Tobacco use or Smoking as a Cardiovascular Risk Factor

Smoking as a Cardiovascular Risk Factor Smoking/Tobacco

Smoking is recognized as the single most preventable cause of death and disability in the United States. Annually, smoking is responsible for approximately 440,000 deaths in the U.S. alone, while more than 4.8 million deaths occur globally due to tobacco use. The World Health Organization (WHO) projects that by 2030, tobacco will kill 10 million individuals annually (Schroeder, 2004). These statistics underscore the urgent need for comprehensive efforts to address smoking and tobacco use as a major public health crisis.

Smoking as a Health Disorder

Smoking is a highly addictive behavior that results in both physiological and psychological dependence. Nicotine, the primary addictive substance in tobacco, has stimulating and tranquilizing effects, making it particularly difficult to quit. Addiction to nicotine and tobacco is characterized by several key features:

1. Predictable Withdrawal Symptoms: When a person who is dependent on nicotine stops using it, they experience predictable withdrawal symptoms such as irritability, anxiety, difficulty concentrating, and increased appetite.
2. Physical Dependence and Tolerance: Over time, individuals develop a tolerance to nicotine, requiring increasing amounts to achieve the same effects. This physical dependence makes quitting challenging, as the body has adapted to the regular presence of nicotine.
3. Continued Use Despite Negative Consequences: Addictive disorders, such as smoking, involve the continued use of a substance despite social disapproval, medical advice, or harm to physical, social, psychological, or economic well-being.
4. Use to Cope with Stress: Many smokers use nicotine as a coping mechanism to manage stress, anxiety, boredom, or anger.
5. Immediate Gratification: Smoking provides an immediate sense of relief or pleasure, reinforcing the behavior and making it difficult to break the habit.
6. Restoration of Physical and Psychological Comfort: Smokers often use nicotine to alleviate withdrawal symptoms, creating a cycle of dependency.

Smoking is also an over-learned behavior closely associated with various aspects of daily life, such as driving, eating, talking on the phone, or drinking coffee. Many smokers find themselves automatically reaching for a cigarette in these situations. The success of interventions aimed at helping smokers quit must therefore address the complex interplay of nicotine addiction, psychosocial influences, and habitual behavior.

Prevalence of Smoking

The prevalence of smoking has declined by 40% among individuals aged 18 years and older since 1965. However, this decline plateaued in the 1990s, and among individuals aged 18-24, the prevalence actually increased from 23% to 27% between 1991 and 2000. In 2001, approximately 48.1 million Americans (about 1 in 4 adults) were smokers, including 25.2% of males and 20.7% of females (American Heart Association, 2003). All of these individuals are at increased risk for cardiovascular events such as myocardial infarction and stroke, with cardiovascular deaths accounting for at least one-third of all smoking-related deaths annually.

The prevalence of smoking varies significantly from state to state, largely depending on the effectiveness of tobacco-related legislation and policy changes. Smoking rates tend to be highest in states where tobacco is cultivated, such as Kentucky. Additionally, there is a strong relationship between smoking and educational attainment; the prevalence is several times higher among those with less than 12 years of education compared to those with more than 16 years. Smoking rates are also disproportionately higher (33.3%) among individuals living below the poverty line compared to those with higher income levels (American Heart Association, 2003).

Statistics About Smoking

Approximately 80% of people who smoke began using tobacco before the age of 18, with the most frequent age of initiation being 14 to 15 years. In 1998, an estimated 1.7 million Americans started smoking daily, which translates to over 4,000 new smokers every day (American Heart Association, 2003). To slow the rate of cardiovascular disease, it is crucial to incorporate prevention strategies into educational efforts within schools.

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

Body Effects of Smoking

Smoking affects nearly every tissue and organ in the body, with particularly harmful effects on the cardiovascular system. These effects include:

• Increased Blood Pressure and Heart Rate: Smoking elevates blood pressure and heart rate, increasing the strain on the heart.
• Increased Peripheral Vascular Resistance: Smoking causes blood vessels to constrict, which raises blood pressure and makes the heart work harder.
• Increased Catecholamines: Smoking stimulates the release of catecholamines, which can lead to arrhythmias and other heart problems.
• Impaired Coronary Artery Dilation: Smoking impairs the ability of coronary arteries to dilate properly, reducing blood flow to the heart muscle.
• Increased Susceptibility to Clotting: Smoking increases the risk of blood clots, which can lead to heart attacks and strokes.
• Reduction in High-Density Lipoprotein (HDL) Cholesterol: Smoking reduces levels of HDL cholesterol, which is protective against cardiovascular disease.

