Tobacco effects

on cardiovascular
system

Objectives of the Lecture

GOAL OF LECTURE:
Epidemiology of CVD and Tobacco
Provide students with knowledge on the burden of smoking and
tobacco use among patients with cardiovascular diseases (CVD)
Tobacco and Cardiovascular Diseases the Mechanisms
Provide students with knowledge on the mechanisms of hazardous
effects of smoking and tobacco use to cardiovascular diseases
Smoking Cessation for CVD Patients
Provide students with knowledge on the benefits of smoking cessation
on cardiovascular disease burden and its risk factors.

Objectives of the Lecture

LEARNING OBJECTIVES
Learners will be able to:

List the global burden of CVD and smoking

Discuss the burden of smoking in CVD patients
Describe the association between active and passive
smoking and CVD
Discuss how smoking can cause cardiovascular diseases
Discuss the mechanisms underlying the hazardous
effects of smoking on cardiovascular diseases
List the impacts of passive smoking on cardiovascular
diseases Describe the beneficial effects of smoking
cessation on CVD burden and CVD risk factors.
Discuss the impacts of cessation on CVD morbidity and
mortality.

Epidemiology of
CVD and Tobacco

Cardiovascular diseases (CVD) as

leading cause of global death
Globally, non-communicable diseases (NCD)
accounted for 58% and 62% of deaths in men and
women, respectively, in 2004
Cardiovascular diseases (CVD) death in 2004: 26.8
million in men and 31.5 million in women
Two leading causes of death: ischemic heart disease
(12.2% of all deaths) and cerebrovascular disease (9.7%)
Both diseases were the leading causes of death globally,
in middle- and high- income countries.
In low income countries, ischemic heart disease came 2 nd
(9.4%) and cerebrovascular disease came 5 th (5.6%).

World Health Organization., 2008.

Global tobacco-attributable deaths

In 2030, smoking will account for 10% of
global death
Between 2002-2030, tobacco-related
deaths are projected to:
Decrease by 9% in high-income countries
Double in low-and middle-income countries
(from 3.4 million to 6.8 million)
Leading causes of tobacco-attributable deaths
are: cancer (33%), cardiovascular diseases
(29%), and chronic respiratory diseases
(29%).

Smoking-attributable death in Asia

Pacific
Smoking attributable to 30% of
cardiovascular death in Pacific and SouthEast Asia regions. (Martiniuk et al., 2006)
Smoking causes
10-33% of heart diseases among men (10%
in Australia and 33% in Kiribati)
3-12% of hemorrhagic stroke among men (3%
in Australia and Palau, and 12% in Kiribati)
8-27% of ischemic stroke among men (8% in
Australia and 27% in Kiribati)

Prevalence CVD in Indonesia

Indonesians national prevalence for :
- Heart diseases:
7,2 % based on symptoms told by patients
0,9 % based on health practitioners diagnose
- Hypertension diseases:
31,7% based on measurement
7,2% based on health practitioners diagnose
(Basic Health Survey, 2007)

So far, national data on smoking attributable death in

Indonesia is not available. Further research on this is
urgently needed.

Smoking as CVD risk factor

Smoking is an established risk factor for many
cardiovascular diseases such as: peripheral
vascular disease (PVD), aortic aneurysm,
coronary heart disease (CHD), and
cerebrovascular disease (stroke)
12 % of death in China were attributable to
smoking (22% were respiratory disease, 16%
neoplastic disease, and 9% vascular disease)
Smoking attributable to 30 % of cardiovascular
death in Pacific and Southeast Asia region.
World Health Organization, 2002; Niu SR, et al. BMJ 1998;317(7170):1423-4.

