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Canadian Journal of Cardiology

Smoking Cessation and the Cardiovascular Specialist: Canadian Cardiovascular Society Position Paper

      Abstract

      Tobacco addiction is the leading cause of preventable disease, disability, and death in Canada and is the most significant of the modifiable cardiovascular risk factors. Tobacco addiction is a principal contributor to the development of coronary artery disease (CAD) and its consequences, including sudden cardiac death, acute myocardial infarction, and heart failure. Its prevention and treatment should be accorded high priority. In fact, 30% of all CAD deaths are attributable to smoking. The identification and documentation of the smoking status of all patients, and the provision of cessation assistance, should be a priority in every cardiovascular setting. Systematic approaches to the identification and treatment of smokers can dramatically enhance the likelihood of cessation—the most cost-effective of all the interventions to prevent the development or progression of CAD. It is the view of the Canadian Cardiovascular Society that all patients in every medical setting—private office, outpatient clinic, or hospital—should have their smoking status systematically identified and documented and be offered specific assistance in initiating a cessation attempt. The provision of unambiguous, nonjudgemental advice regarding the importance of cessation and assistance with the initiation of a smoking cessation attempt should be seen as a fundamental responsibility of any cardiovascular clinician who encounters smokers in any setting. All cardiovascular specialists should be familiar with the principles and practice of smoking cessation. It is important for cardiovascular specialists to be as familiar with the initiation of smoking-cessation pharmacotherapy as they are with the pharmacological management of hypertension and hyperlipidemia.

