Pharmacological Approach to Smoking Cessation: An Updated Review for Daily Clinical Practice

Brain Glucose Metabolism as a Readout of the Central Nervous System Impact of Cigarette Smoke Exposure and Withdrawal and the Effects of NFL-101, as an Immune-Based Drug Candidate for Smoking Cessation Therapy

Neuroimaging biomarkers are needed to investigate the impact of smoking withdrawal on brain function. NFL-101 is a denicotinized aqueous extract of tobacco leaves currently investigated as an immune-based smoking cessation therapy in humans. However, the immune response to NFL-101 and its ability to induce significant changes in brain function remain to be demonstrated. Brain glucose metabolism was investigated using [18F]fluoro-deoxy-glucose ([18F]FDG) PET imaging in a mouse model of cigarette smoke exposure (CSE, 4-week whole-body inhalation, twice daily). Compared with control animals, the relative uptake of [18F]FDG in CSE mice was decreased in the thalamus and brain stem (p < 0.001, n = 14 per group) and increased in the hippocampus, cortex, cerebellum, and olfactory bulb (p < 0.001). NFL-101 induced a humoral immune response (specific IgGs) in mice and activated human natural-killer lymphocytes in vitro. In CSE mice, but not in control mice, single-dose NFL-101 significantly increased [18F]FDG uptake in the thalamus (p < 0.01), thus restoring normal brain glucose metabolism after 2-day withdrawal in this nicotinic receptor-rich region. In tobacco research, [18F]FDG PET imaging provides a quantitative method to evaluate changes in the brain function associated with the withdrawal phase. This method also showed the CNS effects of NFL-101, with translational perspectives for future clinical evaluation in smokers.

Effect of Ramadan fasting on changes in smoking and vaping behaviors and withdrawal symptoms severity: a cross-sectional study

BACKGROUND

Ramadan fasting, an obligatory duty for adult Muslims, entails refraining from eating, drinking, smoking, and vaping from dawn until sunset. Throughout Ramadan, people accept major changes to daily routines. Consequently, Ramadan is associated with abstinence symptoms and changes in smoking or vaping behavior.

AIM

The study aims to assess the presence of withdrawal symptoms and its severity, as well as smoking or vaping behavior change and its determinants during Ramadan fasting.

METHODS

A cross-sectional study was conducted during Ramadan in 2023. Data were collected online using a Google form, including questionnaires assessing socio-demographic data, nicotine dependence using Fagerstrom Test for Nicotine Dependence, vaping and shisha smoking, presence and severity of physiological and psychological withdrawal symptoms and its coping strategies. Smoking and vaping behavioral change during Ramadan and its contributing factors were also evaluated.

RESULTS

A total of 251 participants (96% males), mean age ± standard deviation (33 ± 12.1) were surveyed. Withdrawal symptoms were reported among 70.5%, however, their severity was generally low both physiologically and psychologically. Education, nationality, smoking duration, nicotine dependence, and the amount of consumed E-liquid per day were the independent predictors of withdrawal symptoms presence. Attempts to quit smoking and vaping were reported by 54.6% of the participants; young age and higher educational levels were the factors associated with more quitting attempts.

CONCLUSIONS

The withdrawal symptoms severity linked to Ramadan fasting is minimal. Many smokers and vapers made attempts to quit during Ramadan. Ramadan presents a chance for smoking and vaping cessation with some behavioral support.

Adipocentric origin of the common cardiometabolic complications of obesity in the young up to the very old: pathophysiology and new therapeutic opportunities

Obesity is a multifactorial chronic disease characterized by an excess of adipose tissue, affecting people of all ages. In the last 40 years, the incidence of overweight and obesity almost tripled worldwide. The accumulation of "visceral" adipose tissue increases with aging, leading to several cardio-metabolic consequences: from increased blood pressure to overt arterial hypertension, from insulin-resistance to overt type 2 diabetes mellitus (T2DM), dyslipidemia, chronic kidney disease (CKD), and obstructive sleep apnea. The increasing use of innovative drugs, namely glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2-i), is changing the management of obesity and its related cardiovascular complications significantly. These drugs, first considered only for T2DM treatment, are now used in overweight patients with visceral adiposity or obese patients, as obesity is no longer just a risk factor but a critical condition at the basis of common metabolic, cardiovascular, and renal diseases. An adipocentric vision and approach should become the cornerstone of visceral overweight and obesity integrated management and treatment, reducing and avoiding the onset of obesity-related multiple risk factors and their clinical complications. According to recent progress in basic and clinical research on adiposity, this narrative review aims to contribute to a novel clinical approach focusing on pathophysiological and therapeutic insights.

Evaluation of the effectiveness of cytisine for the treatment of smoking cessation: A systematic review and meta-analysis

BACKGROUND AND AIMS

Smoking is considered the main cause of preventable death world-wide. This study aimed to review the efficacy and safety of cytisine for smoking cessation.

METHODS

This review included an exhaustive search of databases to identify randomized controlled trials (RCTs) in health centers of any level with smokers of any age or gender investigating the effects of cytisine at standard dosage versus placebo, varenicline or nicotine replacement therapy (NRT).

