Effect of smoking reduction and cessation on cardiovascular risk factors

Smoking Cessation and Mortality from Aortic Dissection and Aneurysm: Findings from the Japan Collaborative Cohort (JACC) Study

AIMS

Active cigarette smoking was intensively reported to increase the risk of aortic mortality while research on the association between smoking cessation and aortic mortality remains scarce. This study aimed to reconfirm the associations of exposure to cigarettes and smoking cessation associated with aortic mortality in a large Japanese population.

METHODS

In the Japan Collaborative Cohort (JACC) Study, 91,141 residents (57±10 years; men, 43%) who were free of stroke, coronary heart disease, and cancer were followed up from 1989-90 until 2009 during which 110 deaths from aortic dissection and 112 deaths from aneurysm were identified. Cox proportional hazard model was used to estimate multivariable hazard ratios (95%CI) for total and specific aortic mortality.

RESULTS

Compared to never smoking, HRs for total aortic mortality were 2.39 (1.40-4.08) for ＜20, 3.57 (2.19-5.83)for 20-39, and 3.92 (2.37-6.48) for ≥ 40 pack-years exposure. Compared to current smoking, HRs for total aortic mortality were 0.42 (0.18-0.97) for 10-15 years, 0.27 (0.11-0.66) for ＞15 years of cessation, and 0.24 (0.13-0.44) for never smoking. Similar inverse dose-response pattern was observed between smoking cessation duration and risk of mortality from aortic aneurysm (p for trend=0.001), but the association with aortic dissection mortality did not reach statistical significance.

CONCLUSIONS

Cigarette smoking was associated with an increased risk of aortic mortality while smoking cessation was so with a reduced risk among the Japanese population.

Inflammation and atherogenic markers in patients with type 2 diabetes mellitus

Type two diabetes mellitus (T2DM) is characterized by a chronic inflammation status. Altered markers such as lipid concentrations are usually found in this disease. Elevated inflammation markers have been described such as cytokines (interleukin 6, tumour necrosis factor-alpha, and IL-8). However, there is a lack of information about the behaviour of the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), lipid coefficients, and atherogenic index in T2DM.

OBJECTIVE

To describe the atherogenic and inflammation parameters in a group of patients with T2DM.

MATERIALS AND METHODS

42 patients with T2DM were included, all patients were surveyed on clinic history (disease history, comorbidity, smoking, and other relevant variables), measurements of haematological, biochemical, and anthropometric parameters were taken and atherogenic coefficients and inflammation ratios were calculated.

RESULTS

Inflammation markers such as interleukin 6 and 8, necrosis tumour factor, and NLR were elevated. Of the patients, 88% were classified as high risk according to the atherogenic index. Former smokers had lower levels of IL-8 and higher NLR than non-smokers.

CONCLUSION

The atherogenic and inflammation markers such as atherogenic index, IL-8, and NLR make it possible to identify a subgroup of patients that are at risk of severe complications and mortality.

Favorable Changes in Biomarkers of Potential Harm to Reduce the Adverse Health Effects of Smoking in Smokers Switching to the Menthol Tobacco Heating System 2.2 for 3 Months (Part 2)

INTRODUCTION

Tobacco Heating System (THS) 2.2, a candidate modified-risk tobacco product, aims at offering an alternative to cigarettes for smokers while substantially reducing the exposure to harmful and potentially harmful constituents found in cigarette smoke.

METHODS

One hundred and sixty healthy adult US smokers participated in this randomized, three-arm parallel group, controlled clinical study. Subjects were randomized in a 2:1:1 ratio to menthol Tobacco Heating System 2.2 (mTHS), menthol cigarette, or smoking abstinence for 5 days in confinement and 86 subsequent ambulatory days. Endpoints included biomarkers of exposure to harmful and potentially harmful constituents (reported in our co-publication, Part 1) and biomarkers of potential harm (BOPH).

RESULTS

Compliance (protocol and allocated product exposure) was 51% and 18% in the mTHS and smoking abstinence arms, respectively, on day 90. Nonetheless, favorable changes in BOPHs of lipid metabolism (total cholesterol and high- and low-density cholesterol), endothelial dysfunction (soluble intercellular adhesion molecule-1), oxidative stress (8-epi-prostaglandin F2α), and cardiovascular risk factors (eg, high-sensitivity C-reactive protein) were observed in the mTHS group. Favorable effects in other BOPHs, including ones related to platelet activation (11-dehydrothromboxane B2) and metabolic syndrome (glucose), were more pronounced in normal weight subjects.

CONCLUSIONS

The results suggest that the reduced exposure demonstrated when switching to mTHS is associated with overall improvements in BOPHs, which are indicative of pathomechanistic pathways underlying the development of smoking-related diseases, with some stronger effects in normal weight subjects.

IMPLICATIONS

Switching to mTHS was associated with favorable changes for some BOPHs indicative of biological pathway alterations (eg, oxidative stress and endothelial dysfunction). The results suggest that switching to mTHS has the potential to reduce the adverse health effects of smoking and ultimately the risk of smoking-related diseases. Switching to mTHS for 90 days led to reductions in a number of biomarkers of exposure in smokers, relative to those who continued smoking cigarettes, which were close to those observed when stopping smoking (reported in our co-publication, Part 1). Initial findings suggest reduced levels of 8-epi-prostaglandin F2α and intercellular adhesion molecule 1, when switching to mTHS for 90 days. These changes are comparable to what is observed upon smoking cessation. In normal weight subjects, additional favorable changes were seen in 11-dehydrothromboxane B2, fibrinogen, homocysteine, hs-CRP, percentage of predicted forced expiratory volume in 1 second, systolic blood pressure, diastolic blood pressure, glucose, high-density lipoprotein, apolipoprotein A1, and triglycerides.

TRIAL REGISTRATION

NCT01989156.

Exposure to harmful and potentially harmful constituents decreased in smokers switching to Carbon-Heated Tobacco Product

BACKGROUND

"Heat-not-burn" tobacco products are designed to heat processed tobacco instead of combusting it, thus significantly reducing the formation of harmful and potentially harmful constituents (HPHCs) found in cigarette smoke, and ultimately reducing the risk of smoking-related diseases. The Carbon-Heated Tobacco Product (CHTP), a heat-not-burn tobacco product similar in appearance and use ritual to cigarettes, has been developed for smokers who would otherwise continue smoking as an alternative to cigarettes. To evaluate reduced risk of harm potential of CHTP, it is critical to quantify exposure to HPHCs and consequent biological pathway disturbances involved in disease onset in smokers who switch to CHTP.

METHODS

In this 2-arm, parallel-group study, adult healthy smokers, not willing to quit, were randomized to switch to CHTP 1.2 (n = 80) or to continue using cigarettes (n = 40) for 5 days in confinement followed by 85 days in an ambulatory setting. Endpoints included biomarkers of exposure (BoExp) to HPHCs, and to nicotine, urinary excretion of mutagenic constituents (Ames assay), CYP1A2 activity, biomarkers of effect, and safety.

RESULTS

In switchers to CHTP, BoExp were 40%-95% lower compared to smokers after 5 days of product use, with sustained reductions (36%-93%) observed on Day 90. Urine mutagenicity and CYP1A2 activity were also lower in the CHTP group. Exposure to nicotine was higher in the CHTP group at Day 5, but was similar between the two groups at Day 90. Favorable changes in some biomarkers of effect were observed in the CHTP group showing reductions in white blood cell count, soluble intracellular adhesion molecule-1, and 11-dehydro-thromboxane B2, respectively, indicative of reduced inflammation, endothelial dysfunction, and platelet activation.

CONCLUSIONS

Switching from cigarettes to CHTP resulted in significantly reduced exposure to HPHCs and was associated with observed improvements in some biomarkers of effect representative of pathomechanistic pathways underlying the development of smoking-related diseases.

