Cigarette Smoking Health Effects and Cessation Strategies

Discriminative Stimulus Properties of S(-)-Nicotine: "A Drug for All Seasons"

S(-)-Nicotine is the major pharmacologically active substance in tobacco and can function as an effective discriminative stimulus in both experimental animals and humans. In this model, subjects must detect and communicate the nicotine drug state versus the non-drug state. This review describes the usefulness of the procedure to study nicotine, presents a general overview of the model, and provides some relevant methodological details for the establishment of this drug as a stimulus. Once established, the (-)-nicotine stimulus can be characterized for dose response and time course effects. Moreover, tests can be conducted to determine the similarity of effects produced by test drugs to those produced by the training dose of nicotine. Such tests have shown that the stimulus effects of nicotine are stereoselective [S(-)-nicotine >R(+)-nicotine] and that other "natural" tobacco alkaloids and (-)-nicotine metabolites can produce (-)-nicotine-like effects, but these drugs are much less potent than (-)-nicotine. Stimulus antagonism tests with mecamylamine and DHβE (dihydro-β-erythroidine) indicate that the (-)-nicotine stimulus is mediated via α4β2 nicotinic acetylcholine receptors (nAChRs) in brain; dopamine systems also are likely involved. Individuals who try to cease their use of nicotine-based products are often unsuccessful. Bupropion (Zyban®) and varenicline (Chantix®) may be somewhat effective as anti-smoking medications because they probably produce stimulus effects that serve as suitable substitutes for (-)-nicotine in the individual who is motivated to quit smoking. Finally, it is proposed that future drug discrimination studies should apply the model to the issue of maintenance of abstinence from (-)-nicotine-based products.

[Campaign against smoking in a home for the elderly: the report of an experiment]

Studies on institutionalized elderly smokers are important for developing appropriate preventive measures. This was a cross-sectional population-based study of individuals over 60 admitted to a Home for the Elderly in the Federal District. The following aspects were investigated: smoking prevalence, socio-demographic and clinical profile, gender, education, probable depression, degree of motivation to stop smoking, prior use of medication to stop smoking and perception of the harm of smoking to health. Spirometry, the measurement of exhaled carbon monoxide and classification according to severity of nicotine dependence were conducted. The program followed guidelines for stopping smoking, and was evaluated one year later. Results revealed that 25.7% were smokers, 22.8% men and 2.9% women, mean age 68.3 ± 8.5 years. A significant decrease in smoking among the more elderly was detected. Significant associations emerged between the degree of nicotine dependence and education, probable depression, degree of motivation for stopping smoking and perception of the harm of smoking to health. Higher indices of carbon monoxide were identified in individuals with severe obstruction. Initially, 37.9% of smokers agreed to participate in the campaign, and after a year 9% of them succeeded in stopping smoking.

Tabagismo em idosos internados em instituições de longa permanência

OBJETIVO: Determinar a prevalência de tabagismo entre idosos internados em instituições de longa permanência para idosos (ILPIs) e verificar a associação do grau de dependência nicotínica com variáveis sociodemográficas, vínculo afetivo, motivação para cessação e depressão. MÉTODOS: Estudo transversal de base populacional, incluindo 573 idosos com idade > 60 anos, internados em 13 ILPIs no Distrito Federal. Foram analisadas as seguintes variáveis: tipo de ILPI, gênero, idade, escolaridade, renda mensal, estado civil, condição previdenciária, vínculo afetivo, motivação para a cessação, depressão provável e o grau de dependência nicotínica. Para a obtenção dos dados, foram utilizados os seguintes instrumentos: questionário sociodemográfico, Escala de Qualidade de Vida de Flanagan, Miniexame do Estado Mental, Escala de Depressão Geriátrica, teste de Richmond e Teste de Fagerström para Dependência de Nicotina. RESULTADOS: A prevalência geral de fumantes na amostra (573 indivíduos) foi de 23,0%. Dos 132 fumantes, havia 81 homens (24,9%) e 35 mulheres (20,1%). Foram incluídos no estudo 116 fumantes, dos quais 70 (60,3%) apresentavam depressão provável. Houve significativas associações entre o grau de dependência nicotínica e as seguintes variáveis: escolaridade, renda mensal, vínculo afetivo, motivação para a cessação e depressão provável. Não houve associações significativas entre a dependência de nicotina e as seguintes variáveis: tipo de ILPI, gênero, idade, condição previdenciária e estado civil. CONCLUSÕES: Nos idosos institucionalizados em ILPIs no Distrito Federal, constatamos uma elevada prevalência de tabagismo, havendo entre eles baixa motivação para a cessação tabágica.

