Smoking

Ambulatory Care Lecture Bassel Ericsoussi, MD, PG-Y3 Internal Medicine Resident Smoking Advocate Christ Medical Center Powerful Medicine. Passionate Care.

Smoking
Epidemiology of smoking.
The effects of nicotine and nicotine withdrawal .
Medical complications of smoking.
Counseling patients who smoke.
Pharmacotherapy , acupuncture and hypnosis for smoking cessation.
Advocate Christ Medical Center Powerful Medicine. Passionate Care. Advocate Christ Medical Center Powerful Medicine. Passionate Care.

Epidemiology of smoking in the U.S.
Smoking is the single most important cause of preventable morbidity and mortality in the United States.
73 million Americans currently use a tobacco product.
35 million Americans were classified as nicotine dependent.
40% of the population young adults aged 21-25. Most smokers begin during adolescent years
Smoking is more prevalent among males (36%) than females (23%), but among adolescents, the rates are roughly equivalent (10%).
rates decline with increasing level of education .
Most new smokers (63%) are under age 18 ; this is despite the fact that the sale of tobacco products to minors is illegal.

Why certain adolescents acquire this habit?
Peer factors (having friends who smoke).
Family factors (having smokers in the family, family conflict and poor communication.
Personal factors (learning problems, depression and antisocial behavior).
Tobacco industry promotional activities .

A number of societal factors may reduce smoking rates:
Increasing the cost of cigarettes
Mandating smoke-free workplaces

Facts about Nicotine
Nicotine is the active component of tobacco and is responsible for the habit-forming effects.
The typical cigarette delivers about 1 mg of nicotine (through the lungs) ; those who chew may absorb up to 2-3 mg (through the oral mucosa).
Nicotine is poorly absorbed from tobacco when ingested .
Nicotine has a half-life of about 2 hours
Primarily metabolized by the liver into cotinine , which has a much longer half-life .
Nicotine receptors are selective acetylcholine receptors

Effects of Nicotine
Mild stimulating effect :
Increased alertness.
Improved attention.
Decreased appetite.
Acute toxicity or overdose (rare):
Nausea.
Vomiting.
Diarrhea.
Weakness.
Dizziness.
There are reports of myocardial infarction associated with smoking and concomitant use of transdermal nicotine patches (some studies showed no such association).

Potential Therapeutic Uses of Nicotine
Nicotine patches improve short-term verbal memory in elderly non-smokers.
Nicotine is beneficial for the prevention and treatment of ulcerative colitis .

Nicotine Withdrawal
During the first few days-month (more intense during the first four days) of abstinence:
Irritability.
Anxiety.
Difficulty concentrating.
Restlessness.
Slowing of heart rate.
Increased appetite.
Beyond the first month – for as long as 6 months (or longer):
Increased appetite and weight gain (3-4 kg).

Medical complications of smoking
Death
Mostly due to cardiovascular disease, followed closely by COPD and lung cancer .
Higher in current smokers compared to former smokers (hazard ratio: 2.77 vs. 1.23).
The higher the number of cigarettes smoked ,the higher mortality rate.
The younger the age (≤ 17) smoking started ,the higher rate of mortality (particularly from lung cancer and COPD).
The mortality declines significantly within the first 5 years after quitting and decreased to the level of never smokers after 20 years.
The risk of lung cancer declines with smoking cessation, but still significantly higher than never smokers even 30 years after quitting.
The risk of mortality from vascular disease declined more rapidly than other causes.
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Cardiovascular Complications:
Endothelial impairment .
Adverse effects on lipid profiles .
Increased risk of developing aortic aneurysms.
Increased risk of developing peripheral vascular disease.
“ Chewing” tobacco (nicotine is poorly absorbed from tobacco when ingested) causes less cardiovascular complications than smoking tobacco.

“ Chewing” Tobacco Advocate Christ Medical Center Powerful Medicine. Passionate Care. Advocate Christ Medical Center Powerful Medicine. Passionate Care.

Pulmonary Complications:
COPD:
The most important cause of morbidity and mortality
Half of all smokers will eventually develop COPD
Airway inflammation , lung destruction and airway obstruction.
Quitting smoking is the only way to reduce the decline in lung function
Smoking cessation will improve survival, even among those with severe lung disease.

