Effects of Smoking on Human Health: A Research Proposal and Dissertation

This research proposal and dissertation focuses on the effects of smoking on human health, including respiratory infections, asthma, lung cancer, ischemic heart disease, and other cardiovascular abnormalities. The dissertation includes a systematic review and primary research involving interviews and surveys on smokers to assess the effects of smoking on their health and awareness.

Running head: UNIT 6 RESEARCH PROJECT
Research Proposal and Dissertation
Name of the Student
Name of the University
Author Note

1UNIT 6 RESEARCH PROJECT
Executive summary
Cigarette smoking is found to harm almost every organ of the human body, and results in the
formation of a plethora of diseases that reduce the health and wellbeing of all smokers in general.
The effect of tobacco varies from person to person. The ways by which nicotine, the primary
chemical present in tobacco plant affects the physiological system of a person depends on a
range of factors that include their weight, size, and health. Smoking is found to generally exert
multiple negative health effects. Owing to this fact smoke inhalation is considered to inherently
poses a range of challenges to the various physiological processes such as, respiration and
circulation. Health abnormalities associated to tobacco smoking have already been shown to
result in death of approximately more than half proportion of long-term smokers, upon
comparison with the average mortality reported by non-smokers. The tar present in cigarettes
generally coat both the lungs and can result in onset of throat, oral and lung cancer among
smokers. This tar is also responsible for leading to development of yellow or brown staining on
the fingers and teeth of smokers. Furthermore, carbon monoxide gas present in cigarettes also
reduce the amount of oxygen that is available to the brain, muscles, and bloodstream. This results
in narrowing of the airways, which directly increase the blood pressure and increase the
likelihood of suffering from stroke and heart attack. The dissertation initially contains a research
proposal that explains the plan of action of the research activities that will be undertaken. This
will be followed by an exhaustive information gathered from secondary research (in the form of
systematic review) and primary research. The primary research will involve conduction of
interviews and surveys on smokers to assess effects of smoking on their health, and their
awareness on the same.

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Table of Contents
Chapter 1: Research Proposal..........................................................................................................3
Background..................................................................................................................................3
Literature review..........................................................................................................................4
Research question........................................................................................................................7
Research objectives.....................................................................................................................7
Methodology................................................................................................................................8
Action plan...................................................................................................................................9
Chapter 2: Secondary research......................................................................................................11
Discussion and Conclusion........................................................................................................19
Chapter 3: Primary research..........................................................................................................23
Interview....................................................................................................................................23
Survey........................................................................................................................................26
Chapter 4: Results..........................................................................................................................31
Analysis of the interview responses..........................................................................................31
Analysis of the survey...............................................................................................................34
Chapter 5: Conclusion and Recommendations..............................................................................40
Discussion..................................................................................................................................40
Limitations.................................................................................................................................41
Recommendations......................................................................................................................42

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Chapter 1: Research Proposal
Background
Cigarette smoking is considered as the leading cause of morbidity and death all over the
world. It is stated that a person who smokes approximately one pack of cigarettes per day is
estinated to lose one day of his life every week1. Furthermore, reports state that tobacco smoking
was responsible for more than 100 million deaths in the 20th century2. WHO estimates also
suggest that more than one-half children present all over the world are exposed to prolonged
tobacco smoke in the form of passive smoking, from 1.2 billion adult smokers3. The most
common diseases that occur due to smoking and tobacco consumption include respiratory
infections, asthma, lung cancer, ischemic heart disease and other cardiovascular abnormalities4.
Smoking is primarily followed as the route of administration that facilitates drug use for
recreational purpose. The aforementioned diseases that occur as a direct manifestation of
smoking are found to kill more than half the proportion of long-term smokers, upon comparison
with non-smokers. In addition, statistical evidences also suggest that smoking accounted for
1 Peters, Sanne AE, Rachel R. Huxley, and Mark Woodward. "Do smoking habits differ between women and men in
contemporary Western populations? Evidence from half a million people in the UK Biobank study." BMJ open 4,
no. 12 (2014): e005663.
2Jassem, Jacek, Krzysztof Przewoźniak, and Witold Zatoński. "Tobacco control in Poland—successes and
challenges." Translational lung cancer research 3, no. 5 (2014): 280.
3Jha, Prabhat, and Richard Peto. "Global effects of smoking, of quitting, and of taxing tobacco." New England
Journal of Medicine 370, no. 1 (2014): 60-68
4 Reitsma, Marissa B., Nancy Fullman, Marie Ng, Joseph S. Salama, Amanuel Abajobir, Kalkidan Hassen Abate,
Cristiana Abbafati et al. "Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–
2015: a systematic analysis from the Global Burden of Disease Study 2015." The Lancet 389, no. 10082 (2017):
1885-1906.

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death of 5 million people from 1990-2015. The research proposal will illustrate the effects of
smoking on human health and the mechanism by which it exerts the negative impacts.
Literature review
According to research evidences, upon inhalation of the vaporized gas obtained by
burning dried extracts of tobacco plant, the substances get released into the lungs and get
delivered to the bloodstream5. The gas is found to diffuse directly into the pulmonary vein and
reach the heart, thereby getting transferred to the brain. Research findings suggest that smoking
is found to commonly affect the lungs and the heart6. Similar findings were also confirmed by
other studies that also provided evidence for correlation between first signs of smoking and
numbness in the hands or feet7. Evidences confirmed the fact that overall life expectancy is found
to get reduced in smokers than non-smokers. Associations of smoking with lung cancer has been
established by several authors, with regards to etiology and public perception8. Evidences
suggest that the risk of an individual to contract a disease is always directly proportional to the
time that is spent by the individual to smoke. Effects of smoking are also found to get directly
influenced by the amount of tobacco that had been consumed9. However, some authors argued
that upon adhering to sudden smoking cessation programs, the relative chances of damaging the
5 Hecht, Stephen S. "Lung carcinogenesis by tobacco smoke." International journal of cancer 131, no. 12 (2012):
2724-2732.
6 Damgaard, Dres, M. Friberg Bruun Nielsen, M. Quisgaard Gaunsbaek, Yaseelan Palarasah, Viggo Svane-
Knudsen, and Claus Henrik Nielsen. "Smoking is associated with increased levels of extracellular peptidylarginine
deiminase 2 (PAD2) in the lungs." Clinical and experimental rheumatology 33, no. 3 (2015): 405-408.
7 Berciano, José, Enrique Marco de Lucas, and Onofre Combarros. "Thumb, forefinger, and lip numbness: a
distinctive thalamic lacunar syndrome." Neurological Sciences(2013): 1-2.
8 Pesch, Beate, Benjamin Kendzia, Per Gustavsson, Karl‐Heinz Jöckel, Georg Johnen, Hermann Pohlabeln, Ann
Olsson et al. "Cigarette smoking and lung cancer—relative risk estimates for the major histological types from a
pooled analysis of case–control studies." International journal of cancer 131, no. 5 (2012): 1210-1219.
9 Alam, Dewan S., Prabhat Jha, Chinthanie Ramasundarahettige, Peter Kim Streatfield, Louis W. Niessen,
Muhammad Ashique H. Chowdhury, Ali T. Siddiquee, Shyfuddin Ahmed, and Timothy G. Evans. "Smoking-
attributable mortality in Bangladesh: proportional mortality study." Bulletin of the World Health Organization 91
(2013): 757-764.

