Dose-related cardiovascular and endocrine effects of transdermal nicotine

Obstructive Sleep Apnea and Smoking Increase the Risk of Cardiovascular Disease: Smoking Cessation Pharmacotherapy

Tobacco smoking has been a recognized risk factor for cardiovascular diseases (CVD). Smoking is a chronic relapsing disease and pharmacotherapy is a main component of smoking cessation. Obstructive sleep apnea (OSA) and smoking both increase the risk of CVD and are associated with significant morbidity and mortality. There are few existing data examining how pharmacological treatment, such as nicotine replacement therapy (NRT), bupropion, and varenicline, affect smokers suffering with OSA and especially their cardiovascular effects. The aim of this review was to evaluate the effects of smoking cessation pharmacotherapy on OSA with a special emphasis on the cardiovascular system. Results: Only small studies have assessed the effect of NRTs on OSA. Nicotine gum administration showed an improvement in respiratory events but with no permanent results. No specific studies were found on the effect of bupropion on OSA, and a limited number evaluated varenicline's effects on sleep and specifically OSA. Varenicline administration in smokers suffering from OSA reduced the obstructive respiratory events, especially during REM. Studies on second-line medication (nortriptyline, clonidine, cytisine) are even more limited. There are still no studies evaluating the cardiovascular effects of smoking cessation medications on OSA patients. Conclusions: Sleep disturbances are common withdrawal effects during smoking cessation but could be also attributed to pharmacotherapy. Smokers should receive personalized treatment during their quitting attempts according to their individual needs and problems, including OSA. Future studies are needed in order to evaluate the efficacy and safety of smoking cessation medications in OSA patients.

Role of aldosterone and mineralocorticoid receptor (MR) in addiction: A scoping review

Preclinical and human studies suggest a role of aldosterone and mineralocorticoid receptor (MR) in addiction. This scoping review aimed to summarize (1) the relationship between alcohol and other substance use disorders (ASUDs) and dysfunctions of the aldosterone and MR, and (2) how pharmacological manipulations of MR may affect ASUD-related outcomes. Our search in four databases (MEDLINE, Embase, Web of Science, and Cochrane Library) indicated that most studies focused on the relationship between aldosterone, MR, and alcohol (n = 30), with the rest focused on opioids (n = 5), nicotine (n = 9), and other addictive substances (n = 9). Despite some inconsistencies, the overall results suggest peripheral and central dysregulations of aldosterone and MR in several species and that these dysregulations depended on the pattern of drug exposure and genetic factors. We conclude that MR antagonism may be a promising target in ASUD, yet future studies are warranted.

Twenty-Four-Hour Cardiovascular Effects of Electronic Cigarettes Compared With Cigarette Smoking in Dual Users

Background

Cardiovascular safety is an important consideration regarding the benefits versus risks of electronic cigarette use (EC) for public health. The single‐use cardiovascular effects of EC have been well studied but may not reflect effects of ad libitum use throughout the day. We aimed to compare the circadian hemodynamic effects as well as 24‐hour biomarkers of oxidative stress, and platelet aggregation and inflammation, with ad libitum cigarette smoking (CS) versus EC versus no tobacco product use.

Methods and Results

Thirty‐six healthy dual CS and EC users participated in a crossover study in a confined research setting. Circadian heart rate, blood pressure and plasma nicotine levels, 24‐hour urinary catecholamines, 8‐isoprostane and 11‐dehydro‐thromboxane B2, and plasma interleukin‐6 and interleukin‐8 were compared in CS, EC, and no nicotine conditions. Over 24 hours, and during daytime, heart rate and blood pressure were higher in CS and EC compared with no tobacco product conditions (P<0.01). Heart rate on average was higher with CS versus EC. Urinary catecholamines, 8‐isoprostane, and 11‐dehydro‐thromboxane B2 were not significantly different, but plasma IL‐6 and IL‐8 were higher with both CS and EC compared with no tobacco product (P<0.01).

Conclusions

CS and EC had similar 24‐hour patterns of hemodynamic effects compared with no tobacco product, with a higher average heart rate with CS versus EC, and similar effects on biomarkers of inflammation. EC may pose some cardiovascular risk, particularly to smokers with underlying cardiovascular disease, but may also provide a harm reduction opportunity for smokers willing to switch entirely to EC.

Registration

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02470754.

The effect of long term nicotine exposure on endothelial function in rats

Nicotine is one of the main chemicals in the cigarettes responsible for addiction formation. Many researches investigating the effects of nicotine on coronary heart disease and atherosclerosis have been published. The robustness of endothelial cells is very important in the development of atherosclerosis. The aim of this study is to evaluate the effect of nicotine exposure on the indicators of endothelial function either by examining the vascular reactivity of aorta taken from rats exposed to nicotine during prenatal (starting by the mating period) and postnatal periods (6 weeks after delivery), or by determining the protein expression of nitric oxide synthase (NOS) enzymes, NADPH oxidase (Nox) and nitrotyrosine. Chronic nicotine exposure at 6 mg/L in drinking water produced a significant decrease in phenylephrine contractility of thoracic aortic rings compared to control and low dose exposure group (0.4 mg/L, p < 0.001). Endothelium-dependent relaxations to acetylcholine increased dose-dependently while no changes were observed in endothelium-independent relaxations to sodium nitroprusside and protein expressions in rat thoracic aorta. It has been concluded that long term nicotine exposure does not have serious effects on endothelial vasodilator response directly and does not change protein expression of NOS or Nox enzymes. However, more studies should be done for the exact mechanisms responsible for the effect of nicotine on endothelial function.

Cancer potencies and margin of exposure used for comparative risk assessment of heated tobacco products and electronic cigarettes aerosols with cigarette smoke

Health risk associated with the use of combustible cigarettes is well characterized and numerous epidemiological studies have been published for many years. Since more than a decade, innovative non-combusted tobacco products have emerged like heated tobacco products (HTP) or electronic cigarettes (EC). Long-term effects of these new products on health remain, however, unknown and there is a need to characterize associated potential health risks. The time dedicated to epidemiological data generation (at least 20 to 40 years for cancer endpoint), though, is not compatible with innovative development. Surrogates need, therefore, to be developed. In this work, non-cancer and cancer risks were estimated in a range of HTP and commercial combustible cigarettes based upon their harmful and potentially harmful constituent yields in aerosols and smoke, respectively. It appears that mean lifetime cancer risk values were decreased by more than one order of magnitude when comparing HTPs and commercial cigarettes, and significantly higher margin of exposure for non-cancer risk was observed for HTPs when compared to commercial cigarettes. The same approach was applied to two commercial ECs. Similar results were also found for this category of products. Despite uncertainties related to the factors used for the calculations and methodological limitations, this approach is valuable to estimate health risks associated to the use of innovative products. Moreover, it acts as predictive tool in absence of long-term epidemiological data. Furthermore, both cancer and non-cancer risks estimated for HTPs and ECs highlight the potential of reduced risk for non-combusted products when compared to cigarette smoking.