Lung cancer:
Strong association with all types of lung cancer.
This risk increases with duration and number of cigarettes smoked.
Higher mortality with active smoking.
Cutting down on smoking may reduce the risk of lung cancer, but to a lesser extent than quitting .
Respiratory infections:
Higher risk of pneumonia, tuberculosis and influenza.


Gastrointestinal Complications
Malignancies:
Esophageal carcinoma (both squamous and adenocarcinoma).
Pancreatic cancer .
peptic ulcer disease :
Synergistic effect with concomitant Helicobacter pylori infection.
Increased risk of gastroesophageal reflux disease .

Head and Neck Complications
Squamous cell carcinoma of the head and neck (oropharyngeal cancers):
“ Chewing” tobacco
Further increased with concomitant alcohol use.
Premature aging of the skin and increased facial wrinkling:
greatly increased by the combination of smoking and sun exposure.

Genitourinary Complications
Accelerates decline in renal function (diabetics, elderly)
Renovascular disease.
Renal cell carcinoma .
Bladder cancer .
Erectile dysfunction .

Counseling Smokers
“ Cutting down” may be beneficial, the goal of treatment should be smoking cessation.
Patients who have medical complications due to smoking are more likely to respond to advice .
Switching to lower tar cigarettes doesn’t make any difference.
Those who do quit typically make multiple attempts before they achieve success.

Interventions that help smokers to quit smoking
Physician advice
Telephone counseling
Group and individual therapy
Providing smokers with educational materials
Pharmacologic interventions:
Nicotine replacement
Antidepressants (buproprion and nortriptyline)
And most recently, varenicline (Chantix).
Physician advice “has a small effect on smoking cessation.”
Higher percentage of smokers will quit with brief physician advice vs. no advice

Recommendations on counseling smokers
Identify all tobacco users at every visit.
Strongly urge all tobacco users to quit.
Determine willingness to make a quit attempt.
Aid the patient in quitting.
Schedule follow-up contact.

Pharmacologic Interventions
Antidepressants
Varenicline (brand name: Chantix )
Acupuncture and Hypnosis

Antidepressants
Bupropion and nortriptyline
The most effective treatments for smoking cessation after Chantix ( more effective than nicotine replacement therapy)
bupropion is FDA-approved and the treatment of choice for smoking cessation (more studies done on buprpion)
Bupropion is equally effective to norteiptyline
Longer-term use of antidepressants (a year or longer) may reduce relapse rates .

Advocate Christ Medical Center Powerful Medicine. Passionate Care. Advocate Christ Medical Center Powerful Medicine. Passionate Care. Antidepressants (dosage) Bupropion (150 mg po BID) Nortriptyline (75 mg po Daily) Side Effects Insomnia Headache seizure Dry mouth Sedation

Less effective than antidepressant for helping individuals to quit smoking.
Most smokers do not find the available nicotine replacement Products to be a satisfying alternative.
No additional benefit from using courses of nicotine replacement longer than 8-12 weeks (2-3 months)
The best predictor of longer-term abstinence is quitting smoking during the first two weeks of treatment.
Higher-dose nicotine replacement in highly dependent smokers:
number of cigarettes smoked
time to first cigarette in the morning
Combining two forms (gum, patches, nasal spray, inhaler, or sublingual tablet/lozenge) may improve abstinence rates:
Nicotine patch + as needed nicotine gum
Nicotine patch + as needed nicotine inhaler

Nicotine Replacement Products Advocate Christ Medical Center Powerful Medicine. Passionate Care. Advocate Christ Medical Center Powerful Medicine. Passionate Care.

Varenicline (brand name: Chantix )
Nicotinic acetylcholine receptor partial agonist
Reduces the craving for nicotine while blockes the effect of smoked nicotine.
Doesn’t prevent the weight gain associated with smoking cessation
The most effective treatment (more effective than bupropion and nicotine replacement )
The usual dosage 0.5 mg daily for 3 days, then 0.5 mg twice daily for 3 days, followed by 1 mg twice daily for 12 weeks.
side effects:
Nausea (30% of subjects, mild and diminishes over time)
Suicidal thoughts
Erratic and aggressive behavior
For smokers who are able to achieve abstinence on varenicline, continuation of treatment beyond 12 weeks can help them maintain abstinence

Acupuncture and Hypnosis
Recent randomized controlled trial of acupuncture for smoking cessation failed to show a sustained effect
There is no clear evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation
Hypnosis doesn’t have greater effect on six month quit rates than other interventions or no treatment.

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Smoking

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