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Smoking Cessation

AUTHOR: Dr. Don McCarville MD FRCSC

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.

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 (A Saskatchewan initiative, however, your home province will have a similar portal) (An American source of information on many types addictive agents) (A Canadian based smoking cessation site, featuring many Canadian leaders involved in this health care concern)

Vascular Conditions

The benefits of a tobacco free life are felt quickly. Here's a resource for smoking cessation.

CSVS Guidelines for Abdominal Aortic Aneurysm screening

“The 2018 CSVS guidelines suggest all men 65-80 and all women who have smoked or have heart disease and are between the ages of 65-80 should have an abdominal ultrasound (US) to rule out an abdominal aortic aneurysm (AAA).

Those older than 80 can be considered for screening, but it is important to talk to your doctor. Speak to your primary care physician or vascular surgeon to ensure you have been screened.


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