Effects of reduced exposure to cigarette smoking on changes in biomarkers of potential harm in adult smokers: results of combined analysis of two clinical studies

Purpose: Nonconventional vapor products (NVP), designed to reduce exposure to cigarette smoke toxicants (CSTs), could cause changes in biomarkers of potential harm (BoPH). Although, NVPs reduced CSTs exposure compared to conventional cigarettes (CC), the changes in the BoPH values varied among the studies. Hence, further information on BoPH using NVPs is needed. Material and methods: The data of two similarly designed studies using a kind of NVP, a noncombustion and nonheating inhaler type of smokeless tobacco product (NCIT) used under 31-day confinement, were pooled, and the differences in 15 BoPH between smokers and nonsmokers at baseline and between the 1 mg tar CC (CC1) group and NCIT group at Day 28/29 were analyzed. Results: At baseline, the levels of eight BoPH (red blood cells, white blood cells, 8-epi-prostaglandin F2α, 8-hydroxy-2'-deoxyguanosine, malondialdehyde, 11-dehydrothromboxane B2, total cholesterol and glucose) were significantly different between smokers and nonsmokers. At Day 28/29, the levels of six BoPH were significantly different between NCIT and CC1 (8-epi-prostaglandin F2α, malondialdehyde, 11-dehydrothromboxane B2: CC1 > NCIT, total bilirubin, low-density lipoprotein cholesterol and total cholesterol: CC1 < NCIT). Conclusions: Reduced exposure to CSTs has favorable effects on BoPH associated with oxidative stress, antioxidant capacity and platelet activation/coagulation but not in lipid metabolism.

Echo-tracking evaluation of changes in common carotid artery wall elasticity after smoking cessation

The aim of this study was to explore changes in the common carotid arterial wall elasticity after smoking cessation. Carotid artery ultrasonographic examination was performed in 136 patients, then 1 or 2 years after smoking cessation. We used echo-tracking (ET) to measure stiffness index (β), pressure-strain elasticity modulus (Ep), arterial compliance (AC), augmentation index (AI), and local pulse wave velocity (PWVβ). Patients were divided into four groups based on whether or not they successfully stopped smoking (groups M and N, respectively) and whether (groups M2 and N2, respectively) or not (groups M1 and N1, respectively) they showed comorbidities. In group M1, β, Ep and PWVβ were lower at 1 year than before smoking cessation, while AC and AI did not change. At 2 years, β, Ep, PWVβ, and AC, but not AI, improved further. In group M2, β, Ep, and PWVβ decreased at 2 years, whereas AC and AI did not change. In groups N1 and N2, none of the variables changed significantly. ET can be used quantitatively to evaluate the impact of smoking cessation on the elasticity of the common carotid artery wall.

Evaluation of Biological and Functional Changes in Healthy Smokers Switching to the Tobacco Heating System 2.2 Versus Continued Tobacco Smoking: Protocol for a Randomized, Controlled, Multicenter Study

BACKGROUND

Tobacco harm reduction, substituting less harmful tobacco products for combustible cigarettes, is a complementary approach for smokers who would otherwise continue to smoke. The Philip Morris International (PMI) Tobacco Heating System (THS) 2.2 is a novel tobacco product with the potential to reduce the risk of harm in smokers compared to continued smoking of combustible cigarettes. It heats tobacco electrically in a controlled manner, never allowing the temperature to exceed 350°C, thereby preventing the combustion process from taking place and producing substantially lower levels of toxicants while providing nicotine, taste, ritual, and a sensory experience that closely parallels combustible cigarettes. Previous clinical studies have demonstrated reduced exposure to the toxicants (approaching the levels observed after quitting) for smokers who switched to THS 2.2, for three months. For adult smokers who would otherwise continue smoking combustible cigarettes, switching to THS 2.2 may represent an alternative way to reduce the risk of tobacco-related diseases.

OBJECTIVE

This study aimed to further substantiate the harm reduction potential of THS 2.2 by demonstrating favorable changes in a set of 8 coprimary endpoints, representative of pathomechanistic pathways (ie, inflammation, oxidative stress, lipid metabolism, respiratory function, and genotoxicity), linked to smoking-related diseases, in smokers switching from combustible cigarettes to THS 2.2.

METHODS

This study was a randomized, controlled, two-arm parallel group, multicenter ambulatory US study conducted in healthy adult smokers switching from combustible cigarettes to THS 2.2 compared with smokers continuing to smoke combustible cigarettes for six months. Subjects had a smoking history of at least ten years and did not intend to quit within the next six months.

RESULTS

Enrollment started in March 2015 and the trial was completed in September 2016. In total, 984 subjects were randomized (combustible cigarettes, n=483; THS 2.2, n=477), and 803 completed the study. The results are expected to be available in a subsequent publication in 2019.

CONCLUSIONS

In this paper, we describe the rationale and design for this clinical study that focused on the evaluation of THS 2.2's potential to reduce the risk of smoking-related diseases compared with that of combustible cigarettes. This study will provide insights regarding favorable changes in biological and functional endpoints informed by effects known to be seen upon smoking cessation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02396381; http://clinicaltrials.gov/ct2/show/NCT02396381 (Archived by WebCite at http://www.webcitation.org/71PCRdagP).

REGISTERED REPORT IDENTIFIER

RR1-10.2196/11294.

Cardiovascular mortality - Comparing risk factor associations within couples and in the total population - The HUNT Study

BACKGROUND

To compare associations of conventional risk factors with cardiovascular death within couples and in the population as a whole.

METHODS

We analysed baseline data (1995-97) from the HUNT2 Study in Norway linked to the national Causes of Death Registry. We compared risk within couples using stratified Cox regression.

RESULTS

During 914776 person-years, 3964 cardiovascular deaths occurred, and 1658 of the deaths occurred among 1494 couples. There were consistently stronger associations of serum lipids and blood pressure with cardiovascular mortality within couples compared to the population as a whole. For instance, for systolic blood pressure (per 20mmHg), the hazard ratio (HR) within couples was 1.28 (95% confidence interval: 1.17, 1.40) compared to 1.16 (1.12, 1.20) in the total population, and for diastolic pressure (per 10mmHg), the corresponding HRs were 1.16 (1.07, 1.26) and 1.11 (1.08, 1.13). Anthropometric factors (BMI, waist circumference, waist-hip ratio) as well as diabetes, smoking, physical activity, and education, showed nearly identical positive associations within couples and in the total population.

CONCLUSIONS

Prospective population studies may tend to slightly underestimate associations of these factors with cardiovascular mortality.

Efficacy of a Rheumatoid Arthritis-Specific Smoking Cessation Program: A Randomized Controlled Pilot Trial

OBJECTIVE

Smoking adversely influences comorbidities in rheumatoid arthritis (RA). The aim of this pilot study was to investigate whether smoking cessation is increased following a 3-month smoking cessation intervention tailored for people with RA.

METHODS

Thirty-nine current smokers with RA were recruited. Participants were randomized into the control group to receive the current local standard of care for smoking cessation (i.e., ABC = brief advice and subsidized nicotine replacement therapy [NRT], or into the intervention group to receive ABC plus additional smoking cessation advice for 3 months (ABC+), including face-to-face, telephone, and e-mail contact. Advice was tailored to the participants' specific needs from a range of intervention tools focused on education about smoking and RA, pain control, exercise, coping, and support. The primary outcome was smoking cessation at 6 months. The secondary outcome was sustained reduction in smoking at 6 months. Disease and psychosocial characteristics of quitters and nonquitters were examined.