These adverse effects contribute to an increased risk of cardiovascular events such as angina pectoris, myocardial infarction, stroke, and death. Smoking also exacerbates other cardiovascular risk factors, such as dyslipidemia, hypertension, and obesity, and 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 a Social Burden

Smoking imposes a significant social burden due to the high costs of tobacco-related illnesses. Health-related costs in the United States now exceed $157 billion annually, driven by loss of productivity, increased medical expenditures among smoking adults, and increased neonatal medical costs attributable to maternal smoking. Combating the aggressive tobacco industry, which spent $11.2 billion on advertising and promotion in the U.S. alone in 2001, requires robust strategies for both prevention and intervention (Schroeder, 2004).

Several theories and models have been effectively incorporated into smoking interventions. These include:

• The Transtheoretical Model (Prochaska & DiClemente, 1983): Classifies individuals into stages based on their readiness to quit smoking.
• Social Learning Theory (Bandura, 1997): Emphasizes self-efficacy, or the belief in one’s ability to quit smoking.
• Cognitive Behavioral Model of Relapse (Marlatt & Gordon, 1985): Focuses on relapse prevention training to help individuals maintain cessation.

Guideline for Tobacco Treatment

In 2000, the U.S. Department of Health and Human Services published the Clinical Practice Guideline titled “Treating Tobacco Use and Dependence” (Fiore et al., 2000). This guideline reviewed over 6,000 smoking-related studies conducted from 1975 to 1999, providing a comprehensive overview of evidence-based practices for tobacco treatment. The strength of the evidence, primarily from randomized controlled trials, indicates that tobacco dependence must be considered a chronic disease due to the high rates of relapse that can persist for weeks, months, or even years after quitting.

Intervention strategies should 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 remain tobacco-free. The guideline emphasizes that more than 70% of smokers express a desire to quit, yet only 5% succeed without assistance. Evidence from randomized clinical trials cited in the guideline indicates that smoking cessation is fostered by:

1. Brief Cessation Messages: Three-minute messages about the importance of cessation provided by multiple healthcare professionals.
2. High-Intensity Counseling: Counseling sessions longer than 10 minutes per session, with a total duration of 30 minutes or more.
3. Follow-Up Sessions: Four or more follow-up sessions to provide ongoing support.
4. Multicomponent Interventions: Use of self-help materials, telephone follow-up, pharmacotherapies, and behavioral counseling.

Tobacco Cessation and Treatment

Effective treatments for smoking cessation include both behavioral and pharmacologic interventions. Treatments lasting 8 or more weeks can more than double cessation rates. Pharmacologic therapies, such as nicotine replacement therapies (NRT) and bupropion chloride (Zyban, Wellbutrin), have been shown to facilitate quitting. Nicotine replacement therapies, including gum and patches, are available over the counter, while newer agents like nicotine spray and inhalers are available by prescription.

Research suggests that nicotine replacement therapies are often ineffective unless carefully prescribed and combined with follow-up education (Pierce & Gilpin, 2002). Therefore, nurses play a significant role in providing education and ensuring follow-up for patients who choose to use pharmacologic agents.

Nursing Role in Cessation

Nurses have played a key role in developing and testing effective smoking cessation interventions in various treatment settings, such as hospitals and clinics. Interventions that link the 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 et al., 1997; Taylor et al., 1990).

Research by Froelicher et al. (2004) suggests that women with cardiovascular disease may require more intensive interventions, including a systematic plan for follow-up and greater use of pharmacotherapies in conjunction with behavioral interventions. This finding highlights the need for tailored approaches to smoking cessation that consider individual patient characteristics and needs.

Associated Disorders

Smoking is a significant risk factor for numerous health conditions, including cardiovascular disease, respiratory diseases, and several cancers. Cardiovascular disease remains the leading cause of death and disability worldwide. The progress made in reducing smoking rates in the U.S. over the past three decades offers hope that this addictive behavior may someday be a distant memory. However, achieving this goal requires strong support from the nursing, medical, and public health communities.

All healthcare professionals must take an advocacy role in clinical practice and community settings to promote smoking cessation and address the broader social determinants of health that contribute to tobacco use. By working together, healthcare providers can help individuals quit smoking, reduce the burden of tobacco-related diseases, and improve overall public health outcomes.