Dopamine D4 receptor gene variation moderates the efficacy of bupropion for smoking cessation.

Smokers (≥10 cigarettes per day, N=331) of European ancestry taking part in a double-blind placebo-controlled randomized trial of 12 weeks of treatment with bupropion along with counseling for smoking cessation were genotyped for a variable number of tandem repeats polymorphism in exon III of the dopamine D4 receptor gene. Generalized estimating equations predicting point-prevalence abstinence at end of treatment and 2, 6 and 12 months after the end of treatment indicated that bupropion (vs placebo) predicted increased odds of abstinence. The main effect of Genotype was not significant. A Genotype × Treatment interaction (P=0.005) showed that bupropion predicted increased odds of abstinence in long-allele carriers (odds ratios (OR)=1.31, P<0.0001), whereas bupropion was not associated with abstinence among short-allele homozygotes (OR=1.06, P=0.23). The Genotype × Treatment interaction remained when controlling for demographic and clinical covariates (P=0.01) and in analyses predicting continuous abstinence (P's≤0.054). Bupropion may be more efficacious for smokers who carry the long allele, which is relevant to personalized pharmacogenetic treatment approaches.

Lifetime characteristics of participants and non-participants in a smoking cessation trial: implications for external validity and public health impact.

BACKGROUND: Detailed information about the characteristics of smokers who do and do not participate in smoking cessation treatment is needed to improve efforts to reach, motivate, and treat smokers. PURPOSE: The aim of this study is to explore a broad range of characteristics related to participation in a smoking cessation trial. METHODS: Eligible smokers were recruited from a longitudinal birth cohort. Participants and non-participants were compared on a broad range of sociodemographics, smoking, psychiatric and substance abuse disorders, personality, and prospective measures from early childhood. Eligible smokers were compared to a matched regional subsample of the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: Few differences were observed, most of which were statistically significant but not clinically meaningful. Compared to non-participants, participants were more likely to be single, have lower income, be more nicotine-dependent, be more motivated to quit, and have higher levels of depressed mood and stress even after covariance of gender, income, and marital status. Sociodemographic differences between participants and the BRFSS sample reflect the skew toward lower socioeconomic status in the original birth cohort. CONCLUSIONS: The encouraging conclusion is that smokers who enroll in cessation trials may not differ much from non-participants. Information about treatment participants can inform the development of recruitment strategies, improve the tailoring of treatment to individual smoker profiles, help to estimate potential selection bias, and improve estimates of population impact.

Physician's advice on quitting smoking in HIV and TB patients in south India: a randomised clinical trial.

Setting: National Institute for Research in Tuberculosis, Madurai, India. Objective: To determine the efficacy of physician's advice on quitting smoking compared with standard counselling in patients with tuberculosis (TB) and patients with human immunodeficiency virus (HIV) infection. Design/Methods: This was a clinical trial conducted in Madurai, south India, among 160 male patients (80 with TB and 80 with HIV), randomised and stratified by nicotine dependence (low/high according to the Fagerström scale), who received physician's advice with standard counselling or standard counselling alone for smoking cessation. Abstinence at 1 month was assessed by self-report and carbon monoxide breath analysis. Results: The patients' mean age was 39.4 years (SD 8.5). Overall, 35% of the patients had high nicotine dependence. Most patients (41%) smoked both cigarettes and bidis. In a combined analysis including both the HIV and the TB groups, quit rates were 41% of the 68 patients in the physician group and 35% of the 68 patients in the standard counselling arm. Conclusions: Physician's advice to quit smoking delivered to patients with TB or HIV is feasible and acceptable. Smoking cessation could easily be initiated in TB patients in programme settings. Future studies should assess long-term abstinence rates with a larger sample size to demonstrate the efficacy of physician's advice.