Nicotine Gum as a Therapeutic Approach for Low Blood Pressure in Parkinson's Disease: A Randomized Pilot Study

Introduction

One cause for low blood pressure (BP) in Parkinson's disease (PD) is denervation of the sympathetic nervous system and reduced levels of norepinephrine. Nicotine increases heart rate and BP acutely by causing sympathetic stimulation. The absorption rate of nicotine gum is relatively quick and absorbed at a constant rate. Our objective was to evaluate how nicotine gum affects acute low BP in PD.

Methods

Ten subjects (age 69.3 ± 8.8) completed this double blind, placebo controlled, cross-over design trial using nicotine gum (4 mg) and placebo gum on two separate days. The gum was administered for 30 min. BP was recorded every 10 min for 90 min.

Results

On the nicotine gum treatment day, the baseline systolic BP was 94.8 (standard deviation [SD] = 4.4), and it increased in a parabolic pattern to be 115.8 (SD = 11.2) in 20 min, 124.2 (SD = 9.3) in 40 min, and 133.2 (SD = 13.1) in 60 min reaching the highest value, and then decreased to be 121.6 (SD = 10.4) in 90 min. On the placebo day, the baseline systolic BP 95.2 (SD = 3.0) didn't show an outstanding change with the mean systolic BP values from 93.0 to 95.7 (SD from 2.1 to 3.7) at all time points.

Conclusions

Our data suggests that 4 mg of nicotine gum can increase systolic BP within 10 min of administration. It is strongly warranted that further research should pursue the use of nicotine gum as an intervention to treat acute episodes of low BP in individuals with PD.

Implications

More than 50% of Parkinson's disease (PD) patients have low blood pressure (BP) that fluctuates throughout the day and decreases quality of life. This study found an increase in systolic blood pressure within 10 min of administering nicotine gum to Parkinson's subjects with low BP. Their BP remained elevated for 90 min. Nicotine gum gets absorbed rapidly and may act as a therapeutic novel approach to individuals whose daily lives are interrupted with low BP.

Biomarkers of Potential Harm: Summary of an FDA-Sponsored Public Workshop

Introduction

Since 2009, the United States (US) Food and Drug Administration (FDA) Center for Tobacco Products (CTP) has had the authority to regulate the manufacture, distribution, and marketing of tobacco products in order to reduce the death and disease caused by tobacco use. Biomarkers could play an important role across a number of FDA regulatory activities, including assessing new and modified risk tobacco products and identifying and evaluating potential product standards.

Methods

On April 4-5, 2016, FDA/CTP hosted a public workshop focused on biomarkers of potential harm (BOPH) with participants from government, industry, academia, and other organizations. The workshop was divided into five sessions focused on: (1) overview of BOPH; (2) cardiovascular disease (CVD); (3) chronic obstructive pulmonary disease (COPD); (4) cancer; and (5) new areas of research.

Results and Conclusions

The deliberations from the workshop noted some promising BOPH but also highlighted the lack of systematic effort to identify BOPH that would have utility and validity for evaluating tobacco products. Research areas that could further strengthen the applicability of BOPH to tobacco regulatory science include the exploration of composite biomarkers as predictors of disease risk, "omics" biomarkers, and examining biomarkers using existing cohorts, surveys, and experimental studies.

Implications

This paper synthesizes the main findings from the 2016 FDA-sponsored workshop focused on BOPH and highlights research areas that could further strengthen the science around BOPH and their applicability to tobacco regulatory science.

Biological effects of nicotine exposure: A narrative review of the scientific literature

The emergence of new tobacco heating products and electronic nicotine delivery systems (ENDS) is changing the way humans are exposed to nicotine. The purpose of this narrative review is to provide a broad overview of published scientific literature with respect to the effects of nicotine on three key health-related areas: 1) cardiovascular risk, 2) carcinogenesis and 3) reproductive outcomes. These areas are known to be particularly vulnerable to the effects of cigarette smoke, and in addition, nicotine has been hypothesized to play a role in disease pathogenesis. Acute toxicity will also be discussed. The literature to February 2019 suggests that there is no increased cardiovascular risk of nicotine exposure in consumers who have no underlying cardiovascular pathology. There is scientific consensus that nicotine is not a direct or complete carcinogen, however, it remains to be established whether it plays some role in human cancer propagation and metastasis. These cancer progression pathways have been proposed in models in vitro and in transgenic rodent lines in vivo but have not been demonstrated in cases of human cancer. Further studies are needed to determine whether nicotine is linked to decreased fertility in humans. The results from animal studies indicate that nicotine has the potential to act across many mechanisms during fetal development. More studies are needed to address questions regarding nicotine exposure in humans, and this may lead to additional guidance concerning new ENDS entering the market.

Cardiovascular, carcinogenic and reproductive effects of nicotine exposure: A narrative review of the scientific literature

The emergence of new tobacco heating products and electronic nicotine delivery systems (ENDS) is changing the way humans are exposed to nicotine. The purpose of this narrative review is to provide a broad overview of published scientific literature with respect to the effects of nicotine on three key health-related areas: 1) cardiovascular risk, 2) carcinogenesis and 3) reproductive outcomes. These areas are known to be particularly vulnerable to the effects of cigarette smoke, and in addition, nicotine has been hypothesized to play a role in disease pathogenesis. Acute toxicity will also be discussed. The literature to February 2019 suggests that there is no increased cardiovascular risk of nicotine exposure in consumers who have no underlying cardiovascular pathology. There is scientific consensus that nicotine is not a direct or complete carcinogen, however, it remains to be established whether it plays some role in human cancer propagation and metastasis. These cancer progression pathways have been proposed in models in vitro and in transgenic rodent lines in vivo but have not been demonstrated in cases of human cancer. Further studies are needed to determine whether nicotine is linked to decreased fertility in humans. The results from animal studies indicate that nicotine has the potential to act across many mechanisms during fetal development. More studies are needed to address questions regarding nicotine exposure in humans, and this may lead to additional guidance concerning new ENDS entering the market.

