Complications
Both smoking and NRT increase insulin resistance. The effect of NRT on insulin resistance is less than that of smoking. Patients with diabetes whose blood sugars are very tightly controlled should have their blood glucose levels monitored for hypoglycaemia when they stop smoking or when they stop NRT use, as insulin resistance will decrease.
Polycyclic aromatic hydrocarbons in cigarette smoke lower the blood levels of theophylline and some psychiatric medicines, including alprazolam, chlorpromazine, clomipramine, clozapine, diazepam, fluphenazine, fluvoxamine, haloperidol, imipramine, lorazepam, olanzapine, and oxazepam. Smoking cessation can thus result in 10% to 40% increases in blood levels of these medicines. Careful monitoring is required, and may require dose reductions to avoid toxicity.[219]
NRT can cause acute, but clinically minimal, fluctuations in heart rate and BP in patients with hypertension. However, studies demonstrate that NRT is safe in these patients. In patients presenting with untreated or uncontrolled hypertension and desiring smoking cessation, both problems can be treated simultaneously (beginning both NRT and antihypertensives at the same time).
Stopping smoking is often accompanied by weight gain of 4-6 kg due to a combination of increased energy intake from the need to substitute food for cigarettes in hand-to-mouth habits and oral gratification, and decreased metabolic rates.[213] Concerns about weight gain particularly among women smokers may reduce the motivation to stop, although the health risks of weight gain are small in comparison with the risks of continued smoking.
One study showed that an increase in body mass index after smoking cessation had no moderating effect on the protective association of smoking cessation with myocardial infarction and stroke.[214] It is not recommended to advise smokers to limit their calorie intake during stopping attempts, as hunger may trigger cravings and reduce stopping rates. This approach has not been effective in reducing weight gain.[215] Individualised behavioural weight control plans, exercise programmes, very low-calorie diets, and cognitive behavioural therapy may reduce weight gain without reducing stopping rates, but the effects of these interventions are modest.[216] Further research is needed. No pharmacological interventions specifically to reduce weight gain have shown evidence of long-term benefit, although nicotine replacement therapy (NRT), antidepressants, and probably varenicline for smoking cessation all reduce weight gain in the short term.[215] Data suggest that a combination of smoking cessation medications results in less short-term post-cessation weight gain compared with monotherapy or placebo.[217] In people with serious mental illness, adjunctive behavioural support for weight gain (e.g., weight management counselling and support for physical activity) may be beneficial in addition to standard treatment for smoking cessation.[218]
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