Tobacco Use and Cessation

Farzana Amir
HOD Preventive Cardiology and rehabilitation
Director Allied Health, Co-Chair CME
DPT, M.Phil., PhD(enroll), MBA, PGD – Bio med ethics,
Cert. Cardiac rehabilitation, Sudbury ,Ontario
Cert. Cardiac rehabilitation and sports sciences, Switzerland.
Cert. research ethics and Public health, Nairobi
Member ICCPR
Member board of study at UoK 1
Ex. Committee member at Bahria University
Overview
• Revisit a Case Study
• Tobacco Consumption, Consequences in CardiacPatients
• Global Consumption
• Anatomy of the Cigarette and Properties of Cigarette Smoke
• Tobacco Use and CardiovascularDisease
• Levels of Exposure and Harms of Different Tobacco Products
• Challenges of Cessation/Nicotine Dependence
• Interventions for Tobacco Cessation (Pharmacological and Behavioral)
• Implementation Considerations for CR
• Case Study
• Summary 2
CaseStudy
• Mr. ABC is a 47 year-old investment banker
• Generally sedentary life in general, but used to play tennis at his
local club every weekend.
• One Sunday while playing, the heaviness felt like an ’elephant sitting
on his chest‘
• In the ambulance, he turned unresponsive, and CPR was started,
and he needed two shocks to be resuscitated.
• At the hospital, he was rushed to the cath lab, where an
angiography showed blockages, between 70-90% in his RCA, LAD
and left circumflex artery.
• A bypass surgery was recommended, and he had a CABG X 4.
• He was discharged from the hospital, 8 days later on the following
meds:
• Aspirin 150 mg once a day, Atorvastatin 40 mg once a day, long-acting
metoprolol 50 mg once a day, Ramipril 5 mg, once a day
• Nice work! But did we miss something?
Main Points about TobaccoUse
• Tobacco use is the most common preventable cause of death world-wide
• The number of tobacco users has not significantly decreased
• Tobacco cessation is the most effective (and cost-effective) treatment to reduce
morbidity and mortality in those with cardiovascular disease
• Tobacco cessation is a Class 1 treatment guideline supported by many entities
(e.g. American Heart Association/American College ofCardiology)
• Comprehensive CR should include screening for and treatment of tobacco use

Levy et al., 2016; Kazi et al., 2017; Perk et al., 2012; Smith et al., 2011 4
 Global Cigarette Consumption
• Globally in 2019, 1.14 billion (95% 1.13–1.16) individuals were
current smokers
• Consumed 7.41 trillion (7.11–7.74) cigarette-equivalents of tobaccoin
2019
• Prevalence of smoking has decreased significantly since 1990 among
both males (27.5% [26.5–28.5] reduction) and females (37.7% [35.4–
39.9] reduction)
• However, population growth has led to a significant increase in the
total number of smokers from 0.99 billion (0.98–1.00) in 1990

GBD 2019 Tobacco Collaborators, Lancet 2021; 397: 2337– 5

60.
 Global Cigarette Consumption Consequences
• Globally in 2019, tobacco use accounted for 7.69 million (7.16–8.20)
deaths and 200 million (185–214)disability-adjusted life-years
• Smoking was the leading risk factor for death among males (20.2%
[19.3–21.1] of male deaths)

GBD 2019 Tobacco Collaborators, Lancet 2021; 397: 2337– 6

60.
 Cigarette Consumption among Those with CVD
• Globally, smoking also continues to be a concern specifically in those
with CVD
• In the PURE study, covering 14 countries (low/middle/high income)
• 18.5% of those with self-reported CHD also reported current smoking
• Smoking rates are likely higher in those with a history of CVD than in
the general adult population
• Using a national sample fromUSA
• Current smoking
• 26% of those with a history of MI
• 22.5% of those without such a history

Teo et al., 2013, JAMA. Gaalema et al., 2018, Prev Med 7

 Anatomy of the Cigarette

A cigarette is designed as a drug delivery device that delivers nicotine to the

brain in seconds
Stratton et al., 2016 BMC Public Health 8
 Compounds in aCigarette

https://www.oasas.ny.gov/admed/fyi/anacig.cfm
http://www.compoundchem.com/wp-content/uploads/2014/05/Cigarette-Smoke-Compounds- 9
1024x723.png
• Dangers of combusted
tobacco use
• Endothelial dysfunction
• Blood vessel
constriction
• Platelet activation
• Chronic inflammatory
state
• Dyslipidemia
• Outcomes
• Accelerate
atherosclerosis
• Destabilize coronary
artery plaques
• Precipitate acute
coronary events

10
Levels of Exposure and
Continuum of Risk

11
How Can We Reduce the Harm from
Smoking?
• Does cutting down on the number of cigarettes help?
• What about exposure to other sources of smoke?
• What about other sources of nicotine?

