Nicholas Bachynsky- The Use of Anticholinergic Drugs for Smoking Cessation: A Pilot Study

8/3/2019 Nicholas Bachynsky- The Use of Anticholinergic Drugs for Smoking Cessation: A Pilot Study

1/9

TIK: Imnnaliorul Journal of the MdklfeM. 2l


2/9

750HACMYNSKY

dence of developing coronary heart disease (CUD) It directly related t o ilic num

ber of cigarettes smoked;IHOM

imoklng more than 20 cigarettes a day and (hosewho begin smoki ng before the age of 20 are three to five times mo re likely to

suffer coronary bean disease than nonsmokers (Ramidale et al.). Up to 30% of

deaths from CUD can be attributed to cigarette smoking(MMWR, 1984;Cashin

et al., 1984). The expense of Heating diseases caused by smoking is currently

being assessed. Osier et at. (1984 ) estimate that "male heavy smokers between

the ages of 40 and 44 will generate, on Jth eJ average, over SSb,0 00 in additional

costs of illness duiiftg their lifetimes, while for wom tn. these costs will be over

$19,000" (p. 384).

The decision lo cease smoking does not ensure permanent cessation. Al

though definit ive data are n ot available, over ihe past decad e it has been esij.

mated that three-fourths of the smokers have tried to stop, but only about 20

to 25% actually succeed (Wliy People Smoke. 1983; Russell. 1971). Recidivism

among those who quit smoking equals that of heroin addicts 75% (Russell and

Feycribend, l9?8;Pomerleau, Adkins,and Piertschuk, 1978).

Clinical experience and a search of Ihe literature indicate that a decision toslap smoking often, means choosing a suppoit program (Hunt and Bcspaltc,

1981). This study r epoits encouraging results found in a pilot test of new medi-

cal protocols not previously described or repotted.

The program consists of a prescribed anticholinergic drug regimen aimed a i

eliminating physiological withdrawal symptoms. Treatment achieves positive

effects for persons who enroll in the program with the intention of remaining

nonsmokers. Drug inleiTCntion treatment reduces the extreme discomfort of

withdrawal usually experienced by smokers that urges them to return lo smok

ing. The scientific basis of this medical technique is described in the next sec

tion (Theory).This yearlong pilot study had four purposes:

1. To ttit through medical observation if a piesciibcd drug regimen does, in

effect, eliminate physiological withdrawal sym ptoms .

2. To identify and describe demographic characteristics common t o I sampl

ing of patienl tin the program.

3. To monitor Tor both expected and unexpected imme diat e eff ect.4. To track cessation behavior.

The underlying assumption held that the absence of uncomfortable physio

logical withdrawal sympt oms and the perception of (his relief serve is a positive

reinforcem ent for cessatio n, increasing the chance of a smoker' s changing his

behavior,

Research dining (he past decide has emphasized responsibility for one's

own health and the need t o educate Ihe public about the physical benefits of

ANTICHOLlNr.Hr.lC DKUGS FOR SMOKING CESSATION '9 1

smoking cessation. A number of approaches have been attempted including

electroshock, hypnosis, psychotherapy, and counselling through support groups

(Myrsten, Elegerot, and Edgren, 1977 ; Pedeison. SciSmgeour , and Ufc oe, 1979;

Crosz, 1978-1979).

However, it is well documented that a smoker desiring to cease smoking and

remain a nunimoker must address both physiological and psychosocial effects.

For best success, Ihe patient must have a specific motivational reason |SMR] to

slop smoking, and social reasons seem to impose sironger motivation than medi-

cal reasons (Russell and Feyerabend, 197 8; Elser and Sut ton , l 978 ;Ma Iot te

e l i ! . , 1981).

THEORY

Nicotine is addictive, having a neurobiochemlcal bails (Jarvik, 1979). Nico

tine has an agonistic action al the nicotine receptor sites in the cholinergic ner

vous system (Birdsall. Burgen, and Hulme. 1978; Rosecrans, 1979) (Fig. I).

lis primary action upon prolonged use is that of a blocking agent. While this

activity is less documented in the central than In the peripheral nervous syterm,the preponderance of such nicotine receptors appears to be located centrally

I the midbrain level (Welncr, l974 ;P opo t and Changeux. 1984) . With chronic

nicotine use, biochemical tolerance and physiological dependency are devel

oped by increased acetylcholine accumulation mediated by enzyme induction

und/or derepression thro ugh choline acetyl transferase (Brlmblecombe, 1974;

Wills, 1970; Dahlstrom, Booj, Heiwall, and Uisson, 1980; Kelchum el al.,

1973) (Fig. 2),

A "tobacco withdrawal syndrome" providing for nicotine abstinence thus

comes about by elimination of the nicotine blockade at specific nicotine-cholin

ergic synapses. Tolerance and dependency, developed by Increased acetylcho

line synthesis activity, are replaced by wllhdiawal, which results from excessive

acetylcholine rebound stimulation (Jarvik, 1979; Dahl str omel al., 1980; Ketch-

vmetal., 1973) (Fig. 3).