Contexte : National Institute for Research in Tuberculosis (NIRT), Madurai, Inde.Objectif : Déterminer l'efficacité des conseils d'un médecin comparés aux conseils standard d'arrêt du tabac chez des patients atteints de tuberculose (TB) et chez des patients infectés par le virus de l'immunodéficience humaine (VIH).Schéma/Méthodes : Cet essai clinique a été réalisé à Madurai, dans le sud de l'Inde. Cent soixante patients masculins (80 TB et 80 VIH) ont été randomisés, stratifiés en fonction de leur dépendance à la nicotine (faible/élevée selon l'échelle de Fagerström) pour bénéficier soit des conseils d'un médecin avec des conseils standard ou des conseils standard seuls pour l'arrêt du tabac. L'abstinence à un mois a été évaluée par déclaration des patients et analyse du monoxyde de carbone dans l'air expiré.Résultats : L'âge moyen (DS) a été de 39,4 (±8,5) ans. Dans l'ensemble, 35% des patients avaient une dépendance élevée à la nicotine. La majorité des patients (41%) fumait à la fois des cigarettes et des bidis (cigarettes indiennes). En analyse combinée (à la fois le groupe VIH et TB), les taux de cessation ont été de 41% sur 68 patients dans le groupe « médecin ¼ et de 35% de 68 patients dans le bras « conseil standard ¼ (non significatif).Conclusions: Les conseils d'un médecin en matière d'arrêt de tabac délivrés aux patients atteints de TB ou de VIH sont faisables et acceptables. L'arrêt du tabac pourrait bien être mis en œuvre dans le contexte des programmes chez les patients TB. De futures études devraient évaluer le taux d'abstinence à long terme avec des échantillons de plus grande taille afin de démontrer l'efficacité des conseils d'un médecin.

Marco de referencia: El Instituto Nacional de Investigación en Tuberculosis de Madurai, en la India.Objetivo: Comparar la eficacia de los consejos que da el médico con el asesoramiento corriente sobre el abandono del tabaco, en pacientes aquejados de tuberculosis (TB) o infección por el virus de la inmunodeficiencia humana (VIH).Métodos: El ensayo clínico inicial se llevó a cabo en Madurai, en el sur de la India. Se escogieron de manera aleatoria 160 pacientes de sexo masculino (80 con diagnóstico de TB y 80 de infección por el VIH), se estratificaron en función de la dependencia de la nicotina (baja y alta, según la escala de Fagerström) y se asignaron a un grupo que recibiría consejos del médico además del asesoramiento corriente sobre el abandono del tabaco o un grupo que solo recibiría el asesoramiento corriente. Al cabo de un mes, se evaluó la abstinencia a partir de la información proporcionada por los pacientes y la medición de monóxido de carbono en el aire espirado.Resultados: El promedio de edad de los participantes fue 39,4 años (desviación estándar 8,5 años). En general, el 35% de los participantes exhibía una alta dependencia de la nicotina. La mayoría fumaba cigarrillos y también bidis (41%). En el análisis conjunto (ambos grupos: TB y VIH), las tasas de abandono fueron 41% en los 68 pacientes del grupo que recibió consejo médico y 35% en los 68 pacientes del grupo que obtuvo asesoramiento corriente (diferencia no significativa).Conclusión: El consejo sobre el abandono del tabaco ofrecido por el médico a los pacientes con diagnóstico de TB o infección por el VIH es factible y bien aceptado. Es posible iniciar intervenciones de abandono del tabaco con los pacientes TB en el marco programático. Futuros estudios podrían evaluar las tasas de abstinencia a largo plazo con muestras más grandes, a fin de demostrar la eficacia del consejo dado por los médicos.

Physicians counseling smokers. A population-based survey of patients' perceptions of health care provider-delivered smoking cessation interventions.

OBJECTIVE: To examine associations between sociodemographic and psychological characteristics of smokers and delivery of 5 types of smoking cessation counseling interventions by physicians and office staff. METHODS: We used a telephone survey of a population-based sample of adult cigarette smokers (N = 3037) who saw a physician in the last year. Primary outcomes included patients' report of whether a physician or other health care provider (1) talked about smoking, (2) advised them to quit, (3) offered help to quit, (4) arranged a follow-up contact, and (5) prescribed nicotine gum or other medication. RESULTS: Fifty-one percent of smokers were talked to about their smoking; 45.5% were advised to quit; 14.9% were offered help; 3% had a follow-up appointment arranged; and 8.5% were prescribed medication. In multivariate analyses, the most consistent predictors of receipt of almost all counseling behaviors were medical setting (private physician's office only > care in other settings), health status (fair or poor > good, very good, or excellent), more years of education, greater number of cigarettes smoked per day, stage of readiness to quit smoking (preparation > precontemplation), and greater reported benefits of smoking. CONCLUSIONS: Physicians and other health care providers are not meeting the standards of smoking intervention outlined by the National Cancer Institute and the Agency for Health Care Policy and Research. Health care providers who intervene only with those patients who are ready to quit smoking are missing opportunities to provide effective smoking interventions to the majority of their patients. Interventions are also less likely to be provided to healthier and lighter smokers.