RESULTS

The overall smoking cessation rate was 24%. There was no significant difference in smoking cessation rates between the ABC and ABC+ groups (21% versus 26%; P = 0.70). The mean number of cigarettes smoked daily was reduced by 44% (P < 0.001) but did not differ between ABC and ABC+ groups (mean reduction 47% versus 41%; P = 0.72). Successful quitters had more years in education and had smoked less across their lifetime, but these differences were not statistically significant.

CONCLUSION

Smoking cessation in RA may lead to a reduced comorbid burden. The lack of added benefit of the tailored intervention suggests that brief advice and NRT are currently the best practice for supporting people with RA who wish to quit smoking.

Interventions to reduce harm from continued tobacco use

BACKGROUND

Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced-exposure tobacco products (PREPs), as an alternative to cigarettes.

OBJECTIVES

To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long-term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco?

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free-text and MeSH terms for harm reduction, smoking reduction and cigarette reduction.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long-term smoking abstinence), using fixed-effect models. Where it was not possible to meta-analyse data, we summarized findings narratively.

MAIN RESULTS

Twenty-four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically-heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as 'low' or 'very low', due to imprecision and indirectness. A 'low' grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A 'very low' grade means we are very uncertain about the estimate.

AUTHORS' CONCLUSIONS

People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high-quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high-quality RCTs are conducted, and that these also measure the long-term health effects of treatments.

A Japanese cross-sectional multicentre study of biomarkers associated with cardiovascular disease in smokers and non-smokers

We performed a cross-sectional, multicentre study in Japan to detect the differences in biomarkers of exposure and cardiovascular biomarkers between smokers and non-smokers. Several clinically relevant cardiovascular biomarkers differed significantly between smokers and non-smokers, including lipid metabolism (high-density lipoprotein cholesterol concentrations – lower in smokers), inflammation (fibrinogen and white blood cell count – both higher in smokers), oxidative stress (8-epi-prostaglandin F_2α – higher in smokers) and platelet activation (11-dehydro-thromboxane B₂ – higher in smokers) (p ≤ 0.0001). These results provide further evidence showing that cardiovascular biomarkers can discriminate smokers from non-smokers, and could be used to evaluate the risks associated with tobacco products.

Clearing the Air: Smoke-Free Housing Policies, Smoking, and Secondhand Smoke Exposure Among Affordable Housing Residents in Minnesota, 2014-2015

INTRODUCTION

During the past 30 years, local and state tobacco use control laws in the United States have helped reduce smoking prevalence and exposure to secondhand smoke, but progress among low socioeconomic populations has been slow. Implementing smoke-free housing policies in affordable housing may help address this issue. The purpose of our study was to assess how such policies affect smoking rates and exposure to secondhand smoke among residents of affordable housing.

METHODS

We conducted a pretest-posttest longitudinal study of 180 residents from 8 affordable housing properties in Minnesota. Participating properties agreed to adopt a smoke-free housing policy covering indoor grounds, and 3 of these properties also prohibited smoking on all outdoor grounds. Policies were implemented with assistance from local public health departments and the Statewide Health Improvement Program. Participants completed surveys one month before policy implementation and 6 months postimplementation. Surveys assessed smoking, quit attempts, and indoor and outdoor secondhand smoke exposure.

RESULTS

Results indicated a significant reduction in nonsmokers' indoor exposure to secondhand smoke (F1,144 = 22.69, P < .001) and no change in outdoor exposure to secondhand smoke from Time 1 (pretest) to Time 2 (posttest) (F1,140 = 2.17, P = .14). However, when examining sites that only prohibited smoking indoors, we observed an increase in outdoor secondhand smoke exposure that approached significance (F1,118 = 3.76, P = .055). Results showed no change in quit attempts over time, but 77% of residents who smoked at pretest reported reducing the amount that they smoked at posttest, and an additional 5% reported that they had quit.

CONCLUSIONS

Smoke-free housing policies may be an effective strategy to reduce exposure to indoor secondhand exposure and promote decreased cigarette smoking among residents of affordable housing.

Current cigarette smoking is a reversible cause of elevated white blood cell count: Cross-sectional and longitudinal studies

While cigarette smoking is a well-recognized cause of elevated white blood cell (WBC) count, studies on longitudinal effect of smoking cessation on WBC count are limited. We attempted to determine causal relationships between smoking and elevated WBC count by retrospective cross-sectional study consisting of 37,972 healthy Japanese adults who had a health check-up between April 1, 2008 and March 31, 2009 and longitudinal study involving 1730 current smokers who had more than four consecutive annual health check-ups between April 1, 2007 and March 31, 2012. In the cross-sectional study, younger age, male gender, increased body mass index, no alcohol habit, current smoking, and elevated C-reactive protein level were associated with elevated WBC count. Among these factors, current smoking had the most significant association with elevated WBC count. In subgroup analyses by WBC differentials, smoking was significantly associated with elevated counts of neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Ex-smoking was not associated with elevated WBC count. In the longitudinal study, both WBC and neutrophil counts decreased significantly in one year after smoking cessation and remained down-regulated for longer than next two years. There was no significant change in either WBC or neutrophil count in those who continued smoking. These findings clearly demonstrated that current smoking is strongly associated with elevated WBC count and smoking cessation leads to recovery of WBC count in one year, which is maintained for longer than subsequent two years. Thus, current smoking is a significant and reversible cause of elevated WBC count in healthy adults.

Evaluating the relationship between biomarkers of potential harm and biomarkers of tobacco exposure among current, past, and nonsmokers: data from the National Health and Nutrition Examination Survey 2007-2012

Potential long-term health effects from tobacco products can be estimated by measuring changes in biochemical indicators of disease mechanisms like inflammation. This study assesses the potential relationships between biomarkers of potential harm (BOPH) and biomarkers of cigarette smoke exposure (BOE) based on data from the NHANES (2007-2012, n = 17,293 respondents). Statistically significant relationships were observed between white blood cells (WBC) and high-density lipoprotein (HDL) and BOE; between WBC and high-sensitivity C-reactive protein and smoking status; and between WBC and HDL and smoking intensity. This analysis suggests that WBC and HDL are useful BOPH in studies assessing the health risks of cigarette smoking.

Outcomes of a Tailored Intervention for Cigarette Smoking Cessation Among Latinos Living With HIV/AIDS

INTRODUCTION

Tobacco use has emerged as a leading killer among persons living with HIV, with effective approaches to tobacco treatment still unknown. HIV infection is nearly 3 times as prevalent in Latinos than in non-Latino Whites. This study reports the results of a randomized trial comparing a tailored intervention to brief counseling for smoking cessation among Latino smokers living with HIV (LSLWH).

METHODS

LSLWH (N = 302; 36% female, 10% employed full-time, 49% born in United States) were randomized to 4 in-person sessions of a tailored intervention (Aurora) or 2 in-person sessions of brief advice (enhanced standard care [ESC]). Both groups received 8 weeks of nicotine replacement therapy (NRT) patch. Biochemically validated 6- and 12-month 7-day point-prevalence abstinence (PPA) rates were compared, along with secondary outcomes (e.g., reduction to light smoking, NRT adherence).

RESULTS

Seven-day PPA rates reached 8% versus 11% at 6 months and 6% versus 7% at 12 months, for Aurora and ESC, respectively, with no between-group differences (p values > .40). Significant changes from baseline to 6 and 12 months among intervention targets were noted (percentage reduction in heavy smoking and dependence; increases in knowledge and self-efficacy). Baseline smoking frequency, older age, and higher intensity of patch use during the trial emerged as significant predictors of abstinence at 6 months.

CONCLUSIONS

There was no evidence that the tailored intervention improved cessation rates. Interventions that encourage use of, and adherence to, empirically validated cessation aids require further development to reduce tobacco-related death and disease in this vulnerable population.