The final biochemical Interpretation of nicotine withdrawal is through

acetylcholine inter synaptic stimul ation of predominately muscarinic cholinergiclies at higher neuronal levels, including the cerebral cortex (Hfrschoin arid Rose-

can s, 1974). Usual clinical symptoms include a decrease in heart rate and blood

pressure, increased Irritability, nervousness, gastrointestinal disturbances, electro

encephalogram changes, and a temporary decrease in the ability to concentrate.

Tests of a variety of anticholinergic and other drugs found that only sco

polamine and d-amphetamine decreased smoking (puffing pattern) In monkeys.

By using animal paradigms ai a model for human nicotine dependency, Click,

JirvUc, and Naksmura (1970) showed the effecllvenesi of parasympathetic ner

vous system antagonists. Clinical data gathered from medical pat ients , as reported


3/9

792

MUSCARINIC

RECtpTORS

NICOTINE

BtC tPTOHi

fNAPTlC

/ESICtL

Pig. 1. NpJl chrilnwglc Unimiiik>r.

ANTICHOLINERGIC DRUGS FOR SMOKING CESSATION 79J

NICOTINE

(SMOKl)

/BLOCIUNGX\ ACINI I

IN( REA5ED

SYNAPTIC

VISICLES

Pij. 2. NKolino blockjdo: tncicaiod nnuoui niinllt ci lyntheih.


4/9

794 BACHYNSKY

mCRIAStOMUSCftBINIC" w wIHAmMISSION - ^ . - ^ V

R OTO RS - 1 ^ < (BOMMMlNrKU.LI IOi


5/9

7 *BACHYNSKY

in this pilot study, demonstrate the usefulness of their research. Aniicholi nergic

drugs cT predominately at muscarinic sites In the cerebral cortex. By blocking

these sites, we prevent the ultimate Interpret ation o f the Inteisynapilc rebound

phenomenon caused by excessive acetylch oline stimu lation at lower ni cotine

mlilbnm-Uvel receptors cicated by cessation of chronic nicotine (tobacco) use

Since wit hdrawal symptoms to nicotine cessation are most pronounced dur

ing the first 24-48 hours, Immediate and high levels of anticholinergic activi ty

are achieved by injecting described anticholiner gic drugs in the subcutaneous

areas over the mastoids. Nicotine is eliminat ed in approxim ately 3 days. t ut It

may lake approximately 2 weeks to reduce withdrawal symptoms (Go)diiein

and Coldslcin, 1%B). Consequently, oral medication is recommended 10 main

tain a low level o f anticholinergic Activity Tor a peno J up to 2 weeks. This t ech

nique ii based on laboratoiy evidence that approximately 2 weeks arc required

for a significant decrease in enzyme synthesis of the end product (acetylcho

line).

The anticholinergic method helps patients develop an aversion to cigarettes

by also effe cting taste and sensory receptors. The effect of dry mou th, for ex*

ample, wh ile disadvantageous in many insta nces. Is hel pfu l where It is a come*

quence of therapeutic techniques.

M E T H O D S

For l l it i pilot st udy, leliospect ivc, longitudinal da\a were collected over a

2fc.year period, 1980 to mid-1983, using the smoking cessation protocol. For

purposes of this initial report, demographic and other characteristics of the pro

gram's seir-selectuig population were comhined to better profile the smoke- who

is likely to seek out and complete this approach to smoking cessation.

Pour primary variables were used to describe the program population and

(he pilot group:

Age at entran ce into the program

Sex

Number uf cigarettes smoked per day

Reason ftn wantli\g to slop smoking

The pilot study describes asingle treatment group consisting of a cohor t o f

500 adult patients from total study population of 3,700 patients tracked for a

12-mnnlh period (Tables I and 2), A systematic convenience sample was drawn

from patients' cherts and clinic recordings on follow-up log books. Patients Tot

the treatment program were sciT-refcrrais, those attracted by public advertise

ment media, and physician referrals. They paid for the program by private pay

ment or medical insurance coverage.

