Elsevier

Canadian Journal of Cardiology

Volume 27, Issue 2, March–April 2011, Pages 132-137
Canadian Journal of Cardiology

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

https://doi.org/10.1016/j.cjca.2010.12.060Get rights and content

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.

Section snippets

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.”18 Evidence continues to accumulate, however,

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.4, 36, 37 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

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

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.51, 52, 53

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

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.26, 59, 60 Examples

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,

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    This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

    The disclosure information of the authors and reviewers is available from the CCS on the following websites:www.ccs.caand www.ccsguidelineprograms.ca.

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