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And welcome to another session with C three collaborating for help. My name is Michaela Nuttall. I'm a cardiovascular nurse and I'm delighted to have you join me this evening for me. It might not be the evening for you on another of our sessions as part of our diabetes and smoking initiative. I'm just gonna walk us through how this session is going to run. Now, some people are here watching it live, which is brilliant and you might be watching it a little bit later on on demand, but you get to experience the same things if you're watching on demand and you will also get the opportunity to do your evaluation at the end and get a copy of some slides and of course a certificate. So I'm just going to share my slides now. And while I do that, I will just start to think about what we're going to tell you a bit more about this session. So, welcome to those people and I'm just looking at the people here now that are coming in and joining us. So that's really lovely. Now, for those of you that are watching on demand, you won't be able to see the chat function. But those of you that are here. Now, of course, I'll be able to see you in the chat as well. So my name is Michaela Nuttall. I'm a cardiovascular nurse. I work at collaborates, see three, collaborating for health. And my session is about, well, just how does smoking cause blockages in those arteries. Now, see three is a charity where we have a vision and that's a vision where there were no preventable deaths from noncommunicable diseases because people find it easier to live healthier lives. And I was delighted to join c three many years ago because as a cardiovascular nurse, I, you know, I've been working in the world of prevention for, I would say many decades now. So it was wonderful to work with an organization who really had the same, the same ethos of me as trying to prevent those heart attacks and strokes and those heart attacks and strokes along with diabetes, cancers and lung diseases. Those four chronic conditions, well, they happen for the same three risk factors that tobacco use, physical in activity and what we eat and drink. And that accounts for 70% of the burden of these four chronic diseases worldwide. And that's why I'm delighted that you're joining me on one of our sessions around tobacco use and a specific one. And the reason why we're doing this is because we have an initiative at the moment, I'm supported by the Burdette Trust for Nursing and it's called winning hearts and minds and this is where we are trying to raise the issue and explore further around smoking and mental health. This session is a bit of a standalone one and we're looking at cardiovascular disease and smoking. But my colleague more, if they're not already, if you haven't already watched them, they'll be more available on demand over the next coming months as well as a part of sweet of training as part of this initiative. So why have we focused on people with mental health issues? Well, it's because people with a mental health condition are way more likely to be smokers than those 40% when compared to the general population. And this is in the UK at around oil England at about 14%. So this really puts this group of people at a much higher risk of heart disease. Now, what I'm going to talk about tonight though is purely around tobacco, cigarette smoking and cardiovascular disease. I won't be overlapping the mental health side of it. That's my colleague, Joe. You'll be doing that one as part of this initiative. We've got a, we're developing a whole suite, as I said of training. So this is one of them, which is just how does the smoking cause blockages in arteries and it's not something we've spend much time pausing thinking about unless it's really a part of our world. As I said, Jay's done one on mental health and cardiovascular disease. We've got one on motivational interviewing. We've got a fantastic one scheduled for June the 23rd and that's around table that's being led by Cath Gamble are really exploring further about mental health and smoking. And there's a quiz available on the website to and it's likely in the next couple of weeks, there'll be an opportunity to take part in a survey of which there will be some, some, some vouchers that will be able to give randomly to some people. We can't give everybody a voucher, but we can give some people randomly will select for the vouchers. But up to what we're doing tonight, well, it's tonight now you might be watching at a different time but just how does smoking cause blockages in those arteries. And I'm going to spend about the next 25 minutes taking us through this. No, cigarettes haven't always been bad for us. You know, it's still relatively recent, you know, it was only in the forties, fifties with Richard Dull that came up with cigarettes causes cancer. And prior to that, there was masses of advertising. And in fact, we've only recently lost a lot of the advertise, but even here, we started to see on that cutting it back, maybe having milder cigarettes. So even when we didn't fully know it, there were still evidence out there that cigarettes wasn't going to be good for us. And I say that as quite an understatement and it really isn't good for us. You know, it accounts for so many deaths and this is just deaths that are just looking at the UK. So whether it's cancer's or chronic diseases, it causes so many problems and even down to things like reduced fertility and hip fracture, gum infections. This isn't put something people naturally think about when we think about cigarette smoking. But for the session tonight, it's really thinking about those heart attacks. And actually cigarette smoking accounts for 17% of all deaths from