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health condition get reduced10. This facilitates recovery and enhances the overall health and
wellbeing, Furthermore, evidences suggest that risks of contracting cardiovascular diseases gets
reduced to half, upon comparison to an active smoker. Depression and low quality of life are
associated with higher rates of active smoking11.
Figure 1- Difference between a good and a smoke affected lungs12
These are considered as subclinical adverse impacts that are found to be directly
associated with social ostracism, gained weight, intense cravings and loss of pleasure.
Researches have been conducted to address effects of smoking on physical and mental health.
These findings emphasized the fact that smokers are found to report significantly poorer mental
and cognitive functioning than non-smokers or former smokers13. Further evidences indicate that
individuals who have been successful in showing compliance to smoking cessation programs
have reported higher satisfaction and happiness quotient, than what was reported while they
actively smoked14. However, one major limitation in determining effects on quality of life
10 Sandhu, Roopinder K., Monik C. Jimenez, Stephanie E. Chiuve, Kathryn C. Fitzgerald, Stacey A. Kenfield, Usha
B. Tedrow, and Christine M. Albert. "Smoking, Smoking Cessation and Risk of Sudden Cardiac Death in
Women." Circulation: Arrhythmia and Electrophysiology (2012): CIRCEP-112.
11 Mendelsohn, Colin. "Smoking and depression: a review." Australian family physician 41, no. 5 (2012): 304.
12Graphs, Infographics. Infographics | Graphs.Net, (2018): https://graphs.net/lungs-of-smoker-vs-non-smoker.html.
13 Taylor, Gemma, Ann McNeill, Alan Girling, Amanda Farley, Nicola Lindson-Hawley, and Paul Aveyard.
"Change in mental health after smoking cessation: systematic review and meta-analysis." Bmj 348 (2014): g1151.
14 Cahill, Kate, Lindsay F. Stead, Tim Lancaster, and Igor Bastos Polonio. "Nicotine receptor partial agonists for
smoking cessation." Sao Paulo Medical Journal 130, no. 5 (2012): 346-347.

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include poor temporal resolution and disease status. Improvement in affect that occurs due to
cessation have also been related to a significant reduction in withdrawal experiences that are
performed on a repeated basis. Psychomotor stimulant effects exerted by nicotine have also
reported to result in significant reduction in levels of restlessness, arousal or anxiety15.
Exposure to tobacco in the form of smoke has been found to increase levels of oxidative
stress in the body by the operation of several mechanisms such as depletion of vitamin C like
plasma antioxidants16. Articles have also established the effects of cigarette smoke on cell
division process, and subsequent change in the shape of cardiac muscles. Further evidences have
confirmed correlation between smoking and elevated blood cholesterol levels17. Smokers have
demonstrated lower ratio between high-density and low-density lipoproteins, than non-smokers18.
Furthermore, smoking is also found to increase the levels fibrinogen and platelets, thereby
leading to thicker blood composition and increased chances of clotting19. The aforementioned
factors, in conjunction with exposure to carbon monoxide increase the likelihood of a person to
suffer from arteriosclerosis. This leads to reduced blood flow through the narrow arteries and is
15 Mychasiuk, Richelle, Arif Muhammad, Slava Ilnytskyy, and Bryan Kolb. "Persistent gene expression changes in
NAc, mPFC, and OFC associated with previous nicotine or amphetamine exposure." Behavioural brain
research 256 (2013): 655-661.
16 Zuo, Li, Feng He, Georgianna G. Sergakis, Majid S. Koozehchian, Julia N. Stimpfl, Yi Rong, Philip T. Diaz, and
Thomas M. Best. "Interrelated role of cigarette smoking, oxidative stress, and immune response in COPD and
corresponding treatments." American Journal of Physiology-Lung Cellular and Molecular Physiology 307, no. 3
(2014): L205-L218.
17 Messner, Barbara, and David Bernhard. "Smoking and Cardiovascular DiseaseSignificance: Mechanisms of
Endothelial Dysfunction and Early Atherogenesis." Arteriosclerosis, thrombosis, and vascular biology 34, no. 3
(2014): 509-515.
18 Slagter, Sandra N., Jana V. van Vliet-Ostaptchouk, Judith M. Vonk, H. Marike Boezen, Robin PF Dullaart,
Anneke C. Muller Kobold, Edith J. Feskens, André P. van Beek, Melanie M van derKlauw, and Bruce HR
Wolffenbuttel. "Associations between smoking, components of metabolic syndrome and lipoprotein particle
size." BMC medicine 11, no. 1 (2013): 195.
19 Gitte, Rashmi Narayanrao. "Effect of cigarette smoking on plasma fibrinogen and platelet count." Asian Journal
of Medical Sciences (E-ISSN 2091-0576; P-ISSN 2467-9100) 2, no. 3 (2014): 181-184.

7UNIT 6 RESEARCH PROJECT
likely to contribute to clot or thrombosis. It may directly result in blockage in the blood vessels
and contribute to infarctions.
Figure 2- Difference between a normal vapor’s lungs and a smoker’s lungs20
Research question
Smoking is found to create variety of ongoing complications in the human body,
including long-term effects on the physical and mental health. The major health consequences
include different forms of addiction, cancer, respiratory diseases, cardiovascular disease and
impact on wellbeing. The primary objective of the research is to understand the direct impacts of
smoking on the health condition of current smokers. This will contain an evaluation of the
impacts of both physical and mental health. The primary research question is given below:
Why smoking affects the health condition of a patient?
Research objectives
 To identify the effects of smoking on health of a person
 To understand the underlying mechanisms by which smoking affects the health of a
person
 To highlight the impact of smoking on the quality of life of person who smoke
20Nicotine - Smoketastic. Finding The Best E Cig - Top Brands By Type For 2018 [Rankings], (2018):
https://www.smoketastic.com/nicotine/.

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Methodology
The purpose of the study will be to assess the impact or effects of smoking on the
physical and mental health of smokers. Furthermore, it will also investigate the mechanism by
which nicotine, the principle chemical compound of tobacco affects or disrupts the physiological
system of smokers. The study will involve two phases, a qualitative and a quantitative one. The
qualitative part of the research design will be based on conduction of an exhaustive systematic
review that will facilitate collection and critical analysis of multiple research studies that address
the aforementioned research objectives. The systematic review will help in providing a
comprehensive summary of current and relevant literature. This will involve creating a structured
question (the research questions stated above) that will guide the review. The second step will
involve performing a thorough search of journals and databases for extracting relevant articles.
The methodology section present in the systematic review will contain a list of all databases that
have been searched for article retrieval.
The abstracts and titles of each selected article will be checked against a set of pre-
determined inclusion and exclusion criteria to determine their relevance and eligibility. The
PRISMA statement will be used to assign an objective assessment for determining the
methodological quality. Thus, a qualitative approach will be followed for the systematic review
to adhere to a set of standards for collection, gathering and reporting of data. The PRISMA
statement will act as a standardized way of ensuring a complete and transparent reporting of the
articles included in the review. Thus, the first part of the research design will be based on
secondary research that will involve summary, collation and synthesis of already existing
primary research data.

