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Cytisine vs. Nicotine for Smoking Cessation

Cytisine vs. Nicotine for Smoking Cessation | Heart and Vascular Health | Scoop.it

Motivation, it’s often said, is half the battle of behavior change.  In the battle against nicotine addiction, however, motivation alone may not be enough.  Mass media campaigns have helped to raise awareness about the dangers of smoking.  But for the majority of smokers who already want to quit, the question remains: how? 

A study published this week in NEJM compared the effectiveness of cytisine versus nicotine replacement therapy for smoking cessation.  1300 adult smokers in New Zealand were randomized to receive either cytisine for 25 days or nicotine replacement therapy for 8 weeks.  Participants also received behavioral support. At one month, 40% of participants in the cytisine group reported continuous abstinence, as compared to 31% of those on nicotine replacement therapy (absolute difference of 9.3 percentage points; 95% confidence interval 4.2 to 14.5; number needed to treat = 11).  Abstinence was also higher with cytisine than with nicotine replacement therapy at two and six months.  

Seth Bilazarian, MD's insight:

Today, cytisine use is mostly limited to Eastern Europe.  Considering it is much less expensive than Chantix ($20-$30 for the recommended 25 day treatment course of cytisine versus $500 for 12 weeks of Chantix), if cytisine is indeed more effective than nicotine replacement therapy, as the findings of this study suggests, then introducing it to the US market could yield tremendous value.

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Smoking and Health (1964)

Smoking and Health (1964) | Heart and Vascular Health | Scoop.it

January 11, 2014 marks the 50th anniversary of the first Surgeon General's report on Smoking and Health. The 1964 report was the first comprehensive compilation of research linking cigarette smoking to severe adverse health effects. Victories have occurred since the release of this landmark report, but there are ongoing challenges and gaps in protections and the course that we will chart to ensure that everyone lives and works in a smokefree environment, that no one picks up the smoking habit and subsequent nicotine addiction, and that no one has to needlessly suffer from a smoking- or secondhand smoke-related disease is an ongoing effort.

Seth Bilazarian, MD's insight:

I still see patients in there 70 and 80's who say that the day the Surgeon general's report came out they put down their cigarettes and never smoked again.  Its a testament to the power of information.  It's estimated that 50% of smokers quit on there own.  We live in a new era and information is more disseminated via the web, and often less authoritative than in 1964, but information still has a potent effect on prevention for many.

The patients that did quit smoking in the early 60's would not be alive today had they not responded  to the surgeon general's call.

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Electronic cigarettes for smoking cessation: Only work 7.3% at 6 months

Electronic cigarettes for smoking cessation: Only work 7.3% at 6 months | Heart and Vascular Health | Scoop.it

Electronic cigarettes (e-cigarettes) can deliver nicotine and mitigate tobacco withdrawal and are used by many smokers to assist quit attempts. We investigated whether e-cigarettes are more effective than nicotine patches at helping smokers to quit.657 people were randomised (289 to nicotine e-cigarettes, 295 to patches, and 73 to placebo e-cigarettes) and were included in the intention-to-treat analysis. At 6 months, verified abstinence was 7·3% (21 of 289) with nicotine e-cigarettes, 5·8% (17 of 295) with patches, and 4·1% (three of 73) with placebo e-cigarettes (risk difference for nicotine e-cigarette vs patches 1·51 [95% CI −2·49 to 5·51]; for nicotine e-cigarettes vs placebo e-cigarettes 3·16 [95% CI −2·29 to 8·61]). Achievement of abstinence was substantially lower than we anticipated.. We identified no significant differences in adverse events, with 137 events in the nicotine e-cigarettes group, 119 events in the patches group, and 36 events in the placebo e-cigarettes group. We noted no evidence of an association between adverse events and study product.E-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches, and few adverse events. Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels.

