Promoting smoking cessation during hospitalization for coronary artery disease

BACKGROUND: Quitting smoking is the most effective intervention to reduce mortality in patients with coronary artery disease who smoke. Guidelines for the treatment of tobacco dependency recommend that health care institutions develop plans to support the consistent and effective identification and treatment of tobacco users. The University of Ottawa Heart Institute (Ottawa, Ontario) has implemented an institutional program to identify and treat all smokers admitted to the Institute. OBJECTIVES: The objectives of the present paper are to describe core elements of this program and present data concerning its reach and effectiveness. PROGRAM DESCRIPTION: The goal of the program is to increase the number of smokers who are abstinent from smoking six months after a coronary artery disease-related hospitalization. Core elements of the program include: documentation of smoking status at hospital admission; inclusion of cessation intervention on patient care maps; individualized, bedside counselling by a nurse counsellor; the appropriate and timely use of nicotine replacement therapy; automated telephone follow-up; referral to outpatient cessation resources; and training of medical residents and nursing staff. Program reach and effectiveness were measured over a one-year period. RESULTS: Between April 2003 and March 2004, almost 1300 smokers were identified at admission, and 91% received intervention to help them quit smoking. At six-month follow-up, 44% were smoke-free. CONCLUSIONS: Hospitalization for coronary artery disease provides an important opportunity to intervene with smokers when their motivation to quit is high. An institutional approach reinforces the importance of smoking cessation in this patient population and increases the rate of smoking cessation. Posthospitalization quit rates should be a benchmark of cardiac program performance.     

Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease

Cigarette smoking is the leading preventable cause of death in the United States and a major risk factor for cardiovascular disease (CVD). Large observational epidemiologic studies conducted in diverse populations have demonstrated a strong association between smoking and CVD morbidity and mortality. Observational epidemiologic studies have also demonstrated a substantial benefit of smoking cessation on cardiovascular morbidity and mortality. Smoking cessation after myocardial infarction reduces subsequent cardiovascular mortality by nearly 50%. Therefore, the use of effective strategies to reduce the prevalence of tobacco use is a high priority for both the primary and secondary prevention of CVD. Effective smoking cessation interventions have been identified in randomized controlled trials in the general population of smokers. These methods, which include behavioral counseling and pharmacotherapy, are incorporated into clinical practice guidelines for physicians in the United States and Great Britain. A smaller but still substantial body of evidence demonstrates the efficacy of these interventions in hospital- and clinic-based settings for smokers with CVD. This evidence is sufficient to support the routine implementation of these smoking cessation methods in inpatient and outpatient settings for smokers with CVD. Copyright 2003, Elsevier Science (USA). All rights reserved.     

心血管疾病患者戒烟效果的影响因素

目的 分析心血管疾病患者戒烟效果的影响因素。 方法 心血管内科住院的吸烟患者在接受戒烟健康教育后随访观察12个月，按戒烟效果分为戒烟有效组（n = 156）和戒烟无效组（n = 188）, 采用病例对照研究方法分析戒烟效果的影响因素。 结果 单因素分析显示年龄>70岁、冠心病、高血压病和心功能不全患病率高及既往每日吸烟数量少（≤10 支/d）的人群戒烟有效率显著增高（均P<0.01）；独居及接触吸烟的患者戒烟有效率显著降低（均P<0.01）。多因素Logistic回归分析显示患有冠心病、心功能不全、独居、接触吸烟者及每日吸烟数量少均是戒烟效果的独立影响因素，患有冠心病，心功能不全和每日吸烟数量少能提高戒烟有效率，而独居和接触吸烟者降低戒烟有效率。 结论 患者患有严重疾病有利于提高戒烟有效率，但独居和接触吸烟者不利于提高戒烟有效率。     

Smoking, smoking cessation, and risk of cardiovascular disease

Opinion statement Cigarette smoking increases the risk of atherothrombotic clinical events such as myocardial infarction and the effect is dose dependent for persons who continue to smoke. Reductions in smoking habit and smoking cessation are important ways to improve cardiovascular risk and favorably affect primary and secondary prevention of clinical disease. Therapeutic methods to improve smoking reduction and cessation include nicotine replacement, behavioral interventions, and medications (bupropion, clonidine). Improved cessation rates are under active study and include behavioral methods, targeting smokers immediately after myocardial infarction, consideration of depression in smokers, pharmacogenomics to identify persons who may respond more favorably to specific interventions, and newer medications that affect endocannabinoid receptors.     

