吸烟与心血管疾病防控南方医院心内科吴平生内容吸烟的形势吸烟——心血管疾病的独立危险因素戒烟难——慢性成瘾性疾病，且具有高复发性医生的力量由吸烟引起死亡的前三位疾病： 内容吸烟的形势吸烟——心血管疾病的独立危险因素戒烟难——慢性成瘾性疾病，且具有高复发性医生的力量心血管疾病的危险因素（中国NEHNS IV ）高血压	 160M 血脂异常	 160M 糖尿病	 20MIFG 20M 肥胖 60M 超重200M 吸烟	 350M 被动吸烟540M 烟草和烟雾的主要成分研究吸烟促发心血管疾病的发病机理内皮功能紊乱血栓生成增加炎症反应加强氧化修饰吸烟使心血管疾病雪上加霜！吸烟使冠心病的风险倍增主动脉粥样硬化的风险随吸烟量增加冠心病死亡率的增加与吸烟率直接相关心绞痛的风险与吸烟量直接相关吸烟增加心源性猝死的风险吸烟使冠状动脉介入治疗后发生Q波心梗的风险增高吸烟使血管手术后的死亡率增加为了提供最新的生存资料，Kazmers 等人对310 位择期进行血管手术的患者进行了评估随访时间为6.64 4.62 年年龄、糖尿病、吸烟以及较低的射血分数是术后死亡率的独立相关危险因素戒烟使心血管疾病患者受益！美国NCCP 公布前三位有效的临床预防措施高危人群服用阿司匹林儿童疫苗接种戒烟4 直肠癌筛查5 高血压筛查6 流感疫苗接种戒烟给心血管系统带来的益处短期益处纤维蛋白原浓度下降纤维蛋白原合成速率减低白细胞计数下降高密度/低密度脂蛋白比例改善卒中风险降低高密度脂蛋白增加低密度脂蛋白下降动脉压心率下降动脉顺应性改善心梗后心律失常所致猝死风险减低血小板体积减小血小板环磷酸腺苷反应增强，促使前列腺素E1 发生腺苷酸环化吸烟导致的血小板聚集减少长期益处减少下列风险卒中重复冠脉搭桥术心梗后反复发生冠脉事件心梗后心律失常所致猝死继发心血管疾病冠脉搭桥术后血运重建术减少冠脉搭桥术后的死亡率经皮冠状动脉成形术后死亡率与心血管疾病进展相关的炎症标志分子水平(C 反应蛋白, 白细胞, 纤维蛋白原) 戒烟是冠心病强效干预措施为什么戒烟这么难？吸烟者想戒烟但成功比例低戒烟难，还在于戒断后容易复发信―从转变观念开始 烟草依赖不只是一种个人习惯， 而是一种明确界定的慢性病。1998 年世界卫生大会决议烟草依赖作为一种疾病列入《国际疾病分类（第10 版）》确认烟草是目前对人类健康的最大威胁尼古丁成瘾环 ——正性强化和负性强化吸烟者一般来讲会增加吸烟量，以获得更大的愉快感并避免戒断症状和对烟草的渴求医生的帮助中国医院的戒烟模式医生戒烟戒烟门诊戒烟热线将戒烟纳入慢病管理常规烟草依赖符合慢性疾病的特征导致身体结构和功能改变具有迁延性、无自愈性或治愈困难需要长期治疗、护理、特殊康复训练的疾病易导致各种并发症。医生的力量在中国：190 万临床医生每人每年帮助10 个病人戒烟如果有一个能戒烟成功每年190 万吸烟人戒烟近100 万人今后免于死于吸烟相关疾病哪一项临床手段，公共卫生措施能取得如此效果？USDHHS: 不同类型人员干预效果(n=29 项研究) 中国戒烟ABC ：给患者三分钟时间讨论戒烟行动―应用科学方法，有效控烟摘自2008 版《美国戒烟指南》Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking-except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications(5 nicotine and 2 non-nicotine)reliably increase long-term smoking abstinence rates: -Bupropion SR -Nicotine gum -Nicotine inhaler -Nicotine lozenge -Nicotine nasal spray -Nicotine patch -Varenicline 尼古丁受体部分激动剂 通用名：酒石酸伐尼克兰片商品名：Champix 中文名：畅沛英文名：Varenicline Tartrate Tablets 与安慰剂相比，伐尼克兰显著降低对尼古丁的渴求、戒断症状和强化作用1,2 比值比1 1.1 1.7 2.2 1 1.5 2 2.5 无自助非医务人员医生CI 1.3-2.1 CI 1.5-3.2 USDHHS: United States Department of Health and Human Service 戒烟表率控烟先锋—心血管医生戒烟宣言中国是全球最大的烟草生产和消费国，控烟工作任重道远。心血管医生，每日面对受吸烟之害的心脏病患者，怎能熟视无睹。第一部国际公共卫生公约《烟草控制框架公约》已经生效，中国政府目前正在积极履约。同时，面对“无烟奥运”的契机，中国必将迎来控烟高潮。作为一名心血管医生，我们责无旁贷，将致力控烟，践诺“健康所系，性命相托”的医学誓言。A (Ask) ：询问您目前吸烟吗？强化吸烟与心血管疾病的关系了解吸烟的程度：每天抽几支烟？抽了多少年？早晨醒来后多长时间抽第一支烟？策略：用清晰的、强烈的、个性化的方式，劝说每一位吸烟者戒烟信息：吸烟对健康危害巨大您现在所患的心血管疾病与吸烟有密切关系戒烟对您恢复健康非常重要行动：劝戒吸烟者“您现在就必须完全戒烟”您希望尝试戒烟吗？行动：发放宣传资料安排下一次的随诊策略：明确障碍，具体支持信息：戒烟是一个需要毅力的艰难过程，经常需要医生和药物的协助；行动：发放宣传资料设定戒烟日期戒烟的策略：心理治疗＋药物治疗建议患者咨询戒烟门诊或电话热线否是否是B (Brief Advice) ：建议C (Cessation Support) ：支持烟草依赖的治疗烟草依赖最佳治疗方案：药物和心理、行为治疗结合。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)。