Trial design: blood pressure control and weight gain prevention in prehypertensive and hypertensive smokers: the treatment and prevention study

BACKGROUND: Cigarette smokers with elevated blood pressure (BP) are at substantially higher risk for cardiovascular events compared to normotensive smokers. Although smoking cessation should be a primary treatment goal for these patients, increases in body weight accompanying smoking abstinence may further increase BP. Intervention strategies that facilitate smoking cessation and modify adverse changes in body weight and BP are needed. METHODS: We describe an ongoing multi-site, two-phase, five-year randomized clinical trial. Participants are cigarette smokers with Prehypertension or Stage I Hypertension. In the first phase, participants receive a smoking cessation intervention combining behavioral counseling and nicotine replacement in an open-label fashion. In the second phase, participants who successfully quit smoking are randomly assigned to one of three lifestyle interventions: 1) weight gain prevention, 2) blood pressure control, or 3) usual lifestyle. Participants are followed for one year to assess changes in blood pressure, body weight, dietary intake, and physical activity. CONCLUSIONS: Results from the proposed study will provide important insights into the efficacy of various approaches to lifestyle modification in smokers at increased risk for cardiovascular events.     

Tobacco-related diseases

OBJECTIVE: To provide an overview of the disease risks associated with cigarette smoking and the benefits of smoking cessation. DATA SOURCES: Government reports and monographs, and research articles. CONCLUSION: Cigarette smoking causes over 400,000 deaths per year and is a major cause of coronary heart disease, chronic obstructive pulmonary disease, and lung cancer. The disease risks associated with cigarette smoking are proportional to the intensity and duration of smoking. Cessation of cigarette smoking results in a decline in risk in relation to the risks of continuing smokers. IMPLICATIONS FOR NURSING PRACTICE: Clinicians must be aware of the magnitude of smoking-related risks and the benefits of smoking cessation as a critical intervention.     

Smoking and mortality among women with type 2 diabetes: The Nurses' Health Study cohort.

OBJECTIVE: To assess the relationship between cigarette smoking and mortality among women with type 2 diabetes in the Nurses' Health Study cohort. RESEARCH DESIGN AND METHODS: The Nurses' Health Study, a prospective cohort of U.S. female registered nurses, included 7,401 women with type 2 diabetes diagnosed at baseline or during follow-up from 1976 to 1996. Total and cause-specific mortality of these diabetic women were the outcomes of interest. RESULTS: We documented 724 deaths during 20 years of follow-up (67,420 person-years) among women with type 2 diabetes. In multivariate analyses, adjusting for age, history of high blood pressure and high cholesterol, and other cardiovascular risk factors, compared with never smokers, the RRs of mortality were 1.31 (95% CI 1.11-1.55) for past smokers, 1.43 (0.96-2.14) for current smokers of 1-14 cigarettes/day, 1.64 (1.24-2.17) for current smokers of 15-34 cigarettes/day, and 2.19 (1.32-3.65) for current smokers of > or =35 cigarettes/day (P for trend = 0.0002). Women with type 2 diabetes who had stopped smoking for > or =10 years had a mortality RR of 1.11 (0.92-1.35) compared with diabetic women who were never smokers. CONCLUSIONS: Cigarette smoking is associated in a dose-response manner with an increased mortality among women with type 2 diabetes. Furthermore, quitting smoking appears to decrease this excess risk substantially. Diabetes patients should be strongly advised against smoking.     

