吸烟 人类心血管健康的大敌吸烟与死亡率冠心病—是吸烟致死疾病的前三位之一吸烟使冠心病的发生风险增加吸烟者发生急性心肌梗死的风险平均增加3倍被动吸烟与心血管疾病的风险被动吸烟与血小板活性戒烟使冠脉介入治疗后死亡率下降戒烟降低心血管疾病死亡风险戒烟$ 2,000 –6,000 降血压药物 $ 9,000 –26,000 降血脂药物 $ 50,000 –196,000 中国烟草流行现状　全球近三分之一吸烟者在中国　吸烟人口众多，目前每天吸烟者超过3亿　被动吸烟率高，5.4 亿人每天生活在烟雾环境中　世界卫生组织《烟草控制框架公约》生效以后烟草产量增加14% 全球每三个吸烟者中就有一个来自我国吸烟对我国人民健康的危害每年100 万人死于吸烟相关疾病—比美国高2.5 倍，超过艾滋病、结核病、交通事故、自杀死亡人数总和如果吸烟率不能有效降低，2025 年死于吸烟的人数将要翻番高血压 	 160M 血脂异常	 	 160M 糖尿病 	 20M IFG 	 20M 肥胖	 	 	 60M 超重	 200M 吸烟	 		 350M 被动吸烟		 540M 我国医务人员在戒烟方面的行为、 认知和技能现状也不容乐观2004 年中国六城市医生吸烟状况调查表明: 中国医生吸烟率男性为45.8%, 女性为1.3%. 有近1/3 的医生在患者面前吸烟. 六个城市医生总戒烟率仅为10.6%, 低于普通人群戒烟率(男性10.4%, 女性19.0%). 正确掌握吸烟危害知识的医生不足50%,97.4% 的医生不了解尼古丁替代疗法,只有7.1% 的医生能够帮助吸烟者制定戒烟计划. 应用科学方法，有效控烟中国医师在行动提高戒烟能力，建设戒烟网络，在全国建立戒烟网络加强培训，完善戒烟工具杨功焕等，中华流行病学杂志2005 ，26 ：246 2002 年吸烟易患冠心病吸烟易患气管炎吸烟易患肺癌孕妇吸烟对胎儿有严重危害吸烟有严重危害1996 年被动吸烟有严重危害比例（％）国人对吸烟与心血管病间的关系缺乏认识0 10 20 30 40 50 60 70 80 90 中国医务工作者吸烟率高 年		1984		1996		2002 总吸烟率	33.9%		37.6%		35.8% 男性吸烟率	61%		66.9%		66.0% 男性医务人员吸烟率		60.0%		56.8% ——三次全国吸烟流行病学调查结果2008 年China Care 研究 男性医生吸烟率29.8% 女性医生吸烟率0.2% 吸烟者平均支数：男性10.9±0.6 支吸烟者平均吸烟年数：男性17.01±8.4 年中国心血管医生吸烟率医生在控烟中的作用不吸烟或戒烟的楷模现有医生吸烟下降，才有全民吸烟下降医生是否吸烟对患者戒烟影响不同建议病人戒烟、提供戒烟治疗健康教育、咨询的强度以及是否用戒烟药物对戒烟率有不同作用承担公众教育，协助政府制定相关政策是降低吸烟率强有力的措施约70% ～90% 的吸烟者每年与医生接触约70% 的戒烟成功者因医生的劝告实现医生的行为被视为楷模和榜样医生是协助人们戒烟的最佳人选控烟-- 医生义不容辞的责任戒烟-治疗慢性病的心态烟草依赖已被认定是一种慢性疾病WHO （ICD-10, F17.2) 2000 年和2008 年美国公共卫生署颁布的有关烟草使用和依赖治疗临床实践指南（USPHS Clinical Practice Guideline-2000 and 2008) 烟草依赖是一种高复发性疾病，戒烟是一个过程只有极少数吸烟者第一次戒烟就完全戒掉，大多数吸烟者均有戒烟后复吸的经历，需要多次尝试才能最终戒烟US guideline (AHRQ, 2000) 　UK guideline (1998) New Zealand guideline (2007) 烟草依赖的治疗戒烟药物治疗生理依赖（躯体依赖）—减轻戒断症状心理支持治疗心理依赖（精神依赖）-- 提供心理辅导支持小组和个别辅导行为疗法（行为矫正）烟草依赖最佳方案：药物、心理支持和行为干预结合戒烟药物治疗酒石酸伐尼克兰美国2008 指南推荐七种一线药物尼古丁替代疗法的五种相应制剂盐酸安非他酮“戒烟是世界上最容易的事情，我已经做过一千次了” “Quitting smoking is the easiest thing in the world. I‘ve done it a thousand times.”		 －－Mark Twain * * "Heart Healthy National, State and Local Events" provided an overview of current and emerging policy issues and initiatives related to cardiovascular disease (CVD) prevention and health promotion within the national, state, and local context as well as a discussion of key clinical preventive services related to CVD risk. Eduardo Sanchez, MD, MPH,[2] Director of the Institute for Health Policy at The University of Texas School of Public Health, Houston, Texas, and Chair of the National Commission on Prevention Priorities (NCPP), gave a general overview of heart health status in the United States with respect to national trends in CVD, obesity, and smoking, and how these affect national health spending, which was more than $7000 per person in 2006.[3] He then discussed the most valuable preventive services, as ranked by the NCPP. NCPP rates preventive services recommended by the US Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) on the basis of 2 measures -- health impact and cost-effectiveness. According to the NCPP, the 5 clinical preventive services that would have the most impact on cardiovascular health (in order from greatest to least impact) include (1) aspirin use to prevent heart disease, (2) smoking cessation advice and help to quit, (3) cholesterol screening in the past 5 years, (4) hypertension screening and treatment, and (5) influenza immunization in adults ages 50 and older.  * 尼古丁成瘾会导致生理和心理上的依赖。针对生理、心理依赖，戒烟的方法主要有：戒烟药物，治疗生理依赖，减轻戒烟是产生的戒断症状；心理支持，治疗心理依赖，如帮助患者树立正确的观念、审查戒烟理由、确定戒烟日期、回顾戒烟经历、做好戒烟思想准备、处理戒断症状、提供辅助材料及电话咨询等；其他的方法，如行为疗法，即行为矫正，改变吸烟者在日常生活过程中会提示吸烟的习惯。烟草依赖最佳的方案是药物和心理、行为治疗相结合。因为单纯自行戒烟的失败率约为90-95% ，而有效的药物措施可使成功率倍增（2- 3 倍)。* Smoking has been implicated as a cause of both peripheral and coronary endothelial dysfunction and has been shown to be a predictor of long-term cardiovascular events, but its mechanism is not fully understood. Potential mechanisms by which smoking may play a role in cardiovascular events prior to the development of significant coronary artery disease (CAD) include induction of endothelial dysfunction, oxidative stress, increased blood thrombogenicity, and an enhanced inflammatory response. Reference Lavi S, Prasad A, Yang EH, et al. Smoking is associated with epicardial coronary endothelial dysfunction and elevated white blood cell count in patients with chest pain and early coronary artery disease. Circulation. 2007; 115:2621-2627. 有大量临床研究证实吸烟加重使冠心病发生风险增加。这样图显示的是一项对美国男性白人进行的调查。从图中我们可以看到：冠心病的发病率与吸烟、胆固醇升高和高血压都有着密切的关系，其中吸烟加上另外两个风险因素之一的参与者（请看第三根柱子），其冠心病发病率比胆固醇加高血压因素的参与者（请看第四根柱子）的发病率要高，而三个危险因素皆有的参与者（请看第五根柱子）发病率最高，间接说明了吸烟在冠心病发病中的重要作用。Key Point Smoking has a multiplicative interaction with the major risk factors for coronary artery disease (CAD), to increase disease risk. For example, if the presence of smoking alone doubles the level of risk for CAD, the presence of another major risk factor in conjunction with smoking results in approximately a 4-fold (2 2) increase in risk, and the presence of 2 other risk factors together with smoking results in approximately an 8-fold increase in risk (2 2 2). As shown above, baseline risk of a new cardiac event is 23/1000 (without risk factors present). Presence of any one of the major risk factors increases the risk for a new cardiac event over a 10-year interval to 31/1000. If the presence of each additional risk factor acted independently, then the risk would increase by 31 for 1, by 62 for 2, and by 93 for 3 risk factors. However, as noted above, adding smoking to another risk factor results in markedly higher risk than would have resulted from simply adding together independent risks. This indicates that smoking interacts with other risk factors to produce a level of risk greater than that of independent risk factors alone. Reference Burns DM. Epidemiology of smoking-induced cardiovascular disease. Prog Cardiovasc Dis. 2003;46(1):11-29. 同时，戒烟还能提高冠脉介入治疗后患者的生存率，本图为我们展示了经冠脉介入治疗后的戒烟者比相同情况的吸烟者生存率下降明显延缓，说明戒烟能延缓冠脉介入治疗后的死亡。Key Point Persistent smokers had a significantly greater risk of overall mortality after percutaneous coronary revascularization. Patients (N=6600) who underwent percutaneous coronary revascularization at the Mayo Clinic from 1979 through 1995 were followed for up to 16 years by Hasdai et al. Patients were questioned about their smoking status at baseline and follow-up. Study population was divided into 4 groups on the basis of smoking status at baseline: nonsmokers, defined as patients who had never smoked cigarettes regularly; ex-smokers, who had quit smoking a minimum of 6 months before the procedure; quitters,