ANTICHOLINERGIC DRUGS TOR SMOKING CFSSATION M l

la

Smoking Ct tut Ion

blc I

Record {500 Co*ei>'

A6< (mala, 267;

female. 233)

''''""

No. ycus Ni. ci,;-1clit1 Noiuinoh*--. (mala, 267;female. 233)

''''""smoki ng srnuhed pei d*V aflu WmoDlhi

At e

srnuhed pei d*V

ranee Ca Years Cue s No. (lis. Ci Months Cam15-25 35 IS 19 1-10 2 O * 50026-35 158 6-10 71 11-20 70 2 * J536-45 141 11-13 86 21-30 H I 4 344

46-55 115 16-20 77 31-40 166 0 327

36-55 44 21-23 5) 41-63 99 1 102

66-75 6 26-30 98 6) 6) SC 12 199

76-80 1 31-40

41-50

76

12

Main- 39.9 yr Mean: 19.3 yr Ma n 35.4 ct&t Ued im: 6.5 aftf

SO: 11.4 SO: 10.9 SO: 14,9 nonsmoking time

D ili woie ga(heie4 iii aip iive ly fi om charts of ti n Physician*' Clinic.

Criteria for acceptance into the program ln:tuded:

1. The desire and will ingness to Hop smoking

2. No medical contra indicatio ns for the uie of anticholinergic drugs, as wit h

acute-angle glaucoma, prostatic hypertrophy, or cardiac arryirunias(Csln

ct al 1984)

The baseline screening protoco l Included but was not limit ed lo, these

checkpoints:

1. Assessment of medical history

2. Routine cltesl X-iay

3. Urinalysis

4. Electrocardiogram

5. Blood woi k, complete blood count, scru^i clcclrotyl cs. and an SMA-12

panel

6. Assessment of surgical history f or previous* occurre nce of idiosyn crat ic or

prolonged refr actory times in the dissipation of antkholi neigi c drug effects

LigneiAll pat ients meeting the program criteria ugned an Informed consent t o

treatment w hich spells out the expecte d effctjis as well as possib le-hu t not

necessarily anilcipated-uniowaid reaction-.


6/9

BACHVNSKY

rb!t>2

Bsuhne Averagetof Yttri Smoktd tnd Numbir of Cl$amtct

Smohfd i>*f 0*y by StM _

Averse numbe; of

' Avenuje yo ui imoktxt descen t! imofccd pf i day

Male 21.4 37.8

Fomak 20.8 33.6

Tolal 21.1 35.5

THE PROTOCOLSOFTREATMENT

Having conu nlcd lo treatment wi th anticholinergi c drugs, patients submit

ted to the rollowiiu set of protocols:

1. The |nlii!f)i (Cixhes an iniikil intramuscular ii i jcclinn of u 2-ml lalbn solution with scopolamine 0.2 mg arid atropine 0.2 mg.

2. The patient o monitoicd In the physician's office with the room darkened

for u ni i i i im im pci iud of 5 ni inules, fol lowed by an BKSHUM1 of normal

pupillary const riction and mil d xerostomia ,

3. Given thai factors in Step 2 are within norm al limi ts, two additiona l injec

tions are adailmilcied subcutancously over each mastoid area. The tola]

drag icgimcr is atropine 0.2 mg, scopolamine 0.2 mg, and chloipi oma-

zinc 10 mg. OnebaJf of the tol al solution is injected in each site,

4. The patient again is monito red in itio physician's office for a min imu m

period of 5 rrinulct.

5. Given lha ( ifae response Is wi th in the sange of antici pate d effect s, the pa

tient Js allowed to leave the office w it h instru ctions not to drive, not lo

consume alcohol, and not lo lake medications wit h a synergistic effect for

24 hours. Arceplable anticipated effects include moderate xerostomia,

lightheadedness, and some dif fic ulty in focusing.

6. Day 2 thro uih Day 11, the patient is lo lake a prescribed oral anticho lin

ergic drug tin t is know n to act on the central , rather th an the periphera l,

nervous syslcu . The most commonl y used drugs arc trlhexp henid yl hydro

chlor ide, bcii i i io pinc mesylate, or scopolamine patches.