Promoting smoking cessation in the rehabilitation setting

Cigarette smoking is a known risk factor in patients with ischemic and hemorrhagic stroke. Smoking also increases the risk of cardiovascular disease, chronic bronchitis, emphysema, peptic ulcers, and cancer of several organs among middle-aged individuals and the elderly. In the elderly, smoking has also been associated with a general decline in physical functioning as a result of the increased incidence of chronic illnesses. The prevalence of smoking among community-dwelling adults aged 65 to 74 yr has been estimated to be 18% for men and 15% for women. More than 30% of Americans who are hospitalized each year are smokers. Although there are no published studies that have established the prevalence of smoking in a rehabilitation population, these data and our own clinical experience suggest that smoking continues to be a significant health problem for many persons who enter the inpatient rehabilitation setting. Because most hospitals have adopted a smoke-free policy, hospitalization itself may initiate a period of nonsmoking in patients who were smokers at the time of their admission. In addition, some smokers choose to quit smoking after stroke or other medical crisis caused by the health risks associated with cigarette smoking. However, research has also revealed a rather low-smoking cessation rate (30%) among smokers who have had a transient ischemic attack despite the health benefits associated with smoking cessation. Given the significant health risks associated with cigarette smoking, particularly in the elderly and those with cerebrovascular compromise, the effects of smoking on the patient's health should be discussed with the patient during inpatient rehabilitation. Unfortunately, given the current healthcare demands of reducing lengths of hospitalization and the focus on functional outcomes, health promotion issues, such as smoking cessation, nutrition, exercise, may not receive the attention that they deserve. Despite these constraints, we believe that the inpatient rehabilitation setting provides an opportunity for a "teachable moment" to introduce the idea of smoking cessation to the active smoker or to encourage continued smoking cessation and relapse prevention to those patients who have not smoked since their admission to the acute care hospital. If instituted in an effective manner, we believe that there could be significant healthcare benefits in establishing a formal smoking cessation or relapse prevention program in the rehabilitation setting.     

Prevalence of patients continuing to smoke after vascular interventions

INTRODUCTION: Smoking is one of the most important risk factors for the development and progression of atherosclerosis. Smoking cessation is an obligatory element in the management of vascular problems and in patients scheduled for vascular interventions. The aim of this study was to assess the prevalence of patients smoking before and after vascular surgical procedures and to evaluate the requirements for inpatient programs for smoking cessation and nicotine replacement therapy. METHODS: 500 patients admitted for vascular interventions were included in this prospective study. Smoking status was evaluated both objectively and subjectively. All patients underwent measurements of exhaled breath carbon monoxide to quantify nicotine dependency and all answered a standardized Fagerstr?m questionnaire both on admission and after surgery to identify current smokers. RESULTS: Of 500 vascular patients included in the study, only 70 (14 %) never had smoked, 243 (49 %) had given up smoking before admission and 161 (32 %) were current smokers. Of the current smokers, 64 (40 %) did not smoke during hospitalization but 97 (60 %) continued to smoke in hospital. Of these 97 patients, 78 (80 %) were men and 19 women; their mean age was 61 +/- 4 years (range 40-84). Four patients had surgery for infrarenal aortic aneurysm, 40 underwent carotid endarterectomy and 53 had peripheral arterial occlusive disease (PAD). There was no difference between abstinent patients and continuing smokers in previous cigarette consumption or Fagerstr?m score, a predictor for long-term smoking behavior. Patients with carotid artery stenosis were significantly more abstinent while hospitalized (P = 0.006); patients with PAD, however, were more likely to continue smoking as inpatients (P = 0.004). Sixty-five percent of continuing smokers stated that they would stop smoking in hospital if counseling and nicotine replacement therapy were provided. With regard to their predominant location of atherosclerosis, patients with PAD were less willing than those with carotid stenosis to abstain from smoking while hospitalized (53 % vs 88 %, respectively; P < 0.001). CONCLUSION: A substantial proportion of patients admitted for vascular surgery are smokers. More than half of these continue to smoke in the hospital, an environment where smoking is prohibited by law. Counseling, nicotine replacement therapy and smoking-cessation programs are urgently needed for vascular surgical inpatients.     