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The second part of the research will involve a primary research approach where suitable
answers to the research question will be collected with the use of interview and surveys.
Conduction of this primary research will be imperative to the research design since it will help in
supplementing the evidences collected from the secondary research. The interviews will act as
one-on-one or a small group based question and answer session. The interviews will be
conducted among current smokers to understand their perceptions and knowledge on effects of
smoking on health status. The surveys will also form an essential aspect of questioning and will
be more rigid than the interviews, owing to the fact that a larger group of people will be involved
in the former. Surveys will be involved in providing limited information from a larger group of
people. Quantitative analysis of the surveys will help in generalizing the findings.
Action plan
Conduction of the systematic review will take place over a period of three weeks, which
will involve extraction of data and their analysis. The research will involve taking prior approval
from the ethics committee before recruiting participants for the surveys and interviews. Prior
approval will be taken from the hospitals and health clinics from where a considerable proportion
of their patients will be recruited for the study. The respondents, selected from the community as
well as the healthcare centres will be given an exhaustive explanation of the research, and its
purpose over telephonic discussions or by distribution of informed consent forms in sealed
envelopes. Upon receiving their willingness to participate in the research, the survey
questionnaires will be dispatched to each participant. Appointments will be made for conduction
of interviews on a one-to-one basis in home settings. The interviews and surveys will be
conducted over a period of two months, followed by quantitative analysis of the survey

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responses. Hence, drawing a summary of all relevant findings after analysig the data would take
around one month.
Figure 3- Gantt Chart for the research

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Chapter 2: Secondary research
As smoking is found to have deleterious long term impact on health, the main aim of
secondary research is to understand the mechanism by which smoke has an impact on health of
current smokers and review the impact of smoking on quality of life of people. Hence, by means
of systematic review method, the first part of the research focused on identifying and analyzing
existing research on effects on smoking on health of an individual. The systematic review of
relevant research articles were done based on the following methodological approach:
Objective of systematic review:
 To understand different impact of smoking on health of a person
 To understand the mechanism by which smoke has an impact on lungs of individuals
 To review the deleterious effect of smoking on quality of life of smokers
 To gain an understanding regarding steps needed to improve smoking cessation program
Methods:
PRISMA is an evidence based tool to improve the reporting of systematic reviews and
the PRISMA guidelines were followed for this review too.
Data extraction and search strategy:
Relevant articles related to the research question were taken from health and biomedical
databases like PubMed, Cochrane Library, CINAHL and Science Direct. All these are
exceptional databases that cover citations and provide access to research in the area of life
science, behavioral science and health science. The key search terms that were used to retrieve
articles included ‘cigarette smoking and health’, ‘’impact of cigarette smoking on health’ and

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‘cigarette smoking and quality of life. The search process was also refined by setting publishing
date from 2008 onwards and selecting English as the language of the study. To conduct search in
CINAHL database, limiters like ‘AND’ and ‘OR’ was also used to get high quality and relevant
research articles.
Inclusion and Exclusion criteria:
The inclusion criteria for the selection of articles were as follows:
 The research articles must be published between 2008 to 2018
 It should have smoking and its impact on health as the main research question
 It can include both primary or secondary research method
 It should be published within English language.
The exclusion criteria for the systematic review were are as follows:
 Research article discussing about other risk factors except smoking will be excluded
 The research article published before 2008 will be excluded from the review
 Research article published in any other article apart from English will not be included
Data analysis:
The screening of the articles was done after reading the abstract and title of research
articles. Based on inclusion and exclusion criteria, many articles were excluded as they were
duplicates. The second phase of analysis involved reading the whole article as well as reviewing
the reference list to find out any papers that have been overlooked. At this stage, many articles
were also excluded after reviewing the full text version of the article. Furthermore, the quality of

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the article was judged by independently assessing methodological rigour and biasness in research
studies. The following is the flow chart of the search process to gain relevant database.
No. of records obtained from
database search (n=45)
No. of articles included on the basis
of title (n=37)
No. of records
excluded (n=8)
No. of records screened on the
basis of abstract (n=30)
No. of full text articles included
for eligibility (n=20)
No. of duplicates
removed (n=10)
No. of articles included for
systematic review (n=12)

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Results:
Based on systematic review and evaluation of articles related to the ill-effect of smoking,
several important themes have emerged which are as follows:
Effect of smoking on lung function:
There were about 10-12 studies that assessed the effect of smoking and nicotine on lung
function and development of lung cancer. Out of this, only four of them were evaluated based on
relevance to research objective and quality of the paper. Some papers were excluded as the study
was done with animals like mice.
The harmful effect of smoking on lung function has been mainly evaluated for the
developing fetus. One study mainly gave insight into the chemical properties of nicotine and its
pathological effect on various organ systems. The toxicity of nicotine was explained by direct
applications in subject which result in burning sensation in the mouth, abdominal pain and
diarrhea. Apart from effect of nicotine exposure on other organ system, nicotine exposure mainly
led to lung carcinogenesis because of the effect of genetic variation in the CYP2B6 gene21.
However, the limitation of the study is that it evaluated the effect of nicotine exposure on other
body system apart from lungs thus limiting the source of information obtained specifically for
lung function. There were also two-three studies that evaluated the effect of maternal smoking on
the developing fetus and infants. One research study explained maternal smoking during
pregnancy increases risk of asthma, lower respiratory tract function and poor lung function in
children. Although tobacco smoke contains thousands of compounds that might contribute to
lung disease, however researchers have mainly paid attention to the effects of nicotine because of
21 Mishra, Aseem, Pankaj Chaturvedi, Sourav Datta, Snita Sinukumar, Poonam Joshi, and Apurva Garg. "Harmful
effects of nicotine." Indian journal of medical and paediatric oncology: official journal of Indian Society of Medical
& Paediatric Oncology 36, no. 1 (2015): 24.

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they can easily cross the placental barrier. It acts by binding to the nicotinic acetylcholine
receptors (nAChRs)22. Hence, it can be said that tobacco smoke has detrimental effect on the
developing lungs.
Lung cancer is the leading cause of death worldwide and majority of patients have been
found to have a history of tobacco consumption23. Another quantitative study has been found
useful as the study adapted method to find quantitative relation between smoking and different
types of lung cancer. By the pooled analysis of data, it was found that squamous cell carcinoma
(SqCC) was the leading subtype of lung cancer found in men and adenocarcinoma is the leading
subtype in women. The subtype of cancer in individual differed on the basis of age at which the
participants initiated smoking. Hence, the age of initiation changes by intensity, duration and
pack-years. Another significant result of this study was that quitting at younger age had greater
benefit on health24. The strength of the study is that it is a consolidated assessment of relations
between smoking and lung cancers by level exposure and age of initiation of smoking habit. The
above evidence mainly established link between types of cancer in smokers, however this raised
the question whether risk of lung cancer may increase in second hand smokers or not. This
aspect was analyzed in a meta-analysis of epidemiological studies. The systematic evaluation of
22 Wongtrakool, Cherry, Ningshan Wang, Dallas M. Hyde, Jesse Roman, and Eliot R. Spindel. "Prenatal nicotine
exposure alters lung function and airway geometry through α7 nicotinic receptors." American journal of respiratory
cell and molecular biology 46, no. 5 (2012): 695-702.
23 Proctor, Robert N. "The history of the discovery of the cigarette–lung cancer link: evidentiary traditions, corporate
denial, global toll." Tobacco control 21, no. 2 (2012): 87-91.
24 Pesch, Beate, Benjamin Kendzia, Per Gustavsson, Karl‐Heinz Jöckel, Georg Johnen, Hermann Pohlabeln, Ann
Olsson et al. "Cigarette smoking and lung cancer—relative risk estimates for the major histological types from a
pooled analysis of case–control studies." International journal of cancer 131, no. 5 (2012): 1210-1219.