Effectiveness of smoking cessation intervention in patients with cardiovascular disease]

INTRODUCTION AND OBJECTIVES: The incidence of coronary events descends in patients with cardiac disease who quit smoking. Only around 50% of the patients who quit smoking after an acute event remain abstinent three months after hospital discharge. The objective of this study was to evaluate the effectiveness of a tobacco dishabituation program in patients with cardiovascular disease. METHODS: We studied a cohort of smokers who started a smoking cessation program between September 1993 and June 1999. We compared 348 patients with cardiovascular disease with 1.107 smokers without disease. A twelve-month protocolized follow-up was performed, measuring carbon monoxide for evaluating relapse on every control. We calculated the abstinence in each period and estimated the odds ratio for relapse at twelve months. RESULTS: We observed a global continued abstinence at twelve months of 37.1% (129/348) in the patients with cardiovascular disease and of 39.6% (438/1.107) in the patients without disease. The consonant smokers (precontemplatives) showed a greater number of relapses, with an adjusted Odds ratio of 1.36. CONCLUSIONS: Exhaustive treatment and follow-up achieved a percentage of great abstinence in the cardiovascular patients of our study who were unable to quit smoking during hospitalisation or after diagnosis. We therefore suggest that these patients may benefit from inclusion in smoking cessation units.     

Depressive symptoms and clustering of cardiovascular disease risk factors in diabetes patients

Depressive symptoms may be related to the development of coronary heart disease (CHD) in patients with diabetes mellitus. The objective of the present study was to investigate the relationship between cardiovascular disease risk factors and depressive symptoms in patients with type 2 diabetes. A total of 179 patients with type 2 diabetes completed a questionnaire and gave a blood sample. The questionnaire consisted of demographics, the medication adherence questionnaire, the summary of diabetes self-care activities questionnaire, and the Beck Depression Inventory II questionnaire. Blood samples were analyzed for glucose and lipid profile. Elevated depression Beck score had a significant relation with female gender, numbness or pain in peripheries, younger age group ≤50 years, and elevated triglycerides (TG). Diabetes complications also had a significant relation with depression and more specifically with performance impairment and depression-nonspecific items. A significant relation was found between uncontrolled diabetes and somatic disturbance. Under-adherence to medications was significantly related to depression-specific items. Obesity was significantly related to depression-nonspecific items. Several factors are correlated with depression symptoms in diabetes patients. Additionally, control of somatic disturbance and performance impairment of depression should be regarded as important components of appropriate diabetes care to ensure diabetes control and medication adherence.

     

抗血小板治疗及戒烟与糖尿病心血管病的防治

糖尿病的流行已成为全球性的公共卫生问题。糖尿病的巨大危害在于可导致各种并发症．严重影响患者的生活质量和寿命,增加医疗成本支出。其中,心血管疾病在糖尿病患者中发病率高,并最终导致约75％的糖尿病患者死亡,是威胁患者生命的主要原因。对于糖尿病患者应严格控制包括血糖、血压、血脂在内的所有危险因素,并进行抗血小板、戒烟、限制酒精摄入等综合治疗．方可最大限度降低心血管疾病风险。本文通过对大量循证医学证据和国内外诊疗指南的复习,阐述抗血小板治疗及戒烟在糖尿病心血管病防治中的作用。     

Depressive symptoms in the trajectory of craving during smoking cessation treatment: A latent growth curve model

