Smoking and mechanisms of cardiovascular control

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Electronic Cigarette Use and the Risk of Cardiovascular Diseases

Electronic cigarettes or e-cigarettes are the most frequently used tobacco product among adolescents. Despite the widespread use of e-cigarettes and the known detrimental cardiac consequences of nicotine, the effects of e-cigarettes on the cardiovascular system are not well-known. Several in vitro and in vivo studies delineating the mechanisms of the impact of e-cigarettes on the cardiovascular system have been published. These include mechanisms associated with nicotine or other components of the aerosol or thermal degradation products of e-cigarettes. The increased hyperlipidemia, sympathetic dominance, endothelial dysfunction, DNA damage, and macrophage activation are prominent effects of e-cigarettes. Additionally, oxidative stress and inflammation are unifying mechanisms at many levels of the cardiovascular impairment induced by e-cigarette exposure. This review outlines the contribution of e-cigarettes in the development of cardiovascular diseases and their molecular underpinnings.

Cigarette smoking and metabolic syndrome components: a cross-sectional study from Maracaibo City, Venezuela

Background: A growing body of evidence suggests that cigarette smoking can cause the onset of metabolic syndrome prior to cardiovascular diseases. Therefore, the objective of this study was to evaluate the relationship between smoking habit and metabolic syndrome components in an adult population from Maracaibo city, Venezuela. Methods: The Maracaibo City Metabolic Syndrome Prevalence Study is a descriptive, cross-sectional study with random and multi-stage sampling. In this sub-study, 2212 adults from both genders were selected. On the basis of their medical background, they were classified as smokers, non-smokers and former smokers. Metabolic syndrome was defined according to Harmonizing 2009 criteria, using population-specific abdominal circumference cut-off points. The association between risk factors was evaluated using a logistic regression model. Results: In the studied population, 14.8% were smokers, 15.4% were former smokers. In the multivariate analysis, the presence of metabolic syndrome (smokers: OR, 1.54; 95% CI, 1.11-2.14; p=0.010) and its components were related to cigarette smoking, with the exception of hyperglycemia. High blood pressure was inversely associated with current smoking status (smokers: OR, 0.70 (0.51-0.95); p=0.025). Conclusion: Cigarette smoking represents a related factor with metabolic syndrome, being associated with low high-density lipoprotein-cholesterol, increased abdominal circumference and elevated triacylglyceride levels. Former smokers did not present a greater risk for developing this metabolic disease when compared to non-smokers. The effect of avoiding this habit should be evaluated in future studies in our population.

Cigarette smoking and metabolic syndrome components: a cross-sectional study from Maracaibo City, Venezuela

Background: A growing body of evidence suggests that cigarette smoking can cause the onset of metabolic syndrome prior to cardiovascular diseases. Therefore, the objective of this study was to evaluate the relationship between smoking habit and metabolic syndrome components in an adult population from Maracaibo city, Venezuela. Methods: The Maracaibo City Metabolic Syndrome Prevalence Study is a descriptive, cross-sectional study with random and multi-stage sampling. In this sub-study, 2212 adults from both genders were selected. On the basis of their medical background, they were classified as smokers, non-smokers and former smokers. Metabolic syndrome was defined according to Harmonizing 2009 criteria, using population-specific abdominal circumference cut-off points. The association between risk factors was evaluated using a logistic regression model. Results: In the studied population, 14.8% were smokers, 15.4% were former smokers. In the multivariate analysis, the presence of metabolic syndrome (smokers: OR, 1.54; 95% CI, 1.11-2.14; p=0.010) and its components were related to cigarette smoking, with the exception of hyperglycemia. High blood pressure was inversely associated with current smoking status (smokers: OR, 0.70 (0.51-0.95); p=0.025). Conclusion: Cigarette smoking represents a related factor with metabolic syndrome, being associated with low high-density lipoprotein-cholesterol, increased abdominal circumference and elevated triacylglyceride levels. Former smokers did not present a greater risk for developing this metabolic disease when compared to non-smokers. The effect of avoiding this habit should be evaluated in future studies in our population.

Cigarette smoking and metabolic syndrome components: a cross-sectional study from Maracaibo City, Venezuela

Background: A growing body of evidence suggests that cigarette smoking can cause the onset of metabolic syndrome prior to cardiovascular diseases. Therefore, the objective of this study was to evaluate the relationship between smoking habit and metabolic syndrome components in an adult population from Maracaibo city, Venezuela. Methods: The Maracaibo City Metabolic Syndrome Prevalence Study is a descriptive, cross-sectional study with random and multi-stage sampling. In this sub-study, 2212 adults from both genders were selected. On the basis of their medical background, they were classified as smokers, non-smokers and former smokers. Metabolic syndrome was defined according to Harmonizing 2009 criteria, using population-specific abdominal circumference cut-off points. The association between risk factors was evaluated using a logistic regression model. Results: In the studied population, 14.8% were smokers, 15.4% were former smokers. In the multivariate analysis, the presence of metabolic syndrome (smokers: OR, 1.54; 95% CI, 1.11-2.14; p=0.010) and its components were related to cigarette smoking, with the exception of hyperglycemia. High blood pressure was inversely associated with current smoking status (smokers: OR, 0.70 (0.51-0.95); p=0.025). Conclusion: Cigarette smoking represents an independent risk factor for the development of metabolic syndrome, being associated with low high-density lipoprotein-cholesterol, increased abdominal circumference and elevated triacylglyceride levels. Former smokers did not present a greater risk for developing this metabolic disease when compared to non-smokers. The effect of avoiding this habit should be evaluated in future studies in our population.

Haemodynamic responses to tobacco smoke inhalation in male adolescents in Lusaka, Zambia

Background

Tobacco smoke causes changes in the levels of catecholamines in the blood. This leads to an increase in blood pressure and heart rate. This is due to nicotine which has also been noted to cause a decrease in vasodilatory activities leading to an increase in both the blood pressure and heart rate.

Aim

To determine the acute effects of tobacco smoke on haemodynamics in black male adolescents in Lusaka, Zambia.

Study design

This was an observational study done at the University of Zambia School of Medicine Cardiovascular Research Laboratory in the month of December, 2014.

Methodology

Twenty-two (22) black, male-adolescent (age range 19-25 years), active-smokers, consented to participate in the study. The Diasys Ambulatory Blood Pressure Monitoring system (Novacor, France) was used to obtain the Systolic and Diastolic blood pressures (SBP and DBP) and the heart rate. These were obtained 15 minutes before smoking at 5 minute intervals and averaged to obtain the baseline, during the 15 minutes of smoking and on immediate cessation of smoking and thereafter every 15 minutes up to an hour after smoking.

Results

There was a significant rise in SBP (mmHg) during smoking (127.9 ± 13.80 mmHg) from baseline values (113.5 ± 13.15 mmHg) (P = .00). It took 30 minutes for the SBP to return to baseline after cessation of smoking. DBP (mmHg) also increased from baseline (79.5 ± 8.79 mmHg) to 85.6 ± 10.92 mmHg during smoking (P = .01). It returned to baseline values immediately after cessation of smoking. The heart rate (bpm) was also noted to significantly increase during smoking (95.2 ± 16.72 bpm) from the values noted before smoking (74.3 ± 13.75 bpm) (P = .05). The mean value for heart rate returned to baseline value by the 15^th minute of recovery.

Conclusion

The present study demonstrates that smoking may be the cause for the acute increases in SBP, DBP and heart rate in smokers. The smoking caused significant increases in all the haemodynamic indices considered in this study within 15 minutes. Both SBP and DBP increase are indices for stroke and coronary heart disease respectively. The effect of increased SBP was noted to last for 30 minutes while DBP returned to baseline immediately after smoking. A significant increase in heart rate was also noted in the study.