Effects on abstinence of nicotine patch treatment before quitting smoking: parallel, two arm, pragmatic randomised trial

OBJECTIVE

To examine the effectiveness of a nicotine patch worn for four weeks before a quit attempt.

DESIGN

Randomised controlled open label trial.

SETTING

Primary care and smoking cessation clinics in England, 2012-15.

PARTICIPANTS

1792 adults who were daily smokers with tobacco dependence. 899 were allocated to the preloading arm and 893 to the control arm.

INTERVENTIONS

Participants were randomised 1:1, using concealed randomly permuted blocks stratified by centre, to either standard smoking cessation pharmacotherapy and behavioural support or the same treatment supplemented by four weeks of 21 mg nicotine patch use before quitting: "preloading."

MAIN OUTCOME MEASURES

The primary outcome was biochemically confirmed prolonged abstinence at six months. Secondary outcomes were prolonged abstinence at four weeks and 12 months.

RESULTS

Biochemically validated abstinence at six months was achieved by 157/899 (17.5%) participants in the preloading arm and 129/893 (14.4%) in the control arm: difference 3.0% (95% confidence interval -0.4% to 6.4%), odds ratio 1.25 (95% confidence interval 0.97 to 1.62), P=0.08 in the primary analysis. There was an imbalance between arms in the frequency of varenicline use as post-cessation treatment, and planned adjustment for this gave an odds ratio for the effect of preloading of 1.34 (95% confidence interval 1.03 to 1.73), P=0.03: difference 3.8% (0.4% to 7.2%). At four weeks, the difference in prolonged abstinence unadjusted for varenicline use was odds ratio 1.21 (1.00 to 1.48), difference 4.3% (0.0% to 8.7%), P=0.05, and adjusted for varenicline use was 1.32 (1.08 to 1.62) P=0.007. At 12 months the odds ratio was 1.28 (0.97 to 1.69), difference 2.7% (-0.4% to 5.8%), P=0.09 unadjusted for varenicline use and after adjustment was 1.36 (1.02 to 1.80) P=0.04. 5.9% of participants discontinued preloading owing to intolerance. Gastrointestinal symptoms-chiefly nausea-occurred in 4.0% (2.2% to 5.9%) more people in the preloading arm than control arm. Eight serious adverse events occurred in the preloading arm and eight in the control arm (odds ratio 0.99, 0.36 to 2.75).

CONCLUSIONS

Evidence was insufficient to confidently show that nicotine preloading increases subsequent smoking abstinence. The beneficial effect seems to have been masked by a concurrent reduction in the use of varenicline in people using nicotine preloading, and future studies should explore ways to mitigate this unintended effect.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33031001.

Influence of smoking cessation drugs on blood pressure and heart rate in patients with cardiovascular disease or high risk score: real life setting

Background

Smoking is the most important reversible cardiovascular risk factor. It is well established that quitting smoking reduces coronary events. However, on several occasions, the cardiovascular safety of smoking cessation drugs has been questioned. Our goal is to evaluate the effects of smoking cessation drugs on blood pressure and heart rate in patients from a smoking cessation service in a cardiology hospital.

Methods

We examined the PAF database (Smoking Cessation Assistance Program database) between January 2008 and March 2014. We analyzed data from 900 patients who were compliant with the treatment (50.5 % male, average age 53 ± 17 years). The most frequent clinical diagnoses were coronary artery disease (25.2 %), hypertension (57.2 %), and diabetes (13.4 %). Blood pressure, heart rate, and carbon monoxide (CO) concentration in exhaled air were analyzed at consecutive visits during the first 45 days of treatment (mean visits - 3). Analysis of repeated measures was used for the statistical analysis (p < 0.05).

Results

Two hundred seventy one patients used nicotine replacement therapy (NRT) alone, 81 used bupropion alone, 154 used varenicline alone, 283 used NRT plus bupropion and 111 used bupropion plus varenicline. For all smoking cessation drugs, used alone or in combination, no increase occurred in the average value of systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR). Significant reductions in CO concentrations occurred in all smoking cessation drug groups.

Conclusion

Smoking cessation drugs used in monotherapy or in combined regimens did not influence systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) in this group of patients during the observation period.

Does reduced smoking if you can't stop make any difference?

BACKGROUND

Promoting and supporting smoking reduction in smokers with no immediate intention of stopping smoking is controversial given existing fears that this will deter cessation and that reduction itself may not improve health outcomes.

DISCUSSION

Evidence shows that smokers who reduce the number of daily cigarettes smoked are more likely to attempt and actually achieve smoking cessation. Further, clinical trials have shown that nicotine replacement therapy benefits both reduction and cessation. Worldwide data suggests that 'non-medical' nicotine is more attractive to people who smoke, with electronic cigarettes now being widely used. Nevertheless, only one small trial has examined the use of electronic cigarettes to promote reduction, with direct evidence remaining inconclusive. It has been suggested that long-term reduced smoking may directly benefit health, although the benefits are small compared with cessation.

SUMMARY

The combined data imply that smoking reduction is a promising intervention, particularly when supported by clean nicotine; however, the benefits are only observed when it leads to permanent cessation.

Effects of using electronic cigarettes on nicotine delivery and cardiovascular function in comparison with regular cigarettes

The development of electronic cigarettes (e-cigs) has the potential to offer a less harmful alternative for tobacco users. This clinical study was designed to characterize e-cig users' exposure to nicotine, and to investigate the acute effects of e-cigs on the hemodynamic measurements (blood pressure and heart rate) in comparison with the effects of regular smoking. Five e-cigs and one Marlboro® cigarette were randomized for twenty-three participants under two exposure scenarios from Day 1 to Day 11: half-hour controlled administration and one hour ad lib use. The nicotine plasma concentrations after 1.5h of product use (C90) were significantly lower in the users of e-cigs than of Marlboro® cigarettes. The combination of glycerin and propylene glycol as the vehicle facilitated delivery of more nicotine than glycerin alone. The heart rate, systolic and diastolic blood pressure were significantly elevated after use of Marlboro® cigarettes, but the elevation was less after use of most of the e-cigs. Use of e-cigs had no impact on the exhaled CO levels, whereas the Marlboro® cigarette significantly increased the exhaled CO more than 8 times above the baseline. In conclusion, e-cigs could be a less harmful alternative for tobacco users.

