CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 3, May/June 2011
AFRICA
157
Your Life and Your Heart
The management of tobacco smoking
Dr Karl Fagerstrom, founding member, Society for Research on Tobacco and Nicotine
‘Smoking is more complicated than just
nicotine.’ This is the view of Swedish
clinical psychologist, Dr Karl Fagerstrom,
who visited South Africa recently as a
guest of Pfizer.
The WHO Framework on Tobacco
Control recognises smoking as the most
preventable health risk factor, and almost
every country in the world has signed
on. Dr Fagerstrom cited a meta-analy-
sis of 20 cohort studies, which showed
unequivocally that smokers who stopped
using tobacco after a myocardial infarc-
tion (MI) experienced a high reduction in
risk of mortality or another MI. A criti-
cal aspect was post-hospital follow-up.
‘These reductions in risk can be achieved
with relatively little input, just follow up
by a nurse’, he said.
Nicotine dependence
‘The brain is the key organ where nico-
tine dependence is concerned. Nicotine
is more multifaceted than other depend-
ence-producing drugs, with effects that
go beyond dopamine release’, noted
Dr Fagerstrom. ‘Nicotine receptors are
present virtually throughout the brain.’
He feels that it is therefore important
to make patients understand that smok-
ing is not just a bad habit that can be
overcome by a little will power. ‘Many
smokers are reluctant to acknowledge
that they are, shall we say, mini-addicts’,
he said, ‘but they need to understand that
it’s not weakness of character that’s the
issue here.’ Prolonged smoking brings
about structural changes in the brain. The
brain is fundamentally altered, as organs
and cells adapt as a defence against
the nicotine, with some receptors being
downregulated while others are upregu-
lated. Because the brain has adapted to
function well in the presence of nicotine,
withdrawal symptoms appear when the
regular supply, which it now needs to feel
good, is cut off. These include:
•
cravings
•
irritation
•
weight gain
•
insomnia
•
concentration difficulties
•
anxiety
•
restlessness
•
dysphoria
•
headache
•
performance deficits.
In 1975 Dr Fagerstrom developed the
widely used test for nicotine depend-
ence that bears his name. He pointed out
that back then, smoking was still widely
perceived as a learned behaviour, rather
than a dependence, and that the role nico-
tine played was not fully understood. It is
a six-point test, but Dr Fagerstrom noted
that the answers to two of the questions
will tell the healthcare professional most
of what they need to know:
•
How soon after waking up do you
smoke?
•
How many cigarettes do you smoke
per day?
The answer to the first question will
determine where the smoker is on the
continuum of dependence. ‘Because nico-
tine has a very short half-life, anyone who
can go several hours after waking without
smoking will not be overly dependent’,
said Dr Fagerstrom.
Smoking cessation
Dr Fagerstrom believes that smoking-
cessation strategies have a tendency to be
low-tech and often no-tech. ‘It’s impor-
tant to confirm that the smoker has indeed
given up, as they may not always tell the
truth. You need to find a way to corrobo-
rate their smoking status.’
When approaching a smoker with a
view to encouraging cessation, doctors
need to realise that it probably won’t
happen quickly and they must avoid fall-
ing into the trap of being confronta-
tional and judgemental. ‘Rather open up
a discussion that increases knowledge
and awareness’, Dr Fagerstrom advised.
‘Probe the smoker’s feelings, ascertain
what they find difficult about giving up
and underscore that it’s a difficult process
for everyone. Where there is no motiva-
tion yet to give up smoking, be careful to
open the patient up to the idea of cessa-
tion. The five seconds it takes to say,
“If you would like to stop, I’m happy to
assist” increases the impact of the advice
and can make all the difference.’
Dr Fagerstrom maintains that there is
nothing mystical about behavioural treat-
ment. ‘There are no special procedures or
techniques, it’s just common-sense coun-
selling’, he said. He offered the following
as examples of common-sense tips:
•
Change habits that have become
signals to smoke.
•
Undertake more non-smoking-associ-
ated activities.
•
Broaden goals to embrace more than
just smoking cessation (e.g. take up a
new hobby, embrace diet and lifestyle
changes).
•
Avoid triggers of negative emotions
that might prompt smoking.
•
Identify high-risk relapse situations.
Pharmacological aids
Nicotine-replacement therapy has been
available since the 1970s, most common-
ly in the form of patches and gum. ‘To
maximise its effects and because under-
dosing is common, it may be necessary
to combine administration forms’, said
Dr Fagerstrom. ‘It’s also more effec-
tive if introduced a few weeks before
actually stopping smoking, rather than
afterwards.’
Bupropion has been shown to be gener-
ally well tolerated. Its benefits outweigh
its risks in smoking cessation and it has
no significant potential for abuse. While
all its mechanisms are not yet understood,
it appears to stabilise the dopaminergic
system. Dr Fagerstrom warned, however,
that data are still lacking in respect of its
safety during pregnancy and in the pres-
ence of cardiovascular disease.
‘The advent of varenicline, the first in
a new class of cessation agents, is a valu-