      Résumé

      La dépendance au tabac est la cause principale des maladies évitables, des incapacités et de la mort au Canada, et le facteur de risque cardiovasculaire modifiable le plus important. La dépendance au tabac est ce qui contribue principalement au développement de la maladie coronaire (MC) et aux conséquences, dont la mort cardiaque subite, l'infarctus du myocarde aigu et l'insuffisance cardiaque. Sa prévention et son traitement devraient être prioritaires. De fait, 30 % de tous les décès liés à la MC sont attribuables au tabagisme. L'identification et la notification du statut de fumeur de tous les patients, et les dispositions pour aider à la désaccoutumance devraient être une priorité pour chacun des cas à risque cardiovasculaire. Les approches systématiques pour l'identification et le traitement des fumeurs peuvent améliorer de façon frappante la probabilité de désaccoutumance – la plus rentable de toutes les interventions pour prévenir le développement ou la progression de la MC. L'opinion de la Société canadienne de cardiologie est que tous les patients dans tous les secteurs médicaux – bureau privé, consultations externes ou hôpital – devraient avoir leur statut de fumeur systématiquement identifié et documenté, et recevoir une aide spécifique pour tenter d'entreprendre la désaccoutumance. Des dispositions pour des conseils, sans jugement ni ambiguïté, sur l'importance de la désaccoutumance au tabac et l'aide pour entreprendre cette désaccoutumance devraient être prises à titre de responsabilité fondamentale par les cliniciens cardiovasculaires de tous les secteurs qui rencontrent des fumeurs. Tous les spécialistes cardiovasculaires devraient être familiarisés avec les principes et la pratique de désaccoutumance au tabac. Il est important pour les spécialistes cardiovasculaires d'être aussi familiarisés dans l'initiation d'une pharmacothérapie de désaccoutumance au tabac qu'ils le sont dans la gestion pharmacologique de l'hypertension et l'hyperlipidémie.
      Tobacco addiction is the leading cause of preventable disease, disability, and death in Canada, contributing to more than 37,000 deaths each year; more than 11,000 (29% of all smoking-related deaths) are cardiovascular related.
      Canadian Tobacco Use Monitoring Survey
      Canadian Tobacco Use Monitoring Survey.
      Tobacco addiction is the most significant of the “modifiable” cardiovascular risk factors, and its prevention and treatment should be accorded high priority. The Canadian Tobacco Use Monitoring Survey reports that 17% of Canadians were current smokers (19% males; 16% females) in 2009. In a Canadian general hospital population, 19.8% of patients have been found to be smokers, compared with 22.4% of patients in cardiac settings.
      • Reid R.D.
      • Mullen K.A.
      • Slovinec D'Angelo M.E.
      • et al.
      Smoking cessation for hospitalized smokers: an evaluation of the “Ottawa Model.”.
      Smokers are addicted to nicotine but, in the act of smoking, inhale thousands of other chemicals, many of which play critical roles in the initiation and acceleration of atherosclerosis by adversely influencing endothelial function and, through the oxidation of lipids and coagulation-factor stimulation, enhance atheroma development.
      • Benowitz N.
      Nicotine addiction.
      • Pipe A.L.
      • Papadakis S.
      • Reid R.D.
      The role of smoking cessation in the prevention of coronary artery disease.
      • Ambrose J.
      • Barua R.
      The pathophysiology of cigarette smoking and cardiovascular disease: an update.
      There is no doubt about the role that tobacco addiction plays in the development and progression of cardiovascular disease and the frequency and severity of its complications.
      • Erhardt L.
      Cigarette smoking: an undertreated risk factor for cardiovascular disease.
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      • et al.
      Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
      Tobacco use is a principal contributor to the development of coronary artery disease (CAD) and its consequences, including sudden cardiac death, acute myocardial infarction, and heart failure. In fact, 30% of all CAD deaths are attributable to smoking.
      US Department of Health and Human Services
      The Health Consequences of Smoking: A Report of the Surgeon General.
      Such deaths in smokers younger than 45 years exceed the mortality produced by any other tobacco-related disease.
      • Burns D.M.
      Epidemiology of smoking-induced cardiovascular disease.
      The benefits of smoking cessation in those with established CAD accrue rapidly and result in a substantial reduction in the risk of disease progression, recurrent events, and death.
      • Tonstad S.
      • Andrew Johnston J.
      Cardiovascular risks associated with smoking: a review for clinicians.
      Distinct and dramatic physiological benefits emerge within weeks of cessation: procoagulants, carboxyhemoglobin levels, atherogenic lipoproteins, proinflammatory agents, and inflammatory biomarkers decline; endothelial and circulatory function improve.
      • Pipe A.L.
      • Papadakis S.
      • Reid R.D.
      The role of smoking cessation in the prevention of coronary artery disease.
      • Haustein K.O.
      • Krause J.
      • Haustein H.
      • Rasmussen T.
      • Cort N.
      Changes in hemorheological and biochemical parameters following short-term and long-term smoking cessation induced by nicotine replacement therapy (NRT).
      In asymptomatic patients, within 1 year of cessation, the risk of dying from smoking-related heart disease is reduced by almost one-half.
      • Ockene I.S.
      • Miller N.H.
      Cigarette smoking, cardiovascular disease, and stroke: a statement for healthcare professionals from the American Heart Association American Heart Association Task Force on Risk Reduction.
      In smokers with existing CAD, quitting smoking is associated with a 32% reduction in the risk of nonfatal reinfarction and a 36% reduction in mortality.
      • Barth J.
      • Critchley J.
      • Bengel J.
      Efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease: a systematic review and meta-analysis.
      • Critchley J.A.
      • Capewell S.
      Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review.
      Indeed, quitting smoking reduces mortality risk more than the application of other secondary prevention measures such as the use of statins, aspirin, β-blockers, or angiotensin-converting enzyme inhibitors.
      • Critchley J.A.
      • Capewell S.
      Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review.
      • Wilson K.
      • Gibson N.
      • Willan A.
      • Cook D.
      Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies.
      Furthermore, in patients with heart failure, quitting smoking is associated with a 40% reduction in heart failure readmission or mortality.
      • Suskin N.
      • Sheth T.
      • Negassa A.
      • Yusuf S.
      Relationship of current and past smoking to mortality and morbidity in patients with left ventricular dysfunction.
      Accordingly, the identification and documentation of the smoking status of all patients, and the provision of cessation assistance, should be a priority in every cardiovascular setting.