Projection target-specific action of nicotine in the caudal nucleus of the solitary tract

The brainstem nucleus of the solitary tract (NTS) is the key integrating relay in the central processing of sensory information from the thoracic and from most subdiaphragmatic viscera. Modulation of neuronal excitability and synaptic activity in the NTS by nicotinic agents can have potent effects on vital physiological functions, such as feeding, digestion, respiration, and blood circulation. Caudal NTS neurons demonstrate considerable heterogeneity in projection targets, synaptic properties, and expression of nicotinic acetylcholine receptors (nAChRs). However, despite its heterogeneity, the caudal NTS may contain discrete subsets of neurons with unique projection target-specific properties. To test this hypothesis, we used in vivo fluorescent tracing and ex vivo patch-clamp electrophysiology to evaluate responsiveness to nicotine of anatomically identified caudal NTS neurons that project to the hypothalamic paraventricular nucleus (PVN) and the brainstem caudal ventrolateral medulla (CVLM). The results of this study demonstrate that responsiveness to nicotine correlates with where the neurons project. Specifically, PVN-projecting caudal NTS neurons respond to nicotine only presynaptically (i.e., via activation of presynaptic nAChRs and potentiation of synaptic release of glutamate), suggesting indirect, glutamate-dependent effects of nicotine on the PVN-projecting NTS circuitry. By contrast, CVLM-projecting caudal NTS neurons exhibit only limited presynaptic, but dominant somatodendritic, responsiveness to nicotine, suggesting that the effects of nicotine on the CVLM-projecting NTS circuitry are direct and largely glutamate independent. Understanding the relationships among function-specific brainstem/hypothalamic neuronal networks, nuclei, and individual neurons could help develop therapies targeting identifiable neuronal circuits to offset impaired autonomic homeostasis.

Patterns of nicotinic receptor antagonism II: cardiovascular effects in rats

BACKGROUND

Tobacco cessation pharmacotherapies currently are limited to nicotine itself, the partial nicotine agonists varenicline and cytisine, and the antidepressant bupropion. Compared with agonists, nicotinic antagonists such as the noncompetitive, nonselective compound mecamylamine, and the competitive, α4β2-preferring antagonist dihydro-β-erythroidine (DHβE) may be a novel approach to the treatment of tobacco smoking as both are effective antagonists of nicotine's central effects. Considering nicotinic acetylcholine receptors mediate critical peripheral effects of acetylcholine, such as cardiovascular effects, it is important to study how nicotinic antagonists would alter the cardiovascular system and the cardiovascular changes induced by nicotine.

METHODS

The effects of several nicotinic agonists and antagonists on blood pressure and heart rate were measured in conscious, unrestrained rats following parenteral administration using a telemetry system.

RESULTS

Nicotine and other nicotinic receptor agonists (epibatidine, varenicline, and cytisine) produced similar increases in blood pressure, whereas their effects on heart rate were biphasic. The cardiovascular changes were attenuated by the nonselective nicotine antagonist, mecamylamine, but the peripherally restricted antagonist hexamethonium blocked only the agonist-induced changes in blood pressure. The α7-preferring antagonist, MLA, and the α4β2-preferring antagonist, DHβE, were much less effective in blocking the agonist-induced cardiovascular changes, indicating that nicotine's cardiovascular effects, are due to activation at autonomic ganglia involving nicotinic receptor subtypes other than α4, α7, or β2.

CONCLUSIONS

The data indicate that the cardiovascular effects of nicotine and nicotine-like agents are mediated through receptor mechanisms that are distinct from those that mediate the central effects of nicotine.

AAV-directed persistent expression of a gene encoding anti-nicotine antibody for smoking cessation

Current strategies to help tobacco smokers quit have limited success as a result of the addictive properties of the nicotine in cigarette smoke. We hypothesized that a single administration of an adeno-associated virus (AAV) gene transfer vector expressing high levels of an anti-nicotine antibody would persistently prevent nicotine from reaching its receptors in the brain. To test this hypothesis, we constructed an AAVrh.10 vector that expressed a full-length, high-affinity, anti-nicotine antibody derived from the Fab fragment of the anti-nicotine monoclonal antibody NIC9D9 (AAVantiNic). In mice treated with this vector, blood concentrations of the anti-nicotine antibody were dose-dependent, and the antibody showed high specificity and affinity for nicotine. The antibody shielded the brain from systemically administered nicotine, reducing brain nicotine concentrations to 15% of those in naïve mice. The amount of nicotine sequestered in the serum of vector-treated mice was more than seven times greater than that in untreated mice, with 83% of serum nicotine bound to immunoglobulin G. Treatment with the AAVantiNic vector blocked nicotine-mediated alterations in arterial blood pressure, heart rate, and locomotor activity. In summary, a single administration of a gene transfer vector expressing a high-affinity anti-nicotine monoclonal antibody elicited persistent (18 weeks), high titers of an anti-nicotine antibody that obviated the physiologic effects of nicotine. If this degree of efficacy translates to humans, AAVantiNic could be an effective preventative therapy for nicotine addiction.

Determination of nicotine absorption from multiple tobacco products and nicotine gum

INTRODUCTION

Snus is a smokeless tobacco product traditionally used in Scandinavia and available in pouched or loose forms. The objective of this study was to determine nicotine absorption for current pouched and loose snus products in comparison with a cigarette and an over-the-counter nicotine gum.

METHODS

We conducted an open-label, randomized, 6-way, crossover study involving 20 healthy snus and cigarette users. One of 6 products (2 pouched snus, 2 weights of loose snus, a cigarette, and a nicotine gum) was administered at each of 6 visits. Blood samples were taken at intervals over 120 min and sensory perception assessed by questionnaire.

RESULTS

For the 4 smokeless tobacco products and the nicotine gum, blood plasma levels of nicotine were ranked according to total nicotine content as follows: loose snus (27.1 mg nicotine) > pouched snus (14.7 mg nicotine) > loose snus (10.8 mg nicotine) = pouched snus (10.7 mg nicotine) > nicotine gum (4.2 mg nicotine). The area under the plasma concentration-time curve (AUC) and maximum plasma concentration (C(max)) of nicotine ranged from 26.9 to 13.1 ng.h/ml and 17.9 to 9.1 ng.h/ml, respectively across all the products. Nicotine was absorbed more rapidly from the cigarette but systemic exposure was within the range of the smokeless tobacco products (AUC = 14.8 ng.h/ml; C(max) = 12.8 ng.h/ml).

CONCLUSIONS

This study has generated new information on comparative nicotine absorption from a cigarette, loose snus, and pouched snus typical of products sold in Scandinavia. The similar nicotine absorption for 1 g portions of loose and pouched snus with approximately 11 mg of nicotine indicate that absorption kinetics were dependent on quantity of tobacco by weight and total nicotine content rather than product form.

Effects of cigarette smoking on hearing recovery from noise-induced temporary hearing threshold shifts in mice

HYPOTHESIS

Cigarette smoking may potentiate noise-induced hearing loss.

BACKGROUND

Many epidemiological studies have shown that cigarette smoking is a major risk factor for noise-induced hearing loss.

METHODS

BALB/c mice were exposed to passive smoking for 2 h/d for 2 weeks before exposure to 110-dB sound pressure level white noise for 3 hours once. Hearing was assessed via the auditory brainstem response with tone-burst stimulation and distortion product otoacoustic emissions before and at 1, 3, 5, 7, 14, 21, and 28 days after noise exposure. Oxidative stress and hypoxia were assessed by immunostaining with 8-oxoG and hypoxia-inducible factor 1α, respectively.

RESULTS

Control mice unexposed to both smoking and noise and mice exposed to smoking only showed no shift in hearing threshold. In contrast, mice exposed to noise only or smoking plus noise showed abrupt increases in hearing threshold. In mice exposed to noise only, hearing threshold returned to prenoise levels after 2 weeks. However, in mice exposed to smoking plus noise, the loss of hearing was significantly higher, and hearing threshold did not return to the pre-exposure levels until 4 weeks later. Positive staining with 8-oxoG and hypoxia-inducible factor 1α were observed in the inner ear of the smoking-only and smoking-plus-noise group similar to noise-only mice, whereas no positive staining was observed in control group.

CONCLUSION

These results indicate that cigarette smoking may potentiate the harmful effects of noise on hearing and disturb the recovery mechanism in the cochlea.