heart disease. And if you're under 40 and you're a smoker, you are five times more at risk of a heart attack than somebody who is a nonsmoker. Now, smoking, as I said, is associated with multiple conditions and this is just some more of them that were necessarily on that other slide, things like psoriasis type two, diabetes, infertility, age relating here loss, Crohn's disease. It's, you know, there's no bit of us that escapes almost from the impact of tobacco from the impact of smoking. And that's why I'm delighted that you are participating in this session tonight. Now, let's ride it right back to the cigarette itself. And what is it? Well, the cigarettes in essence is three main bundles when we're thinking about it, three main bundles. One is the tar. Now tar is really the main reason for the smoking related diseases that we get out there. That's the yellow, we brown stuff that goes in people's lungs that causes the damage. And actually, that tar contains at least 60 different Costinha genes. Then there's a carbon monoxide, you know, we only have a certain amount of space when we breathe I/O. And if we start putting that the cigarette smoking, we're going to reduce our capacity to carry that oxygen. So we have less oxygen um that's there and it actually impacts on our ability for the oxygen to be able to attach to the red blood cells. Although carbon monoxide does get eliminated quite quickly at the body. And then we have the nicotine. I'm not really addictive part of the cigarette. Okay. So the tar is the bad stuff, the carbon monoxide is how it moves around and the nicotine. Well, that's the stuff that keeps us smoking. It's addictive but does not necessarily the bit that gives us the counselors. And then, although there is some limited risk around cardiovascular disease, but that's the thing that keeps us coming back to the cigarettes. And that's because we have, and that nicotine really helps to train us to continue smoking. So we have a puff on a cigarette. Now I'm an ex smoker, but I can still, and I stopped smoking. I was 23 but I can still remember what it was like to have a drag off a cigarette and then you have a puff of a cigarette and you end up with a dopamine release you know, all the stuff goes on inside your body, but you end up with this dopamine release. And what that does is it releases. It allows us to learn something. We get this positive reward because of the dopamine. And without that positive reward makes us want to go back around that loop again and take another drag off the cigarette to give us another positive reward. And it's cycled round now we can get that positive reinforcement. Not just with, not just with nicotine that can happen with food, with alcohol, but we're just obviously exploring it to do with cigarettes tonight. And so alongside that positive reinforcement, there's also a negative one. And when we try and break this cycle, we try and break that cycle that we have with that dopamine release, that's when we have willing to trouble. And that's when we get really unpleasant symptoms. And that's all of the withdrawal that we have to go through when we stop smoking. So, cigarettes are made to keep us smoking. That's one part of it. And that's why it's so hard to stop because it's made there. But when we start to overload that with heart attacks there, you know, and people say, well, you know, surely it's just one or two a day. Is it really that bad? Well, the answer is yes. And you can see here and this is from an amazing study called into heart and, um, done by a guy called Salem user who looked at, uh, heart attacks and why they happened around the world. And I'm gonna show you quite a few slides from Salem's work at the moment. And so if you've never smoked, okay, you've never smoked and that smoking doesn't cause your risk of heart attacks, you might have risk of heart attacks for other reasons, but not through smoking the minute you start smoking and even as few as, between one and five a day, it starts to increase your risk. And what you can see here is the more you smoke, the more you're going to have you at risk of heart attack. So cutting down is good, it is good but not as good as not stopping smoking. So we really see the direct correlation here as the more cigarettes you smoke, the worse it is for your heart now into heart forms part of. So cigarette smoking forms part of inter heart. And they looked at in this study, they looked at the notorious nine, the nine traditional and maybe less traditional risk factors. When thinking about heart attacks, this is an odds ratio and what I want to walk you through here is this number one, hear anything that is less than the number one is a benefit and anything that is more than a number one is a harm. And the blue blocks are the men and the pink blocks are the women. We can see this down here. And what we can see anything to this, right? Of this number one is a harm and we can clearly slee whether you're male or female smoking isn't good for you nor is diabetes nor is high BP, abdominal obesity, psychosocial index. This is this locus of control. Okay. None of these things are good for us. And down here at the bottom we see cholesterol, that's the way we measure. They measured cholesterol in the Sun, apple ways and Applebee's Apple ways. So not good for us. We can see things that are good for us and that's fruit and veg exercise and some alcohol in moderation. This is all good for us. So this into heart study really help to reinforce cigarette smoking but also in the context of other risk factors. Now, this is looking at the risk factors and isolations and what we found. What we, I wasn't part of what they found was 90% of all heart attacks happened for five risk factors. That's 90% of