29. Smoking, Alcohol, And Drugs

8/3/2019 29. Smoking, Alcohol, And Drugs

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SMOKING, ALCOHOL,AND DRUGS

RAPHAEL ZAHLER, M.D., Ph.D.

CAROLINE PISELLI , R.N., M.B.A.

INTRODUCTION SMOKING

Of all the risk factors for heart disease, the ones overwhich an individual has the most control are those

related to bad habits, namely the use or abuse oftobacco (especially cigarettes), alcohol, and illicitdrugs. Numerous studies show that people who usethese substances have a marked increase in risk ofdeveloping heart disease. Still, there is hearteningnews for longtime smokers, drug users, and heavydrinkers who quit The increased risks can be loweredand even eliminated.

The benefits of controlling or, better still, elimi-nating these risk factors can be dramatic. In fact,smoking cessation is the single most effective stepthat smokers can take to lower their risk of heart

disease. Former smokers live significantly longerthan do continuing smokers, and-their reduced in-cidence of heart disease is one of the major reasons.

This chapter reviews the dangers of smoking,drinking, and using illicit drugs. The ways in whichthese habits raise the risk of heart disease and meth-ods for quitting or moderating consumption are alsodiscussed. The chapter also reiterates a key theme,namely, that quitting can lower the risk of the de-velopment and progression of heart disease, even af-ter decades of use.

Cigarette smoking is by far the leading cause of pre-mature or preventable deaths in the United States.

And cancer is not, as many people believe, the onlyrisk of smoking. According to a 1990 report by the

Surgeon General, tobacco use is responsible for morethan 350,000 deaths a year from heart disease. Cig-arettes hold the dubious distinction of being the onlymass-marketed product that when used as directedactually causes disease and death. If cigarettes wereinvented now, health officials would no doubt bantheir sale. Unfortunately, for a variety of reasons, ap-propriate restrictions on smoking are often difficultto implement.

SMOKING AND LUNG DISEASE

Since the first Surgeon Generals Report on Smokingand Health in 1964, lung cancer has been recognizedas one of the long-term dangers of smoking. How-ever, lung cancer is not the only pulmonary diseasecaused by tobacco. Smoking is also the most impor-tant risk factor for developing chronic bronchitis andemphysema, a chronic pulmonary disease in whichthe lungs gradually lose their normal elasticity. A per-

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HOW TO LOWER YOUR RISK OF HEART DISEASE

son with emphysema is often short of breath, andpersons with chronic bronchitis frequently cough upthick phlegm. Emphysema also makes the heart (par-ticularly the right side) work harder. This strain onthe heart can lead to a debilitating disease called corpulmonale, in which the right atrium and ventricle

enlarge and fail to function adequately.

SMOKING AND HEART DISEASE

Smoking by itself greatly increases the risk of heartdisease, but there is a synergistic effect when ciga-rette smoking is combined with other cardiovascularrisk factors, such as high blood pressure, high serumcholesterol (or low HDL) levels, obesity, and a familyhistory of heart disease. When smoking is combinedwith these factors, the increased risk is not simply

additive; instead, the risks are compounded, with thetotal risk exceeding the sum of the individual risks.Thus, even moderate smoking can triple a personsrisk of heart disease.

The increased cardiovascular risk from smoking issignificantly lower among pipe and cigar smokersthan among cigarette smokers, probably becausethey are less likely to inhale. However, when smokersswitch from cigarettes to pipes or cigars, they maycontinue to inhale, and their risk may not be reduced.Likewise, changing to low-tar, low-nicotine, or fil-tered cigarettes has not been shown to lower and may

even increase the risk of heart disease. Nicotine isonly one of about 4,000 potentially harmful sub-stances in cigarettes, and some of these other com-

pounds may affect the heart. There is also evidencethat people who switch to low-nicotine, low-tar cig-arettes inhale more deeply, thereby increasing the

amount of harmful substances entering the body.The heart disease risk in users of smokeless to-

bacco (chewing tobacco and snuff) has not beenthoroughly studied. However, the nicotine fromsmokeless tobacco has been shown to have the sameadverse effect on the heart and blood vessels as that

HOW SMOKING RAISES

CARDIOVASCULAR RISK

from cigarettes.Fortunately, cigarette smoking has become less

popular in the United States, particularly among peo-ple with more than a high school education and in

the group at highest risk of heart disease: middle-aged men. Unfortunately, there has also been a dra-matic rise in smoking among teenagers, especiallyteenage girls. If this trend continues, the number offemale smokers is expected to equal the number ofmale smokers by the rnid-1990s and then surpass it.

