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.     

Cigarette smoking, alcohol consumption, and risk of hip fracture in women

BACKGROUND: Previous studies regarding the impact of cigarette smoking on the risk of hip fracture in postmenopausal women have been inconsistent, suggesting different effects in different groups. The effect of alcohol intake on fracture risk is puzzling: moderate alcohol intake appears to increase bone density, and its association with hip fracture is not clear. METHODS: To assess the associations of cigarette smoking and alcohol consumption with hip fracture risk among postmenopausal women, we conducted an analysis of a population-based case-control study from Sweden. Cases were postmenopausal women, aged 50 to 81 years, who sustained a hip fracture after minor trauma between October 1, 1993, and February 28, 1995; controls were randomly selected from a population-based register during the same period. A mailed questionnaire requesting information on lifestyle habits and medical history was used 3 months after the hip fracture for cases and simultaneously for controls. Age-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed by means of logistic regression. RESULTS: Of those eligible, 1328 cases (82.5%) and 3312 controls (81.6%) responded. Compared with never smokers, current smokers had an increased risk of hip fracture (age-adjusted OR, 1.66; 95% CI, 1.41-1.95). Duration of smoking-particularly postmenopausal smoking-was more important than the amount smoked. Former smokers had a small increase in risk (age-adjusted OR, 1.15; 95% CI, 0.97-1.37) that decreased with the duration of cessation. The age-adjusted OR for women consuming alcohol was 0.80 (95% CI, 0.69-0.93). CONCLUSIONS: Cigarette smoking is a risk factor for hip fracture among postmenopausal women; risk decreases after cessation. Alcohol consumption has a weak inverse association with risk.     

Smoking cessation in women with cardiac risk

This article summarizes what is known about smoking among women, in particular the consequences of smoking on women's cardiac health. Smoking is recognized as a major independent cause of coronary heart disease, a condition that ranks first among the causes of death for middle-aged and older women. Women who stop smoking greatly reduce their risk of heart disease and other smoking-related illnesses. Research since the 1980 report of the US Surgeon General has been inconsistent in finding differences by gender in smoking cessation, and few approaches have been devised specifically for women. Several factors are of unique concern among women and potential barriers to smoking cessation, including weight concerns, negative affect regulation, and hormonal influences. More research is needed to determine whether these factors, when targeted specifically, improve cessation success rates among women.     

Smoking and smoking cessation in pregnancy

Smoking during pregnancy is among the leading preventable causes of adverse maternal and fetal outcomes. Smoking prevalence among young women is the primary determinant of smoking prevalence during pregnancy. Smoking among women of childbearing age is associated with reduced fertility, increased complications of pregnancy, and a variety of adverse fetal outcomes. There is increasing evidence of lasting adverse effects on offspring. Guidelines for smoking cessation during pregnancy have been developed. This article reviews the epidemiology of smoking during pregnancy, the adverse effects of smoking on the mother, fetus, and offspring, and recommended approaches to smoking cessation for pregnant women.     

Smoking cessation treatment, analysis of smoking cessation rate, and the reason of lower smoking cessation rate in women compared with that in men]

Smoking cessation treatment started in July of 2005. The number of patients for smoking cessation surged, after health insurance became applicable for the treatment in April 2006. However, after increases for 2 months, the number of patients decreased. The patients were mainly treated with nicotine patches following "the standard manual for the therapy of smoking cessation". I assessed 143 patients who visited for "health insurance covered smoking cessation treatment" from April 2006 to January 18 2007. The smoking cessation rate 1 week to 2 months after the end of the treatment was 61.2% ; 52.6% on the assumption that undetermined patients were all smokers. Subgroup analysis revealed that the factors for higher smoking cessation rate were (1) men, (2) a history of less than 20 cigarettes daily, (3) lower score of Tobacco Dependence Screener, (4) no other smokers in the household. The reason why the smoking cessation rate of women was lower than that of men was considered to be mainly because there are higher rate of other smokers in the households of women.     

Smoking and smoking cessation in cancer patients

Persons with malignant disease have been a neglected population for research in smoking cessation. Besides the well-established role of cigarette smoking in the development of several types of cancers, there are numerous adverse health consequences of continued smoking for the diagnosed cancer patient. These include: increased risk of further neoplasms, poorer survival, and complications of surgery, radiation and chemotherapy; risk of non-neoplastic smoking-related diseases; and additional impairment of appetite and nutrition. Smoking prevalence at diagnosis is highest among patients with smoking-related cancers. Prospective studies of a variety of cancer patient populations are needed to assess patterns of continued smoking and cessation. Systematic quit smoking programs should be integrated into cancer treatment regimens. Currently, two trials testing interventions delivered by medical providers are in progress. Important research issues concerning intervention in cancer patient smoking behavior include: identification of relevant target groups; definition of intervention style and content; delineation of dimensions of treatment; and documentation of beneficial effects. The growing number of long-term cancer survivors and the complications from other smoking-related diseases dictate that the smoking cessation needs of this population be addressed.     