Seth Bilazarian, MD's insight:

The lack of success using e-cigarettes to quit smoking is consistent with the experience of my patients.  The 7.3% rate is low and not different from nicotine patches. For my patients, I fear that the well intentioned switch to e-cigarettes, with plans to quit, results in permanent e-cigarette use.  We just don't have any safety data about the use of these devices that are not regulated for quality or purity by FDA and largely made outside the US.  This study was small and there was a trend toward more adverse events with e-cigs.  The best I can tell my patients is that short term use as a strategy to quit smoking is probably safe. My blog on the topic:  http://www.medscape.com/viewarticle/801964?t=1

 

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Anti-smoking campaign: Is social smoking analogous to social farting?

Some says social smoking can be good. This is Ontario Ministry of Health answer. A farting one! WeWantAds shows you the most funny, creative and sexy ads all...
Seth Bilazarian, MD's insight:

Occasional social smoking is smoking.

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Ellen Diane's comment, June 26, 2013 7:33 AM
ha ha- excellent articles-glad I found you:)
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Important facts about quitting smoking and weight gain

Important facts about quitting smoking and weight gain | Heart and Vascular Health | Scoop.it

Quitting smoking is arguably the most important step that smokers can take to improve their health and prevent premature death. Smoking cessation greatly reduces the risk of multiple types of cancer, cardiovascular disease (CVD), and chronic obstructive pulmonary disease (COPD) complications and has other health benefits such as improved wound healing and reduced risk of hip fractures and cataracts.

Patients should not be concerned about the health effects of cessation-related weight gain. About 50% of female smokers and about 25% of male smokers are “weight concerned,” which may discourage quit attempts and quitting success. Even though no treatments have been shown to reliably prevent cessation-related weight gain, exercise regimens may be beneficial, and use of nicotine replacement medications can suppress weight gain during their use.

The most important message of two articles in the 3/13/2013 JAMA is that every smoker should be encouraged to quit smoking and given support to do so.

Seth Bilazarian, MD's insight:

Patients worry about weight gain with smoking cessation.  It may be an excuse to not want to tackle this tough addicition.

Weight gain is a frequent side effect when people quit smoking.  But the health benefits of stopping smoking far outweigh the cardiovascular hazard of weight gain.

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FDA Drug Safety Communication: Safety review update of Chantix (varenicline) and risk of cardiovascular adverse events

FDA Drug Safety Communication: Safety review update of Chantix (varenicline) and risk of cardiovascular adverse events | Heart and Vascular Health | Scoop.it
FDA is informing the public about a meta-analysis of trials that compared patients who received the smoking cessation drug Chantix (varenicline). FDA first notified the public about a possible increased risk of cardiovascular adverse events with Chantix in its June 2011 Drug Safety Communication (DSC).
The meta-analysis showed higher rates of composite outcomes on Chantix. Although these findings were not statistically significant, they were consistent. It should be noted that the incidence of cardiovascular mortality (Chantix 0.05% [2/4190] vs. placebo 0.07% [2/2812]) and all-cause mortality (Chantix 0.14% [6/4190] vs. placebo 0.25% [7/2812]) was lower in the Chantix group compared to the placebo group, although this finding was also not statistically significant.
Seth Bilazarian, MD's insight:

Balancing the risk of ongoing smoking vs. these tiny differences during 6 months of treatment with Chantix will have to be made individulally by patients and their doctors.  Ideally patients quit smoking without any added drugs but for many patients addicted to smoking this is not possible.

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Women Who Quit Smoking Do Live Longer

Women Who Quit Smoking Do Live Longer | Heart and Vascular Health | Scoop.it
Life expectancy was dramatically improved among participants in Great Britain's Million Women Study who quit smoking compared with continuous smokers, confirming the previously uncertain benefits of smoking cessation in women, researchers said.

Although women who stopped smoking around age 50 remained at significantly higher risk of all-cause mortality compared with never-smokers (relative risk 1.56, 95% CI 1.49 to 1.64), it was much lower than the tripled risk of death seen in current smokers.

"Even cessation at about 50 years of age avoids at least two-thirds of the continuing smoker's excess mortality in later middle age."

