The American College of Cardiology (ACC) has published an Expert Consensus Decision Pathway to provide guidance to clinicians treating patients with cardiovascular disease (CVD) who are also smokers.
Tobacco use is responsible for over 6 million deaths annually; more than 30 million adults in the United States smoked in 2017. According to the ACC, tobacco use can be characterized as a “chronic relapsing substance use disorder,” encouraged by nicotine addiction. It is noted that most smokers who attempt to quit experience “repeated cycles of abstinence followed by relapse to smoking” prior to experiencing long-term abstinence.
In early 2017, the Prevention of Cardiovascular Disease Leadership Council assembled with Tobacco Cessation Think Tank in an effort to bring together expert clinicians, stakeholders, and members of federal agencies to address the ongoing risks of exposure to tobacco and nicotine. The Think Tank identified a need for expert consensus guidance to provide “comprehensive smoking cessation strategies.”
Authors of the pathway suggest that clinicians should ask all patients about smoking and tobacco use at every office visit, extending beyond cigarette smoking and asking about the use of cigars, hookah, smokeless tobacco, and electronic cigarettes. Patients’ exposure to secondhand smoke should also be assessed, since regular secondhand smoke exposure increases the risk of CVD in nonsmokers.
The pathway includes 4 actions that clinicians should take when treating a current smoker: 1) assessment; 2) advice to quit; 3) offer and provide treatment; 4) follow-up.
Assessment of Nicotine Dependence: The strength of a person’s nicotine dependence is key in predicting the likelihood of relapse after smoking cessation. Simple screens can be used to determine the strength of addiction, and virtually all patients with nicotine dependence will likely benefit from both pharmacological and behavioral smoking cessation treatments. Clinicians should pose the 2 questions in the Heaviness of Smoking Index (“How may cigarettes do you smoke?” and “How soon after waking up do you smoke your first cigarette of the day?”) to assess the strength of a patient’s nicotine dependence.
Advice to Quit: Provide “strong, clear, personalized advice” to patients advising them to cease all tobacco use as soon as possible. Advice should be tailored to patients’ individual health situations and should emphasize the benefits of smoking cessation, including “financial savings, health benefits, behavioral control, [and] setting an example for others.”
Offer Treatment and Connect to Resources: Offer patients a prescription for pharmacotherapy, and connect patients with behavioral support resources. Encourage patients to set a quit date within the next month. Pharmacotherapy should be started in all patients, even those who may not quit smoking immediately. Referral to behavioral support is more effective than only providing information
Follow-up: Risk of relapse is highest during the first few days and weeks after smoking cessation. Clinicians should follow up with patients to monitor treatment progress within 2 to 4 weeks of the patients quitting attempt. Close monitoring shows patients that their clinician has made smoking cessation a high priority, and can encourage patients to sustain their efforts to quit.
“The effective provision of smoking cessation support to patients requires a team approach,” the committee wrote. “There may be multiple pathways that can be taken for treatment decisions, and the goal is to help clinicians and patients make a more informed decision together.”
To read the complete decision pathway, please visit the Journal of the American College of Cardiology online.
Barua RS, Rigotti NA, Benowitz NL, et al; for the Task Force on Expert Consensus Decision Pathways. 2018 ACC expert consensus decision pathway on tobacco cessation treatment [published online December 5, 2018]. J Am Col Cardiol. doi:10.1016/j.jacc.2018.10.027