Smoking cessation for the prevention of heart attack.

Smoking cessation is one of the important step in prevention of heart attack. Smoking  has several effect on the risk factors for heart attack. Smoking increases the heart attack risk 6 fold in women and 3 fold in men. It is the most important modifiable heart attack risk factor and a preventable cause of death due to heart attack.

Adverse effect due to smoking is

1. Dose dependent.

2. More for high tar than low tar cigarettes

Effects of smoking on coronary risk factors are given below.

1. Smoking causes increase in blood pressure

2. It decreases the good cholesterol that is HDL cholesterol. HDL cholesterol will protect from heart attack.

3. Smoking predispose the blood clotting which is the  key factor in  heart attack.

4. Reduce the effective lysis or removal of clot.

5. Increase the fibrinogen and C-reactive protein both of them are risk factors of heart attack.

6. Smoking change the function of wall of blood vessel thus predispose to clot formation.

7. Smoking  causes spasm of blood vessels and thus reduce the blood supply.

8. It causes increase in heart rate.

9. There is increased risk of  recurrent infection of oral cavity and lungs.

Following cessation of smoking, there will be immediate beneficial effect in people of all age groups. Smoking cessation thus help to reduce the heart attack  incidence. But the problem is that smoking cessation is very difficult.

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Clinical features of depression

Depression is a common clinical problem. Many of us at sometime or other experience sadness, fed up or down in dumps. It is called as depressive illness when such symptoms become qualitatively different and interfere with normal functioning. It can vary in severity may be mild, moderate or severe. Symptoms can be transient or persistent. Patients usually experience disturbance of mood , speech, energy and ideas. Some patients describe symptoms in physical terms. Two most common physical symptoms are fatigue and headache. If symptoms  are severe patients require hospitalization.

Many patients describe the world looking grey and they are devoid of pleasure and interest in life (anhedonia). Anxiety and phobic disorders are common in these patients. Symptoms usually last for at least 2 weeks. In severe forms of the disease diurnal variation in mood can be seen. Such people feel worse in the morning after awaking. One of the major risk is suicide, risk is 5%in out patients and 15% in those whose symptoms are severe enough to require hospital admission.

The following changes are noted in depression.

Mood - May be depressed, miserable or irritable.

Talk - Slow, monotonous.

Energy - Low energy and lethargic.

Ideas - Feeling of futility, guilt, self unworthiness, hypochondriacal preoccupation, worrying, suicidal thoughts, delusions of guilt and persecution.

Cognition - There can be impaired learning and pseudodementia in elderly patients .

Behavior - Retardation or agitation ,poverty of movements and expression.

Hallucination - Auditory ,often hostile and critical

Physical - Early waking, poor appetite ,constipation, loss of libido, erectile dysfunction, fatigue, bodily aches and pains.

Other psychiatric disorder associated with depression

1. Misuse of alcohol

2. Amphetamine and derivatives misuse and withdrawal

3. Dementia

4. Delerium

5. Schizophrenia

Other medical illness associated with depression

1. Cushing syndrome

2. Thyroid disorders

3. Increased parathyroid hormone

4. Steroid treatment

5. Brain tumours

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Quitting smoking is difficult ,Why ?

Principal content of tobacco is nicotine. It is responsible for its addictive behavior. Tobacco smoking produce physical as well as psychological dependence. Many smoke cigarette as way to cope up with stress and depression. So it is a part of many people’s daily rituals. On quitting smoking people experience withdrawal symptoms that is, unpleasant effects. Addicted smokers control nicotine intake by adjusting the frequency and dose of tobacco intake to obtain the desired psychological effect and avoid withdrawal. Even if they know that smoking is harmful, the addictive behavior prevents them from quitting. Not only addiction is preventing cessation other factors such as peer group pressure, advertisement of cigarette companies also make the attempt of cessation difficult.

Methods for smoking cessation

Smokers who are not motivated

• Record smoking status at regular intervals
• Anti-smoking advice should be given.
• Encourage change in attitude towards smoking to improve motivation

Motivated light smokers (smoke < 10cigarette /day)

• Anti-smoking advice
• Anti-smoking support programme.

Motivated heavy smokers (10–15cigarette /day)

• As above plus nicotine replacement therapy (NRT) (minimum 8 weeks).

Motivated heavy smokers (> 15 cigarette /day)

• As above plus bupropion if NRT and behavioral support are unsuccessful and patient remains motivated. 

Placebo or will-power alone has a ~2% chance of abstinence for ≥ 6 months. This can be increased by the following

• Written self-help materials: 1%
• Opportunistic advice from doctor: 2%
• Face-to-face behavioral support from specialist: 4–7%
• Proactive telephone counseling: 2%
• NRT with limited or intensive behavioral support: 5–12%
• Bupropion with intensive behavioral support: 9%.

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