Commentary

A practical approach to tobacco dependence for clinicians, smokers

The 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment offers important advice.

Cigarette smoking is one of the leading preventable causes of death in the United States. Globally, up to one-third of all deaths from CVD may be attributed to cigarette smoking. Tobacco smoking increases risks for CAD, stroke, abdominal aortic aneurysm, peripheral artery disease, HF, arrhythmias and stent thrombosis after revascularization. Cigarette smoke exposure is nonlinear, such that even short-term exposure is damaging to the CV system and secondhand smoke exposure results in a 25% to 30% increased risk for CVD.

Smoking cessation reduces subsequent CV events and mortality, regardless of the duration of smoking or presence of clinical CVD. However, sustained tobacco cessation remains an ongoing challenge for both patients and health care providers. The 2018 American College of Cardiology Expert Consensus Decision Pathway provides a practical, structured and evidence-based approach to evaluation, treatment and ongoing management of tobacco dependence.

Key points

In our opinion, the ACC Expert Consensus Decision Pathway offers six key points that are important for clinicians to consider. These include:

Pranoti G. Hiremath

1. Smoking cessation is a critical component of CV care. Tobacco cessation treatment should be provided to both outpatients and inpatients by the CV team.

2. Tobacco dependence should be viewed as a chronic medical issue. It should be addressed at every visit and added to the “Problem List,” regardless of the smoking stage (current, former, etc).

3. Secondhand smoke exposure should be addressed in every patient, given the associated increase in CV risk.

4. At every visit, pharmacotherapy and behavioral support should be offered to every patient who smokes. Patients would thus need to “opt-out,” rather than “opt-in.”

5. Patients who smoke should think twice before undergoing elective surgery and should use this opportunity to quit, given the high complication rates for surgical patients who continue to smoke. The perioperative CV risk assessment visit provides an excellent opportunity to engage and motivate patients to quit.

6. Electronic cigarettes (e-cigarettes) are likely less harmful than combustible cigarettes and may be a reasonable “harm-reduction” strategy for some patients. FDA-approved pharmacotherapy should be used first because the long-term risks of e-cigarettes are not known. If a patient chooses to use them, he or she should be advised to switch completely from combustible to e-cigarettes and then ultimately taper off.

Approach to smoking cessation

There are five basic steps to encourage smoking cessation outlined in the ACC Decision Pathway.

No. 1, ask about and document tobacco use status at every visit using a standardized assessment. One approach would be to implement a system of routine assessment within the health record system for every clinic visit. Another method would be to add a diagnosis of current or former tobacco use to the “Problem List,” thereby enabling care providers to reiterate smoking cessation advice and facilitate coordination of care. Questions should also assess use of other tobacco products such as smokeless tobacco, cigars, hookah and e-cigarettes.

No. 2, assess the current degree of nicotine addiction, risk for relapse if a former smoker and exposure to secondhand smoke if a nonsmoker. For current smokers, understanding the degree of nicotine dependence is a major factor in modifying the intensity and methodology of treatment.

Elizabeth Ratchford

Secondhand smoke exposure should be routinely assessed. Asking where and when patients are exposed to tobacco smoke will assist the clinician in advising the best methods for avoiding secondhand smoke. Questions in the assessment should include Heaviness of Smoking Index, which is a validated test to assess a daily smoker’s nicotine dependence: quantification of cigarettes and time to first cigarette upon waking.

Daily smokers are likely nicotine-dependent, and are therefore likely to benefit from pharmacotherapy and behavioral treatment. Nondaily smokers may not have withdrawal symptoms but may use cigarettes compulsively or as a coping mechanism. Factors that may increase the likelihood of relapse include low motivation to stop smoking, reduced confidence in ability to stop smoking, other substance abuse, cohabitation with a smoker and comorbid psychiatric disorders.

No. 3, advise all tobacco users to quit, emphasizing the benefits of cessation or smoke avoidance rather than the harms of exposure. As opposed to prior paradigms of smoking cessation that encouraged reliance on an individual’s “readiness to quit,” newer models of smoking cessation suggest that tobacco dependence is a chronic medical condition for which therapies should be offered at every visit in association with an “opt-out” approach from patients who decline treatment.