Cardiovascular adverse events associated with smoking-cessation pharmacotherapies

Smoking continues to be the leading cause of preventable deaths in the USA, accounting for one in every five deaths every year, and cardiovascular (CV) disease remains the leading cause of those deaths. Hence, there is increasing awareness to quit smoking among the public and counseling plays an important role in smoking cessation. There are different pharmacological methods to help quit smoking that includes nicotine replacement products available over the counter, including patch, gum, and lozenges, to prescription medications, such as bupropion and varenicline. There have been reports of both nonserious and serious adverse CV events associated with the use of these different pharmacological methods, especially varenicline, which has been gaining media attention recently. Therefore, we systematically reviewed the various pharmacotherapies used in smoking cessation and analyzed the evidence behind these CV events reported with these therapeutic agents.

Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review

Electronic cigarettes are a recent development in tobacco harm reduction. They are marketed as less harmful alternatives to smoking. Awareness and use of these devices has grown exponentially in recent years, with millions of people currently using them. This systematic review appraises existing laboratory and clinical research on the potential risks from electronic cigarette use, compared with the well-established devastating effects of smoking tobacco cigarettes. Currently available evidence indicates that electronic cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to electronic cigarettes. Research will help make electronic cigarettes more effective as smoking substitutes and will better define and further reduce residual risks from use to as low as possible, by establishing appropriate quality control and standards.

Cardiovascular events associated with smoking cessation pharmacotherapies: a network meta-analysis

BACKGROUND

Stopping smoking is associated with many important improvements in health and quality of life. The use of cessation medications is recommended to increase the likelihood of quitting. However, there is historical and renewed concern that smoking cessation therapies may increase the risk of cardiovascular disease events associated within the quitting period. We aimed to examine whether the 3 licensed smoking cessation therapies-nicotine replacement therapy, bupropion, and varenicline-were associated with an increased risk of cardiovascular disease events using a network meta-analysis.

METHODS AND RESULTS

We searched 10 electronic databases, were in communication with authors of published randomized, clinical trials (RCTs), and accessed internal US Food and Drug Administration reports. We included any RCT of the 3 treatments that reported cardiovascular disease outcomes. Among 63 eligible RCTs involving 21 nicotine replacement therapy RCTs, 28 bupropion RCTs, and 18 varenicline RCTs, we found no increase in the risk of all cardiovascular disease events with bupropion (relative risk [RR], 0.98; 95% confidence interval [CI], 0.54-1.73) or varenicline (RR, 1.30; 95% CI, 0.79-2.23). There was an elevated risk associated with nicotine replacement therapy that was driven predominantly by less serious events (RR, 2.29; 95% CI, 1.39-3.82). When we examined major adverse cardiovascular events, we found a protective effect with bupropion (RR, 0.45; 95% CI, 0.21-0.85) and no clear evidence of harm with varenicline (RR, 1.34; 95% CI, 0.66-2.66) or nicotine replacement therapy (RR, 1.95; 95% CI, 0.26-4.30).

CONCLUSION

Smoking cessation therapies do not appear to raise the risk of serious cardiovascular disease events.

Cardiovascular effects of pharmacologic therapies for smoking cessation

Tobacco dependence is a potent risk factor for cardiovascular (CV) diseases and, despite known harms of smoking and benefits associated with smoking cessation, approximately 20% of the adult population with CV diseases or hypertension continue to smoke. Extensive research has demonstrated that nicotine replacement, varenicline, and bupropion sustained-release are superior to placebo for short- and intermediate-term smoking cessation. Because of their mechanisms of action, some smoking cessation therapies have been thought to have the potential to increase CV risk, particularly if the pharmacotherapies are taken while individuals are still smoking. Hence, we have analytically reviewed the literature describing the CV effects of therapies for smoking cessation, particularly as they apply to patients with CV disease.

Risk of methylphenidate-induced prehypertension in normotensive adult smokers with attention deficit hyperactivity disorder

The authors studied predictors of methylphenidate-induced increases in blood pressure (BP). In this secondary analysis of a randomized, double-blind, placebo-controlled smoking cessation trial, nonhypertensive adult smokers with attention deficit hyperactivity disorder randomized to osmotic-release oral system methylphenidate (OROS-MPH) (n=115) were matched one-to-one on baseline systolic BP (SBP) (±5 mm Hg) with participants randomized to placebo (n=115) and followed for 10 weeks. In adjusted mixed linear models of SBP and diastolic BP (DBP), baseline normal SBP (P<.0001) and DBP (P<.0001) were associated with significant OROS-MPH-induced increases compared with placebo, whereas significant increases were not observed in participants with baseline prehypertensive SBP (P=.27) and DBP (P=.79). Participants randomized to OROS-MPH with baseline normal BP had increased odds of developing either systolic (odds ratio [OR], 3.32; 95% confidence interval [CI], 1.41-8.37; P=.006) or diastolic prehypertension (OR, 4.32; 95% CI, 1.56-14.0; P=.004) compared with placebo using simple logistic regression. The authors demonstrated an augmented OROS-MPH-induced BP elevation and risk of prehypertension in adults with baseline normal BP. Significantly increased BP was not observed in adults with baseline prehypertension.

Use of nicotine replacement after a smoking lapse

INTRODUCTION

Current labeling for nicotine replacement therapy (NRT) in the United States and many countries discourages continued use of NRT after a lapse; however, recent studies and consensus statements conclude that continuing NRT postlapse substantially increases long-term abstinence. What percent of clinicians recommend continuation of NRT upon a lapse and what percent of NRT users continue NRT postlapse are unclear.

METHODS

The author queried 24 treatment smoking cessation programs or providers, treatment protocols, directors of quitlines and state programs, published treatment texts, and self-help manuals, books, and Internet sites. The author also recruited 101 current smokers who had attempted to stop smoking in the last 3 months and lapsed while using NRT to complete a survey via an E-mail invitation to an Internet consumer database (www.zoomerang.com).

RESULTS

Most programs and providers (67%) did not discuss use of NRT postlapse, and only 8% recommended continuing NRT postlapse. Among recent quitters using NRT, about one fourth (27%) stopped NRT on the day of the lapse, and one fourth (25%) used NRT for only 1 or 2 days postlapse. Most (73%) reported that use of NRT postlapse was helpful.