Heart rate variability in occupational health --a systematic review

This systematic review evaluates and summarizes the evidence of association between work-related factors and heart rate variability (HRV) in workers. We reviewed English articles indexed in MEDLINE under the key words: work, worker, occupational, industrial, and heart rate variability. Studies were included if one or more of the dependent variables was one of the time- or frequency-domain indexes of HRV [standard deviation of all normal-to-normal (NN) intervals (SDNN), mean of the 5-min standard deviations of NN intervals calculated over several hours (SDNN index), the root mean squared differences of successive NN intervals (RMSSD), integrated spectral powers of high (HF, > 0.15 Hz) and low frequency (LF, 0.04-0.15 Hz) HRV, and the LF/HF ratio] as recommended by the European Society of Cardiology and the North American Society of Pacing Electrophysiology. Physical and chemical work environments (i.e. exposure to occupational toxicants and hazardous environments), psychosocial workload (i.e. job stressors), and working time (i.e. shift work) had been examined and identified as having associations with low HF power. These findings may indicate that research into parasympathetic nervous system activity should be focused to protect cardiovascular health at work. We also propose the use of very low and ultralow frequency HRV components in autonomic research for workers' health.

Nitric oxide modulates the cardiovascular effects elicited by acetylcholine in the NTS of awake rats

Microinjection of acetylcholine chloride (ACh) in the nucleus of the solitary tract (NTS) of awake rats caused a transient and dose-dependent hypotension and bradycardia. Because it is known that cardiovascular reflexes are affected by nitric oxide (NO) produced in the NTS, we investigated whether these ACh-induced responses depend on NO in the NTS. Responses to ACh (500 pmol in 100 nl) were strongly reduced by ipsilateral microinjection of the NOS inhibitor NG-nitro-l-arginine methyl ester (l-NAME; 10 nmol in 100 nl) in the NTS: mean arterial pressure (MAP) fell by 50 ± 5 mmHg before l-NAME to 9 ± 4 mmHg, 10 min after l-NAME, and HR fell by 100 ± 26 bpm before l-NAME to 20 ± 10 bpm, 10 min after l-NAME (both P < 0.05). Microinjection of the selective inhibitor of neuronal nitric oxide synthase (nNOS), 1-(2-trifluoromethylphenyl) imidazole (TRIM; 13.3 nmol in 100 nl), in the NTS also reduced responses to ACh: MAP fell from 42 ± 3 mmHg before TRIM to 27 ± 6 mmHg, 10 min after TRIM ( P < 0.05). TRIM also tended to reduce ACh-induced bradycardia, but this effect was not statistically significant. ACh-induced hypotension and bradycardia returned to control levels 30–45 min after NOS inhibition. Control injections with d-NAME and saline did not affect resting values or the response to ACh. In conclusion, injection of ACh into the NTS of conscious rats induces hypotension and bradycardia, and these effects may be mediated at least partly by NO produced in NTS neurons.

Effects of cigarette smoking on heart rate variability and plasma N-terminal pro-B-type natriuretic peptide in healthy subjects: is there the relationship between both markers?

BACKGROUND

Cigarette smoking increased the risk of acute cardiac events related with endothelial dysfunction and increased sympathetic activity. Impaired autonomic nervous activity is recognized as a considerable symptom of cardiac dysfunction and is strongly associated with increased risk overall mortality.

METHODS

A total of 75 healthy habitual smokers (40 female, 35 male, mean age 36.5 +/- 8.5 years), and 73 non-smokers subjects (45 female, 28 male, mean age 34.6 +/- 7.2 years) were studied. LF and LF/HF ratio were significantly higher in smokers than in non-smokers. On the contrary, SDNN, SDANN, RMSSD, and HF values were lower in smokers compared to those in non-smokers. Not the duration of smoking but the number of cigarettes smoked per day was correlated with the HRV parameters and NT-pro BNP. Furthermore, the average levels of NT-pro BNP were found to be positively correlated with LF, LF/HF and inversely correlated with SDNN, SDANN, RMSSD and HF.

RESULTS

As a result, smoking impaires sympathovagal balance and decreases the heart rate variability in healthy subjects. And even a one cigarette smoking leads to overt sympathetic excitation. Furthermore, smoking results in an increase in NT-proBNP levels and the changes in adrenergic nervous system and NT-proBNP levels are well correlated.

CONCLUSION

These findings could contribute to the higher rate of cardiovascular events in smokers.

Prevalence of substance-related disorders in heart transplantation candidates

Substance abuse cessation is one of the leading factors in determining the eligibility for the heart transplantation waiting list, as noncompliance with this issue may seriously endanger posttransplantation outcomes. Yet, the prevalence of substance-related disorders among candidates for heart transplantation has not been evaluated enough. Eighty three heart transplantation candidates were assessed for prior or current substance-related disorders through the Structured Clinical Interview for mental disorders according to DSM-IV. A prior history of at least one substance-related disorder was found in 64% of patients, with nicotine dependence as the most prevalent diagnosis (61.4% of the sample). Ten subjects were currently smokers, despite heart failure. A prior history of alcohol abuse and caffeine intoxication was found in 9.6% and 2.4% of patients, respectively. Substance abuse or dependence behaviors should be monitored during all the phases of heart transplantation program. Early identification of current substance-related disorders may allow better allocation of organ resources and proper lifestyle modification programs provision. A prior history of substance-related disorders should alert physicians to assess patients for possible relapse, especially after transplantation. The inclusion of a specialist in the assessment and treatment of substance-related disorders in the heart transplantation unit may reduce the risk of unsuccessful outcomes due to noncompliance with an adequate lifestyle.

Chronic nicotine administration. Analysis of the development of hypertension and glutamatergic neurotransmission

Among numerous neurotransmitters involved in central cardiovascular control, glutamate is one of the most studied transmitters that are related to nicotine considering its release and its postsynaptic regulation. However, there are no conclusive studies about nicotine effects on glutamatergic system and its relevance on hypertension development, which can help to understand the role of these two systems in that pathology. In this context, the objective of the present study is to evaluate the effects of systemic chronic nicotine exposure on hypertension development as well as the interaction between nicotine and the glutamatergic system in normotensive and neurogenic hypertensive rats. By means of high performance liquid chromatograph, immunohistochemistry, in situ hybridization and binding techniques, glutamatergic system was evaluated in SHR and Wistar Kyoto (WKY) rats treated with nicotine, delivered subcutaneously through nicotine pellets, for 8 weeks. The most important findings in this study were that (1) moderate doses of nicotine accelerated the onset and increased blood pressure in SHR but not in WKY rats, (2) the nicotine dosage and time of treatment employed did not affect body weight, (3) chronic nicotine treatment differentially affected glutamatergic system in normotensive and hypertensive rats, and (4) spontaneously hypertensive rats seem to be more sensitive to peripherally administered nicotine than Wistar Kyoto rats considering blood pressure and glutamatergic neurotransmission changes. In conclusion, we have demonstrated that a moderate dose of nicotine accelerates the onset and exacerbates hypertension in the SHR and that might be, at least in part, related to the modulation of glutamatergic neurotransmission.

Association between smoking status and cardiovascular and cortisol stress responsivity in healthy young men

Acutely, cigarette smoking stimulates increases in blood pressure (BP), heart rate (HR), and cortisol, but little evidence is available concerning the impact of habitual smoking status on cardiovascular stress responsivity. This relation was assessed in 86 healthy male firefighters, age 19 to 31. comprising 52 nonsmokers and 34 smokers. Measures of BP, HR, salivary free cortisol, breathing pattern, and self-reported stress and alertness were obtained while subjects performed nonverbal mental arithmetic and a socially evaluative speech task. Systolic and diastolic BP were higher at rest in nonsmokers than smokers, and a consistent difference in stress responsivity was also found. BP, HR, and cortisol responses to mental arithmetic were significantly smaller in smokers than nonsmokers, with mean changes in BP (adjusted for body weight) averaging 19.3/11.0 mmHg and 28.5/15.4 mmHg in smokers and nonsmokers, respectively. There were no effects of smoking status on task performance or subjective stress responses and no differences between groups in family health history, health-related behaviors, o r psychological characteristics that might account for the reactivity difference. Possible explanations of the results are discussed, and methodological implications for cardiovascular stress reactivity studies are outlined.