Cigarette smoking and the risk of gestational and pregestational diabetes in two consecutive pregnancies

OBJECTIVE: Cigarette smoking during pregnancy may increase the risk of gestational diabetes mellitus (GDM) or pregestational diabetes mellitus (PDM). Smoking has been associated positively with hyperinsulinemia and insulin resistance in experimental studies, although the association with diabetes remains unclear. To further explore this issue, we examined the association with smoking in the largest prospective cohort study of GDM and PDM to date. RESEARCH DESIGN AND METHODS: The study population comprised 212190 women in the population-based Swedish Birth Registry who had their first and second deliveries between January 1987 and December 1995. Maternal characteristics were recorded in a standardized manner at the first prenatal visit, followed by a clinical examination and a standardized in-person interview to assess lifestyle habits. Women were categorized as nonsmokers, light smokers (one to nine cigarettes per day), or moderate-to-heavy smokers (at least 10 cigarettes per day). RESULTS: Women with GDM in their first pregnancy experienced an eight- to ninefold increased risk of GDM or PDM in their second pregnancy. Cigarette smoking was not associated with increased risk of these conditions. Neither women who smoked during their first and second pregnancies nor those who commenced smoking between pregnancies had a higher risk of GDM or PDM than nonsmokers. CONCLUSIONS: Our findings do not support an association between cigarette smoking and risk of GDM or PDM in young women of childbearing age.     

Quality improvement in primary health care using computerised journal, exemplified by a smoking cessation programme for diabetic patients

OBJECTIVE: To study the possibility of using the computerised journal for quality improvement in diabetes care. DESIGN: The computerised journal was used to reach all diabetic smokers aged 30-75 years and to invite them to a structured smoking cessation programme. The follow-up time was 18 months. SETTING: Habo, a Swedish community with 9600 inhabitants, with one primary health care centre. SUBJECTS:147 subjects, aged 30-75 years, were registered with the diagnosis of diabetes mellitus in the computerised journal at the primary health care centre. Altogetber 25 of these patients were registered as smokers in the journal. All of them were invited to a smoking cessation group. RESULTS: Information about smoking habits in the journal was available for all but 11%. After 18 months' follow-up, 9 of the 14 patients (64%) who started in the smoking cessation group had become non-smokers. Of those 11 subjects who did not attend the group, 6 had stopped smoking during the follow-up time in spite of not participating in the structured programme. CONCLUSION: The computerised journal is a useful tool for quality improvement, giving the opportunity for directed preventive efforts on selected patient groups.     

Smoking cessation in patients with diabetes mellitus: results from a controlled study of an intervention programme in primary healthcare in Sweden

OBJECTIVE: To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare. DESIGN: Regional controlled intervention study. SETTING: Seventeen primary healthcare centres in Sweden. INTERVENTION: In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up. PATIENTS: Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients. MAIN OUTCOME MEASURES: Self-reported smoking habits after one year. RESULTS: In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking. CONCLUSION: A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.     

Smoking cessation and low-income women: theory, research, and interventions

There is a growing body of evidence indicating women's experiences with smoking and cessation may be unique from those of men. Advanced practice nurses (APNs) in primary care are ideally suited to assess and intervene with this complex addiction. APNs must be competent in interventions that address cigarette smoking. This article will summarize the literature on smoking cessation interventions with an emphasis on women smokers.     

Assessment of cardiovascular risk factors among residents of a city in Jordan

Cardiovascular diseases are a leading cause of morbidity and mortality in many countries. The purpose of this study was to assess cardiovascular risk factors in a stratified randomly selected sample of a city near Amman, Jordan. A stratified sample of two hundred and nine randomly selected households were selected for this study. Adults from each of the households who agreed to participate in this study were asked about their cardiovascular risk factors including cigarette smoking, high blood pressure, cholesterol, diabetes, obesity, and sedentary lifestyle. The sample consisted of 84 males and 125 females ranging in age from 17 to 93 years with a mean age of 37 years. Findings identified significant cardiovascular risk factors included cigarette smoking, obesity, hypertension, stress, and diabetes. Cigarette smoking was much more common in men than women. Implications for nurses are discussed with suggestions for future research.     

