11

SMOKING CESSATION SMOKING CESSATION AND AND

WEIGHT PROBLEMSWEIGHT PROBLEMS

Dr. Zeynep A. SolakDr. Zeynep A. SolakEge University School of MedicineEge University School of Medicine

Department of Chest Diseases, İzmirDepartment of Chest Diseases, İzmir

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The goals of this presentationThe goals of this presentation

Weight gain after smoking cessation, Weight gain after smoking cessation, a reason for relapsea reason for relapse

Mechanism of weight gainMechanism of weight gain

Is it possible to avoid body weight Is it possible to avoid body weight gain?gain?

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Weight gain after smoking Weight gain after smoking cessationcessation

About 80% of people gain weight after stop About 80% of people gain weight after stop smokingsmoking

It starts just after cessation and continues It starts just after cessation and continues through abstinencethrough abstinence

This problem is a primary reason for not This problem is a primary reason for not trying to quit and for relapsing after trying to quit and for relapsing after cessationcessation

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MMeanean changechange after smoking cessationafter smoking cessation

0

1

2

3

4

5

6

7

7 8 9 10 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 100104

Visit Week

Weig

ht

Ch

an

ges (

kg

)

(N Engl J Med 1997, 337)

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The average 5-year weight gain of The average 5-year weight gain of sustained quitters was sustained quitters was 8.78.7 kg for women kg for women 7.67.6 kg for men kg for men

(Am J Epidemiol 1998; 148)(Am J Epidemiol 1998; 148)

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For smokers who gain For smokers who gain 1010 kg or more, the kg or more, the risks associated with weight gain may risks associated with weight gain may negate some negate some

of the health benefits achieved in quitting:of the health benefits achieved in quitting:

• Blood pressure Blood pressure • Serum lipids Serum lipids • Blood glucose Blood glucose • Uric acid levelsUric acid levels

• Reduction in lung volumes Reduction in lung volumes • Respiratory symptomsRespiratory symptoms

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Risk Factors:Risk Factors:

Age (Younger smokers) Age (Younger smokers) Gender (Women)Gender (Women) Obesity Obesity Number of cigarettes/dayNumber of cigarettes/day Genetic factors Genetic factors

(Dopamine receptor polymorphism) (Dopamine receptor polymorphism) ??

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Mechanism of weight gainMechanism of weight gain

NicotineNicotine

AppetiteAppetite Altered Altered feeding feeding patternspatterns

Metabolic Metabolic rate both at rest and rate both at rest and

during activityduring activity

Reduced body weightReduced body weight

LipolysisLipolysis

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Effects of nicotine onEffects of nicotine on

adipose tissue andadipose tissue and

peptides ?peptides ?

Adipose tissue Adipose tissue lipoprotein lipaselipoprotein lipase

LeptinLeptin Neuropeptide YNeuropeptide Y Orexins Orexins

Effects of nicotine onEffects of nicotine on

monoaminesmonoamines::

Noradrenaline (Noradrenaline ()) Dopamine (Dopamine ()) Serotonin (Serotonin ())

1010

Effects of nicotine onEffects of nicotine oninsulin and insulin and

adiponectinadiponectin

Impair glucose Impair glucose tolerancetolerance

Insulin resistanceInsulin resistance DyslipidaemiaDyslipidaemia Post-prandial lipid Post-prandial lipid

intoleranceintolerance Decreased adiponectinDecreased adiponectin

Effects of nicotine onEffects of nicotine on

İnflammation (?)İnflammation (?)

İnhibition of the effects İnhibition of the effects of inflammatory of inflammatory mediators on adipocyte mediators on adipocyte metabolismmetabolism

1111

Smoking Smoking cessationcessation

CaloricCaloricintakeintake

Lipoprotein Lipoprotein lipase activitylipase activity

Resting Resting metabolic rate metabolic rate

Weight gainWeight gain

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Is it possible to avoid body weight Is it possible to avoid body weight gain?gain?

Behavioural TherapyBehavioural Therapy Pharmacologic TherapyPharmacologic Therapy

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I) Behavioural therapyI) Behavioural therapy

Cognitive-behavioural therapy to reduce Cognitive-behavioural therapy to reduce concernconcern

Behavioural weight control programmeBehavioural weight control programme

(J Consult Clin Psychol 2001; 69)(J Consult Clin Psychol 2001; 69)

(Obesity Reviews 2004; 5)(Obesity Reviews 2004; 5)(Smoking Cessation Clinical Practice Guideline, AHCPR, 2000)(Smoking Cessation Clinical Practice Guideline, AHCPR, 2000)

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The great majority The great majority of of

smokers gain smokers gain weightweightSmokers will gain weight, Smokers will gain weight,

even if they do not eat more. even if they do not eat more.