As a consequence of increased smoking bywomen, lung cancer has replaced breast cancer asthe number one cause of cancer death amongwomen. In recent decades, the risk of heart diseasehas also risen among women smokers. Since smokinginterferes with estrogen production and metabolism,

it lowers the natural protection against prematureatherosclerosis conferred by estrogen. Taking certainoral contraceptives (especially those with high levelsof estrogen) raises the smoking-related risk of vas-

cular disease even higher, especially in women overage 35.

ATHEROSCLEROSIS

Research has shown conclusively that smoking ac-

celerates arteriosclerosis (hardening of the arteries)and atherosclerosis (a type of arteriosclerosis char-acterized by fatty deposits in the artery walls),increasing the risk of heart disease, stroke, and per-

ipheral vascular disease. Consequently, smokers havea higher risk of cardiovascular disease in general, andheart attacks in particular, than nonsmokers.

Cigarettes may promote atherosclerosis by a va-riety of mechanisms. Smoking increases the levels ofcarbon monoxide, a poisonous gas that is inhaled insmoke. Over the long term, this increased level ofcarbon monoxide from the inhaled smoke itself con-tributes to damaging the lining of the blood vesselsand accelerates the process of atherosclerosis.

Smoking also affects serum cholesterol. Smokerstend to have decreased levels of high-density lipo-proteins (HDLthe good cholesterol) and in-creased levels of low-density lipoproteins (LDL-thebad cholesterol) and triglycerides (a blood fat),

thereby raising the risk and severity of atheroscle-rosis.

Blood levels of fibrinogen, a component of bloodnecessary for clotting, are raised by smoking. Thismay increase the likelihood of blood clots forming

and blocking the coronary arteries, leading to a heartattack or stroke. Such clots are most likely to formon areas of the endothelium (the inner lining of bloodvessel walls) that are clogged by atheroscleroticplaque and have been roughened by prior damage,


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SMOKING, ALCOHOL, AND DRUGS

rather than on those that remain smooth and intact.

Smoking may also cause blood platelets to clump ab-normally, adding to the risk of clotting.

Stopping smoking results in an increase in the ra-tio of HDL to LDL cholesterol and lowers the level offibrinogen in the blood. Both of these changes helpreduce the risk of a heart attack.

SHORT-TERM EFFECTS

Smoking causes surges in the concentrations of cat-echolamines (the stimulator chemical messengers ofthe autonomic nervous system) as well as increasesin carbon monoxide in the blood. Both of these short-term effects can exacerbate existing heart disease,resulting, for instance, in attacks of angina (chestpain). Nicotine raises blood pressure and heart rate,requiring the heart to work harder. It also constricts

the coronary arteries, thereby lessening the supplyof blood and oxygen to the heart muscle. It also pro-motes irregular heartbeats (cardiac arrhythmias).

HOW SMOKING CESSATION

LOWERS RISKThe increased cardiovascular risk from smoking canactually be reversed simply by stopping smoking.Even smoking fewer cigarettes or switching to a pipeor cigars has been shown to lower the risk, butstopping all tobacco use is much more effective ineliminating the increased risk. Not surprisingly, thegreatest benefits are to heavy smokers, those whosmoke more than two packs a day. (See Figure 6.1.)

Some smokers are reluctant to quit smoking forfear of gaining weight. Still, the health benefits of

quitting far outweigh any increased health risks fromthe average 5-pound weight gain that may followsmoking cessation. (Even this minor weight gain canbe avoided or reversed with careful planning priorto quitting and behavior modification.)

Quitting lowers the risk of heart disease for peoplewho have never had any symptoms, as well as thosewho have suffered extensive heart disease. Often aheart attack or a coronary artery bypass graft op-eration compels individuals to stop smoking, and it

Figure 6.1Cessation ofSmoking and CoronaryHeartDisease (CHD):

Mortality Ratios ofCurrentSmokers Versus Ex-smokers

Number of Cigarettes Smoked Daily

Source: E. Rogot and J. L. Murray, Smoking and causes of death among U.S.veterans: 16 years of observation. Public Health Reports 95(3) 213-222, MayJune 1960.

is certainly true that they will be better off if they quit.However, a heart attack does irreversible damage to

part of the muscle of the heart. Therefore, it is muchbetter to stop smoking whether or not heart diseasemay be presentor, better yet, never start. After aheart attack, quitting smoking may be the most ef-

fective single risk factor intervention. It can lower therisk of developing a second heart attack and of dyingof a future heart attack if it does occur.