RESULTS

We identified 12 RCTs. Eight RCTs compared cytisine with placebo at the standard dose covering 5922 patients, 2996 of whom took cytisine, delivering a risk ratio (RR) of 2.25 [95% confidence interval (CI) = 1.42-3.56; I2  = 88%; moderate-quality evidence]. The greater intensity of behavioral therapy was associated directly with the efficacy findings (moderate-quality evidence). The confirmed efficacy of cytisine was not evidenced in trials conducted in low- and middle-income countries. We estimate a number needed to treat (NNT) of 11. Two trials compared the efficacy of cytisine versus NRT, and the combination of both studies yields modest results in favor of cytisine. Three trials compared cytisine with varenicline, without a clear benefit for cytisine. Meta-analyses of all non-serious adverse events in the cytisine group versus placebo groups yielded a RR of 1.24 (95% CI = 1.11-1.39; participants = 5895; studies = 8; I2  = 0%; high-quality evidence).

CONCLUSIONS

Cytisine increases the chances of successful smoking cessation by more than twofold compared with placebo and has a benign safety profile, with no evidence of serious safety concerns. Limited evidence suggests that cytisine may be more effective than nicotine replacement therapy, with modest cessation rates.

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Changes in distinct brain systems identified with fMRI during smoking cessation treatment with varenicline: a review

BACKGROUND

Varenicline is considered one of the most effective treatment options for smoking cessation. Nonetheless, it is only modestly effective. A deeper comprehension of the effects of varenicline by means of the in-depth review of relevant fMRI studies may assist in paving the development of more targeted and effective treatments.

METHODOLOGY

A search of PubMed and Google Scholar databases was conducted with the keywords "functional magnetic resonance imaging" or "fMRI", and "varenicline". All peer-reviewed articles regarding the assessment of smokers with fMRI while undergoing treatment with varenicline and meeting the predefined criteria were included.

RESULTS

Several studies utilizing different methodologies and targeting different aspects of brain function were identified. During nicotine withdrawal, decreased mesocorticolimbic activity and increased amygdala activity, as well as elevated amygdala-insula and insula-default-mode-network functional connectivity are alleviated by varenicline under specific testing conditions. However, other nicotine withdrawal-induced changes, including the decreased reward responsivity of the ventral striatum, the bilateral dorsal striatum and the anterior cingulate cortex are not influenced by varenicline suggesting a task-dependent divergence in neurocircuitry activation. Under satiety, varenicline treatment is associated with diminished cue-induced activation of the ventral striatum and medial orbitofrontal cortex concomitant with reduced cravings; during the resting state, varenicline induces activation of the lateral orbitofrontal cortex and suppression of the right amygdala.

CONCLUSIONS

The current review provides important clues with regard to the neurobiological mechanism of action of varenicline and highlights promising research opportunities regarding the development of more selective and effective treatments and predictive biomarkers for treatment efficacy.

The Effects of ESC/ESH-Based Written Generic Lifestyle Advice and a Nutraceutical on 24-Hour Blood Pressure in Patients with High-Normal Office Blood Pressure and Low-Moderate Cardiovascular Risk

(1) Background: Lifestyle changes, eventually coupled with a nutraceutical, are recommended strategies for managing high-normal blood pressure (BP) patients with low-moderate cardiovascular (CV) risk. In a real-life clinical setting, we evaluated the effects of generic written lifestyle advice, extrapolated from the 2018 ESC/ESH guidelines, and a beetroot-based nutraceutical on 24 h BP in a population with a high-normal office BP and low-moderate CV risk. (2) Methods: A longitudinal observational study was conducted in two ESH Hypertension Excellence Centres on 43 consecutive subjects with high-normal BP according to repeated office BP (OBP) measurements and a low-moderate CV risk based on SCORE2/SCORE2-OP. Additionally, 24 h ambulatory BP monitoring (ABPM) was carried out at baseline and three months after lifestyle changes, according to generic written advice from the 2018 ESC/ESH guidelines, coupled with a nutraceutical containing 500 mg of dry beetroot extract. (3) Results: The mean age was 50 ± 11 years, with male prevalence (54%). The prevalence of overweight/obesity was 58%. The mean OBP was 135 ± 3/85 ± 3 mmHg. At baseline, the mean 24 h BP, daytime BP, and night-time BP were 127 ± 7/80 ± 6 mmHg, 131 ± 8/83 ± 6 mmHg, and 118 ± 8/70 ± 5 mmHg, respectively, BP profiles compatible with hypertension status in some subjects. After a median follow-up of 98 (92-121) days, all BPs, except night-time diastolic BP, were significantly decreased: -3 ± 6/-2 ± 4 mmHg for 24 h BP, -3.9 ± 6.0/-3.0 ± 4.0 mmHg for daytime BP, and -3.3 ± 7.4/-1.3 ± 4.7 mmHg for night-time BP, respectively. No significant clinical changes in body weight were detected. BP decreased independently of baseline BP levels, sex, smoking status, and body mass index, while a more substantial BP decrease was observed in older patients. (4) Conclusions: Our exploratory study shows, for the first time, that written generic lifestyle advice taken from the ESC/ESH hypertension guidelines coupled with a beetroot-based nutraceutical may represent a valid initial non-pharmacological approach in subjects with a high-normal office BP and low-moderate CV risk, even without personalized diet interventions.

