Ischaemic Heart Disease Special Therapeutic Situations

and฀chewing฀gum,฀whereas฀no฀indings฀have฀yet฀been฀published฀for฀the฀inhaler.฀Details฀are฀ presented฀in฀Table฀ 11.7 .

11.5.2 Pregnancy

Women฀who฀smoke฀during฀pregnancy฀must฀expect฀their฀neonates฀to฀display฀signs฀of฀embry- otoxic฀and฀foetotoxic฀damage฀ [70] .฀Since฀the฀prescription฀of฀drugs฀is฀quite฀properly฀restricted฀ during฀pregnancy฀and฀lactation,฀controversy฀surrounds฀the฀use฀of฀nicotine฀products฀because฀ the฀harmful฀effects฀of฀the฀combustion฀products฀of฀cigarettes฀cannot฀be฀clearly฀separated฀ from฀the฀effects฀of฀nicotine.฀The฀accumulation฀of฀nicotine฀in฀breast฀milk฀is฀well฀known,฀but฀ heavy฀metals,฀CO฀and฀numerous฀carcinogens฀also฀pass฀into฀the฀mother’s฀milk.฀In฀spite฀of฀ this,฀it฀has฀been฀argued฀that฀it฀is฀better฀for฀smoking฀mothers฀to฀breast-feed฀their฀babies฀than฀ solely฀to฀expose฀them฀to฀the฀effects฀of฀passive฀smoking฀ [161] .฀Non-drug฀smoking฀cessation฀ programmes฀should฀be฀offered฀irst฀see฀Sect.฀10.11฀in฀ Chap.฀10 ,฀but฀NRT฀should฀be฀insti- tuted฀very฀promptly฀where฀non-drug฀interventions฀are฀found฀to฀be฀ineffective฀ [73] .฀Analysis฀ of฀the฀literature,฀including฀the฀results฀of฀experimental฀animal฀research,฀indicates฀that฀nico- tine฀does฀not฀cause฀any฀teratogenic฀or฀embryotoxic฀effects.฀The฀carcinogens฀detected฀in฀the฀ urine฀of฀neonates฀are฀derived฀from฀tobacco฀and฀are฀not฀metabolites฀of฀nicotine฀ [162] . Since฀pregnant฀women฀who฀smoke฀are฀heavily฀dependent,฀they฀incorporate฀the฀combus- tion฀products฀of฀tobacco฀as฀well฀as฀larger฀amounts฀of฀nicotine฀which฀reach฀the฀foetal฀brain฀ [163,฀164] ,฀and฀the฀binding฀capacity฀for฀the฀alkaloid฀has฀been฀shown฀to฀increase฀in฀foetal฀ brain฀structures฀between฀weeks฀12฀and฀19฀of฀pregnancy.฀Nicotine฀binding฀in฀the฀brainstem฀ attains฀peak฀levels฀at฀mid-gestation,฀with฀a฀subsequent฀fall฀at฀the฀time฀of฀delivery,฀indicating฀ that฀adverse฀effects฀of฀nicotine฀may฀be฀expected฀to฀occur฀during฀mid-to-late฀gestation฀ [164] .฀ Since฀ the฀ risk฀ of฀ malformations฀ and฀ obstetric฀ complications฀ is฀ demonstrably฀ higher฀ in฀ IndicationTreatment Proposal Proven฀use Indications Myocardial฀infarction Nicotine฀may฀be฀used฀2–3฀ days฀after฀infarction Nicotine฀was฀used฀up฀to฀2–3฀weeks฀ after฀myocardial฀infarction Arrhythmias Nicotine฀may฀be฀used฀in฀all฀ patients To฀date,฀no฀experience฀in฀patients฀with฀ severe฀ventricular฀arrhythmias,฀ second฀and฀third฀degree฀AV฀blocks฀ or฀hospitalised฀for฀arrhythmias฀up฀ to฀2฀weeks฀afterwards Treatment ³ 10฀cigarettesday ³ 15฀cigarettesday Nicotine฀patch 15฀mg16฀h฀8–12฀weeks 21฀mg24฀h a ฀in฀CHD฀patients฀proven฀ over฀5–10฀weeks Nicotine฀chewing฀gum 5–15฀pieces฀2฀mg฀eachday฀ 12–24฀weeks Not฀tested฀in฀CHD฀patients Table 11.7 ฀ ฀ ฀ Recommendations฀ on฀ the฀ use฀ of฀ nicotine฀ products฀ in฀ patients฀ with฀ cardiovascular฀ disease฀ [160] a Based฀on฀our฀own฀experiences,฀the฀use฀of฀nicotine฀patches฀overnight฀is฀not฀recommended฀because฀ of฀the฀occurrence฀of฀insomnia฀etc. women฀who฀smoke฀than฀during฀smoking฀cessation฀therapy฀with฀NRT,฀the฀women฀in฀ques- tion฀ should฀ agree฀ to฀ NRT฀ if฀ non-drug฀ interventions฀ fail฀ to฀ achieve฀ smoking฀ cessation.฀ Meticulous฀research฀into฀this฀question฀is฀required฀in฀the฀years฀ahead฀see฀ [71,฀73] .

