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Smoking Cessation

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By Riddhi Patel, MD | Image – Serhiy Kobyakov/Shutterstock |

Smoking is the number one preventable cause of death. It’s responsible for 400,000 annual deaths in the US and 6 million deaths around the world. Smoking causes death through causing lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease. Since all of this is preventable, it is essential for healthcare providers to counsel patients on tobacco cessation and the many benefits and few risks.

Benefits

There are countless benefits to smoking cessation. The nicotine in cigarettes causes coronary vasoconstriction, dyslipidemia, endothelial dysfunction, and increased hyper coagulability, all of which result in cardiovascular events such as stroke, sudden cardiac death, and myocardial infarction. Tobacco use is also the number one risk factor for several different types of cancers and so quitting reduces cancer risk. Furthermore, the  most significant risk factor for COPD is cigarette smoking history. Quitting smoking also decreases the risk of pulmonary infections such as pneumonia, tuberculosis, influenza. The risk of developing diabetes, osteoporosis, reproductive problems, and peptic ulcer disease is also decreased through smoking cessation. Patients also save thousands of dollars in the long term by quitting smoking.

Risks

The countless benefits of quitting smoking go on and on and they greatly outweigh the risks. However it is important for providers to know the risks of smoking cessation so they can inform their patients of what to expect and in doing so maximize the likelihood that patients will successfully quit smoking.

Weight gain is one of the most common risks of smoking cessation and it is the primary concern of most patients. Patients normally gain 1 to 2 kg in the first 2 weeks of quitting followed by another 2 to 3 kg over the next few months. In total the weight patients can be expected to gain is 4 to 5 kg. There are several mechanisms of this weight gain. Smoking causes over expression of the gene AZGP1 which results in lipolysis and so quitting results in decreased lipolysis and therefore increased weight. Smoking also suppresses appetite because nicotine acts on central nervous system neurons. Quitting smoking therefore results in increased appetite resulting in increased caloric intake and increased weight. There are several health risks of obesity but these are not as numerous as those from smoking.

Nicotine withdrawal syndrome is another potential risk of smoking cessation. Patients with a long smoking history get a physical dependence and tolerance for nicotine. Without this nicotine patients develop cravings and get withdrawal symptoms of increased appetite/weight gain, depression, insomnia, irritability, restlessness, anxiety, and problems concentrating. These usually pass after four weeks but may continue for months to years in some patients.

Management

Providers should begin their discussion of smoking cessation with patients by starting with a 5 step algorithm of the 5 A’s. These are:

  • Ask: ask all patients about tobacco use
  • Advise: urge smokers to quit
  • Assess: determine how willing patients are to try quitting
  • Assist: help the patient quit
  • Arrange: follow up with patients

There are a variety of pharmacologic therapies that can be offered to patients wanting to quit smoking. First line medication is varenicline, buproprion, or combination nicotine replacement therapy.

  • Buproprion: Enhances central nervous system noradrenergic and dopamine release.       Recommended use is for a minimum of 12 weeks
  • Varenicline: Partial agonist at the alpha-4 beta-2 subunitof the nicotine acetylcholine   receptor. This acts by reducing withdrawal symptoms and decreasing the rewards from   smoking. Recommended use is a 12 week course
  • Combination nicotine replacement therapy: Available as nicotine patch, gum, lozenge,       inhaler, nasal spray

There are other alternative methods of smoking cessation such as acupuncture and hypnosis that some patients have reported to being beneficial.

Due to the several health benefits of quitting smoking, providers need to discuss this topic with patients and offer them assistance when necessary.

 

References

  1. Filozof C, Fernández Pinilla MC, Fernández-Cruz A. Smoking cessation and weight gain. Obes Rev 2004; 5:95.
  2. Flegal KM, Troiano RP, Pamuk ER, et al. The influence of smoking cessation on the prevalence of overweight in the United States. N Engl J Med 1995; 333:1165
  3. Rigotti, NA. Pharmacotherapy for smoking cessation in adults. Up to date. 2016.
  4. Rigotti, NA. Benefits and risks of smoking cessation. Up to date. 2015.
  5. Vanni H, Kazeros A, Wang R, Harvey BG, Ferris B, De BP, Carolan BJ, Hübner RH, O’Connor TP, Crystal RG. Cigarette smoking induces overexpression of a fat-depleting gene AZGP1 in the human. Chest. 2009.

 

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