all heart attacks and so abdominal obesity, smoking, diabetes, cholesterol and smoking. Okay. Abdullah BT hypertension diabetes, cholesterol and smoking. You see smoking was the biggest one here. It counts for 90% of all of them. Now, these risk factors don't often appear in isolation. They keep bad friends and so often what will happen is if you're overweight, you might have diabetes and you might have a bit of high cholesterol. So they start to cluster together and this is what happens with the clustering effect. So remember that number one that I told you about. So anything above a number one is a harm. So smoking causes harm, diabetes causes harm, hypertension causes harm, cholesterol causes harm. If you start to put all three together, smoking diabetes and hypertension, you get way more harm than if you'd have just added them up. Adding all four. So you add in a bit, all four smoking diabetes, high, pedestrian, I high cholesterol, massive amounts of harm. We've thrown some obesity and the number's really start to rocket layer on that psychosocial, this locus of control, this ability to control our stress. So we're not talking about the busy businessman, the managing director stress. This is around your low paid workers. People are struggling to put food on the table type of stress that creates the most uh even more harm. And if we have all of those risk factors together, I can't even have an objective. That's big enough, such a big amount of harm that goes on there. So what we're trying to do is reduce down the harm in the context of heart attacks because that's what we're looking at here is the risk of heart attacks. Now, this isn't new. And although this was in the early two thousands, I remember this work, I remember this was Neil Poulter when his work started coming out and he started to look again or previously at the clustering effect and this might be a slightly easier one to read. So if you look at smoking in itself, the risk was what appears to be compared to the other things relatively low at 1.6, if you have hypertension, and this is quite severe hypertension. Now, at a BP of 195, a systolic and a cholesterol of four. So you see three and four. Now, these are absolutely huge numbers in context of smoke. Uh cholesterol's on high BP. But when you start to put these together, they really start to multiply up. So if you had high BP and high cholesterol, instead of being seven times more, you would be nine times more. And then if you throw in a bit of cigarette smoking, it doesn't become 10.6, it becomes 16 times more at risk. So there's something multiplicative. I think that's the word that happens when these risk factors come together. So if we can get somebody to stop smoking, then we'll really start to reduce their risk of having heart attacks. So I'm gonna take it right down into the inside of arteries now. And let's start to explore what goes on because that's the session. Just what does it do to the inside of our arteries. I know it causes all these heart problems. How does it do it? Well, this is an artery and arteries are really powerful blood vessels that take blood away from the heart, not like veins, veins are floppy, old creature's that bring the blood back. Another arteries have got a really special lining and that special lining is called your endothelium. And when we're born, it's lovely and smooth. And then the life that we lead or do we smoke, are we overweight? Do we exercise along with things like our genetics? What's our age? What's your gender? What's our ethnicity? What's our family history cause us to progress a different rates down this process. Now, this thing here is a blockage could happen in a blockage in my heart, in my neck, in my legs. And we are all growing. These blockages were adults and so we're all growing it all the time. We grow it all the time we're alive and some of us will be growing it about the right rate as we should be growing it and others will be growing it faster than we should be growing it. And it's all to do with our risk factors are modifiable and non modifiable risk factors that cause the damage. Now, you'll see here, we also have the role of inflammation and this has, you know, been coming out over the years, the role that inflammation has and certainly cigarette smoking also directly affects the role of inflammation and the effect it has on your endothelium. So I want you to hold those endothelium thoughts because we will be coming back to it in a little while. Now, wherever we've got an artery, we can get a blockage all over our body. So we get blockages in the arteries in our heart will get anti in that heart attacks or maybe heart failure. Also, heart failure to do with the hypertension side of the world. Our next we can have strokes or T I A S peripheral arterial disease down in our legs, chronic kidney disease. And if I had a penis, I could get erectile dysfunction. And it's all down to those blockages in the arteries. So how does cigarette smoking cause them blockages? We know we've got those blockages. Now, we know it causes lots of problems. We know what are the inside of our artery should look like. So what the cigarette smoking do and how does it really make us more likely to have what you can see here at the Roast Sclerosis. Now, remember atherosclerosis is a term like at the Roma a plaque, a blockage, it's all the same thing we're thinking about. So it affects different mechanisms that go in so throm basis. So you know the ability to clot the insulin resistance within the cells, it can change our cholesterol profile, the vascular inflammation and we'll keep coming back to that word inflammation and thrombosis will keep these with, these phrases will keep popping up over the next 10 minutes