The smoking gun: many conditions associated with tobacco exposure may be attributable to paradoxical compensatory autonomic responses to nicotine

Tobacco exposure is implicated in many illnesses such as cardiovascular disease and cancer, but the mechanisms underlying these associations are poorly understood. The mechanisms by which tobacco induces pro-sympathetic and pro-inflammatory changes also remain elusive. Some studies have attributed these changes to the direct effects of nicotine, but such findings run counter to the pro-vagal, anti-inflammatory nature of the nicotinic pathway. We hypothesize that the illnesses associated with smoking may be partly attributable to autonomic dysfunction, sympathetic bias, and T helper (Th)2 inflammation induced by a paradoxical compensatory response to intermittent nicotinic exposure. The confusion of interpreting the adrenergia and inflammation associated with nicotine as a primary response instead of a secondary compensation may be explained by the unusually rapid absorption, action, and serum elimination of nicotine. Given the fast action and clearance of nicotine, even heavy smokers spend large portions of the day and the entire night in nicotine withdrawal, at which time rebound sympathetic bias may manifest as a result of desensitization of nicotinic receptors. This may help reconcile why the features observed in smokers such as tachycardia, hypertension, inflammation, insomnia, and anxiety, which are perhaps mistakenly attributed to the direct action of nicotine, are identical to those seen during acute nicotine withdrawal after smoking cessation. On the other hand, delayed responses to cessation of smoking such as weight gain and increased heart rate variability are compatible with reduced sympathovagal ratio and resensitization of nicotinic receptors. Sympathetic bias and the associated Th2 inflammation underlie many systemic diseases. Tobacco-related cancers may be partly attributable to immunomodulatory properties of chronic nicotine exposure by dampening Th1 immunity and enabling tumoral evasion of immune surveillance. Other conditions associated with tobacco exposure may also operate through similar autonomic and immune dysfunctions. Therapeutic implications are discussed.

Oral vitamin C ameliorates smoking-induced arterial wall stiffness in healthy volunteers

We have investigated whether the oral administration of vitamin C could prevent smoking-induced acceleration of arterial stiffness in healthy volunteers. Subjects were pretreated with 2 g vitamin C and their heart rate (HR), mean blood pressure (MBP), and brachial-ankle pulse wave velocity (baPWV) were measured before and after smoking. Smoking significantly increased the HR, MBP, baPWV (13, 6.4, 7.0%). Vitamin C treatment significantly reduced the smoking-induced elevation in baPWV at 0 min (- 58.5%, p = 0.0002) without affecting HR or MBP. These findings suggest that oral vitamin C treatment prevents smoking-induced acceleration in arterial stiffness through reducing endothelial dysfunction.

Cardiac autonomic activity in methylmercury neurotoxicity: 14-year follow-up of a Faroese birth cohort

OBJECTIVE

To determine whether heart function in childhood is affected by exposure to methylmercury (MeHg) from seafood.

STUDY DESIGN

Prospective study of a Faroese birth cohort (N=1022). Examinations at ages 7 and 14 years included blood pressure, heart rate variability (HRV) and its frequency components of autonomic origin, and brainstem auditory evoked potentials (BAEPs). Mercury concentrations were determined in cord blood and in the child's hair.

RESULTS

Both low-frequency (LF) and high-frequency (HF) activities decreased by about 25% from 7 to 14 years; they correlated well with the blood pressures. A doubling of prenatal MeHg exposure was associated with a decrease in LF and HF powers of about 6.7% (P=.04) and in the coefficient of variation of the electrocardiographic R-R interval of 2.7% (P=.04) at age 14 years. No discernible effect on blood pressure was apparent. Decreased LF variability was associated with increased latency of BAEP peak III, but adjustment for MeHg exposure substantially attenuated this correlation.

CONCLUSIONS

Methylmercury exposure was associated with decreased sympathetic (LF) and parasympathetic (HF) modulation of the HRV. Parallel MeHg-related delays of BAEP latencies may be caused by underlying MeHg neurotoxicity to brainstem nuclei.

Cardiovascular effects of nicotine, chlorisondamine, and mecamylamine in the pigeon

Chlorisondamine and mecamylamine are nicotinic antagonists that produce both ganglionic and central blockade. Chlorisondamine, when administered as a large systemic dose, produces a persistent central block, despite being charged. The present study evaluated the cardiovascular effects of chlorisondamine. Shortly after administration, chlorisondamine (0.10, 1, and 10 mg/kg i.m.) lowered blood pressure significantly and decreased heart rate at the low dose (0.1 mg/kg i.m.) and increased heart rate at the high dose (10 mg/kg i.m.). Mecamylamine (1 and 10 mg/kg i.m.) also lowered blood pressure and heart rate. After both antagonists, heart rate returned to baseline values within 90 min and blood pressure within 24 h. Low doses of nicotine (0.01-0.03 mg/kg i.m.) lowered blood pressure but did not affect heart rate. Higher doses (0.10-3.2 mg/kg i.m.) transiently increased blood pressure and heart rate. Subsequent to antagonist administration, nicotine was administered to determine whether either drug blocked the cardiovascular effects of nicotine. Chlorisondamine (0.1, 1, and 10 mg/kg i.m.) administered 30 min before nicotine blocked the increases in blood pressure and heart rate. Only the high dose (10 mg/kg i.m.) of chlorisondamine administered 24 h before nicotine produced a blockade of nicotine's pressor effect. This block diminished within 3 days. Mecamylamine (1 mg/kg i.m.) antagonized only nicotine's tachycardic effect. Longer pretreatment with mecamylamine (10 mg/kg, 24 h before nicotine challenge) did not antagonize the cardiovascular effects of nicotine. Thus, chlorisondamine produces a longer lasting blockade of nicotine's cardiovascular effects than mecamylamine.

Differential rate responses to nicotine in rat heart: evidence for two classes of nicotinic receptors

Nicotinic acetylcholine receptors are pentameric, typically being composed of two or more different subunits. To investigate which receptor subtypes are active in the heart, we initiated a series of experiments using an isolated perfused rat heart (Langendorff) preparation. Nicotine administration (100 microM) caused a brief decrease (-7 +/- 2%) followed by a much larger increase (17 +/- 5%) in heart rate that slowly returned to baseline within 10 to 15 min. The nicotine-induced decrease in heart rate could be abolished by an alpha7-specific antagonist, alpha-bungarotoxin (100 nM). In contrast, the nicotine-induced increase in heart rate persisted in the presence of alpha-bungarotoxin. These results suggest that the nicotinic acetylcholine receptors (nAChRs) that mediate the initial decrease in heart rate probably contain alpha7 subunits, whereas those that mediate the increase in heart rate probably do not contain alpha7 subunits. To investigate which subunits may contribute to the nicotine-induced increase in heart rate, we repeated our experiments with cytisine, an agonist at nAChRs that contain beta4 subunits. The cytisine results were similar to those obtained with nicotine, thereby suggesting that the nAChRs on sympathetic nerve terminals in the heart probably contain beta4 subunits. Thus, the results of this study show that pharmacologically distinct nAChRs are responsible for the differential effects of nicotine on heart rate. More specifically, our results suggest that alpha7 subunits participate in the initial nicotine-induced heart rate decrease, whereas beta4 subunits help to mediate the subsequent nicotine-induced rise in heart rate.

