Tabaquismo en el consultorio del cardiólogo.

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Tabaquismo en el consultorio del cardiólogo.
Tabaquismo en el consultorio
del cardiólogo.
La enfermedad coronaria y el ACV —tipos primarios de enfermedad
cardiovascular causados por el tabaquismo—son la primera y
tercera causa de muerte en los EEUU.
61 millones de personas sufren alguna forma de ECV en EEUU.
HTA, Enfermedad coronaria, ACV, ICC y otras.
Más de 2,600 Americanos muere por dia de ECV.
Una muerte cada 34 segundos.
Las enfermedades cardiovasculares relacionadas con el
tabaquismo resultan en más muertes por año que las
resultantes de cáncer de pulmón.
Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. The Health Consequences of Smoking:
A Report of the Surgeon General. Available at: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/. Accessed October 15, 2008.
VII Joint National Comitee (VII JNC)
World Health Organization (WHO)
Comittee Tabaquismo:
Factor de riesgo importante en el desarrollo de enfermedad cardiovascular.
Su interrupción reduce el riesgo de accidente vascular encefálico,
enfermedad isquémica del corazón y enfermedad vascular periférica.
Minami J, Ishimitsu T, Matsuoka H. Effects of smoking cessation on blood pressure and heart rate variability in habitual smokers.
Hypertension 1999a;33(part II):586-90.
Guideline Subcomittee World Health Organization - International Society of Hypertension - Guidelines for the management of
hypertension. J Hypertens 1999;17:151-83.
Eng.
Las mujeres que fuman y usan ACO o THR en la
menopausia aumentan el riesgo de Stroke y ECV.
American Heart Association. Cigarette Smoking and Cardiovascular Disease. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4545.
Accessed October 15, 2008.
El tabaquismo aumenta la presión arterial y la
tendencia a la coagulación.
American Heart Association. Cigarette Smoking and Cardiovascular Disease. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4545.
Accessed October 15, 2008.
El riesgo de un fumador de desarrollar
enfermedad coronaria es dos a cuatro veces
mayor que el de un no fumador.
American Heart Association. Risk Factors and Coronary Heart Disease. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4726.
Accessed October 16, 2008.
British Doctor Study,
Evaluación prospectiva de 34 439 médicos /40 años.
Probabilidad 3 veces mayor de desarrollar enfermedades cardiovasculares en el grupo de
fumadores.
Las enfermedades isquémicas, en comparación con el cáncer de pulmón, provocaron el
doble de óbitos.
Mayor longevidad entre individuos no tabaquistas que entre tabaquistas.
La probabilidad de un no fumador de vivir hasta 70 u 85 años es, respectivamente, de
80 y 33 %.
La de un fumador diminuye a 59 y 12 % respectivamente.
NIC
INTERACCIÓN TABACO/HTA.
Fumar eleva momentáneamente los niveles de
presión en hipertensos y normotensos.
Goulbourt U, Medalie JH. Characteristic of smokers, non-smokers and ex-smokers among 10.000 adults males in Israel. II.
Physiological, biochemical and genetic characteristics. Am J Epidemiol 1977;105:75-86.
Wilhensen L. Coronary heart disease: epidemilogy of smoking and intervention studies of smoking. Am Heart J 1998;115:242-9.
El tabaquismo aumenta la presión arterial de
individuos normotensos.
Monitoreo ambulatorio de presión arterial (MAPA) de tabaquistas normotensos durante 8
h (9,00 a 17,00 h), mientras fumaban 1 cigarrillo cada 30 min y lo compararon con un
período idéntico sin fumar. Niveles de presión persistentemente más elevados
mientras fumaban.
Aumento inmediato y persistente de aproximadamente 12 mmHg en la presión sistólica y
15 mmHg en la diastólica después de fumar el primer cigarrillo.
De Cesaris encontró ese aumento persistente y continuo en hipertensos. Cuando el
individuo deja de fumar, ya es posible observar en la primera semana disminución de la
frecuencia cardíaca y de la presión arterial.
Groppelli A, Giorgi DM, Omboni S, Parati G, Mancia G. Persistant blood pressure increase induced by heavy smoking. J Hypertens 1992;10(5):495-9.
De Cesaris R, Ranieri G, Andriani A. Effects of cigarette-smoking on blood pressure and heart rate. J Hypertens 1991;9(suppl):S122-3.
Ward MM, Swan GE, Jack LM, Javitz HS, Hodgkin JE. Ambulatory monitoring of heart rate and blood pressure during the first week after smoking cessation Am