Cardiovascular risks of
secondhand smoke
Secondhand smoke (SHS) increases the risk of coronary
heart disease among nonsmokers by 25%-30%, for both
among men and women, and exposure in home and
workplace.
A significant dose-response relationship between intensity
and duration of exposure to SHS and CVD risks
Risk increases sharply with low doses of SHS (< 5
cigs/day)
Risk increases more slowly and linearly with higher level
of exposure (5-20 cigs/day)
(He et al., 1999; Pechacek et al., 2004)

Cost-effectiveness of Smoking
Cessation for CVD Prevention
Compared to different CVD prevention
strategies (ex. Lowering blood pressure,
blood glucose, LDL cholesterol, BMI),
smoking cessation is the most costeffective intervention for CVD prevention.
Kahn et al. (2008)

Tobacco use and Acute Myocardial

Infarction (AMI)
A current smoker has three times risk to
experience non-fatal MI compared with
never smoker
Dose response relationship between number
of cigarettes smoked per day and risk of AMI
independent with age
The risk of AMI increase even with low levels
of smoking
Risk increases by 5.6% for every additional
cigarette smoked
Teo et al (2006)

Factors associated with risk of AMI

Young smokers are at higher risk of AMI
compared to older smokers
higher prevalence of smoking
higher numbers of cigarettes smoked per day

Risk of acute myocardial infarction (AMI) from:

smoking beedies: 2.89

chewing tobacco: 2.23
smoking and chewing: 4.09
low doses of exposure (1-7 hour/week)=1.24
high doses of exposure (>21 hour/week)=1.62

Teo et al (2006)

Risk factor Tobacco Smoking

Odds of myocardial infarction according to number of cigarettes smoked

Lancet 2004; 364: 93752

Tobacco and
Cardiovascular Diseases
the Mechanisms

Smoking and CVD: causation

Cigarette smoking is a cause of peripheral vascular
disease (PVD), aortic aneurysm, coronary heart
disease (CHD), and cerebrovascular disease (stroke).
Smoking contributes to the development and
progression of atherosclerosis plaque, which lead to
the increase risk of thrombosis of the narrowed
vessels.
Smoking induces a localized inflammatory response in
the lungs
Smoking induces a systemic inflammatory response
elevations in inflammatory markers which is a risk
marker (and potentially a risk factor) of CVD
(USDHHS, 2004; Burns, 2003)

Pathophysiology of Cigarette
Smoking and CVD
Mechanisms by which smoking causes
acute cardiovascular disease :
Thrombosis
Endothelial dysfunction
Inflammation
Hemodynamic changes
Smoking-mediated thrombosis appears
to be a major factor in the pathogenesis
of acute cardiovascular events.
(Benowitz, 2003)

Pathophysiology of Cigarette
Smoking and CVD

Overview of mechanisms by which cigarette smoking causes acute cardiovascular event.

(Benowitz, 2003)

Secondhand smoke and CVD:

the underlying mechanism
Secondhand smoke increases platelet
aggregation that leads to thrombosis,
endothelial dysfunction, inflammation

(Law and

Wald, 2003)

Exposure of secondhand smoke to nonsmoker increases white blood cells, C-reactive

protein, homocysteine, fibrinogen, and
oxidized low density lipoprotein cholesterol
value similar to active smokers (Pechacek and Babb,
2004)

A cause-effect evidence of vascular toxicity in

animal experimentation (Law and Wald, 2003)

Smoking Cessation
for CVD Patients

Cessation in CVD clinical

management (1)
Tobacco cessation counseling should be
integrated in the treatment of patients with
CVD, because :
Smoking directly accelerate atherogenesis,
causes acute cardiovascular events, and is a
substantial contributor to morbidity and
mortality in patients with CVD.
Smoking contributes to or acts synergistically
with other risk factors such as hyperlipidemia
and diabetes.
(Graham et al., 2007; Benowitz, 2003; Mohiuddin et al., 2007; Wilson et al., 2000)

Risk of ACS associated with exposure to

multiple risk factors
THE INTERHEART STUDY

Lancet 2004; 364: 93752

Smk=smoking. DM=diabetes mellitus. HTN=hypertension.
Obes=abdominal obesity. PS=psychosocial. RF=risk factors.