DISCUSSION

In summary, advice to use NRT postlapse and actual use of NRT for several days postlapse are uncommon.

Cautions and warnings on the US OTC label for nicotine replacement: what's a doctor to do?

BACKGROUND

FDA-approved labeling for over-the-counter (OTC) nicotine replacement therapy (NRT) limits duration of use to a relatively short period of time (10-12 weeks) and explicitly advises against NRT use while smoking or with additional forms of NRT.

OBJECTIVE

To consider and summarize evidence accumulated since the OTC label was created regarding the safety and efficacy of longer-term and concomitant use to provide recommendations regarding these uses.

METHOD

Literature searches were conducted on Medline, journal websites, and Internet search engines, with findings reviewed by six smoking cessation researchers.

RESULTS

Persistent (i.e., long-term) use of NRT does not appear harmful and self-selected persistent use is primarily driven by concerns about relapse to smoking, not addiction. Similarly, continued use of NRT and tobacco during a lapse or relapse and combination NRT treatment do not appear harmful and appear to enhance efficacy.

CONCLUSIONS

Persistent users of NRT should be counseled to reduce and stop NRT only when they are not concerned about relapsing to smoking. Use of NRT with return to smoking during a lapse or relapse should not be automatically discontinued. Combination NRT therapy should be considered for all smokers, especially those who are unable to quit smoking using a single form of NRT.

Vasoprotective effects of resveratrol and SIRT1: attenuation of cigarette smoke-induced oxidative stress and proinflammatory phenotypic alterations

The dietary polyphenolic compound resveratrol, by activating the protein deacetylase enzyme silent information regulator 2/sirtuin 1 (SIRT1), prolongs life span in evolutionarily distant organisms and may mimic the cytoprotective effects of dietary restriction. The present study was designed to elucidate the effects of resveratrol on cigarette smoke-induced vascular oxidative stress and inflammation, which is a clinically highly relevant model of accelerated vascular aging. Cigarette smoke exposure of rats impaired the acetylcholine-induced relaxation of carotid arteries, which could be prevented by resveratrol treatment. Smoking and in vitro treatment with cigarette smoke extract (CSE) increased reactive oxygen species production in rat arteries and cultured coronary arterial endothelial cells (CAECs), respectively, which was attenuated by resveratrol treatment. The smoking-induced upregulation of inflammatory markers (ICAM-1, inducible nitric oxide synthase, IL-6, and TNF-alpha) in rat arteries was also abrogated by resveratrol treatment. Resveratrol also inhibited CSE-induced NF-kappaB activation and inflammatory gene expression in CAECs. In CAECs, the aforementioned protective effects of resveratrol were abolished by knockdown of SIRT1, whereas the overexpression of SIRT1 mimicked the effects of resveratrol. Resveratrol treatment of rats protected aortic endothelial cells against cigarette smoking-induced apoptotic cell death. Resveratrol also exerted antiapoptotic effects in CSE-treated CAECs, which could be abrogated by knockdown of SIRT1. Resveratrol treatment also attenuated CSE-induced DNA damage in CAECs (comet assay). Thus resveratrol and SIRT1 exert antioxidant, anti-inflammatory, and antiapoptotic effects, which protect the endothelial cells against the adverse effects of cigarette smoking-induced oxidative stress. The vasoprotective effects of resveratrol will likely contribute to its antiaging action in mammals and may be especially beneficial in pathophysiological conditions associated with accelerated vascular aging.

Effect of transdermal nicotine replacement on alcohol responses and alcohol self-administration

RATIONALE

Nicotine replacement is commonly used to treat tobacco use in heavy-drinking smokers. However, few studies have examined the effect of nicotine replacement on subjective and physiological responses to alcohol and alcohol drinking behavior.

OBJECTIVE

The primary aim of this within-subject, double-blind study was to examine whether transdermal nicotine replacement (0 mg vs 21 mg/day) altered response to a low-dose priming drink and subsequent ad libitum drinking behavior.

MATERIALS AND METHODS

Subjects (n=19) were non-treatment-seeking, non-dependent heavy drinkers who were daily smokers. Six hours after transdermal patch application, subjective and physiological responses to a priming drink [designed to raise blood alcohol levels (BALs) to 0.03 g/dl] were assessed. This was followed by a 2-h self-administration period where subjects could choose to consume up to eight additional drinks (each designed to raise BALs by 0.015 g/dl) or to receive monetary reinforcement for drinks not consumed.

RESULTS

We found that 6 h after patch application, tobacco craving associated with withdrawal relief was decreased, and systolic blood pressure and heart rate were increased in the active patch condition compared to the placebo patch condition. Subjective intoxication in response to the priming drink was attenuated in the active nicotine patch condition compared to 6 h of nicotine deprivation (i.e., placebo patch). During the self-administration period, subjects had longer latencies to start drinking and consequently appeared to consume fewer drinks when administered the active patch compared to the placebo patch.

CONCLUSIONS

In heavy drinkers, transdermal nicotine replacement compared to mild nicotine deprivation attenuated subjective and physiological alcohol responses and delayed the initiation of drinking.

Blood pressure circadian rhythm and endothelial function in heavy smokers: acute effects of transdermal nicotine

Nicotine replacement therapy appears to be safe when used by healthy patients to aid in smoking cessation; however, the immediate acute effects of nicotine replacement therapy on the circadian rhythm of blood pressure (BP) and endothelial function in heavy smokers are not well understood. Twenty-six heavy smokers were requested to stop smoking for 48 hours. BP and heart rate were recorded over 48 hours by ambulatory BP monitoring, with beat-to-beat changes being monitored for the first 10 hours by a noninvasive finger device. The reactivity of the brachial artery was evaluated using flow-mediated dilation immediately after smoking cessation, before the application of a 21-mg nicotine patch or placebo patch, and 24 hours after patch placement. Transdermal nicotine caused a mild but significant elevation in BP in the early morning in 21 of 26 volunteers. The decrease in nocturnal BP was attenuated in patients with the nicotine patch compared with the placebo patch; this was associated with impaired endothelium-dependent vasodilation.