Rationale and design of a clinical trial investigating resistance training as an aid to smoking cessation in persons with multiple sclerosis

Cigarette smoking is the leading preventable cause of death and disease among adults, and there is evidence that smokers with multiple sclerosis (MS) are at an increased risk for accelerated disease conversion and progression toward disability. Recent research has shown resistance training (i.e., weight training) to be beneficial for smoking cessation in the general population; however, no study has examined the use of resistance training as an aid to cessation in those with MS. Methods: After receiving brief smoking cessation counseling and the nicotine patch, smokers with relapsing-remitting MS will be randomized into a Resistance Training (RT) or Contact Control (CC) group. Participants in the RT group will attend a 60-minute resistance training session twice weekly for eight weeks, while participants in the CC will attend a 30-minute health education control session twice weekly for eight weeks. Measurements will be taken at baseline, weekly during the intervention, at the end of the eight-week study period, and at a one-month follow-up. The primary outcome will be smoking cessation, indicated by a 7-day abstinence, and verified by biochemical assay (i.e., carbon monoxide breath test). Secondary outcomes will include other smoking-related variables (e.g., nicotine withdrawal symptoms), multiple sclerosis-related factors (e.g., fatigue), and physical assessments (e.g., muscular strength). Discussion: The results from this study will lay the foundation for subsequent tests of the intervention in smokers with MS, with the long-term goal of providing specific recommendations and guidelines for smoking cessation that can be integrated into the clinical care of persons with MS.     

Promoting smoking cessation among nursing students: how faculty can help

Cigarette smoking is a major health issue in the United States. Research has shown that more than a quarter of young adults aged 18-24 are smokers, and there has been a recent rise in the prevalence of cigarette smoking among college students. Many researchers have investigated smoking among nursing students, in the United States and worldwide. This article provides an overview of these research findings and a discussion of interventions that may help promote smoking cessation. Nurse faculty are encouraged to take a lead in smoking cessation efforts.     

Association of Smoking Status, Weight Change, and Incident Metabolic Syndrome in Men: A 3-Year Follow-Up Study

OBJECTIVE

We investigated the incidence of the metabolic syndrome and assessed the effect of smoking status and weight change on incident metabolic syndrome.

RESEARCH DESIGN AND METHODS

This study included 4,542 men without metabolic syndrome at baseline who were followed for an average of 3 years. Subjects were divided into four categories according to smoking status at baseline and at the 3-year follow-up.

RESULTS

The overall incidence of metabolic syndrome was 10.6%: 8.0% in nonsmokers, 7.1% in new smokers, 17.1% in ex-smokers, and 13.9% in sustained smokers (P < 0.001). In a multivariate regression model, ex-smokers had significantly increased odds for incident metabolic syndrome with a mean 1.45 (95% CI 1.06–1.98) compared with sustained smokers. This was no longer significant after including weight change.

CONCLUSIONS

Smoking cessation within 3 years may be a higher risk factor for incident metabolic syndrome than sustained smoking, indicating that weight control in ex-smokers is critical to attenuate the additional risk for incident metabolic syndrome.As the number of smokers who quit cigarette smoking is increasing, recent research has focused on the impact of prior smoking on cardiometabolic disorders. Several epidemiological studies have reported that smoking cessation is associated with an increased prevalence of the metabolic syndrome (1,2) compared with that of nonsmokers. However, the studies were cross-sectional and could not exactly evaluate the effects of smoking status on the risk of incident metabolic syndrome. The aim of the present study was to investigate the 3-year incidence of metabolic syndrome in men who did not have metabolic syndrome at baseline and to assess the effect of smoking status and weight change on the risk of incident metabolic syndrome.     

The effect of smoking cessation and subsequent resumption on absorption of inhaled insulin