Tracking pat ents dur ing the 12 nion ih pe riod was a task sequiring syste

matic review. Subjects responded favoiably lo fo llow-u p activi ty, for periodic

contacts provided them with motivation lo continue cessation. Follow-up In

forma tion on smoking status was self-report ed by pat ients' responses to tele

phone contacts every 2 months and mailings util izing a brief, tersely worde d

ANTICHOLINERGIC DRUGS FOR SMOKING CESSATION 709

questionnaire (see the Appendix). Results were libuUed b/ staff of the Physi

cians' Clinic and entered into pat ient ch arts. The tnt eipl aj betwee n SMR andmedical inter vention c ould f urth er refine kn o wedge of fictor s thai enhance

or inhibit success and affect a smoker's chance "or bng-term cessation (Gold

stein and Goldstein, 1968).

R E S U L T S

1 . Prelim inary findings ind icate thai this (Jiatmrnl pnt oc ol is successful

for a large number o f paii enls. Success is desc.ibed at tv o points In lim e:

cross-sectionally, where (he patient has or has no. ceaied tc smoke, and longi

tudin ally, lo determi ne the length of smoking absthence over a 12-month

observation period. The use of anticholinergic drugs or smoking cessation is

a technique easily administered In the offic e oT ; private pacli l io nei and ac

cessible to most practicing physicians.

Future Intake should focus on a thorough physical assessment ( wor kup )

rinco t reatmen t Is by physical (chemical) means. Isy dol ogi cjl usscsmicnl muybe worthwhi le to determine SMRs, but this may >rovt a sei*-se|ect(on process

because paiienls w ould no i choose to participate vif hout a rood or immedia te

reason lo do so.

2. Findings support th e main purpose of thi stuly , indicating that 434

(86.8%) of the 500 patients of the pilot stud y stepped srmxi ng al 2 mont hs;

J99 (39.8%) r emained n onsmoker s at ihe end of the ysar. Results of the pro

gram arc higher than Ihe general popu lati on of snok e s who attempt lo stop

smoking (Cond iott e and Uch tens tein , 1981) (Fig . 5). Further study rs needed

lo repor l wi th c onfidence an znlicipa tcd program rucccss rat* for Ibis particu

lar smoking cessation prot oco l. If, however, the average smok ng cessation pro

gram finds an average of 20% of Ihe paii enls abstinent J! 6 raonlht ( Hunt and

Iksps fec, 19 81), this methodol ogy m ay offer the i inab ilit y of cessation lo a

greater percentage of smokers.

3. Table 3 summarizes motivatio nal charad eislt ct of subjects lesled at

the beginning of Ihe cessation program. The study (onesided hat in long -term

cessation, Ihe patient must perceive a specific motivational rrason (SMR] to

stop smoking. Smokers who could clearly identfy in SNR wire more success

ful in sm oking cessation than those who could not.S oca) reasons repiesenied

a SMR among 63.6% o f ihe paiienls who slopped anok-ng a "iil l 12 mou th s-

the need to satisfy a spouse, childre n, friends, or cmo loy e co ndiiiuns- wherea s

only 30.7% slopped w ho had medic al reasons for drin g :i>. SfcRs include such

concerns as (I ) social acceptance in a peer group; (2)inlcspcrsooal rela tionships;

(3) Intolerance in a work station or business she; (4) pessun from a sexual

partner; (S) parental disap proba tion; (6) cosmetic effects, (Deluding stained

iv.- ih and wrinkle d lips; and (7) co mplaints ab out Ihe (ten


7/9

HOO BACHYNSKY

NUMBER

OF

'ATIENTS

500 Cases)

100-

?K>39. i

300

3787S.8H

3S571.C46

795

400 43*

MO

0 1 4 6 0 HOI

MONTHS NONSMOKING

Fig. 5. SucociifuIn DMjnokai.

TiMt J

Union to' Bn\Bilng thmProgum

Subjects

Male Female Total*

Koason A1 * rV % A' 7:

SocialMedicalMissing valuer

Tout

185 (37 0}62 (12,4)

35 (0?m

282 (56.4)

J (26.6)

54 (JO.6)

31 C06.2)

216 (43.6)

318

116

66

500

(6J.6)

(2i.2>

OJ.2)

(100.0)

ANTICHOLINERGIC DRUGS FOR SMOKING CESSATION goi

Table 4

, _ , _ . . AffcoCftw Lavcti at Builin* and7tvo Fillaw-Up Ptrlodi

Smoker 2 mo 12 mo

baiellne nonsmoker aonunokei

Nicotine fcml A* % N % N %

Low [0.3 mg) 388 57.6 244 56.9 J ? J 62.B

Hgl idJ mg) 212 42.4 191 43.1 74 37.)

