Transcript)
66

• ETS is risk factor for
• lung cancer
• asthma attacks
• worsening symptoms of bronchitis
• recurrent respiratory illnesses
• ETS can also cause
• shortness of breath
• airway irritation
• coughing