OBJECTIVE: To assess the absorption profile of inhaled insulin in healthy, actively smoking subjects at baseline, after smoking cessation, and after smoking resumption and compare it with nonsmoking subjects. RESEARCH DESIGN AND METHODS: Insulin pharmacokinetics and glucodynamics were measured in 20 male smoking subjects (10-20 cigarettes/day) and 10 matched nonsmoking subjects after receiving inhaled insulin (1 mg) or the approximate subcutaneous insulin equivalent (3 units) in a randomized cross-over fashion. All smokers then received inhaled insulin 12 h, 3 days, and 7 days into a smoking cessation period. They then resumed smoking for 2-3 days before again receiving inhaled insulin 1 h after the last cigarette. RESULTS: Before smoking cessation, maximum insulin concentration (Cmax) and area under the curve (AUC) for insulin concentration time (AUC-Insulin(0-360)) with inhaled insulin were higher, and time to Cmax (t(max)) shorter, in smokers than nonsmokers (Cmax 26.8 vs. 9.7 microU/ml; AUC-Insulin(0-360) 2,583 vs. 1,645 microU x ml(-1) x min(-1); t(max) 20 vs. 53 min, respectively; all P < 0.05), whereas with subcutaneous insulin, systemic exposure was unchanged (AUC-Insulin(0-360) 2,324 vs. 2,269 microU x ml(-1) x min(-1); P = NS). After smoking cessation, AUC-Insulin(0-360) decreased with inhaled insulin by up to 50% within 1 week and approached nonsmoker levels. Cmax decreased and t(max) increased relative to baseline but were still not comparable with nonsmoker values. Smoking resumption completely reversed the effect of smoking cessation. Glucodynamics corroborated the observed findings in insulin pharmacokinetics. CONCLUSIONS: Cessation and resumption of smoking greatly altered the pharmacokinetics of inhaled insulin. As rapid changes in systemic insulin exposure increase hypoglycemia risk, inhaled insulin should not be used in people with diabetes who choose to continue smoking. This is consistent with recommendations that people with diabetes refrain from smoking altogether.     

Why are death rates from coronary heart disease decreasing? Which preventive measures are effective?

Many factors have probably contributed to the observed decline in mortality from coronary disease in the United States since 1968. The issue of whether the incidence of such disease is declining remains to be clarified. The efficacy of primary prevention of coronary artery disease by multiple risk factor modification has been tested in large-scale clinical trials. Among middle-aged, normotensive, hypercholesterolemic smokers, smoking cessation and reduction of cholesterol levels by dietary change are followed by a decreased incidence of coronary events. Groups at high risk because of the combination of hypertension, cigarette smoking, and hypercholesterolemia show reduced coronary disease mortality after drug treatment of hypertension combined with cessation or reduction of cigarette smoking and dietary reduction of cholesterol levels. Primary prevention may be more effective if efforts begin early in life before behaviors and physiologic characteristics that may increase risk become established.     

Cigarette Smoking does not Induce Plasma or Pulmonary Oxidative Stress after Moderate-intensity Exercise

[Purpose] Cigarette smoking increases oxidative stress, which is a risk factor for several diseases. Moreover, strenuous exercise has been shown to induce plasma and pulmonary oxidative stress in young cigarette smokers. However, no previous reports have demonstrated whether plasma and pulmonary oxidative stress occur after moderate-intensity exercise. Therefore, the aim of this study was to clarify whether moderate-intensity exercise induces pulmonary and plasma oxidative stress in smokers. [Subjects] Ten young male smokers and 10 young male nonsmokers participated in this study. [Methods] Plasma hydroperoxide concentrations were measured at baseline and then immediately and 15 min after moderate-intensity exercise. Hydrogen peroxide concentrations in exhaled breath condensate were measured at baseline and after exercise. [Results] No significant interactions were found between smokers and nonsmokers in terms of hydroperoxide or hydrogen peroxide concentrations following moderate-intensity exercise at any time point. [Conclusion] These findings suggested that moderate-intensity exercise did not induce plasma or pulmonary oxidative stress in young cigarette smokers.Key words: Oxidative stress, Cigarette smoker, Moderate-intensity exercise     

Weight gain among women during smoking cessation: testing the effects of a multifaceted program.

Cigarette smoking continues to be the leading preventable cause of chronic illness in the United States. A high percentage of smokers attempt to quit each year; however, smoking cessation success rates are low. Adding an exercise program to traditional therapies can increase smoking cessation rates among women. An experimental design was used to test two hypotheses. The first was that women who engage in a multifaceted approach to smoking cessation that includes a structured exercise program, nicotine replacement therapy (NRT), and weekly counseling sessions will experience less weight gain during an 8-week smoking cessation program and at the 4-month follow-up session than women who engage in NRT and weekly counseling sessions alone. The second was that women who engage in a structured exercise program with NRT and weekly counseling sessions will have higher smoking cessation rates at the end of the 8-week smoking cessation program and at the 4-month follow-up session than women who engage in NRT and weekly counseling sessions alone.     