Even for people who have been smoking for dec-ades, the cardiac benefits of quitting are greatandthey start the moment a person quits. Within 20 min-utes after the last puff, nicotine-induced constrictionof the peripheral blood vessels lessens, decreasingthe coldness of the hands and feet that troubles somesmokers. Eight hours later, the bloods oxygen level

returns to normal, and its carbon monoxide levellessens.

Perhaps most important, the risk of having a heartattack starts to decline within the first day after stop-ping smoking. According to the 1990 Surgeon Gen-erals Report on the Health Benefit of SmokingCessation, the smoking-related excess risk of heart

disease is cut in half within one year of quitting.Within 5 to 10 years after stopping, the average ex-smokers risk of heart disease is the same as that of

someone who has never smoked. This is true for bothmen and women.

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In contrast to the heart, the lungs take somewhatlonger to show the beneficial effects of quitting. Butthere, too, the rewards of stopping smoking aregreat Ten years after quitting, a former pack-a-daysmoker has nearly the same chance of avoiding fatallung cancer and other smoking-linked cancers as

does a lifetime nonsmoker.

SMOKING CESSATION METHODS

Quitting cold turkey, rather than tapering off grad-ually, seems to be the best method for most people,

although it is not successful for everyone. It helps iffriends, relatives, or coworkers who smoke can stop

on the same dayor at least not smoke in front ofthe new ex-smoker. Many smokers who want to stopcan do it on their own, while others may need thehelp of individual or group counseling, relaxationtraining, hypnosis, or behavior modification to easewithdrawal symptoms.

Among structured programs, the best successrates have been reported for those that provide thequitter with a support system and that include coun-seling and education on behavior modification, stressmanagement, and nutrition. Behavior modification isthe most important component. It makes people con-

front the reasons why they smoke and assists themin finding the path that will help each one individuallyachieve success in quitting. (See the Why Do YouSmoke? self-assessment quiz.) Most smokers are ac-customed to lighting up in response to stress. Bylearning better techniques for managing stress, theycan prevent themselves from starting to smoke again.

Sometimes weight gain accompanies smoking ces-sation. Part of the reason is that, with quitting, tastebuds regain their keenness, so food tastes better. Eat-ing also provides something to do with the hands andmouth, which want a cigarette. Finally, it appears thatmetabolism (the rate at which the body expends cal-ories) is speeded up by nicotine and tends to slowdown with quitting. Exercise can help boost metab-olism again, while nutritional counseling can teachquitters how to choose healthy, low-fat snacks andstructure their regular meals to compensate for extranibbling. With these changes, most weight gain isnot significant.

Smokers who want to quit and fear weight gainshould keep in mind that although true obesity is alsoa risk factor for heart disease, a few extra pounds are

not nearly as detrimental as smoking. It would take

an additional 75 pounds to offset the benefit the av-erage smoker gains from quitting. Furthermore, mostex-smokers find that once they have completelystopped smoking, it is easier to lose the few extrapounds than it was to give up smoking.

YaleNew Haven Hospitals Center for Health Pro-motion offers a smoking cessation program calledSmoke Stoppers, developed by the National Centerfor Health Promotion, to its employees and patients,as well as corporate and community participants. Theprogram features behavior modification, stress man-agement, and nutritional counseling, and has a suc-

cess rate of 50 percent to 70 percent at the end of oneyear. On average, program participants gain ap-proximately 2 pounds. The programs success islargely attributed to carefully trained and certifiedinstructors. All are ex-smokers who can empathize

with the participants-and see through their de-fenses and denial.

At the first group session, smokers in the Yale pro-gram learn about the benefits of smoking cessationand methods of treatment. They do not quit at thatmeeting, but set a quit date within the next week.In the interim, they are encouraged to start keepinga diary of their activities, including smoking. (See box,Daily Cigarette Count.) This diary-keeping helpsthem identify the individual behavior that has chainedthem to the smoking habit. Such analysis, in itself,often results in a curtailment of smoking, which low-

ers the bodys dependence on nicotine, thus easingthe next step: quitting cold turkey.

At the next meeting, the program participantsthrow out their cigarettes and learn survival tech-niques for their first day of staying quit. Daily meet-

ings over the next three weeks then reinforce thissupport, with nutritional counseling and extensivetraining in stress management techniques. Thoseparticipants who are found to be highly nicotine de-pendent and those in whom withdrawal symptomspose a particular problem can consult their doctorsabout nicotine-replacement therapy. The instructors

follow up with the quitters at intervals of six, 12, and18 months after the quit date. Participants who beginto smoke again are invited to repeat the program atno charge.

