This chart illustrates (schematically) plasma nicotine concentrations for a ‘single dose’ of a number of different nicotine delivery systems. It shows that a cigarette is the ‘formula one car’ of nicotine delivery. In contrast, NRT products provide slower, less variable plasma nicotine concentrations, which means that, while they alleviate nicotine withdrawal symptoms, the addictive potential of these products is minimised.
893 smokers Randomized to 9 weeks of treatment with Placebo (n=160) Nicotine patch (n=244)—21 mg weeks 2-7, 14 mg week 8, and 7 mg week 9 Zyban (n=244)—150 QD x 3d, then 150 BID x days 4-63 Zyban and Nicotine patch (n=245) Primary end point—Abstinence at 1 year
CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION Adapted and Modified from: Luepker RV, Lando HA. Tobacco Use and Passive Smoking, in: Wong ND, Black HR, Gardin JM, eds. Preventive Cardiology, Mc Graw Hill, 2000 and NANCY HOUSTON MILLER, R.N., B.SN., Stanford University Roger Blumenthal, MD et al ACC Prevention Guidelines 2007
Smoking Statement Issued in 1956 by American Heart Association
“ It is the belief of the committee that much greater knowledge is needed before any conclusions can be drawn concerning relationships between smoking and death rates from coronary heart disease. The acquisition of such knowledge may well require the use of techniques and research methods that have not hitherto been applied to this problem.”
Arch Intern Med . 2003;163:2301–2305. Surgeon General’s Health Consequences of Smoking, 2004. CDC/NCHS. Tobacco-Related Mortality, Fact Sheet. CDC.gov/tobacco. February 2004. Heart Disease and Stroke Statistics—2005 Update, AHA. • MMWR, Vol. 51, No. 14, 2002, CDC/NCHS. 33.5% of smoking-related deaths among Americans are cardiovascular-related Male smokers die an average of 13.2 years earlier than male nonsmokers Female smokers die an average of 14.5 years earlier than female nonsmokers Current cigarette smoking is a powerful independent predictor of sudden cardiac death in patients with CHD Cigarette smoking results in a two- to threefold risk of dying from CHD Smoking: Mortality
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study . Men <55 Yrs. 14-yr. Rate/1000 119 206 210 59 112 210
Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS:2004). Source: MMWR. 2004;54:1121-24. NH – non-Hispanic.
Percent of Adults Who Reported Cigarette Smoking, 1996, CDC
Prevalence of high school students in grades 9-12 reporting current cigarette smoking by race/ethnicity and sex. (YRBS:2005). Source: MMWR. 2006;55:SS-5. June 9, 2006. . NH – non-Hispanic.
Percent of High School Students Who Reported Cigarette Smoking, 1995, CDC
In PDAY study of autopsies performed on 1443 men and women aged 15-34 years, smoking was associated with excess of fatty streaks and raised lesions in the abdominal aorta.
Mechanism of injury from cigarette smoking may come from injury to endothelium, and acute effects ma include alterations in clotting, platelet adhesion, and coronary vasoconstriction due to nicotine.
Relative risk of CHD death from MRFIT study 2.1 for 1-25 cigarettes/day rising to 2.9 for >25 cigarettes/day
Acute MI and sudden death strongly associated with cigarette smoking.