Smoking and inflammation: evidence for a synergistic role in chronic disease

Tobacco smoking is the most important preventable risk factor for periodontitis; however, the underlying biological mechanisms responsible for the detrimental effects of smoking on periodontal health remain largely unclear. It is also well established that smoking has a negative impact on several inflammatory diseases, including rheumatoid arthritis, multiple sclerosis and inflammatory bowel disease. The aim of this paper was to review smoking-related changes in local and systemic host responses with a focus on cellular and molecular effects that could explain a hyperinflammatory response leading to periodontal destruction. Biological mechanisms that may be common to periodontal disease and other chronic inflammatory diseases were also explored, together with gene-smoking interactions. An epidemiologic perspective on the burden of smoking on periodontal health and the potential for smoking cessation is also presented. Tobacco smoking seems to induce changes ranging from decreased leukocyte chemotaxis to decreased production of immunoglobulins. Smoking also seems to cause a stronger inflammatory reaction with an increased release of potentially tissue-destructive substances (e.g. reactive oxygen species, collagenase, serine proteases and proinflammatory cytokines). These findings support a hypothesis that periodontitis is a hyperinflammatory condition rather than a hypo-inflammatory condition.

Cigarette smoking is associated with dose-dependent adverse effects on paraoxonase activity and fibrinogen in young women

CONTEXT

Smoking is associated with increased fibrinogen and decreased paraoxonase (PON) activity, markers of inflammation and oxidative stress, in patients with coronary artery disease.

OBJECTIVE

We tested the hypothesis that the adverse effect of smoking on these biomarkers of inflammation and oxidative stress would be detectable in otherwise healthy young female habitual smokers.

MATERIALS AND METHODS

Thirty-eight young women participated in the study (n = 20 habitual smokers, n = 18 non-smokers). Fibrinogen, PON-1 activity and HDL oxidant index (HOI) were measured.

RESULTS

Mean values of fibrinogen, PON-1 activity and log HOI were not different between the groups. Importantly, however, decreased PON-1 activity (rs = -0.51, p = 0.03) and increased fibrinogen (rs = 0.49, p = 0.04) were significantly correlated with increasing number of cigarettes smoked per day in habitual smokers.

DISCUSSION AND CONCLUSION

Cigarette smoking is associated with a dose-dependent adverse effect on PON-1 activity and fibrinogen in young women, which may have implications for future cardiovascular risk.

Evaluation of health promotion programmes in severe mental illness: theory and practice

Health promotion programmes for patients with severe mental illness (HPP) are not uniformly evaluated. We discuss the evaluation of HPP in theory and practice, as a prerequisite for future uniform evaluation. We explored the expected outcome and mechanism of HPP in the current literature. Based on this theoretical exploration we selected measures assessing the expected outcome and mechanism in current practice. The individual properties of these measures were described. Based on our theoretical exploration the outcome of HPP can be expressed in several aspects of health. Health can be improved through several mechanisms. In the current evaluation of HPP only some of the expected outcomes were evaluated. The measures used for evaluation were not all representative for the constructs they should assess. Important aspects of HPP are currently not evaluated, based on a comparison between our theoretical exploration of expected outcome and mechanism and current practice. Additionally, not all measures in use are suitable for evaluation of HPP. Therefore, development and identification of suitable measures is necessary. Our framework offers valuable directions for the development of such measures and the future evaluation of HPP.

Dose-related association between urinary cotinine-verified smoking status and dyslipidemia among Korean men: the 2008-2010 Korea National Health and Nutrition Examination Survey

This cross-sectionally designed study was based on data collected during the 2008-2010 Korea National Health and Nutrition Examination Survey. A total 3231 South Korean men aged more than 19 years were included. Urinary cotinine concentrations were measured. Smoking status was defined using questionnaire responses and urinary cotinine concentrations. Hierarchical multivariate logistic regression analyses were used to assess the association of urinary cotinine concentrations with the prevalence of dyslipidemia and various parameters of dyslipidemia. There is a significant dose-related association between smoking as assessed by urinary cotinine concentration and dyslipidemia and various parameters of dyslipidemia among South Korean men.

Using exhaled carbon monoxide and carboxyhemoglobin to evaluate the effectiveness of a chimney stove model in Peru

BACKGROUND

Measurement of biological indicators of physiological change may be useful in evaluating the effectiveness of stove models, which are intended to reduce indoor smoke exposure and potential health effects.

OBJECTIVES

We examined changes in exhaled carbon monoxide (CO), percentage carboxy-hemoglobin, and total hemoglobin in response to the installation of a chimney stove model by the Juntos National Program in Huayatan, Peru in 2008.

METHODS

Biomarkers were measured in a convenience sample comprising 35 women who met requirements for participation, and were measured before and three weeks after installation of a chimney stove. The relationships between exposure to indoor smoke and biomarker measurements were also analyzed using simple linear regression models.

RESULTS

Exhaled CO reduced from 6.71 ppm (95% CI 5.84-7.71) to 3.14 ppm (95% CI 2.77-3.66) three weeks after stove installation (P < 0.001) while % COHb reduced from 1.76% (95% CI 1.62-1.91) to 1.18% (95% CI 1.12-1.25; P < 0.001). Changes in exhaled CO and % COHb from pre- to post-chimney stove installation were not correlated with corresponding changes in exposure to CO and PM2.5 even though the exposures also reduced after stove installation.

CONCLUSION

Exhaled CO and % COHb both showed improvement with reduction in concentration after the installation of the chimney cook stoves, indicating a positive physiological response subsequent to the intervention.

The effect of quitting smoking on HDL-cholesterol - a review based on within-subject changes

A higher concentration of high density lipoprotein cholesterol (HDL-C) in ex-smokers than smokers has consistently been observed. Better evidence of quitting effects comes from within-subject changes. We extend an earlier meta-analysis to quantify the reduction, and investigate variation by time quit and other factors. We conducted Medline and Cochrane searches for studies measuring HDL-C in subjects while still smoking and later having quit. Using unweighted and inverse-variance weighted regression analysis, we related changes (in mmol/l) to intra-measurement period, and estimated time quit, and to study type, location and start year, age, sex, product smoked, validation of quitting, baseline HDL-C, baseline and change in weight/BMI, and any study constraints on diet or exercise. Forty-five studies were identified (17 Europe, 16 North America, 11 Asia, 1 Australia). Thirteen were observational, giving changes over at least 12 months, with most involving >1000 subjects. Others were smoking cessation trials, 12 randomized and 20 non-randomized. These were often small (18 of <100 subjects) and short (14 of <10 weeks, the longest a year). Thirty studies provided results for only one time interval. From 94 estimates of HDL-C change, the unweighted mean was 0.107 (95% CI 0.085-0.128). The weighted mean 0.060 (0.044 to 0.075) was lower, due to smaller estimates in longer term studies. Weighted means varied by time quit (0.083, 0.112, 0.111, 0.072, 0.058 and 0.040 for <3, 3 to <6, 6 to <13, 13 to <27, 27 to <52 and 52+ weeks, p=0.006). After adjustment for time quit, estimates varied by study constraint on diet/exercise (p=0.003), being higher in studies requiring subjects to maintain their pre-quitting habits, but no other clear differences were seen, with significant (p<0.05) increases following quitting being evident in all subgroups studied, except where data were very limited. For both continuing and never smokers, the data are (except for two large studies atypically showing significant HDL-C declines in both groups, and a smaller decline in quitters) consistent with no change, and contrast markedly with the data for quitters. We conclude that quitting smoking increases HDL-C, and that this increase occurs rapidly after quitting, with no clear pattern of change thereafter.

