Andreas Jaehne

How smoking affects sleep: a polysomnographical analysis.

OBJECTIVE Subjective quality of sleep is impaired in smokers compared with non-smokers, but there is only limited evidence from methodologically sound studies about differences in polysomnography (PSG) sleep characteristics. Therefore, this study used PSG to evaluate sleep in smokers and non-smokers while controlling for other parameters that affect sleep. METHODS After an adaptation night, PSG sleep laboratory data were obtained from 44 smokers (29 men and 15 women, median age 29.6 years) and compared with PSG data from 44 healthy, sex- and age-matched never smokers. Exclusion criteria were alcohol or other substance abuse, psychiatric or endocrine diseases, and treatment with any kind of psychotropic medication. Nicotine and cotinine plasma levels were measured (in the smoking group) and subjective sleep quality assessed in both groups. RESULTS The smokers had a Fagerström tolerance score of 6.4, consumed an average of 21.2 cigarettes per day and had been smoking for 13.1 years (median). Smokers had a shorter sleep period time, longer sleep latency, higher rapid eye movement sleep density, more sleep apneas and leg movements in sleep than non-smokers. There were no differences regarding parameters of spectral analysis of the sleep electroencephalogram as well as in the sleep efficiency measured by PSG. Nevertheless smokers rated their sleep efficiency lower on the Pittsburgh Sleep Quality Index compared with non-smoking individuals, but no differences were detected on the SF-A. Plasma cotinine level correlated negatively with slow wave sleep in the smoking group. CONCLUSIONS Smokers showed a number of insomnia-like sleep impairments. The findings suggest that it is important for sleep researchers to control smoking status in their analyses. Further research should focus on the causes and consequences of impaired sleep during tobacco cessation, as sleep disturbances are a known risk factor for early relapse after initial tobacco abstinence.

Impaired sleep quality and sleep duration in smokers-results from the German Multicenter Study on Nicotine Dependence

Cigarette smoking is a severe health burden being related to a number of chronic diseases. Frequently, smokers report about sleep problems. Sleep disturbance, in turn, has been demonstrated to be involved in the pathophysiology of several disorders related to smoking and may be relevant for the pathophysiology of nicotine dependence. Therefore, determining the frequency of sleep disturbance in otherwise healthy smokers and its association with degree of nicotine dependence is highly relevant. In a population‐based case‐control study, 1071 smokers and 1243 non‐smokers without lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorder were investigated. Sleep quality (SQ) of participants was determined by the Pittsburgh Sleep Quality Index. As possible confounders, age, sex and level of education and income, as well as depressiveness, anxiety, attention deficit hyperactivity, alcohol drinking behaviour and perceived stress, were included into multiple regression analyses. Significantly more smokers than non‐smokers (28.1% versus 19.1%; P < 0.0001) demonstrated a disturbed global SQ. After controlling for the confounders, impaired scores in the component scores of sleep latency, sleep duration and global SQ were found significantly more often in smokers than non‐smokers. Consistently, higher degrees of nicotine dependence and intensity of smoking were associated with shorter sleep duration. This study demonstrates for the first time an elevated prevalence of sleep disturbance in smokers compared with non‐smokers in a population without lifetime history of psychiatric disorders even after controlling for potentially relevant risk factors. It appears likely that smoking is a behaviourally modifiable risk factor for the occurrence of impaired SQ and short sleep duration.

Sleep changes in smokers before, during and 3 months after nicotine withdrawal

Nicotine may affect sleep by influencing sleep‐regulating neurotransmitters. Sleep disorders can increase the risk for depression and substance dependency. To detect the influence of sleep disturbances on the effect of smoking cessation, we investigated polysomnographically (PSG) the sleep of smoking subjects during a period of smoking, during withdrawal and after a period of abstinence from nicotine. Thirty‐three smokers (23 male, 10 female, median age 29 years, Fagerström Test for Nicotine Dependence score 6.3) were examined during smoking, 24–36 hours after smoking and 3 months after cessation. All subjects had an adaptation night followed by the PSG night. Compared with the smoking state, we found increased arousal index and wake time during nicotine withdrawal. Smokers who later relapsed (11) presented a higher degree of nicotine dependence and more withdrawal symptoms than those who abstained (22) and were characterized by less rapid eye movement (REM) sleep, a longer REM latency as well as by more intense sleep impairments in the subjective sleep rating during the withdrawal. Impairments of sleep during the withdrawal phase may reflect more severe nicotine dependence and may contribute to earlier relapse into smoking behaviours.

