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Public Health

Behind the smoke screen

A study shows how to identify and treat high risk smokers

ESCHER, LIBERATIONIt is a known fact that only willpower is not enough to quit smoking. Of every one hundred people who attempt to stop smoking merely by willpower, only five manage. Their state of health has a lot to do with it  – the more damaged the organism, the greater are the chances of success of an anti-tobacco treatment – and family support, according to a study coordinated by Andrea Cotait Ayoub, from the Dante Pazzanese Institute of Cardiology, one of the largest medical research and treatment centers specializing in cardiovascular illnesses, linked to the public health network of the state of São Paulo. After following for six months the 124 smokers who participated in the anti-tobacco program, some had been attempting for the fourth time to free themselves of the habit, only with behavior therapy, one of the anti-tobacco treatment resources, did Andrea create an equation with five variables that identify the smokers with a high risk of being unsuccessful and anticipate the probability of the treatment being successful or not.

This manner of classifying the smokers into high and low probability of being unsuccessful, once validated in tests with a higher number of participants, many become a tool similar to the evaluations adopted to measure alcohol or cocaine dependence, identifying the person who needs more intensive care. In the most serious cases, according to Andrea, who heads the institute’s nursing division, it may well be necessary to reinforce psychological counseling, right from the start of treatment, with the use of antidepressants and nicotine patches or chewing gum. Such medicines, nevertheless, are not always supplied by the public health service. Another strategy to be used would be to bring to the hospital the family members closest to the smoker, in order to convince them of the risks of illnesses that amplify with each cigarette puff.

According to this risk classification, developed under the supervision of professor Riad Naim Younes, the director of the Thoracic Surgery Department, of the Sâo Paulo Cancer Hospital, if a smoker presents emphysema, bronchitis or any other form of what is called chronic obstructive pulmonary disease, the chance of that person making the effort to the point of quitting the habit is 26.4 times greater than for the person with their lungs in order. If the smoker were to live with someone –  husband, wife, son, father or mother – who hates this habit that spreads smoke throughout the house, the chance of success is 19.5 times greater than that of another who is not criticized at home. To participate in a tobacco support group raises by a 11.3 times the probability of treatment success and of having a wheezy chest, the sign that the smoking habit is old or damaging runs to 3.3 times. The sum of these four values must be subtracted from nicotine dependency – measured by the test named the Fagerström Test, whose value varies from 2 to 8 points for the less dependent and from 9 or more for the more dependent – multiplied by a factor of 5.3.

When the accounting is done, the sub-group of smokers that obtain a final score less or equal to 49 will be classified as high probability of being unsuccessful, while those who manage a score greater than 49 will have more of a chance of success with the treatment. The arithmetic reflects reality: people with chronic obstructive pulmonary disease, a chest wheeze and low nicotine dependency who have participated in the smoker support programs and live with someone who hates this habit, have more chance of freeing themselves from the cigarette than those found to be in the opposite situations.

Essential dialogue
A graduate in nursing from the Federal University of São Paulo (UNIFESP) and with a doctorate degree from the Cancer Hospital, Andrea talked about the risks of smoking, showed the difference between a generic and impersonal statement such as cigarettes kill and one as cigarettes are killing you, and encouraged this study’s participants to confront, without any medication, the revolt of the body to the shortage of nicotine. “Dedication, acceptance and dialogue are essential for the treatment to work”, she says. Only with group meetings and psychological follow-ups during two months, 40% of the high risk smokers managed to quit smoking and six months after stopping the treatment, they had managed to keep themselves a long way from their old habit without having to bite their nails.

“The success rate would certainly have been higher if this study’s participants had also received medication”, the researcher says. At the Cancer Hospital, also in São Paulo, 47.5% of the 237 total of participants in a quit -smoking support program were able to count upon both resources, behavioral therapy and the replacement of nicotine. This experience facilitated the implementation of a more personalized attention model than at the Dante Pazzanese Institute. “The more attention that is offered to the smoker, the better their response to treatment.”

