Papel de N-acetilcisteína (NAC) en pacientes con tabaquismo / Role of N-acetylcysteine (NAC) in patients with smoking

Antecedentes y objetivo. El tabaquismo es el principal factor de riesgo de la enfermedad pulmonar obstructiva crónica (EPOC). N-acetilcisteína (NAC) es un agente mucolítico con propiedades antioxidantes y antiinflamatorias que ha demostrado ser eficaz en la reducción de la tasa de exacerbaciones y mejoría clínica de los pacientes con EPOC. El objetivo del trabajo es conocer la opinión de terapeutas expertos acerca del perfil o perfiles de los pacientes fumadores que pueden ser candidatos al uso de NAC. Métodos. Se efectuó una encuesta distribuida a las unidades de tabaquismo de España y una Reunión de Expertos en tabaquismo y EPOC, en la que los Expertos pudieron debatir abiertamente los tópicos seleccionados. Resultados. Los expertos reconocieron el papel del tabaquismo en la generación de estrés oxidativo y concordaron en emplear la terapia mucolítica/antioxidante para fumadores o exfumadores con síntomas respiratorios. Se debatió la necesidad de ampliar las indicaciones de esta terapia a otros perfiles de pacientes. Se señaló también el potencial efecto preventivo de la NAC sobre el daño pulmonar por su acción antioxidante, aunque se necesitaría más evidencia en este ámbito específico del tabaquismo. Se puso énfasis en diferenciar la dosis de NAC como mucolítico (600 mg/día)o antioxidante (1.200 mg/día). Conclusiones. Los expertos valoraron a NAC como un fármaco bien tolerado, de sencillo uso, con un conocido buen perfil de seguridad y un gran potencial para lograr los objetivos terapéuticos por su alta capacidad antioxidante. (AU)

Background and objective. The smoking habit is the main risk factor for chronic obstructive pulmonary disease (COPD). N-Acetylcysteine (NAC) is a mucolytic agent with antioxidant and anti-inflammatory properties that has been demonstrated to be effective in the reduction of the rate of exacerbations and clinical improvement of patients with COPD. This study aims to know the opinion of the expert therapists on the profile(s) of the patients who smoke and who may be candidates for the use of NAC. Methods. A survey was performed, distributing it to the smoking units in Spain and to a Meeting of Experts on the smoking habit and COPD in which the Experts could openly debate on the selected topics. Results. The experts recognized the role of the smoking habit in the generation of oxidative stress and agreed to use the mucolytic/antioxidant treatment for smokers or ex-smokers with respiratory symptoms. The need to extend the indications of this therapy to other patient profiles was debated. The potential preventive effect of NAC on lung damage due to its antioxidant action was also pointed out, although more evidence in this special area of the smoking habit would be necessary. Emphasis was placed on differentiating the NAC dose as a mucolytic (600 mg/day) or as an antioxidant (1,200 mg/day). Conclusions. The experts evaluated NAC as a drug that is well-tolerated, easy-to-use, with a known good safety profile and having great potential to achieve the therapeutic objectives due to its high antioxidant capacity. (AU)

[Teenagers and smoking: prevalence, patterns and attitudes]. / Jóvenes y tabaco: prevalencia, patrón y actitud ante el consumo de tabaco.