      Smoking and the Cardiovascular Patient

      In Canada there have been distinct changes in societal attitudes toward smoking, with a dramatic decrease in the tolerance of smoking in public spaces and indoor environments. Clinical approaches to the treatment of nicotine addiction have often reflected a serendipitous delivery of educational and exhortational messages. It has been noted, sadly, that tobacco addiction represents “a unique combination of prevalence, lethality, and … neglect.”
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.
      Evidence continues to accumulate, however, demonstrating that systematic approaches to the identification and treatment of smokers, particularly in cardiac settings, can dramatically enhance the likelihood of cessation.
      • Reid R.D.
      • Mullen K.A.
      • Slovinec D'Angelo M.E.
      • et al.
      Smoking cessation for hospitalized smokers: an evaluation of the “Ottawa Model.”.
      • Reid R.D.
      • Pipe A.L.
      • Quinlan B.
      Promoting smoking cessation during hospitalization for coronary artery disease.
      Professional organizations and health authorities consistently recommend the identification, documentation, and provision of cessation assistance to all smokers in every professional setting.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.
      • Forrester J.S.
      • Merz C.N.
      • Bush T.L.
      • et al.
      27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events Task Force 4. Efficacy of risk factor management.
      This approach is particularly relevant to those with cardiac disease, as it has been demonstrated that smokers with CAD have higher spontaneous quit rates than those in other diagnostic categories, yet without assistance, most will be smoking 1 year after CAD-related hospitalization.
      • Rea T.D.
      • Heckbert S.R.
      • Kaplan R.C.
      • Smith N.L.
      • Lemaitre R.N.
      • Psaty B.M.
      Smoking status and risk for recurrent coronary events after myocardial infarction.
      • Rigotti N.A.
      • McKool K.M.
      • Shiffman S.
      Predictors of smoking cessation after coronary artery bypass graft surgery: results of a randomized trial with 5-year follow-up.
      • Rigotti N.A.
      • Singer D.E.
      • Mulley Jr, A.G.
      • Thibault G.E.
      Smoking cessation following admission to a coronary care unit.
      Numerous meta-analyses of randomized controlled trials have demonstrated that counselling and pharmacotherapy, used either alone or in combination, improve long-term quit rates.
      • Cahill K.
      • Stead L.
      • Lancaster T.
      Nicotine receptor partial agonists for smoking cessation.
      • Fiore M.C.
      • Bailey W.C.
      • Cohen S.J.
      • et al.
      Treating Tobacco Use and Dependence.
      • Fiore M.C.
      • Jaen C.R.
      A clinical blueprint to accelerate the elimination of tobacco use.
      • Hughes J.
      • Stead L.
      • Lancaster T.
      Antidepressants for smoking cessation.
      • Lancaster T.
      • Stead L.F.
      Individual behavioural counselling for smoking cessation.
      • Ranney L.
      • Melvin C.
      • Lux L.
      • McClain E.
      • Lohr K.N.
      Systematic review: smoking cessation intervention strategies for adults and adults in special populations.
      • Silagy C.
      • Lancaster T.
      • Stead L.
      • Mant D.
      • Fowler G.
      Nicotine replacement therapy for smoking cessation.
      • Wu P.
      • Wilson K.
      • Dimoulas P.
      • Mills E.J.
      Effectiveness of smoking cessation therapies: a systematic review and meta-analysis.
      • Eisenberg M.J.
      • Filion K.B.
      • Yavin D.
      • et al.
      Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials.
      Among smokers hospitalized with CAD, interventions for smoking cessation can boost quit rates at 1 year to 35% to 70%.
      • Mohiuddin S.M.
      • Mooss A.N.
      • Hunter C.B.
      • Grollmes T.L.
      • Cloutier D.A.
      • Hilleman D.E.
      Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease.
      • Rigotti N.A.
      • Munafo M.R.
      • Stead L.F.
      Interventions for smoking cessation in hospitalised patients.
      In addition, smoking cessation is the most cost-effective of all the interventions designed to prevent the development or progression of CAD.
      • Kahn R.
      • Robertson J.T.
      • Smith R.
      • Eddy D.
      The impact of prevention on reducing the burden of cardiovascular disease.
      In light of this clinical and scientific evidence, it is the view of the Canadian Cardiovascular Society that all patients in every medical setting—private office, outpatient clinic, or hospital—should have their smoking status identified and documented and be offered specific assistance in initiating a cessation attempt. Disease progression, recurrence of symptoms, readmission rates, myocardial infarction, and death can be significantly reduced as a result of successful cessation.
      • Ockene I.S.
      • Miller N.H.
      Cigarette smoking, cardiovascular disease, and stroke: a statement for healthcare professionals from the American Heart Association American Heart Association Task Force on Risk Reduction.
      The provision of unambiguous, nonjudgemental advice regarding the importance of cessation and the offer of specific assistance with the initiation of a smoking cessation attempt should be seen as a fundamental responsibility of any clinicians who sees smokers in their practice. The role of the specialist in delivering specific advice in this regard may itself result in enhanced rates of cessation. All cardiovascular specialists should be familiar with the principles and practice of smoking cessation.