or so. And it's all how it relates down to the inside of our arteries. We'll also get abnormal vascular growth. So when we get damage on the inside of our arteries, and I'm going to tell you about in the moment and we start to grow these smooth muscle cells over, it will grow abnormally and the loss of our endothelial function or the endothelium is amazing. Okay. I'll tell you more about that in a moment, but we'll lose some of the function from it as well. So it is not good. It has multiple effects around the ability to develop blockages. But the plot thickens, the plot thickens. It's not just that there are other mechanisms in place as well and they actually accelerate our vascular disease and it's not straightforward. Okay. It's really complex. And this is because get this, there are over 4000 different chemicals in smoke. It's very hard to relate them all down, but some of them are worse than others. Now, this fell at the polycyclic aromatic hydrocarbons. Okay. Now, that's a long thing. They are oxidizing agents. And I want you to keep that in your mind, oxidizing agents because I'm going to show your process a minute where the oxidase ation is not a good thing for us to have happen. And it's this oxidase ation um that in nicotine that has been seen to really think about the thing that's causing more problems in the blockages. And not only that the nicotine also because of the habitual roll this constant reinforcement and this positive mechanism to have another cigarette means we're constantly adding to this oxidizing agent, but it gets worse when smoking, we re loose, really something called catacholamines. And, um, now this, along with the nicotine makes our heart beat a bit faster and makes our BP go up. And this isn't good for, is when we're sitting there smoking, it's not too bad if we're exercising in our heart rate goes up and there's a reason for the heart rate to go up. And so all of these things is increased heart rate and this increased BP as a result of smoking actually has really adverse henna damanik effects on our bodies. And that speeds up that process of atherosclerosis. And I'm going to tell you an easy way to remember atherosclerosis in a minute and that catecholamine release the nicotine and juice, catecholamine release. Well, that makes our plate that's even stickier, remember, platelets involved with plots. And we really don't want that either. Now, just when you thought that wasn't bad enough that gets even worse the journey, those platelets, particularly when they've been aggregated when they're not happy. Okay, because we've got all that nicotine going on. Well, then they start to make the cell walls grow even less regular. So they induce this smooth mail. It's smooth, it's called smooth muscle cells, this proliferation and we might even overgrow and you'll see where all of this comes together in just a couple of minutes. But we're trying to show you all the steps and all the pathways that uh cigarettes in particular nicotine house. So then we look back inside our bodies and the system of our bodies having a heart attack, it kind of all starts to make a bit more sense. So this is classically somebody having a heart attack. And actually this is what it's like when a man has a heart attack because remember women, we have heart attacks in different ways. Most of what we know about heart disease is based on men. And a lot of the research that's out there is not equipment. We'll come back to that at the moment. I keep saying, well, come back to that. But you know, I keep giving you a taste do and saying right that we will. So this is an inside of an artery. So let's imagine that's your artery in your heart, on artery in your heart. And this is the special lining that I mentioned your endothelium here and this is the blockage on the inside. Now, this all starts with something called endothelial damage. Remember we talked about endothelial function, dysfunction maybe about 10 minutes ago. And your endothelium is a very special creature and we don't pay it enough attention. The endothelium should really get more attention. So your endothelium, look at it here. It's beautiful and this is the inside of your arteries. It's lovely, lovely and smooth, your end of feeling. Imagine when you're born the entire inside of our arteries and our arterial system is in totally smooth. There is not one breaking it, there is not one element of damage. It's wonderful and smooth, blood will flow through it beautifully. It won't collect in different places. It's just flow wonderfully. It's so smooth our endothelium but endothelial damage in the atheroma process. Well, I'm going to tell you a little bit about that. Now, by using this, uh, cooker that I used to have this hub. Now, your endothelium, as I mentioned is lovely and smooth, smooth, like this stainless steel hub. And actually, this was a hub that I had when I used to live in a, in, in the house before this one. And we renovated the house. And, um, the last room we did was the kitchen and in the kitchen was an island and on top of the island was five ring stainless steel hub and stainless steel is beautiful and smooth. Absolutely beautiful and smooth. Anyway, one day, my husband 11, 2 bits, my husband cleaned our lovely stainless steel whole and I'm gonna stop presenting for a session and talk here when I talk to him about my lovely, still our lovely stainless steel hub. But he cleaned and one day he came out, I came home and he cleaned it and what had he cleaned it with one of these things, a scrubbing brush and he cleaned it and cleaned it. And so the top of that lovely, smooth, smooth stainless steel hub was like an ice skating rink. Absolutely scratched to bits. So, whenever we cooked anything after that and if