OBJECTIVES: To determine the prevalence of smoking among 12 to 14-year-olds in the province of Salamanca and to identify their knowledge of and attitudes to smoking as well as the impact of information provided on the subject in comic strip form. MATERIAL AND METHOD: We performed a descriptive study (n = 4907). The variables analyzed were: age, sex, place of residence, school, smoking, and degree of awareness of the consequences of smoking before and after being given the comic book. Statistical analysis was carried out using measures of central tendency, the chi-squared test and Student's t-test T (p < 0.05). RESULTS: Of the teenagers surveyed, 45.4 % of the boys and 39 % of the girls had smoked at some time and 20.5 % reported they were current smokers, with no differences between sexes. In both sexes the first cigarette was offered by a friend (59.8 % of boys and 66.5 % of girls). The teenagers began to smoke at a mean age of 11.1 years. Most of these adolescents smoked between 1 and 5 cigarettes a day. Most (91.8 %) considered tobacco to be a drug and after reading the comic strip this percentage rose to 99.1 %. A total of 70.1 % knew what passive smoking was, and after reading the comic strip this figure increased to 88.2 %. More than half (64.9 %) associated tobacco consumption with cancer, bronchitis and heart attack and 44.4 % considered mild cigarettes to be less harmful; after reading the comic strip these percentages changed to 95.3 % and 1.4 % respectively. Before reading the comic strip 84.2 % associated addiction with nicotine whereas after reading the comic this figure was 97.8 %. CONCLUSIONS: Children have contact with tobacco at a relatively early age. Current information on smoking is acceptable but could be improved. Information provided through comic strips can be an effective way of reaching adolescents and of preventing them from taking up the habit.

[Smoking cessation in primary and specialized care: a real opportunity and a public health necessity]. / El abordaje del tabaquismo en atención primaria y especializada, una oportunidad real y una necesidad de salud pública.

AIM: To determine whether primary care provides a suitable framework for integrated treatment aimed at smoking cessation with systematic minimal intervention or pharmacological treatment with nicotine replacement therapy (NRT). To compare the results with those obtained in a specialized pneumology unit. DESIGN: Prospective, quasi-experimental study. SETTING: Primary and specialized care services. PARTICIPANTS: 357 smokers who were followed at a health center (166) or a specialized clinic (191) during a 6-month period. INTERVENTIONS: Two types of intervention were used depending on the patients' degree of nicotine dependence: systematic minimal intervention for those with low dependence or who were still in the contemplation or precontemplation phase, and NRT for those with high dependence, in the preparation phase. MAIN OUTCOME MEASURES: Twelve months after the start of the study, abstinence among participants who received systematic minimal intervention was 36.5% in primary care patients and 41.8% in specialized care patients (P>.05). Among participants who received NRT abstinence was 37.1% in the former group and 35.5% in the latter (P>.05). The percentage of patients lost to follow-up was 8.6% in specialized care and 6.3% in primary care. CONCLUSIONS: The results lead us to recommend smoking cessation treatment integrated in the primary care setting, either with systematic minimal intervention or NRT.

Attitudes of teachers about tobacco prevention at school.

BACKGROUND: To know the smoking habits of the Spanish teachers, the anti-smoking teaching and the influence on the smoking habits of the students. METHODS: A cross-sectional study was conducted using a self-administrated and anonymous questionnaire. Of the he questionnaires addressed to the headmasters of 8,000 school centers selected as a random sample among the 18,457 existing in Spain, 3,050 valid answers were received. RESULTS: 29.7% of Spanish teachers are smokers, smoking significantly more (p < 0.001; 95% C.I.) in Secondary education (37.2 +/- 15.9%) than in Primary education (26.2 +/- 19.4%) and 7% smoke in front of the pupils, significantly more in state schools (p < 0.05) and in Secondary education (p < 0.001). There are positive correlations between the percentage of smoking teachers and the percentage of pupils who tasted tobacco (p < 0.001) or are regular smokers (p < 0.001), and also between the percentage of teachers who smoke in front of the pupils and the percentage of students who tried tobacco (p < 0.001) or smoke regularly (p < 0.001). In the school centers which apply the non-smoking regulation or teach antitobacco contents, the percentage of teachers smoking in front of pupils is significantly lower (p < 0.001). CONCLUSIONS: The attitude of teachers has an influence on the students; headmasters must ask for the application of non-smoking regulation and include health education contents in school curriculum.

[Opinion of heads of schools about the impact of school setting factors on the attitude of children and youngsters regarding smoking]. / Opinión de los directores escolares sobre la influencia de factores del medio escolar en la actitud de niños y jóvenes ante el tabaco.