Lipid and lipoprotein responses to episodic occupational and academic stress.

We examined the effects of psychological stress on plasma lipid, lipoprotein, and apolipoprotein levels in three related studies. In the first study, tax accountants (N = 20) and a comparable control group (N = 20) were assessed during and after the tax season. In the second and third studies, first-year medical students (N = 24 and N = 16) were assessed at midsemester and immediately before the examinations. Across studies, the stressors induced significant psychological distress. There were no corresponding changes in lipid and lipoprotein levels. Mean stress-induced change in total cholesterol level was -0.04 mmol/L (-1.6 mg/dL) (95% confidence interval, -0.23 to 0.16 mmol/L [-9 to 6 mg/dL]) for the accountants and 0 mmol/L (0 mg/dL) (95% confidence interval, -0.16 to 0.21 mmol/L [-6 to 8 mg/dL]) and 0.10 mmol/L (4 mg/dL) (95% confidence interval, -0.18 to 0.39 mmol/L [-7 to 15 mg/dL]) for medical students in the second and third studies, respectively. In all studies, change in total cholesterol level correlated with change in total serum protein levels (r = .42 to .60). These results suggest that commonly occurring stressful situations do not produce significant changes in plasma lipid and lipoprotein levels.

The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial.

BACKGROUND: Smoking prevalence rates among women are declining at a slower rate than among men. OBJECTIVE: To determine if exercise, a healthful alternative to smoking, enhances the achievement and maintenance of smoking cessation. METHODS: Two hundred eighty-one healthy, sedentary female smokers were randomly assigned to either a cognitive-behavioral smoking cessation program with vigorous exercise (exercise) or to the same program with equal staff contact time (control). Subjects participated in a 12-session, group-based smoking cessation program. Additionally, exercise subjects were required to attend 3 supervised exercise sessions per week and control subjects were required to participate in 3 supervised health education lectures per week. Abstinence from smoking was based on self-report, was verified by saliva cotinine level, and was measured at 1 week after quit day (week 5), end of treatment (week 12), and 3 and 12 months later (20 and 60 weeks after quit day, respectively). RESULTS: Compared with control subjects (n = 147), exercise subjects (n = 134) achieved significantly higher levels of continuous abstinence at the end of treatment (19.4% vs 10.2%, P = .03) and 3 months (16.4% vs 8.2%, P=.03) and 12 months (11.9% vs 5.4%, P=.05) following treatment. Exercise subjects had significantly increased functional capacity (estimated VO2 peak, 25+/-6 to 28+/-6, P<.01) and had gained less weight by the end of treatment (3.05 vs 5.40 kg, P = .03). CONCLUSIONS: Vigorous exercise facilitates short- and longer-term smoking cessation in women when combined with a cognitive-behavioral smoking cessation program. Vigorous exercise improves exercise capacity and delays weight gain following smoking cessation.

Effects of behavioral skills training and schedule of nicotine gum administration on smoking cessation.

Eighty-nine smokers were randomly assigned to four nicotine gum treatments for smoking cessation: behavioral treatment plus a fixed schedule of nicotine gum, behavioral treatment plus an ad lib schedule, education plus a fixed schedule, and education plus an ad lib schedule. The four treatment conditions produced similar rates of abstinence (40.9% to 58.3%) at the end of 11 weeks of treatment. However, at 6-month follow-up, the subjects who had received behavioral treatment had a significantly better abstinence rate (36.7%) than those receiving education (17.5%). Nicotine gum schedule had no effect on treatment outcome.

Relation of psychosocial and stress reactivity variables to ventricular arrhythmias in the Cardiac Arrhythmia Pilot Study (CAPS).