Background: Depressive symptoms and craving are related to smoking maintenance; however, little is known about the association between trajectories of depressive symptoms and smoking craving after quitting. Objectives: We examined if depressive symptom change relates to change in craving following smoking cessation treatment. Methods: Participants were 362 (64.1% female; 35.9% male) adult treatment seeking smokers who quit smoking after treatment. Depressive symptoms and craving trajectories were evaluated during smoking cessation treatment until 6 months follow-up. A latent growth curve model was used to study the correlation between trajectories. Results: Depressive symptoms and smoking craving reduced significantly after quitting. Change in depressive symptoms was significantly related to change in craving symptoms over time. Conclusions: Quitting smoking was related to a reduction in depressive symptoms and craving. Clinically, the reduction of depressive symptoms is associated with reduce craving. The data suggest depression plays an important role in craving change following treatment.     

Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease

PURPOSES: To compare an intensive smoking cessation intervention against usual care in hospitalized high-risk smokers with acute cardiovascular disease. METHODS: A total of 209 hospitalized smokers were randomized to the intensive intervention (n = 109) or to usual care (n = 100). Usual care consisted only of counseling and printed educational material provided prior to hospital discharge. Intensive treatment consisted of a minimum of 12 weeks of behavior modification counseling and individualized pharmacotherapy provided at no cost to the participant. Smoking status in all subjects was confirmed biochemically (ie, by measuring expired carbon monoxide) at 3, 6, 12, and 24 months after randomization. Outcomes included point prevalence and continuous abstinence smoking cessation rates, hospitalizations, and all-cause mortality. RESULTS: At each follow-up interval, point prevalence and continuous abstinence smoking cessation rates were significantly greater in the intensive-treatment group compared to the usual-care group. At 24 months, continuous abstinence smoking cessation rates were 33% in the intensive-treatment group and 9% in the usual-care group (p < 0.0001). Over the 2-year follow-up period, 41 patients in the usual-care group were hospitalized compared to 25 patients in the intensive-treatment group (relative risk reduction [RRR], 44%; 95% confidence interval [CI], 16 to 63%; p = 0.007). The all-cause mortality rate was 2.8% in the intensive-treatment group and 12.0% in the usual-care group (RRR, 77%; 95% CI, 27 to 93%; p = 0.014). The absolute risk reduction in mortality was 9.2% with a number needed to treat of 11. CONCLUSION: Hospitalized smokers, especially those with cardiovascular disease, should undergo treatment with a structured intensive cessation intervention. The duration of the initial treatment should be 3 months.     

Associations between cigarette smoking, pipe/cigar smoking, and smoking cessation, and haemostatic and inflammatory markers for cardiovascular disease.

AIMS: To examine the associations between cigarette smoking, pipe/cigar smoking, and years since quitting smoking, and inflammatory and haemostatic markers. METHODS AND RESULTS: A study in 2920 men aged 60-79 with no history of myocardial infarction, angina, stroke, or diabetes, and who were not on warfarin, from general practices in 24 British towns. After adjustment for other major cardiovascular risk factors, compared with never smokers, current cigarette smokers showed significantly higher levels of C-reactive protein (2.53 vs. 1.35 mg/L), white cell count (7.92 vs. 6.42 x 10(9)/L), and fibrinogen (3.51 vs. 3.13 g/L). They also showed higher levels of haematocrit, blood and plasma viscosity, tissue plasminogen activator antigen, and fibrin D-dimer, and lower levels of albumin. Primary pipe/cigar smokers showed levels similar to never smokers. Ex-cigarette smokers and secondary pipe/cigar smokers showed intermediate levels although secondary pipe/cigar smokers showed higher odds of having elevated white cell count and fibrinogen than ex-cigarette smokers. Most inflammatory and haemostatic levels improved within 5 years of smoking cessation but took over 20 years to revert to levels of never smokers. CONCLUSION: These findings suggest that activation of inflammation and haemostasis may be potential mechanisms by which cigarette and pipe/cigar smoking increase cardiovascular risk.     