12
 Cutting Down?
• Manyfactors influence exposure from a
cigarette:
• Puff volume
• Depth of inhalation
• Rate and intensity ofpuffing
• Often, cutting down does NOTchange
exposure levels
• The most damaging cigarette is the first
one
• Goal is cigarette0!
• Directly inhaled smoke not the only
Naiura et al, Psychopharmacology (2013)230:261
problem
Secondhand Smoke and Cardiovascular Risk
Relative risk of ischemic heart

2 .0
disease event

1 .5
Passive smoking studies (0.2 cigarettes per day)

No exposure
1 .0
0 5 10 15 20 25 30
No. of cigarettes smoked a day

Pechacek TF, Babb S. BMJ. 2004 Apr 24;328(7446):980-3.

Light Active = HeavyPassive
P=0.002
Proportion with major CHD

Light active
0 .2 0

Heavy passive
0 .1 5

0 .1 0

Light passive
0 .0 5

0 .0 0
0 5 10 15 20

Years of follow-up

Whincup PH, et al. BMJ. 2004 Jul 24;329(7459):200-5

 Reduction of Second-Hand Smoke can Makea
Large Difference!

In a 2012 meta-analysis, comprehensive smoke-free laws were

associated with significant reductions in hospitalizations ordeaths
from acute myocardial infarction (RR: 0.85; 95% CI: 0.82 to 0.88)
and other heart disease (RR: 0.61; 95% CI: 0.44 to 0.85)

Tan and Glantz, 2012. Circulation

16
 Other Combusted Products
• Need to worry about more than cigarettes!
• Most of the harm to the cardiovascular system is from combusted
products
• Should ask about anything that is being burned and inhaled
• Cigars
• Cigarillos
• Bidis
• Hookah
• Marijuana
• Pipes

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Kalkhoran, et al., 2018, JACC
 Non-Combusted Tobacco
• The harms of combusted tobacco products are unquestioned
• Cigarettes, cigars, cigarillos, pipe tobacco,hookah
• Other tobacco products may be reduced harm, but are not free of harm
• Snuff, chew, dip
• Electronic cigarettes and heat-not-burn (HNB)products

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Kalkhoran, et al., 2018, JACC
 Non-Combusted Tobacco

19
Kalkhoran, et al.,2018
 Challenges of
Cessation/Nicotine
Dependence

20
 Healing Timeline

• Within those withCVD

• Cigarette smoking has
serious health
consequences
• But quitting has
immediate benefits!

21
WHO report global tobaccoepidemic 2019.
 SoWhy Continued Smoking? Realities of Relapse
• Most tobacco users (80%)want
to quit
• Most (70%+)of smokers will
relapse
• Mediantime to relapse is only 1-
2 weeks
• Smoking is a chronic,relapsing
condition
• May take 30+ tries to quit
• Nicotine is the activeagent

Riley, JCRP 2018; Colivicchi et al, Am J Cardiol. 2011;108:804-808; CMAJ March 2018; Chaiton M, BMJ
open. 2016 Jun 1;6(6):e011045.
 Nicotine Actions
Neurotransmitters Action Facilitated by
Nicotine
Dopamine: Pleasure, Appetite Suppression

Norepinephrine: Arousal, AppetiteSuppression

Acetylcholine: Arousal, CognitiveEnhancement

Nicotin Glutamate: Learning, Memory Enhancement
e Serotonin: Mood Modulation, Appetite Suppression
Beta-Endorphin: Reduction of Anxiety and Tension

GABA: Reduction of Anxiety and Tension

Adapted from Benowitz. (2008). Clin Pharmacol
23
Ther83:531–541
 Nicotine Dependence

Nicotine binds predominantly to nicotine acetylcholine

receptors in the CNS; the primary is the alpha4beta2 nicotinic
receptor in the Ventral Tegmental Area (VTA). After nicotine
binds to alpha4beta2 receptor – relapse of dopamine in
Nucleus Accumbens. Benowitz 2010:NEJM 24
 Nicotine Dependence- Addiction Cycle

Cigarette
Smoking
Craving for
Nicotine to Nicotine
Alleviate Absorption
Withdrawal

