Zeitschrift für Kardiologie

, Volume 94, Supplement 3, pp iii30–iii42

Rauchen und koronare Herzkrankheit

  • T. Heitzer
  • T. Meinertz
Article

Zusammenfassung

Der Tabakkonsum stellt heute das bedeutendste einzelne Gesundheitsrisiko und die führende Ursache für frühzeitige Sterblichkeit in Deutschland dar. In der Erwachsenenbevölkerung raucht immer noch etwa 1/3, bei Kindern und Jugendlichen zeigt der Zigarettenkonsum eine steigende Tendenz. Obwohl der Zusammenhang zwischen Rauchen und frühzeitiger Atherosklerose vielfach belegt ist, sind weder die schädigenden Komponenten des Zigarettenrauchs bislang eindeutig identifiziert noch die Mechanismen der Gefäßschädigung vollständig geklärt. Unmittelbare Wirkungen des Rauchens sind Anstieg der Pulsfrequenz, des systemischen und koronaren Widerstands, der myokardialen Kontraktilität und des myokardialen Sauerstoffbedarfs. Rauchen verursacht eine Schädigung der normalen Endothelfunktion, die durch die gesteigerte Inaktivierung von Stickstoffmonoxid durch freie Sauerstoffradikale erklärt wird. Rauchen bewirkt eine Steigerung der oxidativen Modifikation von LDL und eine Verminderung der HDL-Plasmaspiegel. Rauchen ist mit einer Erhöhung der Leukozytenzahl und des C-reaktiven Proteins verbunden, beides Ausdruck von gesteigerter inflammatorischer Aktivität. Als prothrombotische Effekte des Rauchens sind Aktivierung der Thrombozyten, Erhöhung der Fibrinogenspiegel und Verminderung der Fibrinolyseparameter bekannt. In Anbetracht der massiven Gesundheitsschäden in Folge des Tabakrauchs muss eine vollständige Abstinenz erreicht werden. Dies gilt sowohl für bislang Gesunde als auch besonders für schon an Schäden des Tabakrauchs Erkrankte. Interventionen zur Tabakentwöhnung sind im Vergleich zu den Kosten tabakbedingter Folgeschäden in hohem Maß kosteneffektiv. Durch professionelle Beratung und Behandlung sowie pharmakologische Entwöhnungshilfen soll der Ausstieg erleichtert werden. Um auch langfristig den Anteil erfolgreicher Entwöhnungsversuche zu erhöhen, sind Rückfallprävention und -management von besonderer Bedeutung. Zur Kontrolle und Prävention des Tabakkonsums sind umfangreiche gesellschaftspolitische und individuumsbezogene Maßnahmen erforderlich. Dazu gehören Erhöhung der Tabaksteuer, Verbot von Tabakwerbung und Sponsoring, Schaffung einer rauchfreien Umwelt, striktere Kontrolle zu Abgabe und Vertrieb von Tabakwaren, umfangreiche Produktregulierung und Verbraucherinformation und Verbesserung der Beratungs- und Behandlungsangebote.

Schlüsselwörter

Rauchen Tabakentwöhung Nikotinersatztherapie Tabakkontrolle 

Prevention of coronary heart disease: smoking

Summary

Smoking is the leading preventable cause of illness and premature death in Germany, claiming over 110 000 lives a year because it directly increases the risk of dying from heart disease, stroke, emphysema and a variety of cancers. The overwhelming majority of smokers begin tobacco use before they reach adulthood. Among those young people who smoke, the average age is now 13–14. In Germany, about 39% of male and 31% of female adults (age 18–60 years) continue to smoke, despite information about the unequivocally negative health consequences of smoking. The exact mechanisms of smoking-related vascular disease are not yet known. Smoking causes acute hemodynamic alterations such as increase in heart rate, systematic and coronary vascular resistance, myocardial contractility, and myocardial oxygen demand. These short-term effects could lower the ischemic threshold in smokers with coronary artery disease and contribute to the increased risk for acute cardiovascular events. Endothelial damage is thought to be an initiating event in atherosclerosis and early studies have demonstrated that long-term smoking has direct toxic effects with structural changes of human endothelial cells. Recent research has shown the importance of the functional role of the endothelium in regulating vascular tone, platelet-endothelial interactions, leukocyte adhesion and smooth muscle cell proliferation via synthesis and release of a variety of substances such as nitric oxide. There is strong evidence that smoking leads to endothelial dysfunction mainly by increased inactivation of nitric oxide by oxygen-derived free radicals. Smoking also increases oxidative modification of LDL and is associated with lower HDL plasma levels. Smoking induces a systemic inflammatory response with increased leukocyte count and elevation of the C-reactive protein level. Importantly, the prothrombotic effects of smoking have been repeatedly demonstrated to cause alterations in platelet function, imbalance of antithrombotic vs prothrombotic factors, and decrease of fibrinolytic activity. Given the enormous health hazard of tobacco use, complete abstinence from smoking should be achieved. Smoking cessation counselling should be given to healthy subjects and even more vigorously to patients with manifested disease. Every effort should be undertaken to prevent children and adolescents from starting to smoke. Brief tobacco dependence treatment is effective, and every smoker should be offered at least brief treatment at every office visit. More intensive treatment is more effective in producing long-term abstinence from tobacco. Nicotine replacement therapy (nicotine patches or gum), clinician-delivered social support, and skills training are the three most effective components of smoking cessation treatment. A framework for tobacco control measures is necessary to reduce tobacco consumption and exposure to tobacco smoke. Recommendations on specific tobacco control intervetnions are: 1. increase in tobacco taxes; 2. comprehensive tobacco advertising bans; 3. legislation prohibiting smoking in work and public places; 4. prohibiting the sales of tobacco products to persons under 18; 5. comprehensive disclosure of the physical, chemical and design characteristics of all tobacco products; 6. training of health professionals to promote smoking prevention and cessation interventions; and 7. development of a national network of smoking cessation treatment services.

Key words

Smoking smoking cessation nicotine replacement tobacco control 

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Copyright information

© Steinkopff-Verlag 2005

Authors and Affiliations

  • T. Heitzer
    • 1
  • T. Meinertz
    • 1
  1. 1.Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-EppendorfHamburgGermany

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