The effectiveness of covering smoking cessation services for medicare beneficiaries

OBJECTIVE

To examine whether reimbursement for Provider Counseling, Pharmacotherapies, and a telephone Quitline increase smoking cessation relative to Usual Care.

STUDY DESIGN

Randomized comparison trial testing the effectiveness of four smoking cessation benefits.

SETTING

Seven states that best represented the national population in terms of the proportion of those > or = 65 years of age and smoking rate.

PARTICIPANTS

There were 7,354 seniors voluntarily enrolled in the Medicare Stop Smoking Program and they were followed-up for 12 months.

INTERVENTION(S)

(1) Usual Care, (2) reimbursement for Provider Counseling, (3) reimbursement for Provider Counseling with Pharmacotherapy, and (4) telephone counseling Quitline with nicotine patch.

MAIN OUTCOME MEASURE

Seven-day self-reported cessation at 6- and 12-month follow-ups.

PRINCIPAL FINDINGS

Unadjusted quit rates assuming missing data=smoking were 10.2 percent (9.0-11.5), 14.1 percent (11.7-16.5), 15.8 percent (14.4-17.2), and 19.3 percent (17.4-21.2) at 12 months for the Usual Care, Provider Counseling, Provider Counseling + Pharmacotherapy, and Quitline arms, respectively. Results were robust to sociodemographics, smoking history, motivation, health status, and survey nonresponse. The additional cost per quitter (relative to Usual Care) ranged from several hundred dollars to $6,450.

CONCLUSIONS

A telephone Quitline in conjunction with low-cost Pharmacotherapy was the most effective means of reducing smoking in the elderly.

Clinical Implications of Smoking and Aging: Breaking Through the Barriers

In the United States, there are almost 4 million smokers older than 65. Yet, older smokers often receive suboptimal care. Inaccurate information and myths about older smokers may have become ingrained in the attitudes and beliefs of both older smokers and health care providers. In this article, prominent myths about older smokers will be explored and refuted. The realities include the following: Smoking tobacco has no benefit; it does not improve cognition or mood; smoking cessation, even among older, frail adults, produces significant benefits in terms of health and quality of life; and using filtered cigarettes or reducing the number of cigarettes smoked per day does not reduce harm. Gerontological nurses are at the forefront of treating tobacco use among older smokers. They should assess the smoking status of all older adults at every contact, treat smokers with pharmacotherapy and counseling, follow up with patients, and stay informed.

Condições de saúde e tabagismo entre idosos residentes em duas comunidades brasileiras (Projetos Bambuí e Belo Horizonte)

O objetivo deste trabalho foi determinar a prevalência do tabagismo e verificar os fatores associados a este hábito entre idosos (> 60 anos). O estudo foi conduzido na Região Metropolitana de Belo Horizonte e na Cidade de Bambuí, ambas localizadas em Minas Gerais, Brasil. Foram selecionados 1.774 idosos na Região Metropolitana e 1.742 em Bambuí. Na Região Metropolitana, a prevalência de tabagismo atual e passado foi de 19,6% e 39,2% entre os homens, e 8,1% e 14,1% entre as mulheres, respectivamente. Em Bambuí, os dados correspondentes foram 31,4% e 40,2% entre os homens, e 10,3% e 11,2% entre as mulheres, respectivamente. Na Região Metropolitana, os indicadores de pior condição de saúde e pior capacidade funcional apresentaram associações significantes com o tabagismo passado, mas estas associações não foram observadas em Bambuí. Entre os fumantes atuais, as associações pesquisadas não foram consistentes. Estes resultados mostram a grande heterogeneidade dos fatores associados ao tabagismo, como observado em países desenvolvidos. As estratégias para a redução do tabagismo nessa população devem considerar esta ausência de associação entre sinais e sintomas e o hábito de fumar.

Providers' smoking cessation attitudes and practices for older patients

A mail survey of 136 providers in a health maintenance organization in the Chicago metropolitan area examined smoking cessation attitudes and performance of the 4As protocol (asking, advising, assisting, arranging) for patients aged 50 years or older. Asking about smoking was most frequent, followed by arranging, advising, and assisting. Physicians and nurse practitioners performed each of the 4As more often than did registered and licensed practical nurses. In multiple logistic regression analyses, provider type was the only significant predictor of asking about smoking. Advising, assisting, and arranging follow-ups were more likely to be performed by providers who perceived a sense of professional responsibility about older patients' smoking; advising was more likely for providers who perceived that they had enough time to advise older patients about smoking; and assisting and arranging were more likely for providers with a stronger sense of self-efficacy for helping older patients stop smoking.