Some other programs and individuals have re-ported success with the wrap method. During theperiod before the quit date, the smoker wraps eachpack of cigarettes with paper and rubber bands (avariation calls for wrapping each individual cigarettein aluminum foil). Whenever there is an urge tosmoke, the automatic response is broken by the chore


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SMOKING, ALCOHOL, AND DRUGS.-c


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Daily Cigarette Count .

Instructions: Attach a copy of this table to a pack of cigarettes. Complete the information each time you smoke acigarette (those from someone else as well as your own). Note the time and evaluate the need for the cigarette (1is for a cigarette you feel you could not do without; 2 is a less necessary one; 3 is one you could really gowithout). Make any other additional comments about the situation or your feelings. This record helps youunderstand when and why you smoke.

time

6AM

6:30

7

7:30

8

8:30

9

9:30

10

10:30

11

11:30

12PM

12:30

1

1:30

2

2:30

33:30

4

4:30

5

5:30

6

6:30

7

7:30

8

8:30

9

9:30

10

10:30

11

11:30

12AM

12:30

1

1:30

Need Feelings/Situation


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of having to unwrap and rewrap the pack. For eachcigarette, the smoker must write down the time and

his or her mood and current activity, and then ratethe importance of the cigarette. Like the diary, thishelps potential quitters start to think about why theysmoke.

A program of this type requires a time and finan-cial commitment that may be difficult or unnecessaryfor some people. On the other hand, some smokersfind that the financial commitment is an added in-centive to quit.

A number of government and voluntary healthagencies offer free or nominally priced self-helpmaterials for smokers who want to quit on theirown. (See box, Smoking Cessation Resources.) TheAmerican Cancer Society and the American LungAssociation run relatively inexpensive smoking-cessation programs, as do the Seventh Day Adven-

tists and some hospitals. At the same time that theyintroduce workplace no-smoking policies, many em-ployers are offering such programs as well.

SECONDHAND SMOKE

Smokers are not the only people harmed by tobacco.Toxic fumes from cigarettes pose a health threat to

all those around smokersfamily, friends, and co-workers. Because the organic material in tobaccodoes not burn completely, smoke contains many toxicchemicals, including carbon monoxide, nicotine, andtar. Cotinine, a breakdown product of nicotine in thebody, can be detected even in infants of smoking par-ents, as well as in nonsmoking adults who were un-aware that they had been passively exposed tosmoking.

As a result of this exposure, smokers childrenhave more colds and flu, and they are more likely totake up smoking themselves when they grow up.

Women who smoke increase the risk of miscarriage,delivering an underweight baby, and other healthproblems during delivery and infancy. There seemsto be an increased incidence of sudden infant deathsyndrome (SIDS) among babies whose motherssmoke. Otherwise, most of the effects of passivesmoking appear to be reversible. For instance,women who quit smoking before becoming pregnantor during their first four months of pregnancy elim-inate their risk (unless other factors are present) ofbearing a baby of low birth weight.

Smoking Cessation Resources

Local offices of the American Cancer Society, theAmerican Heart Association, and the AmericanLung Association can provide pamphlets onsmoking cessation and resources for low-cost

cessation programs. To find the office in yourarea, check your local telephone book orcontact:

American Cancer Society1599 Clifton Road NEAtlanta, GA 30329

American Heart Association7320 Greenville AvenueDallas, TX 75231

American Lung Association1740 BroadwayNew York, NY 10019

A Quit Kit of smoking cessation information,

lists of local stop-smoking programs, and over-the-phone counseling is available from:

The National Cancer Institute

Cancer Information ClearinghouseOffice of Cancer CommunicationBuilding 31, Room 10A189000 Rockville PikeBethesda, MD 202051-800-4-CANCER for all areas of the U.S. except:Alaska (800) 638-6070Oahu, HI (800) 524-1234

National Center for Health PromotionSmoker Stoppers Program3920 Varsity DriveAnn Arbor, Ml 48108(313) 971-6077

For several years, secondhand smoke (passivesmoking) has been implicated as potentially raisingthe risk of lung cancer. Evidence linking passivesmoking to heart disease has been documented. New

estimates released recently by the Surgeon Generalsoffice indicate that passive smoking may cause tentimes as much heart disease as lung disease. Ac-cordingly, passive smoking is now ranked as the thirdleading cause of preventable death, after active smok-ing and alcohol abuse.