Abstinence Arousal/Mood
Produces Modulation/
Withdrawal Pleasure
Tolerance and
Physical
Dependence

Adapted from Benowitz 2010, NEJM. 25

Symptoms of Withdrawal
• Symptoms peak between 1-2weeks:
• Dysphoric or depressedmood
• Insomnia
• Irritability, frustration, or anger
• Anxiety, difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased appetite or weightgain
• Usually subside in 4weeks
• Treat to no symptoms
 Nicotine Withdrawal Syndrome
Irritability Insomnia
Frustration disturbance
(< 4 Weeks)

Dizziness
Anger / Headache
(< 4 Weeks) Increase appetite
Or weight gain
(> 10 weeks)

Anxiety Dysphonic or
(Increase / decrease) Depressed mood
(< 4 weeks)
Rest less ness
Or impatience (< 4 weeks)

oDifficulty in concentration
(< 4 weeks)
Other minor effects
oFatigue
oConstipation
o Cough
oThroat infections
oFlue
oMouth ulcers
Assessment and Treatment
of TobaccoUse

27
 Key Points:
• 5As for TobaccoUse
• Tobacco use is a
chronic relapsing
disease
• Keep this on the
problem list

Barua et al.,2018
Interventions for TobaccoCessation
Pharmacological & Behavioral

30
Tobacco Cessation Approaches – Pharmacological
Three general classes ofdrugs:
1. Nicotine Replacement therapy (NRT)
• Nicotine gum, lozenges, patches, inhaler, nasal spray

2. Psychotropics
• Sustained release bupropion

3. Partial Nicotinic ReceptorAgonist

• Varenicline

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 Pharmacological Interventions for Tobacco
Cessation within Those with CVD- Safety
• Nicotine Replacement Therapy (NRT) can be used safely by majority
of people with cardiovascular disease, even with concomitant
smoking > N =33,247
• Meta-analysis shows no difference in rate of acute MI between NRT
patch and placebo
• The benefits of NRT outweigh the risks, even in smokers with cardiovascular
disease
• Meta-analyses have also demonstrated no significant association
between bupropion and varenicline and serious adverse events (CVD
or psychiatric, e.g., Mills et al., 2014; Anthenelli etal., 2016)
Benowitz N. Cigarette smoking and cardiovascular disease: pathophysiology and implications for treatment .Prog Cardiovasc Dis, (2003) 46:91-111. Joseph AM & Fu SS. Safety issues in pharmacotherapy
for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis, (2003) 45: 429-441. Hubbard et al. Use of nicotine replacement therapy and the risk of acute myocardial infarction, stroke, and 31
death. Tob Control, (2005)14:416–21
 Pharmacological Interventions for Tobacco
Cessation within Those with CVD- Safety
• Stopping smoking produces nicotine withdrawal symptoms (depressed
mood, anxiety and irritability)
• Does the tobacco cessation medication vs did quitting smoking cause the psychiatric
symptoms?

• 2005 meta-analysis of 39 varenicline RCTs found NO excess of depressive or

suicidal thoughts (few patients had mental illness)

• EAGLES Study

Thomas KH, et al. Risk of neuropsychiatric adverse events associated with varenicline: systematic review and meta-analysis. BMJ (2015), 350:h1109;
Anthenelli et al. Anthenelli et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, 32
placebo-controlled clinical trial. Lancet. (2016), 387(10037):2507-20. Lancet. 2016 Jun 18;387(10037):2507-20
• 8,144 smokers, half with history of neuropysch disorders,
currently stable
• 140 centers, 16countries, 6-month follow-up
• Randomized to placebo, varenicline, bupropion, nicotinepatch

Lancet, April 22, 2016

EAGLESResults
EAGLES– Psych Side Effects
FDA removed the Black Boxwarning
from varenicline

Smoking cessation (not varenicline) is a risk factor for

mental health problems
Given Good Safety and Efficacy Profiles – What are
the RecommendedTreatments?