Cost and clinical consequences of smoking cessation in outpatients after cardiovascular disease: a retrospective cohort study

This cohort retrospective study explored the cost and clinical consequences of smoking cessation in outpatients after cardiovascular events (CVEs), in Spain. A total of 2,540 patients (68.1 years; 60.7% male; 8.4% smokers, 52.9% ex-smokers, and 38.7% never smokers) fulfilling the selection criteria and followed up throughout a period of 36 months after the event were considered eligible for analysis. Total costs were higher among current smokers in comparison with ex-smokers and never smokers (€7,981 versus [vs] €7,322 and €5,619, respectively) (P < 0.001). Both health care costs (€6,273 vs €5,673 and €4,823, respectively) (P < 001) and loss of productivity at work costs (€1,708 vs €1,650 and €796, respectively) (P < 001) accounted for such differences. There was also a difference in CVE recurrence rates (18.6% vs 16.5% and 9.6%, respectively) (P < 01). Smoking cessation in CVE outpatients was associated with lower cost and risk of CVE recurrence compared with smokers, and their health status was similar to that of never smokers, in routine clinical practice in Spain.

Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 7: A one-month, randomized, ambulatory, controlled clinical study in Poland

This randomized, open-label, ambulatory, controlled clinical study investigated biomarkers associated with cardiovascular risk and biomarkers of exposure to 10 selected harmful and potentially harmful constituents (HPHC) in cigarette smoke in 316 male and female Polish smokers. Subjects were randomized to continue smoking conventional cigarettes (CC; N=79) or switch to smoking the Electrically Heated Cigarette Smoking System series-K cigarette (EHCSS-K6; N=237). Biomarker assessments were performed at several time points during the study at baseline and during the 1-month investigational period. The primary biomarkers were high-sensitivity C-reactive protein and white blood cell counts. No statistically significant differences in the two primary biomarkers were found between the study groups at the end of the study. End-of-study comparisons of secondary biomarkers between study groups indicated an increase in high-density lipoprotein cholesterol, and reductions in red blood cell count, hemoglobin, and hematocrit levels in the EHCSS-K6 group. All biomarkers of exposure to cigarette smoke HPHC were decreased in the EHCSS-K6 group, despite an increase in cigarette consumption, compared to the CC group. There were no apparent differences in any of the safety assessment parameters between the groups, and the overall incidence of study-related adverse events was low.

Very low nicotine content cigarettes and potential consequences on cardiovascular disease

Cigarette smoking remains highly prevalent in the U.S. and contributes significantly to cardiovascular disease (CVD). Tobacco control policies, including product regulation, can reduce smoking-related harm. One approach being considered in the U.S. is for the FDA to set a low nicotine standard for cigarettes. Such a standard could result in multiple beneficial outcomes including reduced cardiovascular toxicity related to nicotine, reduced smoking intensity in current smokers, increased cessation rates, decreased development of smoking dependence in youth, and decreased passive smoke exposure. Consequently, CVD risk in the U.S. could be dramatically improved by nicotine reduction in cigarettes. Possible pathways linking nicotine reduction in cigarettes to decreased CVD risk are discussed, while potential unintended consequences that could offset expected gains are also presented. Gaps in the literature, including limited data on CVD biomarkers and long-term CVD outcomes following the use of very low nicotine cigarettes, are discussed to highlight areas for new research.

Influence of smoking cessation on carotid artery wall elasticity evaluated by echo-tracking

OBJECTIVE

Exploring the use of echo-tracking (ET) for evaluating changes in carotid artery wall elasticity after smoking cessation.

METHODS

Carotid artery ultrasound examination was performed in 67 male patients before and after smoking cessation treatment, for measurement of intimal media thickness (IMT), and ET measurement of wall elasticity variables, ie, wall stiffness index (β), pressure-strain elastic modulus (Ep), compliance (AC), augmentation index (AI), and local pulse wave velocity (PWVβ). We also measured heart rate (HR), systolic pressure (Ps), diastolic pressure (Pd), total cholesterol (TC), triglyceride level (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL).

RESULTS

Hyperlipemia and/or arterial hypertension and/or hyperglycemia were absent in 22 (group A1) and 12 (group B1) and present in 19 (group A2) and 14 (group B2) of the patients with successful (group A, n = 41) and unsuccessful (group B, n = 26) treatment, respectively. In the A1 group, there was no significant difference in AI before and after smoking cessation, whereas β, Ep, and PWVβ decreased, and AC increased (p < 0.05). None of these variables changed after smoking cessation in groups A2, B1, and B2. There was no change in IMT in either group. HR decreased and HDL increased in the A1 group, without change in Ps, Pd, TC, TG, and LDL. There was no change in HR, Ps, Pd, TC, TG, LDL, and HDL in groups A2, B1, and B2.

CONCLUSIONS

ET can be used to evaluate quantitatively the impact of smoking cessation on common carotid artery wall elasticity.

Cigarette smoking, illicit drug use, and routes of administration among heroin and cocaine users

Cigarette smoking is ubiquitous among illicit drug users. Some have speculated that this may be partially due to similarities in the route of administration. However, research examining the relationship between cigarette smoking and routes of administration of illicit drugs is limited. To address this gap, we investigated sociodemographic and drug use factors associated with cigarette smoking among cocaine and heroin users in the Baltimore, Maryland community (N=576). Regular and heavy cigarette smokers were more likely to be White, have a history of a prior marriage, and have a lower education level. Regular smoking of marijuana and crack was associated with cigarette smoking, but not heavy cigarette smoking. Injection use was more common among heavy cigarette smokers. In particular, regular cigarette smokers were more likely to have a lifetime history of regularly injecting heroin. Optimal prevention and treatment outcomes can only occur through a comprehensive understanding of the interrelations between different substances of abuse.

Smoking cessation program with exercise improves cardiovascular disease biomarkers in sedentary women

BACKGROUND

Several cardiovascular disease (CVD) biomarkers sensitive to tobacco exposure have been identified, but how tobacco use cessation impacts them is less clear. We sought to investigate the effects of a smoking cessation program with an exercise intervention on CVD biomarkers in sedentary women.

METHODS

This is a cohort study on a subsample of a 2×2 factorial randomized controlled trial (RCT) (exercise setting: home vs. facility; level of exercise counseling: prescription only vs. prescription and adherence counseling) conducted January 2004 through December 2007. The analyses were completed in October 2010. In the greater Boston area, 130 sedentary female smokers aged 19-55 completed a 15-week program. All participants received nicotine replacement therapy (transdermal patch) and brief behavioral counseling for 12 weeks. They all received an exercise prescription on a moderate intensity level. All exercise interventions lasted for 15 weeks, from 3 weeks precessation until 12 weeks postcessation. Main outcome measures were selected CVD biomarkers hypothesized to be affected by smoking cessation or exercise measured at baseline and 12 weeks postcessation.

RESULTS

Independent of tobacco abstinence, improvement was seen in inflammation (white blood cells [WBC]), prothrombotic factor (red blood cells [RBC]), and cardiovascular fitness level (maximum oxygen consumption [Vo(2)max]). This suggests that even if complete abstinence is not achieved, reduction in tobacco exposure and increase in exercise can improve the cardiovascular risk profile. A significant decrease was seen for total cholesterol and the total cholesterol high-density lipoprotein cholesterol (HDL-C): ratio only among the abstainers. The heart rate was reduced among all participants, but this decrease was more profound among abstainers. A significant weight gain and body mass index (BMI) increase were observed among abstainers and those who relapsed. We also found an increase in hemoglobin A1c (Hb A1c), although significant only when the groups were combined.

CONCLUSIONS

A smoking cessation intervention including exercise reduced tobacco-induced cardiovascular damage selectively within 3 months.

Associations among smoking status, lifestyle and lipoprotein subclasses

BACKGROUND

The relationship between cigarette smoking and cardiovascular disease is well established, yet the underlying mechanisms remain unclear. Although smokers have a more atherogenic lipid profile, this may be mediated by other lifestyle-related factors. Analysis of lipoprotein subclasses by the use of nuclear magnetic resonance spectroscopy (NMR) may improve characterisation of lipoprotein abnormalities.

