Researchers have claimed a 20-25 year shorter life span for smokers with a history of smoking compared to non-smokers

How to act as a doctor

"Doctors of any specialization need to carry out special work with smoking patients, here is important interdisciplinary approach, - said candidate of medical sciences, associate professor of the department of "Polyclinic therapy and family medicine" FGBOU V.F. Voyno-Yasenetsky Krasnogorsk State Medical University named after Prof. V.F. Voyno-Yasenetsky Ekaterina Zorina. - We must recognize that not every patient is motivated to give up tobacco smoking".

Tobacco smoking is the main modifiable risk factor for premature mortality in the world. According to the World Health Organization (WHO), 1 person dies every 6 seconds worldwide from tobacco-related diseases, with an annual death toll of 5 million. Scientific studies have shown that people who started smoking in adolescence (which is more than 70% of all smokers) and those who have smoked for 20 or more years die 20-25 years earlier than those who have never smoked. The main risk factors for CVD are smoking, irrational diet, hypercholesterolemia and low physical activity. According to the Interheart Global Study, smoking accounts for 36% of the population risk of first myocardial infarction. The incidence of myocardial infarction in those who smoke more than a pack of cigarettes a day is 6 times higher for women and 3 times higher for men, compared to those who have never smoked. And quitting smoking reduced mortality more than lowering blood cholesterol or blood pressure (BP).

"Tobacco smoke is extremely toxic," Ekaterina Zorina explained. - It contains more than 7 thousand chemicals, of which at least 250 are harmful and at least 69 cause cancer. In cigarette smoke in high concentrations there is carbon monoxide (carbon monoxide) - one of the most toxic gases, whose ability to connect with hemoglobin is 200 times higher than that of oxygen. As a result, elevated levels of carbon monoxide in a smoker's lungs and blood reduce the blood's ability to carry oxygen, impairing the functioning of all body tissues. Without adequate oxygen supply, the brain and muscles do not function properly, and the heart and lungs are strained. Carbon monoxide damages arterial walls and increases the risk of coronary vasoconstriction, which can lead to heart attacks".

Smoking cessation is an integral part of therapy, one of the most important interventions for the prevention and treatment of disease, she said. In her opinion, evidence-based smoking cessation interventions should be integrated into any comprehensive program. First of all, a district therapist should work with a patient who smokes, because more than 90% of patients come to him. General practitioners and doctors of other specialties should also participate in the work with the patient on smoking cessation.

The specialist described the algorithm of doctor's actions when seeing a patient who smokes:

1. Smoking status assessment: smoking status, readiness to quit, and nicotine dependence. A simple six-question Fagerström test provides a quick assessment of nicotine dependence and helps predict the success of quitting smoking.
   
2. Assessment of the type of smoking behavior using the Horn Questionnaire. The questionnaire allows to reveal individual features of smoking behavior. There are 6 in total: "stimulation", "playing with a cigarette", "relaxation", "support", "craving" and "reflex".
3. The calculation of the "smoker's index" is the product of cigarettes smoked per day and smoking status in years divided by 20. An index greater than 10 is a reliable risk factor for the development of COPD.
4. Assessment of motivation to quit smoking. It can be high, medium and low. An alternative to this test is the question: "Do you want to quit smoking?". There are 3 answer options: "I don't plan to quit", "I don't rule out the possibility" and "Yes, I want to quit".
5. Analyzing the results of the examination, estimation of total cardiovascular risk according to the SCORE scale. The scale takes into account gender and age, smoking status, BP and cholesterol values.
6. Development of tactics of management and treatment of the patient. This depends primarily on the assessment of the degree of motivation to quit smoking. 

Nicotine replacement therapy method

Tobacco addiction is a disease, not a bad habit, and in the ICD-10 International Classification of Diseases it is listed under code F-17 (mental and behavioral disorders caused by tobacco use). The production of dopamine in the pleasure center of the brain that occurs during nicotine delivery is a key factor in the development of addiction.

The only way to treat tobacco addiction, according to WHO, is nicotine replacement therapy, said Ekaterina Zorina. Its action is based on mitigation of withdrawal syndrome and acute craving for cigarettes with the help of medical nicotine, and its effectiveness is confirmed by 150 studies involving 50 thousand patients. The methods of therapy are selected individually and depend on the degree of dependence and the patient's response to a particular treatment tactic. Nicotine replacement therapy is the use of nicotine-containing medications that provide nicotine to the body and reliably increase the likelihood of long-term smoking cessation. These include, for example, nicotine-containing chewing gum, inhaler, lozenges, nasal spray, patch. Consistent reduction of nicotine intake with pharmacotherapy for tobacco dependence facilitates subsequent smoking cessation.

When the patient is not motivated to quit smoking

If a patient is not ready to quit smoking "here and now", in addition to raising awareness about the harmful effects of smoking on health and the benefits of quitting, it is advisable to follow the principles of the harm reduction concept, says Ekaterina Zorina. The concept involves reducing the associated risks for patients who do not want to or cannot currently quit smoking. Such patients can be offered to switch to a less harmful alternative - smokeless nicotine-containing products. For example, Ekaterina Zorina mentions electronic tobacco heating systems. "The principle of action of smokeless tobacco products is based on heating, not burning," she told us. - This means that the process of electronic tobacco heating systems involves lower temperatures than the combustion of traditional cigarettes. Smoking conventional cigarettes inhales carbon monoxide, toxic substances and carcinogenic tars that settle in the lungs and cause serious health problems, while using reduced-risk tobacco products reduces the amount of harmful substances entering the smoker's body by 90-95% compared to conventional cigarettes - that is, minimized, as confirmed by studies in the U.S., Europe and Asia.

In summary, there is now a wide range of evidence-based tobacco dependence treatment tools that are effective. Studies show significant reductions in exposure to harmful substances in smokers who switched to electronic tobacco heating systems, close to the results of a control group who stopped smoking. Of course, the first priority for physicians is to motivate patients to quit smoking completely. However, if the patient is not ready to quit smoking right now, it is reasonable to reduce the risk of complications by switching to alternative nicotine-containing products, summarized Ekaterina Zorina.