Drug Interactions With Smoking

Lisa A. Kroon, Pharm.D


Am J Health Syst Pharm. 2007;64(18):1917-1921. 

In This Article

Abstract and Introduction

Purpose: The mechanisms for drug interactions with smoking and clinically significant pharmacokinetic and pharmacodynamic drug interactions with smoking are reviewed.
Summary: Polycyclic aromatic hydrocarbons (PAHs) are some of the major lung carcinogens found in tobacco smoke. PAHs are potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1A1, 1A2, and, possibly, 2E1. After a person quits smoking, an important consideration is how quickly the induction of CYP1A2 dissipates. The primary pharmacokinetic interactions with smoking occur with drugs that are CYP1A2 substrates, such as caffeine, clozapine, fluvoxamine, olanzapine, tacrine, and theophylline. Inhaled insulin's pharmacokinetic profile is significantly affected, peaking faster and reaching higher concentrations in smokers compared with nonsmokers, achieving significantly faster onset and higher insulin levels. The primary pharmacodynamic drug interactions with smoking are hormonal contraceptives and inhaled corticosteroids. The most clinically significant interaction occurs with combined hormonal contraceptives. The use of hormonal contraceptives of any kind in women who are 35 years or older and smoke 15 or more cigarettes daily is considered contraindicated because of the increased risk of serious cardiovascular adverse effects. The efficacy of inhaled corticosteroids may be reduced in patients with asthma who smoke.
Conclusion: Numerous drug interactions exist with smoking. Therefore, smokers taking a medication that interacts with smoking may require higher dosages than nonsmokers. Conversely, upon smoking cessation, smokers may require a reduction in the dosage of an interacting medication.

Tobacco smoke consists of two phases: the vapor (or gaseous) and particulate phases. Of the estimated 4800 compounds in tobacco smoke, the majority are found in the particulate phase.[1] Nicotine, a natural substance found in tobacco leaves, is the major component of the particulate phase.[2] Nicotine comprises 1.5% of the total weight of a commercial cigarette and is the primary alkaloid found in tobacco. The carcinogens are found in tar, which is the particulate matter minus nicotine and water.[3] Of the 69 carcinogens identified in tobacco smoke, 11 are known human carcinogens and 7 are probably carcinogenic in humans.[1]

Numerous drug interactions have been identified with tobacco smoke. Therefore, clinicians should routinely ask their patients if they are current smokers. Patients who smoke or have recently quit should be screened for potential drug interactions with smoking. One of the quality performance measures of the Joint Commission is the provision of smoking-cessation counseling to adult patients with heart failure, myocardial infarction, or pneumonia. Therefore, information regarding a patient's smoking habits may be more readily available in institutional settings.


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