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Tobacco Cessation

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Smoking Cessation: Why it’s important to help decrease the risk of primary cardiovascular disease.
Shannon Donovan, FNP-BC, CHFN

Tobacco use is the leading preventable cause of disease, disability, and death in the United States.Smoking and smokeless tobacco (eg, chewing tobacco) use increases the risk of all-cause mortality and is a cause of ASCVD. Secondhand smoke is a cause of ASCVD and stroke, and almost one-third of CHD deaths are attributable to smoking and exposure to secondhand smoke. Reducing the number of cigarettes per day does not totally eliminate risk, because even low levels of smoking increase risks of acute MI. Electronic Nicotine Delivery Systems (ENDS), often called e-cigarettes, are a new class of tobacco product that emit aerosol containing fine and ultrafine particulates, nicotine, and toxic gases that may increase risk of cardiovascular and pulmonary diseases. Arrhythmias and hypertension with e-cigarette use have also been reported. Chronic use of ENDS is associated with persistent increases in oxidative stress and sympathetic stimulation in young, healthy subjects. Also, ENDS are not recommended as a tobacco treatment method. The evidence on the use of ENDS as a smoking-cessation tool in adults (including pregnant women) and adolescents is insufficient or limited. It is recommended that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety.

All adults should be assessed at every visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit on every visit. Adding tobacco use status as a vital sign and recording tobacco use status (eg, current, former, never) in the health record at every healthcare visit not only increases the rate of tobacco treatment but also improves tobacco abstinence. When assessing tobacco use status, it is important to use multiple questions to assess tobacco use status to improve the accuracy of reporting and disclosure. Questions a provider should ask include: “Have you smoked any tobacco product in the past 30 days, even a puff?” “Have you vaped or ‘juuled’ in the past 30 days, even a puff” or “Have you used any other tobacco product in the last 30 days?”. If answered yes, the patient is considered a current smoker. When patients are asked the questions “Are you a smoker?” or “Do you smoke?” they are less likely to report tobacco use, especially products that are not cigarettes or cigars, like smokeless tobacco and even e-cigarettes.

Tobacco users are more likely to quit after 6 months when clinicians strongly recommend adults to quit using tobacco. It is important to use language that is clear and strong, yet compassionate, non judgemental and personalized to urge every tobacco user to quit. Statements like “The most important thing you can do for your health is to quit tobacco use. I (we) can help and the ASCVD benefits of quitting are immediate.” The risk of heart failure and death for most former smokers, even among older adults, is similar to that of those that never smoke after >15 years of tobacco cessation. Tobacco use dependence should be considered a chronic disease that requires highly skilled chronic disease management. Referral to specialists is helpful for both behavioral modification, nicotine replacement,and drug treatments. Amongst the treatments include varieties of nicotine replacement, the nicotine receptor blocker varenicline, and bupropion, an antidepressant. See the following table for recommended behavioral and pharmacotherapy modalities. Resource for a list of accredited Tobacco Treatment Specialist programs is available here: http://ctttp.org/accredited-programs.

Reference: Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA guideline
on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678

Table 8. Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers *

Timing of Behavioral Interventions
<3 min of tobacco status assessment with cessation counseling at each clinic encounter	>3-10 min of tobacco status assessment with cessation counseling at each clinic encounter		> 10 min of tobacco status assessment with cessation counseling at each clinic encounter
Treatment	Dosing:‡		Precautions
NRT*
Patch	21 mg, 14 mg, or 7 mg	Starting dose: 21 mg for ≥ 10 CPD; 14 mg for <10 CPD	Local irritation possible; avoid with skin disorders; may remove for sleep if needed
Gum	2 mg or 4 mg	Starting dose: 4 mg if first tobacco use is ≤ 30 min 2 mg if first tobacco use is after use >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d. Chew and park gum*	Hiccups/dyspepsia possible; avoid food or beverages 15 min before and after use
Lozenge	2 mg or 4 mg
Nasal spray	10 mg/ml	Starting dose: 1-2 doses/h (1 dose= 1 spray each nostril); maximum of 40 doses/d	Local irritation possible; avoid with nasal or reactive airway disorders
Oral inhaler	10-mg cartridge	Starting dose: Puff for 20 min/cartridge every 1-2 h; maximum 16 cartridges/d	Cough possible; avoid with reactive airway disorders
Other§
Bupropion (Zyban [GlaxoSmithKline], Wellbutrin SR [GlaxoSmithKlin])	150mg SR	150 mg once daily (am) for 3 d; then 150 mg twice daily; may use in combination with NRT^54.5-21	Avoid with history/risk of seizures, eating disorders, MAO inhibitors, or CYP 2D6 inhibitor
Varenicline (Chantix [Pfizer])	0.5 mg or 1 mg	0. 5 mg once daily (am) for 3 d; then 0. 5 mg twice daily for 4 d; then 1 mg twice daily (use start pack followed by continuation pack) for 3-6 mo	Nausea common; take with food. Renal dosing required. Very limited drug interactions; near-exclusive renal clearance.

*CPD can guide dosing. 1 CPD is kl -2 mg of nicotine. Note. Use caution with all NRT products for patients with recent (≤2 wk) Ml, serious arrhythmia, or angina; patients who are pregnant or breastfeeding; and adolescents.
†Timing of assessment relates to ICD-10 coding.
‡Dose and duration can be titrated on the basis of response^54.5-21
§ The FDA has issued a remova l of black box warnings about neuropsychiatric events.^{54.5-20,54.5-21}
am indicates morning; CPD, cigarettes smoked per day; FDA, US Food and Drug Administration; ICD-10, International Oassification of Diseases, Tenth Revision; MAO, monoamine oxidase; NRT, nicotine replacement; and SR, sustained release.

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Tobacco Cessation