anything would jump out the pan, any bits would spit out the pan, it would go into those scratches. That's how blockage is happening. Arteries, we have risk factors that are like scrubbing brushes on the inside of our arteries and that's things like not enough fruit and veg ah, wait, do we exercise? Do we smoke? What's our BP? What's our waist circumference? We could keep adding all of these on these are, are modifiable risk factors. And then we have them called are non modifiable risk factors. Uh What, what's our age? What's our, you know, socio economical status, our family history, our ethnicity are sex when we're born. Sex at birth makes a difference. Okay. Now we're talking about gender about sex at birth, makes a difference. These are, are non modifiable risk factors. So, what I want you to think about is the more risk somebody's got the more damage that happens on the inside of arteries. And I often get people to think about this. Imagine you're doing this on the inside of an artery. It is going to cause damage. And that's really what goes on with our risk factors inside of our arteries. So we have our lovely, smooth, smooth, smooth, smooth endothelium and there it is here, lovely and smooth and we have all of our risk factors and we've got different ones here. So not enough exercise, pizzas, smoking, of course, diabetes, too much sugar. These are all risk factors in our lives and they cause the blockages to happen. So we start off with our lovely smooth artery here, lovely and smooth and with standard starting with endothelial damage. You know what that is? Now, endothelial damage happens because of our risk factors. Then we have circulating blood that flows through the arteries. And in that blood is our cholesterol and we have our LDL. That's our bad cholesterol. And that will go into the grazes, the grazers we've created with our risk factors. Now, once it goes inside there, then those cholesterol starts to become oxidized. Remember when I said we've got to remember the wed oxidation from earlier on. So what a really powerful oxidants. Well, cigarettes really powerful oxygen. So they amplify what's going on here. What a really good antioxidants, I can find it here. Fruit and veg. So if we increase our veg fruit and veg intake, we'll lose that as a risk factor. Now, once it starts going inside becomes oxidized, it forms foam cells and this cells start to die and we will start to grow this smooth muscle over the top. Remember when we've heard a, a few minutes ago about the smooth muscle that make make is made even worse. It goes a little bit bumpier when we've got the nicotine presence and that's what happens here as well. And we end up forming this plaque. Now, we are building this plaque all the time. All of us, we do it when we're asleep, we do it when we're awake. We do it when you're in the shower. It just happens in our bodies and it's not so much the plaque, okay. The plaque can give us problems, but it's when the plaque ruptures here and causes the heart attack or stroke. That's what we're looking at here. Now, we never get rid of this plaque. It's always going to be there. So, however much we've all grown, we've got it if it got big enough and bad enough and it gave us symptoms, we might end up going in and we might have an anti plastics where we put a little wire down and open it up. We might put a stent in it. We might bypass it if it's in our neck, we might wrote oblate it, but we don't just, you know, stop smoking and it goes away. It's always going to be there, but not all plaques grow in the same way. So this is a, you know, we're having a whistle stop tour now through this. So look at this plaque here. So there is the inside of our, our to this is an artery. This is the inside of the artery, that's where the blood flows down. And this is a plaque starting to build up Okay. Remember, it builds up over years and years and years and then we can see the cholesterol core. Imagine all the little scrubbing brushes on the inside here. Cholesterol's flowing through the blood, through the blood vessel, through the arteries and it's going inside here and it's causing the blockage is now some people will grow what's called a stable plaque. And when we look at this one, it's only got a very sort of thin lipid court here. It's got a lot of this smooth muscle cells here and a really thick fibrous cap. This plaques not going to rupture, but what it does house is a very small lumen. So what that means is the blood flow can be restricted through that lumen. So when we're at rest, okay, when we're at rest and our heart is just beating regularly and beating all normal, there's enough blood supply to it. But maybe if we exercised and the heart muscle is calling for more blood because it's calling for more oxygen. The supply can't get through to the demand and the people will get chest pain and they get chest pain. But if they rest have a bit of spray, chest pain goes away. That is stable plaque. Now, some people will grow plaques a bit like this and then you get other people who grow plaques more like this. Now, this one ignore the big clot. If you look at the inside here, the lumen, it's a great big hole. So there's no problem with blood phone, maybe never get chest pain. But what we do get here is this really thick, thick, horrible lipid court? Okay. This is really unpleasant. It's like a melted marshmallow inside a hot water bottle. It's really gooey and unpleasant. If you could put a temperature, little temperature probing, it would be a couple of degrees warmer than our body temperature. It's quite like a little mini volcano going on inside the bodies. Now, you'll also see there's a really thin fibrous cap over here. It's a really thick fibrous cap over here, it's