Literature Review: Smoking And Coronary Artery Disease

Literature freshen up grass And Coronary Artery DiseaseCig artte dope extremely boosts the risk of coronary artery disease (CAD), and the associated risk is particularly mellowed in subjects with diabetes mellitus (DM) (Mhlha procedurer, 1994). The preponderance of hummer worldwide is wiz and quarter one gazillion million million adult smokers, 10% of them reside within South East Asian countries. Smoking preponderance in these countries is a range from 12.6% to 40% in Singapore and Laos, on an individual basis. Malaysia is recording 21% adult current smokers (Southeast Asia Tobacco break Alliance (SEATCA), 2008). Cig bette fastb both is estimated to ca give more than five million deaths, making it the leading cause of preventable mortality worldwide (Peto et al., 1996). atherosclerotic cardiovascular disease, chronic obstructive pulmonary disease (COPD) and lung cancer rec alone the trinity relevant causes of weed related mortality (Centers for Disease instruction P revention, 2008). It has well known that cigarette pot increases the risk of microvascular complications in DM (ie, nephropathy, retinopathy, and neuropathy) probably by its metabolic effectuate (worsening diabetes control and insulin resistance) in conspiracy with increase inflammation and endothelial dysfunction. It appears to be stronger in type 1 diabetic patients, mend the enhanced risk for macrovascular complications, coronary heart disease (CHD), stroke, and peripheral vascular disease, is well-nigh pronounced in type 2 diabetic patients (Eliasson, 2003, Haire-Joshu et al., 1999, Solberg et al., 2004).Smoking extremity can safely and cost efficaciously be recommended for all patients, and it is a gold standard a puddlest which separate wellnessful behaviors should be estimated. Stopping sess at any age has a considerable impact on improving life expectancy, reducing morbidness and reducing wellness vexation costs associated with treating smoke related conditions (Asaria et al., 2007, Ward, 2008), but effective st swangies are lacking completion support (Everett and Kessler, 1997). on that particular are several discussion interventions have been identified as essential to get done completion. These interventions include brief focus by multiple wellness care providers, use of individual or group counseling st rangegies, and use of pharmac new(prenominal)apy (Haire-Joshu et al., 1999).Smoking cessation medicines are among the most cost-effective disease streak interventions usable (Fiore, 2000). There are several types of them assist in have cessation are available. (Wu et al., 2006). The 2008 up involvement to Treating Tobacco Use and Dependence, a Public wellness overhaul-sponsored Clinical Practice Guideline Panel identified seven first-line (FDA-approved) medications (bupropion SR, nicotine mumble, nicotine inhaler, nicotine lozenge, nicotine gaunt spray, nicotine patch, and varenicline) and two second-line (non-FDA-approv ed for tobacco use treatment) medications (clonidine and nortriptyline) as being effective for treating smokers (Fiore et al., 2008). The most comm only if utilize formulation is nicotine replacement therapy (NRT). It reduces motivation to smoke and numerous of physiological and psychomotor withdrawal symptoms usually experienced during an assay to take leave smoking, and thitherfore, may increase the likelihood of remaining abstinent (Gourlay and McNeil, 1990, West and Shiffman, 2001). NRT is presently recommended as a safe intervention to habitual populations and higher-risk groups, including pregnant and breastfeeding women, adolescents, and smokers with cardiovascular disease (National Institute for Health and Clinical Excellence (NICE), 2008). Systematic reviews show that all forms of NRT have been proven to be effective (Fiore et al., 2008) and it increase retire from rate one and a half to two fold in comparison with placebo. There are umpteen stu oversteps provide good prove that smoking cessation pharmacotherapy enhance the success of retract smoking attempt (Cahill et al., 2008, Fiore et al., 2008, Hughes et al., 2007, Stead et al., 2008). Unfortunately, there are insufficient tests to recommend one preservation system over a nonher.Literature reviewThis review ordain spine the aims of this research. Globally, it was estimated that there are nearly 1.3 billion smokers, half of whom provide die from smoking-related diseases (Shafey et al., 2009). While in Malaysia, the Third National Health and Morbidity sketch has fibed some decline in smoking statistics among general population (18 historic period and above) in