Cessation in CVD clinical

management (2)
Tobacco cessation counseling should be
integrated in the treatment of patients with
CVD, because :
Smoking cessation reduces morbidity and
mortality in CVD patients.
The mortality benefit of tobacco cessation in
patients with left ventricular dysfunction is
equal to or greater than the benefit of therapy
with angiotensin converting enzyme inhibitors,
beta blockers, or spironolactone.
(Graham et al., 2007; Benowitz, 2003; Mohiuddin et al., 2007; Wilson et al., 2000; Teo et al., 2006)

Cessation in CVD patients

CVD hospitalization is a strong motivator for
quitting. Twelve months quitting rate was
higher in smokers admitted to coronary care
unit than general population (25% vs. 3%,
respectively)
Predictors for quitting: light smokers and
newly diagnosed CVD
Patients were more likely to successfully quit
with intensive cessation intervention and
sufficient follow-up post-hospitalization
(Tonstad and Johnston, 2006)

Cessation reduces CVD morbidity

and mortality
Data from Asia Pacific showed that
quitting smoking reduces the risk of
CVD by 29% and stroke by 16%.
(Asia Pacific Cohort Studies Collaboration, 2005)

Physician should repeat cessation

messages in every clinical outpatient
visit, and offer combination of cessation
counseling and pharmacotherapy, if
available.

Benefits of Cessation for reducing

CVD risk factors
Following smoking cessation, traditional CVD risk
factors and inflammation markers decline gradually.
The level of inflammation markers reach the baseline
level of non-smoker five years after smoking cessation.
Most of these factors have dose-dependent trends: the
levels of the factors increase with number of daily
cigarettes smoked.
Time-dependent trends also observed: the levels of
other risk factors decrease gradually over time if the
patient stays quit.
(Bakhru and Erlinger, 2005)

The NRT available in

Indonesia

Nicotine gum
Nicotine patch OTC
Nicotine Lozenge
Nicotine nasal spray
Nicotine inhalation
Nicotine sub lingual

Nicotine replacement
therapy (NRT)
NRT delivers nicotine without the toxins
from tobacco1
NRT helps combat the symptoms of
withdrawal2
Nicotine dose from NRT is lower and
administered more gradually than with
smoking and this reduces the addictive
potential1,3
1 Benowitz & Gourlay. J Am Coll Cardiol, 1997; 29: 1422-1431.
2 Silagy et al. Cochrane Database Syst Rev, 2004; (3): CD000146.
3 Le Houezec. Int J Tuberc Lung Dis, 2003; 7: 811-819.

NRT Transdermal Patch

& Inhaler

NRT Gum &

Lozenges

Cessation Medication for CVD

patients
Varenicline (Champix) is one of cessation medication
currently available in Indonesia. The cost for Champix is
35USD (for two weeks treatment) which is almost half
the regional minimum salary in Yogyakarta Province (Rp
700.000}
Other medications include nicotine (chewing-gum, patch,
nasal spray, inhaler and tablet), and bupropion.
Risks of nicotine or bupropion in CVD patients is minimal
Benefit of cessation pharmacotherapy for CVD patients
far outweighs the risk of continued smoking or of the
medications themselves.
(Ford and Zlabek, 2005; Tonstad and Johnston, 2006)

Benefits of Quitting and CVD

mortality
Patients who quit will have one half the risk of
cardiovascular disease that patients who continue
to smoke.
The overall mortality risk and the risk of dying from
cardiovascular diseases among people who quit
and stayed quit, were similar to those who never
smoked.
The likelihood of dying from cardiovascular diseases
were three to four times higher in people who
continued to smoke compared to those who never
smoked.
(Bjartveit and Tverdal, 2009)

Cessation and CVD prevention

Decline in smoking, serum cholesterol, and
blood pressure explained more than 50% of
the decline of CVD mortality.
Smoking cessation with 5A approach have
been integrated in the CVD patient
management in Europe.

Ask smoking behavior

Advise patients to quit
Assess willingness to quit smoking
Assist in preparing quitting plan
Arrange for follow-up visit

(Graham et al., 2007)