Researchers suggest that nonsmokers who livewith smokers have a 30 percent higher risk of dyingfrom heart disease than do other nonsmokers. Sincethe U.S. Environmental Protection Agency estimatesthat exposure to secondhand smoke in the workplace

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is about four times that of a typical household, theproblem may be even worse for employees.

Not only can passive smoking contribute to thedevelopment of heart disease, but it also has beenshown to worsen the condition of people with exist-

ing heart disease. The transportation of oxygen to

the heart via red blood cells is hampered by the car-bon monoxide in secondhand smoke. In peoplewhose oxygen supply is already hampered by coro-nary artery disease, this places an excess burden onthe heart. There is also evidence that passive smokingmakes blood platelets abnormally sticky and morelikely to form clots; these effects play a role in thedevelopment of atherosclerotic plaques on the arterywalls.

The exposure of nonsmokers to environmental to-bacco smoke is reducedbut not eliminatedwhensmokers and nonsmokers are placed in separaterooms that are ventilated by the same system. Sinceit is not practical to remove all tobacco smokethrough air filters in ventilation systems, many mu-nicipalities and employers have now instituted no-

smoking policies, either prohibiting all cigarettesmoking within their buildings and certain publicplaces or confining it to areas that are ventilated sep-arately, with exhaust channeled directly outdoors.

QUITTING TIPSqMake a list of all the possible reasons to quit

and the benefits youll receive from doing so.Mark those that are most important to you,such as so my children wont breathe mysmoke or mimic my smoking. Read over thelist at least once a day and try to add to it.

Think about your smoking patterns-when andwhy you have each cigarette. This analysis

alone can help taper off the habit, lower yourbodys dependence on nicotine, and help youget a head start on actually quitting.

qChoose a date, in advance, to give up smokingcompletely. One popular day is the Great Amer-ican Smokeout sponsored each November bythe American Cancer Society, but it can be yourbirthday, the anniversary of a special day, orany day.

qShare your plan with a friend, coworker, orspouse. If your confidant is a smoker, ask him

or her to quit with you. If not, ask for under-standing and support or make it a challengeand propose a bet that you can do it.

Start getting ready to quit by changing the typeof cigarette you smoke (such as from regularto menthol) and the brand. Buy only one pack

at a time and switch each time. Stop carryingmatches or a lighter, and keep your cigarettesin an unhandy place.

Get a large jar and start collecting all your buttsin it.

In another large jar start collecting the moneyyou would normally spend on cigarettes each

time you forgo buying a pack. Set aside thesaved money as a reward for yourself.

Remember, the first days are the hardest, so dowhatever is needed to get through them. Atfirst, it maybe necessary to avoid activities thattrigger the urge to smoke, such as socializing

with other smokers. Try to spend as much timeas possible in places where smoking is prohib-ited (or at least awkward).

Brush your teeth or use mouthwash or sprayseveral times a day. Enjoy the clean taste inyour mouth.

Change the behavior associated with yourstrongest urges. For example, if you alwayshave a cigarette with your coffee during your

morning break, have tea or juice or go for aquick walk instead.

Keep your mouth and hands busy. Especially

during the difficult early days, eat plenty ofhealthful snacks (such as fresh vegetables orfruits), chew gum (or consider a nicotine-con-taining gum available by prescription), and tryholding a pencil between your fingers, doo-dling, or whittling. Suck on a toothpick or astraw.

Enjoy not smoking: Think of the healthy returns

of quitting; savor the taste of food, now thattobacco is no longer dulling the taste buds.

HELPING OTHERS TO QUIT

Smoking is psychologically and physically addictive,making it difficult for most people to quit. By keeping


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these tips in mind, a supportive nonsmoker can makea decisive difference for a friend, family member, orcoworker who is trying to stop smoking:

q

q

q

q

q

q

Do not nag or preach.

Praise the smokers efforts to stop, no matterhow tentative or small.

Show confidence in the smokers ability to quit.

Invite the smoker to share pleasurable activitiesin places where smoking is prohibited. For ex-

ample, go to the movies, visit a museum, attenda concert, or have dinner in a restaurant witha nonsmoking section.

Offer healthful snacks to keep the quittersmouth and hands busy while keeping weightgain to a minimum.

Encourage the smoker to call you for help ingetting through a sudden urge for a ciga-rette.

Most important, be patient.


