I decided to dedicate a medical blog on smoking cessation after realizing that too many people in Douglas County (Omaha, Nebraska) smoke. Did you know that despite a smoking ban in restaurants and bars, 18.3% of people in Nebraska are smokers? That’s one in five people. And this number contributes to Omaha’s health ranking of 142 out of 182 cities in America.
Diabetes and hypertension (high blood pressure) worsen kidney function over time. Many people do not appreciate that smoking is also responsible for worsening kidney function! Smoking hurts your kidneys.
Blood vessels are blood vessels. Just like coronary arteries (heart arteries), the renal arteries (kidney arteries) are susceptible to blockage in smokers. Blockages to the kidneys lead to renal artery stenosis, accelerated secondary hypertension, and loss of kidney function. In addition, smoking causes hypertension. A patient’s systolic blood pressure (the top number) can be increased as much as 20 points if they smoke. Recall that for every 20/10 point increase in blood pressure, your risk of dying doubles!
Please stop smoking. Yes, I know it is tough. But you really must try to quit. Obama wants to. And he also would like you to quit, given the costs associated with smoking in the setting of a health care bubble that is about to burst.
So what can you do?
Chantix (generic name: varenicline) is a medication that can be considered to help patients stop smoking. There is risk associated with this therapy. In fact, I received a letter in the mail from Pfizer regarding the side effect profile of Chantix.
Why would Dr. Aaronson consider this medication (as well as Zyban [generic name: Buproprion] and nicotine) given the associated risks of therapy? Because I believe in the concept of risk to benefit ratio.
Every medication has what is termed a “therapeutic range.” As the concentration of a drug increases in the body, the benefit of the medicine increases. Low doses equal sub-optimal levels, but as we increase the dose, the benefit increases — up to a point — where additional medicine is not going to help. An example I like to use with patients is blood pressure medication. Benazepril is an ace inhibitor that is good for the kidneys. Once we get to the maximum dose (40 mg daily), there is no additional effect, and we have to add another blood pressure medication to get you to goal.
However, as the concentration of a drug is increased in the body, the side effects of that medication start to be seen — this is the risk of taking a medicine. For example, ACE inhibitors are sometimes associated with a cough at high doses. If we decrease the dose of benazepril in this setting, we can see the cough go away with a beneficial effect of the medication still present.
Therapeutic range defines a concept in which we want maximal efficiency of a medication with minimal side effects (toxicity) in most people. In my humble opinion, therapeutic range explains why you want a competent physician on your side. All medicines that work have side effects. If we focus only on the side effects without considering the benefits of therapy, we are at a disadvantage and will have difficulty helping those who need treatment the most. The risk to benefit ratio is an important concept for patients and providers to appreciate.
Chantix in my opinion has a “narrow therapeutic range.” Therefore, when patients take this medication, they need to be careful and work closely with their health care provider to make sure they can tolerate the medication. That said, the result of taking Chantix for a short period of time to help smokers quit may be worth the risk because of the huge benefit of stopping smoking.
On the other end of the spectrum, there are medicines which have a “wide therapeutic range.” Consider the use of inhaled nasal steroids to treat perennial allergies (vasomotor rhinitis). Nasal steroids work like gangbusters to help people with vasomotor rhinitis stop dripping. The condition, as opposed to smoking, is a benign one. Therefore, there needs to be minimal risk with almost no side effects when this inhaler is given. Why? Because using a lot of tissues and giving someone the allergic salute is not going to kill you. Smoking will kill you and your loved ones through second hand smoke and third hand smoke.
So is Chantix worth the risk? What is more dangerous, the disease or the cure? The choice is yours with your providers input. I only opine…
Therefore, if you are a smoker who wants to quit, here is your job:
- Watch the YouTube videos on smoking cessation so you can learn more about counseling, treatment options, and determine if you are ready to quit.
- Make an appointment with your primary care provider to have a conversation regarding whether the benefits of the therapy outweigh the side effect risks associated with taking medication for a period of 3-6 months.
- If you decide to go forward and begin therapy for smoking, be vigilant. If you notice, or your loved ones notice, that you are feeling down, are acting strange, or are having thoughts you may hurt yourself or others, stop the medicineand call your doctor immediately.
Dialysis patients who smoke can take Chantix at a reduced dose. The negative side: your kidneys are not working and you are on dialysis. The kidneys cannot be saved. However, on the positive side, reduced dosage equates to decreased medication costs. Quitting smoking protects the other blood vessels in your body from hardening — think heart attack and stroke prevention.
Keep an open mind in terms of the risks of Chantix versus the benefits.
Michael Aaronson is a nephrologist who blogs at his self-titled blog, Michael L. Aaronson M.D.
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