The Efficacy of Stepped Care Models Involving Psychosocial Treatment of Alcohol Use Disorders and Nicotine Dependence: A Systematic Review of the Literature

Of particular interest in the psychosocial treatment of addictions is determining how much therapy is required to bring about behaviour change. Stepped care approaches, where non-responders to a less intensive therapy receive a more intensive intervention, aim to only provide intensive assistance to those who need it, thereby allocating therapeutic resources more efficiently. This paper provides a systematic review of stepped care models involving different levels of psychosocial intervention for the treatment of alcohol use disorders and smoking cessation. Five publications on alcohol and three on smoking were included in the review. Due to the heterogeneity of outcome measures, participant characteristics and interventions, a narrative review format was employed. Overall, little evidence was found to suggest that stepping up non-responders to more intensive therapy improved outcomes, a finding that could partially be attributed to a lack of power to find significant effects. In one study, the application of a stepped care approach was found to reduce treatment costs compared with usual care. There was some evidence that the greater differentiation between the intensity of the interventions offered at each step, the better the outcome. Further research is needed to evaluate the efficacy of stepped care approaches to providing psychosocial treatment, employing larger samples and/or consistent definitions of the nature of the interventions offered at each step, and assessing treatment response in a timely manner.

Implementation and effectiveness of a hospital smoking cessation service in Germany

OBJECTIVE Hospitalized smokers are often highly motivated to quit and receptive to assistance. There are few published accounts of hospital-based smoking cessation programmes implemented outside of a trial setting, particularly outside North America. We describe the implementation and effectiveness of a dedicated smoking cessation service in Freiburg, Germany. METHODS Measures of implementation (e.g. number of patients referred and consenting to participate, receipt of post-discharge support) and effectiveness are presented. RESULTS In the first 2 years of the service, 1432 patients were referred. Over half (55.3%) of counselled smokers agreed to participate. Sustained abstinence for 6 months was achieved by 28.0% (missing cases coded as smokers), whereas 7-day point prevalence rates were between 30 and 35% at 3, 6 and 12 months. Those who received 4+ post-discharge calls were more likely to achieve sustained abstinence, as were older smokers, those with higher self-efficacy, and cardiovascular patients. CONCLUSION Hospitalized patients in Germany are receptive to the offer of bedside counselling and to phone support post-discharge, and success rates are comparable to those achieved in other countries. PRACTICE IMPLICATIONS The findings argue strongly for the routine identification of smokers upon hospital admission, and the availability of cessation support both during hospitalization and following discharge.

“Tobacco dependence treatment makes no sense because”…: Rebuttal of commonly-heard arguments against providing tobacco dependence treatment in the hospital setting

BackgroundThe provision of tobacco dependence treatment in health care settings, particularly in countries lacking a history of strong tobacco control policy implementation, is limited by continued misconceptions on the part of health professionals and decision-makers regarding its worth and efficacy. In this paper, we rebut 9 arguments against the provision of tobacco dependence treatment that we have encountered in our experiences implementing and maintaining a dedicated smoking cessation service at a large university hospital in southern Germany.DiscussionBroadly, the arguments relate to the nature of addiction, the efficacy and safety of stop-smoking medication and behavioural support, and the benefits and challenges of quitting. They include: (a) If smokers really want to quit, they will be able to do it alone (without help); (b) You can’t forbid patients from doing what they want; (c) Patients will be upset if you talk to them about their smoking; (d) Stop-smoking medication has side effects that are more dangerous than smoking; (e) You have to be well trained to help smokers to quit (otherwise you can do more harm than good); (f) If you smoke yourself, you lack credibility; (g) If you have cancer, it is too late to quit; (h) Nicotine withdrawal is dangerous for heavy smokers; and (i) Smokers die earlier, thus reducing costs to the health system.SummaryIt is hoped that the counter-arguments presented here arm tobacco control advocates and practitioners working in health care settings, particularly in countries which have not prioritised tobacco control, to respond appropriately and convincingly to those opposed to the provision of tobacco dependence treatment.