J Hypertens 1995;8(6):630-4.
Tabaquismo y MAPA
28 tabaquistas y 73 no tabaquistas, normotensos.
MAPA en invierno y en verano.
Medias de presión sistólica (MPS) y Medias de presión diastólica (MPD) durante la
vigilia y en el período nocturno son significativamente más altas en invierno que en
verano.
En las dos estaciones los tabaquistas presentaron elevación
significativa tanto en la vigilia como en el período nocturno
al compararlos con los no tabaquistas.
Los factores tabaquismo y período invernal asociados
pueden elevar la morbilidad y la mortalidad cardiovascular.
Kristal-Boneh E, Harari G, Green MS. Seasonal change in 24-hour blood ppressure and heart rate is greater
among smokers than nonsmokers. Hypertension 1997;30(3pt1):436-41.
Tabaquismo e hipertensión.
Effects of Smoking Cessation on Changes in Blood Pressure and Incidence of Hypertension
A 4-Year Follow-Up Study
Duk-Hee Lee; Myung-Hwa Ha; Jang-Rak Kim; David R. Jacobs, Jr
From the Department of Preventive Medicine (D.-H.L.), College of Medicine, Kosin University, Pusan, Korea; Health Care Center (M.-H.H.), Pohang Steel Company, Pohang,
Korea; Department of Preventive Medicine (J.-R.K.), College of Medicine, Gyeongsang National University, Chinju, Korea; and Division of Epidemiology (D.R.J.), School of
Public Health, University of Minnesota, Minneapolis.
The adjusted increments in both systolic and diastolic blood pressure were
higher in those who had quit for 1 year than in current smokers. These
trends among weight losers, as well as gainers and maintainers, were
similar. We observed progressive increases in blood pressure with the
prolongation of cessation in men, although at this time the mechanism
remains unknown and must be clarified. This study implies that the
cessation of smoking may result in increases in blood pressure,
hypertension, or both.
SISTEMA NERVIOSO
AUTÓNOMO.
AUMENTO DE 50 %
DE LA INCIDENCIA
DE ARRITMIAS
GRAVES.
ESTIMULACIÓN DE LOS
GANGLIOS
AUTONÓMICOS.
AUMENTO DE LAS CATECOLAMINAS.
(Alteraciones de FDVI, vasoconstricción general y coronaria).
Las principales manifestaciones hemodinámicas derivadas del
tabaquismo están asociadas a la acción sobre el sistema nervioso
simpático.
Agudamente, el aumento de la presión arterial es regulado por la
liberación de noradrenalina en las suprarrenales y adrenalina en las
terminaciones nerviosas periféricas.
Yugar-Toledo JC, Moreno Júnior H. Implicações do tabagismo ativo e do tabagismo passivo como mecanismo de instabilização da placa
aterosclerótica. Rev Soc Cardiol 2002;4(12):595-602.
También se produce la estimulación de quimiorreceptores carotídeos
e intrapulmonares.
Aumentan las catecolaminas circulantes, la frecuencia cardíaca, los
niveles de presión, débito cardíaco y vasoconstricción periférica.
Karvonen M, Orma E, Keys A, Fidanza S, Brozek J. Cigarette smoking, serum cholesterol, blood pressure and body fatness. Observation
in Finland. Lancet 59;1:492-H6.
Ragueneau I, Michaud P, Demolis Jl, Moryusef A, Jaillon P, Funck-Brentano C. Effects of cigarette smoking on short-term variability of
blood pressure in smoking and non smoking healthy volunteers. Fundam Clin Pharmacol 1999;13(4):501-7.
Long-term Smoking Impairs Platelet-Derived
Nitric Oxide Release
En el largo plazo, fumar, empeora la vasodilatación
endotelio dependiente mediada por el Óxido Nítrico
(NO).
Kazuya Ichiki, MD; Hisao Ikeda, MD; Nobuya Haramaki, MD; Takafumi Ueno, MD; Tsutomu Imaizumi, MD
the Third Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan.
Fumar un sólo cigarrillo rapidamente
reduce las concentraciones de Nitratos y Nitritos y la
concentración de antioxidantes del plasma.
El humo del cigarrillo contiene superóxido y otras
especies reactivas al oxígeno, que al dañar las células
endoteliales disminuyen la liberación de óxido nítrico
(NO)
Masahiko Tsuchiya, MD; Akira Asada, MD; Emiko Kasahara; Eisuke F. Sato, MD; Mitsuo Shindo,
MD; Masayasu Inoue, MD
From the Department of Biochemistry and Molecular Pathology (M.T., E.K., E.F.S., M.I.) and the
Department of Anesthesiology and Intensive Care Medicine (M.T., A.A., M.S.), Osaka City
University Medical School, Abenoku, Osaka, Japan. NO
NICOTINA Y ACTIVACIÓN PLAQUETARIA.
El humo del cigarrillo produce:
