Cardiologists play critical role in smoking cessation, counseling on CV hazards of vaping
SAN ANTONIO — The use of alternative devices to cigarettes has become increasingly popular since they entered the market in 2016. For some patients, e-cigarettes and vaping devices may be helpful tools to aid in cessation of combustible tobacco products.
However, research in this area is sparse, and more data are needed on the risks and benefits, as well as the long-term impact, of e-cigarettes, Pamela B. Morris, MD, FACC, FAHA, FASPC, FNLA, director of the Seinsheimer Cardiovascular Health Program and professor of medicine at The Medical University of South Carolina in Charleston, said during a presentation at the American Society for Preventive Cardiology Congress on CVD Prevention.
Growing rates of smoking cessation
The per-capita consumption of combustible products, including cigarettes and cigars, has declined by 73% in the past 50 years. Each year, there are an estimated 500,000 deaths in the United States and 6 million worldwide associated with smoking, according to Morris.
In general, most patients want to stop smoking, she said. Morris cited data from 2015 that show 68% of current smokers reported wanting to quit. However, long-term cessation remains challenging, she said, with 58% of smokers reporting trying to quit each year, although few succeeding long term. Among people who successfully stopped smoking, only 31% sought help from their physician.
“It is so important for us to offer help each and every day in our clinic to our patients who smoke,” Morris said.
Even with proven effective treatments, challenges remain, such as the need for more effective delivery of smoking-cessation options to smokers. It is important for clinicians to acknowledge and manage tobacco use as a chronic relapsing disorder, she said.
“We need to be more effective, more diligent, about regularly approaching our patients about smoking in our clinics, despite the fact that this is a difficult conversation,” Morris said.
The American College of Cardiology published an expert consensus decision pathway in 2018 on tobacco-cessation treatment. One of the sections in this document includes a three-step model for treating tobacco use in the office, which includes asking the patient about their smoking history, advising patients to stop smoking to stay healthy and acting to offer pharmacotherapy and resources for behavioral support.
The first-line recommended pharmacotherapy for smoking cessation in patients with CVD is varenicline (Chantix, Pfizer) or combination nicotine-replacement therapy. Second-line therapy includes bupropion or a single nicotine-replacement therapy product and third-line therapy is nortriptyline. If these approaches do not work, it is recommended to combine categories of FDA-approved drugs.
Regardless of the treatment approach selected for smoking cessation, care of patients should be a team-based approach.
“It should involve primary care providers, PharmDs, advanced practice professionals, medical assistants or others involves in the intake and assessment of tobacco use history for successful long-term support of tobacco cessation,” Morris said.
For patients who are not ready to quit smoking, data suggest that prescribing pharmacotherapy in advance of the attempt to quit smoking can help them reduce tobacco intake and increase their motivation to quit smoking, according to the presentation.
E-cigarette use continues to grow
E-cigarettes are another approach to tobacco cessation.
“This is such a disruptive technology because it has evolved far faster than our knowledge of these products,” Morris said. “Patients know more about these products than we do. The devices and e-liquids have rapidly evolved and medical science must catch up to understand the long-term potential benefits and risks of these devices.”
E-cigarettes became available in the U.S. in 2007 and were originally sold in mall kiosks and tobacco retail outlets. The devices were rapidly marketed in print advertisements and on the internet. There are currently 10.8 million e-cigarette users in the U.S., with the greatest increase in use among young adults and adolescents.
E-cigarettes have had rapid market penetration, with their ability to produce a smoke-like inhaled aerosol that imitates tobacco smoke visually. It replicates the sensation of smoking in the throat and mouth, and replicates the hand-to-mouth behavior associated with combustible cigarettes.
“It’s very comfortable for current users of combustible products,” Morris said.
Claims included in the marketing of e-cigarettes include that they are healthier, cheaper and cleaner than traditional cigarettes. In addition, advertisements mention that the devices can be smoked anywhere, do not produce secondhand smoke, produce harmless water vapor and can be used for smoking cessation, Morris said here.
There are an infinite number of questions about electronic nicotine-delivery systems including harms associated with use, whether they truly help tobacco smokers quit, if they serve as a gateway to tobacco smoking and whether they should be tolerated over tobacco products as a less harmful substitute.PAGE BREAK
There are four generations of e-cigarettes that have changed in appearance and features, according to the presentation.
“Suffice it to say that they really are outpacing our understanding and our ability to counsel a patient about these devices,” Morris said.
E-liquids that are used with e-cigarettes contain water, humectants, nicotine and flavoring agents. Although the vapor products by e-cigarettes contain fewer carcinogens and toxic chemicals, there are trace levels compared with traditional tobacco products, according to the presentation.
Some minor adverse events associated with these products have been reported, such as chest pain, headache, cough, nausea and mouth irritation. Major adverse events that have been observed with these products are singular case reports of hospitalization for congestive HF, pneumonia, rapid heart rate, seizure and burns.
“The bottom line is that we just don’t have enough long-term data to understand,” Morris said.Morris said multiple factors will determine the net public health effect of e-cigarettes: the potential to help current smokers quit, the potential to increase the uptake of combustible tobacco product use by non-smokers, the uptake of use by youth and young adults and subsequent nicotine addiction or use of combustible products and the inherent toxicity of e-cigarettes.
Some current studies have shown that the use of e-cigarettes may help patients quit smoking combustible cigarettes, although more research is needed on the long-term effects of these products.“Some experts believe in the 'less-harm philosophy,' that use of e-cigarettes is less harmful than combustible cigarettes for those patients who will not quit and are willing to completely switch,” Morris said. “Other experts prefer 'to end the nicotine addiction' and support complete cessation of all nicotine-related products other than evidence-based therapies.”
Early clinical trials assessed the effects of e-cigarettes. However, this research had limitations, including very small sample sizes, lack of a control group in most studies, lack of behavioral support and use of early-generation devices that are no longer used, Morris said.
A randomized trial was published in The New England Journal of Medicine in February, in which patients were assigned e-cigarettes or nicotine-replacement therapy. Researchers reported that 18% of patients assigned e-cigarettes were nonsmokers at 1 year vs. 9.9% of those assigned nicotine-replacement therapy. At the end of 1 year, 80% of patients who quit with e-cigarettes and 9% of those who quit with nicotine-replacement therapy were still using their assigned therapy.
‘Friends or foes?’
When cardiologists are discussing smoking cessation and e-cigarettes with patients, Morris recommended emphasizing the goal of complete cessation of all combustible tobacco products; recommending evidence-based, FDA-approved smoking-cessation aids; and being prepared to discuss the available evidence on the risks and benefits of e-cigarettes.
“Are these friends or foes? The data are still out,” Morris said. “We need to be educated as clinicians on what to tell our patients when they do prefer to use e-cigarettes for smoking cessation and how to guide them through the process of tapering the nicotine content so that their long-term goal can be to end the addiction.” – by Darlene Dobkowski
Morris PB. Tobacco Cessation and Cardiovascular Hazards of Vaping. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 19-21, 2019; San Antonio.
Disclosure: Morris reports she is on the advisory board and serves as a consultant for Akcea and is an investigator for Esperion.