心血管医生戒烟知识及策略PPT课件

1、Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited, Atlanta, Georgia, 2006. Also available online at: http:/ 2%肯尼亚肯尼亚21%1%瑞典瑞典17%18%菲律宾菲律宾41%8%葡萄牙葡萄牙33%10%南非南非23%8%印度印度47%17%俄罗斯俄罗斯60%16%意大利意大利33%17%西班牙西班牙39%25%德国德国37%28%中国NEHNS IV由吸烟引起死亡的前三位疾病：由吸烟引起死亡的前三位疾

2、病：国外资料为：国外资料为：COPDCOPD冠心病冠心病肺癌肺癌国内资料为：国内资料为：COPDCOPD肺癌冠心病肺癌冠心病1. Surgeoen Generals Report. Health Consequences of Smoking; 2004. 2. J Natl Cancer Inst. 1993;85(24):1994. 2 3. Crane. Cancer Epidemiol Biomarkers Prev. 1996;5(8):639. 4. Miligi. Am J Ind Med. 1999;36(1):60. 5. Roman. Cerebrovasc Dis, 20

3、05;20(Suppl 2):91. 6. Willigendael. J Vasc Surg. 2004;40:1158. 7. Yang. BMJ. 1999;319:143Lavi et al. Circulation. 2007;115:2621-2627; /HIC/Topics/Diag/diangio.cfm. Accessed June 14, 2007.右冠状动脉粥样硬化右冠状动脉粥样硬化Sambola et al. Circulation. 2003;107:973-977.Factor Xa (FXa) p

4、mol/L/minP=.0032172830100200300400吸烟者吸烟前（2支烟）吸烟者吸烟后(2支烟)Waters et al. Circulation. 1996;94:614-621. 已有病变加重的发生率已有病变加重的发生率吸烟者非吸烟者P=.002患者百分率新病变发生率新病变发生率吸烟者P=.007非吸烟者患者百分率aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Teo.

5、 Lancet. 2006;368:647-658.OR (95% CI)a109876543210年龄年龄407070非吸烟者戒烟者吸烟20支/天吸烟1-19支/天Yusuf S et al . Lancet. 2004;364:937-52OR (99% CI)13579never156101115162021252630314040ORLinear (OR)a The probability of an event (developing a disease) occurring in exposed people compared with the probability of the

6、 event in nonexposed people. Adjusted for age.Willett et al. N Engl J Med. 1987;317(21):1303-1309.吸烟者每日吸烟量吸烟者每日吸烟量相对风险可信区间95aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age.Wannamethee et

7、 al. Circulation. 1995;91:1749-1756.1.02.30.01.02.03.04.0不吸烟者吸烟者相对风险可信区间95aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for the baseline variables significantly associated with each end point.

8、Hasdai et al. N Engl J Med. 1997;336:755-761.Q波心梗波心梗 (MI)相对风险可信区间950.01.02.03.04.0不吸烟者戒烟者吸烟者aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Adjusted for age, follow-up period, history of diabetes, hypert

9、ension, high cholesterol levels, and relative weight (in 5 categories).Colditz et al. N Engl J Med. 1988;318(15):937-941.1-1415-24不吸烟者25吸烟者每日吸烟量（支）吸烟者每日吸烟量（支）相对风险可信区间95aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexp

10、osed people.Adjusted for age, exercise, alcohol consumption, body mass index, history of hypertension, and history of diabetes. Kurth et al. Stroke. 2003;34:2792-2795.总出血性脑卒中脑内出血蛛网膜下腔出血不吸烟者 (n=20,339)每日吸烟量少于15支 (n=1914)每日吸烟量多于15支 (n=3265)相对风险可信区间95aTwenty-year age-adjusted mortality per 10,000 perso

11、n-years for men. P.014 for trend. Hart et al. Stroke. 1999;30:1999-2007.15-241-1525吸烟者每日吸烟量（支）吸烟者每日吸烟量（支）死亡率/10000人*年Freund KM, The Framingham Study: 34 years of follow-up. Ann Epidemiol 1993; 3:417-424Witteman JC,. Circulation 1993; 88:2156-2162Wilmink TB, J Vasc Surg 1999; 30:1099-11051. CDC. Surg