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link between secondhand smoke exposure and lung cancer in Japan revealed statistically
significant increase in risk of lung cancer due to second hand smoke exposure at home25.
Impact of smoking on health of active and passive smokers/ smokers and non-smokers
Although the above studied investigated about the affect of tobacco smoke on lung
function, the results did not differentiated between active and passive smoker. Therefore, there
was a need to find out research evidence that could explain about the adverse impact of smoking
on health of both passive and active smokers. A research literature investigated about the
pulmonary impact of active and passive smoking among students in Mexico. By means of cross-
sectional study design, the lung function of each participant was measured by spirometry and the
data related to respiratory health were collected by means of standardized respiratory
questionnaire. The research showed that respiratory complaints were more prevalent among
active smokers than those exposed to second hand smoke. Another important research outcome
was that second hand smoke exposure also increased respiratory symptom in adolescence thus
pointing out to the need for reducing second hand smoke exposure in adolescents26.
Environmental tobacco smoke is getting attention worldwide as passive smoking has been found
to increase risk of many disease such as cancer, lower respiratory tract infection, childhood
asthma and allergic diseases in children. Therefore, smoking control should be made a necessity
25 Hori, Megumi, Hirokazu Tanaka, Kenji Wakai, Shizuka Sasazuki, and Kota Katanoda. "Secondhand smoke
exposure and risk of lung cancer in Japan: a systematic review and meta-analysis of epidemiologic
studies." Japanese journal of clinical oncology 46, no. 10 (2016): 942-951.
26 Bird, Yelena, and Hugo Staines-Orozco. "Pulmonary effects of active smoking and secondhand smoke exposure
among adolescent students in Juárez, Mexico." International journal of chronic obstructive pulmonary disease 11
(2016): 1459.

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not just for the health of smokers, but also for the health of neighboring people surrounding
smoker27.
In contrast to evaluation of respiratory function in active and passive smokers, another
study focused on quantifying the effect of smoking on smoking and non-smoking male
participant. Survey questionnaire was used to collect data on smoking habits, Fagerstrom test
was done for nicotine dependence and respiratory function of participants were tested. In terms
of respiratory function, significant differences were found between smokers and non-smokers.
Other parameters were also higher for smoking group compared to non-smoking youths. It also
showed that early stage of smoking reduces lung function which is consistent with other research
studies28.
Apart from impact on respiratory health, one study highlighted about difference in
physical fitness among male smokers and non-smokers. The cross sectional study was done with
smokers and non-smokers aged 19-27 years and the data related to physical fitness were
collected by means of questionnaire and physical fitness test. Smokers were found to have lesser
muscle strength compared to non-smokers, thus indicating that smoking also has an impact on
body muscles and their flexibility. This in turn can have an impact on daily work and quality of
life of participants29.
Impact of smoking on other system of the body:
27 Frazer, Kate, Jack McHugh, Joanne E. Callinan, and Cecily Kelleher. "Impact of institutional smoking bans on
reducing harms and secondhand smoke exposure." status and date: New, published in 9 (2015).
28 Tantisuwat, Anong, and Premtip Thaveeratitham. "Effects of smoking on chest expansion, lung function, and
respiratory muscle strength of youths." Journal of physical therapy science 26, no. 2 (2014): 167-170.
29 Moslemi-Haghighi, Farzaneh, Iman Rezaei, Farahnaz Ghaffarinejad, Reza Lari, and Fatemeh Pouya. "Comparison
of Physical Fitness among Smoker and Non-Smoker Men." Addiction & health 3, no. 1-2 (2011): 15.

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Out of 12 evidences, 3 evidences were found to be significant for the systematic review
as they suggested how smoking leads to deleterious impact on vascular function and
cardiovascular function of the body. For instance, one study indicated the mechanism by which
smoking increases risk of atherosclerosis and heart attacks. Smoking contributes to
cardiovascular effect because of increased myocardial work, reduction in oxygen carrying
capacity of blood, induction of hypercoaguble state and coronary vasoconstriction. Presence of
toxicants like CO, superoxide, N2O and other oxidant gases contribute to heart disease. The
research suggested that health of smokers can be improved if they are encouraged to use
electronic cigarettes instead of smoking tobacco30.
Another study established link between impact of smoking on oxidative stress and
vascular function by comparing both tobacco smoke and electronic smoking. A crossover single
blind study was conducted in which health subjects smoked traditional tobacco cigarettes for one
week and then the same subject smoked e-cigarette one week later. Blood samples of subject
were collected and oxidative stress and flow mediated dilation (FMD) was measured. The result
showed that both form of smoke had unfavorable impact on oxidative stress, however e-cigarette
had lesser impact compared to tobacco31. However, this evidence is not transferable because e-
cigarettes have different composition and all types of e-cigarette may not have the same effect.
The mechanism for cardiovascular risk due to smoking is also understood by a research study
that aimed to find out the adverse effect of cigarette and non-cigarette smoke on autonomic
nervous system. The author explained that fine particulate matter present in tobacco smoke
increases sympathetic nerve activity and these functions can be restored by means of smoking
30 Yan, X. Sherwin, and Carl D’Ruiz. "Effects of using electronic cigarettes on nicotine delivery and cardiovascular
function in comparison with regular cigarettes." Regulatory Toxicology and Pharmacology 71, no. 1 (2015): 24-34.
31 Carnevale, Roberto, Sebastiano Sciarretta, Francesco Violi, Cristina Nocella, Lorenzo Loffredo, Ludovica Perri,
Mariangela Peruzzi et al. "Acute impact of tobacco vs electronic cigarette smoking on oxidative stress and vascular
function." Chest150, no. 3 (2016): 606-612.

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cessation32. However, the limitation is that primary research method was not used to get the
result and for this reason, the research is a low quality evidence.
Impact of smoking on quality of life:
Health related quality of life (HRQoL) is an important indicator to get idea about health
status of an individual or group. As the systematic review revealed different adverse impact of
smoking on respiratory and cardiovascular health and physical fitness, it is evident the impact on
quality of life is huge. A research literature assessed associating between smoking and HRQoL
among current smokers, past smokers and never smokers in Iran. The outcome of the study
revealed lower HRQoL for current smokers compared to other group. The level of nicotine
dependence also influenced HRQoL score for the study participants33. This evidence can be used
to develop appropriate smoking cessation program for the health of the community.
Discussion and Conclusion
Although there is great awareness regarding the risk of lung cancer in tobacco smokers,
however the review of many research articles in this systematic review also gave idea about the
mechanism by which nicotine cause harm to the liver and quantified link between lung cancer
and cigarette smokers. From the review of articles in the first theme of impact of smoking on
alterations in lung function, many important insights has been presented that policymakers can
use to promote behavioral changes in people and implement effective intervention to motivate
smokers to quit and reduce nicotine smokers among non-smokers. The main findings from the
32 Middlekauff, Holly R., Jeanie Park, and Roya S. Moheimani. "Adverse effects of cigarette and noncigarette
smoke exposure on the autonomic nervous system: mechanisms and implications for cardiovascular risk." Journal of
the American College of Cardiology 64, no. 16 (2014): 1740-1750.
33 Rezaei, Satar, Behzad Karami Matin, Ali Kazemi Karyani, Abraha Woldemichael, Farid Khosravi, Masoud
Khosravipour, and Shahab Rezaeian. "Impact of smoking on health-related quality of life: A general population
survey in West Iran." Asian Pacific journal of cancer prevention: APJCP 18, no. 11 (2017): 3179.