36
Barua RS, Rigotti NA, Benowitz NL, Cummings KM, Jazayeri MA, Morris PB, Ratchford EV, Sarna L, Stecker EC, Wiggins BS. 2018 ACC expert consensus decision pathway on tobacco cessation treatment: a 37
report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. Journal of the American College of Cardiology. 2018 Dec 25;72(25):3332-65.
Pharmacological Interventions - NRT

39
Pharmacological Interventions for Tobacco
Cessation within Those with CVD

40
Clinician Tobacco Cessation Approaches Nicotine
Gum - Chew and Park

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Pharmacological Interventions - NRT

42
Pharmacological Interventions - Bupropion

43
Pharmacological Interventions - Bupropion

44
Pharmacological Interventions - Varenicline

45
Clinician Tobacco Cessation Approaches –
Varenicline

46
Medication
Behavioral Interventions for TobaccoCessation
within Those with CVD

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Behavioral Interventions for TobaccoCessation

51
 Combination of Pharmacological andBehavioral
Likely Most Effective
• Cochrane review of smoking cessation interventions
• Adding behavioral interventions to pharmacological increased
effectiveness 10-25%
• Real world example:
• The use of prescription medication in combination with intensive
behavioral counseling was associated with smokers >3xs as likely to quit
(OR 3.25)
• Use of prescription medication with brief counseling was associated with
< 2xs as likely to quit (OR 1.61)
• No such association was detected for NRT bought over the counter (OR
0.96

Stead LF, Lancaster T.Behavioural interventions as adjuncts to pharmacotherapy for smoking cessation. Cochrane Database of
Systematic Reviews. 2012(12). Kotz D, Brown J,West R. ‘Real‐world’ effectiveness of smoking cessation treatments: a population
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study. Addiction. 2014 Mar;109(3):491-9
Implementing Within Cardiac
Rehabilitation

49
Smoking & Cardiac Rehab Use
• Those who smoke:
• More like to bereferred
• Less likely to enroll
• More like to dropout
• Relapse is related to dropout
• Attendance
• Doubles the chance tostay quit
long term
• Exercise can help with weightgain
and craving!
• Want to keep thesepatients
engaged Sochor, Am JCards, 2015
Riley et al, JCRP2019
• Non judgmental Gaalema et al, Prev. Med. (2015)
Tobacco Cessation Approach
1No safe level of exposure to tobacco smoke & tobacco use is a
chronic disease with periods ofrelapse

2Treat tobacco cessation in exactly the same way that you would
manage any other CVD riskfactor

3Manage tobacco cessation medications in the same way that you

would manage other cardiacmedications

4 Best approach is a combination of pharmacological and behavioral

Andrew Pipe, CM, MD Chief, Division of Prevention & Rehabilitation Ottawa Medical Center,Canada 51
 52
Barua et al.,2018
Clinician Tobacco Cessation Approaches

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Clinician Tobacco Cessation Approaches

58
Clinician Tobacco Cessation Approaches

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 First Assess: Nicotine Dependence Level

Barua RS, Rigotti NA, Benowitz NL, Cummings KM, Jazayeri MA, Morris PB, Ratchford EV, Sarna L,Stecker EC, Wiggins BS. 2018 ACC expert consensus decision pathway on tobacco cessation treatment: a 60
report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. Journal of the American College of Cardiology. 2018 Dec 25;72(25):3332-65.
Important AssessmentQuestions

 Reasons to quit- family, health, financial,

other
How motivated are you toquit smoking?
 Motivation & Confidence Ruler- 1-10 (1 being
How confident are you to quit smoking? 57
lowest level)
Clinician Tobacco Cessation Approaches –
Behavioral Strategies

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Clinician Tobacco Cessation Approaches

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 Special Pharmacological Considerations within CR

• Patients with depression

• Bupropion increases long term cessation in those with a history of
depression
• Varenicline increases cessation among patients with stable current
depression of history ofdepression
• No exacerbation of depressive or anxious symptoms