Only the use of antidepressants already helps considerably. By way of a study involving 144 people published during 2002 in the magazine Chest, a team from the Cancer Hospital, coordinated by Célia Costa concluded that the antidepressant nortriptyline (known in Brazil by the brand names Pamelor or Aventil) – of lower cost than bupropion (Zyban or Wellbutrin), up until that moment adopted as first choice – could be very helpful in the treatment of smokers, especially those with high dependency on nicotine. Of the 68 people in this study who took nortriptyline, 51% quit smoking for at least one week, while only 24% of the 76 who took a placebo managed to maintain themselves away from the cigarette. Six months later, 26% of those who had taken the antidepressant and 5% of those who had taken the placebo had maintained total abstinence, a strong indication that the old habit has been left aside.

To widen or to induce access to treatment in such a way as to lead half of the current smokers to quit smoking could avoid 20 million to 50 million premature deaths over the next 25 years, since smokers tend to die on average ten years sooner than non-smokers, according to a study that came out in the British Medical Journal. Even the non-smokers would benefit. Dr. Koon Teo, from the McMaster University, Hamilton, Canada, coordinated a recent survey upon 27,000 people in 52 countries that established a direct relationship between the quantity of cigarette smoke inhaled and the risk levels for an acute heart attack. According to this survey, published on the 18th of August in the magazine Lancet, the person who only breathes in the exhaled smoke is subject to higher risks than had been imagined. From one to seven hours exposure to cigarette smoke from others increases the risk of a heart attack by 24%; more than 21 hours per week inhaling the smoke makes the possibility rise to 60%. Anyone who smokes is subject to a risk three times higher of having a heart attack than the non-smoker, and the risk increases 5.6% for every cigarette smoked. Even chewing tobacco, something apparently less harmful, but it doubles the risk of a heart attack.

ESCHER, EYEUnder the mist
“With more treatment and prevention”, says Younes, from the Cancer Hospital, based on a series of studies, “cancer cases, mainly those of the lung, can fall by 70%, since one is dealing with a disease that stems from a habit that can be avoided”. Tobacco is pointed to as the main cause of avoidable premature deaths: every year around 5 million people die in the entire world due to the fifty diseases associated to the habit of smoking cigarettes, looked upon today as a form of chemical and psychological dependence. It is estimated that the whitened mist that helped to compose the Humphrey Bogart style in Casablanca and of so many other personalities in the cinema, results in the combination of around 4,700 toxic substances, of which 60 are associated with the emergence and development of cancer, not only that of the lungs, but also of the mouth, larynx, esophagus, stomach and bladder, as well as heart attacks and other problems linked to blood circulation and to the heart and, in a manner more and more consistent, to damages to the eyesight.

According to Younes, attention to smokers must be more decentralized and involve even the community health agents, since hospitals rarely manage to attend to more than one hundred people per year. In an article published in the magazine Salud Pública de México  [Public Health of Mexico], Tânia Cavalcante, the coordinator of the National Smoking Control Program of the Brazilian National Cancer Institute (Inca in the Portuguese acronym), described some of the country’s advances in the fight against smoking, such as the prohibition of the use of classifying cigarettes as light, ultralight or mild, so as not to give the impression that they are less harmful, the disclosing of the message and of the disturbing images about the harmful effects of the cigarette on health and the progressive installation of specialized clinics when attending to smokers, throughout the country.

In the coming and going of this international movement, the prevalence of smokers over 15 years of age in Brazil went from 32.6% in 1989 to 19.0% in 2003. An Inca survey showed a greater reduction for men than for women. Nevertheless, there are still barriers, such as the growing number of teenagers  who are beginning to smoke, and the price of a pack of cigarettes in Brazil, one of the cheapest in the world – the same brand sold in the country costs four times more in Canada and 4.7 times more in Denmark, according to a World Health Organization (WHO) survey. Just a price rise of 10%, also according to a WHO survey, would make 3% of smokers quit moking – something equivalent to almost 2 million Brazilians.

For the government, tobacco is at the same time a source of income, continuous and immediate, since 75% of the price of each pack of cigarettes is held back in the form of taxes, and of expenses, in such a way that for every R$1.00 that comes out of the consumer’s pocket to purchase cigarettes some R$ 2.60 are spent on the medical treatment of people who contract cancer or cardiac problems because of their smoking habit. Even with such damages and risks, that the prevention campaigns attempt to relate, 1.3 billion people in the entire world currently still smoke and 700 million children are exposed in their homes to cigarette smoke, also losing their health. The majority of smokers (82%) live in developing countries such as Brazil – where here, 33.8% of the population, equivalent to 60 million people, cannot live without their cigarette.

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