Activación plaquetaria en fumadores activos y
pasivos.
Marcado aumento de la activación por
rozamiento aún en casos de cigarrillos Low tarr.
La nicotina disminuye la activación plaquetaria
secundaria a rozamiento.
David Rubenstein; Jolyon Jesty, PhD; Danny Bluestein, PhD
From the Department of Biomedical Engineering (D.R., D.B.) and the Division of Hematology, School of Medicine (J.J.), Stony Brook
University, Stony Brook, New York. September 22, 2003.
Asp.
Coronary Artery Surgery Study (CASS).
Entre los que continuaron fumando durante los 6 años que duró
el estudio, el riesgo de muerte C.V. fue 1.7 y el de IAM 1.5,
para los que continuaron fumando comparados con aquellos
que abandonaron.
Independiente de la edad.
Holter monitoring: los fumadores tres veces más episodios
isquémicos. Doce veces más duraderos. Comparado con un
grupo control, el estrechamiento luminal coronario, de los
fumadores, fue el doble que en no fumadores en dos años.
Igual efecto se observa sobre la progresión de AE en las
carótidas.
TIMI
EFECTO DEL CIGARRILLO EN LA
EVOLUCIÓN POST TROMBOLISIS EN EL
IAM.
Los fumadores tienen pronóstico más favorable
luego de la trombolisis comparados con los no
fumadores.
Determinado por predominio de los fenómenos de
trombosis (aumento del Hto. y fibrinógeno) en la
fisiopatología y la consiguiente menor lesión
residual posterior.
Cindy L. Grines, MD; Eric J. Topol, MD; William W. O'Neill, MD; Barry S. George, MD; Dean Kereiakes, MD; Harry R. Phillips, MD; Jeffrey D. Leimberger,
PhD; Lynn H. Woodlief, MS; Robert M. Califf, MD
From the Division of Cardiology, Department of Medicine, William Beaumont Hospital, Royal Oak, Mich.
AORTA
Impact of Smoking and Smoking Cessation on Arterial Stiffness and Aortic Wave Reflection in
Hypertension.
Noor A. Jatoi; Paula Jerrard-Dunne; John Feely; Azra Mahmud
From the Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre, St James’s Hospital, Dublin, Ireland.
(Hypertension. 2007;49:981.)
© 2007 American Heart Association, Inc.
Cigarette smoking is an important modifiable cardiovascular risk factor and pathophysiological
mechanisms may include a stiff vascular tree. Although smokers have stiffer arteries, whether
smoking cessation is associated with reduced arterial stiffness is not known. We compared
never-treated patients with essential hypertension (n=554) aged 18 to 80 years (56% females)
classified as current smokers (n=150), ex-smokers (n=136), and nonsmokers (n=268). Exsmokers were categorized into <1 year, >1 and <10 years, and >10 years of smoking cessation.
Measurements included aortic stiffness, assessed as pulse wave velocity (Complior), wave
reflection (augmentation index [AIx]), and transit time (TR) (Sphygmocor). Current and exsmokers had significantly higher pulse wave velocity and AIx compared with nonsmokers (pulse
wave velocity for current smokers: 10.7±0.2; ex-smokers: 10.6±0.2; nonsmokers: 9.9±0.1 m/s;
P<0.001; AIx for current smokers: 31±1; ex-smokers: 30±1; nonsmokers: 27±0.8%; P<0.05),
whereas TR was lower in current and ex-smokers compared with nonsmokers (TR for current
smokers: 131±1.0; ex-smokers: 135±1; nonsmokers: 137±0.8 m/s; P<0.0001). There was a
significant linear relationship between smoking status and pulse wave velocity (P<0.001), AIx
(P<0.001), and TR (P<0.001), even after adjusting for age, sex, mean arterial pressure, heart
rate, and body mass index. In ex-smokers, duration of smoking cessation had a significant linear
relationship with improvement in pulse wave velocity (P<0.001), AIx (P<0.001), and TR
(P<0.001), with arterial stiffness parameters returning to nonsignificant levels after a decade of
smoking cessation.
CIGARETTE SMOKING AND THE DEVELOPMENT AND
PROGRESSION OF AORTIC ATHEROSCLEROSIS. A 9-YEAR
POPULATION-BASED FOLLOW-UP STUDY IN WOMEN
758 mujeres. 45 a 64 años.
Seguimiento radiológico de aorta abdominal. 9 años.
Directa asociación AE-Nº de cigarrillos diarios
1 a 9…………………………………….RR 1.4 (95%IC 1.0 to 2.0)
10 a 19 ………………………………..RR 2.0 (1.6 to 2.5)
Más………………………………………RR 2.3 (1.8 to 3.0)
Entre ex fumadoras el riesgo disminuyó.
Aún persistió en RR 1.6 95% (IC 1.1 a 2.25) a 10 años.
JC Witteman, DE Grobbee, HA Valkenburg, AM van Hemert, T Stijnen and A Hofman
Department of Epidemiology and Biostatistics, Erasmus University Medical School, Rotterdam, The