ALCOHOLAfter smoking, excess alcohol is the second mostcommon cause of preventable death. Alcohol is toxicto virtually every organ in the human body, but whenconsumed in moderate amounts, it is detoxified bythe liver and does little or no harm. Alcoholicbeverages contain ethyl alcohol (ethanol), which ismetabolized in the body to acetaldehyde. In largeamounts, both ethanol and acetaldehyde interferewith normal functions of organs throughout thebody, including the heart.

There is a significantly higher incidence of highblood pressure among those who consume morethan 2 ounces of ethanol a day (which translates into4 ounces of 100-proof whiskey, 16 ounces of wine, or

48 ounces of beer). Abrupt withdrawal of alcoholfrom those consuming large amounts on a regularbasis may cause the condition known as delirium tre-mens (DTs), which is associated with a significant riskof cardiac arrest.

Binge drinking can provoke arrhythmias (irregu-

lar heart rhythms)-frequently in the form of atrialfibrillation-in people with no previous symptoms ofheart disease. This alcohol-induced rhythm disturb-ance is most common among people who have chron-ically abused alcohol. It is sometimes called holidayheart because it often occurs over the holidays or

on weekends, after consumption of more alcohol thanusual. People who are deprived of sleep are suscep-tible to developing holiday heart from drinking toomuch at one time, even if they do not regularly abusealcohol.

Alcohol is thought to provoke arrhythmias bystimulating the sympathetic nervous system. Alco-holics tend to have higher blood levels of the chemicalmessengers of this system such as epinephrine(adrenaline). Deficiency of the trace mineral magne-sium, which often occurs with chronic alcohol abuse,may also play a role.

Up to a third of all cases of a type of heart diseasecalled cardiomyopathy are attributed to excessivedrinking. Alcoholic cardiomyopathy occurs mostoften in middle-aged men. In this disorder, the heartmuscle (myocardium)particularly the right and leftventriclesenlarges and becomes flabby. (See Chap-ter 15.) As the working cells deteriorate, they becomemore sparse, and are replaced by fibers of connectivetissue in the spaces between the cells (interstitial fi-brosis). Eventually, alcoholic cardiomyopathy can re-sult in heart failure, in which the heart does not pump


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blood efficiently to all parts of the body. Fatigue,shortness of breath during exercise, and swelling inthe ankles are its most common symptoms. Thehearts inability to send blood efficiently to the kid-neys, where excess salt and water are normally fil-

tered out, means the body begins to retain salt, andthus water. This in turn raises blood volume andcauses a backup of fluid into tissues such as the lungs

(hence the breathing difficulty).When individuals with congestive heart failure

caused by alcoholic consumption continue to drink,their prognosis is poor. In contrast, those who ab-stain from alcohol raise their chances of reversingthe progress of alcoholic cardiomyopathy, especiallyif the problem is detected early Their hearts mayreturn to normal size, and they can live for manyyears. In fact, patients with alcoholic cardiomyopathywho abstain from drinking have a better prognosis

than do patients with cardiomyopathy from othercauses.Physicians once believed that malnutrition was the

sole mechanism by which alcohol damaged the heart.In extreme cases, alcoholics consume too many cal-

ories as drink and not enough as food, and they be-come malnourished. This could cause depletion of theprotein in heart muscle. However, it is now recog-

nized that in most cases, alcohol damages the hearteven in the absence of malnutrition.

MODERATE USE OF ALCOHOL

A number of epidemiologic studies have suggestedthat the risk of heart disease is somewhat loweramong people who regularly drink small amounts ofalcohol, such as a glass of wine a day, than among

teetotalers. Likewise, higher levels of high-density-Iipoprotein (HDL) cholesterol have been reportedamong light drinkers than among nondrinkers. Theoverwhelming evidence, however, indicates that ex-cess alcohol is harmful to the cardiovascular system.

In all of the studies showing a lower than averagerisk among light drinkers, the highest risk was shownto be among heavy drinkers. Excess alcohol has beenproved to damage the heart-and other organs, in-cluding the liver, stomach, and brain.

Alcohol Content By the Drink

Alcohol, in its pure, undiluted form, is too strong forthe mouth and stomach. The type of alcohol inalcoholic drinks is ethyl alcohol.

Alcohol content is expressed in percentages byvolume. Thus, the amount of liquid is not thedetermining factor. At a bar or party, the size of theglass in which a certain type of drink is usually serveddetermines the amount of alcohol a person canexpect to ingest. For instance, although there is amuch smaller proportion of alcohol in beer than in acocktail, beer is usually served in a mug many timesthe size of a cocktail glass. Below are approximationsof the amounts of alcohol found in various kinds ofdrinks.