Advice should be strong and personalized, and should focus on the benefits of stopping smoking, such as financial savings, avoidance of future clinical CVD, preservation of stent/graft patency and serving as a role model for family. One example of an effective statement is, “Quitting smoking now is by far the best way for you to improve your health.” The pathway recommends against emphasizing the deleterious effects of tobacco dependence because the emphasis on a positive change may reduce guilt and encourage confidence in an individual’s sustained decision to quit smoking.

No. 4, assist (offer and connect) smokers to appropriate pharmacologic and behavioral treatment options. Setting a “quit date” within the next month can provide structure for the effort to quit smoking. Pharmacotherapy is an important component of smoking cessation and can be started even in those who are not yet ready to quit smoking. Prescriptions are suggested for over-the-counter medications as well, since insurance coverage may reduce the cost to the patient. Nonpharmacologic behavioral interventions work synergistically with pharmacotherapies.

Roger S. Blumenthal

As opposed to simply providing advice or resources, active referral to a behavioral support program is more effective. Free resources by telephone include 800-QUIT-NOW (800-784-8669) and online include www.smokefree.gov. Since the motivation to quit changes over time, treatments should be offered at every visit, even though patients may have previously declined therapies.

No. 5, follow up at subsequent visits to monitor smoking status and sustain engagement in smoking-cessation treatments. The risk for smoking relapse is highest in the first days after making a quit attempt; therefore, a follow-up call, message or visit is recommended within 2 to 4 weeks of the initial visit. Follow-up also shows patients that providers place a high priority on tobacco cessation, and therefore encourages efforts to remain smoke-free.

Tobacco-cessation therapies

Pharmacologic therapies have been shown to be more effective than placebo in promoting smoking cessation for 6 months or more, and each is safe for use in patients with CVD. Five nicotine replacement therapy (NRT) options and two medications, bupropion and varenicline (Chantix, Pfizer), are approved for smoking cessation. The Table outlines the advantages and disadvantages of each as described by the authors of the ACC Expert Consensus Decision Pathway.

NRT provides nicotine to reduce withdrawal symptoms such as concentration changes, weight gain and irritability. NRT is absorbed more slowly and produces lower peak blood concentration of nicotine, such that it is usually unable to replicate the pleasurable effects of smoking. Nicotine patches are a convenient delivery system, providing a sustained dose of nicotine throughout the day.

More rapidly absorbed NRT include lozenges, gum, spray and inhalers; these relieve withdrawal symptoms more quickly than the patch. In light of a meta-analysis demonstrating that the combination of nicotine patch with rapidly absorbed NRT is more effective than a single product, combination NRT is now considered standard of care for initial therapy when NRT is chosen.

Different dosages of NRT are available. It is reasonable to taper from higher to lower doses over a course of 12 weeks or even longer. Long-term NRT has not been reported to cause harm, however. Any negative repercussions of NRT use in individuals with CVD are unclear, despite the known sympathomimetic properties of nicotine. A meta-analysis of NRT studies found increased CV symptoms such as tachycardia, but no increase in major CV events, similar to other trials demonstrating no increase in adverse CV events with NRT compared with placebo.

Bupropion is FDA-approved as an antidepressant and for smoking cessation, and its efficacy is similar to NRT in smokers with and without depression. Although approved for 12 weeks of usage, extended treatment for 1 year reduced the relapse rate after initial cessation. Combination therapy with both NRT and bupropion is superior to either agent alone.

Bupropion may be combined with varenicline, with studies demonstrating less smoking at 12 and 26 weeks, although not at 52 weeks. Bupropion also has no adverse effects on BP or CVD risk in studies thus far. However, it should not be used in individuals with history of seizure.

Varenicline has been more effective in promoting smoking cessation than single NRT or bupropion in many trials. Varenicline has been FDA-approved for extension to 6 months of therapy to prevent relapse. Like combination NRT, varenicline is a first-line recommendation for smoking cessation in smokers with CVD. Varenicline is additionally thought to be safe in patients with stable CVD. Although the FDA in 2009 issued a black box warning for neuropsychiatric side effects of varenicline, this warning was removed in 2016 based on more recent trial data.

Pharmacotherapies may be started before smoking cessation, in a “preloading” approach, although limited data support this approach. In hospitalized smokers with ACS, varenicline was effective for cessation, whereas bupropion was not effective. The committee does not have a consensus regarding whether varenicline should be started within the hospital or after discharge; advantages to the former include maximizing likelihood of patient adherence after discharge, but disadvantages include possible gastrointestinal upset in patients who are receiving loading doses of antiplatelet therapy and other cardiac medications.

