Cigarette Smoking, Cardiovascular Disease, and Stroke
A Statement for Healthcare Professionals From the American Heart Association
Ira S. Ockene, MD; Nancy Houston Miller, RN, For the American Heart Association Task Force on Risk Reduction
As many as 30% of all coronary heart disease (CHD) deaths in the United States each year are attributable to cigarette smoking, with the risk being strongly dose-related.1,2 Smoking also nearly doubles the risk of ischemic stroke.3 Smoking acts synergistically with other risk factors, substantially increasing the risk of CHD.4 Smokers are also at increased risk for peripheral vascular disease, cancer, chronic lung disease, and many other chronic diseases. Cigarette smoking is the single most alterable risk factor contributing to premature morbidity and mortality in the United States, accounting for approximately 430 000 deaths annually.5
Numerous prospective investigations have demonstrated a substantial decrease in CHD mortality for former smokers compared with continuing smokers.6 This diminution in risk occurs relatively soon after cessation of smoking, and increasing intervals since the last cigarette smoked are associated with progressively lower mortality rates from CHD.7 Similar rapid decreases in risk with smoking cessation are also seen for ischemic stroke.8,9 Benefits from quitting are seen in former smokers even after many years of heavy smoking.2 Investigations also have demonstrated benefits from cessation for smokers who have already developed smoking-related diseases or symptoms. Persons with diagnosed CHD experience as much as a 50% reduction in risk of reinfarction, sudden cardiac death, and total mortality if they quit smoking after the initial infarction.10,11 Furthermore, the patient who has recently developed a clinical illness is very motivated to change, and several studies have shown that intervention in this "teachable moment" can be very effective. Thus, the provision of smoking cessation advice is associated with a 50% long-term (more than 1 year) smoking cessation rate in patients who have been hospitalized with a coronary event, and even modest telephone-based counseling can increase this percentage to >=70% in a particularly cost-effective manner.12,13
The pathophysiology of smoking, the evidence linking smoking to disease, and the value of smoking cessation have been extensively documented in other AHA scientific statements.14-16 At present every healthcare professional is aware of the hazards of cigarette smoking. Recently the Agency for Health Care Policy and Research produced a comprehensive monograph on smoking cessation, and readers are referred to that and other cited publications for full background information and extensive discussion of intervention methods.17 This advisory emphasizes the value of smoking cessation intervention by healthcare professionals and outlines methods found to be of value (Table 1).
Although not separately discussed, these methods are also applicable to younger smokers. The specific problem of cigarette smoking by children is more fully discussed elsewhere.18
The literature continues to document the failure of physicians and other healthcare professionals to intervene with all of their patients who smoke, with only half of current smokers reporting having been encouraged to quit and even fewer receiving specific counseling.19 Why is this, given the known hazards of smoking and the amply demonstrated benefits of cessation? Physicians report the following barriers to providing smoking interventions: a belief that they are not effective; poor intervention skills; a belief that patients do not want their physicians to intervene; and little time to fit intervention into their practice, especially when reimbursement for these services is not provided.20 Each of these barriers can be overcome, as discussed below.