There are medication that There are medication that

will help youwill help you

The amount of weight you The amount of weight you

will likely gain will be a minor will likely gain will be a minor

risk compared with smokingrisk compared with smoking

You are most likely to be You are most likely to be successful if you first try to quit successful if you first try to quit smoking and then smoking and then later take steps to reduce your later take steps to reduce your weightweightThink about eating plenty of fruit Think about eating plenty of fruit and vegetables, getting enoug and vegetables, getting enoug sleep, not eating a lot of fatssleep, not eating a lot of fats

Although you may gain some weight, Although you may gain some weight, compare the importance of this with compare the importance of this with the added years of healty living you the added years of healty living you will gain, your better appearance will gain, your better appearance and good feelings about quittingand good feelings about quitting

Cognitive-behavioural therapy to reduce concernCognitive-behavioural therapy to reduce concern

Evidence CEvidence C

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Change eating patternsChange eating patterns

Smaller portions, eaten Smaller portions, eaten slowlyslowly

When finished, get upWhen finished, get up

from the tablefrom the table

and brush own’s teethand brush own’s teeth Stay away from alcoholStay away from alcohol

Behavioural weight control programmeBehavioural weight control programme

Change lifestyle Change lifestyle patternspatterns Community walking-Community walking-groupsgroups Exercise programmes Exercise programmes at at workwork

Change physical Change physical activityactivity Regular exerciseRegular exercise If possible do not start If possible do not start at the same timeat the same time

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Recommendation Recommendation (Evidence B)(Evidence B)

Bupropion SRBupropion SR

Nicotine replacement therapy,Nicotine replacement therapy,ın particular nicotine gumın particular nicotine gum

(Smoking Cessation Clinical Practice Guideline, AHCPR, 2000)(Smoking Cessation Clinical Practice Guideline, AHCPR, 2000)

II) Pharmacologic therapyII) Pharmacologic therapy

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Nicotine replacement therapy (NRT)Nicotine replacement therapy (NRT)

-Nicotine gum - delaying postcessation weight -Nicotine gum - delaying postcessation weight gaingain

(J Consult Clin Psycol 1989)(J Consult Clin Psycol 1989)

-Nicotine patches - prevention of weight gain (?)-Nicotine patches - prevention of weight gain (?) (Clin Cardiol 1999; 22)(Clin Cardiol 1999; 22)

(Horm Metab Res 2004; 36)(Horm Metab Res 2004; 36)

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Nicotine gum -Nicotine gum -Behavioural Behavioural adviceadvice

Behavioural weight Behavioural weight control programme - dietcontrol programme - diet++

(BMJ 1999; 319)(BMJ 1999; 319)

Treated (%)Treated (%) Control (%)Control (%) PP

QuittersQuitters 68/137 (50)68/137 (50) 53/150 (35)53/150 (35) =0.01=0.01

Weight Weight (Kg)(Kg)

- 2.1- 2.1 + 1.6+ 1.6 <0.001<0.001

After 16 weeksAfter 16 weeks

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Nicotine gum -Nicotine gum -Behavioural Behavioural adviceadvice

Behavioural weight Behavioural weight control programme - dietcontrol programme - diet++

Treated Treated (%)(%)

Control (%)Control (%) PP

QuittersQuitters 38/137 (28)38/137 (28) 24/150 (16)24/150 (16) <0.05<0.05

Weight Weight (Kg)(Kg)

No significant differenceNo significant difference

After 1 yearsAfter 1 years

2020

Bupropion SRBupropion SR

ReferenceReference TreatmenTreatmentt

duration duration

(week)(week)

Drug doseDrug dose

(mg)(mg)No. of No. of patientpatient

ss

AbstinencAbstinencee

rate (%)rate (%)

(6-month)(6-month)

Mean Mean weight gain weight gain

(kg)(kg)

at the end at the end of of

treatmenttreatment

Hurt Hurt et alet al 77 BUP 300BUP 300 156156 12.212.2 1.51.5

77 BUP 150BUP 150 153153 13.713.7 2.32.3

77 PLPL 153153 5.95.9 2.92.9

Jorenby Jorenby et et alal

99 BUP 300BUP 300 244244 2525 1.71.7

88 NICNIC 244244 1616 1.61.6

99 B300+NICB300+NIC 245245 2525 1.11.1

99 PLPL 160160 1010 2.12.1

Hays Hays et alet al 5252 BUP 300BUP 300 432432 52.352.3 3.83.8

5252 PLPL 214214 55.155.1 5.65.6

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Botella-Carretero Botella-Carretero et al. et al.

Open-randomised studyOpen-randomised study

BUP 300 or nicotine patches - 7 week BUP 300 or nicotine patches - 7 week treatment treatment

Weight gain is not dependent on obesity or Weight gain is not dependent on obesity or drug takendrug taken

(Horm Metab Res 2004; 36)(Horm Metab Res 2004; 36)

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New drug - RimonabantNew drug - Rimonabant

-- Endocannabinoid system Endocannabinoid system Plays role in regulation of food intake and Plays role in regulation of food intake and

energy expenditureenergy expenditure Plays role in tobacco dependencePlays role in tobacco dependence

- RimonabantRimonabant First selective CB1 blocker First selective CB1 blocker Helps to normalize the disrupted EC Helps to normalize the disrupted EC systemsystem

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Obesity drugsObesity drugs

FluoxetineFluoxetine SibutramineSibutramine OrlistatOrlistat

??

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Smoking cessation frequently leads to weight gainSmoking cessation frequently leads to weight gain

The cause is a change in body's metabolic rate and The cause is a change in body's metabolic rate and in eating habitsin eating habits

Behavioural advises and pharmacotherapy (NRT, Behavioural advises and pharmacotherapy (NRT, bupropion SR) bupropion SR) can limit weight gaincan limit weight gain

DDrugs rugs are effective in reducing weight gain, but are effective in reducing weight gain, but weight starts to increase when drug administration weight starts to increase when drug administration stopsstops

Smokers not take strong measures (e.g., strict Smokers not take strong measures (e.g., strict dieting) to counteract weight gain during a guit dieting) to counteract weight gain during a guit attemptattempt

SummarySummary