Efficacy and safety of physical therapy in patients with stage III COPD during ambulatory rehabilitation

This study aimed to determine the efficacy of a combined physical therapy and pharmacological treatment for patients recovering from stage III COPD exacerbation. The efficacy of the rehabilitation program was assessed using anthropological parameters, physical condition, respiratory system function, and functional endurance capacity. Data were collected from 39 patients with stage III COPD who underwent the rehabilitation program. Physical and anthropometric assessments were conducted using the Quetelet Body Mass Index, the Pignet Index, and the Vital Capacity Index (VCI). The functional capacities of the cardiorespiratory system were measured before and after the rehabilitation program using the Ruffier and Ruffier-Dickson tests and the hypoxic Shtange and Genchi tests. Exercise tolerance was evaluated using the Harvard Step Test and the Six-Minute Walk Distance Test (6MWD). Statistical analysis was conducted using the non-parametric Mann-Whitney U test for independent and dependent groups. Participants were randomly divided into two groups for rehabilitation: Group I received standard therapy and a routine physical therapy program, while Group II was given standard therapy along with a modified physical therapy regimen. There was a slight improvement in patient condition during the rehabilitation period for both groups. However, there was a low compliance rate for smoking cessation among the majority of patients, with some reducing their daily cigarette intake. Further long-time research is required to determine the efficacy of the proposed physical therapy program in combination with basic pharmacological therapy. The study suggests incorporating psychotherapeutic sessions and occupational therapy into future rehabilitation programs.

Efficacy and safety of pharmacological intervention for smoking cessation in smokers with diseases: A systematic review and network meta-analysis

OBJECTIVE

To investigate the most effective and best-tolerated drugs for treating diseased smokers.

METHODS

Eight databases were searched for randomized controlled trials (RCTs) involving different pharmacological interventions for smoking cessation in disease patients (January 2023). Network meta-analysis was performed using STATA 15.1 software. The Cochrane Risk of Bias Tool assessed the risk of bias, and confidence in evidence was assessed using CINeMA.

RESULTS

A total of 60 RCTs involving 13,009 patients of 12 disease categories were included. All trials reported 13 interventions, resulting in 78 comparisons. Network meta-analysis showed that varenicline (OR = 2.30, 95% CI (1.77, 3.00)) and bupropion (OR = 1.65, 95% CI (1.29, 2.11)) showed favorable abstinence effects compared to placebo in the cardiovascular disease population. Nicotine replacement therapy (NRT) had better withdrawal advantages than placebo (OR = 11.18, 95% CI (2.25, 55.54)) in the chronic obstructive pulmonary disease (COPD) population. Some combination treatments showed better results than monotherapy, such as bupropion + NRT was superior to bupropion (OR = 8.45, 95% CI (1.84, 38.89)) and NRT (OR = 4.98, 95% CI (1.25, 19.78)) in mental illness population. The final surface under the cumulative ranking curve indicated that bupropion + NRT achieved the best smoking cessation effect. Overall confidence in the evidence was low. In a comparison of drugs, the results showed that bupropion + NRT had the best safety.

CONCLUSIONS

Most interventions show the benefit of quitting smoking compared with placebo, including monotherapy and combination therapy. Moreover, varenicline or bupropion combined with NRT is superior to some monotherapies.

Cardiovascular Risk Assessment and Control in Outpatients Evaluated by 24-hour Ambulatory Blood Pressure and Different LDL-C Equations

INTRODUCTION

Office blood pressure (OBP) and low-density lipoprotein cholesterol (LDL-C) calculated by the Friedewald formula (F) are the cornerstones of the cardiovascular risk (CVR) assessment and management based on the SCORE2/SCORE2-OP model proposed by the 2021 ESC Guidelines on Cardiovascular Disease Prevention.

AIM

We compared the CVR stratification estimated by the old SCORE and the SCORE2/SCORE2-OP using OBP and ambulatory blood pressure measurement (ABPM), and we evaluated the prevalence of LDL-C control, after calculating it using three validated equations, in outpatients referred for arterial hypertension.

METHODS

A cross-sectional study on 1539 consecutive patients with valid ABPM. LDL-C was calculated using the Friedewald formula (F), its modification by Martin (M), and the Sampson (S) equation. SCORE and SCORE2/SCORE2-OP were estimated using OBP, mean daytime (+ 5 mmHg adjustment), and mean 24-hour systolic blood pressure (+ 10 mmHg adjustment). Individual CVR by 2021 ESC Guidelines (and SCORE2/SCORE2-OP) was compared to the 2019 ESC/EAS Guidelines (and SCORE). Differences in the prevalence of LDL-C control according to the three methods to calculate LDL-C were also analysed.

RESULTS

Mean age was 60 ± 12 years, with male prevalence (54%). Mean LDL-C values were 118 ± 38 mg/dL (F), 119 ± 37 mg/dL (M), and 120 ± 38 mg/dL (S), respectively. Within the same population, SCORE and SCORE2/SCORE2-OP significantly varied, but no differences emerged after comparing the average SCORE2/SCORE2-OP calculated with OBP (6% IQR 3-10), mean 24-hour systolic BP (7% IQR 4-11), and mean daytime systolic BP (7% IQR 4-11). SCORE2/SCORE2-OP and 2021 ESC Guidelines reclassified the CVR independently of the method used for BP measurement. The low-moderate risk group decreased by 32%, whereas the high and veryhighrisk groups increased by 18% and 12%, respectively. We found a significant reduction in reaching the LDL-C goals regardless of the equation used to calculate it, except for those > 65 years, in whom results were confirmed only by using the M.