Malaysia with an overall smoking rate of 21.5% male and effeminate smoking rates of 46.4% and 1.6%, respectively (Ministry of Health, 2006). To our noesis, there is limited training most the preponderance of smoking among diabetes mellitus patients, but it seems to be mirror to general population, at least for young adults. Findings from the national Behavioral Risk Factor surveillance System show that the prevalence of smoking in young adults with diabetes mellitus is convertible to the prevalence in the general population (Ford et al., 2004). Other learn in the United States found the age-adjusted prevalence of smoking was 27.3% and 25.9% among people with and without diabetes, respectively. The prevalence of smoking did non differ portentously amongst participants in both groups when they were secernate by age, sex, wake, or education (Ford et al., 1994). a few(prenominal) studies examined the prevalence of tobacco use with diabetic patients, information that is critical for targeting prevention efforts. There is no estimated prevalence for smoking in diabetes mellitus patients in Malaysia.Few studies was conducted about the knowledge and ken of diabetic patients towards smoking cessation and its pharmacotherapies. There is a survey do in the United Kingdom to investigate sensory faculty of pharmacotherapeutic aids to smoking cessation in diabetic cigarette smokers. A structured questionnaire-based question was held by research nurse individually with current smokers in a private room. Of 597 diabetic patients visiting a routine clinic, one coulomb diabetic patients were current smokers. The majority of them were type 2 diabetic patients (96%). There were 66% and 54% had heard about NRT and bupropion, respectively. Those who had heard about NRT, only 49% considered it safe with diabetes, while who knew of bupropion 39% thought it unsafe in diabetic patients. Approximately 84% were aware of the UK National Health Service (NHS) quit line, but only 8% had used it. The authors conclude that this subpopulation has ridiculous knowledge and awareness of NRT and bupropion as aids to quit smoking (Gill et al., 2005).A qualitative withdraw done in the United States, aimed to investigate beliefs about cigarette smoking and smoking cessation among Urban African Am ericans with font 2 Diabetes. Focus groups and a short survey were used to appraise cigarette use patterns, perceived smoking health make, preferences for treatment, and attitudes toward smoking cessation among this subpopulation. Twenty five participants were included in this study. The mean age was (SD) 48.5 courses (10.23), 60% female, smoked 20.9(12.54) cigarettes per daytime. Regarding the beliefs and knowledge about smoking and diabetes, Participants believed that smoking increased their risk for all health outcomes, though there was not a clear understanding of how. Furthermore, they believed smoking decreased their appetite and quitting smoking makes you gain weight, and that it would negatively affect diabetes. Regarding beliefs and opinions about get outping most participants desired to quit and believed it was important to quit, but were not motivated to quit or assured they could achieve cessation (Janet L. Thomas et al., 2009).Another study established in the Uni ted States, aimed to assess what smokers believe about the health risks of smoking and the effects of smoking filtered and low-tar cigarettes, as well as their awareness of and interest in trying so-called reduced risk tobacco products and nicotine medications. It was conducted between may and September 2001. They gathered data on demographic characteristics, tobacco use behaviors, awareness and use of nicotine medications, beliefs about the health risks of smoking, study of smoke and excogitate features of cigarettes, and the safety and cogency of nicotine medications. The findings of this study showed a substantial percentage of respondents both answered incorrectly or responded dont know to questions about health risks of smoking (39%), content of cigarette smoke (53%), safety of nicotine (52%), low-tar cigarettes and filtered cigarettes (65%), additives in cigarettes (56%), and nicotine medications (56%). The smokers characteristics most commonly associated with take infor mation when all six indices were combined into a summary mightiness were as follows those aged 45 years or older, smokers of ultra-light cigarettes, smokers who believe they result stop smoking before they experience a serious health problem caused by smoking, smokers who have never used a stop-smoking medication, and smokers with a put down education level. Those who