"Stopping well before age 40 years would avoid well over 90% of the excess hazard in continuing smokers."

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Vaccine Shows Promise for Nicotine Addiction (in mice)

Vaccine Shows Promise for Nicotine Addiction (in mice) | Heart and Vascular Health | Scoop.it

Take Home message:  Smoking addiction is very difficult to overcome for many patients.  Our most effective strategy currently is a combination of Chantix with counseling.  A life time strategy of vacciantion is attractive, but would need very long term data on overall safety but especially psychiatric safety for it to win my confidence for my patients.

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Electronic Cigarettes

Electronic Cigarettes | Heart and Vascular Health | Scoop.it

Electronic cigarettes (E-cigarettes) are devices that deliver nicotine to a user by heating and converting to an aerosol a liquid mixture typically composed of propylene glycol, vegetable glycerin, flavoring chemicals, and nicotine. E-cigarette use doubled in just 1 year among both adults and children, from 3.4% to 6.2% in adults (2010–2011) and 3.3% to 6.8% in youth (2011–2012), with high levels of dual use with tobacco cigarettes.  Although most youth using e-cigarettes are dual users, up to one third of adolescents who tried an e-cigarette have never smoked a conventional cigarette, indicating that some youth are initiating use of the addictive drug nicotine with e-cigarettes.

Smoke-free policies are a critical intervention both to protect nonsmokers and to support smoking cessation attempts. To avoid reversing the effectiveness of these policies, e-cigarettes should not be used anyplace where smoking cigarettes is not allowed (including in homes that are smoke-free). There is no reason to reintroduce toxins into clean indoor air environments.

Seth Bilazarian, MD's insight:

I tell patients who want to use  E-cigarettes that we don't have adequate information to say that these new nicotine drug delivery devices are safer than cigarettes.  For patients who are motivated to quit smoking, use of  E-cigarettes has not been shown to be an effective  aid to end the addiction of smoking.

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JAMA => The War Against Tobacco: 50 Years and Counting

JAMA => The War Against Tobacco: 50 Years and Counting | Heart and Vascular Health | Scoop.it

JAMA theme issue on tobacco control.  Epidemiology, original reserach and the status of e-cigarettes and strategies for quitting cigarettes is reviewed.  It's been 50 years since the Surgeon General's report. 

Seth Bilazarian, MD's insight:

The cover collage is great.  How far we've come, but not all the way there.  The advertisement of a physician recommending smoking at the top left with highlights of the Surgeon general's report and other news highlights over the last 50 years.

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Preventable Deaths from Heart Disease & Stroke infographic

Preventable Deaths from Heart Disease & Stroke infographic | Heart and Vascular Health | Scoop.it

Important progress has been made, but more is needed to continue to save lives, particulalry for people under 65 yeras.  Black men are at the highest risk of dying early fromheart disease and stroke.  Counties in Southern states have the greratest risk overall.

Seth Bilazarian, MD's insight:

Nearly 800,000 Americans die each year from heart disease and stroke.  Most of the major risk factors can be manged or prevented: high blood pressure, high cholesterol, diabetes, smoking, unhealthy diet, physical inactivity and obesity.

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Teen smoking rates stuck at 1 in 12.

Teen smoking rates stuck at 1 in 12. | Heart and Vascular Health | Scoop.it
For years, health officials watched with satisfaction as rates of teen smoking in New York City plummeted, far outpacing the national average. In 2007, the rate dipped to 8.5%. Then it stopped falling.
Seth Bilazarian, MD's insight:

To be sure, the 8.5% is still a dramatic improvement from 15 years ago, when nearly a quarter of the city's high school-age students smoked, according to data from the Department of Health and Mental Hygiene.

The stagnation mirrors a national trend, experts said, though the city's numbers remain well below the national teen-smoking average of 18.1% and even the state average of 12.5%.