4. Table 4 indicates Out a greater percentage of smokers of low-nicotine

cigarettes were able (o stop smoking for a period of 12 months than smokers

of high-nico tine cigaret tes. We ate cognizant of the fact Dial 60. 8% of the

participants enrolled in (he program enlered as smokers of low-nicotine cigar

ettes. (See Table 1.) Therefore, we encountered a design group with positive

motivation to slop smoki ng since (he majority had, in this way, demonstrated a

practic e intende d (o reduce nicoti ne dependency. In 1964 the World HeaUh

Organization substit uted the single term "depend ence" to describe physic*! or

psychological "Iwblluation" or "addiction." Physical dependence includes

"lolcruncc of the effects of .. . (a) drug due primirily to changes al synapses"

and "withdrawal symptoms resulting from reboind over-acdvity at synapses

when intake of the drug is reduced or dis continued" (Russell, 197 1, p. 2).

Nicotine dependency is characterized as Increase*! acetylcholine synthes is ac

tivity resulting from nicotine blockade at specific nicoiine-chollnerglc syn

apses. Chronic nicotine use causes increased acetylcholine accumulation. Smok

ers of low-nicotine cigarettes help themselves because lower levels of acetyl

choline buildup enable earlier and less painful wilhda wa).

5. Experience ui till* pilot gro up showed that 39.5% of those who stopped

smoking a period o f 12 months used regular cigait ties; but only ) 1% of thos e

who smoked mentholated cigarettes were able t o stop. It is possible thai smok

ers of mentho lated cigarettes may have a greater Isvel of nicotine dependency

because mentholatum has a soothing action on the respiratory membrane, thuspermi ttin g deeper inhalatio n and retentio n of smoke with higher levels of nico

tine titration and dependency.

CONCLUSIONS

I. Develop ment of a rigorous program of smoking cessation ujing anti

cholinergic drugs requires establishment of piotoccls for (1) patient selection,

(2) conduct of a physical examination, (3) administration of drugs, (4) follow-

up activity, and (5) evaluation of short-term and long-term success and failure.

The short-term measuie it completion and compllarce within ireatnsent of (he


8/9

S02 IACHYNSKY

program. The intermediary, long-term measure requires follow-up of past Heal-

ment. By establishing criteria foi protocols and following these protocols inclinical practice, physicians could obtain data for a longitudinal study of smok

ing cessation based upon medical intervention techniques.

2. A sustained research effort is desirable In aspects of smoking cessation

with drug Intervention protocols. Specifically, medical science would benefit

from scientific reports treating the following concerns:

A prospective longitudinal stud y with supporting standardized Intervention,

recordkeeping , and administrative follow-up.

Improved behavioral modification supporl lo complement physical/medical

treatment.

Outcom e measures related to smoking cessation, including quit levels, pa

tient evaluations of the program (strong points and weak points), and

physiological measures (including self-reporting) such as improvements in

respiratory or cardiovjsculiir stains rc|K>r(cd in pus (c au ti on or self-worth

assays. Development of an operational definition of a program' s "success" or "fail

ure" at both (he Individual level and the clinic program level.

Articulati on of demographic sociopsychologlca) descript ors to afford more

precise intake data (patient profiles) and complementary follow-up informa

tion (changes in status).

APPENDIX

THE PHYSICIANS* CLINIC

6535 SOUTHWEST FREEWAY

HOUSTON.TEXAS 77074

SMOKING CESSATION PROGRAM

PATIENT FOLLOW-UP LETTER

Dear

In oui continuing follow-up lo determine the effectiveness of our Clinic's smok

ing treatment program, we ask that you answer the questions below.

ANTICHOLINERGIC DRUGS FOR SMOKING CESSATION 833

When you have completed this form, please return U lo us in the enclosed self-

addresied envelope.

Thank you.

1. Are you smoking now'

YES NO

2. If your answer lo quetllon I was "ye s," how many month s after comple t

ing the Clinic's treatment did you re-slarl?