believed they would stop smoking in the next year were more knowledgeable about smoking. The authors conclude that smokers are misinformed about many aspects of the cigarettes they smoke and stop smoking medications (Cummings et al., 2004).Unfortunately, there is a dearth of information on the efficacy of smoking cessation pharmacotherapies in diabetic patients because large-scale studies involving this group do not report results separately for them. Additionally, there are few postulate result to head comparison studies among them in this subgroup population.In an open-label, randomized mental testing conducted in Belgium, France, the Netherlands, the United Kingdom, and the United States, compared varenicline with transdermic NRT for smoking cessation. Participants were randomized to receive either 12 work hebdomads of varenicline or 10 calendar hebdomads of transdermal NRT (Aubin et al., 2008). The primary end point was continuous mode balancen rate ( automobile) during the experience 4 weeks of each treatment. Secondary end points were CARs from the pop off 4 weeks of treatment through weeks 24 and 52 and the 7-day point prevalence of sobriety assessed at the end of treatment, week 24, and week 52. The Minnesota Nicotine secession Scale (MNWS) and The change Cigarette Evaluation Questionnaire (mCEQ) measures of craving, withdrawal, and smoking satisfaction were assessed at baseline and at each weekly visit through week 7 (or at early ratiocination).Data were analyzed in both the prespecified primary psychoanalysis population (all randomized participants who true at least 1 back breaker of study drug 376 varenicline, 370 NRT) and the all-randomized population (378 varenicline, 379 NRT). CARs were substantively higher in the remainder 4 weeks of treatment of varenicline group compared with NRT group (55.6% vs 42.2%, respectively Odds proportionality (OR) = 1.76 95% CI, 1.31-2.36 P 0.001). At week 24, there was no significant going away in CARs (32.2% and 26.6% OR = 1.33 95% CI, 0.97- 1.82). At week 52, CARs were not significantly higher for varenicline over to NRT in the primary analysis population, although the difference in CARs remain significant through week 52 in all-randomized population analysis (25.9% vs. 19.8% OR = 1.44 95% CI, 1.02-2.03 P = 0.04). The 7-day point prevalence of abstinence at week 12 was significantly higher for varenicline compared with NRT (62.0% vs 47.0%, respectively OR = 1.71 95% CI, 1.27-2.30 P 0.001). The differences in 7-day point prevalence of abstinence were not significant at week 24 or week 52.For weeks 1 th rough 7, the average scores of MNWS and mCEQ for cravings, withdrawal symptoms, and the reinforcing effects of smoking were significantly lower with varenicline compared with NRT (all population analysis, P 0.001). Varenicline group had significantly lower MNWS subscale scores for negative affect and restlessness compared with NRT (both, P 0.001) there was no difference between varenicline and NRT in the subscale scores for increased appetite or insomnia.A guideline Treating Tobacco Use and Dependence 2008 Up encounter is a product of the Tobacco Use and Dependence Guideline Panel. This guideline contains strategies and recommendations intentional to assist clinicians tobacco dependence treatment specialists and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence (Fiore et al., 2008). A meta-analysis displayed the strength of the first-line smoking cessation medications compared with placebo at 6 m onths post-quit. They gear upd the estimated abstinence rate and betting odds ratio at 6 months post-quit (95% CI) compared with placebo estimated abstinence rate of 13.8% and estimated odds ratio of 1.0. Varenicline had the highest estimated abstinence rate and odds ratio (33.2% and 3.1), while nicotine gum had the lowest estimated abstinence rate and odds ratio (19.0% and 1.5).Another multicenter, randomized, double-blind, placebo-controlled trial compared the efficacy and safety of varenicline with placebo for smoking cessation in 714 smokers with stable cardiovascular disease that had been diagnosed for 2 months. Participants received either varenicline (1 mg twice daily) or placebo at ratio 11, along with smoking-cessation counseling, for 12 weeks. Follow-up lasted 52 weeks. The primary end point was carbon monoxide-confirmed CAR for last 4 weeks of treatment. The secondary outcomes were the CAR from week 9 through 52 CAR for weeks 9 to 24 and 7-day point prevalence of tobacc o abstinence at weeks 12 (end of drug treatment), 24, and 52. The CAR was higher for varenicline than placebo during weeks 9 through 12 (47.0% versus 