The Use of Smoking Cessation in the Management of Hypertension in Older Adults

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The Use of Smoking Cessation in the Management of Hypertension in Older Adults

The significance of the smoking cessation in the management of hypertension in a very vital and important issue in the current context of nursing practice. According to WHO 2014, smoking is one of the main risk factors for many chronic illnesses including cancer, lung diseases, and cardiovascular diseases, making it one of the largest preventable causes of premature death and disease across the world. Smoking kills nearly 6 million people each year and this could rise to 8 million by 2030.

The overall idea of the AIMS of the systematic critical review is highlighted in the study search using strategies for the search. This systematic review is aimed at identifying the effect of smoking cessation as a lifestyle modifications associated with the regulation and management of hypertension in older adults.

According to Higgins et al 2011, a bias is a systematic error or deviation from truth that can lead to underestimating or overestimating the true effect of a studied intervention in randomized controlled trials (RCTs). In the systemic review, the risk of bias is used to measure smoking cessation intervention in the management of hypertension in older adults. According to Higgins et al 2011, Cochranes risk of bias (ROB) tool is used in Cochrane systematic reviews to appraise methods used in RCTs (Higgins et al 2011). Higgins et al 2011 also indicated that Cochranes ROB tool has seven domains; for each of them, authors should make a judgment whether the ROB is high, unclear, or low and provide an accompanying comment to explain their judgment (Higgins et al 2011). Assessing ROB is standard procedure for Cochrane systematic reviews, as results of that assessment can influence the analyses of data and the conclusions drawn from a review.

In an overview of systematic reviews, evaluating the effects of smoking cessation in the management and regulating hypertension in older people, was reviewed. This involved randomized controlled trials. The search strategy involved the use of library search was considered for outcomes relating to benefits while randomized controlled trials, non-randomized controlled trials, and comparative observational studies will be considered for evaluating harms. In the search strategies will be developed and peer-reviewed by medical information specialists. The search strategy for the updated review on e-cigarettes will be developed using that of the candidate systematic review.

In the synthesis of the articles, the research questions and the critically analysed using the search strategy criterias to arrive at a meaningful articles that answers the research questions with the purpose of the synthesis of the articles. The synthesising of the systematic reviews of complex interventions is that data available for synthesis are often extremely limited, due to small numbers of relevant studies and limitations in how these studies are conducted and their results are reported.

In the synthesis of the articles, the study outcomes were measured in different ways and at different time points. The possible outcomes were discussed, with possible approaches when data are highly limited or highly heterogeneous, including the use of graphical approaches to present very basic summary results. The statistical approaches for combining results and for understanding the implications of various kinds of complexity was discussed.

The synthesis of the findings from the 3 original research articles based on the research question was presented. The synthesis of the findings derived from these research articles and the key recommendations. The articles are peer-reviewed, primary research articles relating to research question were presented in a literature review that synthesises the relevant research evidence related to the research questions.

Hypertension is one of the leading causes of death in the older adults. Smoking cessation is a lifestyle choice which is used in the management of hypertension in older adults. Smoking cessation is effective in the regulation of hypertension, and significant in the of management of Hypertension as lifestyle choices in the plder adults. Hypertension in older adults is highly prevalent and lifestyle choices for example smoking cessation is associated with effective management and regulation of hypertension. This systematic review is aimed at identifying the effect of smoking cessation as a lifestyle modification associated with the regulation and management of hypertension in older adults. The importance of education about smoking cessation will help patients to know how cigarette smoking impairs and exacerbate any existing respiratory and cardiac disorders (Koutoukidis, Stainto, & Hughson, 2013).

Literature search has been a vital aspect of this assignment especially with the use of systemic search strategy. Burns and Grove (2005) define literature searching as an organised search system which identifies information relevant to the topic of interest, in this case the use of smoking cessation in managing and regulating hypertension in older adults. Moreover, searching has an essential role in supporting clinicians who want to keep up with the development of evidenced-based practice in the healthcare professions. The term ‘evidenced-based practice’ has come to be used to refer to the combination of evidences which improve the quality of information in relation to clinical and patient interests (De Brun & Pearce-Smith, 2009).

In order to find the best medical resources, a good search technique is required for finding information more efficiently, otherwise the researcher could waste lots of time and find nothing. The aim of this essay is to describe an appropriate search strategy by defining databases and the reasons for choosing a particular one for this assignment. The essay will then go on to describe the search steps used to identify articles on the use of smoking cessation to manage and regulate hypertension in older adults.