Cardiac rehabilitation: structure, effectiveness and the future

Despite advances in the investigation and treatment of angina and myocardial infarction, and increased knowledge of the factors associated with the development and progression of ischaemic heart disease, it remains the leading cause of death and morbidity in the majority of industrialized countries. Cardiac rehabilitation provides a means of modifying lifestyle and other risk factors in patients presenting with established, symptomatic coronary artery disease, thereby reducing the risk of further cardiac events. It has also been proven to be cost-efficient.

Readiness of older adults to stop smoking in a televised intervention

Smokers aged 60 and older who enrolled in a televised smoking cessation program were compared with older smokers in the target population, using data from telephone interviews. Multiple logistic regressions identified factors that differentiated older smokers at various stages of readiness to quit. Within the target population, smokers planning to quit someday (N = 238) were more likely to have had greater concern about health effects of smoking and perceived a stronger desire by others for them to quit than smokers with no such plan (N = 127). Compared with older smokers in the target population who were planning to quit someday, program registrants (N = 95) perceived greater severity of lung cancer, had greater concern about the health effects of smoking, perceived greater reduction of lung cancer risk from quitting, and had more determination to quit. These findings indicate important factors according to the stage in the smoking cessation process that must be considered when intervening with older smokers.

Methods of smoking cessation

Smoking-cessation treatment consists of three phases: preparation, intervention, and maintenance. Preparation aims to increase the smoker's motivation to quit and to build confidence that he or she can be successful. Intervention can take any number of forms (or a combination of them) to help smokers to achieve abstinence. Maintenance, including support, coping strategies, and substitute behaviors, is necessary for permanent abstinence. Although most smokers who successfully quit do so on their own, many use cessation programs at some point during their smoking history. Moreover, many people act on the advice of a health professional in deciding to quit. Some are also aided by a smoking-cessation kit from a public or voluntary agency, a book, a tape, or an over-the-counter product. Still others receive help from mass-media campaigns, such as the Great American Smokeout, or community programs. Counseling, voluntary and commercial clinics, nicotine replacement strategies, hypnosis, acupuncture, and behavioral programs are other methods used by smokers to break the habit. Programs that include multiple treatments are more successful than single interventions. The most cost-effective strategy for smoking cessation for most smokers is self-care, which includes quitting on one's own and might also include acting on the advice of a health profession or using an aid such as a quit-smoking guide. Heavier, more addicted smokers are more likely to seek out formal programs after several attempts to quit. Many people can quit smoking, but staying off cigarettes requires maintenance, support, and additional techniques, such as relapse prevention. Physicians, dentists, and other health professionals can provide important assistance to their patients who smoke. Quit rates can be improved if clinicians provide more help (e.g., counseling, support) than just simple advice and warnings. Clinicians also play an important role in providing nicotine replacement products such as nicotine gum or transdermal patches. These products are particularly useful for smokers who show evidence of strong physiologic addiction to nicotine. Attitudes toward smoking have shifted dramatically. In the 1950s, fewer than 50% of American adults believed that cigarette smoking caused lung cancer. In 1986, this proportion had increased to 92%. A majority of the public favors policies restricting smoking in public places and worksites. Half of all Americans who ever smoked had stopped smoking by 1988. Of those who continue to smoke, more than 70% report that they would like to quit. By increasing their knowledge about smoking-cessation methods, health professionals can support and encourage the large majority of smokers who want to quit.

A clinical approach to help psychiatric patients with smoking cessation

In this paper we briefly review the dynamics of smoking and nicotine dependence, discuss the evaluation of the addicted smoker, and describe interventions to facilitate the attempt to quit smoking. We also discuss the interface of psychiatric illness and smoking, particularly among those chronically hospitalized in psychiatric institutions, and suggest a rational approach to help patients with psychiatric illness stop smoking.

Smoking cessation strategies: what works, what doesn't

Health professionals can effectively help patients quit smoking with a minimal, intervention-oriented, office-based treatment program. Clear-cut, unequivocal, unambiguous, stop-smoking advice can produce sustained, 1-year abstinence rates in the 5% range. This capability has been clearly documented for physicians. Dental literature increasingly supports the same conclusion for dentists. These studies show that although the yield from such brief advice may seem small, it is 17 times greater than the yield which results from saying nothing. Moreover, because dentists and physicians see so many patients during the course of 1 year, the potential impact of such intervention is staggering. More than 3.5 million patients could be cured of tobacco dependence annually. While specialized smoking cessation treatment programs can achieve 1 year sustained abstinence rates as high as 70%, they reach relatively few patients and can only achieve such high success rates because of the intensive, time-consuming nature of their interventions. The impact of basic dental advice can be increased during regular follow-up visits, when "teachable moments" in dental health often occur. Impact of advice on the 1-year sustained abstinence rates can be increased by arranging to see the patient at regular follow-up visits after the target quit date has been set, making certain that the medication, nicotine polacrilex, is used correctly.(ABSTRACT TRUNCATED AT 250 WORDS)