13.9% odds ratio, 6.11 95% CI, 4.18 to 8.93) and weeks 9 through 52 (19.2% versus 7.2% odds ratio, 3.14 95% CI, 1.93 to 5.11). The varenicline and placebo groups did not differ significantly in cardiovascular mortality (0.3% versus 0.6% difference, _0.3% 95% CI, _1.3 to 0.7), all-cause mortality (0.6% versus 1.4% difference, _0.8% 95% CI, _2.3 to 0.6), cardiovascular events (7.1% versus 5.7% difference, 1.4% 95% CI, _2.3 to 5.0) (Rigotti et al., 2010).Nides and his colleagues conducted a multicenter, double-blind, placebo-controlled, trial to evaluate the efficacy and tolerability of three varenicline doses in adult smokers. Bupropion hydrochloride was included as an bustling control. Participants were randomized to receive varenicline 0.3 mg formerly daily, varenicline 1 mg once daily, varenicline 1 mg BID, bupropion SR 150 mg BID, or placebo for 7 weeks, with the option of participation in follow-up through week 52. The varenicline groups received lively drug for 6 weeks, followed by placebo for 1 week. The primary efficacy outcome in this study was CAR for any 4-week period from baseline through week 7. Secondary efficacy outcomes involved the 4-week CAR for weeks 4 through 7, 4 through 12, 4 through 24, and 4 through 52 cravings and withdrawal symptoms, assessed utilize the MNWS and the brief Questionnaire of Smoking Urges (QSU-brief) reinforcing effects of smoking, assessed utilize the mCEQ and changes in body weight (Nides et al., 2006). The findings of this study presented that the patients treated with varenicline (except of those who received varenicline 0.3 mg once daily) or bupropion SR had significantly higher CARs for any 4 weeks compared with placebo (P 0.001 and P = 0.002, respectively). The CARs for any 4 weeks were 48.0% for varenicline 1 mg BID (OR = 4.71 P 0.001), 37.3% for varenicline 1 mg once daily (OR = 2.97 P 0.001), 33.3% for bupropion SR (OR = 2.53 P=.002), and 17.1% for placebo. No statistical comparison was performed between the varenicline and bupropion SR groups. Only varenicline 1 mg BID was significantly more efficacious than placebo throughout the stallion follow-up period (P 0.01). Varenicline 0.3 mg once daily and varenicline 1 mg once daily were significantly more efficacious than placebo through week 7 (P 0.05), and bupropion SR was significantly more efficacious than placebo through week 12 (P 0.05). Scores on the MNWS and QSU-brief indicated reductions from baseline in cravings with varenicline 1 mg BID compared with placebo at each weekly time point during active treatment (week 2 P 0.01 weeks 1 and 3-6 P 0.001). Varenicline 1 mg BID was also associated with consistent improvements from baseline (the day before the TQD) to week 1 in scores on several subscales of the mCEQ compared with placebo, including satisfaction (mean change, -4.82 P 0.05), enjoyment of respiratory tract sensations (mean change, -0.84 P 0.05), and aversion (mean change, 0.82 P 0.05). (The mCEQ was not used beyond week 1 of the active-treatment period.) There were no significant differences on any of the mCEQ measures between the lower doses of varenicline and placebo (Nides et al., 2006).Rationale/JustificationFew studies examined the prevalence of tobacco use with diabetic patients, information that is critical for targeting prevention efforts. To our knowledge, there is no estimated prevalence for smoking in diabetes mellitus patients in Malaysia. near people today recognize major health risks from smoking, but this general knowledge does not necessarily translate into a belief that one is personally at high risk of becoming seriously ill as a consequence of smoking. Furthermore, general awareness of health risks does not mean that people are adequately informed about smoking in ways that might influence their smoking behavior. Because th e knowledge, beliefs, and preferences of smokers facilitate supreme receptivity to programs, these are important considerations when developing effective cessation interventions. Therefore, we bequeath investigate smokers knowledge about the health risks of smoking and their awareness of nicotine medications.Unfortunately, there is a dearth of information on the efficacy of smoking cessation pharmacotherapies in diabetic patients because large-scale studies involving this group do not report results separately for them. Additionally, there are few direct head to head comparison studies among them in this subgroup population.ObjectivesGeneral objectivesDetermine the prevalence of smoking among diabetic patients in outpatient clinic at General Hospital Penang.To investigate diabetic smokers knowledge about the health