AIM: Knowing the influence of school environment on children and teenagers' attitudes about tobacco consumption. METHODS: A survey was carried on 3.050 Spanish school headmasters (16% of the total in Spain), who were asked about the main variables related to the school environment able to influence the attitude of children and teenagers towards tobacco, such as the fulfilment of the official anti-tobacco legislation at educational centres, the education for nicotine poisoning prevention, or the teachers attitudes about tobacco, among others. Multiple regressions were made so as to value the variables that most influence the pupils' tasting tobacco and becoming usual smokers. RESULTS: In the opinion of the headmasters the variables that individually most influence the percentage of pupils that have tasted tobacco are the percentage of smoker teachers (beta 0.21) and the percentage of teachers who smoke in the presence of pupils (beta 0.091), as on the percentage of students usual smokers (beta 0.21 and 0.19 respectively). All the variables from school environment analysed jointly, explain some percentages of variance of the 9.65% and 10.7% of the estimated percentages of pupils who have tasted tobacco and pupils that are usual smokers, respectively. CONCLUSIONS: The efforts most be doubled, in order to reach the real fulfilment of the official anti-tobacco legislation in all educational centres and the pupils receive teachings for the prevention of tabaquisme in the context of Health Education, since these measures may make the schools play a more determinant role in the prevention of the nicotinism.

[Individual treatment of smoking addiction. Results using 2 and 4 mg nicotine gum]. / Tratamiento individualizado del tabaquismo. Resultados con chicles de 2 y 4 mg de nicotina.

We present the results of an open follow-up study aimed at analyzing the efficacy of combining psychological counseling with prescription of 2 and 4 mg nicotine gum to treat smokers. Two groups of smokers wer studied. Group A contained 124 subjects (74 men, 50 women) with a mean age of 37.4 (15.3) yr who were smokers of 15.3 (8.7) cigarettes/day. In this group physical addiction to nicotine was low, assessed as 1.7 (1.3) on the Fagerström test. Group B consisted of 107 subjects (61 men, 46 women) with a mean age of 38.9 (14.6) who were smokers of 26.9 (9.3) cigarettes/day and whose level of physical addiction to nicotine was moderate-to-high, assessed as 6.1 (2.4) on the Fagerström test. Standard deviations are shown between parentheses. Both groups were given minimal psychological counseling; additionally, patients were prescribed one piece of nicotine gum very 90 to 120 minutes during waking hours (2 mg in group A and 4 mg in group B). The dose was gradually reduced after the sixth to the eight week. The subjects were seen eight times over the first year (first day of consultation and during the first, second, fourth, eight and twelfth weeks after quitting, and again after six and twelve months). After twelve weeks of follow-up, sixty-one subjects (49%) in group A and 50 (47%) in group B were still abstinent. These proportions fell to 56 (45%) and 46 (43%), respectively, after one year of follow-up. Eighty-one percent of group A patients who were successful after three months of follow-up, and 87% of the successful group B patients, had used the nicotine gum as prescribed. Oropharyngeal, dental, and temporo-mandibular joint symptoms, hiccoughins, flatulence and heartburn were the most frequent side effects (ranging from 3% to 18%). Side effects were always slight and were not detected after the eighth week of treatment. In conclusion, combined therapy (minimal psychological counseling plus use of 2 or 4 mg nicotine gum depending on the level of physical addiction) yields a success rate between 43% and 45% still abstaining after one year of follow-up. Side effects are few and mild.

[Extent of law compliance and anti-smoking teaching at Spanish schools]. / Grado de cumplimiento de la legislación e impartición de enseñanzas anti-tabaco en los centros escolares españoles.

OBJECTIVE: Knowing the degree of fulfillment of the anti tobacco legislation in Spanish schools and the influence that this has on the percentage of smoking pupils. MATERIAL AND METHODS: A survey was carried out among 3050 headmasters of Spanish schools, who were asked about different aspects of the fulfillment of the antitobacco laws in their schools and about the main characteristics of tobacco consumption in their centers. RESULTS: A 80.9% of the headmasters claim that the fulfillment of the legislation is demanded in their centers, and only a 64.9% of them have posters in theirs schools that warn people about smoking ban. Anti tobacco teachings are imparted in a 82.2% of the schools where laws is demanded and only in a 64.8% where is not demanded. The percentage of teachers who, smoke in the presence of the pupils is of a 5.9% in the schools where anti tobacco legislation is demanded and a 12.9% where is not demanded. In the schools where anti tobacco teachings are imparted, a 29% of the pupils have tried tobacco, opposite a 31% who have tried in the schools where these teachings are not imparted. CONCLUSIONS: The, headmasters of the schools, as people in charge of watching over the fulfillment of the anti tobacco legislation in theirs schools, must demand the fulfillment of this one, because this measure is effective in order to improve the global functioning of the schools and to reduce the percentages of smoking pupils and teachers.