Predictors of fatigue in healthy young adults: moderating effects of cigarette smoking and gender

Fatigue is a common complaint of patients seen in primary care. Factors that contribute to fatigue in a patient population include poor health status, psychological stress, poor nutrition, and pregnancy. Less well understood are factors that contribute to fatigue among healthy, nonpregnant individuals. Within the framework of the theory of unpleasant symptoms, 40 healthy young smoking and nonsmoking adults between the ages of 18 and 35 were evaluated to determine self-report level of fatigue and contributing physiological, psychological, and situational factors. Results indicate that while self-report of fatigue did not vary in this population based on gender, subjects who were moderate to heavy cigarette smokers were significantly more fatigued than were nonsmokers (F = 10.24, df = 1, 38, P < 0.01), with the effect being specific to male smokers. Self-report of fatigue did not correlate with body mass index, baseline inflammatory or immune status, or blood pressure. Positive psychological and situational predictors of fatigue included depression (r = 0.556, P < 0.001), state anxiety (r = 0.569, P < 0.001), sleep quality (r = -0.399, P < 0.05), and sleep quantity (r = -0.411, P < 0.05). These results suggest that psychological and situational factors are key contributors to fatigue in young adults and that smoking is a risk factor for fatigue in men.

Smoking or its cessation does not alter the susceptibility to in vitro LDL oxidation

BACKGROUND

Enhanced induction of low density lipoprotein (LDL) oxidation may play a role in the increased cardiovascular risk in smokers. We determined LDL oxidisability in vitro in non-smokers, smokers and in subjects after smoking cessation.

PATIENTS AND METHODS

Plasma lipids and copper induced LDL oxidation in vitro were measured in 31 persistent smokers, 47 smokers who tried to stop smoking and 25 non-smokers. In the smoking cessation group, blood was collected before then 1, 3, 6 and 12 months after smoking cessation, and in the persistent smoking and non-smoking groups at baseline and after 12 months. Plasma thiobarbituric acid reactive substances (TBARS) were measured 3 times (at baseline then after 1 and 3 months) in all subjects who refrained from smoking (controlled by urinary cotinine concentrations) for at least 3 months.

RESULTS

At baseline, no differences in mean age, body mass index and lipid profiles between groups were present. Seventeen subjects of the smoking cessation group (36%) managed to quit during 12 months. Smoking cessation was associated with an increase in mean weight (P </= 0.001) and waist-hip ratio (P </= 0.001). No major differences in LDL oxidisability were found between groups. A significant transient increase in high density lipoprotein (HDL) cholesterol was seen (from 1.20 +/- 0.39 to 1.34 +/- 0.42 mmol L-1) after 1 month of smoking cessation that disappeared after 3 months. However, after 1 month of smoking cessation, plasma TBARS decreased significantly (P < 0.05).

CONCLUSIONS

Neither the previously observed increased cardiovascular risk in smokers nor the decreased risk in those who stopped smoking seem to be mediated by permanent changes in lipid profiles or by alterations in the susceptibility to in vitro oxidation of LDL.

Differential effects of response-contingent and response-independent nicotine in rats

Passive administration of nicotine activates the hypothalamic-pituitary-adrenocortical axis and sympathetic nervous system. However, little is known about the effects of self-administered nicotine. Drug-naive rats were trained to respond for food reinforcement and then tested in one, 1-h session in which they received response-contingent i.v. nicotine or response-independent i.v. nicotine or saline. Blood draws were taken immediately prior to the session, 15 min after the first infusion and immediately after the session. Both response-contingent and response-independent nicotine (RI/N) increased corticosterone within 15 min, however, corticosterone levels returned to baseline in animals receiving response-contingent nicotine (RC/N) by the end of the session while remaining elevated in those receiving RI/N. Furthermore, only RI/N increased plasma epinephrine and norepinephrine levels; RC/N produced no effect. These differences indicate that nicotine's acute effects are powerfully modified by the presence of a contingency relationship between drug administration and the animal's behavior and that this relationship develops very rapidly.

Intima-media thickness of peripheral arteries in asymptomatic cigarette smokers

BACKGROUND AND PURPOSE

Although it is known that smoking is associated with an increase in arterial wall thickness, most studies have been performed in heterogeneous groups of older age, already suffering from atherosclerotic diseases or having additional cardiovascular risk factors. The purpose of this study is to assess the effect on arterial wall thickness of the carotid and femoral artery in cigarette smokers.

METHODS

In a cross-sectional study, intima-media thickness of the common and internal carotid artery, carotid bulb and common femoral artery was determined with the use of a B-mode ultrasound device, in 184 (44.3+/-9.0 years) cigarette smokers for whom smoking is the single cardiovascular risk factor. Comparisons were made with 56 non-smokers, matching in age and gender.

RESULTS

The posterior walls of both carotid bulbs (right: P=0.0005; left: P=0.02) and of the internal carotid arteries (right: P=0.004; left: P=0.003) as well as the posterior wall of the right common carotid artery (P=0.02) and of the right common femoral artery (P<0.0001) were thicker in smokers.

CONCLUSIONS

Cigarette smoking as the single cardiovascular risk factor causes wall thickening of the carotid and femoral arteries, which indicates that early atherosclerosis is already present in smokers entering middle age.

Effects of cigarette smoking on short-term variability of blood pressure in smoking and non smoking healthy volunteers

The present trial was planned to study the effects of smoking on short-term variability of blood pressure and on haemodynamic parameters after an overnight cessation and after one day of repeated smoking in healthy cigarette smoking volunteers, compared to a control group of non-smokers who were not asked to smoke. 40 healthy male volunteers, 20 smokers and 20 non-smokers, participated in an open study with two period of measurements over a single day (morning and afternoon). Blood pressure and heart rate were measured using standard and finger recordings over 6 min before and 10 min after smoking one cigarette (in smokers only). During the two periods, smokers were asked to smoke 4 cm of a cigarette containing 1 mg of nicotine in 2 min, and a blood sample was taken for a plasma nicotine assay. In the smoking group, smoking the first cigarette of the day caused a significant increase of systolic blood pressure (+7%), diastolic blood pressure (+10%) and heart rate (+25%). The blood pressure variability in the frequency range of the Mayer waves (66-129 mHz) was increased after an overnight cessation of smoking in the smoking group in comparison to the non-smokers, and decreased significantly after the first cigarette of the day (7.1 +/- 4.0 to 3.2 +/- 1.8 mmHg2; P < 0.01). The changes observed in the afternoon after continuous smoking were significantly less important (3.8 +/- 1.9 to 3.2 +/- 1.9 mmHg2; NS). In the non-smoking group, the different parameters remained stable between the different measurements. These results suggest that an overnight cessation of smoking in smoking subjects is associated with a increase in sympathetic activity to the vascular system in the morning, which is released by smoking the first cigarette. This effect of smoking is reduced in the afternoon after a continuous nicotinic impregnation.

Relation of salivary cotinine to blood pressure in middle-aged cigarette smokers

BACKGROUND

In laboratory research, nicotine administration is associated with increases in blood pressure. In epidemiologic research, however, the amount of reported cigarette smoking has no consistent relation with blood pressure. The objective of this study was to examine the relation of a nicotine metabolite (salivary cotinine) to systolic and diastolic blood pressure in current smokers being screened for entry to a clinical trial.

METHODS AND RESULTS

Data were obtained from 5164 middle-aged cigarette smokers during screening for the Lung Health Study. Multiple linear regression was used to examine the association of salivary cotinine and number of cigarettes smoked per day to systolic and diastolic blood pressure with age, body mass, years of education, alcohol intake, and recent caffeinated beverage use controlled in all analyses. Although smoking frequency was unrelated to blood pressure, salivary cotinine was related to greater systolic blood pressure in both men and women and greater diastolic blood pressure in men.

CONCLUSIONS

The association between salivary cotinine and blood pressure in these analyses suggests that long-term nicotine exposure may be related to modest elevations in blood pressure in cigarette smokers.

