Cigarette Smoking

Key Points

• Cigarette smoking is the single most preventable cause of mortality in the United States.

• Cigarette smoking cessation reduces risk for myocardial infarction and mortality by 36%.

On an annualized basis, cigarette smoking in the United States incurs over $193 billion in lost productivity and direct health care costs. Approximately 23.5% of American men and 20.9% of American women are smokers. Unfortunately, the incidence of smoking among adolescents and teenagers continues to rise despite legislation limiting some forms of advertising and the sale of cigarettes to minors. Smoking is the single most preventable cause of mortality in the United

States. In addition to increasing risk for developing pulmonary, oral, laryngeal, and bladder neoplasms, cigarette smoking significantly raises risk for developing all forms of atherosclerotic disease and potentiates myocardial ischemia, adverse structural damage to the lung parenchyma, and arterial aneurysm formation. More than 440,000 Americans succumb annually from tobacco-related disease. Smoking also increases risk for erectile dysfunction, osteoporosis, insulin resistance, poor wound healing, pneumonia, and other complications.

Cigarette smoke contains more than 4000 exogenous chemicals. Cigarette smoking is associated with increased intravascular oxygen free-radical production and induces diffuse endothelial dysfunction, resulting in marked reductions in nitric oxide and tissue plasminogen activator (tPA) production (Chia and Newby, 2002). These changes result in increased oxidative injury to cells and lipoproteins, vasoconstriction, and reduced capacity for fibrinolysis in the setting of plaque rupture and overlying thrombus formation. In addition to accelerating rates of atherogenesis in native arteries, continued smoking reduces rates of arterial and venous graft patency in the heart and peripheral vasculature. Cigarette smoking is associated with increased serum levels of multiple emerging risk factors, including CRP, fibrinogen, and homocysteine (Bazzano et al., 2003).

Achieving lifelong smoking cessation in patients who have, or are at risk for, cardiovascular disease is a critical therapeutic goal. Smoking cessation results in a 36% reduction in risk for MI and mortality (van Berkel et al., 1999). Bupropion (Zyban, 150-300 mg orally daily) reduces the intensity of withdrawal symptoms in patients trying to quit smoking by inhibiting the neuronal reuptake of norepinephrine, serotonin, and dopamine. These neurotransmitters are associated with central centers modulating addiction and craving/appetitive behaviors. After taking bupropion for about 2 weeks, patients can begin to wean themselves from cigarette smoke according to a plan established with their provider. Sustained smoking cessation is facilitated by continuing bupropion for 3 to 6 months after patients smoke their last cigarette. Continued counseling and encouragement are important. Smoking cessation classes are also usually available as part of community health awareness programs. Another approach involves the use of nicotine replacement therapies, such as NicoDerm CQ or Habitrol (transdermal delivery systems) and Nicorette gum. These therapies also control withdrawal and craving by providing an alternative source of nicotine that can be progressively weaned over weeks to months. One recommended regimen for the nicotine patch is to wear each dose (21, 14, and 7 mg) for 1 month in a stepped-down fashion. Patients wearing the patch should be counseled not to smoke because this can induce headache, nausea, flushing, and even angina. If a patient cannot achieve smoking cessation on single-agent therapy, the combination of bupropion and a transdermal nicotine patch has been shown to increase success rates compared to the use of either agent alone.

Another smoking-cessation agent, varenicline (Chantix), is a nicotinic acetylcholine receptor agonist that controls withdrawal symptoms during abstinence from nicotine. Treatment with varenicline at 1 mg orally twice daily is associated with a 44% smoking-discontinuation rate after 3 months of continuous therapy (Gonzales et al., 2006). However, side effects have been a concern.

KEY TREATMENT

Smoking cessation is facilitated by patient education about the dangers of smoking and pharmacologic intervention with nicotine replacement products, bupropion, and varenicline (SOR: A). Relapse rates are high in the absence of education, encouragement, and individualized courses of therapy and follow-up (SOR: A).

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