CONCLUSION

SCORE2/SCORE2-OP and 2021 ESC Guidelines recommendations led to a non-negligible CVR reclassification and subsequent lack of LDL-C goal, regardless of estimating SCORE2 using OBP or ABPM. Calculating the LDL-C with the M may be the best choice in specific settings.

Implementation of Specialty Tobacco Use Disorder Services in a Community Health Setting: Support for Enhanced Prescription Practices

OBJECTIVES

Although public efforts to reduce tobacco use have been successful, millions of US adults currently smoke tobacco. Reducing the public health burden of tobacco use disorder (TUD) and eliminating disparities experienced by underresourced communities requires increased accessibility to services. The goal of this study was to assess whether prescriptions for evidence-based medications for tobacco treatment showed steeper growth rates among community health clinics providing specialty TUD services as compared with treatment as usual.

METHODS

Clinic-wide data on prescriptions for smoking cessation pharmacotherapy at 18 primary care or mental health community clinics operated by Los Angeles County were retrieved for 4 years of an ongoing implementation trial. Specialty services included behavioral counseling and medications for tobacco treatment. Descriptive statistics characterized prescriptions rates across clinics and time. Analyses compared the slopes of the changes between intervention groups across time for primary care and mental health sites.

RESULTS

Within primary care clinics, the most commonly prescribed smoking cessation medications were nicotine patches, nicotine gum, and varenicline. Throughout the trial, all clinics displayed increased rates of prescribing smoking cessation medications. Analytic results supported overall steeper increases in prescription rates for these medications among clinics randomized to specialty services versus treatment as usual within primary care ( P = 0.020) and mental health sites ( P = 0.004).

CONCLUSIONS

This work provides support for the effectiveness of community-based implementation interventions that promote prescribing smoking cessation medications with the potential to reduce health disparities among communities at greater risk for TUD and its consequences.

Pharmacists' Perceptions of Physician-Pharmacist Collaboration-A 2022 Cross-Sectional Survey in Poland

Patient-centered care requires close collaboration among multiple healthcare professionals, including physician-pharmacist collaboration (especially as a part of pharmaceutical care). This study aimed to assess pharmacists' perceptions of physician-pharmacist collaboration as well as to identify factors associated with the willingness to provide pharmaceutical care services in Poland. This questionnaire-based survey was carried out in 2022 among community pharmacists from one of the largest franchise chain pharmacy networks in Poland. Completed questionnaires were received from 635 community pharmacists (response rate of 47.9%). Almost all the pharmacists agreed with the statement that there is a need for physician-pharmacist collaboration (98.2%), and 94.8% declared that pharmacists can help physicians in patient care and pharmacotherapy. Most pharmacists (80%) believed that physicians were not aware of the competencies of pharmacists resulting from Polish law. Patient education (89.9%), detection of polypharmacy (88%), and detection of interactions between drugs and dietary supplements (85.7%) were the most common tasks in the field of pharmaceutical care that can be provided by a pharmacist. Females were more likely (p < 0.05) to declare the need for physician-pharmacist collaboration. Age and location of the pharmacy were the most important factors (p < 0.05) associated with pharmacists' attitudes toward physician-pharmacist collaboration.

Psychopharmacology of smoking cessation medications: focus on patients with mental health disorders

The adverse effects of smoking cessation in individuals with mental health disorders have been a point of concern, and progress in the development of treatment has been slow. The primary first-line treatments for smoking cessation are Nicotine Replacement Therapy, Bupropion, Varenicline, and behavioural support. Nortriptyline and Clonidine are second-line treatments used when the first-line treatments are not effective or are contraindicated. Smoking cessation medications have been shown to be effective in reducing nicotine cravings and withdrawal symptoms and promoting smoking cessation among patients living with mental disorders. However, these medications may have implications for patients' mental health and need to be monitored closely. The efficacy and side effects of these medications may vary depending on the patient's psychiatric condition, medication regimen, substance use, or medical comorbidities. The purpose of this review is to synthesise the pharmacokinetics, pharmacodynamics, therapeutic effects, adverse effects, and pharmacological interactions of first- and second-line smoking cessation drugs, with an emphasis on patients suffering from mental illnesses. Careful consideration of the risks and benefits of using smoking cessation medications is necessary, and treatment plans must be tailored to individual patients' needs. Monitoring symptoms and medication regimens is essential to ensure optimal treatment outcomes.

Bupropion Mediated Effects on Depression, Attention Deficit Hyperactivity Disorder, and Smoking Cessation