      Nicotine Addiction in the Cardiovascular Setting

      Smokers frequently experience a range of unpleasant moods and physical symptoms (eg, irritability, nervousness, increased appetite, depression, difficulty concentrating), referred to as “tobacco withdrawal syndrome,” when they cannot smoke.
      • Benowitz N.
      Nicotine addiction.
      • Frishman W.H.
      • Mitta W.
      • Kupersmith A.
      • Ky T.
      Nicotine and non-nicotine smoking cessation pharmacotherapies.
      • McEwen A.
      • Hayek P.
      • McRobbie H.
      • West R.
      Manual of Smoking Cessation: A Guide for Counsellors and Practitioners.
      The development of nicotine withdrawal following hospitalization is more common than realized and contributes to patient discomfort, behavioural “challenges,” and lack of compliance with treatment. The prevention and treatment of withdrawal in the hospital setting enhances patient comfort and may contribute to enhanced rates of cessation postdischarge. Based on the growing evidence of the effectiveness of such interventions, contemporary recommendations for the delivery of a smoking cessation intervention emphasize the provision of advice, the use of smoking-cessation pharmacotherapy, and the facilitation of ongoing follow-up.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.
      The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel Liaisons and Staff
      A clinical practice guideline for treating tobacco use and dependence: 2008 update A US Public Health Service Report.
      Therefore, it is important for cardiovascular specialists to be as familiar with the initiation of smoking-cessation pharmacotherapy as they are with the pharmacologic management of hypertension and hyperlipidemia.
      • Tonstad S.
      • Andrew Johnston J.
      Cardiovascular risks associated with smoking: a review for clinicians.

      Smoking Cessation Pharmacotherapy

      There are currently 3 classes of pharmacotherapy for smoking cessation: nicotine-replacement therapy (NRT); bupropion; and varenicline. Cardiovascular specialists should be familiar with the benefits, limitations, use, and prescription of smoking cessation therapies when and where appropriate. These treatments, like many cardiovascular disease therapies, can subsequently be supervised by a primary care physician and/or other allied health professional. All pharmacotherapies are intended to eliminate or reduce the symptoms of withdrawal and craving so that the patient can begin to acquire, without discomfort or distress, a repertoire of nonsmoking behaviours.

      Nrt

      The safety of NRT use in cardiac patients has been established in a variety of settings.
      • Joseph A.M.
      • Fu S.S.
      Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease.
      • Hubbard R.
      • Lewis S.
      • Smith C.
      • et al.
      Use of nicotine replacement therapy and the risk of acute myocardial infarction, stroke, and death.
      Nicotine is delivered via a transdermal patch, gum, or “inhaler” or a combination of these vehicles. The dosage can be adjusted by a patient to deliver an amount sufficient to ease withdrawal and craving. A cigarette typically delivers 1 to 2 mg nicotine, and smokers are known to titrate their personal nicotine intake precisely.
      • Hoffman D.
      • Hoffman I.
      The changing cigarette, 1950–1995.
      Use of a patch (Habitrol or NicoDerm) results in the slow absorption of nicotine. Nicotine gum (Nicorette) and an inhaler (Nicotrol) can be used throughout the day and deliver nicotine more rapidly. Knowledge of the pharmacodynamics of nicotine and of smokers' development of tolerance to its effects, along with an understanding that nicotine delivered by NRT patches enters the venous system at levels markedly lower than those produced in the arterial system by the inhalation of tobacco smoke and produces lesser effects with respect to increasing myocardial work or coronary vascular resistance, provides a theoretical basis for its safe use in any situation in which a smoker may wish to continue smoking, such as when admitted to hospital for acute coronary syndromes or heart failure.
      • Benowitz N.L.
      • Gourlay S.G.
      Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy.
      Evidence that NRT is safe for smokers with acute coronary syndromes continues to accrue; it may be commenced during a hospital stay if the smoker is experiencing serious withdrawal symptoms and is unable to abstain from smoking.
      • Meine T.
      • Patel M.
      • Washam J.
      • Pappas P.
      • Jollis J.
      Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes.
      NRT has been demonstrated to increase the rate of quitting by 50% to 70%, regardless of setting.
      • Stead L.F.
      • Perera R.
      • Bullen C.
      • Mant D.
      • Lancaster T.
      Nicotine replacement therapy for smoking cessation (review).
      The use of a nicotine inhaler, nicotine patch, and nicotine gum have been shown to produce abstinence rates at 6 months of follow-up or longer of 24.8% (95% confidence interval [CI] 19.1, 31.6), 23.4% (95% CI 21.3, 25.8), 19% (95% CI 16.5, 21.9) respectively.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.
      The odds ratio (OR) of smoking abstinence at 6 months or longer for these treatments compared to placebo are: inhaler (OR 2.1; 95% CI 1.5, 2.9); patch (OR 1.9; 95% CI 1.7, 2.2); and gum (OR 1.5; 95% CI 1.2, 1.7).
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.