Effectiveness of Physician Intervention
Healthcare settings provide an important teachable moment for smoking cessation intervention. Seventy-five percent of the adult population visit a physician at least once a year, with the average adult making five visits per year. In the physician's office, patients are often conscious of their health and most receptive to risk factor intervention, providing an important opportunity for change.21 A number of studies have documented that physician-delivered counseling interventions for smoking cessation can be effective. However, these studies have also documented that two factors are especially important: the physician (or other healthcare professional) should receive skill-building training in counseling methods, and an office system that facilitates delivery of such counseling and enhances its effect must be in place.22-24 With such training and support, more intensive interventions produce a greater effect. In general, physician-based primary-care interventions have yielded cessation rates of 10% to 20%, a threefold to fivefold increase over the 1-year maintained cessation rate of 4% seen in the general population.17
Smokers clearly value their provider's advice and counsel, believing that it is helpful in their efforts to quit smoking. Furthermore, they see the provision of such counsel as an indicator of caring on the part of the provider, and they appreciate it even if they do not intend to quit.24 Advice alone, taking no more than a few minutes, is of value.23 As a minimum, this should include the elements listed in Table 2. For the healthcare professional who is interested and willing to do more, a patient-centered approach in which the patient is an equal partner is optimal (Table 3). Such an approach helps smokers gain confidence in their ability to quit. Training for such an approach has been incorporated into many educational programs and is available through professional organizations such as the American Heart Association. The patient-centered approach also can be used by simply following the steps outlined in Table 3. Such an intervention process can be adapted to any time frame but optimally takes 5 to 10 minutes.25
Smoking Cessation Pharmacotherapy
Although various pharmacological agents have been used in the past to aid smokers, nicotine replacement therapy has been shown to be effective and should be available in all smoking cessation programs.26,27 Transdermal nicotine has been shown to be safe even for patients with known CHD.28 Both nicotine-containing gum and the transdermal nicotine patch are now available over the counter and are widely advertised. Although both are efficacious, in general the patch is preferable for routine clinical use, although gum may be preferable in certain clinical situations (eg, some persons prefer the oral stimulation that the gum provides). In addition, a nicotine nasal spray is now available by prescription, and a nicotine inhaler is likely to be available soon.29 Suggestions for using the nicotine patch, the most popular form of nicotine replacement therapy, are provided in Table 4. There is little evidence available on the value of nicotine replacement therapy in light smokers (<15 cigarettes per day); in these patients, assessment of nicotine dependency (time to first cigarette, difficulty abstaining when smoking is not permitted, length of longest prior abstinence period) may be of value, and beginning therapy with a lower dose is appropriate.
When dealing with a preventive intervention such as smoking in a busy practice setting, a properly configured office support system can effectively cue the physician to carry out the appropriate intervention. Of major importance are the use of reminders, provision of counseling and treatment algorithms, and staff support for necessary follow-up, education, behavioral change, and monitoring.30,31 The critical elements of such systems are summarized in Table 5.
The person who smokes often has one or more additional risk factors: there is substantial evidence for risk factor clustering, and the smoker is more likely than the nonsmoker to also have elevated lipids and hypertension.32 Thus, smoking is often only one of several risk factors that must be addressed simultaneously. Patient-centered counseling methodology is as applicable to counseling for diet change or exercise as it is to smoking. Specific multicomponent programs have been developed for treatment of these patients, especially those who have already experienced a coronary event. For these patients, it has proved easier to justify the resources necessary for such a program. The program developed by Debusk and colleagues13 demonstrated favorable effects on smoking, lipids, and exercise in patients who had suffered a myocardial infarction, with an increase in 1-year smoking cessation rates from 53% to 70%. In this program trained nurse case managers follow computer-generated treatment algorithms. The program is extensively telephone-based.
Although the physician's office has often been the entryway to smoking cessation, the hospital setting may motivate some patients to quit smoking. During acute illness, patients focus on their health. In addition, smoking bans prevent them from continuing their habit; thus, they encounter the worst part of withdrawal during this period of enforced cessation. As in the office setting, systems that identify the smoking status of all patients and provide for strong advice by physicians and other healthcare professionals in addition to counseling and/or self-help materials have been shown to be efficacious in hospitalized patients.33-35
There is overwhelming evidence demonstrating both the cardiovascular hazards of smoking and the prompt benefit that occurs with smoking cessation. The provision of advice alone significantly increases the smoking cessation rate, and even minimal counseling yields a further benefit. Intervention with patients who have already suffered a cardiac event yields particularly striking benefits. The smoking status of all patients should be assessed and appropriate intervention offered to those who smoke. Physicians should be trained in counseling techniques and the use of nicotine replacement therapy. The importance of ensuring the delivery of smoking cessation counseling was recognized when smoking counseling assessments were incorporated into version 3 of HEDIS, the Health Plan Employer Data Information Set of the National Committee for Quality Assurance.36 Equally important components of appropriate medical care are development of supportive office systems and multicomponent intervention programs and links with smoking cessation specialists and community resources. The universal application of these modalities will contribute to the continued decline of smoking and subsequent CHD events in the United States.