11.5.3 Weight Gain

For฀a฀variety฀of฀reasons,฀many฀smokers฀lose฀weight฀over฀the฀course฀of฀many฀years฀of฀ smoking฀reduced฀appetite,฀increased฀fatty฀acid฀oxidation,฀deteriorating฀insulin฀resistance,฀ increased฀plasma฀insulin฀concentrations,฀although฀tobacco฀smoke฀does฀not฀appear฀to฀be฀an฀ anorectic฀agent฀ [165] .฀Conversely,฀smoking฀cessation฀in฀response฀to฀nicotine฀administra- tion฀brings฀an฀improvement฀in฀insulin฀resistance฀with฀a฀simultaneous฀weight฀gain.฀This฀ weight฀gain฀on฀smoking฀cessation฀is฀clearly฀associated฀not฀with฀the฀withdrawal฀of฀nicotine฀ but฀of฀other฀unidentiied฀components฀of฀cigarette฀smoke฀ [166] .฀Moreover,฀the฀presence฀of฀ nicotine฀has฀been฀shown฀to฀increase฀concentrations฀of฀leptin฀ [167] ฀which฀evidently฀acts฀to฀ reduce฀body฀weight฀ [168] .฀While฀changes฀in฀body฀weight฀following฀smoking฀cessation฀are฀ a฀major฀concern฀for฀many฀smokers,฀the฀transient฀body฀weight฀luctuations฀often฀balance฀ out฀again฀within฀a฀few฀years฀ [169] . In฀particular,฀women฀who฀eat฀more฀in฀stress฀situations฀frequently฀the฀reason฀for฀smok- ing฀ [170,฀171] ฀or฀who฀are฀going฀through฀the฀perimenopause฀ [172] ฀are฀predestined฀to฀gain฀ weight฀when฀they฀stop฀smoking.฀Dietary฀advice฀should฀be฀given฀at฀the฀start฀of฀smoking฀ cessation฀and฀efforts฀should฀be฀made฀to฀encourage฀greater฀physical฀activity,฀since฀this฀has฀ been฀shown฀to฀minimise฀weight฀gain฀in฀middle-aged฀women฀ [173,฀174] .

11.5.4 Alcohol Consumption

A฀close฀association฀exists฀between฀alcohol฀dependence฀and฀nicotine฀dependence.฀The฀vast฀ majority฀of฀alcoholics฀also฀smoke,฀whereas฀only฀5–10฀of฀smokers฀are฀alcohol-dependent.฀ Combined฀dependence฀is฀associated฀with฀an฀increased฀incidence฀of฀head฀and฀neck฀tumours฀ [175] .฀It฀is฀thought฀that฀daily฀cigarette฀consumption฀is฀increased฀during฀recovery฀from฀ alcoholism฀ [176] .฀ In฀ addition,฀ tobacco฀ is฀ the฀ more฀ common฀ cause฀ of฀ death฀ in฀ former฀ patients฀of฀drug฀dependence฀centres฀ [177] .฀According฀to฀several฀studies฀including฀two฀ controlled฀trials฀ [175] ,฀smoking฀cessation฀withwithout฀NRT฀is฀reported฀to฀have฀no฀adverse฀ consequences฀on฀the฀absence฀of฀drinking฀behaviour฀in฀former฀alcoholics฀ [16] .฀In฀this฀ context,฀there฀is฀evidence฀to฀suggest฀that฀NRT฀has฀no฀adverse฀consequences฀on฀simultane- ously฀implemented฀alcohol฀withdrawal฀ [177] .

11.5.5 Organic Depression and Schizophrenia

A฀generally฀pro-smoker฀atmosphere฀dominates฀in฀psychiatric฀clinics฀ [177] .฀The฀percentage฀ of฀patients฀who฀smoke฀increases฀with฀longer฀hospitalisation,฀although฀this฀tendency฀was฀