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Teen Smoking Keeps Falling

Teen Smoking Keeps Falling | Heart and Vascular Health | Scoop.it
Cigarette use among U.S. teenagers fell to historic lows and a four-year rise in marijuana use appears to have leveled off, according to a national study.

 

The annual report, funded by the National Institute on Drug Abuse and conducted by the University of Michigan, found the number of teenagers who reported smoking cigarettes in the prior 30 days fell to 10.6% this year from 11.7% in 2011, the lowest level recorded since the survey began in 1975

Seth Bilazarian, MD's insight:

This is a good trend but it still means 1 in 10 teens is smoking and since they are starting as teens the number of accumulated years of smoking as they reach middle age will be substantial and have a significant impact on hazard for cardiovascular disease and cancer.

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Chantix (varenicline) for smoking cessation does not increase risk of cardiovascular events:

Chantix (varenicline) for smoking cessation does not increase risk of cardiovascular events: | Heart and Vascular Health | Scoop.it

My comment:  There is significant concen about the safety of Chantix.  I explain to my patients that the risk of this drug has to be balanced against the risk of continued smoking (heart disease, stroke, cancer, erectile dysfunction) since this is the most effective strategy we have to help people succeed at qutitting  their addiction to niocotine.

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Danish registry of 35,000 patients comparing the safety of quitting smoking with Chantix (varenicline) comared to Wellbutrin or Zyban (bupropion) on safety of cardiovascular events.

At 6 months the rates were 0.69% vs. 7.1%.  This study found no increased risk of major cardiovascular events associated with use of varenicline compared with bupropion for smoking cessation.

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Job strain as a risk factor for heart disease

Job strain as a risk factor for heart disease | Heart and Vascular Health | Scoop.it

My comment: The risk of job strain or the more common American term "stress" was small (only 3.4%) Dr. Debabrata Mukherjee writing for Cardiosource.org puts this in perspective: risks of "smoking (36%), abdominal obesity (20%) & physical inactivity (12%). While society strives to reduce job strain and improve working conditions, we need to continue to focus on eliminating smoking and encouraging lifestyle modifications (i.e., healthy diet and regular physical activity), which are far more impactful methods of reducing the incidence of cardiovascular diseases."

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Previous assessments of psychosocial stress (job strain) as a risk factor for coronary heart disease are inconsistent.  This study analysed the relation between job strain and coronary heart disease  Thirteen European studies (1985—2006) of men & women without coronary heart disease who were employed at baseline were assessed. Job strain was measured with questionnaires and coronary heart disease defined as the first heart attack (MI) or coronary death.

30,214 (15%) of participants reported job strain and (mean follow-up 7·5 years), recorded 2358 events of incident coronary heart disease. After adjustment for sex and age, the hazard ratio for job strain versus no job strain was 1·23 (95% CI 1·10—1·37).

An association between job strain and coronary heart disease for sex, age groups, socioeconomic strata, and region, and after adjustments for socioeconomic status, and lifestyle and conventional risk factors. The population attributable risk for job strain was 3·4%.
The  findings suggest that prevention of workplace stress might decrease disease incidence; however, this strategy would have a much smaller effect than would tackling of standard risk factors, such as smoking.

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Absolute Risk of Tobacco Deaths: One in Two Smokers Will Be Killed by Smoking

Absolute Risk of Tobacco Deaths: One in Two Smokers Will Be Killed by Smoking | Heart and Vascular Health | Scoop.it
If you have help 2 smokers quit, you have saved (at least) 1 life The acronym “AWARD” is a guide:  (1) Ask about smoking.  (2) Warn smoking patients by saying “If you continue to smoke, your chance of dying from smoking-induced diseases (such as cancer, heart diseases, stroke, and respiratory and many other serious diseases) is 50% (67% for the very young; 40% for the very old).”  (3) Advise: “If you quit now, your risk will be greatly reduced (by 25% at old age, and by much more before age 40 years).” This will take about 10 seconds.  (4) Refer to a cessation clinic or hotline (5) Do it again until they quit
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