Bupropion had been in use since the late 1980s as an unconventional treatment for depression. Unlike other antidepressants, bupropion has no serotonergic activity and inhibits the reuptake of norepinephrine and dopamine. The drug has been used to treat depression, Attention Deficit Hyperactivity Disorder (ADHD), and smoking cessation. This investigation reviews the pharmacokinetic and pharmacodynamic effects of bupropion and its mechanisms of action and interactions with other drugs. We evaluated the efficacy of major on and off-label uses of bupropion, focusing on the indications, benefits, and adverse effects. Our review demonstrates that bupropion is superior to placebo and non-inferior to SSRIs such as escitalopram in treating major depressive disorder. More research is needed to determine positive patient-centered outcomes such as increases in quality of life. In the case of ADHD, the evidence for efficacy is mixed with poorly conducted randomized clinical trials, small sample sizes, and a lack of long-term assessments. The same is true in the case of bipolar disorder in which there is still limited and controversial data available on bupropion's safety and efficacy. In the case of smoking cessation, bupropion is found to be an effective anti-smoking drug with synergistic benefits when used as a combination therapy. We conclude that bupropion has the potential to provide benefit for a subset of patients who do not tolerate other typical antidepressants or anti-smoking therapies or for those whose treatment goals align with bupropion's unique side effect profile, such as smokers who wish to quit and lose weight. Additional research is needed to determine the drug's full clinical potential, particularly in the areas of adolescent depression and combination therapy with varenicline or dextromethorphan. Clinicians should use this review to understand the varied uses of the drug and identify the situations and patient populations in which bupropion can lend its greatest benefit.

Nursing students' attitudes, behaviour, and knowledge toward smoking cessation: Results from a descriptive survey at a regional university

BACKGROUND

Smoking is the largest single cause of lifestyle-related preventable morbidity and mortality. Nurses form the largest cohort of health professionals and are strategically placed to implement smoking cessation interventions. However their capacity is underutilised, particularly in rural and remote areas in countries such as Australia where the incidence of smoking in is higher than average and access to healthcare is limited. One strategy to address the underutilisation of nurses in smoking cessation interventions is to include training in the university/college nursing curriculum. To effectively implement this training, it is vital to have an in-depth knowledge of student nurses' attitudes towards smoking including the role of healthcare professionals in smoking cessation, their smoking behaviour and that of their peers, and knowledge regarding smoking cessation techniques and resources.

OBJECTIVES

Investigate nursing students' attitudes, behaviour, and knowledge towards smoking cessation, determine the impact of demographics and educational experienced on these, and develop recommendations for future research and educational practice.

DESIGN

Descriptive survey.

PARTICIPANTS

Non-probability sample of undergraduate nursing students (n = 247) from a regional Australian university.

RESULTS

Significantly more participants had tried smoking cigarettes than had not (p = 0.026). There were no significant relationships between gender and smoking (p = 0.169) or e-cigarette use (p = 0.200), but a significant relationship was found between age and smoking status where older participants (48-57 years) were more likely to smoke (p < 0.001). Most participants (70 %) were supportive of public health measures to reduce cigarette smoking but felt that they lacked specific knowledge to assist their patients to cease smoking.

CONCLUSIONS

Within education there needs to be an emphasis on the central role that nurses play in smoking cessation with a greater focus on training nursing students about smoking cessation strategies and resources. There is also a need to ensure that students know it falls within their duty of care to address smoking cessation with patients.

2023 Guidelines of the Taiwan Society of Cardiology on the Diagnosis and Management of Chronic Coronary Syndrome

Coronary artery disease (CAD) covers a wide spectrum from persons who are asymptomatic to those presenting with acute coronary syndromes (ACS) and sudden cardiac death. Coronary atherosclerotic disease is a chronic, progressive process that leads to atherosclerotic plaque development and progression within the epicardial coronary arteries. Being a dynamic process, CAD generally presents with a prolonged stable phase, which may then suddenly become unstable and lead to an acute coronary event. Thus, the concept of "stable CAD" may be misleading, as the risk for acute events continues to exist, despite the use of pharmacological therapies and revascularization. Many advances in coronary care have been made, and guidelines from other international societies have been updated. The 2023 guidelines of the Taiwan Society of Cardiology for CAD introduce a new concept that categorizes the disease entity according to its clinical presentation into acute or chronic coronary syndromes (ACS and CCS, respectively). Previously defined as stable CAD, CCS include a heterogeneous population with or without chest pain, with or without prior ACS, and with or without previous coronary revascularization procedures. As cardiologists, we now face the complexity of CAD, which involves not only the epicardial but also the microcirculatory domains of the coronary circulation and the myocardium. New findings about the development and progression of coronary atherosclerosis have changed the clinical landscape. After a nearly 50-year ischemia-centric paradigm of coronary stenosis, growing evidence indicates that coronary atherosclerosis and its features are both diagnostic and therapeutic targets beyond obstructive CAD. Taken together, these factors have shifted the clinicians' focus from the functional evaluation of coronary ischemia to the anatomic burden of disease. Research over the past decades has strengthened the case for prevention and optimal medical therapy as central interventions in patients with CCS. Even though functional capacity has clear prognostic implications, it does not include the evaluation of non-obstructive lesions, plaque burden or additional risk-modifying factors beyond epicardial coronary stenosis-driven ischemia. The recommended first-line diagnostic tests for CCS now include coronary computed tomographic angiography, an increasingly used anatomic imaging modality capable of detecting not only obstructive but also non-obstructive coronary plaques that may be missed with stress testing. This non-invasive anatomical modality improves risk assessment and potentially allows for the appropriate allocation of preventive therapies. Initial invasive strategies cannot improve mortality or the risk of myocardial infarction. Emphasis should be placed on optimizing the control of risk factors through preventive measures, and invasive strategies should be reserved for highly selected patients with refractory symptoms, high ischemic burden, high-risk anatomies, and hemodynamically significant lesions. These guidelines provide current evidence-based diagnosis and treatment recommendations. However, the guidelines are not mandatory, and members of the Task Force fully realize that the treatment of CCS should be individualized to address each patient's circumstances. Ultimately, the decision of healthcare professionals is most important in clinical practice.