12、eon General Report 2004 2. American Cancer Society. Guide to Quitting Smoking2006 肺功能改善减少咳嗽鼻窦充血呼吸急促等 3 3个月个月肺癌发生率是继续吸烟者的30-50% CAD危险减少50%CAD危险与正常不吸烟者相似卒中危险恢复到正常不吸烟者水平1 1年年5 5 年年10 10 年年15 15 年年戒烟戒烟aThe ratio of the odds of development of disease in exposed persons to the odds of development of disea

13、se in nonexposed persons. Adjusted for sex, region, diet, alcohol, physical activity, consumption of fruits, vegetables, and alcohol.Adapted from Teo. Lancet. 2006;368:647-658.比值比可信区间95生存率生存率 (%)100806040200023456789101112时间（年）时间（年）Hasdai. N Engl J Med. 1997;336(11):755-761.戒烟者持续吸烟者Adapted from van

14、Domburg et al. J Am Coll Cardiol. 2000;36(3):878-883.生存概率生存概率 (%)05101520年年不吸烟者持续吸烟者100806040200戒烟者 aAbstention period of 3 years. Hallstrom et al. N Engl J Med. 1986;314:271-275.3年内发生率年内发生率 (%)P=.038心脏骤停反复发作心脏骤停反复发作2719051015202530吸烟者戒烟者aaThe probability of an event (developing a disease) occurring

15、 in exposed people compared with the probability of the event in nonexposed people. Adjusted for age and treatment assignment.Robbins et al. Ann Intern Med. 1994;120(6):458-462.不吸烟者戒烟者吸烟者(20支/日)吸烟者(20 支/日）P .0001(趋势趋势)相对风险可信区间95Jonason et al. Acta Med Scand. 1987;221:253-260.年年累积静息痛累积静息痛 (%)3020100P

16、=.0492716543戒烟吸烟Critchley JA, Capewell S. JAMA; 2003; 290: 86-97平均每挽救一个生命年（人年）的成本平均每挽救一个生命年（人年）的成本: :Benowitz, Prog Cardiovasc Dis, 2003;46:91nAcc= Nucleus Accumbens. Adapted from Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125.a a4b bb b2b b2a a4a a4b b2尼古丁受体尼古丁受体Adapted from Picciotto et al. N

17、icotine Tob Res. 1999;1:S121-S125.DDDDD 包含nAChR 的2 亚单位- 尼古丁- 多巴胺脑腹侧被盖区脑腹侧被盖区伏核伏核轴突轴突D奖赏效应奖赏效应Adapted from Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125; Corringer et al. J Phys Paris. 2006;99:62-171.DDDDDDDDDDD 包含 nAChR 的2 亚单位- 尼古丁- 多巴胺Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al.

18、 Nicotine and Tob Res. 1999: Suppl 2:S121-S125.人们为什么吸烟人们为什么吸烟 . . . 为了放松为了放松; 有味道有味道; 消消遣时间遣时间; 手上有些事情干手上有些事情干. . . . 但，最重要的，但，最重要的，人们不停地吸烟是因为他们戒烟以后会非常难人们不停地吸烟是因为他们戒烟以后会非常难受受”Philip Morris, 1984Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001;70:531-

19、549.坐立不安或性急坐立不安或性急(10周)焦虑焦虑(可能随着戒烟加重或减轻)烦躁或抑郁情绪烦躁或抑郁情绪(4周)易怒易怒, ,受挫感或生气受挫感或生气(4周) 难集中注意力难集中注意力 (4周)失眠失眠/ /睡眠紊乱睡眠紊乱(4周)Diagnostic and Statistical Manual of Mental Disorders, IV-TR. Washington, DC: APA; 2006: Available at http:/. Accessed November 7, 2006. West RW, et al. Fast Facts: Smoking Cessation

20、. 1st ed. Oxford, United Kingdom. Health Press Limited. 2004. Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services. Public Health Service; June 2000. Available at: /tobacco/default.htm