Primarily, the fundamental part of searching is formulating a well-searchable question in order to be capable of sourcing an answer in the chosen database. For De Brun and Pearce-Smith (2009) ‘database’ refers to systemic reviews containing an electronic collection of information that is organised and accessible. There are various search engines in which research could be undertaken and each one of them identifies information and data in its own way.

In the study by Oncken et al, the study demonstrated 6 weeks of smoking cessation in postmenopausal women. In the findings Mann et al investigated that smoking cessation contributed to reducing hypertension as also suggested by other studies. In the study, it was deduced from the study that smoking cessation is an intervention for the management of hypertension. It was also investigated that smoking cessation contribute to management of hypertension. This was also further analysed that there was an 11 mm Hg difference in the awake systolic BP in hypertensive smokers versus non-smokers who had similar clinic systolic BP. One of the bias shown in this study was that the magnitude of our effect was not as large as that found in this study, perhaps because BP values in our patients were lower at baseline.

In the study, it was evident that Poulsen et al showed that smoking was associated with increased hypertension compared with those in their non-smoking population. The bias also shows that study time before and after 6 weeks of smoking cessation. The study was randomised crossover study of 39 normotensive male population show that the BP is lower in the smoking cessation period compared with ongoing smoking period. The study result of was consistently deduced that hypertension was well managed and shows that hypertension is well managed with smoking cessation.

This study compared to the study highlighted above, showed that the treatment with bupropion alone or in combination with a nicotine patch resulted in higher long-term abstinence rates than did the use of placebo or a nicotine patch alone. It further shows that the treatment with both bupropion and the nicotine patch was not significantly better than treatment with bupropion alone either at the end of the treatment period or during follow-up. In this study, the treatments were compared with the use of placebo, treatment with the nicotine patch, the nicotine patch and bupropion, and bupropion alone all resulted in less severe withdrawal symptoms and less weight gain after smoking cessation.

According to Hurt RD, Sachs DPL, Glover ED, et al in the to the research carried out previously shows that bupropion and nicotine replacement therapies contribute to weight reduction after smoking cessation. The bias shows that, although the weight gain was lowest in the combined-treatment group, there were no significant differences in weight gain among the groups after week 7 of treatment Hurt RD, Sachs DPL, Glover ED, et al.

Another bias to the study was that, it was discussed that the study population were all volunteers and thus may not be representative of the majority of smokers.24 However, the smoking cessation rates could have been biased in the study, since the study population underwent weekly biochemical tests to determine whether they were still smoking. It was also indicated that 19.8 percent of the study population dropped out of the study and this may have affected the outcome of the study. This further indicates that the study group who dropped out of the study might have gone back to smoking hence, consideration need to be given to how this could have affected the outcome of the study.

The next study highlights cigarette smoking and hypertension through the research question was about smoking cessation and hypertension. According to the researchers, cigarette smoking is a powerful cardiovascular risk factor and smoking cessation, is the single most effective lifestyle measure for the prevention of a large number of cardiovascular diseases. Impairment of endothelial function, arterial stiffness, inflammation, lipid modification as well as an alteration of antithrombotic and prothrombotic factors are smoking-related major determinants of initiation, and acceleration of the atherothrombotic process, leading to cardiovascular events.

According to the study, cigarette smoking acutely exerts an hypertensive effect, mainly through the stimulation of the sympathetic nervous system. As concern the impact of chronic smoking on blood pressure, available data do not put clearly in evidence a direct causal relationship between these two cardiovascular risk factors, a concept supported by the evidence that no lower blood pressure values have been observed after chronic smoking cessation. Nevertheless, smoking, affecting arterial stiffness and wave reflection might have greater detrimental effect on central blood pressure, which is more closely related to target organ damage than brachial blood pressure. Hypertensive smokers are more likely to develop severe forms of hypertension, including malignant and renovascular hypertension, an effect likely due to an accelerated atherosclerosis.

Firstly, as indicated by the authors, the finding shows that, elevated blood pressure in older men is likely consequent to the well-known increased smoking-related aortic stiffness, a phenomenon which may produce isolated systolic hypertension Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, et al. 2006 [60]. Secondly, the study shows that there is a difference between men and women in body mass index and alcohol intake.It was therefore suggested that the data analysis shows independent chronic effect of smoking on blood pressure is minimal. However, with smoking cessation and hypertension, the study population have to deal with their smoking to manage or regulate their blood pressure issues and to be able to monitor BP to ascertain the link between the cigarette smoking and hypertension. However, there is bias in the study, showing that the results are non homogeneous. The aim of the study compared the office and 24-hour ambulatory blood pressures of 59 untreated hypertensive smokers with 118 non-smoking hypertensive subjects matched for age, sex, and race Mann SJ, James GD, Wang RS, Pickering TG. (1991) [61].

