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The Non-Medicated Life:
The Benefits of Smoking
Cessation
by Dr. Paul E. Lemanski
Editor's Note: This is the eighth in a series
on optimal diet and lifestyle to help prevent and treat heart disease.
Any planned change in diet, exercise or treatment should be discussed
with and approved by your personal physician before implementation.
The help of a registered dietitian in the implementation
of dietary changes is strongly recommended. Medicines are a mainstay
of American life and the healthcare system not only because they
are perceived to work by the individual taking them, but also because
their benefit may be shown by the objective assessment of scientific
study. Clinical research trials have shown that some of the medicines
of Western science may reduce the risk of heart attacks, strokes
and cardiovascular death.
In the first seven installments of The Non-Medicated
Life, informed diet and lifestyle has been shown to accomplish naturally
for the majority of individuals, many, if not most of the benefits
of medications. This is especially true for the lifestyle change
of smoking cessation. Smoking cessation may reduce cardiovascular
risk by 65 percent, and is thus stronger than any single medicine
in a physician's armamentarium. Why cessation is beneficial and
how cessation may most effectively be accomplished is the focus
of this month's Health column.
Most people know that smoking is not healthy.
Indeed, cigarette smoking is the single most important modifiable
risk factor for coronary artery disease and stroke. Yet, in the
United States, one-quarter of all adults smoke - resulting in 400,000
deaths yearly. Worldwide close to one billion people smoke. Moreover,
non-smoking individuals who breathe in a confined space near one
of those one billion smokers - including cigar smokers and pipe
smokers - are at significant increased risk for coronary artery
disease from passive smoke exposure.
Studies suggest that individuals who smoke
one pack per day or more are at 200-300 percent increased risk for
the development of coronary artery disease as compared to non-smokers.
Newer studies show that even as few as one to four cigarettes per
day will increase the risk of coronary artery disease and stroke.
Thus, there is no lower level of smoking which is safe.
There are not one but several different mechanisms
by which smoking increases risk. Smoking damages the endothelial
cells (see The Non-Medicated Life: A New
Laboratory Test to Assess Heart Attack Risk), which line the
innermost aspect of the arteries. Excess LDL or the "bad" cholesterol
enters the artery wall from the blood stream and deposits just beneath
the endothelial cell layer. Smoking damage includes an increase
in the oxidation of LDL or "bad" cholesterol in the plaque. Such
increased oxidation triggers the release of soluble factors into
the blood, which attract white blood cells to the plaque.
Smoking also increases the attachment of white
blood cells to the endothelial cells overlying the plaque resulting
in the white blood cells migrating into the plaque as part of an
inflammatory response. This inflammatory response characterized
by the entry into and then attack on plaque by white blood cells
is the unfortunate first step in weakening the physical structure
of the plaque making it more likely that the plaque become unstable
and crack.
The cracking of the plaque tears the overlying
endothelial cell layer. Small corpuscles in the blood called platelets,
whose role is to plug holes in arteries after trauma, become fooled
into "thinking" that an actual hole has opened in the artery wall.
The platelets stick to the torn endothelial cells and form a blood
clot. When the blood clot on top of the disrupted plaque is large
enough, it stops the flow of blood, oxygen and nutrients downstream
form the plaque and results in the death of heart muscle (heart
attack) when it occurs in a heart artery or brain tissue (stroke)
when it occurs in a brain artery. Smoking also increases the stickiness
of platelets making it more likely they will form a large clot and
it impairs the ability of the artery to dilate to increase blood
flow around a clot.
Smoking cessation is the single most important
intervention in preventing heart attacks and strokes. Alone, it
reduces the risk of first heart attack by 65 percent. Yet, smoking
cessation remains one of the most difficult interventions to implement.
This is true for several reasons. First, nicotine, the most "active"
ingredient in tobacco smoke, is highly addictive. Indeed, nicotine
is more addictive than heroin and is associated, many times, with
severe withdrawal symptoms. Second, the act of smoking itself becomes
a ritual, which reinforces the behavior. Finally, tobacco is legal,
widely available, and may be "enjoyed" as part of a social behavior
with other smokers who validate the behavior.
Smoking cessation is the single
most important
intervention in preventing heart attacks and strokes.
Research has shown that the average smoker makes
six attempts to quit before succeeding. A majority of those who
succeed in smoking cessation share a common approach and knowledge
of successful strategies, which help in reducing the number of attempts
before complete cessation. First, to be successful, a smoker must
want to quit. A series of personal experiences with the negative
effects of smoking - repeat lung infections, cough, shortness of
breath, or even a heart attack - usually occur before an individual
decides to quit. A personal experience with the negative effects
of smoking on a loved one may also fuel the decision to quit.
Once a decision is made an approach which minimizes
the withdrawal symptoms proves helpful. A smoker is more likely
to quit when she or he first reduces the number of cigarettes smoked
per day to between seven and ten. Because the nicotine level in
the blood drops and the body readjusts, "cold turkey" cessation
from this lower level of consumption results in fewer and less severe
withdrawal symptoms.
"Cold turkey" cessation from a level of seven
to ten cigarettes per day has been shown by research to be more
successful than slowly decreasing the number to zero. In part, this
may be a result a final decision to quit. It may be a result of
the removal of the smell and taste of tobacco, which can itself
reinforce a desire to smoke even in the absence of withdrawal symptoms.
This "cold turkey" approach may be made even more successful by
choosing a quit date after which no tobacco will be used. "Advertising"
one's intent and quit date to family and friends and asking for
their help in keeping tobacco away during the first several weeks
after the quit date is important.
While medications exist to aid in smoking cessation,
the basic non-medicated approach suggested above serves as the basis
for all smoking cessation aids. Nicotine inhalers, nasal sprays,
and trans-dermal patch systems all help by dissociating the act
and ritual of smoking from the physiologic effects of nicotine.
By themselves they do not wean one off nicotine. Wellbutrin is an
antidepressant, which may decrease the craving for nicotine and
aid in cessation. By itself, it will not result in cessation in
the absence a behavioral strategy as outlined above.
In summary, smoking cessation is the single
most beneficial intervention one can make to reduce the risk of
heart attack and stroke. This change in lifestyle may reduce cardiovascular
risk up to 65 percent - far greater than the benefit of any single
medication in the Western medical armamentarium. While difficult,
cessation may be aided by an informed approach, which utilizes the
successful strategies proven by scientific research. As such smoking
cessation may be seen as a powerful way to reduce risk and help
avoid the proverbial bottle of pills to solve an individual's cardiovascular
health problems.
©2000-2004 Adirondack Sports
& Fitness. All rights reserved.
Center for Preventive Medicine
& Cardiovascular Health
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at Glens Falls Associates in Cardiology
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