Cigarette smoking has additive effect to CHD risk above lipids, obesity, diabetes, and hypertension
Cohort Studies of Environmental Tobacco Smoke and CHD RR (95% CI) Population Location,Date Source F 1.9 (1.1-3.3) 32046 US 1997 Kawachi M 1.2 (1.1-1.4) F 1.1 (-.96-1.3) 309599 US 1996 Steenland 2.7 (1.3-5.6) 2278 UK 1995 Tunstall-Pedoe M 0.97 (0.7-1.3) F 0.99 (0.8-1.2) 2916 US 1995 Layard 2.0 (1.2-3.4) 7987 UK 1989 Hole M 1.3 (1.1-1.6) F 1.2 (1.1-1.4) 19035 US 1988 Helsing 2.2 (0.7-6.9) 1245 US 1987 Svendsen 2.7 (0.7-10.5) 695 US 1985 Garland 1.2 (0.9-1.4) 91,540 Japan 1984 Hirayama
Time-to-Benefit of Smoking Cessation After Last Cigarette Within 20 minutes: BP decreases; body temperature, pulse rate returns to normal Within 24 hours: Risk of MI decreases Within 1 year: Excess risk for CHD is half that of a person who smokes At 5 years: Stroke risk is reduced to that of someone who has never smoked Within 15 years: CHD risk is the same as a person who has never smoked American Lung Association. www.lungusa.org/tobacco/quit_ben.html
Counseling: 5 A’s Ask: Systematically identify all tobacco-users at every visit Advise: Strongly urge all smokers to quit Attempt: Identify smokers willing to try and quit Assist: Aid the patient in quitting Arrange: Schedule follow-up contact
Tailored vs. generic behavioural support material % Abstinent at 4 months Self-help materials tailored for the needs of individual smokers are more effective than standard materials Strecher VJ. Patient Educ Couns. 1999; 36: 107-117. Strecher VJ, et al. Journal of Family Practice. 1994; 39(3): 262–270.
Pharmacologic Treatment Options POTENTIAL RISKS TREATMENT Slight risk of seizure, contraindicated in those with eating or seizure disorders Zyban (bupropion hydrochloride) May cause mouth or throat irritation Nicotine inhaler Nose and eye irritation, usually disappears within 1 week Nicotine nasal spray Mouth soreness, hiccups, dyspepsia, jaw ache Nicotine polacrilex (nicotine gum) Skin rashes and irritation Nicotine patch
Nicotine Replacement Therapy Potent psychoactive drug that induces euphoria Effects are related to blood concentration and the rate of increase in concentration Safe in patients with cardiovascular disease Should be used as part of smoking cessation therapy; however, many individuals may quit without it
Other toxins in tobacco smoke, not nicotine, are responsible for majority of adverse health effects
>4000 different chemicals
Tar, carbon monoxide, irritants, and oxidant gases
The main adverse effect of nicotine from tobacco is addiction, which sustains tobacco use
Nicotine dependence leads to continued exposure to toxins in tobacco smoke
Smith et al. Food Chem Toxicol. 1997;35:1107–30. Hoffman and Hoffman. J Toxicol Environ Health. 1997;50:307–64. Benowitz NL. Nicotine Safety and Toxicity . New York: Oxford University Press, 1998.
Nicotine Replacement Therapy (NRT) Goal: Attenuate symptoms related to nicotine withdrawal Dysphoric or depressed mood Insomnia Irritability, frustration, or anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain
NRT: Treatment Options Forms of NRT: Gum, Patch, Inhaler, Lozenge, Nasal spray, Sublingual tablet All forms of NRT appear to be similarly effective NRT choice may be based on susceptibility to side effects, patient preference, and availability Little research on combinations of different types of NRT Limited evidence that adding another form of NRT to the nicotine patch increases the success rate
Plasma nicotine concentrations for smoking and NRT Minutes Increase in nicotine concentration ( ng/ml ) Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch 5 10 15 20 25 30 0 2 4 6 8 10 12 14 Balfour DJ and Fagerström KO. Pharmacol Ther . 1996;72:51-81.
NRT: Benefit of Behavioral Support West R, McNeill A and Raw M. Thorax. 2000;55:987-999. Silagy C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2002; 1. Limited Support Intensive Support
NRT is safe in most individuals with cardiovascular disease, even with concomitant smoking
There is a negligible risk of cancer compared to the risk from continued smoking
Although it is a potential fetal teratogen, the benefits outweigh the risks of smoking during pregnancy
There is a low risk of abuse
Buproprion (Zyban) Sustained release form of the antidepressant Acts by enhancing CNS noradrenergic and dopaminergic function Start 1 week before smoking cessation date 150 mg QD x 3d, then 150 mg BID x 60d Higher doses and longer duration with greater side effects and no clear benefit
Buproprion (Zyban) vs. NRT Jorenby DE et al. N Engl J Med. 1999 Mar 4;340(9):685-91