Nonpharmacologic therapies include brief interventions delivered by a doctor or nurse, with positive effect on increasing quit rates by 50%. Additional methods include telephone support with multiple counseling sessions, increasing quit rates by 50% to 100%, and group support with multiple in-person sessions, increasing quit rates by 300%.

Special circumstances

Hospitalized patients are a unique case, and the committee recommends assessing the tobacco use status of all such patients, offering tobacco cessation treatment in the hospital to all current smokers and arranging a dedicated smoking cessation visit at hospital discharge.

For perioperative patients, a unique motivation exists for smoking cessation. For elective procedures, surgeons may mandate complete smoking cessation before surgery. Pharmacotherapy may be used preoperatively as well as in the immediate postoperative period.

Weight gain after smoking cessation is common, estimated at approximately 3 kg to 6 kg for about 80% smokers in the first 3 months after cessation. Bupropion, NRT and varenicline reduce post-cessation weight change while the medication is being used, but seem to delay weight instead of prevent weight gain. Regardless of the anticipated weight gain, recommendations are to encourage smoking cessation primarily, followed by encouragement of weight loss.

E-cigarettes and other alternative nicotine delivery systems vary widely in how much nicotine is delivered to the user. Population studies demonstrate that e-cigarettes are more popular than cigarettes in youth. Some short-term health benefits are observed in switching from combustible cigarettes to e-cigarettes because toxins are present in lower quantities in e-cigarette aerosols; however, the long-term risks are unclear. For example, flavorings found in e-liquids, including diacetyl and cinnamaldehyde, may pose a health hazard. Importantly, patients should be advised to quit combustible tobacco products completely if they are going to use e-cigarettes. Dual use of both combustible and e-cigarettes should be avoided. After making this switch, then the ultimate goal should be to taper off the e-cigarettes as well, since the long-term effects are not known.

‘A call to action’

In summary, the new ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment represents a call to action for clinicians to engage their patients in this critical step to improve CV health. At the same time, the pathway provides a much-needed simple framework for how to approach tobacco dependence in modern clinical practice.

Disclosures: The authors report no relevant financial disclosures.

Cigarette smoking is one of the leading preventable causes of death in the United States. Globally, up to one-third of all deaths from CVD may be attributed to cigarette smoking. Tobacco smoking increases risks for CAD, stroke, abdominal aortic aneurysm, peripheral artery disease, HF, arrhythmias and stent thrombosis after revascularization. Cigarette smoke exposure is nonlinear, such that even short-term exposure is damaging to the CV system and secondhand smoke exposure results in a 25% to 30% increased risk for CVD.

Smoking cessation reduces subsequent CV events and mortality, regardless of the duration of smoking or presence of clinical CVD. However, sustained tobacco cessation remains an ongoing challenge for both patients and health care providers. The 2018 American College of Cardiology Expert Consensus Decision Pathway provides a practical, structured and evidence-based approach to evaluation, treatment and ongoing management of tobacco dependence.

Key points

In our opinion, the ACC Expert Consensus Decision Pathway offers six key points that are important for clinicians to consider. These include:

Pranoti G. Hiremath

1. Smoking cessation is a critical component of CV care. Tobacco cessation treatment should be provided to both outpatients and inpatients by the CV team.

2. Tobacco dependence should be viewed as a chronic medical issue. It should be addressed at every visit and added to the “Problem List,” regardless of the smoking stage (current, former, etc).

3. Secondhand smoke exposure should be addressed in every patient, given the associated increase in CV risk.

4. At every visit, pharmacotherapy and behavioral support should be offered to every patient who smokes. Patients would thus need to “opt-out,” rather than “opt-in.”

5. Patients who smoke should think twice before undergoing elective surgery and should use this opportunity to quit, given the high complication rates for surgical patients who continue to smoke. The perioperative CV risk assessment visit provides an excellent opportunity to engage and motivate patients to quit.

6. Electronic cigarettes (e-cigarettes) are likely less harmful than combustible cigarettes and may be a reasonable “harm-reduction” strategy for some patients. FDA-approved pharmacotherapy should be used first because the long-term risks of e-cigarettes are not known. If a patient chooses to use them, he or she should be advised to switch completely from combustible to e-cigarettes and then ultimately taper off.