OBJECTIVE

We used NMR spectroscopy to investigate the relationships between smoking status, lifestyle-related risk factors, and lipoproteins in a contemporary cohort.

METHODS

A total of 612 participants (360 women) aged 40-69 years at baseline (1990-1994) enrolled in the Melbourne Collaborative Cohort Study had plasma lipoproteins measured with NMR. Data were analysed separately by sex.

RESULTS

After adjusting for lifestyle-related risk factors, including alcohol and dietary intake, physical activity, and weight, mean total low-density lipoprotein (LDL) particle concentration was greater for female smokers than nonsmokers. Both medium- and small-LDL particle concentrations contributed to this difference. Total high-density lipoprotein (HDL) and large-HDL particle concentrations were lower for female smokers than nonsmokers. The proportion with low HDL particle number was greater for female smokers than nonsmokers. For men, there were few smoking-related differences in lipoprotein measures.

CONCLUSION

Female smokers have a more atherogenic lipoprotein profile than nonsmokers. This difference is independent of other lifestyle-related risk factors. Lipoprotein profiles did not differ greatly between male smokers and nonsmokers.

Smoking and atherosclerotic cardiovascular disease: part II: role of cigarette smoking in cardiovascular disease development

Potential mechanisms and biomarkers of atherosclerosis related to cigarette smoking - a modifiable risk factor for that disease - are discussed in this article. These include smoking-associated inflammatory markers, such as leukocytes, high-sensitivity C-reactive protein, serum amyloid A, ICAM-1 and IL-6. Other reviewed markers are indicative for smoking-related impairment of arterial endothelial function (transcapillary leakage of albumin, inhibition of endogenous nitric oxide synthase activity and reduced endothelium-dependent vasodilation) or point to oxidative stress caused by various chemicals (cholesterol oxidation, autoantibodies to oxidized low-density lipoprotein, plasma levels of malondialdehyde and F(2)-isoprostanes and reduced antioxidant capacity). Smoking enhances platelet aggregability, increases blood viscosity and shifts the pro- and antithrombotic balance towards increased coagulability (e.g., fibrinogen, von Willebrand factor, ICAM-1 and P-selectin). Insulin resistance is higher in smokers compared with nonsmokers, and hemoglobin A1c is dose-dependently elevated, as is homocysteine. Smoke exposure may influence the kinetics of markers with different response to transient or chronic changes in cigarette smoking behavior.

Efficacy and safety of bupropion for smoking cessation and reduction in schizophrenia: systematic review and meta-analysis

BACKGROUND

The benefits and harms of bupropion as an aid for smoking cessation in schizophrenia remain uncertain.

AIMS

To summarise the current evidence for efficacy and safety of bupropion as treatment for nicotine dependence in schizophrenia.

METHOD

Systematic review and random-effects meta-analysis of randomised controlled trials (RCTs) comparing bupropion with placebo or alternative therapeutic control in adult smokers with schizophrenia.

RESULTS

Twenty-one reports from seven RCTs were included. Biochemically verified self-reported smoking cessation rates after bupropion were significantly higher than placebo at the end of treatment (risk ratio (RR) = 2.57, P = 0.004) and at 6 months (RR = 2.78, P = 0.05). Expired carbon monoxide level was significantly lower with bupropion at the end of therapy (P = 0.002) but not at 6 months (P = 0.37). There was no significant difference in positive (P = 0.28) or negative symptoms (P = 0.49) between the bupropion and the placebo group.

CONCLUSIONS

Bupropion increases the rates of smoking abstinence in smokers with schizophrenia, without jeopardising their mental state.

Adaptive regression modeling of biomarkers of potential harm in a population of U.S. adult cigarette smokers and nonsmokers

BACKGROUND

This article describes the data mining analysis of a clinical exposure study of 3585 adult smokers and 1077 nonsmokers. The analysis focused on developing models for four biomarkers of potential harm (BOPH): white blood cell count (WBC), 24 h urine 8-epi-prostaglandin F2alpha (EPI8), 24 h urine 11-dehydro-thromboxane B2 (DEH11), and high-density lipoprotein cholesterol (HDL).

METHODS

Random Forest was used for initial variable selection and Multivariate Adaptive Regression Spline was used for developing the final statistical models

RESULTS

The analysis resulted in the generation of models that predict each of the BOPH as function of selected variables from the smokers and nonsmokers. The statistically significant variables in the models were: platelet count, hemoglobin, C-reactive protein, triglycerides, race and biomarkers of exposure to cigarette smoke for WBC (R-squared = 0.29); creatinine clearance, liver enzymes, weight, vitamin use and biomarkers of exposure for EPI8 (R-squared = 0.41); creatinine clearance, urine creatinine excretion, liver enzymes, use of Non-steroidal antiinflammatory drugs, vitamins and biomarkers of exposure for DEH11 (R-squared = 0.29); and triglycerides, weight, age, sex, alcohol consumption and biomarkers of exposure for HDL (R-squared = 0.39).

CONCLUSIONS

Levels of WBC, EPI8, DEH11 and HDL were statistically associated with biomarkers of exposure to cigarette smoking and demographics and life style factors. All of the predictors together explain 29%-41% of the variability in the BOPH.

Longitudinal effect of smoking cessation on physical and laboratory findings

BACKGROUND

Detailed information on the expected physiologic changes after smoking cessation is practically useful to encourage people to stop smoking. Furthermore, weight increase after cessation may affect such physiologic changes.

PURPOSE

This article aims to evaluate the effect of smoking cessation on annual changes in body weight, blood pressure, and blood biochemistry.

METHODS

This study analyzed the results of annual health examinations from 1991 to 2005 in male Japanese workers in 2009. Subjects classified as stopping smoking (n=445) responded initially as smokers in a self-administered questionnaire (baseline year) and then answered consistently as nonsmokers for 3 subsequent years. Of the 2672 smokers identified in the study, 2403 subjects who had data available for at least 4 successive years were selected as controls. The time course of physiologic and laboratory data was analyzed using a linear mixed model.

RESULTS

Data adjusted for age, type of job schedule, drinking and physical activity showed that subjects who stopped smoking had significantly greater increases in weight, BMI, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, and uric acid and a greater decrease in hemoglobin in the 3 years following smoking cessation than continuing smokers. Additional adjustment for change in BMI from baseline negated the significant deterioration in systolic and diastolic blood pressure and total cholesterol that occurred following smoking cessation.

CONCLUSIONS

Increase in body weight, blood pressure, and blood biochemistry can continue for at least 3 years after smoking cessation. This study also indicated that these increases were related to the weight increase that occurred after smoking cessation.

Respiratory, cardiovascular and other physiological consequences of smoking cessation

BACKGROUND

Smoking cessation is associated with substantial reductions in tobacco-related morbidity and mortality. Based on the current literature, the beneficial effects of quitting are particularly evident on pulmonary and cardiovascular function, but the negative physiological effects of cessation are less well documented.

SCOPE

The objective of this article was to review systematically data on the physiological effects of smoking cessation. Articles based upon clinical trials, randomised controlled trials and meta-analyses were selected from titles and abstracts obtained via a MEDLINE search (May 2003-May 2008). Additional studies were identified from the bibliographies of reviewed literature.