Both animal and human data implicate psychosocial distress and cardiovascular reactivity in response to challenge in the etiology of sudden cardiac death. In this study, the relation of these biobehaviorial factors to frequency of ventricular premature complexes, a predictor of sudden death was investigated. The study population was made up of patients enrolled in the National Heart, Lung, and Blood Institute's Cardiac Arrhythmia Pilot Study (CAPS). Ventricular premature complexes (VPCs) were assessed by multiple, 24-hour ambulatory electrocardiographic recordings. Patients completed trait psychosocial measures assessed at baseline and state psychosocial measures assessed periodically during a 1-year follow-up period. Psychosocial measures included self-reports of depression, anxiety, anger and type A behavior pattern. A competitive challenge using a video game was used as a stressor to elicit cardiovascular reactivity and was administered at baseline and during follow-up sessions. Cardiovascular reactivity was defined as peak level during stressor exposure minus the mean of resting levels for systolic and diastolic blood pressure and pulse rate. Results indicated that biobehavioral factors were not associated with diurnal VPC rates. Furthermore, biobehavioral factors did not predict response to antiarrhythmic therapy. Based upon the results of this study, it is speculated that the established relation between behavioral factors and sudden death may not be mediated by VPC rates.

Assessment of quality of life as observed from the baseline data of the Studies of Left Ventricular Dysfunction (SOLVD) trial quality-of-life substudy.

The improvement of aspects of a patient's quality of life may be as important as prolonging survival in evaluating clinical trials of heart failure. The purpose of this study was to analyze the psychometric properties of the baseline measures from the quality-of-life substudy from the Studies of Left Ventricular Dysfunction (SOLVD) trial. The measures included the 6-Minute Walk Test, Dyspnea Scale, Living with Heart Failure, Physical Limitations, Psychologic Distress and Health Perceptions, as reported by both patients and staff. Cognitive functioning, such as Vocabulary, Digit Span and Trails Making, was also assessed. Patients were classified as New York Heart Association class I (n = 158) versus II or III (n = 150). The internal consistencies (i.e., reliabilities) of the self-report measures were high, except for the Health Perceptions of Class II or III patients. Reliability of the SOLVD quality-of-life battery was confirmed by significantly better life quality among New York Heart Association class I patients versus class II or III patients combined on the Walk Test, Physical Limitations, Dyspnea, Living with Heart Failure, Psychologic Distress and staff perceptions of patient health. In accordance with prior studies, the measures were uncorrelated with left ventricular ejection fraction. By demonstrating strong internal consistencies, reliability based on physician reports, and independence of ejection fraction levels, use of this quality-of-life assessment battery in this and other clinical trials of compromised ventricular functioning is supported.

Development of major depressive disorder during smoking-cessation treatment.

BACKGROUND: Several studies have shown an association between smoking and major depressive disorder (MDD), but few have prospectively examined subjects who develop MDD after quitting smoking. This descriptive study evaluated the development of MDD after smoking cessation, as assessed by a structured clinical interview at both baseline and the end of treatment. METHOD: Nondepressed participants (N = 114) in a trial investigating the effect of fluoxetine on smoking cessation were administered the Structured Clinical Interview for DSM-III-R at baseline and posttreatment to evaluate the impact of quitting smoking on the development of MDD. Depressive symptoms were additionally assessed with the Beck Depression Inventory and the Hamilton Rating Scale for Depression. RESULTS: At baseline, 32% of the subjects reported a history of MDD. Sixty-nine subjects completed the SCID at baseline and posttreatment. At posttreatment, 5 subjects (7%) met threshold criteria for MDD; none were taking the highest dose of fluoxetine (60 mg), 4 were taking 30 mg, and 1 was taking placebo. All 5 had a history of MDD; 3 were women. Four had a history of substance abuse and attained at least 3 consecutive biochemically verified weeks of smoking abstinence. Those who developed MDD after treatment scored significantly higher on measures of depressed mood at baseline than those who did not develop MDD after smoking-cessation treatment. CONCLUSION: The results from this descriptive study suggest that a subset of smokers may be at risk for developing MDD after smoking cessation.

The effects of smoking high nicotine cigarettes on prepulse inhibition, startle latency, and subjective responses.