Smoking intensity, duration, and cessation, and the risk of rheumatoid arthritis in women

Background

Cigarette smoking has been associated with rheumatoid arthritis (RA), but the importance of smoking intensity, duration, and time since quitting, and whether the risk is primarily for rheumatoid factor (RF) seropositive versus seronegative RA are still unclear.

Methods

We conducted a prospective analysis of smoking and the risk of RA among 103,818 women in the Nurses’ Health Study. A total of 680 RA cases, diagnosed from 1976 and 2002, were confirmed using a questionnaire and medical record review. Sixty percent were RF positive. Cox proportional hazards models calculated the relative risks (RRs) of RA with smoking, adjusting for reproductive and lifestyle factors.

Results

The RR of RA was significantly elevated among current (RR 1.43 [95% confidence interval 1.16-1.75]) and past smokers (RR 1.47 [95% confidence interval 1.23-1.76]), compared with never smokers. The risk of RA was significantly elevated with 10 pack-years or more of smoking and increased linearly with increasing pack-years (P trend <.01). A greater number of daily cigarettes and longer duration of smoking were associated with increased risk. The effect of smoking was much stronger among RF-positive cases than among RF-negative cases. The risk remained elevated in past smokers until 20 years or more after cessation.

Conclusions

In this large cohort, past and current cigarette smoking were related to the development of RA, in particular seropositive RA. Both smoking intensity and duration were directly related to risk, with prolonged increased risk after cessation.     

Smoking eliminates the protective effect of oral estrogens on the risk for hip fracture among women.

OBJECTIVE: To determine if the association between smoking and osteoporotic fractures is related to the quantity of cigarettes smoked and to determine if smoking modifies the protection by estrogens. DESIGN: Cohort study. SETTING: A population-based cohort study, the Framingham Study. PARTICIPANTS: A total of 2873 women in the Framingham Study followed through examination 19 (1985-1987). MEASUREMENTS: All fractures of the proximal femur sustained by women in the Framingham Study from 1948 to 1987 were ascertained. At almost all examinations, available information on cigarette smoking was used to classify women as "ever smokers" compared with "never smokers," and, among "ever smokers," "current" compared with "former smokers." A similar classification for estrogen use was created. Information on potentially confounding variables was taken from each examination, including age, adiposity (weight/height2), alcohol consumption (ounces per week), and caffeine intake (coffee and tea). RESULTS: Overall, 207 hip fractures occurred among 34,700 woman-examinations of observation. In the entire cohort, current smoking did not appear to increase hip fracture risk (adjusted odds ratio [AOR], 1.22; 95% CI, 0.76 to 1.95; P greater than 0.2). Also overall, current estrogen use appeared to be protective (AOR, 0.38; CI, 0.12 to 1.21, P = 0.10). Among current smokers, however, estrogen use did not protect against fracture (AOR for current use, 1.26; CI, 0.29 to 5.45), whereas estrogen was protective in nonsmokers (AOR for current or past use, 0.37; CI, 0.19 to 0.75; P = 0.005). CONCLUSIONS: Overall, smoking does not appear to increase the risk for hip fracture in women. Although estrogen replacement protects nonsmokers from fracture, smoking may negate the protective skeletal effects of estrogen replacement therapy.     

Determinants of smoking and cessation in older women

BACKGROUND: although the benefits of quitting smoking even at an advanced age have been proved, few campaigns target the older population. The goals of this study were to analyse the characteristics of older women smokers help and support those wanting to quit. METHODS: we assessed the determinants of smoking cessation in a prospective cohort study performed in 7,609 older women. A questionnaire about smoking habits was sent to the 486 eligible smokers. Smoking dependence and smokers' readiness to quit was assessed. Participants who had quit smoking during follow-up were asked about their previous reasons for quitting and the methods used to quit. RESULTS: 372 women of the 424 (88%) responded to our questionnaire and were included. The most common reasons for smoking were relaxation, pleasure, and habit. Major obstacles to quitting smoking were 'no benefit to quitting at an advanced age', 'smoking few or "light" cigarettes yields no negative health consequences', and 'smoking does not increase osteoporotic risk'. During the 3-year follow-up period, 57 of the 372 (15%) women successfully quit smoking. Being an occasional smoker (OR=2.4) and reporting 'quitting is not difficult' (OR=3.7) were positively associated with having recently quit smoking. Only 11% of successful cessations were reported to have received physician advice. CONCLUSIONS: these data illustrate the specific smoking behaviour of older women, suggesting that cessation interventions ought to be tailored to these characteristics. Willingness to quit was associated with a low education level. The most frequent obstacles to quitting were all based on incorrect information.     

Acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fracture

OBJECTIVES: To determine acceptability and compliance with hip protectors in women at high risk of hip fracture who are living independently in the community. METHODS: Women aged 65 yr and over referred for open access bone densitometry who had femoral neck osteoporosis and a high risk of falling were asked to wear hip protectors. RESULTS: Eighty five women fulfilled the inclusion criteria of whom 32 (38%) found the hip protectors acceptable and agreed to participate. Reasons given by the remaining 53 (62%) for not finding the hip protectors acceptable included discomfort on wearing, dislike of their personal appearance with the hip protectors on, and disagreement about their fracture risk. Participants were more likely to have a family history of osteoporosis (47 vs 26%, respectively) and hip fracture (16 vs 8%) compared with non-participants. At 12 months only about half of the subjects were wearing hip protectors daily. CONCLUSIONS: Our findings suggest that only a minority of community-dwelling women at high risk of hip fracture will wear hip protectors to reduce fracture risk. Their use should be restricted to highly motivated women who should be carefully identified.     

Smoking cessation, but not smoking reduction, reduces plasma homocysteine levels.

BACKGROUND: Cigarette smoking has been associated with increased plasma homocysteine levels. Although hyperhomocysteinemia may mediate some of the adverse cardiovascular consequences of smoking cigarettes, the effects of smoking cessation and smoking reduction on homocysteine levels have not been evaluated previously. HYPOTHESIS: The purpose of this study was to determine the effects of smoking cessation and smoking reduction on plasma homocysteine levels. METHODS: Fifty-one healthy subjects who smoked 35.9 +/- 6.4 cigarettes daily were randomized to continue smoking, reduce smoking to 4-8 cigarettes daily, or to stop smoking. A nicotine inhaler and individualized counseling were provided as aids to smoking cessation. RESULTS: In subjects who quit smoking, homocysteine levels decreased by 11.6%, from 8.58 +/- 2.31 to 7.53 +/- 2.26 micromol/l (p = 0.013). Significant changes in homocysteine levels were not observed in subjects who reduced smoking or continued to smoke. CONCLUSION: A "harm reduction" strategy of reducing cigarette use may not be sufficient for reducing the vascular risk associated with smoking cigarettes.     

Smoking patterns and predictors of smoking cessation in elderly populations in Lebanon.

OBJECTIVE: To investigate smoking patterns in an elderly, low-income population and to identify predictors of smoking cessation, in addition to analyzing the importance of smoking in relation to other risk factors for hospitalization. DESIGN: The data were part of an urban health study conducted among 740 individuals aged > or = 60 years in three suburban communities of low socio-economic status in Beirut, one of them a refugee camp. A detailed interview schedule was administered that included comprehensive social and health information. RESULTS: The overall prevalence of current smokers was 28.1%. Almost half of the group were ever smokers, of whom 44% had quit smoking when they experienced negative health effects. Having at least one chronic illness and having a functional disability significantly increased the odds of smoking cessation. In addition, being a former smoker increased the likelihood of hospital admission. CONCLUSIONS: This study is of particular importance, as it has implications for similar low-income and refugee communities in the region and elsewhere. There is a need for more concerted efforts by public health officials to target elderly individuals as a group for smoking cessation interventions, particularly now that mortality and health benefits have been well documented.     

Do drugs affect the risk of hip fracture in elderly women?

The drugs prescribed for 280 women with hip fractures (mean age 83 years) were compared with those prescribed for 145 women controls (mean age 81 years) as recorded in a family practice age-sex register. Thirty-three percent of the fracture patients were taking diuretics compared with 24% of the controls (.10 greater than P greater than .05). Forty-six percent of these diuretics taken by the fracture group (compared with 40% taken by the controls) were either loop or potassium sparing diuretics in combination with another diuretic. Twenty-five percent of the controls (compared with 9% of the fracture patients) were taking nonsteroidal anti-inflammatory drugs (NSAIDs) (P less than .001). The greater use of NSAIDs by control subjects may be due to the small overlap between osteoporosis and osteoarthritis. No significant differences were found for digoxin, anti-hypertensive drugs, and those taking no drugs. Thirty percent of fracture patients were taking sedatives and hypnotics compared with 28% of controls. Within this category, 54% of the fracture patients and 80% controls were receiving drugs (mainly benzodiazepines) with half-lives longer than 24 hours. Thus, this population did not confirm a previously identified association between long-acting sedatives and the risk of fracture. As only 3.5% of fracture patients and 2.1% controls were receiving phenothiazines, a role for these drugs in hip fracture cannot be ruled out. In summary, hip fracture patients were slightly more likely to be taking diuretics and somewhat less likely to be taking NSAIDs than controls but there were no differences with respect to other drugs.