Global trends in smoking cessation research from 2002 to 2021: A bibliometric and visual analysis

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Our study is the first bibliometric and visual analysis on smoking cessation research of the past two decades.

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Our study identifies productive countries/regions, institutions, authors, journals, and reveals a global network of collaborations of smoking cessation research.

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The Co-occurrence Analysis of Keywords shed lights on the research frontier, trends and hot topics on smoking cessation research.

This study aimed to analyze the scientific outputs of smoking cessation research and explore its hotspots and frontiers from 2002 to 2021, using bibliometric methods. We use the core collection of Web of Science as a data source, and apply bibliometric methods to visually analyze articles published in smoking cessation research from 2002 to 2021, including publication year, countries/regions, journals, authors, institutions, and keywords. The VOSviewer (1.6.16) tool was used for the analysis. A total of 8797 articles related to smoking cessation research were identified. The USA was the leading contributor with 4671 publications. NICOTINE＆TOBACCO RESEARCH contributed the most publications (528), with the most citations (13746) and the highest H-index (59). The most contributing institutions were the University College London and University of California San Francisco. Robert West was most productive author. We found active collaborations among both productive authors and productive institutions. There were five hot topics in smoking cessation research: (1) Public health harm from tobacco; (2) The role of e-health in smoking cessation; (3) Role of primary health care in eliminating tobacco dependence; (4) Nicotine replacement therapy and pharmacotherapy; (5) The biological and clinical understanding of addiction. Our current study showed a growing trend in smoking cessation based on the number of published articles over the last 20 years. There was active cooperation between institutions, and authors. Electronic cigarettes, mHealth, eHealth, public health and mental health are foci of new and emerging research.

Efficacy of Motivational Interviewing and Brief Interventions on tobacco use among healthy adults: A systematic review of randomized controlled trials

OBJECTIVES

To assess the effectiveness of a brief intervention and motivational interviewing in reducing the use of different tobacco-related products in adults.

METHODS

For this systematic review, PubMed, Web of Science, and PsychINFO databases were electronically searched for randomized controlled trialson the effect of a brief intervention and / or motivational interview on tobacco reduction among healthy adults published between January 1, 2011 to January 1, 2021. Data from eligible studies were extracted and analyzed. CONSORT guidelines were used to assess the quality of the studies by two reviewers for the included studies. The titles and abstracts of the search results were screened and reviewed by two independent reviewers for eligibility criteria per the inclusion and exclusion criteria. Cochrane review criteria were used to assess the risk of bias in included studies.

RESULTS

A total of 12 studies were included in the final data extraction of 1406 studies. The brief intervention and motivational interviewing showed varied effects on tobacco use reduction among adults at different follow-ups. Seven of the 12 studies (58.3%) reported a beneficial impact on reducing tobacco use. Pieces of evidence on biochemical estimation on tobacco reduction are limited compared to self-reports, and varied results on quitting and tobacco cessation with different follow-ups.

CONCLUSIONS

The current evidence supports the effectiveness of a brief intervention and motivational interviewing to quit tobacco use. Still, it suggests using more biochemical markers as outcome measures to reach an intervention-specific decision. While more initiatives to train nurses in providing non-pharmacological nursing interventions, including brief interventions, are recommended to help people quit smoking.

Addiction and COVID: Issues, Challenges, and New Telehealth Approaches

In recent decades, the United States has seen a substantial increase in the number of people diagnosed with substance use disorder (SUD). Both SUDs and COVID-19 separately have had, and continue to have, a widespread impact on our society. While they are two distinct entities, they are intricately related and have been shown to influence one another. Lockdown mandates intended to enhance public safety produced unintended consequences for people with SUDs by decreasing access to treatment and disrupting their current care. Telehealth could offer a solution to this disruption as its utilization expands the provider’s reach and increases access to treatment in underserved populations, including those with SUDs. The use of telemedicine seems to result in higher rates of patient satisfaction, compliance, and treatment retention rates while maintaining the need for social distancing. Even when pandemic restrictions resolve, telehealth can continue to provide invaluable benefits to individuals with addiction, particularly those in rural America. In summary, ongoing research regarding telehealth delivery and the expansion of telehealth is a byproduct of the pandemic and can advance the American healthcare system beyond the days of COVID-19. This manuscript will review studies regarding the use of telehealth in SUD with the hope that further research within and beyond the COVID-19 pandemic will lead to the increased use of telehealth by those involved in and those receiving care for SUDs.

Tobacco Smoking and Liver Cancer Risk: Potential Avenues for Carcinogenesis

Smoking a cigarette generates over 4000 chemicals that have a deleterious impact on each part of the human body. It produces three main severe effects on the liver organ: oncogenic, immunological, and indirect or direct toxic effects. It results in the production of cytotoxic substances, which raises fibrosis and necro-inflammation. Additionally, it also directs the production of pro-inflammatory cytokines tumour necrosis factor alfa (TNF-α) and interleukins (IL-1β, IL-6) that will be responsible for the chronic liver injury. Furthermore, it gives rise to secondary polycythemia and successively raises the turnover and mass of red cells, which might be a common factor responsible for the development of oxidative stress in the liver due to iron overload. It also produces chemicals that are having oncogenic properties and raises the risk of liver cancer especially in sufferers of chronic hepatitis C. Smoking modulates both humoral and cell-mediated responses by restricting the proliferation of lymphocytes and inducing their apoptosis and ultimately decreasing the surveillance of cancer cells. Moreover, it has been determined that heavy smoking impacts the response of hepatitis C patients to interferon (IFN) therapy through different mechanisms, which can be improved by phlebotomy. Efforts are being made in different nations in decreasing the prevalence of smoking to improve premature death and ill effects of their nation's individuals.

