Tobacco use or Smoking as a Cardiovascular Risk Factor

Cardiovascular Risk Factor and Tobacco use or Smoking

Smoking/Tobacco,Smoking as Health Disorder,Prevalence of Smoking,Statistics About Smoking,Body Effects of Smoking,Smoking as Social Burden,Guideline for Tobacco Treatment,Tobacco Cessation and Treatment,Nursing Role In Cessation,Associated Disorders.

Smoking/Tobacco

    Smoking is the single most preventable cause of death and disability in the United States today. The death toll associated with smoking approaches 440,000 annually, with more than 4.8 million deaths occurring globally. 

    Moreover, by 2030 the World Health Organization projects that tobacco will kill 10 million individuals annually (Schroeder, 2004).

Smoking as Health Disorder

    Smoking is a highly addictive disorder that causes both physiological and psychological dependence. Nicotine, which has both stimulating and tranquilizing effects, is the drug that leads to addiction. Addictive disorders such as smoking are characterized by: 

(a) predictable withdrawal symptoms

(b) physical dependence and tolerance for the drug

(c) use of the drug despite social and medical disapproval, or harm to physical, social, psychological, or economic well-being

(d) use of the drug to cope with stress

(e) an immediate sense of gratification

(f) use of the drug to restore physical and psychological comfort. 

    Smoking is also an over-learned habit. Smoking is associated with many aspects of daily life such as driving in a car, eating a meal, talking on the telephone, or drinking coffee. Finally, smoking is also used as a coping mechanism. 

    Individuals use smoking to deal with stress, boredom, anger, anxiety, and other emotions. The success of interventions to help smokers must focus on the complexity of the behavior including nicotine addiction, psychosocial influences, and the habit itself.

Prevalence of Smoking

    Since 1965, the prevalence of smoking has declined by 40% among those 18 years of age and older. However, the rate of smoking has plateaued since 1990. In those 18-24 years of age, the prevalence actually rose from 23% to 27% between 1991 and 2000. 

    The prevalence of smoking in the United States in 2001 was 48.1 million (1 in 4 adults), which includes 25.2% of males and 20.7% of females. All such individuals are at risk of a myocardial infarction and stroke, with cardiovascular deaths accounting for at least one third of all smoking related deaths annually (American Heart Association, 2003).

    Smoking prevalence varies considerably from state to state, is highly dependent on the success of tobacco related legislation and changes in policies within a state, and is most often highest in states where tobacco is grown, such as Kentucky. 

    A strong relationship exists between smoking and level of education, with the prevalence being several times higher among those with less than 12 years of education compared to those with more than 16 years of education. Smoking prevalence is higher (33.3%) among those living below the poverty line than in those with higher income levels (American Heart Association, 2003).

Statistics About Smoking

    Approximately 80% of people who smoke began to use tobacco before the age of 18 years. The most frequent age of initiation is at 14 to 15 years. In 1998, 1.7 million Americans began to smoke cigarettes daily, which translates to more than 4,000 new smokers per day (American Heart Association, 2003). 

    To slow the rate of cardiovascular disease, prevention strategies must be incorporated into education efforts within schools. It is also known that, for those who use tobacco, it is never too late to quit smoking. According to the World Health Organization, the risk of coronary heart disease (CHD) decreases by 50% within 1 year of quitting. 

    Within 15 years of quitting, the relative risk of dying from CHD approximates that of a non-smoker. In those with established CHD, smoking cessation reduces both morbidity and mortality to a similar degree in both younger individuals and in those over 70 years of age (Williams, MA, et al., 2002).

Body Effects of Smoking

    Smoking affects almost every tissue and organ in the body. The deleterious effects on the cardiovascular system include an increase in blood pressure, heart rate, and peripheral vascular resistance; an increase in catecholamines; an impairment in flow mediated dilation of coronary arteries; increased susceptibility to clotting, and reduction in high-density lipoprotein (HDL) cholesterol. 

    These deleterious effects are often associated with angina pectoris, myocardial infarction, stroke, and death. Smoking compounds significantly the risk of other cardiovascular risk factors such as dyslipidemia, hypertension, and obesity. Tobacco smoke also increases cardiovascular risk among nonsmokers. 