Beer

Most beers contain about 5 percent alcohol byvolume. Malt liquors may contain up to 8 or 9percent.

Wine

A typical table wine contains about 10 to 13 percentalcohol by volume. A wines taste and bouquet are notindicators of alcohol content. A light, fragrant winemay contain a higher percentage of alcohol than a

full-bodied wine. (Wine such as sherry or vermouthis fortified; extra alcohol is added when it isproduced. It sometimes contains up to 20 percentalcohol by volume.)

Cocktails

Hard liquors including brandy, gin, vodka, andwhiskey and most liqueurs contain 40 to 50 percentalcohol by volume. The proof is a measure of alcoholconcentration. In the United States, proof is equal totwo times the alcohol content. Thus, liquor that is 80,proof contains 40 percent alcohol by volume.

Approximate equivalents determined by the size of theconventional drink glasses:

A 12-ounce a 4-to 5-ounce a 1.5-ounce shot

mug of beer glass of wine of 80-proof liquor


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The links between light drinking and cardiovas-

cular protection should certainly not be used as anexcuse for drinkers to consume additional alcohol;

nor should nondrinkers start drinking in order toprotect their hearts. On the other hand, for those whodrink, a modest alcohol intake can be an acceptablemeans of stress modification. (See box, Alcohol Con-

tent By the Drink.) A single cocktail or a glass ofwine or beer at the end of a long day may be quiterelaxing and beneficial. It should not be harmful un-less there is a family history of alcoholism or a dem-onstrated sensitivity to small amounts of alcohol.


q

ALCOHOL ABUSE

Any use of an illicit drug can be considered abuse. The situation with alcohol, however, is more complex.Although alcohol is a drug, and a potentially harmful q

one, its use is legally and socially sanctioned. An es-timated two-thirds of adults in the Western world usealcohol, and at least one in ten is a heavy user. There- fore, definitions of alcoholism vary.

How much alcohol is too much? The level of al-cohol an individual can tolerate before showing men-

also have less alcohol dehydrogenase, an enzyme thathelps neutralize alcohol before it reaches the blood-stream. Thus, more alcohol is absorbed into awomans bloodstream. Drinking on an empty stom-ach, consuming drinks in rapid succession, anddrinking when fatigued can affect tolerance. In moststates, the legal limit for driving is 100 mg/100 ml of

alcohol in the blood. (See Figure 6.2.) But the dele-terious effects of alcohol can begin with far less.

A yes answer to even one of the following ques-tions should be reason to suspect alcohol abuse in anindividual:

Has alcohol ever caused lateness for or absencefrom work?

Has alcohol ever caused neglect of obligationsto family, friends, or job?

Has the individual ever acted out of charac-

ter -obnoxious, belligerent, antisocial, oreven overly sociablewhile drinking?

Has the individual ever blacked out or been

unable to remember the night before on themorning after?

tal and physical effects varies from person to personand may vary for the same individual depending uponthe circumstances. Body size is a major determinantof how much a person can drink: Generally, the largera person is, the more he or she can tolerate. In gen-eral, women cannot tolerate as much alcohol as men

can. Until recently, it was assumed that this is be-cause, on average, they weigh less. A preliminary

Like smokers and drug abusers, alcoholics muststop denying their probIem before they can start to

solve it. Confronting the substance abuser is oftenthe first step in this process. Suspicions that oneorones friend, relative, or coworkerhas a drinkingproblem warrant a consultation with a doctor. Local

resources, including Alcoholics Anonymous chap-ters, are listed in the yellow pages of the telephone

study has shown, however, that womens stomachs book.

Figure 6.2


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ILLICIT DRUGSFriends and even medical personnel may be slow tosuspect that a heart attack is taking place because ofthe victims youth; yet the percentage of cocaine-induced heart attacks that are fatal is equal to the

Like smoking and drinking, using illicit drugs can alsobe hazardous to the heart. The problems vary with

percentage of heart attacks from other causes thatare fatal. Recurrent chest pain and heart attacks have

the drug used and they range from physiologic to been reported among those who continue to use co-

infectious. caine after surviving a cardiac complication.

COCAINE

Use of cocaine has snowballed in recent decades,along with the myth that the drug is relatively safe,especially when it is sniffed (snorted) rather than

injected or smoked as crack. In fact, no matter howit is used, cocaine can kill. It can disturb the heart'srhythm and cause chest pain, heart attacks, and evensudden death. These effects on the heart can causedeath even in the absence of any seizures, the mostcommon of cocaines serious noncardiac side ef-fects. Dabblers should beware: Even in the absenceof underlying heart disease, a single use of only asmall amount of the drug has been known to be fatal.Although such deaths are uncommon, they do occur.