New Insights in the Involvement of the Endocannabinoid System and Natural Cannabinoids in Nicotine Dependence

Nicotine, the main psychoactive component in tobacco smoke, plays a major role in tobacco addiction, producing a high morbidity and mortality in the world. A great amount of research has been developed to elucidate the neural pathways and neurotransmitter systems involved in such a complex addictive behavior. The endocannabinoid system, which has been reported to participate in the addictive properties of most of the prototypical drugs of abuse, is also implicated in nicotine dependence. This review summarizes and updates the main behavioral and biochemical data involving the endocannabinoid system in the rewarding properties of nicotine as well as in nicotine withdrawal and relapse to nicotine-seeking behavior. Promising results from preclinical studies suggest that manipulation of the endocannabinoid system could be a potential therapeutic strategy for treating nicotine addiction.

The Number of Pills, Rather Than the Type of Renin-Angiotensin System Inhibitor, Predicts Ambulatory Blood Pressure Control in Essential Hypertensives on Triple Therapy: A Real-Life Cross-Sectional Study

Introduction

We evaluated the prevalence and predictors of ambulatory blood pressure (BP) control in patients taking a triple antihypertensive therapy (renin–angiotensin system inhibitor + calcium channel blocker + thiazide/thiazide-like diuretic, in either free or fixed-dose combinations) containing an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB).

Methods

We performed an observational cross-sectional study on 520 consecutive patients with essential hypertension taking a stable triple therapy in whom 24-h ambulatory BP was evaluated. Both number of pills and antihypertensive treatment intensity (ATI), as possible pharmacological predictors of ambulatory BP control, were taken into account.

Results

A total of 189 (36.3%) patients were taking triple therapy with ACEi and 331 (63.7%) patients were taking triple therapy with ARB. Mean age was 62.7 ± 12.2 years. Patients on triple therapy with ACEi had a significantly lower ATI and took fewer antihypertensive pills than patients on triple therapy with ARB (22.2% of patients took a single-pill triple fixed-dose combination). Patients taking triple therapy with ACEi had higher prevalence of both 24-h (54.8% vs 44.0%; p = 0.019) and daytime BP control (61.8% vs 49.2%; p = 0.006) than patients taking triple therapy with ARB, even after adjusting for age, sex, body mass index, smoking habit, type 2 diabetes mellitus, estimated glomerular filtration rate, and ATI [OR 1.5 (95% CI 1.1–2.2) and OR 1.6 (95% CI 1.1–2.4), respectively]. However, these independent associations with ambulatory BP control were lost when the number of antihypertensive pills was included in the model.

Conclusion

The higher prevalence of ambulatory BP control found in patients taking a triple therapy with ACEi was affected by the lower number of antihypertensive pills taken, which was also the key predictor of ambulatory BP control in our study. This confirms the importance of fixed-dose combinations in the management of essential hypertension.

When primary care providers and smokers meet: a systematic review and metasynthesis

Primary Care Providers (PCPs) often deal with patients on daily clinical practice without knowing anything about their smoking status and willingness to quit. The aim of this metasynthesis is to explore the PCPs and patients who are smokers perspectives regarding the issue of smoking cessation within primary care settings. It relies on the model of meta-ethnography and follows thematic synthesis procedures. Twenty-two studies are included, reporting on the view of 580 participants. Three main themes emerge: (i) What lacks, (ii) Some expectations but no request, and (iii) How to address the issue and induce patients' motivation. Our results reveal a global feeling of a lack of legitimacy among PCPs when it comes to addressing the issue of tobacco and smoking cessation with their patients, even though they have developed creative strategies based on what is at the core of their practice, that is proximity, continuity, long-term and trustworthy relationship.

Comparative efficacy and safety of pharmacological interventions for smoking cessation in healthy adults: A network meta-analysis

Smoking is the leading cause of morbidity and mortality in different non-communicable diseases, and cessation leads to immense health benefits. The present network meta-analysis has been conducted to evaluate and compare the effects of available pharmacological interventions for smoking cessation in adults. A standard meta-analysis protocol was developed and after performing a comprehensive literature search on MEDLINE/PubMed, Cochrane databases, and International Clinical Trials Registry Platform, reviewers extracted data from 97 randomized controlled trials. PRISMA guidelines were followed in data extraction, analysis and reporting of findings. Random effects Bayesian network meta-analysis was done to pool the effects across the interventions. Network graph was built, and for closed triangles in the network graph, node splitting analysis was performed. The primary outcome measure was self-reported biochemically verified smoking abstinence at six months. The number of participants achieving continuous abstinence was reported. Data for the number of participants reporting at least one adverse event was also extracted, if available. Combination of nicotine receptor agonist and nicotine replacement therapy had a significant odd of 4.4 (95%CrI:2.2-8.7), bupropion and nicotine receptor agonist 4.0 (95%CrI:2.1-7.7), bupropion and nicotine replacement therapy 3.8 (95%CrI:2.3-6.2), combination nicotine replacement therapy has an odd of 2.6 (95%CrI:1.8-3.8), and nicotine receptor agonist had a significant odd of 2.7 (95%CrI:2.3-3.2) when compared to placebo (moderate quality of evidence) for continuous abstinence at 6 months. When compared with behavioural therapy, the odds ratio of interventions was not statistically significant. Combination of nicotine receptor agonist and nicotine replacement therapy has the highest probability of being the best treatment for abstinence from smoking.