I 2 4 S 6 7 S 9 10 I I 12

CIRCLE ONE

3. If you have re-starled snofcfng, why?

STRESS HABIT

(Chcet one or both)

Olher [Pbaseexplain]:

ACKNOWLEDGMENT

J. H. Glasser, PhD, Atsutint Professor of Biometry and Computer Design atthe University or Texas Heilth Science Center, Houston, Texas, was statistical

reviewer of dat a in this study. The auth or is grateful to Dr. Glasser for his pro

fessional insights in Ihe development of t his study and for his recommendat ions

for future research.

REFERENCES

DIRDSALL, N.I.M., BURCEN. 4.S.V., nd HULUE, E.C. Correlation bet wo n Ihe bL-iduiepioportios and phvnuoologGU rorponici of muiearinicrecepttxi. In D. 1. Jenden (ed.),Cholinergic Hccnaittimt an*. Ptyctiophamucology, Vol. 24. New York; Plenum Pica,l?78,pp.2J-33.


9/9

l>4 BACHYNSKY

BRIMBLECiMBE, R.Yf. Aiiiirholincjuxjse igenis. )TI Dnj Acrlant nn Ctinlintrtic Syi-

lemt. Bdliinwc: Ufl[voJBiy ftuh. Viat, 197*. pp.94-9

CASH1N, W.L, IRO0KS, 5.H., ttLANKENHQftN. D.ll SELZLR, R.H.. SANMAHCO.M.E.. nd BLNJAUrtiUlT. B. CoinputeiUtd H) |V lurking and Icjkiri meiniewisfli

In ctxumry incioeumi- A pilol jludy (empuJpe. tmslfrj Willi nr:iijmciktjt, ^J/ifro.

srfcroiirSl: 195-iOU, 19*4.

COKDJO'ITE M.M., and LlOTTE-PfSTElN, E. 3tlr-affkzc> ami leLapsc in miuki re Cfcrta-

ln iniijim"!./ tojJii-'r. C/fn Piftliol. 4S: tit S!fl, I >91,

CORn,C. r1 Hiitarfof Smokirti. Nt h Yurk: llsltuttlt Bfjo, 1TO.

DAHLITItO*, A.. BOG-J, J.. rlElWAI.L, J>.0 and LARSS)N t P,A, The effect u[ -hto'.iii.

-

cAnriJi srmeelofu A 0: . 3 1 3G. 197 ).HUNT. *f,A., mi BESTAlEC, D.A. An evikigilcn oTcvneil intlhadiorngilL'yiniinial.

inl. huJuvnc. J, CMw, ftyenur. 2.7: 4JJ-MS. 1961.

JAR.VJK, M.E. Dlornglcal imlufncoi an e&arellc irnohclnc. In MA. Krmic^or frdj, 77*p

Behaviotd /Ijpn-itcfSiaatvit. MlUA HtsMlcH M(p^dpn i^.6. DHCW, Wjtniigioii.DC: IU . "OVBInnicpll PiinliR- Oirict. 1 979, pp, 7-t5.

KETCT1UM, J.I., S1DCLL, P.B,CROWELL1 Jl., E.B. AGH/MNrAN, G.I.'., gad HAYES,A.H. Jr.UnjpijK, iCapdlttnLne, ind dilran: Comp mliw phunttrglDiy tnd unn^un

[i ll mm n PifctiaphsrmmoiOtia fBal.j 3B: JI I - H i . 1!73.

UAUOTTE, CK., FJELtJlNO. J.E,, ud DAMAHSK, a.U Dncijntivi and cfjiljition

of Lhs making uid li oii WBipaninl af t mul(|j|t ilriifjcpor inicrnntiaa ptupun.

Af r f t Hettttt Britfil\: 844-947, 1 9B1.

Afiflt'A. Snak.n^ ind cmioor. 3J(7); 77AQ. 1*81. Hfiniducid in BDIGW of ^jiJdamijlDgr.

Ttm Haltmy TIlif Wd- W*oV I J: I l-J ], 1981.

MMWR. SmDkrcan*fjjdlttnynlir dijup:. JJ(i7>: 61J SI4.1?it .

MfRSTlN. A. ELCEROT, A,, ind EDC&EM. D. EITtcii of linin!T** Eiom lotorr*imohlnx tri phyil&logJcBi jnd fnyrhobEJca] ir ait ul Icrtli in habiiunl jrtiakcii. ,''r.r-

r^mUFir. JV

Nicholas Bachynsky- The Use of Anticholinergic Drugs for Smoking Cessation: A Pilot Study

Documents

Transcript of Nicholas Bachynsky- The Use of Anticholinergic Drugs for Smoking Cessation: A Pilot Study