Van der Meer RM, et al. Smoking cessation interventions for smokers with current or past depression. Cochrane Database Syst Rev. (2013) (8):CD006102. doi:
10.1002/14651858.CD006102.pub2. Anthenelli RM, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without
psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016 Jun 18;387(10037):2507-20 60
 Special Pharmacological Considerations within CR
• Drug interactions with smoking
• Increases action of P450enzyme system
• Increases metabolism of certain meds andtherefore
may decrease serum levels
• Inhaled insulin’s pharmacokinetic profileis
significantly affected
• Peaking faster and reaching higher concentrations in those
who smoke
• Leads to higher doses of some medications
• Antipsychotics and antidepressants effects reducedby
smoking
• Other affected drugs can includepropranolol,
acetaminophen, theophylline, and warfarin
• May need dose adjustments after smoking cessation
• Independent of nicotine levels
• Dosage adjustments are clearly indicatedfor
warfarin, olanzapine, clozapine and theophylline
• Metabolized by cytochrome P450 CYP1A2 and also have
narrow therapeutic ratios
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Fankhauser, Clinical Psychiatry 2013; Schaffer et al., Clinical Nursing2009
 Back to the CaseStudy
• Mr. ABC was smoking. This was a major risk factor
• Discharged on no smoking cessation medications, with no
counseling, and no follow-up
• How dowe treat his smoking?
 What Should We Know about His Smoking?
• Whatis his level of dependence?
• He smokes 15-20 cigarettes a day, the first within 30 minutes of waking – moderately dependent
• How has he successfully quit in the past?
• Quit for 3 weeks using NRT patch, but it did not help enough with his cravings and he had vivid dreams at
night
• Where does hesmoke?
• He generally smokes in the car while driving to and from work or after work with friends
• His wife, and adult children do not smoke and his house is smoke free
• What would motivate him to quit smoking?
• He has an orthopedic surgery scheduled in 2 months in which he wants to have a speedy recovery with no
complications
 Cessation Plan
• Single NRT was not successful so Mr. ABC should be offered either Varenicline or combination NRT, (patch
and short-acting formulation). If using NRT he should be reminded to remove it at night to avoid vivid
dreams.
• Mr. ABC should be assisted in developing a quit plan to change his routines to minimize his smoking
triggers. Could he change the way he gets to work so that he must travel with others who don’t smoke? Can
he meet with his friends in smoke-free venues after work? He should also be counseled in ways of
overcoming short-term cravings.
• Mr. ABC should also be encouraged to identify why quitting is relevant, and to identify potential negative
consequences of tobacco use (e.g., wife doesn’t like it, it’s costing him money) and to identify potential
benefits of quitting (improved endurance during exercise). He could track the amount he was saving not
smoking cigarettes and then use that money to do a fun activity with his wife.
• It is imperative that Mr. ABC see someone regularly to continue supporting his cessation efforts. Plans
should be made to connect him with a tobacco cessation specialist. If his medication is not sufficient to
control cravings it should be adjusted. He should also be encouraged to attend cardiac rehabilitation, which
may further help his cessationefforts.
• Mr. ABC was concerned about his upcoming surgery so he should be counseled that both attending CR and
smoking cessation will improve his fitness and reduce chances of complications from the upcoming surgery.
 Summary - Take Away Points for TreatingTobacco
Dependence
• Screen all patients for tobacco use at least annually
• Also query non-combusted use, and use of other combustible products!
• Treat as a chronic, relapsingillness
• Patients with a history of use should be checked on frequently!
• To maximize success, combine pharmacotherapy and
counseling/behavioral interventions
• Treat for as long asit takes
• Many people need 30+ tries to quit successfully1
• Treat to target
• Aim for no withdrawalsymptoms
1. Chaiton M, Diemert L, Cohen JE, Bondy SJ, Selby P,Philipneri A, Schwartz R. Estimating the number of quit attempts it takes to quit
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smoking successfully in a longitudinal cohort of smokers. BMJ open. 2016 Jun 1;6(6):e011045.
 Supplemental Resources – Additional readings and
videos
• Centers for Disease Control and Prevention. Identifying and Treating Patients Who Use Tobacco: Action Steps
for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept. of Health and Human
Services; 2016.
• Centers for Disease Control and Prevention Protocol for Identifying and Treating Patients Who Use Tobacco.
Atlanta, Georgia. 2016. Accessed on 7/3/22 at https://millionhearts.hhs.gov/files/Tobacco-Cessation-
Protocol.pdf
• Centers for Disease Control and Prevention. TIPS from former smokers videos. Accessed on 7/3/22.
https://www.cdc.gov/tobacco/campaign/tips/index.html
• Kalkhoran S, Benowitz NL, Rigotti NA. Prevention and treatment of tobacco use: JACC health promotion
series. Journal of the American College of Cardiology. 2018 Aug 28;72(9):1030-45.
• Barua RS, Rigotti NA, Benowitz NL, Cummings KM, Jazayeri MA, Morris PB, Ratchford EV, Sarna L, Stecker EC,
Wiggins BS. 2018 ACC expert consensus decision pathway on tobacco cessation treatment: a report of the
American College of Cardiology Task Force on Clinical Expert Consensus Documents. Journal of the American
College of Cardiology. 2018 Dec25;72(25):3332-65.
• WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use.
https://apps.who.int/iris/bitstream/handle/10665/326043/9789241516204-eng.pdf

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Thank You