Ten things to know about ten cardiovascular disease risk factors

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The “American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update” is a summary document (updated yearly) regarding CVD risk factors. This “ASPC Top Ten CVD Risk Factors 2021 Update” summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the “ASPC Top Ten CVD Risk Factors 2021 Update” to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

The smoking-dyslipidaemia dyad: A potent synergistic risk for atherosclerotic coronary artery disease

BACKGROUND

Smoking and dyslipidaemia are known individual risk factors of coronary artery disease (CAD). The present study examined the combined risk of smoking and dyslipidaemia on coronary atherosclerosis.

METHODS

Coronary artery calcium (CAC), measured by cardiac CT, was used to assess the extent of CAD, which was related to smoking and dyslipidaemia using logistic regression, adjusted for age, sex, hypertension, BMI and family history of ischaemic heart disease.

RESULTS

Seventy-one patients (46 men, 25 women: median age of 53.7yrs; IQR = 47.0-59.5) were recruited. The mean log10 CAC score in never-smokers without dyslipidaemia (reference group) was 0.37 (SD = 0.73), while the value in those with a history of smoking was 0.44 ± 0.48 (mean difference: 0.07, 95%CI:-0.67 to 0.81, p = 0.844), dyslipidaemia was 1.07 ± 1.08 (mean difference: 0.71, 95%CI: 0.24 to 1.17, p = 0.003), and both risk factors was 1.82 ± 0.64 (mean difference: 1.45, 95%CI:0.88 to 2.02, p < 0.001). For individuals in the reference group, the proportions with none, one and multiple vessel disease were 80.6%, 16.1% and 3.2%; for those with a history of smoking or with dyslipidaemia were 50.0%, 25.0% and 25.0%; and for those with both risk factors were 8.3%, 25.0% and 66.7%. Patients with a history of both risk factors had greater adjusted risks of having one- vessel disease - OR = 14.3 (95%CI = 2.1-98.2) or multiple vessel disease: OR = 51.8 (95%CI = 4.2-609.6).

CONCLUSIONS

Smoking and dyslipidaemia together are associated with high coronary artery calcification and CAD, independent of other major risk factors.

Pharmacological strategies for smoking cessation in patients with chronic obstructive pulmonary disease: a pragmatic review

Introduction: Chronic obstructive pulmonary disease (COPD) is progressive inflammatory disease of the lungs in which smoking plays a significant pathogenic role. Smoking cessation is the only therapeutic intervention which was demonstrated to interfere with disease progression. Smoking cessation intervention can benefit from pharmacological therapies such as nicotine replacement therapies, bupropion, or varenicline which can be given individually or in combination, their effectiveness being demonstrated in various clinical trials enrolling COPD patients.Areas covered: The authors provide a pragmatic discussion of the clinical data of the main studies evaluating therapies for smoking cessation within COPD starting with the seminal Lung Health Study and continuing with more recent ones.Expert opinion: Smoking cessation is one of the most difficult therapeutic interventions in COPD, despite having the highest impact on disease progression and despite the demonstrated benefit of the discussed pharmacological therapies. Potential approaches to maximize its chance of success might be represented by prolonging the time of administration, combinational options, or sequential pharmacotherapy.

Dopamine D3 Receptor Heteromerization: Implications for Neuroplasticity and Neuroprotection

The dopamine (DA) D3 receptor (D3R) plays a pivotal role in the control of several functions, including motor activity, rewarding and motivating behavior and several aspects of cognitive functions. Recently, it has been reported that the D3R is also involved in the regulation of neuronal development, in promoting structural plasticity and in triggering key intracellular events with neuroprotective potential. A new role for D3R-dependent neurotransmission has thus been proposed both in preserving DA neuron homeostasis in physiological conditions and in preventing pathological alterations that may lead to neurodegeneration. Interestingly, there is evidence that nicotinic acetylcholine receptors (nAChR) located on DA neurons also provide neurotrophic support to DA neurons, an effect requiring functional D3R and suggesting the existence of a positive cross-talk between these receptor systems. Increasing evidence suggests that, as with the majority of G protein-coupled receptors (GPCR), the D3R directly interacts with other receptors to form new receptor heteromers with unique functional and pharmacological properties. Among them, we recently identified a receptor heteromer containing the nAChR and the D3R as the molecular effector of nicotine-mediated neurotrophic effects. This review summarizes the functional and pharmacological characteristics of D3R, including the capability to form active heteromers as pharmacological targets for specific neurodegenerative disorders. In particular, the molecular and functional features of the D3R-nAChR heteromer will be especially discussed since it may represent a possible key etiologic effector for DA-related pathologies, such as Parkinson’s disease (PD), and a target for drug design.