[The truthfulness of the answers of children, adolescents and young people to surveys on tobacco consumption conducted in schools]. / Veracidad en las respuestas de niños, adolescentes y jóvenes a las encuestas sobre el consumo de tabaco realizadas en los centros escolares.

BACKGROUND: The prevalence of tobacco consumption in scholars has been determined by self-governed inquiries, methodology that presents limitations of reliability and validity. This obstacle has been endeavoured to overcome through methodological inspections such as the test-retest valuation. On the contrary, the available analytical methods (i.e., determination of cotinine in urine or determination of carbon monoxide [CO] in exhaled air) have not been used up to now in this type of studies. Their use together with the inquiries could complement the results of the questionnaires and verify their reliability. POPULATION AND METHODS: 814 scholars took part in the survey, being valid the results of 809, 385 male students and 424 female students, 13 to 24 years old (mean 15.90, SD 1.73) from an urban high school and another in the rural area. The survey included a survey and the measurement of CO levels in exhaled air in the same scholar centre. RESULTS: 257 scholars stated that they had never tried tobacco and in 15 of them (5.8%) levels of CO were equal or higher than 10 ppm (14.26, SD 4.35 ppm). 589 students stated that were not regular smokers; in 46 of them (7.8%) levels of CO were superior to 10 ppm (13.87, SD 4.68). The morning when the survey was held 629 students assured that they had not smoked: in 52 of them (8.3%) levels of CO higher than 10 ppm were observed. The mean level of CO observed in these students was 13.5 (SD 4.4) ppm. In our survey, the measurement of CO in exhaled air allowed us to show percentage between 5.8 and 8.3% of students whose answers to the different questions were not reliable. CONCLUSIONS: The reliability of the results, observed through the carrying out of surveys, can be determined with the use of analytical methods that, owe to their simplicity, can be used massively. We have not found any relation between the shortage of reliability and the variants studied (age, sex or habitat), which reaffirms the difficulty in identifying variants that can determine those "deceives" and demands for its identification the need of practicing analytical determinations.

[Nasal nicotine spray in smoking cessation. Results of a multicenter study]. / Tratamiento del tabaquismo con nebulizador nasal de nicotina. Resultados de un estudio multicéntrico.

We have carried out an open multicenter follow-up study of the efficacy of a smoking cessation therapy that combined psychological support with use of a nicotine nasal spray. Fifty-seven subjects (37 men, 20 women) with a mean age of 40.3 +/- 15.7 yr and smoking 37.4 +/- 4.7 cigarettes per day were enrolled. The mean Fagerström test score was 8.9 +/- 1.1. Patients received minimal psychological support and were prescribed a nicotine nasal spray at the recommended dose of 1 to mg/h for use while awake for a period of three months, with gradual reduction of dose. Subjects were seen on six occasions (on the first day of consultation; 1, 2 and 6 weeks after quitting; 3 and 6 months after quitting). After three months of follow-up, 22 patients (39%) were abstinent; six months after first trying to quit, only 20 of the 57 enrolled had succeeded (35%). Although most subjects (over 90% in the first 15 days, and over 50% at three months) used the treatment, only a small percentage (3%) followed the appropriate doses in the first 15 days and 31% reported doing so at the three-month check-up. The mean score reflecting withdrawal syndrome tripled over baseline level during the first six weeks of follow-up. Over three quarters of the subjects suffered side effects caused by the spray, the most common being nasal irritation, rhinorrhea and tearing. Five patients (87%) lef the study because of intolerance to medication. In conclusion, our study found a rate of success of 35% after six months of follow-up. Use of the prescribed medication was inadequate; withdrawal syndrome was more intense and the prevalence of side effects increased during the early treatment period.