- US Dept of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1989. DHHS Publication (CDC) 89-8411.
- US Dept of Health and Human Services. The Health Benefits of Smoking Cessation. A Report of the Surgeon General. USDHHS, Centers for Disease Control. Office of Smoking and Health; 1990. DHHS Publication (CDC) 90-8416.
- Shinton R, Beevers G. Meta-analysis of relation between cigarette smoking and stroke. BMJ. 1989;298:789-794.
- Anderson KM, Wilson PW, Odell PM, Kannel WD. An updated coronary risk profile: a statement for health professionals. Circulation. 1991;83:356-362.
- Nelson DE, Kirkendall RS, Lawton RL, Chrismon JH, Merritt RK, Arday, DA, Giovino GA. Surveillance for smoking-attributable mortality and years of potential life lost; by state--United States, 1990. MMWR CDC. 1994;43: 1-8.
- Gordon T, Kannel WB, McGee D, Dawber TR. Death and coronary attacks in men after giving up cigarette smoking: a report from the Framingham Study. Lancet. 1974;2:1345-1348.
- Ockene JK, Kuller LH, Svendsen KH, Meilahn E. The relationship of smoking cessation to coronary heart disease and lung cancer in the Multiple Risk Factor Intervention Trial (MRFIT). Am J Public Health. 1990;80:954-958.
- Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger AJ. Cigarette smoking as a risk factor for stroke: the Framingham study. JAMA. 1988;259:1025-1029.
- Kawachi I, Colditz GA, Stampfer MJ, Willett WC, Mason JE, Rosner B Speizer FE, Hennekens CH. Smoking cessation and decreased risk of stroke in women. JAMA. 1993;269:232-236.
- Sparrow D, Dawber TR. The influence of cigarette smoking on prognosis after a first myocardial infarction: a report from the Framingham Study. J Chronic Dis. 1978;31:425-432.
- Salonen JT. Stopping smoking and long-term mortality after acute myocardial infarction. Br Heart J. 1980;43:463-469.
- Ockene J, Kristeller JL, Goldberg R, Ockene I, Merriam P, Barrett S, Pekow P, Hosmer D, Gianelly R. Smoking cessation and severity of disease: the Coronary Artery Smoking Intervention Study. Health Psychol. 1992;11:119-126.
- Debusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE III, Heller RS, Rompf J, Gee D. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721-729.
- Holbrook JH, Grundy SM, Hennekens CH, Kannell, WB, Strong JP. Cigarette smoking and cardiovascular diseases: a statement for health professionals by a task force appointed by the steering committee of the American Heart Association. Circulation. 1984;70:1114A-1117A.
- Jonas MA, Oates JA, Ockene JK, Hennekens CH. Statement on smoking and cardiovascular disease for healthcare professionals: American Heart Association. Circulation. 1992;86:1664-1669.
- Helgason CM, Wolf PA. American Heart Association Prevention Conference IV: Prevention and Rehabilitation of Stroke. Executive summary. Circulation. 1997;96:701-707.
- Fiore MC, Bailey WC, Cohen SJ, et al. Smoking cessation. Clinical Practice Guideline No 18. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. AHCPR Publication 96-0692.
- Strong WB, Deckelbaum RJ, Gidding SS, Kavey RE, Washington R, Wilmore JH, Perry CL. Integrated cardiovascular health promotion in childhood: a statement for health professionals from the Subcommittee on Atherosclerosis and Hypertension in Childhood of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 1992;85:1638-1650.
