Impact of Tobacco Smoking and Smoking Cessation on Cardiovascular Risk and Disease

Christopher Bullen

Disclosures

Expert Rev Cardiovasc Ther. 2008;6(6):883-895. 

In This Article

Five-year View

In 5 year's time, the demand for smoking cessation support will be far higher. Social attitudes towards tobacco smoking will have made smoking socially unacceptable in many countries. The range of safe and effective pharmacotherapies available to clinicians will have expanded significantly. Nicotine delivery systems, such as the nicotine oral pouch and novel inhaler devices (such as the ‘e-cigarette') that mimic more closely the speed and dose of nicotine delivery from cigarettes, will have emerged from the development pipeline. A wide range of nicotine delivery products will be widely available over the counter in retail outlets, hospitals, entertainment venues and airports without prescription. For heavily dependent smokers who simply cannot quit nicotine, a slow-release form such as in smokeless tobacco or nicotine patches will be available, with precautions, for use for long-term maintenance of nicotine addiction.

A growth in understanding of the neurobiology of drug-dependence mechanisms will continue to point the way to new targets for the pharmacotherapy of tobacco dependence, adding to the number of drugs that follow from varenicline. A handful of nicotine vaccines will also be available that stimulate the production of antibodies to nicotine and restrict the amount of nicotine penetrating the brain, thus reducing the psychopharmacological responses to nicotine and reducing dopamine turnover in the nucleus accumbens.[146] While well tolerated, the antibody levels generated by these vaccines vary widely from individual to individual and are short-lived, so this approach will assist some smokers to quit but will have only a limited role in the primary prevention of smoking dependence.[147]

Other groups of agents likely to emerge from the development pipeline include those that interfere with the liver enzymes that metabolise nicotine, such as selegiline, a monoamine oxidase inhibitor used for the treatment of early-stage Parkinson's disease and senile dementia[148] and the next version of tetrahydrocannabinoid receptor blockers, the group to which rimonabant belongs, currently used for weight control but not licensed yet in the USA for cessation, despite evidence that it is effective.[149] Cytisine, the agent from which varenicline was developed, will have become widely available in lower-income countries.[150]

While such novel therapies and delivery systems are important, and more work is clearly needed to develop these, the key treatment challenge for the immediate and near future is to encourage clinicians to be more active in asking their patients if they smoke, giving brief advice to stop smoking and using existing treatments already available that are of proven acceptability, efficacy and safety.

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