Health

The Non-Medicated Life: The Benefits of Smoking Cessation

by Dr. Paul E. Lemanski

Editor’s Note: This is the seventh 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.

Paul E. Lemanski, MD, MS is a board certified internist with a master’s degree in human nutrition. He is director of the Center for Preventive Medicine, Albany Associates in Cardiology, Prime Care Physicians, P.C. and assistant clinical professor of medicine, Albany Medical College.

©2000-2004 Adirondack Sports & Fitness. All rights reserved.