    The 4,000 chemicals and carcinogens found in tobacco smoke increase the risk of death from cardiovascular disease by as much as 30% in nonsmokers (American Heart Association 2003).

Smoking as Social Burden

    Finally, smoking imposes a significant social burden due to the high costs of tobacco related illness. Health related costs to Americans now exceed $157 billion annually. These figures are due to loss of productivity and increased medical expenditures among smoking adults, and increased smoking attributable to neonatal medical expenditures. 

    Many strategies for both prevention and intervention are needed in order to combat the aggressive tobacco industry, which spent $11.2 billion on advertising and promotion in the United States alone in 2001 (Schroeder, 2004).

    Several theories and models have been effectively incorporated into smoking interventions. These include the transtheoretical model (Prochaska & DiClemente, 1983), classifying individuals into stages based on their desire to quit smoking; social learning theory, specifically self-efficacy (Bandura, 1997); and the cognitive behavioral model of relapse which focuses on relapse prevention training (Marlatt & Gordon, 1985).

Guideline for Tobacco Treatment 

    In 2000, the United States Department of Health and Human Services published the Clinical Practice Guideline entitled Treating Tobacco Use and Dependence (Fiore et al., 2000). This guideline reviewed more than 6,000 smoking related studies conducted from 1975-1999. 

    Strength of evidence, primarily from randomized controlled trials, indicates that tobacco dependence must be considered a chronic disease. This is due to the high rates of relapse that persist for weeks, months, or even years after quitting. 

    Intervention strategies must incorporate persuasive advice, behavioral interventions that anticipate and respond to periods of relapse and remission, and the use of appropriate pharmacotherapies and support to help individuals to remain tobacco-free. 

    Further, more than 70% of smokers state their desire to quit, yet only 5% succeed without assistance. Evidence from randomized clinical trials cited in the Clinical Practice Guideline, indicated that smoking cessation is fostered by: 

(a) three minute messages about the importance of cessation, provided by multiple health care professionals

(b) high intensity counseling (longer than 10 minutes). per session with a total duration of 30 minutes or more)

(c) four or more follow-up sessions

(d) provision of multicomponent interventions such as self-help materials, telephone follow-up, pharmacotherapies, and behavioral counseling. 

 Tobacco Cessation and Treatment 

    Treatments lasting 8 or more weeks will more than double cessation rates. Pharmacologic therapies including nicotine replacement therapies (NRT) and bupropion chloride (Zyban, Wellbutrin) facilitate quitting. Nicotine replacement therapies including the gum and patch are available over the counter. 

    Newer agents such as the nicotine spray and inhaler are offered only by prescription. Research suggests that unless carefully prescribed and combined with follow-up education, nicotine replacement therapies are often ineffective (Pierce & Gilpin, 2002). 

    Thus, nurses may have a significant role in providing education and ensuring follow-up for patients who elect to use pharmacologic agents.

Nursing Role In Cessation

    Nurse investigators have played a key role in developing and testing effective interventions in various treatment settings such as hospitals and clinics. 

    Interventions that link identification of smokers, strong physician advice, and nurse-mediated behavioral counseling at the bedside with follow-up telephone contacts have been shown to improve outcomes for both cardiovascular patients and those with various medical and surgical diagnoses (Miller, NH , Smith, DeBusk , Sobel, & Taylor, 1997; Taylor, Houston Miller, Killen, &DeBusk , 1990). 

    This research has been replicated in cardiovascular patients in Canada, and more recently, in clinical practice settings (Smith, Reilly, Miller, DeBusk , & Taylor, 2002). 

    Research by Frolicker and colleagues ( Froelicher et al., 2004) suggests that women with cardiovascular disease may represent a refractory group requiring more intensive intervention, including a systematic plan for follow-up and greater use of pharmacotherapies in conjunction with behavioral interventions.

Associated Disorders

    Cardiovascular disease remains the number one cause of death and disability worldwide. The great strides that have occurred to reduce smoking rates in the US over the past 3 decades offer hope that this addictive behavior may someday be a distant memory. 

    Strong support from the nursing, medical, and public health communities is needed to achieve this goal. Thus, all health care professionals must take an advocacy role in clinical practice and other community settings.