Facilitated nitration and oxidation of LDL in cigarette smokers

BACKGROUND: Cigarette smoking increases the risk of developing atherosclerosis and ischaemic heart disease. Smoking-induced oxidative stress is considered to favour oxidation of low-density lipoprotein (LDL) and subsequently promotes the atherogenic process. We investigated whether peroxynitrite, a reaction product of cigarette smoke, is involved in facilitated oxidation of LDL in smokers. MATERIALS AND METHODS: Plasma LDL was obtained from 10 healthy asymptomatic cigarette smokers and 10 healthy nonsmokers. The state of enhanced oxidative stress in the plasma was assessed by LDL subfraction assay using anion-exchange high-performance liquid chromatography (AE-HPLC) and measurements of thiobarbituric acid-reactive substances (TBARS), 8-hydroxydeoxyguanosine (8-OHdG), vitamin E, 3-nitrotyrosine and 3-chlorotyrosine. RESULTS: Smokers showed a significantly higher level of TBARS and 8-OHdG as well as a significantly lower level of vitamin E than nonsmokers, even after stopping smoking for 10 h or more. The LDL subfraction assay demonstrated an increase in oxidatively modified LDL, as expressed by lower levels of LDL1 and higher levels of LDL2. The 3-nitrotyrosine levels in apolipoprotein B in LDL were significantly higher in smokers than nonsmokers, while the 3-chlorotyrosine levels remained unchanged. In addition, these changes observed in the smokers were further accelerated within 30 min after resumption of cigarette smoking when compared with the levels before smoking resumption. CONCLUSION: The present study suggests that peroxynitrite plays a significant role in oxidative modification of plasma LDL induced by cigarette smoking.     

Smoking cessation improves insulin sensitivity in healthy middle-aged men

Cigarette smokers have recently been shown to exhibit insulin resistance, dyslipidaemia and markers of the insulin resistance syndrome (IRS). The aim of this study was to examine the effects of smoking cessation on insulin sensitivity and IRS. Forty male, non-obese healthy smokers participated in this open parallel study with 8 weeks of follow-up. Seventeen subjects were able to stop smoking, while 23 subjects continued to smoke and served as a controls group. Anthropometric and metabolic data were measured. Degree of insulin sensitivity was determined with the euglycaemic hyperinsulinaemic clamp technique. Smoking cessation increased insulin sensitivity and improved the lipoprotein profile in spite of a modest increase in body weight. Initial smoking habits correlated positively with the increase in BMI as well as the improvements in the metabolic variables after smoking cessation. These data support the view that smoking causes insulin resistance and IRS, and also demonstrate that the beneficial metabolic effects of smoking cessation override the effects of an accompanying modest increase in body weight.     

The impact of repeated spirometry and smoking cessation advice on smokers with mild COPD

BACKGROUND: Smoking cessation is the most important therapeutic intervention in patients with chronic obstructive pulmonary diseases (COPD) and the health benefits are immediate and substantial. Major efforts have been made to develop methods with high smoking cessation rates. OBJECTIVES: To study whether a combination of spirometry and brief smoking cessation advice to smokers with COPD, annually for three years, increased their smoking cessation rate in comparison with groups of smokers with normal lung function. METHOD: Prospective, randomized study in primary care. Smoking cessation rates were compared between smokers with COPD followed-up yearly over a period of three years and smokers with normal lung function followed-up yearly for three years or followed-up only once after three years. RESULTS: The point-prevalence abstinence rate and prolonged abstinence rate at 6 and 12 months increased yearly and in smokers with COPD at year 3 was 29%, 28%, and 25%, respectively. The abstinence rates were significantly higher in smokers with COPD than in smokers with normal lung function. Smoking cessation rates among smokers with normal lung function did not increase with increasing number of follow-ups. CONCLUSION: Smokers diagnosed with COPD stopped smoking significantly more often than those with normal lung function.