Netherlands.
INTERMITTENT CLAUDICATION; A RISK PROFILE FROM
THE FRAMINGHAM HEART STUDY.
38- años de follow-up.
381 varones y mujeres.
Edad, sexo masculino, hipercolesterolemia, HTA,
cigarrillo, diabetes y enfermedad coronaria se
asociaron con aumento del riesgo. Modelo de
regresión logística.
Joanne M. Murabito, MD, MSc; Ralph B. D'Agostino, PhD; Halit Silbershatz, PhD; Peter W. F. Wilson, MD
(Circulation. 1997;96:44-49.)
© 1997 American Heart Association, Inc.
Smoke-free Legislation and Hospitalizations for Childhood
Asthma
Daniel Mackay, Ph.D., Sally Haw, B.Sc., Jon G. Ayres, M.D., Colin Fischbacher, M.B., Ch.B., and
Jill P. Pell, M.D.
N Engl J Med 2010; 363:1139-1145September 16, 2010
Studies in Scotland and in the United States have shown that 40% of 11year-old children and 5-year-old children live with a smoker. Exposure to
environmental tobacco smoke increases the incidence and severity of
asthma, and children are particularly susceptible to the deleterious effects of
such exposure. In the United States, more than 200,000 episodes of
childhood asthma per year have been attributed to parental smoking.
In Scotland, the Smoking, Health and Social Care (Scotland) Act banned
smoking in all enclosed public places and workplaces as of March 26, 2006.
The legislation has been extremely successful in its primary aim of reducing
exposure to environmental tobacco smoke in public places, such as bars. As
a result, there has been a reduction in respiratory symptoms among workers
in bars — even among workers who continue to smoke themselves. Initial
concerns that the legislation would increase smoking in homes have not
been realized. Rather, the legislation has resulted in a greater adoption of
voluntary bans on smoking in homes and a reduction in the overall exposure
of children to environmental tobacco smoke. The aim of this study was to
determine whether the risk of a hospital admission for childhood asthma has
changed since the introduction of comprehensive smoke-free legislation in
Scotland.
Smoke-free Legislation and Hospitalizations for Childhood
Asthma
Daniel Mackay, Ph.D., Sally Haw, B.Sc., Jon G. Ayres, M.D., Colin Fischbacher, M.B., Ch.B., and
Jill P. Pell, M.D.
N Engl J Med 2010; 363:1139-1145September 16, 2010
There is substantial evidence of an association between exposure to environmental
tobacco smoke and the risk of asthma. Exposure to environmental tobacco smoke
increases the risk of asthma, and among those with asthma, it confers a predisposition
to a worse prognosis, including an accelerated decline in lung function, more frequent
exacerbations, more severe symptoms, impairment of the quality of life, and a
diminished therapeutic response to corticosteroids. In a meta-analysis, the pooled
estimate of the relative risk of ever having asthma as a result of exposure to
environmental tobacco smoke was 1.48 (95% CI, 1.32 to 1.65), the relative risk of
current asthma was 1.25 (95% CI, 1.21 to 1.30), and the relative risk of a new
diagnosis of asthma was 1.21 (95% CI, 1.08 to 1.36) The deleterious effects of
exposure to environmental tobacco smoke are greater among children than among
adults, since children have smaller bodies, a higher baseline respiratory rate, and
smaller airways. Preschool children are more likely to be exposed to environmental
tobacco smoke in their homes than in public places. In contrast, school-age children
spend less time with their parents and more time outside their homes and may
themselves start smoking. Among children in Scotland, self-reported exposure to
environmental tobacco smoke in public places has fallen since implementation of the
legislation. In the Scottish Schools Adolescent Lifestyle and Substance Use Survey
(SALSUS), the prevalence of smoking among 13-year-old boys fell from 5% in February
2004 to 3% in February 2007. The corresponding figures for girls were 7% and 4%.
TRATAMIENTO
Este riesgo de ECV disminuye substancialmente
luego de 1 a 2 años de cesación. En 15 años se
normaliza el riesgo de ACV
Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. The Health Consequences of
Smoking: A Report of the Surgeon General. Available at: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/. Accessed October 15, 2008.
Una enfermedad