20UNIT 6 RESEARCH PROJECT
systematic review and its implication on clinical care have been subsequently discussed from the
next paragraph.
The first theme of the systematic review was on the effect of smoking on lung function.
Starting with this theme was necessary as respiratory problem is most common adverse effect of
smoking. Among all the chemicals, the role of nicotine as the most noxious chemical in tobacco
was recognized and the role of nicotine on lung carcinogenesis was also understood. The
strength of the evidence was that it also quantified the rate at which changes in types of lung
cancer is seen due to smoking. As age of initiation and duration of smoking affected the
development of lung cancer, the study provides many clinical implications to curb youths from
smoking at a young age. Smoking cessation strategies needs to mainly target people at young age
such as during their adolescent so that appropriate individual counseling, psychological support
and nicotine replacement therapy can be implemented to reduce impact of tobacco smoke on
physical health34.
From the theme on difference between health outcome in active and passive smokers, it
has been found that respiratory issue is a common problem in both active and passive smokers
compared to non-smokers. The pulmonary function test was an important variable in a research
study as it helped to determine adverse respiratory health in participants35. Difference in
respiratory symptoms like that of daytime cough, wheezing and phlegm were found particularly
in smokers and non-smokers. The systematic review proved the fact that initiation of smoking
and exposure to second hand smoking can lead to acute change in respiratory function leading to
34 Harvey, Johanne, and Nicholas Chadi. "Strategies to promote smoking cessation among adolescents." Paediatrics
& child health 21, no. 4 (2016): 201-204.
35 Bird, Yelena, and Hugo Staines-Orozco. "Pulmonary effects of active smoking and secondhand smoke exposure
among adolescent students in Juárez, Mexico." International journal of chronic obstructive pulmonary disease 11
(2016): 1459.

21UNIT 6 RESEARCH PROJECT
manifestation of symptoms like irritation of the airways and coughing. As the researcher used
cross-sectional study design, it could only indicate association between variable but not
causation. This is supported by other research too as one research study showed that smoking
directly influences chest expansion, lung function and respiratory muscle strength of youths. In
addition, early effects of smoking increase the likelihood of respiratory problem in patient.
Therefore, with the support of this information, youth can be encouraged to quit smoking.
In response to the evidence regarding significant impact of envionronmetal smoke on
health of passive smokers, there is a need to ban smoking in public places and institution as far
as possible. Policies implemented in this area can assist in eliminating threat of second hand
smoke and reducing frequency of tobacco consumption among smokers. Although it cannot
reduce the physical harm, however it can be used as a complementary approach to support
smokers to quit smoking and increase chance of successful quit attempts. The severity of
complication can also be reduced by encouraging active smokers to look towards alternative
options instead of traditional cigarettes to minimize risk of cardiovascular and respiratory
complication36. As the review of research literature pointed out to evidence of poor physical
fitness and poor quality life among smokers, health promotion campaigns should also work to
address coping skill of participants so that changes in life satisfaction level is achieved. The
smoker’s perception that quitting may interfere with their daily life routine, needs to be changed
do that quit attempts become successful37.
36 Frazer, Kate, Joanne E. Callinan, Jack McHugh, Susan van Baarsel, Anna Clarke, Kirsten Doherty, and Cecily
Kelleher. "Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and
tobacco consumption." The Cochrane Library (2016).
37 Piper, Megan E., Susan Kenford, Michael C. Fiore, and Timothy B. Baker. "Smoking cessation and quality of life:
changes in life satisfaction over 3 years following a quit attempt." Annals of Behavioral Medicine 43, no. 2 (2011):
262-270.

22UNIT 6 RESEARCH PROJECT

23UNIT 6 RESEARCH PROJECT
Chapter 3: Primary research
The primary research to know about the effects of smoking on health has been done by
the use of both interview and survey method. The interview method has been selected to get
detailed information from smokers regarding their awareness about the ill-effect of smoking and
any harmful impact on their health, whereas the survey method uses close ended questionnaires
to get information regarding presence of symptoms and harmful effects of smoking on health.
The process followed for both of the approach are as follows:
Interview
Study design:
The secondary research method clearly justified the difference in health outcome,
physical fitness and quality of life between a smoker and a non-smoker. However, since the aim
of this research study is to investigate about the effect of smoking on health condition of a
person, conducting interview with smoker was necessary so that specific information related to
health issues encountered in smokers can be obtained. Another rational for taking interview
method was to collect information on how early do smokers initiate smoking. This is necessary
to evaluate whether age of initiation had an impact on severity of complications or participant’s
intention to quit smoking. The systematic review revealed inaccurate results on reasons for
initiating smoking at an early age, however data collection by means of interview method can
complete the data obtained and decided future steps needed to encourage behavioral change
among people38.
38 Bryman, Alan. Social research methods. Oxford university press, 2015:57.

24UNIT 6 RESEARCH PROJECT
Sample recruitment:
The participants for the study were recruited from two outpatient clinic in UK and the the
strategy was to take a small sample size to get rich data related to study objective. The criteria
for selection of participants was that all of them must be current smokers and above 18 years of
age. Besides this, all ethical process was followed for recruitment of participants. For instance,
after gaining approval from the Human Research Ethics Committee, informed consent
requirement for conducting research were fulfilled. All attendants who came to the clinic were
informed about the purpose of research and the process used to collect data. They were also
made aware that face-to-face interview will be conducted and their response will be audio
recorded to be transcribed later for data analysis. To address the ethical issue of privacy and
confidentiality of participant’s personal detail, they were informed that their private information
will be kept confidential and only response will be recorded. After providing this information,
only those were eligible to participate who fulfilled the inclusion criteria and signed the consent
form after reading about research process and confidentiality procedure. By the use of this
process, a total of 20 participants were recruited for the study. However, after review of medical
history of participant, 5 of them were excluded as they had cognitive impairment. Hence, the
final sample size for the study was 15. The participants were between the age of 18-50 years and
out of 15 participants, 3 were females.
Data collection:
The most vital step was data collection. To collect data for research, 10 interview
questions were prepared which covered the following aspects:
 What was the age at which you started smoking?

25UNIT 6 RESEARCH PROJECT
 You have been smoking since how many years or months?
 What is the number of cigarettes you smoke per day?
 How would you rate you nicotine dependence level on a scale of low, medium or high?
Why?
 What motivated you to start smoking?
 Have you noticed any adverse effect of smoking on your health?
 Are you aware about the harmful effect of smoking on respiratory and vascular system?
 Have you felt physically unfit since you started smoking?
 How often do you visit doctor and for what reason? Do you thing it is linked to your
smoking habits?
 Have you ever tried to quit smoking? If yes, then what strategies you adapted to quit
smoking?
The significance of the above survey questionnaire is that it covered all aspects of
smoking habits of a participants, adverse impact on health, awareness about deleterious affect on
health and participants motivation to quit smoking. Response obtained by the use of these
questionnaire would help to establish how far smoking habits increases or decrease adverse
effect on patient. Hence, the interview questionnaire had three aspects: smoking habits, harmful
effects of smoking on health and motivation to quit or initiate smoking.
The interview was conducted in a closed room by an expert clinical staffs and a translator
was also present if any participant could not understand English language. The duration of the
interview was 30 minutes and interview was discontinued if any participant was found to have
quit smoking. However, no subjects were excluded on the basis of this reason during the
interview. The interview was audio recorded and the final transcribed version was discussed and

26UNIT 6 RESEARCH PROJECT
reevaluated after discussion with other researchers. The content validity of the questionnaire was
checked by a health care professional who was aware about the effects of smoking on body
system.
Data analysis:
After the collection of participant’s response through interview method, the participant’s
response was categorized on the basis of three themes of smoking habits, harmful effect and
motivation to quit smoking. The participant’s names were kept confidential and marked by
numbers. The socio-demographic detail of participants was also collected such as age, gender,
education level and monthly income. To eliminate biasness in data analysis process, the data was
analyzed by separate staff compared to those who collected the data. Differences in response in
terms of smoking habits and motivation to quit or initiate smoking was also analyzed to
determine future steps needed to encourage people to quit smoking and reduce risk of respiratory
and cardiovascular complication.
Survey
Study design:
Data collection refers to the process of gathering relevant and measurable information on
pre-determined specific variables by following a systematic fashion and helps in providing
answers to questions. Thus, data collection methods form an essential component of a research
activity. Survey data collection helps in gaining a sound understanding of a particular concept in
a comprehensive way. Thus, it can be defined as the research method that involves collecting
relevant information from a selected group of individuals with the use of standardized