Nicotine exposure alters in vivo human responses to endotoxin

The alpha 7 nicotinic receptor is reportedly a key element in the cholinergic anti-inflammatory pathway. Because a prototypical ligand for this receptor is nicotine, we studied the in vivo human response to bacterial endotoxin or lipopolysaccharide (LPS) in the context of nicotine or placebo pretreatment. Twelve adult male normal subjects were studied prospectively. Six received overnight transcutaneous nicotine administration by application of a standard patch (7 mg). Six hours later, all subjects were given an intravenous dose of endotoxin (2 ng/kg) and were evaluated for an additional 24 h for circulating levels of inflammatory biomarkers, vital signs and symptoms. The nicotine subjects had elevated blood levels of the nicotine metabolite, continine, prior to and throughout the 24-h post-endotoxin exposure phase. Subjects receiving nicotine exhibited a significantly lower temperature response as well as attenuated cardiovascular responses for 2.5-6 h after LPS exposure. In addition, increased circulating interkeukin (IL)-10 and cortisol levels were also noted in nicotine subjects. These data indicate an alteration in LPS-induced systemic inflammatory responses in normal subjects exposed to transcutaneous nicotine. In this model of abbreviated inflammation, nicotine exposure attenuates the febrile response to LPS and promotes a more prominent anti-inflammatory phenotype.

Effects of high dose transdermal nicotine replacement in cigarette smokers

RATIONALE

Nicotine replacement therapies (NRT) have been evaluated to facilitate cigarette smoking reduction in smokers unwilling or unable to quit. In most of these studies, only conventional doses of NRT have been tested and higher doses may be required to result in significant reductions in smoking and in biomarkers of exposure.

OBJECTIVE

To determine if higher NRT doses in conjunction with smoking are safe and may promote significant reductions in cigarette smoking and biomarkers of exposure.

METHODS

A dose-ranging, within-subject design was implemented to evaluate the effects of 15, 30 and 45 mg nicotine-patch treatment on measures of safety and the extent of smoking reduction and biomarker exposure per cigarette in smokers (N=20 completers) not immediately interested in quitting.

RESULTS

Concurrent smoking and NRT were generally tolerated and resulted in no changes in blood pressure or heart rate. Slightly less than 10% of the study sample was not given the highest dose of NRT due to side effects. Self-reported cigarette smoking decreased with increasing doses of nicotine replacement and significant reductions were observed for total NNAL (a carcinogen biomarker) and carbon monoxide. However, even at the 45 mg dose, increased carbon monoxide and total NNAL per cigarette occurred, even though cotinine levels increased on average, 69.3% from baseline.

CONCLUSIONS

The present results suggest that the use of high dose NRT is safe, leads to significant reductions in smoking (-49%), significant but less reductions in total NNAL (-24%) and carbon monoxide (-37%) due to compensatory smoking.

Analyzing milestones in smoking cessation: illustration in a nicotine patch trial in adult smokers

Tests of addiction treatments seldom reveal where treatment exercises its effect (i.e., promoting initial abstinence, preventing lapses, and/or impeding progression from lapse to relapse). The authors illustrate analyses distinguishing effects on these milestones in a randomized trial of high-dose nicotine patch (35 mg; n = 188) versus placebo (n = 136) in adult smokers, who used electronic diaries to monitor smoking in real time during 5 weeks of treatment. High-dose patch promoted initial abstinence (hazard ratio [HR] = 1.3) and decreased the risk of lapsing among those who achieved abstinence (HR = 1.6). The biggest effect of treatment was to prevent progression to relapse among those who had lapsed (HR = 7.1). Analysis of effects by milestones may enhance understanding of cessation treatments and their mechanisms of action.

Adherence to nicotine replacement patch therapy in cardiovascular patients

Nicotine Replacement Therapy (NRT) is the most frequently used pharmacological intervention for smoking cessation. Research on the effect of NRT showed serious nonadherence among users. We investigated adherence to NRT in cardiovascular patients. A number of 174 outpatients (N = 174), who smoked > 5 cigarettes a day, received free patches and intensive instructions from nurses. Questionnaires were sent to patients assessing patient characteristics, adherence to a 7-8 weeks time frame and appliance instructions, side effects/withdrawal symptoms, and reasons for nonadherence. Only 38% of the patients was adherent to the time frame. Appliance instructions were followed in 76-96% of the cases, except for smoking; 50% continued to smoke during NRT. In conclusion, despite considerable attention to appliance instructions, access to free patches and additional behavioral support, adherence to NRT in these patients is rather low.

Nicotine delivery systems

Over the past 20 years, medicinal nicotine has been used to aid smoking cessation, and has led to a significant increase in the number of smokers who successfully quit. This review describes currently available medicinal nicotine products, which include nicotine patch, gum, lozenge, nasal spray, inhaler and sublingual tablet, including their pharmacokinetics and recommended dosing. New developments in nicotine delivery that could further increase cessation rates include high-dose patches, rapid release gum, combined patch and acute forms, and several novel channels for nicotine delivery, such as nicotine drink, straw, lollipop and a pulmonary inhaler. New applications of existing and novel medicinal nicotine products may include relapse prevention, nicotine maintenance, temporary withdrawal management, reduced smoking and gradual quitting.

Nicotine replacement therapy and cardiovascular disease

Smoking is a well-established and important risk factor for cardiovascular disease. Cessation of smoking clearly decreases the chances of a first or subsequent cardiovascular event. Nicotine replacement therapy (NRT) is a proven adJunctive therapy to increase the probability of quitting smoking. Anecdotal reports of adverse events in patients using NRT have led some to question its safety. Is nicotine, whether in tobacco products or in NRT, the cause of the cardiovascular consequences associated with tobacco use? Is using NRT to assist with smoking cessation safer than smoking? Should health care professionals avoid recommending NRT for patients with established cardiovascular disease? This article summarizes the mechanisms of harm associated with smoking and reviews the safety of NRT in both the general population and the population with cardiovascular disease. Recommendations for NRT use are offered.

Stress triggered rise in plasma aldosterone is lessened by chronic nicotine infusion

The ability of nicotine infusion to modulate plasma aldosterone levels in response to different stressors was investigated. Sprague-Dawley rats given nicotine (5 mg/kg/day) or saline for 14 days were subjected to stress. Baseline plasma aldosterone (86+/-17 pmol/l) was unaffected by nicotine. Aldosterone was significantly elevated by restraint (450+/-72 pmol/l) and especially with cold (1249+/-172 pmol/l) or immobilization (1779+/-247 pmol/l) stress. Nicotine infusion attenuated the rise in aldosterone with restraint and cold stress, but not immobilization. These results reveal that nicotine infusion can attenuate the aldosterone response, depending on the type of stress.