Nicotinic acetylcholine receptors in the rat and primate nucleus tractus solitarius and on rat and human inferior vagal (nodose) ganglia: evidence from in vivo microdialysis and [125I]alpha-bungarotoxin autoradiography

The nucleus tractus solitarius is a key brain centre involved in the regulation of numerous autonomic functions. The present study has employed in vitro autoradiography and in vivo microdialysis to investigate the presence and function of nicotinic acetylcholine receptors located in the medial nucleus tractus solitarius of the rat. Autoradiography using [125I]alpha-bungarotoxin (0.5 nM) enabled visualization of binding sites on sections of rat and monkey brainstem. Specific binding was highest in the medial nucleus tractus solitarius. The presence of binding sites was also apparent on sections of rat nodose ganglia/vagus nerve and human inferior vagal ganglia. Subsequent to unilateral ligation of the vagus nerve in the rat, an accumulation of binding sites was visualized adjacent to the ligature. Unilateral nodose ganglionectomy in the rat caused an approximate 97% reduction in [125I]alpha-bungarotoxin binding site density in the medial nucleus tractus solitarius from 814 +/- 183 to 27 +/- 2 d.p.m./mm2. Microdialysis results indicated that local administration of nicotine (1 mM) into the nucleus tractus solitarius of the rat resulted in increases of extracellular L-glutamate of 146 +/- 9% of basal levels. This effect was not reproducible following a second stimulation and was also blocked by prior and co-administration of the nicotinic acetylcholine receptor antagonist mecamylamine (100 microM). Extracellular levels of L-aspartate exhibited a similar pattern although results were not significant. Taken together, these results are supportive of the presence of a population of [125I]alpha-bungarotoxin binding sites located presynaptically with respect to vagal afferent terminals in the medial nucleus tractus solitarius of the rat. It is possible that these binding sites are the site of action of locally administered nicotine on extracellular levels of L-glutamate, the favoured neurotransmitter at primary baroreceptor afferent fibres. These data are discussed in relation to the functional pharmacology of acetylcholine and nicotinic acetylcholine receptors in this region of the brain.

Marihuana and tobacco use in pregnancy

Marihuana and tobacco smoking are two of the most commonly abused substances in pregnancy. Smoke from both agents contain a multitude of potentially active components, which make them difficult to study. Both have been associated with adverse effects in pregnancy in animal and human studies. Data on marihuana use during pregnancy have been conflicting. There is much evidence, however, demonstrating adverse pregnancy outcomes associated with cigarette smoking which, fortunately, can be reversed with smoking cessation.

Plasma levels of nicotine and safety of smokers wearing transdermal delivery systems during multiple simultaneous intake of nicotine and during exercise

Although transdermal nicotine patches have been studied extensively under recommended conditions, the present studies were designed to assess the nicotine plasma levels and the safety of transdermal nicotine patches in smokers undergoing situations suspected to result in increased nicotine plasma levels. The first study examined the effects of increasing nicotine intake through sequential administration of a nicotine patch (day 2), a patch followed by consumption of nicotine gum (day 3), and a patch followed by gum consumption and cigarette smoking (day 4). In this study, nicotine plasma levels increased transiently after the addition of each nicotine source. Mean areas under the concentration-time curves from 0 to 24 hours (AUC0-24) for nicotine were 453 +/- 120 ng.hr/mL (day 2), 489 +/- 143 ng.hr/mL (day 3), and 485 +/- 143 ng.hr/mL (day 4). The second study evaluated the effects of physical exercise on the kinetics and the safety of two different types of nicotine transdermal devices: Nicoderm and Habitrol. The mean delivered dose of nicotine was higher with Nicoderm compared with Habitrol, and the two products were not considered to be bioequivalent. During a 20-minute exercise period, nicotine plasma levels increased by 13 +/- 9% for Nicoderm and 30 +/- 20% for Habitrol. This increase in nicotine plasma levels was probably related to the exercise-induced increase in peripheral circulation at the patch site. Results from both studies indicate a clinically nonsignificant increase in blood pressure and heart rate after the administration of nicotine. After exercise, subjects taking Habitrol tended to have a higher incidence of adverse events compared with baseline values. Safety profiles remained acceptable in both studies despite the increases in nicotine plasma levels. It was concluded that both superimposed nicotine sources and physical exertion result in short-lived plasma nicotine elevations and temporarily increase nicotine pharmacodynamic parameters without increased risk to the volunteers.

Smoking is associated with higher cardiovascular risk in young women than in men: the Tecumseh Blood Pressure Study

BACKGROUND

Tobacco smoking is associated with a higher prevalence of atherosclerosis and respiratory disease.

OBJECTIVE

To investigate differences between hemodynamic and biochemical findings in smokers and nonsmokers in the two sexes separately in the Tecumseh population.

METHODS

We studied 851 subjects. They were divided according to smoking habits into group 1, nonsmokers (258 men and 234 women); and group 2, smokers (185 men and 174 women).

RESULTS

Unpaired Student's t-tests and nonparametric tests were performed to determine the between-group P-values. Only hematocrit differed significantly between smokers and nonsmokers in both sexes (43.9 +/- 0.2 and 44.6 +/- 9.3%, P < 0.05 in men; 39.2 +/- 0.3 and 40.3 +/- 0.3%, P = 0.007 in women, respectively in nonsmokers and smokers). Triglycerides (80.6 +/- 3.8 and 99.6 +/- 4.3 mg/dl, P < 0.001), left ventricular mass index (95.4 +/- 1.9 and 100.0 +/- 1.2 g/m2, P = 0.008), and posterior wall thickness (9.5 +/- 0.1 and 9.71 +/- 0.01 mm, P = 0.044) were elevated and high-density lipoproteins were decreased (48.7 +/- 0.8 and 44.5 +/- 0.9 mg/dl, P < 0.01) only in women smokers. After adjustment for home systolic blood pressure and body mass index the differences in women remained significant except for posterior wall thickness.

CONCLUSION

Tobacco smoking is deleterious to both sexes but it appears to be particularly harmful to women. Our data can, in part, explain why the relative risk of myocardial infarction is higher in women than it is in men.

Nicotine and sympathetic neurotransmission

Nicotine increases heart rate, myocardial contractility, and blood pressure. These nicotine-induced cardiovascular effects are mainly due to stimulation of sympathetic neurotransmission, as nicotine stimulates catecholamine release by an activation of nicotine acetylcholine receptors localized on peripheral postganglionic sympathetic nerve endings and the adrenal medulla. The nicotinic acetylcholine receptor is a ligand-gated cation channel with a pentameric structure and a central pore with a cation gate, which is essential for ion selectivity and permeability. Binding of nicotine to its extracellular binding site leads to a conformational change of the central pore, which results in the influx of sodium and calcium ions. The resulting depolarization of the sympathetic nerve ending stimulates calcium influx through voltage-dependent N-type calcium channels, which triggers the nicotine-evoked exocytotic catecholamine release. In the isolated perfused guinea-pig heart, cardiac energy depletion sensitizes cardiac sympathetic nerves to the norepinephrine-releasing effect of nicotine, as indicated by a leftward shift of the concentration-response curve, a potentiation of maximum transmitter release, and a delay of the tachyphylaxis of nicotine-evoked catecholamine release. This sensitization was also shown to occur in the human heart under in vitro conditions. Through the intracardiac release of norepinephrine, nicotine induces a beta-adrenoceptor-mediated increase in heart rate and contractility, and an alpha-adrenoceptor-mediated increase in coronary vasomotor tone. The resulting simultaneous increase in oxygen demand and coronary resistance has a detrimental effect on the oxygen balance of the heart, especially in patients with coronary artery disease. Sensitization of the ischemic heart to the norepinephrine-releasing effect of nicotine may be a trigger for acute cardiovascular events in humans, such as acute myocardial infarction and/or life-threatening ventricular tachyarrhythmias.

Captopril does not blunt the sympathoadrenal response to cigarette smoking in normotensive humans

The aim of this study was to assess whether an interaction exists between the renin-angiotensin system and the sympathetic nervous system at the level of the adrenal medulla during smoking in normal humans. Thirteen habitual smoking volunteers were studied in a randomized, single-dose, double-blind, cross-over fashion using 50 mg captopril vs placebo followed by smoking of two high nicotine content cigarettes within 15 min. Blood samples were obtained at frequent intervals before, during and after smoking. We found that the increase in plasma adrenaline concentration during cigarette smoking was modest. There was no difference between captopril treatment as compared to placebo. Thus, the adrenaline response to cigarette smoking was not blunted by acute blockade of angiotensin II generation. A significant increase in heart rate, and blood pressure was found as well. No increase in plasma noradrenaline concentration was found. Plasma renin concentration increased significantly during captopril treatment, whereas it decreased throughout the study period in the placebo phase. Plasma angiotensin II concentration decreased in both the captopril treatment and the placebo phase throughout the study period, but this was more pronounced during captopril treatment. In conclusion, cigarette smoking-induced activation of the sympathetic nervous system was not blunted by acute ACE-inhibition by captopril. This indicates that angiotensin II does not facilitate smoking-induced activation of sympathoadrenal activity in humans.