Depressive symptoms and smoking among Hong Kong Chinese adolescents

AIMS: To examine associations among depressive symptoms, smoking, smoking trajectories and quitting smoking in Hong Kong. DESIGN: Prospective longitudinal design, with wave 1 at baseline (T1) and wave 2 (T2) 12 months later. SETTING AND PARTICIPANTS: Form 1 (equivalent to 7th grade in the United States) students, mean age = 12.7 years, n = 1894. MEASUREMENTS: Self-reported smoking status, attempts to quit and depressive symptoms. FINDINGS: At both waves, current as well as ex-smokers had higher depressive symptoms than never smokers. T1 smoking predicted T2 depressive symptoms among those with low baseline depressive symptoms. Depressive symptoms at T1 predicted smoking at T2 among non-smokers at T1. Trajectories were defined by separating participants who were never smokers at both waves ('non-smokers'), those who smoked at both waves ('persistent smokers'), those who smoked at one time but were not smoking at either wave ('past smokers), and those who had never smoked at T1 but reported smoking a year later ('new smokers'). Persistent, past and new smokers had higher depressive symptoms at both waves than non-smokers. Smokers who reported not wanting or trying to quit and those who had been unsuccessful at quitting had higher depressive symptoms at T2 than those who successfully quit. CONCLUSION: Our results suggest that depressive symptoms promote tobacco use in Asian adolescents by making it more likely that an adolescent will begin smoking and less likely that she or he will quit. These findings elucidate risk factors in Hong Kong for two important public health concerns for adolescents: smoking and depression.     

老年心血管疾病患者合并抑郁症状的初步研究

目的研究老年心血管疾病患者合并抑郁症状的相关危险因素。方法以老年抑郁量表随机调查参加正常体检的482例老年人为研究对象,其中有老年心血管者416例,无心血管疾病者66例,分别调查其抑郁症状发生情况,并探讨抑郁症状与冠心病、心律失常和高血压的关系。结果本组老年心血管疾病患者合并抑郁症状的比例明显高于无心血管疾病者,差异有统计学意义(P=0.01,OR=7.619,95%CI 1.826-31.785)。随着年龄的增长,老年心血管疾病患者合并抑郁症状的比例逐渐增高(P0.01)。老年心血管疾病合并抑郁症状患者在冠心病与非冠心病亚组间差异有显著性(P0.01),对是否合并心律失常、高血压和高血脂的危险因素进行比较,两组之间无统计学差异。结论老年心血管疾病患者合并抑郁症状比例显著高于同龄无心血管疾病对照人群,并随年龄增长逐渐增加。     

Cigarette smoking and cardiovascular disease

Data on the impact of smoking on mortality indicate that 35% of smoking-related deaths are due to cardiovascular causes. Current cigarette smoking is associated with a threefold to sixfold increase in risk of myocardial infarction and increased rates of ischemic stroke and subarachnoid hemorrhage. Tobacco smoking has the greatest deleterious effect on peripheral arteries, with multiple effects ranging from increased peripheral arterial disease and associated intermittent claudication, limb ischemia, and graft failure to a threefold or more increase in abdominal aortic aneurysm formation. The recent recognition of secondhand smoke as a risk factor for cardiovascular disease has led to governmental action to develop smoke-free public environments. Small communities with public smoking bans have already seen reductions in cardiovascular mortality.     