RATIONALE: Several previous investigations with animals and humans have suggested that nicotine enhances prepulse inhibition of the startle reflex (PPI). However, the administration of nicotine activates mesolimbic dopamine, and activation of mesolimbic dopamine is known to attenuate prepulse inhibition of the startle reflex (PPI), which might suggest that nicotine would decrease PPI. OBJECTIVE: The primary aim of this study was to test rigorously the effects of smoking high nicotine cigarettes on PPI and other measures (e.g., heart rate, craving, and mood) when the concentration of nicotine peaks in the brain (i.e., immediately after smoking). METHODS: Thirty smokers participated in two experimental sessions 1 week apart. Two high nicotine cigarettes were smoked in one session, and two control cigarettes were smoked in the other session after overnight deprivation. RESULTS: The results indicated that smoking the high nicotine cigarettes decreased PPI and that PPI increased across trials in both conditions. The interaction between nicotine dose and trial was not significant, although it appeared that high nicotine may have reversed an increase in PPI across trials in the control condition. High nicotine cigarettes also significantly increased heart rate, decreased the latency to peak startle response on control trials, but did not alter the magnitude of the startle response. DISCUSSION: The findings suggest that either high nicotine cigarettes reduced PPI, or possibly, that high nicotine cigarettes may have reversed an increase in PPI across trials as evident in the control condition.

Effects of naltrexone with nicotine replacement on smoking cue reactivity: preliminary results.

Although several studies have examined the effects of opioid antagonists on smoking behavior, there have been no reports of the potentially therapeutic combination of naltrexone and nicotine replacement therapy. The primary objective of the present study was to determine whether naltrexone reduced reactivity to smoking cues among abstinent smokers treated with nicotine replacement. Twenty participants were instructed to abstain from smoking cigarettes for 9 h while using nicotine replacement therapy. Participants were subsequently treated with either naltrexone (50 mg) or placebo before being exposed to smoking cues. Results indicated that the smokers who received the placebo responded to smoking cue exposure with increases in urge to smoke and increases in negative affect. Participants who received naltrexone did not show any increase in urge or negative affect and showed a decrease in withdrawal symptoms after exposure to smoking cues. Although preliminary, the findings suggest that naltrexone may work in combination with nicotine replacement therapies to block the effects of smoking stimuli in abstinent smokers.

Lipid reactivity to stress: I. Comparison of chronic and acute stress responses in middle-aged airline pilots.

Lipids increase during psychological stress, but no studies have compared the effects of acute and chronic stressors on lipid responsivity in the same individuals. One hundred middle-aged men (n = 92) and women (n = 8) were examined during high chronic occupational stress, low chronic stress, and acute laboratory stressors. In addition to measures of perceived stress and affect, an extensive battery of lipid and lipoprotein measures was undertaken at each time point. Most lipid parameters were significantly increased during the chronic and acute stressors, although the responses to the different stressors were not consistently associated. For example, significant correlations among the chronic and acute stress responses were apparent for the apoproteins, but not for total, low density lipoprotein, or high density lipoprotein cholesterol. The factors and processes regulating these variables during stress may be different during acute and chronic stressors.

Lipid reactivity to stress: II. Biological and behavioral influences.

This study examined behavioral and physiological influences on lipid concentrations during acute and chronic stressors. One hundred men (n = 92) and women (n = 8) were tested during a chronic stressor and during 2 acute stressors. During chronic stress, diet, physical activity, exercise, and sleep were examined. During the acute stressors, catecholamines, cortisol, plasma volume, and cardiovascular responses were examined. None of the behavioral influences could explain the lipid response to chronic stress. Responses of the atherogenic lipids to acute stressors were not solely reflecting hemoconcentration of the plasma but were moderately correlated with cardiovascular, epinephrine, and cortisol reactivity. Diastolic blood pressure reactors to the acute stressors had larger lipid responses to the chronic stressor than did nonreactors. Elevations in blood lipids during stress are not artifacts and may be clinically significant.

The stages and processes of exercise adoption and maintenance in a worksite sample.

We applied the model of the stages and processes of change to exercise adoption and maintenance. This model has shown promise in advancing theory and treatment of the addictions and other negative health behaviors, but there have been few systematic attempts to apply the model to positive health behaviors, such as exercise adoption. Questionnaires dealing with the stages and processes of exercise change were developed and administered to a sample of 1,172 participants in a worksite health promotion project. The sample was split randomly into halves for (a) initial model development and testing and (b) confirmatory measurement model testing. Additional model confirmation was obtained by examining the hierarchical structure of the processes of change and by conducting Stage x Process analyses. Results suggest that the underlying constructs derived from smoking cessation and other addictive behaviors can be generalized to exercise behavior. Understanding the stages and processes of exercise behavior change may yield important information for enhancing exercise adoption, adherence, and relapse prevention at both individual and public health levels.

National working conference on smoking and body weight. Task Force 1: Mechanisms relevant to the relations between cigarette smoking and body weight.