      Bupropion

      Bupropion (Zyban) is also used as an antidepressant (Wellbutrin). This drug is no more effective, however, in helping with smoking cessation in depressed patients compared with nondepressed patients.
      • Catley D.
      • Harris K.J.
      • Okuyemi K.S.
      • Mayo M.S.
      • Pankey E.
      • Ahluwalia J.S.
      The influence of depressive symptoms on smoking cessation on African Americans in a randomized trial of bupropion.
      It inhibits the reuptake of dopamine and norepinephrine, which may relieve or suppress nicotine withdrawal symptoms and craving for nicotine. It may also act as a noncompetitive antagonist of nicotinic receptors. Bupropion effectively doubles the rate of smoking cessation when compared with placebo; its safety and effectiveness have been clearly demonstrated in the treatment of smokers with cardiovascular disease.
      • Tonstad S.
      • Farsang C.
      • Klaene G.
      • et al.
      Bupropion SR for smoking cessation in smokers with cardiovascular disease: a multicentre, randomised study.
      • Rigotti N.A.
      • Thorndike A.N.
      • Regan S.
      • et al.
      Bupropion for smokers hospitalized with acute cardiovascular disease.
      Bupropion has been noted to produce an abstinence rate at 6 months of follow-up of 24.2% (95% CI 22.2, 26.4) and an OR of 2.0 (95% CI 1.2, 2.2) when compared with placebo.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.

      Varenicline

      Varenicline (Champix), a partial α4β2 nicotinic acetylcholine receptor agonist, is also effective in smokers with cardiovascular disease.
      • Rigotti N.A.
      • Pipe A.L.
      • Benowitz N.L.
      • Arteaga C.
      • Garza D.
      • Tonstad S.
      Efficacy and safety of varenicline for smoking cessation in patients with cardiovascular disease: a randomized trial.
      By occupying and stimulating the α4β2 nicotinic receptor, this agent initiates the release of dopamine in the forebrain, thereby replicating, although to a lesser degree, the activity of nicotine; the effect is to reproduce sensations produced by smoking, reduce craving and withdrawal, and block the ability of nicotine to occupy the receptor. Varenicline has been shown to produce an estimated abstinence rate of 33.2% (95% CI 28.9, 37.8) at 6 months of follow-up and an OR of 3.1 (95% CI 2.5, 3.8) when compared with placebo.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline.
      All these pharmacotherapies are effective when used appropriately. Their effectiveness is accentuated when accompanied by the provision of strategic, practical advice concerning the settings, circumstances, and situations commonly associated with smoking and the advantages of ensuring support from family and friends.
      • Fiore M.C.
      • Jaen C.R.
      A clinical blueprint to accelerate the elimination of tobacco use.
      • Vidrine J.I.
      • Cofta-Woerpel L.
      • Daza P.
      • Wright K.L.
      • Wetter D.W.
      Smoking cessation 2: behavioral treatments.
      In the primary prevention setting, clinicians can effectively assist smokers by providing advice, counselling, and pharmacotherapies selected on the basis of patient preference and the presence or absence of specific contraindications. For smokers hospitalized with acute CAD, interventions for smoking cessation should commence during the period of hospitalization; those begun during hospitalization in patients with cardiovascular disease are more effective than those initiated thereafter.
      • Wolfenden L.
      • Campbell E.
      • Walsh R.
      • Wiggers J.
      Smoking cessation interventions for in-patients: a selective review with recommendations for hospital-based health professionals.
      Overall, however, it must be recognized that successful smoking cessation often occurs only after several attempts—each of which will contribute to an enhanced likelihood of ultimate cessation.