[Usefulness of CO measurement in expired air in the study of tobacco consumption by youths and adolescents]. / Utilidad de la medida de CO en aire espirado en el estudio del consumo de tabaco por jóvenes y adolescentes.

The objective of our work was to know the relationship between carbon monoxide (CO) levels in expired air and smoking habits among school youths and the relationships that can be established between CO level and some peculiar attitudes regarding consume by youths, such as the number of cigarettes, inhaling technique and time elapsed since the last cigarette was smoked. The study, of cross-sectional design, was performed in two high school centres and a total of 777 students who answered a questionnaire and had an expired air CO sample in their own schoolroom tested were enrolled. CO determination in the schoolroom was a simple and attainable technique for the pupils, as only 32 cases (4.1%) had to be excluded due to poor collaboration or poor technique. The mean (mean and SD) CO level in the control group (n = 247), made up by non-smokers nor tobacco tasters was 4.75 (2.46) ppm, statistically lower than among smokers (p < 0.001), but with no differences compared with non smokers (n = 563), who had a CO level of 5.23 (3.4) ppm. This figure was also lower (p < 0.001) than that obtained in the smokers (12.6 [6.3] ppm), made up of 214 pupils, with a mean consume of 2.7 (1.69) cigarettes/day. Among smokers the mean abstinence time since the last cigarette was smoked was 26 (44) minutes and 54% of them admitted to have smoked in the last 10 minutes. CO in expired air correlated significantly with the number of smoked cigarettes (r = 0.58; p < 0.001). Likewise, it correlated significantly with abstinence minutes (r = -0.38; p < 0.001). The time required for CO level to decrease below 10 ppm was 140 minutes in four cases and 120 minutes in 33 cases.

[Sex differences in experimentation and tobacco consumption by children, adolescents and young adults]. / Diferencias entre sexos en la experimentación y consumo de tabaco por niños, adolescentes y jóvenes.

Studies carried out in the past ten years have found the prevalence or smoking among children and adolescents to be high, with the greatest increase observed for girls and young women, indicating increasing gender-related differences. The aim of our study was to determine the prevalences and differences among children and adolescents of both sexes with regard to experimentation and use of tobacco products and to determine any possible influence related to urban or rural environment. Eight hundred fourteen students participated, with 809 providing valid data for study: 385 males and 424 females ranging in age from 13 to 24 years old (15.90 +/- 1.73 years). The subjects studied in either an urban or a rural school. Data was collected on campus by questionnaire and carbon monoxide in expired air was measured. Smoking had been tried by 68.2%: 241 males (62.5%) and 31 females (73.3%) (p < 0.001). Habitual smoking was reported by 27.2%: 78 males (20.2%) and 142 females (33.4%) (p < 0.001). Mean ages of experimenters (16.18 +/- 1.78 years) and smokers (16.55 +/- 1.85 years) were higher than the mean age of non-experimenters (15.29 +/- 1.43) (p < 0.001). Habitual smokers consumed a mean 2.71 +/- 1.68 cigarettes/day and consumption was similar for both sexes. CO in expired air was 12.61 +/- 6.39 ppm in these smokers, significantly higher (p < 0.001) than that found in experimenters and non smokers (p 0.001). One hundred eighty students (22.2%), 119 females and 61 males (p < 0.001), reported having smoked on the morning of the study. In total, 81.8% of the students who described themselves as smokers had smoked that morning: 78.2% of the males and 83.9% of the females. CO in this group was 13.95 +/- 1.69 ppm, significantly higher than that found for the other groups (non smokers or experimenters). We found no significant differences between number of cigarettes/day smoked by students who reported being habitual smokers and the number consumed the morning of data collection by students who had smoked the day of the study. Changes can be observed in patterns of tobacco use among children and young people. We found that nearly all aspects related to experimentation and consumption of tobacco are significantly higher in females.