CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 5, September/October 2010
AFRICA
289
Your Life and Your Heart
Update on smoking cessation techniques
‘While public attitudes to smoking have
changed radically, medical approaches are
often outdated and need to be reviewed to
resolve tobacco addiction in a strategic
and sensitive manner.’ Dr Andrew Pipe of
the Heart Institute, University of Ottawa,
Canada presented this view in a series
of lectures to South African clinicians
and physicians at the recent SA Heart
Congress.
Reasons for considering renewed
clinical efforts to encourage patients to
stop smoking include important moti-
vating factors. ‘In the management of
patients with post-myocardial infarction,
smoking cessation is the most powerful
intervention available to the clinician.
It reduces mortality by 36%, compared
to statin therapy, which reduces mortal-
ity by 30% and blood pressure control
using
β
-blockers and other agents, which
reduces mortality by 23%.’
Intensive in-hospital smoking cessa-
tion programmes
1
have been shown to
result in a dramatic reduction in hospital
re-admissions and all-cause mortality in
the 24-month period following the initial
event. These effective programmes were
conducted for only a 12-week period.
2
Smoking cessation programmes and the
use of modern therapeutic agents are cost
effective and result in an annual cost of
between $2 000 and $6 000, while treat-
ment of hypertension averages $9 000
to $26 000, and lipid-lowering strategies
some $50 000 or more.
A further relevant consideration is
that smoking diminishes the benefits of
statin therapy. There is a 61% increased
risk of cardiovascular events in smokers
compared to statin-treated non-smokers.
Mortality from chronic obstructive
pulmonary disease (COPD) ranks as the
fourth leading cause of death worldwide.
The benefits of stopping smoking in these
patients include an overall improvement
in life expectancy of six to seven years.
‘Tobacco is truly addictive, as the nico-
tine reaches nicotine receptors in the brain
stem very quickly, causing an increase in
dopamine in the forebrain, which cements
the situational environment in favour
of smoking. Our interventions need to
focus on the cerebral cortex, providing
patients with significant techniques to
address their addiction. That this is a real
addiction has been clearly shown in the
autopsy-evaluated proliferation of nico-
tine receptor-binding sites in smokers’
prefrontal and temporal cerebral cortex’,
Dr Pipe said.
3
‘If you look at cigarette engineering, a
science in itself, you will see the care that
is taken to ensure rapid nicotine delivery.
Essentially the cigarette is a sophisticated
drug-delivery device.’ Dr Pipe pointed
out.
‘As clinicians, we can significantly
help our patients, by not haranguing them
but adopting a constructive, unambiguous,
simple and non-judgemental approach.
We need to realise that we are dealing
with a population of hardened smokers;
smokers who have already tried and found
it very difficult to stop smoking. In my
view, all smokers who are trying to quit,
except in the presence of very special
circumstances, should receive pharmaco-
therapy for smoking cessation.’
There are three main therapeutic
approaches: using nicotine replacement
therapy (NRT), bupropion sustained
release, or verenicline. ‘The chosen agent
should be prescribed in appropriate doses
and taken for as long as it takes to achieve
cessation of smoking’, Dr Pipe advised.
A fundamental concept in NRT is
to up-titrate according to the patient’s
assessment of his level of comfort or
distress. Caffeine levels may also rise on
initiating smoking cessation therapy and
this can be falsely interpreted as with-
drawal symptoms – so patients need to
be warned to lower their normal caffeine
intake.
Bupropion is effective, with approxi-
mately 30% of smokers maintaining non-
smoking status at one year. It should
be taken at a dosage of 150 mg twice a
day but it does cause side effects of dry
mouth, insomnia and shakiness.
The third-generation agent, vereni-
cline, uniquely addresses the neurochem-
istry of tobacco addiction and has become
the gold standard for smoking cessation
therapies. It works as a partial agonist at
the nicotine receptor site, alpha-4
β
2 nico-
tine acetylecholine receptor (nAChR),
stimulating the release of sufficient
dopamine to reduce cravings and with-
drawal while simultaneously acting as a
partial antagonist by blocking the rein-
forcing effects of nicotine.
‘Varenicline has become the gold
standard in pharmacotherapy for smok-
ing cessation because it achieves a 54%
smoking cessation success rate, measured
as non-smoking for a one-year period.
3
Varenicline was synthesised by biochem-
ists, based on cytisine, a natural plant
alkoloid obtained from a plant growing
in eastern Asia, known as Golden Rain,
which was used by local people as a
tobacco replacement.
Varenicline is safe and effective;
particularly as continuing to smoke poses
such high health risks. It does however
cause some nausea and insomnia as it
stimulates nicotine receptors in the gut. It
can be used in combination with bupropi-
on SR, as their different mechanisms can
be helpful. In a study of the combination
therapy,
4
high smoking abstinence was
achieved and no depressive symptoms
were observed.
In conclusion, Dr Pipe urged clini-
cians to show clinical leadership and use
emerging therapies for in-hospital smok-
ing cessation approaches and in their
daily practices.
J Aalbers, Special Assignments Editor
References
1. Mohiuddin SM, Mooss AN, Hunter CB,
Grollmes TL, Cloutier DA, Hilleman DE.
Intensive smoking cessation intervention
reduces mortality in high-risk smokers with
cardiovascular disease.
Chest
2007;
131
(2):
446–452.
2. Reid RD, Pipe AL, Auinlan B. Promoting
smoking cessation during hospitalisation for
coronary artery disease.
Can J Cardiol
2006;
22
(9): 775–780.
3. Perry DC, Davila-Garcia MI, Stockmeier
CA, Keller KJ. Increased nicotinic receptors
in brains from smokers: membrane binding