Careful, comprehensive, and empirical observations provide the building blocks of the sciences, whereas theory and mechanisms provide the "cement" to hold the blocks together and serve as blueprints to direct future building. This article resulted from several days of discussion regarding theories that may underlie the relation between cigarette smoking and body weight and the relation between smoking cessation and body weight. The working group composed of social and biological scientists who addressed this assignment considered what is already known within the smoking and body weight literature and also considered relevant findings from studies of smoking or body weight regulation that have not directly addressed the interaction of these variables. As expected, we were successful at listing some of what is not known and what is worth knowing. We also tried to identify fruitful possibilities for research activity that might clarify mechanisms of action and eventually lead to theoretical development. Because we do not believe that the present state of our deliberations merits the label of theories, we decided, instead, to report the summary of these deliberations as potential mechanisms relevant to the relation between smoking and body weight.

Cognitive social learning and related perspectives on drug craving.

Many modern theories of drug use and dependence assign central prominence to the role of craving in drug use and relapse. However, some continue to debate whether drug craving has any motivational significance in terms of drug-using behaviors. Cognitive social learning theory adds additional perspective by imbedding craving within a network of cognitive processes that, as they inter-relate, influence drug use and relapse. This paper reviews tenets of cognitive social learning theory as they relate to craving, focusing on theoretical models that have attempted to explain how craving fits our understanding of the process of drug relapse. In addition, cognitive social learning theory complements theories that emphasize more biological or information processing aspects of addictive behaviors. Studies of addiction that have assessed elements of social learning theory suggest the following: (1) there exists an inverse relationship between efficacy and craving; (2) there appears to be an association between affect and craving, but the precise nature and strength of this association is unclear; (3) the relationship between outcome expectations and craving is largely unknown; and (4) correspondingly little is known about relationships between coping and craving. More empirical study is needed to address the strengths and limitations of cognitive social learning theory as it relates to our understanding the motivational significance of drug craving.

The measurement of drug craving.

This paper reviews theoretical and methodological issues in the measurement of drug craving, with an emphasis on self-report assessment. Despite the important role that craving plays in many research and clinical settings, the way in which the construct is conceptualized and measured rarely receives sufficient attention. Issues pertinent to conceptualizing craving are identified. Because there is no single perfect measure of craving, it is essential that researchers understand the limitations of each measure. Measurement performance concerns that affect the validity of different measures are reviewed. Non-verbal assessment methods are also reviewed. Research factors that may help determine the optimal measures for a given study are highlighted. It is concluded that advances in assessment will proceed only when combined with additional research and a better theoretical understanding of craving.

Cue exposure treatment for smoking relapse prevention: a controlled clinical trial.

AIMS: In an additive design, test the efficacy of cue exposure treatment for smoking relapse prevention as an adjunct to current standard cognitive behavioral and pharmacological treatments. DESIGN: Randomized, controlled clinical trial. SETTING: Outpatient behavioral medicine clinic. PARTICIPANTS: One hundred and twenty-nine cigarette smokers recruited through newspaper advertisements. INTERVENTION: After receiving an initial counseling session for cessation and setting a quit day, 129 smokers were randomly assigned to one of four relapse prevention treatment conditions: (1) brief cognitive behavioral; (2) cognitive behavioral and nicorette gum; (3) cognitive behavioral and cue exposure; and (4) cognitive behavioral and cue exposure with nicorette gum. All smokers met individually with their counselor for six RP sessions. MEASURES: Seven-day, point-prevalence abstinence rates (CO verified) taken at 1, 3, 6 and 12-months post-treatment and time to first slip. FINDINGS: All manipulation checks and process measures suggested that the treatments were delivered as intended. There were no significant differences between conditions in point-prevalence abstinence rates or in time to first slip. CONCLUSIONS: These results call into question the utility of cue exposure treatment for smoking relapse prevention.

Methods to enhance smoking cessation after myocardial infarction.

The evidence linking smoking and coronary artery disease is quite strong, and there is also a positive relationship between smoking cessation and reduction in cardiovascular disease risk. Nicotine replacement therapy and bupropion are effective treatments for smoking cessation and are most effective when combined with behavioral counseling. Intensive multicomponent interventions that include a case-management component have produced the highest smoking cessation rates for patients who suffer a myocardial infarction.