27UNIT 6 RESEARCH PROJECT
questionnaires or interviews39. In addition to questionnaire, surveys also include pre-testing of
the instruments, determination of the delivery methods, ensuring validity and analysis of the
results. The purpose of conducting a survey in as a part of this research activity helped in driving
the data collection method. Initially the number of people to be included in the survey was
determined, followed by formulating the questions that were supposed to be asked. One major
way that helped in increasing validity of the survey involved ensuring recruitment of appropriate
participants for the same. Thus, the smokers were considered best, upon whom the survey was
intended to get administered. This can be related to the fact that smokers are the key
stakeholders, found to get directly affected in the process that is under investigation (smoking).
There are several ways by which surveys can be conducted. Several factors such as, coverage of
target population, costs, flexibility of questioning, accuracy of response and a willingness of the
respondents to participate in the study. While mobile survey methods are increasingly gaining
importance as the preferred data collection methods, this research activity was built on online or
internet survey methods.
According to evidences, online survey research has been found to account for
approximately 20% of the entire global data collection expenditure that occurred in the year
2006. Furthermore, the fact that online surveys exert capabilities that are way beyond the basic
attributes of other kinds of self-administered questionnaires facilitated selection of this method as
the data collection tool for primary research40. An online cloud-based survey development
software, SurveyMonkey was used for the purpose. Basic advantages of SurveyMonkey that
39 Wilcox, Adam B., Kathleen D. Gallagher, Bernadette Boden-Albala, and Suzanne R. Bakken. "Research data
collection methods: from paper to tablet computers." Medical care 50 (2012): S68-S73.
40 Terrell, Steven R. "Mixed-methods research methodologies." The qualitative report 17, no. 1 (2012): 254-280.

28UNIT 6 RESEARCH PROJECT
helped in its selection for collecting data include its capabilities of providing customizable, free
surveys, in addition to sample selection, data analysis, elimination of bias, and representation of
the collected data. The entire procedure or sample recruitment, survey conduction and its
analysis took about two months.
Sample recruitment:
The sample was selected from the sampling frame that was composed of a list of
potential members belonging to the population of interest (smokers), from the district. The
primary goal of the survey was not to describe the selected sample, but to explain the finings in
regards to the larger population. This property of generalizing the findings was largely dependent
on the representativeness of the recruited sample. Some difficulties related to selection bias were
encountered during sample selection. This can be attributed to the fact that the studies were
conducted on male smokers, due to their higher prevalence in the population. Recruitment of
participants was followed by obtaining their consent for participation in the study about effects
of smoking. The consent form was sent to the participants over email and allows them to state
their preferences regarding whether they wished to remain anonymous while providing their
responses. Participation in the survey was considered completely voluntary41. Initially, the
consent forms were sent to a total of 28 participants, of whom 8 displayed a lack of willingness
or directly refused to respond to the questions.
Thus, the survey was conducted on a sample of 20 participants. Customised email
invitations with the survey link were sent to all 20 participans, following which they were asked
41 Quinn, Sandra Crouse, Mary A. Garza, James Butler, Craig S. Fryer, Erica T. Casper, Stephen B. Thomas, David
Barnard, and Kevin H. Kim. "Improving informed consent with minority participants: results from researcher and
community surveys." Journal of Empirical Research on Human Research Ethics 7, no. 5 (2012): 44-55.

29UNIT 6 RESEARCH PROJECT
to provide their answers. The consent form also stated that the respondents could stop providing
answers to the questions at any time and could also skip questions. Confidentiality of the records
and data were maintained. Furthermore, signing the consent form also made them state that they
had read the entire description of the study and were adults.
Data collection:
There are a range of survey question types that can be used while preparing surveys such
as, open-ended where responses are typed in comment boxes, or demographic questions that
provides information on income level or background. However, for this particular research,
multiple-choice questions were preferred as the mode of giving answers. This helped the 20
participants to select one option from a list of pre-defined answers present in the survey. These
were intuitive and easily accessible. Thus, they facilitated production of data that could be easily
analysed42. The questions ranged from asking about the age of the participants to their opinions
on probable effects of smoking on health. They were also questioned about frequency of
consulting doctors, and presence of symptoms that are direct manifestations of the adverse
effects of smoking. Furthermore, the survey also included questions that asked about their
willingness to quit smoking. A total of 10 questions were used for the purpose (Appendix B).
Owing to the fact that the answering options were kept fixed, the respondents had a better
experience of taking the survey43. In addition, it assisted in getting structured responses that
produced clean data for further analysis. The response format were present in two forms. While
42 Weigold, Arne, Ingrid K. Weigold, and Elizabeth J. Russell. "Examination of the equivalence of self-report
survey-based paper-and-pencil and internet data collection methods." Psychological methods 18, no. 1 (2013): 53.
43 Meade, Adam W., and S. Bartholomew Craig. "Identifying careless responses in survey data." Psychological
methods17, no. 3 (2012): 437.

30UNIT 6 RESEARCH PROJECT
some questions required the participants to provide single answers using the radio button (circle
buttons) that represented the options in the list, most other questions were in the form of a Likert
scale. Responses to these questions ranged were based on degree of agreement of disagreement.
They helped in gauging the feelings and opinions of the participants regarding specific aspects of
smoking44.
The basic rules that were followed while preparing the questionnaire included use of
statements that could be interpreted in a similar fashion by all participants representative of the
larger population. Provisions were created that allowed the participants to express difference in
their opinions. Positive statements were used at all possible places, without making assumptions
about the respondents. Clear and comprehensive wordings were also made use of in the survey.
Few questions contained more than one item per question. The participants duly completed all
the surveys and none of them skipped any questions.
Data analysis:
The SurveyMonkey software provided a thorough analysis of the responses that were duly
submitted by the 20 respondents.
44 Barua, Ankur. "Methods for decision-making in survey questionnaires based on Likert scale." Journal of Asian
Scientific Research 3, no. 1 (2013): 35.

31UNIT 6 RESEARCH PROJECT
Chapter 4: Results
Analysis of the interview responses
The interview was conducted on 15 participants, of whom 3 were females (20%). The
results can be categorized into ten different themes based on the responses provided by the
participants.
Age of starting smoking
12 participants stated that they had started smoking between 18-22 years of age (80%).
Highest proportion was recorded for smoking at 20 years of age and was reported by 9
respondents. Similarities were observed in the responses of all three females, all of whom
suggested that they had first smoked at 21 years of age (20%). Thus, the results indicate a lower
age of onset for smoking habits among males, when compared to females. Two male participants
mentioned starting smoking habits after 25 years of age (13.33%). On the other hand, one male
participant developed the habit late in life, at around 33 years, to cope with financial pressures
(6.67%).
Smoking years
2 female respondents had been smoking for more than 3 years (13.33%). The third female
participant had been a smoker for more than 15 years of her life (6.67%). 8 male respondents
gave responses that suggested presence of smoking habits for more than 10 years (53.33%), with
7 out of them smoking for 12 years approximately (46.67%). 3 male participants had been
smoking for more than 20 years (20%). On the other hand, one male participant, aged 49 years
reported having the smoking habit for more than 26 years (6.67%).