Assessment of autonomic neurotoxicity in occupational and environmental health as determined by ECG R-R interval variability: a review

Measurement of heart rate variability (coefficient of variation of ECG R-R intervals, CVRR) provides a useful approach for the objective assessment of the autonomic nervous function. It is noninvasive and clinically practical, although it tends to be distorted by confounding factors such as age, alcohol, and tobacco. Specifically, two component coefficients of variation of the respiratory sinus arrhythmia (RSA) and Mayer wave-related sinus arrhythmia (MWSA) in the CVRR (i.e., C-CVRSA and C-CVMWSA), computed from component spectral powers by autoregressive spectral and component analyses, are expected to reflect parasympathetic and sympathetic functions, respectively. This article is intended to present an overview of research, utilizing the CVRR method including the C-CVRSA and C-CVMWSA, in occupational and environmental health. The available literature, addressing the impact of some chemicals and work-related factors on human autonomic nervous system, indicates that parasympathetic activity appears to be more vulnerable to these factors than does sympathetic activity. Since decreased cardiac vagal tone is associated with an increased risk of sudden cardiac death or coronary artery disease, attention should be directed to further discovery of hazardous factors in the environment and work place, which are likely to affect the autonomic nervous system.

The maternal and fetal physiologic effects of nicotine

The effects of nicotine are seen in every trimester of pregnancy, from increased spontaneous abortions in the first trimester, to increased premature delivery rates and decreased birth weights in the final trimester. The birth weight of a baby is dependent on two factors: the gestational age of the fetus at the time of delivery and the rate of fetal growth. Nicotine has been shown to affect both of these factors. Carbon monoxide, also found in tobacco, forms carboxyhemoglobin, which inhibits the release of oxygen into fetal tissues. Nicotine readily gains access to the fetal compartment via the placenta, with fetal concentrations generally 15% higher than maternal levels. The primary metabolite of nicotine, cotinine, has a half-life of 15 to 20 hours and serum concentrations that are 10-fold higher than nicotine; thus, cotinine provides a better index of nicotine exposure because of its longer half-life. Nicotine concentrates in fetal blood, amniotic fluid, and breastmilk. The fetus and neonate may also have environmental tobacco exposure that may be significant. In animal models and humans, nicotine increases maternal blood pressure and heart rate, with a concomitant reduction in uterine blood flow. An increase in fetal heart rate is also seen, which is thought to be caused by catecholamine release. The impact of nicotine on the respiratory and central nervous system is also reviewed. In conclusion, the physiological effect of tobacco on fetal growth seems to be a culmination of both the vasoconstrictive effects of nicotine on the uterine and potentially the umbilical artery and the effects on oxygenation by carboxyhemoglobin.

How smoking affects blood pressure

The addictive effects of smoking are only partly known, but it is likely that hemodynamic effects of tobacco smoking may contribute to the habituation. It has since long been known that blood pressure and heart rate increase during smoking. These effects are specifically associated with nicotine while the other components of which more than a thousand have been isolated seem to be of minor importance. The rise in blood pressure is due both to an increase in cardiac output and total peripheral vascular resistance. The blood pressure rise appears immediately and occurs before any increase in circulating catecholamines. In hypertensive patients the blood pressure lowering effect of beta-blockers may be partly abolished by tobacco smoking whereas alpha-receptor blockers seem to maintain the antihypertensive efficacy in smokers. It is a paradox that while smoking acutely increases blood pressure, a slightly lower blood pressure level has been found among smokers than nonsmokers in larger epidemiological studies. Because blood pressure may increase after cessation of smoking, a smoke quitting program should not postpone initiation of antihypertensive treatment in patients otherwise in need of such treatment.

Relation between saliva cotinine concentration, cigarette consumption, and blood pressure among smokers

In conclusion, we found no evidence of any reduction in blood pressure with greater smoking exposure. For smokers allowed to smoke in a natural manner before blood pressure assessment, greater smoking exposure indexed by saliva cotinine concentration is associated with higher systolic blood pressure levels.

Increased level of hemoglobin A1c, but not impaired insulin sensitivity, found in hypertensive and normotensive smokers

Smoking is associated with an abnormal plasma lipoprotein pattern. Recently, both insulin resistance and normal insulin action have been reported in smokers. In a total of 191 hypertensive and normotensive subjects recruited from a health survey, serum lipoprotein lipids, glucose tolerance (by intravenous glucose tolerance test (IVGTT), insulin secretion, and insulin sensitivity (euglycemic insulin clamp) were compared in the 41 smokers and 150 nonsmokers. Subjects were examined in the morning during a fasting state and after abstinence from smoking for 10 to 12 hours. Smokers showed a higher level of hemoglobin A1c (HbA1c) as compared with nonsmokers, 4.9% versus 4.7% (P < .05). There were no significant differences in fasting glucose, insulin, or insulin-mediated glucose disposal. However, a number of indices of insulin sensitivity tended to show enhanced insulin action among smokers. Only lower glucose and insulin values during the late phase (40 to 90 minutes) of the IVGTT reached statistical significance. Compared with nonsmokers, smokers had an expected higher level of serum triglycerides (2.1 v 1.8 mmol/L, P < .05) and an increased low-density lipoprotein (LDL) to high-density lipoprotein (HDL) cholesterol ratio (4.5 v 3.9, P < .05). These differences between smokers and nonsmokers were similar in both hypertensives and normotensives. In conclusion, smokers examined in the abstinence phase showed no signs of impaired insulin action. Lipoprotein abnormalities and elevated HbA1c may be caused in part by the insulin resistance induced during acute smoking and therefore may be quantitatively related to the time exposed to smoking. The effect on insulin sensitivity appears to be reversible over 10 to 12 hours.

Dual effect of nicotine on cardiac noradrenaline release during metabolic blockade

Nicotine-induced noradrenaline was investigated in perfused guinea pig hearts subjected to metabolic blockade that was caused either by anoxia or by cyanide intoxication. Noradrenaline, neuropeptide Y, and dihydroxyphenylethyleneglycol (DOPEG) were determined in the coronary venous overflow Neuropeptide Y is a sympathetic cotransmitter of noradrenaline, and concomitant release of both transmitters indicates an exocytotic, calcium-dependent release mechanism, whereas neuropeptide Y overflow does not occur during nonexocytotic noradrenaline release. Nonexocytotic, calcium-independent noradrenaline release, however, is associated with an increase of DOPEG overflow, which is the main intraneuronal metabolite of noradrenaline formed by monoamine oxidase if oxygen is present. Anoxia per se caused a nonexocytotic release of noradrenaline starting after 10 min of anoxia and reaching peak levels at 30 min. During anoxia, nicotine (3 and 10 mumol/l) accelerated and enhanced noradrenaline overflow, i.e., the period between the onset of anoxia and the begin of noradrenaline release was shortened and peak levels were increased. Nicotine-induced noradrenaline release was accompanied by neuropeptide Y overflow. The action of nicotine was further evaluated during energy depletion caused by cyanide. As anoxia did, cyanide administration alone resulted in noradrenaline release. In accordance with a nonexocytotic mechanism and due to the presence of oxygen, this release of noradrenaline was accompanied by an increase of DOPEG. When added 10 min after the onset of energy depletion, nicotine (10 mumol/l) caused a brief but marked enhancement of exocytotic noradrenaline release, since this release was calcium-dependent and was accompanied by a significant rise of neuropeptide Y overflow. In absence of extracellular calcium to avoid exocytosis, concomitant administration of nicotine (3-100 mumol/l) and cyanide caused a concentration-dependent acceleration of both the overflow of noradrenaline and DOPEG, whereas overflow of neuropeptide Y was not increased, thus indicating a nonexocytotic release mechanism. In conclusion, the application of nicotine during myocardial energy depletion increases overflow of noradrenaline by both calcium-dependent exocytotic release and calcium-independent nonexocytotic release mechanisms.