Interfiere con la capacidad del organismo
para funcionar normalmente.
Impide el éxito de las funciones vitales.
Trastorno o desorden de la mente.
Presenta signos y síntomas, un cuadro clínico, es diagnosticable,
tiene un origen, un desarrollo, un tratamiento y un desenlace.
Una enfermedad bio-psico-social.
ADICCIÓN
ADICCIÒN
Frecuentemente progresiva y fatal.
Episodios continuos o periódicos de:
 Descontrol sobre el uso
 Uso a pesar de consecuencias adversas
 Distorsiones del pensamiento (negación).
ADICCIÓN
ADICCIÒN
 Persiste a lo largo del tiempo.
 Los cambios físicos, emocionales y sociales son
frecuentemente acumulativos y progresan.
 Causa muerte prematura.
ADICCIÓN
ADICCIÒN
Situación en la cual una droga se
impone a la voluntad.
ADICCIÓN
ADICCIÒN
Estado en el cual un individuo
necesita continuar consumiendo,
para evitar efectos determinados
por la carencia.
ADICCIÓN
ADICCIÒN
La nicotina, cambia el estado psicológico de los
fumadores, alterándolo de tal forma que
disminuye las posibilidades de abandono.
TRATAMIENTO
IMPACTO ECONÓMICO.
Short-term Economic and Health Benefits of Smoking Cessation
Myocardial Infarction and Stroke
James M. Lightwood, PhD; ; Stanton A. Glantz, PhD From the Institute for Health Policy Studies, Department of
Medicine, University of California, San Francisco.
Background Most analyses of the economic benefits of smoking cessation consider long-term effects, which are often
not of interest to public and private policy makers. These analyses fail to account for the time course of the short-run
cost savings from the rapid decline in risk of acute myocardial infarction (AMI) and stroke.
Methods and Results We estimate the time course of the fall in risk of AMI and stroke after smoking cessation and
simulate the impact of a 1% absolute reduction in smoking prevalence on the number of and short-term direct
medical costs associated with the prevented AMIs and strokes. In the first year, there would be 924±679
(mean±SD) fewer hospitalizations for AMI and 538±508 for stroke, resulting in an immediate savings of
$44±26 million. A 7-year program that reduced smoking prevalence by 1% per year would result in a
total of 63 840±15 521 fewer hospitalizations for AMI and 34 261±9133 fewer for stroke, resulting in a
total savings of $3.20±0.59 billion in costs, and would prevent 13 100 deaths resulting from AMI that
occur before people reach the hospital. Creating a new nonsmoker reduces anticipated medical costs
associated with AMI and stroke by $47 in the first year and by $853 during the next 7 years (discounting
2.5% per year).
Conclusions Although primary prevention of smoking among teenagers is important, reducing adult smoking pays more
immediate dividends, both in terms of health improvements and cost savings.
TRATAMIENTO
5-6 % de los fumadores, deja de fumar al
cabo de 1 año ante el simple consejo dado en
el consultorio en 2-3 minutos.
Modelo para abordar el tema del
TRATAMIENTO
tabaquismo en consultas médicas:
TRATAMIENTO
Las “5 A”