The blood pressures were similar between the smoking and the non-smoking groups. In contrast, the daytime ambulatory systolic blood pressure, but not the night-time one, was significantly higher in the smokers, an effect observed among older patients but absent among younger. Similar results were obtained by Verdecchia et al. [62], assessed in a case-control study the association between blood pressure and heavy cigarette smoking (20 cigarettes/day) in male and female essential hypertensive patients. Blood pressure was significantly higher in the smokers than in the non-smokers, whereas night-time blood pressure did not differ between the two groups. In the study, these findings were not confirmed by another study, which compared 24h ambulatory blood pressure profiles and blood pressure variability of smokers, before and after a week’s abstention from smoking, and non-smoking controls [63]. All three groups showed similar ambulatory blood pressure profiles but smokers had significantly higher blood pressure variability. Moreover, a recent meta-analysis suggested that smoking is associated with masked hypertension, which is characterized by normal in-office blood pressure but elevated out-of-office blood pressure [64].

On the other hand, other studies reported even lower blood pressure in smokers. In a cross-sectional comparison, Mikkelsen et al. [65] found that a large age-range group of smokers was characterized by statistically significant lower daytime and night-time systolic and diastolic ambulatory blood pressure values as compared to an age-matched group of non-smoking controls. It appears evident that overall these data do not allow to drain conclusive information on a causal relationship between chronic cigarette smoking and blood pressure values. Although a definitive explanation of these contradictory reports cannot be extrapolated, there is no doubt that many discrepancies in the selection and characteristics of subjects among these studies occurs. Furthermore, one could also raise a doubt whether the cross-sectional comparison between smokers and non-smoking controls is methodologically correct.

Alternatively, interventional prospective trials have been proposed as a more appropriate tool to obtain conclusive information on smoking-related blood pressure. This methodological approach has been utilized in two studies, which assessed the effect of short-time or long-time smoking cessation on blood pressure, respectively. In the first study, the authors investigated, by a randomized crossover design, the effects of short-term smoking cessation on blood pressure and heart rate variability in a group of normotensive habitual smokers [66]. In the study, it was found that 24-hour blood pressure was significantly lower in the 1-week smoking-cessation period than in the 1week smoking-continuing period, whereas the night-time blood pressure did not differ significantly among the two groups. 24-hour heart rate also showed a significant reduction in the smoking cessation period [66]. In the second study, the authors prospectively investigated the effects of smoking cessation, up to 4 years, on changes in blood pressure and incidence of hypertension [67].

Adjustment covariates included age, body mass index, cigarette smoking, alcohol consumption, exercise, family history of hypertension, systolic or diastolic blood pressure, and changes in body mass index and alcohol consumption during the follow-up period. Results indicated an increment of blood pressure values among the quitters and current non-smokers, as compared to current smokers. Larger blood pressure increments were observed after 1 year of smoking cessation. These trends for increased risk of hypertension for longer periods of smoking cessation were similar among weight losers, as well as gainers and maintainers [67].

The impact of smoking cessation on blood pressure has been considered by these two studies in a different manner. Short-term (1 week), and long-term periods (up to 4 years) have been considered, respectively. Although very interesting and well-designed, these two studies do not allow definitive conclusions. Nevertheless, if considering the greater clinical impact of chronic smoking cessation on blood pressure values and increased risk of hypertension, results from Lees study [67] suggest that smoking cessation per se does not lower, but in contrast, it may result in increasing blood pressure.

In conclusions, available data on cigarette smoking habit and blood pressure values or risk to develop a sustained hypertension do not put clearly in evidence a direct causal relationship between these two cardiovascular risk factors, a concept supported by the evidence that no lower blood pressure values have been observed after chronic smoking cessation.

The proposal for Assignment 3 is to investigate by focussing on future research which will include additional studies of the effectiveness of smoking cessation on the regulation and management of hypertension and address the research methodological limitations and the sample size. The aim should be to identify the interventions using the RCT for 12 months in the stydy to be able to show the effectiveness of the smoking cessation in the management of hypertension. The sample size in the future study should be wider to look at the effect of smoking cessation amongst wider population.

The focus for future research will aim to identify specific impact of smoking cessation and also to study the areas of interest within the population. The study type should be addressed in the timing of smoking cessation as an intervention in the management of hypertension and whether other interventions should be studied in smoking cessation treatment should be included during the treatment and study period. There is also the possibility of investigating smoking cessation and the use of pharmacological treatment hand in hand during the study period as a suggestion for future research.

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