Investigations using immunization to attenuate the psychoactive effects of nicotine

Despite the enormous health risks, people continue to smoke and use tobacco primarily as a result of nicotine addiction. As part of our immunopharmacotherapy research, the effects of active and passive immunizations on acute nicotine-induced locomotor activity in rats were investigated. To this end, rats were immunized with either a NIC-KLH immunoconjugate vaccine designed to elicit an antinicotine immune response, or were administered an antinicotine monoclonal antibody, NIC9D9, prior to a series of nicotine challenges and testing sessions. Vaccinated rats showed a 45% decrease in locomotor activity compared to a 16% decrease in controls. Passive immunization with NIC9D9 resulted in a 66.9% decrease in locomotor activity versus a 3.4% decrease in controls. Consistent with the behavioral data, much less nicotine was found in the brains of immunized rats. The results support the potential clinical value of immunopharmacotherapy for nicotine addiction in the context of tobacco cessation programs.

Lung morphometry and MMP-12 expression in rats treated with intraperitoneal nicotine

Nicotine, a toxic tobacco component, plays an important role in the development of cardiovascular and lung diseases in smokers. Our objective was to investigate the effects of the intraperitoneal (i.p.) nicotine treatment in lung morphology. Wistar male rats (3-4 months old) were divided in five groups, a control one, and other groups treated with nicotine (1 mg/kg/day) for 8 days and sacrificed after 24, 48, 96, and 192 h. Morphometry was used to estimate the lung alveolar parenchyme and septal elastic fibers changes, and immunohistochemistry was performed to detect macrophage metalloelastase (MMP-12) and quantify vessels by immunolabelling with alpha-smooth muscle cells. Thickening of the alveolar septa was present in all nicotine groups, and associated with mononuclear cell infiltration, angiogenesis, and irregular areas of collapse. After 96 h, rat lungs showed macrophage, expressing MMP-12, that was also present after 192 h of recovery. Pleural and parenchyma inflammation, fibrosis and macrophage were also seen after 192 h. Intraperitoneal nicotine treated rats exhibited an increase of the volume fraction of alveolar parenchyme, a reduction of volume and surface fraction septal elastic fibers, and an increase of the numerical fraction of microvasculature vessels compared to control ones. MMP-12 was detected in groups of macrophages Wistar rats lung exhibited a progressive morphological damage after 192 hours of recovery, after 8 daily doses of 1 mg/kg body weight on i.p. nicotine.

Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease

Twenty percent of patients with cardiovascular disease smoke, and smoking cessation results in a dramatic decline in the relative risk of future cardiovascular events. Questions regarding the safety of nicotine-replacement therapy and bupropion SR for smoking cessation in patients with cardiovascular disease have arisen, in particular because of potential hemodynamic effects of these agents. There have been several randomized, controlled, clinical trials testing the safety of transdermal nicotine in patients with cardiovascular disease that failed to show an increased risk for cardiac events in active treatment conditions compared with placebo. Efficacy trials conducted in other patient populations also support the safety of nicotine-replacement use in cardiac disease patients. To date there is one randomized controlled trial to test bupropion for smoking cessation conducted in this population. Studies to test the efficacy of bupropion for smoking cessation and depression suggest it is safe to use in cardiac disease patients despite recent case reports of adverse events associated with bupropion use. Nicotine-replacement therapy and bupropion significantly increase long-term smoking cessation rates, and the benefits of cessation exceed the risks for pharmacotherapy in patients with cardiovascular disease.

Treatment of tobacco dependence in alcoholics

Because of the high morbidity and mortality that alcoholic smokers experience from tobacco-caused diseases, treatment for tobacco dependence among alcoholics is warranted. Much progress has been made during the last decade in addressing tobacco dependence in alcoholism treatment units. Treatment of tobacco dependence in alcoholic smokers does not seem to cause excessive relapse to drinking and, in fact, stopping smoking may enhance abstinence from drinking. Therefore, treatment for alcoholic smokers should take place whenever and wherever the patient comes in contact with the health care system. Because alcoholic smokers as a rule are more dependent on nicotine than their nonalcoholic counterparts, they may need more intensive pharmacotherapy and behavioral therapy. Because many of them have experienced 12-step approaches to recovery, that same technology can be used to initiate and maintain abstinence from tobacco use. Moreover, several pharmacologic options exist to treat tobacco dependence in alcoholic smokers. However, the efficacy of several pharmacologic therapies for alcoholic smokers needs to be tested. In addition, further research is needed on effective treatments for recovering alcoholics of various racial/ethnic backgrounds.

Nicotine dependence: development, mechanisms, individual differences and links to possible neurophysiological correlates

There is now little doubt that the majority of people who smoke tobacco do so to experience the psychopharmacological properties of the nicotine present in the smoke and that a significant proportion of habitual tobacco users become addicted to the drug nicotine. In the US some 80% and in Europe (Germany) 39% of smokers have been classified as dependent according to the diagnostic guidelines of the American Psychiatric Association. As a result, direct nicotine replacement is used increasingly by many people who want to stop smoking. The objectives of this review are to outline the mechanisms involved in the development and maintenance of nicotine dependence and to link behavioural observations to possible neurophysiologic correlates.

Nicotine patch therapy based on smoking rate followed by bupropion for prevention of relapse to smoking

PURPOSE

To determine whether (1) tailored nicotine patch therapy that is based on smoking rate can be carried out in a multisite oncology investigative group practice setting, (2) long-term use of bupropion reduces the rate of relapse to smoking in smokers who stop smoking with nicotine patch therapy, and (3) bupropion can initiate smoking abstinence among smokers who have failed to stop smoking after nicotine patch therapy.

PARTICIPANTS AND METHODS

Fourteen North Central Cancer Treatment Group sites recruited generally healthy adult smokers from the general population for nicotine patch therapy and based the patch dosage on smoking rates. At completion of nicotine patch therapy, nonsmoking participants were eligible to be assigned to bupropion or placebo for 6 months (for relapse prevention). and smoking participants were eligible to be assigned to bupropion or placebo for 8 weeks of treatment.

