Smoking Cessation Information and Strategies

Author
Dr. Don McCarville MD FRCSC

Title
Smoking Cessation Information and Strategies

What is the benefit of smoking cessation?
The relationship between smoking and the development of peripheral arterial disease has been well established for decades.  The manifestations of peripheral arterial disease are several fold. This includes blockages in the arteries of the neck, leading to strokes, to disturbances in the circulation to the legs, resulting in the inability to exercise to the possiblility of losing one's limb.  The benefits of stopping smoking leading to the reduction in the risk of developing the above problems and  of developing repeated complications thereof is clearly understood.  The risk is reduced within hours of smoking cessation, and benefits  seen for years, regardless of one's smoking history.

What causes tobacco addiction?
Addiction is a medical condition. It consists of the physical and psychological dependance on a substance that is capable of altering the chemical functioning of the brain.  What is initially associated with pleasure and enjoyment is soon required to feel "normal". Of all the substances known to man, tobacco is the one most likely to produce dependance. Indeed, the probability of developing dependence to tobacco after trying it at least once is 32%, a phenomenal number. The active substance in tobacco, nicotine, is one of the most active chemicals in the brain, causing stimulation and allowing behavioral patterns to be established. Thus, tobacco is a natural for creating dependence.

What are the symptoms of  tobacco dependence?
Nicotine stimulates the release of the brain's primary motivation neurotransmitter, dopamine.  Dopamine produces a  yearning or wanting sensation.  Once nicotine levels in the blood fall, so do dopamine levels in the brain, triggering the want to restore nicotine levels.  Each puff ( or snuff ) produces a hit, or euphoria.  Thus behavioral patterns are established to allow access to nicotine ( going out  in - 40 C weather for example ). Falling nicotine levels are associated with cravings, irritability, fatigue and inability to concentrate. Headache and insomnia are common in nicotine withdrawal. The degree of dependance can be judged by how soon you have a cigarette after waking in the am.

Diagnosis and tests for nicotine
There are no  diagnostic tests for nicotine, rather it's metabolites, such as cotinine, that can be assayed in the blood, and are of value to insurance companies and in programs to confirm abstinence.
The pattern of nicotine use can be used to determine the degree of dependence. For example, how soon after rising one has a cigarette, and the amount smoked in a day are indicators of dependence and the potential challenges faces when tobacco cessation programs are initiated.

Lifestyle modification for smoking cessation
Lifestyle modification for smoking cessation is one of many important factors for success in abstinence from tobacco.  This  begins with the choice to quit. Following that, the understanding of the benefits for tabacco free life should be understood, such as withing 20 minutes of cessation heart rate drops to a normal level,  taste and smell improve within 48 hours and at three months circulation is improved. The risk for heart attack is reduced by half at 6 months. Strategies to avoid the environment conducive to smoking are instituted, the support of family and friends, and self rewards should be given. Thus management of cravings, stress relief, and environmental control all play roles.

Non-surgical and medical management for smoking cessation
Many non-surgical approaches are available, such as laser therapy and acupuncture, both with questionable results. Psychotherapy, and support groups are essential, as this is a behavioral disorder, and the aforementioned are beneficial. Medical management consists of nicotine replacement therapies ( NRT), with the  patch and gum the primary agents used, with inhalers available as well. The use of these coincides with the craving for a cigarette, and as well long acting forms.  Other treatments are the pharmacotherapies, medications prescribed by your family doctor or a smoking cessation specialist. These include  Bruproprion ( Zyban), Nortriptyline ( Aventyl) and  Varenicline ( Champix).

Guidelines for Intervention for pharmacologic intervention for smoking cessation
The pharmacotherapies are stategies to be used in combination with the above  treatment methods.  Nortriptyline and Bruproprion are from the antidepressant class of medications and have shown promise in maintaining abstinence.  Considerable side effects are possible, and close supervison by your doctor is imperative. They can be used in combination with the NRT. Varenicline is a novel medication that acts at the same level in the brain that the nicotine from the tobacco does. It can not be used in combination with NRT, and has the highest success rate for abstinence.

Surgical treatment
There is no effective surgical treatment for tobacco addiction, and the challenge for patients and their phyicians is to establish and maintain abstinence so as to ultimately prevent the surgical treatments that may be needed for the peripheal vascular complications of tobacco addiction.

Endovascular Treatment
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When should I see my doctor?
Tobacco addiction is now considered the most important modifiable risk factor for peripheral arterial disease ( including coronary artery disease and lung disease ) and health care professionals are to always ready to fully engage their patients when they wish to persue smoking cessation therapies.  Multidisciplinary  Partnership Pacts have been established in all health districts.  Comprehensive educational programs where the medical condition is managed in a respectful and non-judgemental manner are available . The minute you feel you wish to quit, approach your doctor, nurse practitioner and any other knowledgeable health care practitioner.

References and Resources
www.makeapact.ca    ( a Saskatchewan initiative, however, your home province will have a similar portal )
www.nida.nih.gov/nidahome.html ( An American source of information on many types addictive agents )
www.smokingcessationrounds.ca  ( a Canadian based smoking cessation site, featuring many Canadian leaders involved in this health care concern )

Comments/notes from the author

Smoking cessation has been recognized as the major health care intervention that can be offered to patients to impact on their longterm health outcomes. As such, appropriate comprehensive strategies have been developed. These programs focus on the needs of the patient in a respectful and nonjudgemental manner,  and well beyond the days of a brief mention or lecture on quitting smoking in the physician's office that would occur at the end of the patient visit.