risks of smoking and their awareness of nicotine medications.To estimate direct tete-a-tete comparison between varnicline and nicotine patch regarding to their efficac y in smoking cessation. circumstantial objectivesDetermine the prevalence of smoking among diabetic patients.To assess the knowledge of diabetic smokers about the health risks of smoking and their awareness of nicotine medications.To compare between varenicline and NRT in the abstinence rate of smoking.To compare between varenicline and NRT in the cravings and withdrawal symptoms, assessed using the MNWS and QSU-brief.To compare between varenicline and NRT in the reinforcing effects of smoking, assessed using the mCEQ.To compare between varenciline and NRT in changes in body weight.Research MethodologyStudy figure of speechThis study comprises different types of study design according to the different objectives.For estimating the prevalence of the smoking among DM patients, it go out be achieved by review the medical records for all diabetic patients who attend the diabetic outpatient clinic during 2010. Besides assessing the smoking status, we leave collect also specific demogr aphic and diabetic-related data. Any medical records does not contain information about smoking status forget be excluded.The second objective in investigating knowledge and awareness of diabetic smokers about the health risks of smoking, smoking cessation and smoking cessation pharmacotherapies, the study design it will be cross-sectional survey. All the diabetic smoker patients who attend the outpatient diabetic clinic at General Penang Hospital in 2011 will be invited to participate in the survey. The questionnaire will be either distributed or interviewed by the clinical staff. The questionnaire will be based on another(prenominal) study. More detailed information on how the survey was conducted can be found elsewhere (Cummings et al., 2004). The questionnaire will be divided to two sections involving socio-demographic, tobacco-related and diabetes-specific health information knowledge and awareness towards the health risks of smoking and their knowledge of smoking cessation an d smoking cessation pharmacotherapies.The sociodemographic information will include (age, sex, race etc) diabetic-related information, it will contain type of diabetes, type of diabetic treatment, duration of diabetes while for smoking related information will involve number of cigarettes smoking per day, age started smoking, duration of smoking, are there any attempt to stop smoking for any period of time, Are there other smokers in the household.To compare treatment effect of varenicline and nicotine patch in abstinence rate of smoking cessation for diabetic smoker patients and to investigate the impact of the smoking cessation on the diabetic control. The study design will be randomised, open-label, parallel group study. The participants will be randomized in a 11 ratio either to varenicline or nicotine patch treatments. capable who will receive varenicline will administer 0.5 mg/day for 3 days, 0.5 mg twice daily for 4 days, then 1 mg twice daily thereafter. Full dosing was ac hieved by the target quit date (TQD) and continues up to 12 weeks. Participant who will receive nicotine patch employ transdermal patches each morning starting on the TQD for 10 weeks. Doses of NRT were 21 mg/day for the first 6 weeks, 14 mg/day for 3 weeks, then 7 mg/day for 3 weeks.We engage these two treatments (nicotine patch and varenicline) for several reasons. Nicotine patch is the most commonly used pharmacotherapy for smoking cessation (Burton et al., 2000, Pierce et al., 1995, West et al., 2001). Given that many smokers in general population use this treatment to quit smoking, it is important to determine treatment effect of other agents relative to the patch. Furthermore, recent data evoke that there is decline in the efficacy of nicotine patch over the earlier 10 years (Irvin et al., 2003, Jorenby et al., 1999, Pierce and Gilpin, 2002). Varnecline is selected in this study because yet there is limited studies publish about the effectiveness of this treatment in the d iabetic smoker population. Also, varnecline was found to be the highest efficacy in the 2008 PHS Guideline meta-analysis (odds ratio 3.1) comparing to placebo (Fiore et al., 2008). Finally, smokers could be encouraged to seek out this prescribed agent, and insurers and health care systems could be encouraged to make this treatment more widely available, if it could be demonstrated that varnecline is more efficacious than over-the-counter medication (such as nicotine patch).In this study we will