Gingival response to nicotine polacrilex

Nicotine polacrilex (Nicorette) is the only medication approved by the Food and Drug Administration for tobacco dependency treatment. It is available only by prescription. This study sought to determine whether this medication produced any adverse gingival effects. Thirty-one patients (91%) used the nicotine polacrilex for at least 1 month and 20 (59%) for 3 months or more. Five (15%) developed small (less than 2 mm), painless, clear, nonhemorrhagic vesicles which resolved immediately when patients were reinstructed to position the medication in different sites in the mouth. There were no changes in gingival color, contour, consistency and texture, tooth mobility, or periodontal pocket depth. Nicotine polacrilex does not appear to have any significant adverse effects on the gingiva even with up to 6 months of daily use.

Pharmacological treatment of tobacco dependence

Pharmacologically based approaches for the treatment of tobacco dependence are reviewed. The rational basis for pharmacologic treatment approaches is that tobacco dependence is partially, and critically, mediated by the actions of tobacco-delivered nicotine to the central nervous system. These actions include direct reinforcing properties of nicotine itself, tolerance and physiologic dependence, possible beneficial effects of nicotine in the alleviation of anxiety and control of weight, and neurohormonal regulation which can become important to the maintenance of emotional well-being and performance at work. Insofar as tobacco abstinence leads to negative consequences, via these biobehavioral mechanisms, pharmacologic intervention should be able to assist in initial tobacco detoxification and help tobacco abstinent persons to avoid subsequent relapse. The purpose of this review is to survey some of the efforts to develop such interventions, as well as to elucidate some of the issues relevant to such development. Four distinct approaches are discussed: (1) Nicotine replacement, in which physiologic dependence is transferred to a safer and more therapeutically manageable nicotine delivering formulation; this category includes nicotine polacrilex gum; (2) Blockade therapy, in which a drug is taken that blocks the reinforcing properties of nicotine should relapse occur; (3) Nonspecific pharmacotherapy, in which the biobehaviorally mediated correlates of tobacco abstinence are treated on a symptomatic basis; (4) Deterrent therapy, in which a drug is taken prior to smoking such that any tobacco use would produce reliable aversive effects.

Nicotine gum: chew rate, subjective effects and plasma nicotine

Two studies were conducted to assess the effects of varying the rate at which single pieces of nicotine gum (4 mg) were chewed. In each study, six cigarette-deprived volunteers were tested during four sessions. In each session, they were required to chew the gum for 10 min at varying rates; a variety of self-report and physiologic responses were recorded before and after chewing. All chewed gum was analyzed for amount of nicotine extracted, and blood samples were collected for nicotine analysis. Additionally, in Experiment 2, a measure of masticatory pressure was employed to assess the intensity of chewing and to empirically verify the number of chews. In both studies, we found a weak, but direct, relation between chew rate and the amount of extracted nicotine. Experiment 2 revealed a probable cause of the weaker than expected "dose-effect" function: subjects showed compensatory changes in behavior by chewing slower than instructed in the high rate conditions, and by chewing faster than instructed in the low rate conditions. Thus, despite instructions to vary chew rates across an 8-fold range, actual chew rate varied by only 2.2-fold. Intensity of chewing remained constant across conditions. Taken together, the findings suggest that rate of chewing nicotine gum can make a difference in the amount of nicotine extracted from the gum; however, compensatory changes in chew rate may attenuate attempts to systematically vary nicotine dose in this manner.

Direct methods of obtaining information on cigarette smoking in occupational studies

Many occupational epidemiology studies require complete and accurate information on tobacco use to control for confounding by smoking and to assess interactions of smoking with workplace exposures. This paper reviews and evaluates the availability, reliability, validity, and efficiency of the various data sources and techniques for obtaining individual smoking data, including existing records, biological markers, and surveys. Emphasis is placed on the highly problematic issue of obtaining retrospective smoking histories. In general, the survey technique is currently deemed the most feasible approach for obtaining lifetime smoking histories. Both theoretical and practical aspects of smoking surveys are discussed in detail and are illustrated with a review of the recent literature and with data from two recent retrospective cohort studies conducted at the University of Pittsburgh. Several recommendations involving both the use of smoking data and areas for future methodologic research are presented. These include (1) justification for collecting smoking data in occupational studies based primarily on the potential for smoking to act as an effect modifier rather than solely as a confounder, (2) checks for reliability and validity in all studies which involve the collection of smoking data, (3) more methodologic research to better understand the impact that missing, unreliable, and invalid smoking data may have on the ability to detect and quantify important smoking-exposure interactions, and (4) an assessment of the correlation between biological markers and cigarette carcinogen exposure.