Approach to smoking cessation

There are five basic steps to encourage smoking cessation outlined in the ACC Decision Pathway.

No. 1, ask about and document tobacco use status at every visit using a standardized assessment. One approach would be to implement a system of routine assessment within the health record system for every clinic visit. Another method would be to add a diagnosis of current or former tobacco use to the “Problem List,” thereby enabling care providers to reiterate smoking cessation advice and facilitate coordination of care. Questions should also assess use of other tobacco products such as smokeless tobacco, cigars, hookah and e-cigarettes.

PAGE BREAK

No. 2, assess the current degree of nicotine addiction, risk for relapse if a former smoker and exposure to secondhand smoke if a nonsmoker. For current smokers, understanding the degree of nicotine dependence is a major factor in modifying the intensity and methodology of treatment.

Elizabeth Ratchford

Secondhand smoke exposure should be routinely assessed. Asking where and when patients are exposed to tobacco smoke will assist the clinician in advising the best methods for avoiding secondhand smoke. Questions in the assessment should include Heaviness of Smoking Index, which is a validated test to assess a daily smoker’s nicotine dependence: quantification of cigarettes and time to first cigarette upon waking.

Daily smokers are likely nicotine-dependent, and are therefore likely to benefit from pharmacotherapy and behavioral treatment. Nondaily smokers may not have withdrawal symptoms but may use cigarettes compulsively or as a coping mechanism. Factors that may increase the likelihood of relapse include low motivation to stop smoking, reduced confidence in ability to stop smoking, other substance abuse, cohabitation with a smoker and comorbid psychiatric disorders.

No. 3, advise all tobacco users to quit, emphasizing the benefits of cessation or smoke avoidance rather than the harms of exposure. As opposed to prior paradigms of smoking cessation that encouraged reliance on an individual’s “readiness to quit,” newer models of smoking cessation suggest that tobacco dependence is a chronic medical condition for which therapies should be offered at every visit in association with an “opt-out” approach from patients who decline treatment.

Advice should be strong and personalized, and should focus on the benefits of stopping smoking, such as financial savings, avoidance of future clinical CVD, preservation of stent/graft patency and serving as a role model for family. One example of an effective statement is, “Quitting smoking now is by far the best way for you to improve your health.” The pathway recommends against emphasizing the deleterious effects of tobacco dependence because the emphasis on a positive change may reduce guilt and encourage confidence in an individual’s sustained decision to quit smoking.

No. 4, assist (offer and connect) smokers to appropriate pharmacologic and behavioral treatment options. Setting a “quit date” within the next month can provide structure for the effort to quit smoking. Pharmacotherapy is an important component of smoking cessation and can be started even in those who are not yet ready to quit smoking. Prescriptions are suggested for over-the-counter medications as well, since insurance coverage may reduce the cost to the patient. Nonpharmacologic behavioral interventions work synergistically with pharmacotherapies.

PAGE BREAK
Roger S. Blumenthal

As opposed to simply providing advice or resources, active referral to a behavioral support program is more effective. Free resources by telephone include 800-QUIT-NOW (800-784-8669) and online include www.smokefree.gov. Since the motivation to quit changes over time, treatments should be offered at every visit, even though patients may have previously declined therapies.

No. 5, follow up at subsequent visits to monitor smoking status and sustain engagement in smoking-cessation treatments. The risk for smoking relapse is highest in the first days after making a quit attempt; therefore, a follow-up call, message or visit is recommended within 2 to 4 weeks of the initial visit. Follow-up also shows patients that providers place a high priority on tobacco cessation, and therefore encourages efforts to remain smoke-free.

Tobacco-cessation therapies

Pharmacologic therapies have been shown to be more effective than placebo in promoting smoking cessation for 6 months or more, and each is safe for use in patients with CVD. Five nicotine replacement therapy (NRT) options and two medications, bupropion and varenicline (Chantix, Pfizer), are approved for smoking cessation. The Table outlines the advantages and disadvantages of each as described by the authors of the ACC Expert Consensus Decision Pathway.

NRT provides nicotine to reduce withdrawal symptoms such as concentration changes, weight gain and irritability. NRT is absorbed more slowly and produces lower peak blood concentration of nicotine, such that it is usually unable to replicate the pleasurable effects of smoking. Nicotine patches are a convenient delivery system, providing a sustained dose of nicotine throughout the day.