RESULTS

Of 578 subjects, 31% were abstinent from smoking at the end of nicotine patch therapy. Of those subjects not smoking at the end of nicotine patch therapy who entered the relapse prevention phase, 28% and 25% were not smoking at 6 months (the end of the medication phase) for bupropion and placebo, respectively (P =.73). For those still smoking at the end of nicotine patch therapy, 3.1% and 0.0% stopped smoking with bupropion or placebo, respectively (P =.12).

CONCLUSION

Tailored nicotine patch therapy for the general population of smokers can be provided in a multisite oncology investigative group setting. Bupropion did not reduce relapse to smoking in smokers who stopped smoking with nicotine patch therapy. Bupropion did not initiate abstinence among smokers who failed to stop smoking with nicotine patch therapy.

Lung cancer: the oncologist's role in smoking cessation

Cigarette smoking is by far the most common preventable cause of lung cancer in our society, and is therefore responsible for the leading cause of cancer death in both men and women. Physicians are uniquely positioned to impact smoking rates, but frequently fail to address the issue in practice because of competing concerns and a sense of frustration. Oncologists, though not typically thought of as preventive care providers, can be empowered to advocate for more effective smoking cessation strategies, and to implement treatment guidelines in their practice in an effort to improve cancer outcomes in their community. Pharmacologic and behavioral interventions for smokers, including the role of nicotine replacement therapies and bupropion, and their relevance to oncologic practice are reviewed.

Smoking cessation for patients with cardiovascular disease: what is the best approach?

Tobacco use remains the major preventable cause of early mortality and morbidity in the US and is a major risk factor for cardiovascular disease (CVD). Quitting smoking rapidly reduces the risk of cardiovascular events. In this review, we identify and discuss best approaches to assist smoking cessation among patients with CVD. Establishing office systems that reliably identify smokers to healthcare providers is an essential first step. Once the patient is identified as a smoker, providers should inquire about their willingness to quit and advise them to quit or provide motivation to get ready to make a quit attempt. Behavioral (counseling) and pharmacologic (nicotine replacement and non-nicotine medications) treatments double or triple long-term cessation rates and should be offered in combination to all patients with CVD who use tobacco. More intensive behavioral therapy is more effective and should be delivered when possible. The choice of pharmacotherapy will depend upon the clinical history of the patient and patient preference. Nicotine replacement and sustained release bupropion (bupropion SR) are first-line treatments for smoking cessation. Nicotine patches have been studied extensively in patients with stable CVD and have been shown to be safe. Bupropion SR has relatively few cardiovascular adverse effects and may be especially useful for patients with CVD; its safety is currently being studied. Special consideration is needed for hospitalized patients with acute coronary syndromes (e.g. myocardial infarction and unstable angina). The safety of pharmacotherapy in the acute setting is not yet established. Behavioral interventions, however, are very effective and should be delivered to all hospitalized smokers. Finally, it is important to create a clinical environment that is supportive of treating patients with tobacco dependence. Simple changes in office and hospital routines and procedures (routine screening to identify smokers, prompts to encourage intervention and links to more intensive tobacco dependence treatment programs) will substantially improve the identification, treatment, and outcomes of patients with CVD who use tobacco.

Cardiovascular effects of nasal and transdermal nicotine and cigarette smoking

The purpose of this study was to compare circadian blood pressure and heart rate patterns and other cardiovascular effects of nicotine delivered rapidly (via nasal spray, NNS), slowly (transdermal nicotine, TDN), by cigarette smoking (rapid delivery of nicotine plus other smoke toxins), and placebo NNS. Twelve healthy cigarette smokers were studied on a research ward when they smoked cigarettes (16 per day) or used TDN (15 mg/16 h), NNS (24 1-mg doses per day), or placebo NNS, each for 5 days. There were no significant differences in systolic blood pressure, but diastolic blood pressure was slightly increased during cigarette smoking. Plasma epinephrine, beta-thromboglobulin, and fibrinogen levels were higher during cigarette smoking than with TDN. For most measurements, NNS values were intermediate between and not significantly different from those of cigarette smoking and TDN. We conclude that, at recommended doses, TDN and NNS have fewer effects on biomarkers of cardiovascular risk than does cigarette smoking.

Interventions for treatment-resistant smokers

We can understand resistance to treatment in smokers in two ways. First, when there is no awareness that smoking can be responsible for a physical disease, e.g., chronic obstructive lung disease or a dependence disorder. Second, when smokers actually seek treatment but fail to respond positively. The first kind-resistance related to lack of awareness-may not be so common in adult US smokers, but is more common among young smokers. Information is crucial to increase awareness. However, such information must be presented in such a way that smokers respond to it. Whether a smoker takes action will also depend on what options and choices are available. Encouraging abrupt cessation as the only option is unlikely to motivate the smokers who have tried to quit many times and failed and those who do not want to give up completely. Alternatives such as quitting gradually-even harm-minimization-should be considered. Hopefully, taking some control over smoking with the help of, for example, nicotine replacement can increase self-efficacy and motivation to quit. For those who find it impossible to quit, harm-minimization procedures should definitely be invoked.

Preventing lung cancer by stopping smoking

Much progress has been made in recent years in treating tobacco dependence. The 2000 USPHS Guideline extends the understanding of effective treatments and encourages clinicians to be more diligent in recognizing tobacco users in the practice and more aggressive in treating every tobacco user. The guideline outlines the potential use of the five first-line medications (bupropion, nicotine patches, gum, nasal spray, and inhaler) and the two second-line medications (nortriptyline and clonidine). The use of these medications can be tailored to meet the patients needs and combinations of these medications can be used when appropriate. More intensive treatment, such as residential treatment, may be needed for more addicted smokers.

Smoking and ischemic stroke: a role for nicotine?

Cigarette smoking is a preventable risk factor for ischemic stroke. The mechanisms by which smoking contributes to stroke are poorly understood and the role of nicotine in this process is controversial. Although nicotine administered transdermally and orally does not appear to have as many associated health risks as do cigarettes, nicotine does have acute vasoactive and mitogenic effects on vascular tissues. Nicotine might alter the function of the blood-brain barrier and disrupt normal endothelial cell function. Some of the detrimental effects of nicotine are prevented by nicotinic acetylcholine receptor antagonists. However, recent studies indicate that nicotine might also interact with intracellular signaling pathways that are independent of acetylcholine receptors. In light of these recent developments, the impact of nicotine on cerebrovascular pathology should not be dismissed.