FINDINGS

Smoking cessation is associated with improved lung function and a reduction in the presence and severity of respiratory symptoms. These changes, apparent within months of quitting, are sustained with long-term abstinence. The underlying pathophysiologies of smoking-induced airway inflammation and endothelial dysfunction are partially reversed following cessation in healthy ex-smokers, but not in those with chronic obstructive pulmonary disease. Smoking cessation is also associated with substantially improved cardiovascular function and reduced risk of primary and secondary cardiovascular morbidity and mortality. Although the overall long-term health benefits are unquestionable, smoking cessation is also associated with other possible undesirable short-term physiological effects such as weight gain, hypertension, constipation and mouth ulcers; and altered activity of the enzyme cytochrome P450 1A2 (CYP1A2), which metabolises many commonly used drugs.

CONCLUSION

The negative physiological effects of smoking cessation may adversely affect a smoker's attempt to quit, and physicians should provide their smoking patients with motivation and regular encouragement and support when attempting to quit, whilst educating them on the health benefits of abstinence. Additionally, since cigarette smoke is a potent inducer of CYP1A2, patients attempting to quit smoking should have their dosages of drugs metabolised by this enzyme closely monitored.

Cigarette smoking: an undertreated risk factor for cardiovascular disease

Smoking and other forms of tobacco use are major risk factors for cardiovascular disease. The effect of cigarette smoking on cardiovascular health is evident even at the lowest levels of exposure. Yet, the adverse effects of smoking are reversible, with cardiovascular risk decreasing substantially within the first 2 years of smoking cessation. Significantly, the mortality from coronary heart disease is reduced more through smoking cessation than by other secondary preventive therapies such as cholesterol lowering. Smoking cessation is a highly effective way to improve cardiovascular health in smokers and extremely cost-effective. However, smoking cessation therapies are not implemented maximally if they are implemented at all, perhaps because smoking is seen as a lifestyle choice or because smokers frequently relapse, as indicated by very low long-term quit rates. Too often, healthcare professionals, including lipidologists and cardiologists, do little to address their patients' smoking status, in spite of its impact on cardiovascular health. With the advent of new therapies to treat the nicotine addiction that results from smoking and other tobacco use, it is hoped that physicians will be more proactive in encouraging and implementing smoking cessation programs for their patients, with the goal of increasing long-term quit rates, and reducing the morbidity and mortality associated with cardiovascular disease.

Diretrizes para cessação do tabagismo - 2008

Estas diretrizes constituem uma ferramenta atualizada e abrangente para auxiliar o profissional de saúde na abordagem do tabagista, recomendando atitudes baseadas em evidências clínicas como a melhor forma de conduzir cada caso. De forma reduzida e mais objetiva possível, o texto final foi agrupado em dois grandes itens: Avaliação e Tratamento. Os dois itens apresentam comentários e níveis de recomendação das referências utilizadas, bem como algumas propostas de abordagem, como por exemplo, redução de danos, em situações específicas ainda pouco exploradas, como recaídas, tabagismo passivo, tabagismo na categoria médica e uso de tabaco em ambientes específicos.

Smoking reduction fails to improve clinical and biological markers of cardiac disease: a randomized controlled trial

Cigarette reduction has been proposed as a treatment goal for smokers who are not interested in stopping completely. This randomized controlled trial was designed to determine the effect of a smoking reduction intervention on smoking behavior, symptoms of heart disease, and biomarkers of tobacco exposure. It included 152 patients with heart disease who did not intend to stop smoking in the next 30 days. Participants were randomly assigned to smoking reduction (SR) or usual care (UC). SR subjects received counseling and nicotine replacement therapy to encourage > or =50% reduction in cigarettes per day (CPD). They were followed at 1, 3, 6, 12 and 18 months to assess smoking, heart disease symptoms, quality of life and nicotine, cotinine, carbon monoxide (CO), white blood cell (WBC) count, fibrinogen, hs-C-reactive protein (hs-CRP), F2-isoprostane, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides (total NNAL), and 1-hydroxypyrene (1-HOP). At 6 months SR participants reduced by 10.9 CPD, compared with 7.4 CPD in UC (difference NS). At 18 months, 9/78 SR vs. 9/74 UC participants quit smoking. There were no significant differences between treatment groups in angina, quality of life or adverse events, nicotine, cotinine, CO, WBC count, fibrinogen, hs-CRP, F2-isoprostane, total NNAL or 1-HOP levels at any time point. To determine if smoking reduction, regardless of treatment condition, was associated with improved outcomes, we compared all subjects at 6 months to baseline (mean reduction in CPD from 27.4 to 18.1, p<.01). There were no significant changes in outcome variables except CO, which decreased by 5.5 ppm (p<.01). There were also no significant improvements considering only subjects who reduced by > or =50%, or those who had no history of reduction prior to enrollment in the study. The SR intervention did not significantly reduce CPD or toxin exposure, or improve smoking cessation or clinical outcomes compared to UC. These results emphasize the importance of abstinence for smokers with heart disease to minimize health risks from tobacco.

A 12-month, randomized, controlled study to evaluate exposure and cardiovascular risk factors in adult smokers switching from conventional cigarettes to a second-generation electrically heated cigarette smoking system

This randomized, controlled, forced-switching, open-label, parallel-group study in 97 adult male and female smokers of conventional cigarettes evaluated biomarkers of tobacco smoke exposure and cardiovascular risk factors. After baseline measurements, smokers were either switched to a second-generation electrically heated cigarette smoking system (EHCSS) or continued smoking conventional cigarettes for 12 months. Biomarkers of exposure and cardiovascular risk factors were measured at 0.5, 1, 2, 3, 4, 5, 6, 9, and 12 months. There was a rapid and sustained reduction in all biomarkers of exposure after switching to the EHCSS, with statistically significant reductions from baseline in nicotine equivalents (-18%), plasma cotinine (-16%), total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (-73%), total 1-hydroxypyrene (-53%), urine mutagenicity (-52%), 4-aminobiphenyl hemoglobin adducts (-43%), carboxyhemoglobin AUC7-23 h (-80%), and 3-hydroxypropylmercapturic acid (-35%). These reductions in exposure in the EHCSS group were associated with statistically significant and pathophysiologically favorable changes in several cardiovascular risk factors, including white blood cell count (-0.78 x 10(3)/microL), hemoglobin (-0.16 g/dL), hematocrit (-0.44%), urine 11-dehydrothromboxane B2 (-374 ng/24 h), and high-density lipoprotein cholesterol (+5 mg/dL).

Developing the science base for reducing tobacco harm

The University of Minnesota Transdisciplinary Tobacco Use Research Center has been examining the multiple dimensions and the scientific evidence required to determine the feasibility of tobacco harm reduction as a means to reduce tobacco-related mortality and morbidity. Because of the complexity associated with exploring this area, an interdisciplinary approach is necessary. The research components that have been of particular focus at our center include (a) developing and validating biomarkers of tobacco-related exposure and toxicity, (b) developing animal models and designing studies with humans to assess a variety of smoking reduction approaches and potential reduced exposure products, and (c) determining individual differences in response to these interventions and products. A description of the ongoing activities and challenges in these areas is provided, along with projected directions for the future.

Interventions to reduce harm from continued tobacco use

BACKGROUND

It may be reasonable to try to reduce the harm from continued smoking amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products. The interventions evaluated in controlled trials have predominantly attempted to reduce the number of cigarettes smoked.

OBJECTIVES

To assess the effect of interventions intended to reduce the harm from smoking on the following: biomarkers of damage caused by tobacco, biomarkers of tobacco exposure, number of cigarettes smoked, quitting, and long-term health status.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register using free text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. The initial search was in March 2006, updated in March 2007.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions in tobacco users to reduce amount smoked, or to reduce harm from smoking by means other than cessation. Outcomes were change in cigarette consumption, markers of cigarette exposure and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We pooled trials with similar interventions and outcomes using a fixed-effect model. Other studies were summarised narratively.