      Acupuncture, Hypnotherapy, and Related Treatments

      The popularity and often aggressive advertising that surround these interventions notwithstanding, there is little evidence to support their use as effective, fundamental approaches to cessation.
      • White A.R.
      • Rampes H.
      • Campbell J.L.
      Acupuncture and related interventions for smoking cessation.
      • Abbot N.C.
      • Stead L.F.
      • White A.R.
      • Barnes J.
      • Ernst E.
      Hypnotherapy for smoking cessation.
      • Wu T.P.
      • Chen F.P.
      • Liu J.Y.
      • Lin M.H.
      • Hwang S.J.
      A randomized controlled clinical trial of auricular acupuncture in smoking cessation.

      Other Elements of Cessation Treatment

      Innovative approaches for the ongoing follow-up and management of those engaged in smoking-cessation attempts are now available in many forms and in many community settings. They include primary care programs, community cessation resources (eg, Quitlines), and ongoing follow-up that makes use of sophisticated telephone techniques. Smoking cessation is an integral component of any multifactorial cardiac rehabilitation program, and participation in such programs has been associated with important reductions of smoking prevalence.
      • Balady G.J.
      • Williams M.A.
      • Ades P.A.
      • et al.
      AHA/AACVPR Scientific Statement Core components of cardiac rehabilitation/secondary prevention programs: 2007 update.
      In all inpatient settings in which cardiac patients are treated, a systematic approach to the identification, treatment, and follow-up of all smokers should be established. There is clear evidence of the substantial benefits of such programs in reducing readmission and all-cause mortality.
      • Mohiuddin S.M.
      • Mooss A.N.
      • Hunter C.B.
      • Grollmes T.L.
      • Cloutier D.A.
      • Hilleman D.E.
      Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease.
      The “Ottawa Model” of hospital-based smoking cessation is now in place in more than 70 Canadian hospitals and has been demonstrated effective in enhancing rates of smoking cessation in cardiac patients.
      • Reid R.D.
      • Mullen K.A.
      • Slovinec D'Angelo M.E.
      • et al.
      Smoking cessation for hospitalized smokers: an evaluation of the “Ottawa Model.”.
      • Reid R.D.
      • Pipe A.L.
      • Quinlan B.
      Promoting smoking cessation during hospitalization for coronary artery disease.
      Implicit in the introduction of such programs is the need to ensure appropriate training of health professionals in the fundamentals of smoking cessation treatment.
      Smoking cessation should be accorded a priority in the secondary prevention of all forms of cardiac disease.
      • Forrester J.S.
      • Merz C.N.
      • Bush T.L.
      • et al.
      27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events Task Force 4. Efficacy of risk factor management.
      Even in chronic forms of cardiac disease, such as heart failure and persistent ventricular dysfunction, patient management and disease outcomes are enhanced when accompanied by smoking cessation; the clinical benefits of cessation have been noted to equal those of standard pharmaceutical management of diminished ventricular function (ie, β-blockers and renin-angiotensin-aldosterone system inhibitors).
      • Suskin N.
      • Sheth T.
      • Negassa A.
      • Yusuf S.
      Relationship of current and past smoking to mortality and morbidity in patients with left ventricular dysfunction.
      • Suskin N.
      • Pipe A.
      • Prior P.
      Smokers paradox or not in heart failure Just quit.
      It is important for both cardiovascular disease patients and practitioners to note that evidence exists that the benefits of lipid lowering and blood pressure reduction are significantly reduced in those who continue to smoke.
      • Milionis H.J.
      • Rizos E.
      • Mikhailidis D.P.
      Smoking diminishes the beneficial effect of statins: observations from the landmark trials.
      • Journath G.
      • Nilsson P.M.
      • Petersson U.
      • Paradis B.A.
      • Theobald H.
      • Erhardt L.
      Hypertensive smokers have a worse cardiovascular risk profile than non-smokers in spite of treatment: a national study in Sweden.
      • Frey P.
      • Waters D.D.
      • DeMicco D.A.
      • et al.
      Impact of smoking on cardiovascular events in patients with coronary disease receiving contemporary medical therapy (from the Treating to New Targets [TNT] and the Incremental Decrease in End Points through Aggressive Lipid Lowering [IDEAL] Trials).