32UNIT 6 RESEARCH PROJECT
Number of cigarettes
Similar responses were obtained in this context, with 13 participants (86.67%), of which
2 were female, smoking approximately 15 cigarettes per day. The value generally ranged from
13-15 cigarettes per day. One female, aged 27 years stated that she smoked not more than 5
cigarettes each day (6.67%). Another male, aged 22 years said that he smoked 3 cigaretters per
day (6.67%).
Nicotine dependence
13 participants (73.33% males and 13.33% females) rates their nicotine dependence as
high, depending on the rates of smoking each day (86.67%). One male rated his nicotine
dependence as low (6.67%). On the other hand, moderate dependence was rated by the female
who smoked 5 cigarettes per day (6.67%).
Motivation to start smoking
Peer pressure and a feeling of adventure were cited as the major reasons that made 3
females (20%) and 7 males (46.67%) to develop the smoking habit. 2 male respondents (13.33%)
cited financial stress and unemployment as the reason that made them resort to smoking to
relieve their problems. On the other hand, 3 males (20%) stated that they mirrored their elders
and started smoking in order to socialize with their community members.
Adverse effects
12 participants (80%) (including 2 females) mentioned that they had developed stained
teeth and often complained of shortness in breath, and cough. 1 male and 1 female participant,
with longer smoking history stated that they had developed patches inside their mouth and often

33UNIT 6 RESEARCH PROJECT
found it difficult to swallow food (13.33%). Another male participant, aged 22 years mentioned
experiencing no adverse effects, apart from bad breath (6.67%).
Awareness
8 participants (53.33%) (7 male and 1 female) were aware of the effects that smoking
exerts on the physiological system. 6 of them mentioned about lung cancer (75%) and 2 about
stroke (25%). 5 other participants (33.33%) were not aware of the ill-effects of smoking on
health. 2 respondents (13.33%), which included 1 male and1 female demonstrated an awareness
on oral cancer and decay of lungs.
Physical fitness
13 respondents (86.67%) that included 2 females reported that they often faced
difficulties while performing vigorous exercises or climbing up stairs. They also reported
instances of getting fatigued soon. 1 male and 1 female, the ones who were moderate smokers
gave answers that indicated absence of any deterioration in their health (13.33%).
Doctor visits
Around 11 respondents (73.33%) suggested that they never visited doctors, unless
suffering from any serious health abnormality such as, fever, injuries or infections. 3 males
(20%) replied that they paid annual visits to the doctor to undergo chest x-rays and ECG for
determining functioning of their heart. 1 male (6.67%) replied that he paid quarterly visits to the
doctor and he was sure that it was linked to his smoking habits since he was using an inhaler to
manage his shortness of breath.
Quit smoking

34UNIT 6 RESEARCH PROJECT
.Only 4 respondents (26.67%) suggested that they had taken attempts to quit smoking and
the strategies adopted by them were boosting their will power and taking professional support.
While, they were initially successful in abstaining from smoking for a few hours, they failed to
cope up with the withdrawal symptoms. 11 participants (73.33%) did not display a willingness to
stop smoking and had not even taken any attempts for the same.
Analysis of the survey
The survey was conducted on 20 other participants who represented the larger population
of smokers.
Age
3 respondents were aged 18-24 years (15%), and 4 each for 25-34 years (20%) and 35-44
years (20%). Higher proportion (5 in number) of participants, were aged between 45-54 years of
age (25%). There was only one respondent aged 65-74 years (5%).
Smoking in the family
Majority of the respondents gave results in the survey that indicated none of the family
members had the habit of smoking. These results were observed among 13 participants (65%).

35UNIT 6 RESEARCH PROJECT
However, 7 respondents gave a positive response in relation to presence of a smoker in their
household (35%).
Damage to health
9 participants stated that they agreed on the fact that smoking had created considerable
damage to their health status (45%). Similar number of participants (3 in number) gave responses
that they either strongly agreed or disagreed on the fact (15%). 4 participants (20%) gave a
neutral response and 1 strongly disagreed (5%) on ill-effects of smoking on health status.

36UNIT 6 RESEARCH PROJECT
Visits to the doctor
11 participants (55%) that formed the majority of the recruited sample gave responses,
which indicated that they never visited their doctors to cure problems that rose from smoking
habits. While a considerable proportion of 6 participants (30%) visited their doctors on an annual
basis, only 3 respondents paid a visit twice annually (15%).
Probable effects of smoking on health
The survey responses suggested that 9 participants (45%) were of the view that smoking
caused lung cancer in humans. Equal number of 3 participants (15%) identified stroke, oral
cancer and decay in lungs as the probable effects. On the other hand, 2 of them (10%) recognized
stained teeth as the immediate adverse effect.

37UNIT 6 RESEARCH PROJECT
Reports of chest tightness, shortness of breath and fatigue in past 1 year
12 participants (60%) in their responses reported the aforementioned adverse health
symptoms. Only 8 (40%) of the respondents gave answers that suggested absence of the
symptoms.
Presence of halitosis or bad breath
Similar results were observed with respect to presence of halitosis that was reported by
17 respondents (85%). 3 of the participants did not complain of having bad breath (15%).
Difficulties in speaking, swallowing, or moving the tongue

38UNIT 6 RESEARCH PROJECT
More than half of the participants, 12 of them (60%) reported no such difficulties.
Moderate and little difficulties were reported by 4 (20%) and 3 (15%) participants, respectively.
Only 1 respondent (5%) suggested that he faced extreme difficulties in swallowing or moving the
jaw or tongue.
Development of patch inside mouth
Patch development inside mouth is an early indication of oral cancer. The survey
responses suggested that 15 participants (75%) did not have any such patches in their mouth.
However, 5 of the participants (25%) reported oral patch development.

39UNIT 6 RESEARCH PROJECT
Willingness to quit smoking
Equal proportion of respondents gave responses related to this question. While 10 of
them (50%) suggested a willingness to quit smoking, the other 10 (50%) indicated absence of
smoking cessation will.

40UNIT 6 RESEARCH PROJECT
Chapter 5: Conclusion and Recommendations
Discussion
The analysis of the data presented in the previous chapter helps in showing significant
findings that can be used for reducing prevalence of smoking rates and improving the overall
health of the target population. The result analysis suggests that most of the smokers develop this
habit in their early twenties. The most common reasons that influenced adoption of smoking
habits are related to its addiction, peer pressure, adventure, mirroring others and for stress
removal. Most people consider nicotine responsible for reducing their stress and give them a
sense of relief45. Furthermore, the fact that smoking is considered cool and fun by the youth add
to their habit46. Further result analysis also suggests that most of the participants are not well
aware of the adverse impact that smoking and nicotine consumption exerts on their body. While
long-term effects of smoking increases the risk of developing cardiovascular abnormalities, oral
cancer, and yellowed teeth, the general concept held by majority of the respondents was related
to onset of lung cancer. Further analysis of the results also indicate that majority of smokers had
an average of 15 cigarettes per day, which is associated with significantly higher risks of
developing ischemic heart diseases, diabetes and lung cancer.
Furthermore, the fact that majority of the participants who attended the interviews as well
as the surveys did not consult doctors to cure problems that were a direct manifestation of their
45 Nakajima, Motohiro, and Mustafa Al'Absi. "Predictors of risk for smoking relapse in men and women: A
prospective examination." Psychology of Addictive Behaviors 26, no. 3 (2012): 633.
46 Tapper, Katy, Louise Baker, Gabriela Jiga-Boy, Geoffrey Haddock, and Gregory R. Maio. "Sensitivity to reward
and punishment: Associations with diet, alcohol consumption, and smoking." Personality and Individual
Differences 72 (2015): 79-84.