a really thin and because it's really thin, it's the potential for it to rupture, okay, potential for it to rupture and when it ruptures bit, leak out, okay, technical term, bit leak out. Now, if you cut your arm, okay, you cut your arm and you have a leak. Our body has a system for coping with that leak. And what it does is it makes our platelets become activated and they'll stick together and make a clot and they'll form a thrombus. Absolutely fantastic. But that system still goes on inside our arteries here. So we get the leak platelets become activated, they stick together and they form a clot and we don't want it to do that. Well, we want it to stop leaking, but we don't really want the clot, but our body doesn't know it's because of that as opposed to it. Quite here. Now, remember what we said a few minutes ago about the nicotine and cigarettes and how thrombus and how it leads to more thrombus and how it leads to this platelet aggregation even more. So, so really, we can see that so many steps along this process for heart disease that smoking has an impact. Now, not everybody grows one plaque or the other. Okay. You don't say, well, I'm only going to grow the unstable or I'm gonna grow the stable. We grow different types. Some people might have stable for a while. It might evolve. They might have a variety of different ones. So it's not just about how it grows. It's also where it grows. So, yeah, it's quite a complex thing when it comes to it. But cigarette smoking makes this worse. And we saw in the under forties you're five times more likely to have a heart attack than those who don't smoke. And then we have it in women and I've put this one in because, well, women in heart disease is a particular passion of mine. And most of what we know, as I said before, most of what we know about heart disease is based on men. Men having heart attacks when men have a heart attack, they clutch over. What's what we see on the telly, isn't it? They clutch over and have the heart attack. That's not how women have heart attacks. Ok. Women are more likely to have different symptoms. They might have that classic clutching your chest pain, chest symptoms. But like, you might feel just a bit sick and a bit sweaty and a bit nauseous and maybe a bit breathless and maybe a little bit. Not quite right. We know that half of all women who come forward with thinking they've had a heart attack, over 50 a half of them, 53% of them, their symptoms go unrecognized. So when it finally does get diagnosed, it's worse, they're more likely to have damage myocardium, more likely to have heart failure. It's really bad. Also how we diagnose things isn't so effective and women so ultra opponents are different and angiograms don't pick up stuff in quite the same way. Of course, we have all those unique effects that hormones bring somewhere that's pregnancy, menopause, polycystic ovaries. The reason why I've added this one is if you're a woman and you smoke, it's why it's forgiven if you're a man and you smoke. These are those risk factors that we know these are rob traditional ones, but we're not really linking them in women as much as we are in men. So I want you to really take certain elements away from tonight's session or today's session. So, and being female and heart disease is one of them is we must remember to always because we often think heart disease happens to men, but it happens to women so many times as well. So that's the last half hour we've taken you through cigarettes, nicotine blockages in arteries. Almost how those blockages happened. The atheroma process, we've got our risk factors. We know they clustered together from the inter heart study. It makes things much worse. So at the end of the day, smoking is never good for us. Okay. A Salem we use, if once said, doesn't matter which orifice you put tobacco in, it'll always kill you, it'll always be bad for you. Okay. Smoking will only ever have bad outcomes. Smoking does indeed, it does indeed cause blockages in arteries. Remember those totally causes it. Those blockages can happen anyway because of all of the other risk factors, but it will speed it up and make it worse. So wherever you've got an artery, well, we've got loads of them in our bodies. If you smoke, it will make those blockages in those out trees happen faster than if you don't smoke. So that is me done. I'd like to say thank you to everybody who has joined us here tonight and to everybody who is joining on catch up on demand for those of you that are online. Now, I've submitted the evaluation form so you can do your feedback but equally please do give me any questions and you can't see it on the chat here, on the, on the people on demand, but we've got some thank you is coming through. Um and I'll just put here for a second in case there are any questions coming through. And so for those of you who are online, you do your feedback that gets you copies of your slides and get two copies of the evaluation and your certificate. Um I'm just gonna apply the slides now so you can get it. And for anybody who is watching on demand, then don't forget evaluation as well. It's really important to us because this is how we can look at the sessions. We've got how we can make them better, how we can improve them and what more we can put on for you. So if you haven't already done, so please join some of the other sessions we've got here at C three and maybe you can sign up for our newsletter. We have masses of international breakfast seminars that happen. Um So look out for those as well and it's been a lovely time talking to you all about cigarette smoking and those arteries and just how does it blockages happen? All right, then everyone. Thank you very much. Have a lovely rest of your.