- Frank E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians' smoking cessation advice. JAMA. 1991;266:3139-3144.
- Pearson TA, McBride PE, Miller NH, Smith SC. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary events: task force 8: organization of preventive cardiology service. J Am Coll Cardiol. 1996;27:1039-1047.
- Ockene JK. Smoking intervention: the expanding role of the physician. Am J Public Health. 1987;77:782-783. Editorial.
- Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA. 1988;259:2883-2889.
- Cohen SJ, Stookey GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit: a randomized controlled trial. Ann Intern Med. 1989;110:648-652.
- Ockene JK, Kristeller J, Goldberg R, Amick TL, Pekow PS, Hosmer D, Quirk M, Kuplan K. Increasing the efficacy of physician-delivered smoking intervention: a randomized clinical trial. J Gen Intern Med. 1991;6:1-8.
- Ockene JK, Ockene IS, Kabat-Zinn J, Greene HL, Frid D. Teaching risk factor counseling skills to medical students, house staff, and fellows. Am J Prev Med. 1990;6(suppl2):35-42.
- Fiore MC, Smith SS, Jorenby DE, Baker TB. The effectiveness of the nicotine patch for smoking cessation: a meta-analysis. JAMA. 1994;271:1940-1947.
- Tang JL, Law M, Wald N. How effective is nicotine replacement therapy in helping people to stop smoking? Br Med J. 1994;308:21-26.
- Joseph AM, Norman SM, Ferry LH, Prochazka AV, Westman EC, Steele BG, Sherman SE, Cleveland M, Antonnucio DO, Hartman N, McGovern PG. The safety of transdermal nicotine as an aid to smoking cessation in patients with cardiac disease. N Engl J Med. 1996;335:1792-1798.
- Hjalmarson A, Franzon M, Westin A, Wiklund O. Effect of nicotine nasal spray on smoking cessation: a randomized, placebo-controlled, double-blind study. Arch Intern Med. 1994;154:2567-2572.
- Solberg LI, Kottke TE, Brekke ML. The prevention-oriented practice. In: Ockene IS, Ockene JK, eds. Prevention of Coronary Heart Disease. Boston, Mass: Little Brown & Co; 1992.
- Belcher DW, Berg AO, Inui TS. Practical approaches to providing better preventive care: are physicians a problem or a solution? In: Battista RN, Lawrence RS, eds. Implementing Preventive Services. New York, NY: Oxford; 1988:27-48.
- Luria MH, Erel J, Sapoznikov D, Gotsman MD. Cardiovascular risk factor clustering and ratio of total cholesterol to high-density lipoprotein cholesterol in angiographically documented coronary artery disease. Am J Cardiol. 1991;67:31-36.
- Stevens VJ, Glasgow RE, Hollis JF, Lichtenstein E, Vogt TM. A smoking-cessation intervention for hospital patients. Med Care. 1993;31:65-72.
- Taylor CB, Miller NH, Herman S, Smith PM, Sobel DS, Fisher L, DeBusk RF. A nurse-managed smoking cessation program for hospitalized smokers. Am J Public Health. 1996;86:1557-1560.
- Miller NH, Smith PM, DeBusk RF, Sobel DS, Taylor CB. Smoking cessation in hospitalized patients: results of a randomized trial. Arch Intern Med 1997;157:409-415.
- Hanchak NA. Managed care, accountability, and the physician. Med Clin North Am. 1996;80:245-261.
"Cigarette Smoking, Cardiovascular Disease, and Stroke" was approved by the American Heart Association Science Advisory and Coordinating Committee in April 1997.
A single reprint is available after November 11, 1997 by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71-0128.
© 1997 American Heart Association, Inc.
© 1998 American Heart
Association, Inc. All rights reserved. Unauthorized use prohibited.
The information contained in this American Heart Association (AHA) Web site is not a substitute for medical advice or treatment, and the AHA recommends consultation with your doctor or health care professional.