41UNIT 6 RESEARCH PROJECT
smoking habits increased their susceptibility to a range of preventable diseases. In addition, the
responses were significant by the fact that although several respondents who participated in the
survey or interview reported facing problems such as, shortness of breath, chest tightness, bad
breath, oral patches and fatigue, no significant amounts were found to demonstrate a willingness
to quit smoking. Moreover, higher proportion of participants with reports related to the
aforementioned symptoms indicated that smoking causes several adverse effects related to
reduced immune function.
Limitations
One major limitation of the present study is related to the fact that the primary research
was able to capture a small section of the study population at a given period. Although the results
presented in the survey and interview were able to explore self-reports related to smoking habits
and its effects experienced by the participants over time, the results might have been influenced
by the small sample size. The fact that only 15 respondents were recruited for the interview and
20 participants for the survey might have resulted in less accurate results. Small sample size
might have also affected reliability of the interview and survey results due to the fact that they
contribute to higher variability47. This can be correlated with establishment of bias in the results.
Furthermore, voluntary response bias that occurs due to small number of participants is another
major disadvantage. Only a small number of people had access to the survey or interview being
conducted and it is more likely to skew their opinions on the questions.
Furthermore, smoking has been found to contribute to increased insulin resistance among
smokers, which in turn directly increases the blood glucose levels and results in diabetes.
Uncontrolled blood sugar levels can result in serious complications that include renal failure and
47 Sullivan, Gail M., and Richard Feinn. "Using effect size—or why the P value is not enough." Journal of graduate
medical education 4, no. 3 (2012): 279-282.

42UNIT 6 RESEARCH PROJECT
problems with the heart and blood vessels48. The fact that the survey questions did not contain
mention of diabetes might also have resulted in misleading results. In addition, the number of
survey and interview questions should have been increased by incorporating questions about
other forms of nicotine consumption and the amount of money spent per month on buying
cigarettes. This would have influenced gaining a sound understanding of the smoking frequency
and their role in exerting negative effects on the overall health of the people.
Recommendations
Further research needs to be conducted on a wider sample to get a better understanding of
the harmful effects of smoking on the overall health and wellbeing of smokers. This will be more
representative of the population and will limit influence of possible outliers. Further
recommendations would include raising public awareness of the harm that is caused due to active
or passive smoking. Similar kind of surveys and interviews should also be conducted on passive
smokers to record the indirect effects that nicotine exerts on their health. Conducting a research
on the local laws enforced by the state legislature will also help in determining their positive
impacts on smoking rates and smoking probabilities.
Furthermore, statistical analysis of results obtained from such surveys and interviews will
help in providing accurate description of smoking effects on health. Further recommendations
include conducting randomized controlled trials to observe the effects of smoking cessation
strategies such as, nicotine replacement therapy on the health status of smokers.
48 Bergman, Bryan C., Leigh Perreault, Devon Hunerdosse, Anna Kerege, Mary Playdon, Ali M. Samek, and Robert
H. Eckel. "Novel and reversible mechanisms of smoking-induced insulin resistance in humans." Diabetes 61, no. 12
(2012): 3156-3166.

43UNIT 6 RESEARCH PROJECT

44UNIT 6 RESEARCH PROJECT
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"Secondhand smoke exposure and risk of lung cancer in Japan: a systematic review and meta-

46UNIT 6 RESEARCH PROJECT
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noncigarette smoke exposure on the autonomic nervous system: mechanisms and implications
for cardiovascular risk." Journal of the American College of Cardiology 64, no. 16 (2014): 1740-
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Mishra, Aseem, Pankaj Chaturvedi, Sourav Datta, Snita Sinukumar, Poonam Joshi, and Apurva
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47UNIT 6 RESEARCH PROJECT
Moslemi-Haghighi, Farzaneh, Iman Rezaei, Farahnaz Ghaffarinejad, Reza Lari, and Fatemeh
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health 3, no. 1-2 (2011): 15.
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expression changes in NAc, mPFC, and OFC associated with previous nicotine or amphetamine
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Nakajima, Motohiro, and Mustafa Al'Absi. "Predictors of risk for smoking relapse in men and
women: A prospective examination." Psychology of Addictive Behaviors 26, no. 3 (2012): 633.
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traditions, corporate denial, global toll." Tobacco control 21, no. 2 (2012): 87-91.

48UNIT 6 RESEARCH PROJECT
Quinn, Sandra Crouse, Mary A. Garza, James Butler, Craig S. Fryer, Erica T. Casper, Stephen B.
Thomas, David Barnard, and Kevin H. Kim. "Improving informed consent with minority
participants: results from researcher and community surveys." Journal of Empirical Research on
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Reitsma, Marissa B., Nancy Fullman, Marie Ng, Joseph S. Salama, Amanuel Abajobir, Kalkidan
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195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of
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Khosravi, Masoud Khosravipour, and Shahab Rezaeian. "Impact of smoking on health-related
quality of life: A general population survey in West Iran." Asian Pacific journal of cancer
prevention: APJCP 18, no. 11 (2017): 3179.
Sandhu, Roopinder K., Monik C. Jimenez, Stephanie E. Chiuve, Kathryn C. Fitzgerald, Stacey
A. Kenfield, Usha B. Tedrow, and Christine M. Albert. "Smoking, Smoking Cessation and Risk
of Sudden Cardiac Death in Women." Circulation: Arrhythmia and Electrophysiology (2012):
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PF Dullaart, Anneke C. Muller Kobold, Edith J. Feskens, André P. van Beek, Melanie M van
derKlauw, and Bruce HR Wolffenbuttel. "Associations between smoking, components of
metabolic syndrome and lipoprotein particle size." BMC medicine 11, no. 1 (2013): 195.
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enough." Journal of graduate medical education 4, no. 3 (2012): 279-282.

49UNIT 6 RESEARCH PROJECT
Tantisuwat, Anong, and Premtip Thaveeratitham. "Effects of smoking on chest expansion, lung
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"Sensitivity to reward and punishment: Associations with diet, alcohol consumption, and
smoking." Personality and Individual Differences 72 (2015): 79-84.
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self-report survey-based paper-and-pencil and internet data collection methods." Psychological
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Wilcox, Adam B., Kathleen D. Gallagher, Bernadette Boden-Albala, and Suzanne R. Bakken.
"Research data collection methods: from paper to tablet computers." Medical care 50 (2012):
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Wongtrakool, Cherry, Ningshan Wang, Dallas M. Hyde, Jesse Roman, and Eliot R. Spindel.
"Prenatal nicotine exposure alters lung function and airway geometry through α7 nicotinic
receptors." American journal of respiratory cell and molecular biology 46, no. 5 (2012): 695-
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50UNIT 6 RESEARCH PROJECT
Yan, X. Sherwin, and Carl D’Ruiz. "Effects of using electronic cigarettes on nicotine delivery
and cardiovascular function in comparison with regular cigarettes." Regulatory Toxicology and
Pharmacology 71, no. 1 (2015): 24-34.
Zuo, Li, Feng He, Georgianna G. Sergakis, Majid S. Koozehchian, Julia N. Stimpfl, Yi Rong,
Philip T. Diaz, and Thomas M. Best. "Interrelated role of cigarette smoking, oxidative stress, and
immune response in COPD and corresponding treatments." American Journal of Physiology-
Lung Cellular and Molecular Physiology 307, no. 3 (2014): L205-L218.