      Summary

      The management of tobacco addiction and smoking cessation are of critical clinical importance to all cardiovascular specialists. It is important that they take the following steps (see Table 1 also):
      • Introduce a systematic approach to the delivery of smoking cessation interventions in all of their professional settings. Clinical practice guidelines have stressed the importance of system changes to embed treatment for nicotine dependence in institutional policies and practice.
        • Fiore M.C.
        • Jaen C.R.
        A clinical blueprint to accelerate the elimination of tobacco use.
        • Curry S.J.
        • Orleans C.T.
        • Keller P.
        • Fiore M.
        Promoting smoking cessation in the healthcare environment: 10 years later.
        • Orleans C.T.
        • Woolf S.H.
        • Rothemich S.F.
        • Marks J.S.
        • Isham G.J.
        The top priority: building a better system for tobacco-cessation counseling.
        Examples of systems to promote smoking cessation during hospitalization for CAD have recently been described.
        • Reid R.D.
        • Mullen K.A.
        • Slovinec D'Angelo M.E.
        • et al.
        Smoking cessation for hospitalized smokers: an evaluation of the “Ottawa Model.”.
        • Reid R.D.
        • Pipe A.L.
        • Quinlan B.
        Promoting smoking cessation during hospitalization for coronary artery disease.
        • Reid R.D.
        • Mullen K.A.
        • Slovinec D'Angelo M.E.
        • et al.
        Smoking cessation for hospitalized smokers: an evaluation of the “Ottawa Model.”.
      • Identify and document the smoking status of all patients. Clinicians should ask about any tobacco use during the previous 6 months. Doing so will identify both current users and those who may have recently quit and are at increased risk for relapse.
      • Provide clear, concise, unambiguous, and nonjudgemental advice regarding the importance of cessation.
      • Become familiar with the use and prescription of validated smoking-cessation pharmacotherapies (NRT, bupropion, varenicline).
      • Provide clinical leadership to trainees and colleagues in the appropriate management of the tobacco-addicted patient.
      • Advocate for public policies to appropriately control all tobacco products.
      Table 1Smoking cessation: Summary of recommendations for cardiovascular specialists
      Introduce a systematic approach to smoking cessation in all professional settings.
      Become familiar with the principles and practice of smoking cessation, including the use and prescription of validated pharmacotherapies (NRT, bupropion, varenicline).
      Identify and document the smoking status of all patients.
      Provide clear, concise, unambiguous, and nonjudgemental advice regarding the importance of cessation.
      Offer specific assistance in initiating a cessation attempt.
      For hospitalized smokers, commence interventions for smoking cessation during the period of hospitalization and facilitate ongoing follow-up.
      Provide clinical leadership to trainees and colleagues in the appropriate management of the tobacco-addicted patient.
      Advocate for public policies to appropriately control all tobacco products.

      Acknowledgements

      This position statement was presented at the Annual Conference of the Canadian Cardiovascular Society in Montreal in October 2010. The authors (the “Primary Panel”) gratefully acknowledge the contributions provided by members of the “Secondary Panel” who carefully reviewed the position statement prior to its presentation to the Canadian Cardiovascular Society: Sandeep Aggarwal, MD; Michael Baird, MD; Jeffrey Burton, MD; Gilles Dagenais, MD; Anthony Graham, MD; Paul Hendry, MD; Lyall Higginson, MD; Eldon Smith, MD; Stuart Smith, MD; Rob Stevenson, MD; Guy Tremblay, MD; and Andy Wielgosz, MD.

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