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）US guideline (AHRQ, 2000) 　UK guideline (1998) New Zealand guideline (2007) Coe JW et al. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on Nicotine and Tobacco. 2005. 2. Picciotto MR et al. Nicotine Tob Res. 1999 尼古丁与中脑腹侧背盖区尼古丁乙酰胆碱4 2受体结合导致多巴胺释放伐尼克兰是一种高选择性4 2 受体部分激动剂，具有激动剂和拮抗剂双重活性。可缓解对尼古丁的渴望与戒断症状, 并可阻断尼古丁与受体的结合，减少伏核(nAcc ) 区域释放的多巴胺，从而降低吸烟的奖赏效应。	尼古丁伐尼克兰全新的戒烟新药-双重作用机制食欲增加失眠坐立不安负面情绪吸烟渴求降低心理奖赏吸烟愉悦感与安慰剂相比评分显著降低；与安慰剂相比评分显著增加吸烟冲动(MNWS) 研究2 研究1 研究2 研究1 盐酸安非他酮缓释片伐尼克兰戒断症状强化作用尼古丁渴求1.Jorenby DE et al. JAMA. 2006;296:56-63. 2. Gonzales D et al. JAMA. 2006;296:47-55. THANK YOU Key Point Smoking is causally linked to a host of cardiovascular, respiratory, reproductive, and other conditions, as well as many types of cancer. The top 3 smoking-attributable causes of death in the United States are lung cancer, ischemic heart disease, and chronic obstructive pulmonary disease (COPD). Background In 2004, the US Surgeon General published a report on the health effects of active smoking, focusing specifically on the evidence for a causal relationship between smoking and disease and death. According to the research summarized in the report, many serious conditions are caused by smoking, including cardiovascular, respiratory, reproductive, and other conditions, as well as cancer affecting diverse areas and organs of the body. In addition to the widely-known consequences of lung cancer and respiratory disease, smoking has been causally linked to such diverse morbidities as low-bone density, nuclear cataract, bladder cancer, and reduced fertility.1 Other studies have linked smoking to vascular dementia2 and peripheral arterial disease.3 These conditions can affect young and middle-aged smokers and, in general, as a smoker’s age increases, the frequency of smoking-caused diseases rises.1 References 1. US Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. Atlanta, Ga: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. 2. Roman GC. Vascular dementia prevention: a risk factor analysis. Cerebrovasc Dis. 2005;20(Suppl 2):91-100. 3. Willigendael EM, Teijink JA, Bartelink ML, et al. Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg. 2004;40:1158-1165. 4. Ezzati M, Lopez AD. Regional, disease specific patterns of smoking-attributable mortality in 2000. Tobacco Control. 2004;13:388-395. 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. Key Point The risk of fatal