What Works for Patients in Outpatient Treatment for Alcohol Addiction? An Explorative Study into Clients' Evaluation of Subjective Factors and Therapy Satisfaction

This explorative survey investigated clients’ evaluation of therapy elements and other supportive factors within a randomized controlled trial. The treatment of patients with alcohol dependence consisted of pharmacotherapy (acamprosate/naltrexone/placebo) and biweekly medical management (MM). Forty-nine study participants were surveyed with a questionnaire to measure both the patients’ satisfaction with the therapy and the subjective assessment of treatment elements and supportive factors. Study participants were highly satisfied with the treatment. The supportive factors previously identified by Orford et al 1 were confirmed. ‘Pharmacotherapy’ was rated significantly less effective than ‘MM’ and ‘global study attendance’ (P < 0.001). The significant differences in the evaluation of treatment elements point to a preference for regular low-key contacts rather than for medication. Such contacts based on MM could be a useful intervention in clinical care, and its effectivity should be examined more closely in further research.

The Influence of 8 and 16 mg Nicotine Patches on Sleep in Healthy Non-Smokers

The purpose of this study was to determine whether sleep changes are a consequence of nicotine presence or withdrawal during the night, we examined 66 healthy non-smokers (33 males, 33 females, age: 20–25 years) after an adaptation night in a sleep laboratory setting. Subjects were randomized to receive placebo or either 8 or 16 mg nicotine patches during the day or during the night in a double blind, parallel group design. The 16 mg nicotine patch applied during the night caused a reduced sleep period time and sleep efficiency as well as an increased wake time. A reduced REM-sleep latency and subjective sleep quality rating were found in subjects receiving nicotine during the night. Arousals, apneas and periodic leg movements were not affected by nicotine. This study documents insomnia-like sleep changes in healthy non-smokers caused by nicotine in a dose-dependent manner. There was no evidence for sleep-related withdrawal symptoms after 13 h of nicotine application.

Abstract B17: A novel cancer prevention management strategy at the Comprehensive Cancer Center Freiburg (CCCF), Germany

Background: Smoking is a significant risk factor for cancer. Over 90% of smokers consider quitting, but the majority does not use professional support, thus foregoing substantially higher chances of success (tenfold higher 1-year abstinence-rate). Hospitalized patients are especially receptive to cessation advice, but structured counseling of smoking in-patients is rarely available. The aim of the project at the Comprehensive Cancer Center Freiburg (CCCF)/University Medical Center Freiburg (UMCF) is to establish a Cancer Prevention Management Team (CPMT) dedicated to identify smoking patients, motivate them to quit and link them to appropriate smoking cessation programs offered by external providers. Methods: The CPMT was implemented as a structure to identify smoking patients to provide them with intensive counseling based on Motivational Interviewing, to enhance their motivation to quit and to refer them to suitable cessation programs. Enrolled patients (treatment arm) were referred to at least one form of cessation treatment (structured multicomponent program: individual/group setting, use of self-help materials, nicotine replacement therapy (NRT)) and received continued weekly telephone support by the CPMT. Enrolled patients who were unwilling to use any cessation therapy were followed up only (observation arm). Results: CPMT structures and a screening system for smoking patients have been successfully implemented in 24 departments of the UMCF (1.113 hospital beds) organized in 60 wards and 10 outpatient departments. A network of 52 regional providers of evidence based cessation programs has been established. Within the first 15 months 703 smoking patients were counselled; 371 (52%) patients agreed to participate in the study. Out of these, 337 patients were included in the treatment arm, 34 patients were included in the observation arm of the program. The majority of the patients were suffering from patients (36%) or cardiovascular disease (19%). Abstinence rates after 3 months (n=122) were 34.4% overall, counting patients with lost contact (n=24) as smokers. Among patients in the treatment arm, abstinence rates were higher in patients using behavioural therapy (BT) (44.0%) compared to patients not using BT (41.1%). Conclusion: A Cancer Prevention Management Team is a highly efficient structure in large hospitals to screen patients for smoking status and motivate them to enter into a cessation program. Quit rates after 3 months were high, considering that all of these patients were treated in-hospital for severe illnesses and none of the patients had an initial intention to quit when entering the hospital. Citation Information: Cancer Prev Res 2010;3(12 Suppl):B17.