Averigüe sobre el consumo de tabaco

Aconseje dejar de fumar

Analice la motivación para dejar de fumar

Ayude en el intento de dejar de fumar

Acuerde un seguimiento
Fiore MC et al. US Department of Health and Human Services. Public Health Service. June 2000.
Aconseje
dejar de fumar
TRATAMIENTO




De manera clara, firme y personalizada, inste a cada fumador a dejar de
fumar por lo menos una vez por año.
CLARA

“Creo que es importante que usted deje de fumar ahora, y yo puedo
ayudarlo”
FIRME

Como su médico, necesito que sepa que dejar de fumar es muy
importante para proteger su salud ahora y en el futuro
PERSONALIZADA

Relacione el uso de tabaco con la salud/enfermedad (razón para
realizar la consulta médica), costos sociales/económicos, nivel de
motivación e impacto en otros (niños)
Fiore MC et al. US Department of Health and Human Services. Public Health Service. June 2000.
TRATAMIENTO
DÍGALE CÓMO
Fiore MC et al. US Department of Health and Human Services. Public Health Service. June 2000.
TRATAMIENTO
DÍGALE CÓMO
Regardless of how counseling is delivered, certain types of information increase the
chance of success. A problem-solving approach works well for many smokers. An example
of this would be thinking about times of the day one is likely to smoke (eg, first thing in
the morning or after meals) and then planning something to distract oneself when the
urge strikes (eg, leaving the situation or deep breathing). Social support, in the form of
encouragement, caring, and concern, clearly increases the success rate of smoking
cessation. Social support can come both from healthcare providers (intra-treatment
social support) and from family, friends, and other community members (extra-treatment
social support).
Smoking Cessation Strategies for the 21st Century. Douglas E. Jorenby, PhD From the Department of Medicine, Center for Tobacco
Research and Intervention, University of Wisconsin Medical School, Madison.
Correspondence to Douglas E. Jorenby, PhD, University of Wisconsin Medical School, 1930 Monroe St, Suite 200, Madison WI 53711.
Ayude en el intento de dejar de
TRATAMIENTO
TRATAMIENTO
fumar

Para el paciente que quiere intentar dejar de fumar, utilice
apoyo psicológico y farmacoterapia




Proporcione apoyo psicológico práctico (solución de
problemas y mejora de las capacidades)
Proporcione apoyo social
Ofrezca farmacoterapia
Ofrezca materiales complementarios




OMS: www.who.int
CDC: www.cdc.gov/tobacco
Sociedad para la Investigación de la Nicotina y el Tabaco:
www.snrt.org
Considere la necesidad de derivación a un programa
formal


Presencial
Telefónicamente o por Internet
Fiore MC et al. US Department of Health and Human Services. Public Health Service. June 2000.
TRATAMIENTO
TRATAMIENTO
Síntomas de abstinencia en fumadores que
dejan de fumar cigarrillos

