ACC 2018 Expert Consensus Guidance on Tobacco Cessation
Comprehensive tobacco cessation treatment is a critical component of the clinical care for individuals with or at risk for cardiovascular diseases. The consistent delivery of tobacco cessation treatment remains a significant challenge for healthcare providers. A recently released Expert Consensus Decision Pathway (ECDP) by ACC (American College of Cardiology) provides a structured approach to evaluating and treating tobacco dependence and offers practical guidance for overcoming challenges commonly encountered in the clinical setting.
The Decision Pathway recommends that clinicians and practices establish a team-based system of care that recognizes cigarette smoking as a chronic relapsing substance use disorder caused by addiction to nicotine. The guidance document has been published recently in the Journal of the American College of Cardiology.
Pathway for Tobacco Cessation Treatment
Some important definitions
• Tobacco (or nicotine) dependence: An individual’s perception of the need to smoke characterized by difficulty reducing and/or refraining from smoking for extended periods of time, continued use despite knowledge of harm, and, for most daily smokers, nicotine withdrawal symptoms that develop when chronic exposure to nicotine in tobacco products ends.
• Current smoker: As defined in the National Health Interview Survey (NHIS), a person who reports currently smoking tobacco every day (i.e., daily smoker) or on some days (nondaily smoker). NHIS also requires a current smoker to have smoked at least 100 cigarettes (5 packs) in his or her lifetime.
• Former smoker: As defined in NHIS, a person who does not currently smoke tobacco but has smoked at least 100 cigarettes in his or her lifetime. Because relapse to smoking occurs frequently after quitting, long-term abstinence is often operationally defined as 6 months of abstinence. Abstinence from smoking for at least 7 days in a row is the criterion often required in clinical studies for an individual to be considered a former smoker in the short-term.
• Never smoker: A person who has not smoked tobacco regularly and does not now smoke every day or some days. NHIS defines never smoker as an individual who has not smoked 100 cigarettes (5 packs) in his or her lifetime.
• Nonsmoker: A person who is currently either a former or never tobacco smoker.
• Combustible tobacco products: Products that burn tobacco, producing smoke that users inhale (e.g., cigarettes, cigars, cigarillos, pipe tobacco, hookah). Inhaling smoke exposes the user to a much larger spectrum of harmful chemicals and conveys a much greater risk to CV and overall health than does the use of noncombustible tobacco products (e.g., snuff, chew, dip). However, no tobacco product use is risk-free.
• Alternative tobacco products: Newer nicotine delivery products that differ from conventional combustible and noncombustible tobacco products. This category encompasses electronic nicotine delivery devices, including electronic cigarettes and heat-not-burn (HNB) tobacco products.
• Electronic cigarettes (e-cigarettes): Battery-operated devices that heat a liquid containing nicotine, propylene glycol, and/or vegetable glycerin and flavorant chemicals to generate an aerosol that the user inhales. Because e-cigarettes do not burn tobacco, they do not produce tobacco smoke.
• HNB tobacco products (also called heated tobacco products): A category of tobacco products that heats tobacco to a lower temperature than required for combustion. The result is an aerosol (but not smoke) that the user inhales.
Questions to Assess a Smoker’s Degree of Nicotine Dependence
How many cigarettes do you smoke?
0: 10 or fewer
3: ≥ 31
How soon after waking up do you smoke your first cigarette of the day?
0: After 60 minutes
1: 31–60 minutes
2: 6–30 minutes
3: within 5 minutes
Level of nicotine dependence is computed by adding the scores together as follows:
0-2 = low nicotine dependence
3-4 = moderate nicotine dependence
5- 6 = high nicotine dependence
Algorithm for a Former Smoker SHS = secondhand smoke
Simplified Workflow to Address Smoking Cessation in the Outpatient Cardiology Care Setting
The following are key points to remember:-
• An estimated 6 million deaths each year are attributable to tobacco use. In particular, cigarette smoking carries the highest risk for CVD events.
• Those who do not smoke but are exposed to second-hand smoke are at a 25-30% increased risk for CVD events, which translates into an estimated 33,000 deaths from heart disease each year. Smoke-free policies have reduced exposure to second-hand smoking in public areas; however, most of the second-hand smoking exposure is in the home. Providers are recommended to assess nonsmoking patients for exposure to second-hand smoke.
• All smokers, regardless of duration and intensity of smoking, can benefit from smoking cessation. No one is too old to not benefit from quitting. Even those with established CVD can experience health benefits associated with smoking cessation.
• Providers are key to assisting patients who smoke to quit. They should ask all patients about tobacco use, advise smokers to quit, assess a smoker’s readiness to quit, and assist smokers to quit. Hospitals are recommended to assess smoking status in all admitted patients, offer treatment to hospitalized smokers, and provide treatment at time of discharge.
• Current evidence suggests the combination of pharmacotherapy (i.e., nicotine replacement, bupropion, and varenicline) with behavioral interventions (i.e., cognitive behavior therapy, motivational interviewing) are most effective for smoking cessation. Tobacco cessation programs are cost-effective. E-cigarettes may reduce cigarette smoking among current smokers; however, the long-term risk of e-cigarettes is not known. Ultimately, cessation of all combustible tobacco products is recommended.
The American College of Cardiology is a 52,000-member medical society that is the professional home for the entire cardiovascular care team. The mission of the College is to transform cardiovascular care and to improve heart health.
Note: This list is a brief compilation of some of the key recommendations included in the Guideline and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/7GmKD