More rapidly absorbed NRT include lozenges, gum, spray and inhalers; these relieve withdrawal symptoms more quickly than the patch. In light of a meta-analysis demonstrating that the combination of nicotine patch with rapidly absorbed NRT is more effective than a single product, combination NRT is now considered standard of care for initial therapy when NRT is chosen.

Different dosages of NRT are available. It is reasonable to taper from higher to lower doses over a course of 12 weeks or even longer. Long-term NRT has not been reported to cause harm, however. Any negative repercussions of NRT use in individuals with CVD are unclear, despite the known sympathomimetic properties of nicotine. A meta-analysis of NRT studies found increased CV symptoms such as tachycardia, but no increase in major CV events, similar to other trials demonstrating no increase in adverse CV events with NRT compared with placebo.

Bupropion is FDA-approved as an antidepressant and for smoking cessation, and its efficacy is similar to NRT in smokers with and without depression. Although approved for 12 weeks of usage, extended treatment for 1 year reduced the relapse rate after initial cessation. Combination therapy with both NRT and bupropion is superior to either agent alone.

PAGE BREAK

Bupropion may be combined with varenicline, with studies demonstrating less smoking at 12 and 26 weeks, although not at 52 weeks. Bupropion also has no adverse effects on BP or CVD risk in studies thus far. However, it should not be used in individuals with history of seizure.

Varenicline has been more effective in promoting smoking cessation than single NRT or bupropion in many trials. Varenicline has been FDA-approved for extension to 6 months of therapy to prevent relapse. Like combination NRT, varenicline is a first-line recommendation for smoking cessation in smokers with CVD. Varenicline is additionally thought to be safe in patients with stable CVD. Although the FDA in 2009 issued a black box warning for neuropsychiatric side effects of varenicline, this warning was removed in 2016 based on more recent trial data.

Pharmacotherapies may be started before smoking cessation, in a “preloading” approach, although limited data support this approach. In hospitalized smokers with ACS, varenicline was effective for cessation, whereas bupropion was not effective. The committee does not have a consensus regarding whether varenicline should be started within the hospital or after discharge; advantages to the former include maximizing likelihood of patient adherence after discharge, but disadvantages include possible gastrointestinal upset in patients who are receiving loading doses of antiplatelet therapy and other cardiac medications.

Nonpharmacologic therapies include brief interventions delivered by a doctor or nurse, with positive effect on increasing quit rates by 50%. Additional methods include telephone support with multiple counseling sessions, increasing quit rates by 50% to 100%, and group support with multiple in-person sessions, increasing quit rates by 300%.

PAGE BREAK

Special circumstances

Hospitalized patients are a unique case, and the committee recommends assessing the tobacco use status of all such patients, offering tobacco cessation treatment in the hospital to all current smokers and arranging a dedicated smoking cessation visit at hospital discharge.

For perioperative patients, a unique motivation exists for smoking cessation. For elective procedures, surgeons may mandate complete smoking cessation before surgery. Pharmacotherapy may be used preoperatively as well as in the immediate postoperative period.

Weight gain after smoking cessation is common, estimated at approximately 3 kg to 6 kg for about 80% smokers in the first 3 months after cessation. Bupropion, NRT and varenicline reduce post-cessation weight change while the medication is being used, but seem to delay weight instead of prevent weight gain. Regardless of the anticipated weight gain, recommendations are to encourage smoking cessation primarily, followed by encouragement of weight loss.

E-cigarettes and other alternative nicotine delivery systems vary widely in how much nicotine is delivered to the user. Population studies demonstrate that e-cigarettes are more popular than cigarettes in youth. Some short-term health benefits are observed in switching from combustible cigarettes to e-cigarettes because toxins are present in lower quantities in e-cigarette aerosols; however, the long-term risks are unclear. For example, flavorings found in e-liquids, including diacetyl and cinnamaldehyde, may pose a health hazard. Importantly, patients should be advised to quit combustible tobacco products completely if they are going to use e-cigarettes. Dual use of both combustible and e-cigarettes should be avoided. After making this switch, then the ultimate goal should be to taper off the e-cigarettes as well, since the long-term effects are not known.

PAGE BREAK

‘A call to action’

In summary, the new ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment represents a call to action for clinicians to engage their patients in this critical step to improve CV health. At the same time, the pathway provides a much-needed simple framework for how to approach tobacco dependence in modern clinical practice.

Disclosures: The authors report no relevant financial disclosures.