21、. Jarvis MJ. Why people smoke. BMJ. 2004;328:277-279.做为一个成瘾性医学问题，尼古丁成瘾需要长期临床干预，戒烟是一个反复的长期过程临床常见， 属于成瘾特性，不能完全靠个人毅力解决, 长期吸烟者凭个人努力戒断者仅 3%5%复复 吸吸戒戒 烟烟 治疗的手段常需联合药物、行为及社会环境支持等方法:应使用指南推荐药物，并按照指南完成疗程才能取得较好的疗效心理、社会、生理及环境等多种因素的介入使得戒烟是一个系统工程干干 预预 杨功焕等，中华流行病学杂志2005年2月第26卷第2期2002年年0201030409050607080吸烟易患冠心病吸烟易患冠

22、心病吸烟易患气管炎吸烟易患气管炎吸烟易患肺癌吸烟易患肺癌孕妇吸烟对胎儿有严重危害孕妇吸烟对胎儿有严重危害吸烟有严重危害吸烟有严重危害1996年年被动吸烟有严重危害被动吸烟有严重危害比例（）比例（） US guideline (AHRQ, 2000) UK guideline (1998) New Zealand guideline (2007) Ask ：询问烟草应用情况询问烟草应用情况Advise：建议戒烟建议戒烟Assess：评估尝试戒烟的意愿评估尝试戒烟的意愿Assist：帮助制定戒烟计划帮助制定戒烟计划Arrange：安排随访安排随访Fiore MC, et al. US Depart

23、ment of Health and Human Services. Public Health Service. June 2000.重要生命体征重要生命体征评分1-3分：尼古丁轻度依赖。建议使用戒烟辅助药，或靠毅力戒烟。评分4-6分：尼古丁中度依赖。建议使用戒烟辅助药。评分大于7分：尼古丁重度依赖。建议使用戒烟辅助药。询问询问每一个每一个吸烟者吸烟者语气严肃语气严肃您希望尝试戒烟吗？您希望尝试戒烟吗？行动：行动：发放宣传资料发放宣传资料 安排下一次的随诊安排下一次的随诊策略：策略：明确障碍，具体支持明确障碍，具体支持信息：信息：戒烟是一个艰难的过程，经常需要医生和戒烟是一个艰难的过程，经常

24、需要医生和药物的协助；可能需多次尝试，但最终会成功药物的协助；可能需多次尝试，但最终会成功行动：行动：发放宣传资料发放宣传资料 确定戒烟日期确定戒烟日期 戒烟的策略：心理治疗药物治疗戒烟的策略：心理治疗药物治疗 建议患者咨询戒烟门诊或电话热线建议患者咨询戒烟门诊或电话热线否否是是戒烟对于保护您和您周围人的健康非常重要，戒烟对于保护您和您周围人的健康非常重要，希望您能加入戒烟者的行列！希望您能加入戒烟者的行列！1. Silagy C, et al. Cochrane Database Syst Rev. 2004;(3):CD000146. 2. Stead L, et al. Int J Ep

25、idemiol. 2005;34:1001-1003. 3. Henningfield JE, et al. CA Cancer J Clin. 2005;55:281-299. 4. Hughes JR et al. Cochrane Database Syst Rev. 2004;(4):CD000031. DA NA1.Coe JW et al. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on Nicotine and Tobacco. 2005

26、. 2. Picciotto MR et al. Nicotine Tob Res. 1999与中脑与中脑腹侧背盖区尼古丁乙酰胆碱腹侧背盖区尼古丁乙酰胆碱a a4b b2受体受体结合可以导致多巴胺释放结合可以导致多巴胺释放 伐尼克兰是一种高选择性伐尼克兰是一种高选择性a a4 4b b2 2 受体部分激受体部分激动剂，具有激动剂和拮抗剂双重活性。可动剂，具有激动剂和拮抗剂双重活性。可缓解对尼古丁的缓解对尼古丁的渴求渴求与戒断症状与戒断症状, ,并可阻断并可阻断尼古丁与受体的结合，尼古丁与受体的结合，减少伏核减少伏核( (nAccnAcc) ) 释释放多巴胺，从而放多巴胺，从而降低吸烟的降低吸烟的奖赏效应奖赏效应。尼古丁尼古丁伐尼克兰伐尼克兰3001020405060伐尼