Mechanisms responsible for sympathetic activation by cigarette smoking in humans

BACKGROUND

The pressor and tachycardic effects of cigarette smoking are associated with an increase in plasma catecholamines, suggesting the dependence of these effects on adrenergic stimulation. Whether the stimulation occurs at a central or a peripheral level and whether reflex mechanisms are involved is unknown.

METHODS AND RESULTS

In nine normotensive healthy subjects (age, 33.0 +/- 3.5 years, mean +/- SEM), we measured blood pressure (Finapres device), heart rate (ECG), calf blood flow and vascular resistance (venous occlusion plethysmography), plasma norepinephrine and epinephrine (high-performance liquid chromatography assay), and postganglionic muscle sympathetic nerve activity (microneurography from the peroneal nerve) while subjects were smoking a filter cigarette (nicotine content, 1.1 mg) or were in control condition. Cigarette smoking (which raised plasma nicotine measured by high-performance liquid chromatography from 1.0 +/- 0.9 to 44.2 +/- 7.1 ng/mL) markedly and significantly increased mean arterial pressure (+13.2 +/- 2.3%), heart rate (+30.3 +/- 4.7%), calf vascular resistance (+12.1 +/- 4.9%), plasma norepinephrine (+34.8 +/- 7.0%), and plasma epinephrine (+90.5 +/- 39.0%). In contrast, muscle sympathetic nerve activity showed a marked reduction (integrated activity -31.8 +/- 5.1%, P < .01). The reduction was inversely related to the increase in mean arterial pressure (r = -.67, P < .05), but the slope of the relation was markedly less (-54.1 +/- 7.5%, P < .05) than that obtained by intravenous infusion of phenylephrine in absence of smoking. The hemodynamic and neurohumoral changes were still visible 30 minutes after smoking and occurred again on smoking a second cigarette. Sham smoking was devoid of any hemodynamic and neurohumoral effect.

CONCLUSIONS

These data support the hypothesis that in humans the sympathetic activation induced by smoking depends on an increased release and/or a reduced clearance of catecholamines at the neuroeffector junctions. Central sympathetic activity is inhibited by smoking, presumably via a baroreceptor stimulation triggered by the smoking-related pressor response. The baroreflex is impaired by smoking, however, indicating that partial inability to reflexly counteract the effect of sympathetic activation is also responsible for the pressor response.

Acute occlusion of a remote coronary artery complicating directional coronary atherectomy

Two cases of acute occlusion in a remote coronary artery complicating directional coronary atherectomy are reported. In neither case was there definite angiographic evidence of spasm, dissection, or embolization. Since this complication is seldom seen with coronary angioplasty, it may represent a relatively specific risk of directional atherectomy.

Tobacco and myocardial infarction: is snuff less dangerous than cigarettes?

OBJECTIVE

To estimate the risk of myocardial infarction in snuff users, cigarette smokers, and non-tobacco users in northern Sweden, where using snuff is traditional.

DESIGN

Case-control study.

SETTING

Northern Sweden.

SUBJECTS

All 35-64 year old men who had had a first myocardial infarction and a population based sample of 35-64 year old men who had not had an infarction in the same geographical area.

MAIN OUTCOME MEASURE

Tobacco consumption (regular snuff dipping, regular cigarette smoking, non-tobacco use) and risk of acute myocardial infarction.

RESULTS

59 of 585 (10%) patients who had a first myocardial infarction and 87 of 589 (15%) randomly selected men without myocardial infarction were non-smokers who used snuff daily. The age adjusted odds ratio for myocardial infarction was 0.89 (95% confidence interval 0.62 to 1.29) for exposure to snuff and 1.87 (1.40 to 2.48) for cigarette smoking compared with non-tobacco users, showing an increased risk in smokers but not in snuff dippers. Regular cigarette smokers had a significantly higher risk of myocardial infarction than regular snuff dippers (age adjusted odds ratio 2.09; 1.39 to 3.15). Smoking, but not snuff dipping, predicted myocardial infarction in a multiple logistic regression model that included age and level of education.

CONCLUSIONS

In middle aged men snuff dipping is associated with a lower risk of myocardial infarction than cigarette smoking.

Effects of age, heart rate, gender, tobacco and alcohol ingestion on R-R interval variability in human ECG

To evaluate the possibly confounding effects of age, gender, heart rate, tobacco and alcohol ingestion on the coefficient of variation of the electrocardiographic R-R interval (CVRR), ECGs in the supine posture were obtained in 68 healthy men and 33 healthy women. The C-CVRSA and C-CVMWSA (two component CVs reflecting respiratory sinus arrhythmia and Mayer wave related sinus arrhythmia, respectively) were computed in each subject from component spectral powers using autoregressive spectral and component analyses. Results of multiple regression analysis indicated that age was inversely related to CVRR, C-CVRSA and C-CVMWSA in both sexes. Heart rate was positively related to C-CVMWSA in males. However, no significant difference in the CVRR, C-CVRSA or C-CVMWSA was found between males and females. The C-CVMWSA was not correlated with the C-CVRSA in either males or females. These data indicate that the CVRR, C-CVRSA and C-CVMWSA are affected by age and partly by heart rate; gender, moderate smoking or drinking habits might not strongly influence autonomic nervous system function. On the other hand, the C-CVRSA in the supine posture appears to be independent of the C-CVMWSA. The positive relationship observed between the C-CVMWSA and heart rate suggests that the C-CVMWSA may be associated with sympathetic activity.

Cigarette smoking and the adrenergic nervous system

The acute increase in blood pressure and heart rate that accompanies cigarette smoking is associated with a rise in plasma catecholamines and it is thus believed to result from stimulation of the adrenergic nervous system. We have employed direct recording of efferent post-ganglionic sympathetic nerve activity by the microneurographic technique from the peroneal nerve to determine whether this stimulation occurs centrally or peripherally. It was shown that during cigarette smoking blood pressure, heart rate, plasma norepinephrine and epinephrine do increase markedly. Sympathetic nerve activity, however, shows a concomitant specular reduction. Thus peripheral (adrenal gland stimulation, reduction in norepinephrine reuptake, reduction in catecholamine clearance, etc.) rather than central mechanisms explain the adrenergic involvement in the acute hemodynamic effect of smoking, the central sympathetic drive being inhibited rather than excited probably as a result of arterial baroreceptor stimulation.

Cardiovascular excitatory effects of adenosine in the nucleus of the solitary tract

Adenosine is an inhibitory neuromodulator in several brain regions. In the nucleus tractus solitarius (NTS), however, adenosine exerts excitatory cardiovascular effects. The purpose of the present study was to elucidate the involvement of other endogenous mechanisms that could contribute to the final hemodynamic response to adenosine in this nucleus. In normotensive Sprague-Dawley rats, intra-NTS microinjection of adenosine (2.3 nmol/60 nl) decreased blood pressure and heart rate. These effects were blocked by prior administration of the specific adenosine receptor antagonist 1,3-dipropyl-8-p-sulfophenylxanthine (0.92 nmol) and by the two glutamate receptor antagonists kynurenic acid and glutamic diethylester. The specificity of the adenosine-glutamate interaction in the NTS was demonstrated with adrenergic and angiotensin receptor antagonists that did not affect the adenosine response and by experiments with glutamate receptor antagonists that did not affect nicotine actions in the NTS. Furthermore, an increase in glutamate levels was demonstrated during perfusion of adenosine through a microdialysis probe in the NTS of anesthetized rabbits. These findings indicate that adenosine increases the release of glutamate in the NTS and, thus, are at variance with the concept of a "universal" inhibitory effect of adenosine in the central nervous system.