Cocaine use is not healthful for anyone, but es-pecially for certain groups. Although the drug hasbeen shown to impair the function of normal hearts,it seems even more likely to cause death in peoplewith any underlying heart disease. And when preg-

nant women use cocaine, they not only raise the like-lihood of having a miscarriage, a premature delivery,or a low-birth-weight baby, but also of having a babywith a congenital heart abnormality, especially anatrial-septal or ventricular-septal defect.

A variety of mechanisms conspire to cause co-caines impairment of the heart. Use of cocaine raisesblood pressure, constricts blood vessels, and speedsup heart rate. It may also make blood ceils calledplatelets more likely to clump and form the blood clotsthat provoke many heart attacks. In addition, co-caines effects on the nervous system disrupt the nor-

mal rhythm of the heart, causing arrhythmias(irregular heartbeats). Recently, scientists have es-tablished that cocaine binds directly to heart musclecells, slowing the passage of sodium ions into thecells. Cocaine also causes the release of the neuro-transmitter norepinephrine (noradrenaline), a chem-

ical messenger that stimulates the autonomic nervoussystem. Both changes can lead to arrhythmias.

Heart attacks in young people are rare. However,when they do occur, cocaine is frequently the cause.

INTRAVENOUS (IV) DRUGS

Using a needle to shoot up a drug such as heroincan lead to a deadly disease called infective endo-carditis. Endocarditis is an infection of the endocar-dium, which includes the heart valves. Colonies ofbacteria (usually streptococcus or staphylococcus),fungi, or other microbes introduced into the blood-

stream via intravenous needles grow on the endo-cardium and can damage or destroy the heart valves.The microorganisms can also migrate through thebloodstream to other regions of the body. The clumpsof microbes and their by-products can also formplugs, or emboli; if these plugs become lodged inarteries serving the lungs, heart, or brain, they canlead to pulmonary embolism, heart attack, or stroke,respectively.

Endocarditis is not confined to drug users. How-ever, when it strikes people who do not use drugs, ittends to be confined to artificial valves or to valves

that have been previously weakened by a heart con-dition such as rheumatic heart disease or congenitalheart disease. In contrast, in most IV drug users whodevelop infective endocarditis, the heart valves arenormal at first. It is possible that IV drug use itselfmakes heart valves vulnerable to infection. Particlespresent in the injected material may damage thevalves and blood vessel linings, roughening the sur-face and leading to platelet clumping, thus providinglikely sites for bacteria to grow.

Street drugs carry no verified list of ingredients.Along the way to the buyer, they pass through the

hands of many distributors. Each of these dealersmay cut, or dilute, a single sample of a drug withcheaper powders such as lactose, starch, quinine, andtalc. Bacteria or fungi easily find their way into the

drug sample during the mixing of these substances,or when the drug is dissolved in fluid just prior toinjection, or from the injection paraphernalia itself.

Early symptoms of infective endocarditis includeweakness, fatigue, fever, chills, and aching joints.Without treatment, infective endocarditis is invaria-


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bly fatal. However, recovery is possible when the dis-ease is detected and treated promptly with anantibiotic that has been selected to kill the particularbacteria causing the infection. Sometimes surgerymust be performed to replace the damaged valve; forexample, if antibiotic treatment alone is unsuccessful,or if heart failure develops and cannot be controlled,

surgery may be recommended to replace the dam-aged valve.

AMPHETAMINES

Like cocaine, amphetamines (speed) raise bloodpressure and heart rate. They are dangerous drugs

for anyone, but particularly for people with any his-tory of heart disease. Users of street cocaine mayunknowingly consume amphetamines, as the twodrugs are sometimes mixed together,


RECOGNIZING DRUG ABUSE

Warning signs of drug use include mood swings, ir-

ratability, and nervousness. Like alcoholics, drugusers often miss work on Mondays, Fridays, and the

day after payday. Their job performance may be er-ratic and marked by extra accidents and gross lapsesin judgment. One may be tempted to protect drug-using friends, relatives, and coworkers. However, it

is far better to confront the drug use, not cover upfor it, and to urge the drug user to seek help. Many

employers now offer employee assistance programs(EAPs) for workers who are having problems, in-cluding alcohol and drug abuse. For help and infor-mation, consult a doctor or check the yellow pages

under Drug Abuse Information and Treatment.

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Documents

29. Smoking, Alcohol, And Drugs