collect three types of end points efficacy, beat of craving and withdrawal symptoms, and investigating the impact of smoking cessation on diabetic outcome.The primary outcome for efficacy in the study it will be self-reported CAR, confirm by exhaled CO levels of 6 ppm or below, during the last 4 weeks of treatment (varenicline and NRT, weeks 9-12 after TQD)The secondary is the CAR from the last 4 weeks of each treatment until 6 months. Other secondary outcomes are 7-day point prevalence of tobacco abstinence at weeks end of drug treatment and at 6 months. Continuous abstinence define as self-reported abstinence from any tobacco- or nicotine-containing product during the specific period and it will be verified by carbon monoxide (CO) level 10 ppm. If the CO level is more than 10 ppm will be classified as a smoker regardless of self-reported abstinence. Point prevalence abstinence define as self-reported abstinence from any tobacco- or nicotine-containing product in the past 7 days that was not contradicted by expired air CO 10 ppm. These are traditional standards for assessing efficacy of smoking cessation interventions (Fiore et al., 2008, Hughes et al., 2003).The Minnesota Nicotine Withdrawal Scale (MNWS) (Cappelleri et al., 2005) will be used to assess urge to smoke, cast down mood, irritability, anxiety, poor concentration, restlessness, increased appetite and insomnia. The modified Cigarette Evaluation Questionnaire (mCEQ) (Cappelleri et al., 2007) will be used to assess smoking satisfaction, psychological reward, aversion, enjoyment of respiratory tract sensations and craving reduction. The two previous questionnaires will be administered baseline visit and at each weekly visit through week 6 (after TQD) and at the end of treatment or at termination for participants who discontinued the study before week 6 (TQD). While the MNWS will be administered to all participants, the mCEQ will be administered only to participants who report smoking since their last completed questionnaire.Furthermore, we will assess the level of the nicotine dependence by using the Modified Fagerstrm Test for Nicotine Dependence (Heatherton et al., 1991) that range to three score ranges (0-3) score indicate to low dependent, (4-6) score indicate to mute dependent and (7-10) score indicate highly dependent. It will be administered at the baseline of the study.Schematic presentation of study designScreening all diabetic patients medical records to estimate prevalenc e of smoking among themInterviewed structured questionnaire for all diabetic smoker toTo know characteristics of diabetic smoker (sociodemographic, diabetic narration and tobacco use history)Investigate the knowledge towards smoking cessation and its pharmacotherapiesPatients who attend quit smoking clinic Assessed for eligibilityExcludedDid not meet entry criteriaWithdrew consent randomize at ratio 11Allocated to Varnicline (2mg or 1mg)(For 12 weeks) and gear up for quit dateAllocated to nicotine Patch(For 12 weeks) and arrange for quit dateFollow up at the end of treatment (12 weeks) and at 6 months to assessAbstinence rate of smoking cessationthe cravings and withdrawal symptomsthe reinforcing effects of smokingchanges in body weightAnalysisInclusion criteriaThe inclusion criteria it will be varying among the different objectivesFor investigating the knowledge and awareness towards smoking cessation and its pharmacotherapies, smoker and ex-smoker diabetic patients (either type I or II) of both sexes aged 18 years will be included.For the direct comparison between nicotine patch and varenicline, Diabetic smokers of both sexes aged 18 years who smoke 10 cigarettes/day and willing to quit smoking.censure criteriaPatient is currently using any form of tobacco other than cigarettes any form of NRT or other smoking cessation therapy. world-shaking depression requiring behavioral counseling and those using medications with psychoactive effects (e.g., antidepressants, antianxiety agents). other active psychiatric diseases because of previously identified limitations with delivery of the specific counseling intervention in such subjects.History of skin allergies or evidence of chronic dermatosis.Patient has medical contraindications for any of the study medications.Pregnant, breastfeeding women or at risk of becoming pregnant.Drug abuse or HIV give patient.Recent (3 months) history of myocardial infarction, angina pectoris, serious cardiac arrhythmia, or other m edical conditions that the healthcare provider deemed incompatible with study participation.Participation within the last 12 months in a prescribed smoking cessation program.