Disforia o depresión

Insomnio

Irritabilidad, frustración o ira

Ansiedad

Dificultad para concentrarse

Agitación o impaciencia

Disminución de la frecuencia cardíaca

Aumento del apetito o aumento de peso
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 1994:242–247.
SUSTITUTOS DE LA NICOTINA
CONOCIMIENTO
APRENDIZAJE DE
TÉCNICAS.
ELABORACIÓN
MOTIVACIÓN
MEDICACIÓN SEDANTE
COMPRENDER
EL MECANISMO
POR EL CUAL
NOS HEMOS
VUELTO
FUMADORES.
TABACO
FIRME
DETERMINACIÓN DE
REALIZAR TODOS LOS
ESFUERZOS QUE SEAN
NECESARIOS,
TOLERAR TODAS LAS
DIFICULTADES QUE SE
PRESENTEN Y
SUPERAR TODAS LAS
BARRERAS QUE SE
INTERPONGAN.
LA TOMA DE LA DECISIÓN.
SOBREVALORACIÓN DE LA
DIFICULTAD.
 SENSACIÓN DE AUTOEFICACIA BAJA.
 NEGACIÓN/MINIMIZACIÓN DE LOS
EFECTOS PERJUDICIALES DEL
CIGARRILLO

CONFLICTO.

MAYOR GRADO DE ADICCIÓN.

MENOR GRADO DE DAÑO.

RAZONAMIENTOS DESADAPTATIVOS.
MOTIVACIÓN EXISTENCIAL
POSITIVA.
Nuevos contenidos de vida. Mejora
de las perspectivas futuras en lo
material, afectivo, físico, espiritual.
¿Para qué voy a dejar de fumar, si a lo mejor
mañana me pisa un ómnibus?
Bueno, pero si con la vida que tengo, no voy a
poder ni siquiera fumar, ¿ para qué vivo, me
podés explicar?
Mirá que el cigarrillo va a ser tan malo, si
hasta el Dr. XX que es especialista en
pulmones, fuma...
PEPE FUMÓ TODA LA VIDA Y NUNCA LE
PASÓ NADA... PIPO NUNCA FUMÓ Y TUVO
CÁNCER DE PULMÓN...
Effectiveness of Physician
Training
Smoking Cessation.
There is overwhelming evidence demonstrating both the cardiovascular hazards of smoking and the prompt benefit
that occurs with smoking cessation. The provision of advice alone significantly increases the smoking cessation rate,
and even minimal counseling yields a further benefit. Intervention with patients who have already suffered a cardiac
event yields particularly striking benefits. The smoking status of all patients should be assessed and appropriate
intervention offered to those who smoke. Physicians should be trained in counseling techniques and the use of
nicotine replacement and other therapies.
The importance of ensuring the delivery of smoking cessation counseling was recognized when smoking counseling
assessments were incorporated into version 3 of HEDIS, the Health Plan Employer Data Information Set of the
National Committee for Quality Assurance.36 Equally important components of appropriate medical care are
development of supportive office systems and multicomponent intervention programs and links with smoking
cessation specialists and community resources. The universal application of these modalities will contribute to the
continued decline of smoking and subsequent CHD events in the United States.
Perspective
Promoting Prevention through the Affordable Care Act
Howard K. Koh, M.D., M.P.H., and Kathleen G. Sebelius, M.P.A.
N Engl J Med 2010; 363:1296-1299September 30, 2010
Since tobacco dependence and obesity represent substantial health threats, the Act
addresses these specific challenges in a number of ways. For example, the directives
for the new health plans established after September 23, 2010, also include
coverage, with no cost sharing, of tobacco-use counseling and evidence-based
tobacco-cessation interventions, as well as obesity screening and counseling for
adults and children. Starting this year, pregnant women on Medicaid will receive
coverage, without cost sharing, for evidence-based tobacco-dependence treatments;
in 2014, states will be forbidden from excluding from Medicaid drug coverage any
pharmaceutical agents for smoking cessation, including over-the-counter
medications, that have been approved by the Food and Drug Administration. To
promote healthy weight for populations, the Act appropriates funds for fiscal years
2010 through 2014 for demonstration projects to develop model programs for
reducing childhood obesity. And on the policy front, menu-labeling provisions require
the disclosure of specified nutrient information for food sold in certain chain
restaurants and vending machines. Collectively, these complementary actions in the
clinic and the community will benefit individuals as well as populations.

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