MAIN RESULTS

The 13 included trials all evaluated interventions to help smokers cut down the amount smoked. Self-reported reduction in cigarettes per day (CPD) was validated by reduction in carbon monoxide (CO) levels. Most trials tested nicotine replacement therapy (NRT) to assist reduction. No eligible studies evaluated the use of potentially reduced-exposure products. In a pooled analysis of eight trials, NRT significantly increased the odds of reducing CPD by 50% or more for people using nicotine gum or inhaler or a choice of product compared to placebo (n=3273, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.55 to 2.62). Where average changes from baseline were compared for different measures, CO and cotinine consistently showed smaller reductions than CPD. Whilst the effect for NRT was significant, small numbers of people in either treatment or control group successfully sustained a reduction of 50% or more. Use of NRT also significantly increased the odds of quitting (OR 1.90, 95% CI 1.46 to 2.47). One trial of bupropion failed to detect an effect on reduction or cessation. Four trials of different types of advice and instructions on reducing CPD did not provide clear evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence about long-term benefit to give firm support the use of interventions intended to help smokers reduce but not quit tobacco use. Some people who do not wish to quit can be helped to cut down the number of cigarettes smoked and reduce their carbon monoxide levels by using nicotine gum or nicotine inhaler. Because the long-term health benefit of a reduction in smoking rate is unclear this application of NRT is more appropriately used as a precursor to quitting.

The impact of a smoking ban on hospital admissions for coronary heart disease

OBJECTIVE

In March 2002, the city of Bowling Green, Ohio, implemented a clean indoor air ordinance banning smoking in workplaces and public places. This study evaluates the effect of this ordinance on hospital admissions for smoking-related diseases.

METHODS

A quasi-experimental design with interrupted time-series was used including a matched control city (Kent, Ohio) with no clean indoor air ordinance. Data on hospital admissions during the period of January 1999 to June 2005 were analyzed using Autoregressive Integrated Moving Average (ARIMA) models.

RESULTS

A reduction in admission rates for smoking-related diseases was achieved in Bowling Green compared to the control city. The largest reduction was for coronary heart disease, where rates were decreased significantly by 39% after 1 year and by 47% after 3 years following the implementation of the ordinance. ARIMA models revealed a statistically significant downward trend in monthly admission rates for coronary heart disease (Bowling Green, omega=-1.69, p=0.036 vs. Kent, omega=-1.14, p=0.183) and support the hypothesis that the ordinance had a significant impact on admission rates for coronary heart disease.

CONCLUSION

The findings of this study suggest that clean indoor air ordinances lead to a reduction in hospital admissions for coronary heart disease, thus reducing health care costs.

Smoking reduction and biomarkers in two longitudinal studies

AIMS

To measure reduction in exposure to smoke in two population-based studies of self-reported smoking reduction not using nicotine replacement.

DESIGN

Cross-sectional analyses of biomarkers and smoking.

SETTING

Data from two time-points in the Copenhagen City Heart Study (CCHS), 1981/83 and 1991/94, and the Copenhagen Male Study (CMS) in 1976 and 1985/86, respectively.

PARTICIPANTS

There were 3026 adults who were smokers at both time-points in the CCHS and 1319 men smoking at both time-points in the CMS.

MEASUREMENTS

Smoking status and tobacco consumption were assessed by self-completion questionnaire. Measurements of biomarkers of smoke intake were taken at the second time-point in the two studies: expired-air carbon monoxide (CO) in the CCHS and serum cotinine in the CMS. Biomarker levels in medium (15-29 g tobacco/day) and heavy (> 30 g/day) smokers at the first time-point who later reported a reduction in cigarettes per day of 50% or more without quitting were compared with continuing medium, heavy and light smokers (1-14 g/day) using linear regression. Sex (CCHS only), age, self-reported inhalation of smoke, duration of smoking, type of tobacco and amount smoked were included as covariates in multivariate models.

FINDINGS

Heavy smokers who reduced did not show lower levels of biomarkers at follow-up. Medium smokers who reduced showed a reduction in cotinine but not CO. The reduction in cotinine was not commensurate with the reported reduction in consumption.

CONCLUSIONS

Long-term reductions in self-reported tobacco smoking are probably associated with, at best, modest reductions in smoke exposure.

Biomarkers of exposure and potential harm in adult smokers of 3-7 mg tar yield (Federal Trade Commission) cigarettes and in adult non-smokers

The paper reports levels of 24-h urine nicotine and five of its major metabolites (expressed as nicotine-equivalents) and blood carboxyhaemoglobin as biomarkers of exposure to particulate- and gas-phase cigarette smoke, respectively, from an exploratory pilot study of adult smokers of 3.0-6.9 mg tar delivery (Federal Trade Commission (FTC) method) cigarettes. On multiple occasions over 6 weeks, blood high-sensitivity C-reactive protein (hs-CRP), fibrinogen, HDL- and LDL-cholesterol, and 24-h urine 8-epi-prostaglandin F2alpha (8-epi-PGF2alpha) and 11-dehydro-thromboxane B2 (11-dehydro-TxB2) were also evaluated as biomarkers of potential harm. All the biomarkers examined, except for LDL-cholesterol, discriminated with high sensitivity and specificity between adult smokers and non-smokers overall. Except for HDL-cholesterol, all biomarker medians were greater in adult smokers than in non-smokers: urine nicotine-equivalents 64.514 versus < 0.034 nmol mg-1 creatinine (p<0.001), carboxyhaemoglobin 4.0 versus 0.4% saturation (p<0.001), hs-CRP 0.27 versus 0.12 mg dl-1 (p=0.05), fibrinogen 292 versus 248 mg dl-1 (p<0.001), HDL-cholesterol 46 versus 53 mg dl-1 (p=0.003), LDL-cholesterol 119 versus 109 mg dl-1 (p=0.18), urine 8-epi-PGF2alpha 1935 versus 1034 pg mg-1 creatinine (p<0.001) and urine 11-dehydro-TxB2 973 versus 710 pg mg-1 creatinine (p<0.001). All the biomarkers of exposure and most of the biomarkers of potential harm showed no time of sampling (by visit week) effect.

The effect of smoking, smoking cessation, and passive smoke exposure on common laboratory values in clinical settings: a review of the evidence

Evidence now supports that active and passive cigarette smoke exposure increase the risk for disease manifestations and adverse outcomes for patients in acute and critical care settings. By understanding the effect of active and passive smoke exposure on common laboratory tests, nurses in acute and critical care settings can plan essential components of care more accurately. This article addresses the effects of active and passive smoking and cessation on common parameters of hematology, hemostasis, immunology and inflammation, and chemistry laboratory tests.

In a prospective study in young people, associations between changes in smoking behavior and risk factors for cardiovascular disease were complex

OBJECTIVE

This study investigates how voluntary changes in tobacco consumption are related to changes in biological risk factors for cardiovascular disease in 21- to 36-year-old men and women.

STUDY DESIGN AND SETTING

Data of the Amsterdam Growth and Health Longitudinal Study (AGAHLS) were used to study the association between voluntary changes in tobacco consumption and changes in biological risk factors for cardiovascular disease (CVD) during 4-6 years of follow-up in 165 men and 195 women aged 21-36 years. We used multiple linear regression analyses with corrections for age and changes in other lifestyles.

RESULTS

In both sexes, we found trends for a reduction in blood pressure, high-density lipoprotein cholesterol (HDL-C), body weight, and waist-to-hip ratio (WHR) and a rise in the ratio between total serum cholesterol (TC) and HDL-C (TC/HDL-C) with increasing tobacco consumption. Opposite trends were found with reducing tobacco consumption. In women, body weight, WHR, and waist circumference reduced significantly and independently with increasing tobacco consumption and increased significantly with decreasing tobacco consumption.

CONCLUSION

These results suggest that voluntary changes in tobacco consumption go together with both healthy and unhealthy changes in biological risk factors for CVD.