Smoking and smoking cessation -- the relationship between cardiovascular disease and lipoprotein metabolism: a review

Cigarette smoking is generally accepted as the most preventable cause of death in the United States today. Individuals who smoke experience a wide range of physiologic side effects that increase the risk of cardiovascular disease (CVD), including insulin resistance, elevated catecholamine levels which contribute to an elevated heart rate and blood pressure, and hypercholesterolemia. The link between hypercholesterolemia and cardiovascular disease has been extensively researched and is undeniable. What is more, this link is strengthened in smokers as cigarette smoking is known to increase total cholesterol (TC), triglycerides (TG), and low-density lipoprotein (LDL), while acting to decrease the cardio-protective high-density lipoprotein (HDL). Alterations in the enzymes that control lipid transport may be a key underlying mechanism contributing to these health destroying effects. This review examines the current literature related to: (1) smoking, lipoproteins, and lipid-related enzymes; (2) the impact of nicotine, carbon monoxide and free radicals on physiologic parameters related to health; and (3) metabolic issues involving smoking cessation and nicotine replacement therapy.     

Bupropion SR for smoking cessation in smokers with cardiovascular disease: a multicentre, randomised study.

AIMS: To investigate the safety and efficacy of bupropion sustained release (bupropion SR) in promoting abstinence from smoking in subjects with cardiovascular disease (CVD). METHODS: Six hundred twenty-nine subjects with CVD who smoked >/=10 cigarettes/day were randomised in a double-blind, multicentre study to receive bupropion SR (150 mg twice daily) or placebo for 7 weeks, with a follow-up of 52 weeks. Primary efficacy endpoint: continuous abstinence from smoking from weeks 4 to 7. Secondary endpoints: continuous abstinence (weeks 4-12, 4-26 and 4-52) and weekly point prevalence abstinence. All participants received brief motivational support. Safety was evaluated throughout the study. RESULTS: Continuous smoking abstinence rates from weeks 4 to 7 were significantly higher in subjects receiving bupropion SR compared with placebo (43 vs. 19%, odds ratio [OR]=3.27, 95% confidence interval [CI] 2.24-4.84; P<0.001). Continuous abstinence rates from weeks 4 to 26 and 4 to 52 continued to be more than double for bupropion SR compared with placebo (27 vs. 11%; 22 vs. 9%, P<0.001). Weekly point prevalence abstinence was significantly higher for participants who received bupropion SR compared with placebo at weeks 3, 7, 26 and 52 (P<0.001). In both groups, there were no clinically significant changes in blood pressure and heart rate throughout the treatment phase. Overall, 6% of the participants (n=36) discontinued study medication due to an adverse event (bupropion SR, n=17; placebo, n=19). CONCLUSIONS: After 7 weeks of bupropion SR treatment, more than twice as many smokers with CVD had quit smoking at 1 year compared with placebo. The safety profile of bupropion SR was similar to that previously observed in general smoking populations.     

Effects of smoking cessation and weight gain on cardiovascular disease risk factors in Asian male population

ObjectiveSmoking cessation leads to both beneficial and harmful changes in cardiovascular disease (CVD) risk factors. The basis of the harmful changes, however, is unknown. Our objective was to determine whether they are associated with the weight gain that accompanies smoking cessation.MethodsStudy subjects were male cigarette smokers aged at least 30 years who visited the Health Promotion Center of Seoul National University Hospital between 1995 and 2007 repeatedly with a 1- to 3-year interval between first and second visit. Self-reporting questionnaires gathered clinical and socio-economic characteristics on the initial visit, and CVD risk factors (blood pressure, fasting blood glucose, and serum lipid profile) were measured on both the visits.ResultsWe compared the CVD risk factors between smoking quitters and smoking continuers. The quitters were more likely than the continuers to have harmful health changes such as increase in body weight (P < 0.01), in systolic blood pressure, and in serum levels of total cholesterol, LDL-cholesterol, and non-HDL cholesterol (P < 0.05). When stratified by body weight change, quitters who had gained more than the median (1.3 kg) were more likely than those who had not to have increase in blood pressure (P < 0.01) and in serum levels of total cholesterol, triglycerides, non-HDL cholesterol, and fasting glucose (P < 0.05).ConclusionsHarmful changes in CVD risk factors associated with smoking cessation were mainly secondary to weight gain. To reduce the risk of cardiovascular disease in quitters, therefore, more attention should be focused on preventing weight gain.