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Cardiovasculaer Health & Tobacco Use Time Tool
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A Resource from the American College of Preventive Medicine

ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Cardiovascular Health and Tobacco Use Clinical Reference for more information.

Cardiovascular Health and Tobacco Use
Making Cessation a Priority for Every User

Smoking tobacco is clearly the most important preventable cause of cardiovascular disease; the evidence is overwhelming:

  • 2 to 4-fold increase in risk of developing coronary heart disease (CHD), a 2-3 fold increase in risk of dying from CHD; biggest underlying cause of sudden cardiac death.
  • Doubling the risk for stroke.
  • A 7 to 10-fold increase in risk of developing peripheral vascular disease (PVD).
  • 2 to 9-fold increase in risk for abdominal aortic aneurysm (AAA).
  • 14 years shorter lifespan; half who do not quit by middle age die of tobacco-related disease.
  • Accelerated progression of disease, poorer treatment outcomes, more surgical complications, and a greater disease burden before death.

And … growing evidence that second hand smoke increases cardiovascular risk for nonsmokers much more than previously thought.

The Good News
We are gaining a better understanding of why people smoke and how to help them change their smoking behavior. We know what strategies work best. And we have better tools and guidelines to assist the process.

  • Most smokers want to quit; most believe it is important for them to quit.
  • 2 out of 3 see their physician at least once a year; they look to their doctor for guidance, and are far more likely to try to quit when their doctor advises them to.
Smoking cessation treatments are safe, effective and cost effective.
  • Even brief interventions improve success rates, but more intensive are better.
  • Combinations of medications and counseling are most effective.

The best news for smokers is that quitting swiftly and profoundly reduces their risk of a cardiovascular event – nearly to that of a nonsmoker in about three years.

The Reality
Powerful forces keep people smoking. The repetitive nature makes it habitual. It is soothing for some, pleasurable for others. It relieves stress for many.

Nicotine is extremely addictive, which makes it a very difficult habit to break.

  • 4 out of 5 smokers have tried to quit, 1 in 3 will try again this year, most on their own "cold turkey”. But only 3 to 5 of every 100 who try to quit on their own are successful.
  • Most smokers who relapse see themselves as failures, not realizing that it takes most smokers 5 to 7 attempts to be successful.
  • Few receive optimal combination therapy – both counseling and medication.
  • They do not realize that success is much more likely if they use this approach.
And, relatively few physicians offer comprehensive cessation protocols to their smoking patients, even those at high risk for a cardiovascular event.
  • Most (86%) ask about tobacco use and advise quitting, but relatively few go beyond this.
  • Fewer than 1 in 3 recommend nicotine replacement or other medications (varenicline and bupropion), OR discuss counseling options OR the need for support.
  • Fewer than 1 in 4 provide self help materials, referrals, or follow-up.
Physician Barriers to Overcome
  • Feelings of ineffectiveness because of low success rates in quitting.
  • Perception that smokers lack motivation.
  • Underestimation of the power of their advice and support.
  • Inadequate resources and referral networks.
  • Lack of time to counsel, and that it is not reimbursable.
  • Lack the personal confidence to provide the interventions.
    • 1 in 3 not confident assessing willingness to quit;
    • Half not confident motivating smokers to quit;
    • 1 in 4 not confident discussing treatment options or prescribing medications;
    • 2 of 3 not confident monitoring progress, or making referrals.
  • Need to re-engineer practice to provide protocols led by nurses and assistants.
    • Only 1 in 10 have trained staff; 2 in 5 have a referral system; only half refer patients to group programs.
    • 3 out of 5 not familiar with quitlines; 3 of 4 not familiar with on-line programs; only 1 in 5 ever refer patients to a quitline.
    • 1 in 3 not aware that insurance often pays for cessation counseling; only 1 in 4 usually monitor patients trying to quit; 1 in 10 never do.

The Challenge for Primary Care
1) Make tobacco dependence treatment a top priority for every user, and
2) Deliver effective interventions that give every user the best chance of success.

The Solutions
Comprehensive Approach to Cardiovascular Health:

  • Systematic assessment, education, behavior change counseling, treatment and follow-up of all risk factors using lifestyle change as the foundation, medications as needed.
Systematic Tobacco Dependence Protocol:
  • Apply principles of chronic care to smoking, with relapses part of the process, used to focus counseling and other interventions.
  • Use as intensive an approach as possible – medications, counseling, support, follow-up.
  • Follow the Public Health Service Clinical Practice Guideline strategies for organizing the practice and directing the interventions:
    1. Set up office systems to identify, document and code tobacco use and insurance coverage for smoking cessation for all patients.
    2. Develop a protocol for managing tobacco dependence – using the 5A construct (Ask, Advise, Assess, Assist and Arrange):
      • Every visit: Ask about use, Advise to quit, Assess readiness to quit
      • If ready, Assist with quit plan, Arrange follow-up
    3. Establish a practice team for documenting, counseling and follow-up; obtain necessary training for staff; develop group classes.
    4. Urge the patient to call 1-800-QUIT NOW begin_of_the_skype_highlighting1-800-QUIT NOWend_of_the_skype_highlighting, the national tobacco cessation quitline
    5. Establish a referral network to supplement in-office options.
    6. Provide educational and motivational information.
The Physician Role:
  • Advise quitting, assess readiness to quit, offer support including medications if needed, and refer to staff or outside resource for education, counseling, and quit plan.


Pre-Consult – Medical Assistant or Nurse
ASK about smoking status (current, former, never); document with other vital signs in the medical record [Sample Form]

Consult – All current tobacco users (Physician, Physician Assistant or Nurse Practitioner)

  1. ADVISE all tobacco users to quit in clear, strong, and personalized language. For example: "Quitting tobacco is the most important thing you can do for your health."
    • Make it personal – relate it to cardiovascular risk; emphasize all risk factors but for smokers, smoking cessation is easily the top priority.
    • Emphasize the benefits of quitting, the harms of second hand smoke, the power of the addiction, the effectiveness of an intense multi-faceted approach.

  2. ASSESS readiness to quit tobacco: Ask every tobacco user if he/she is willing to quit at this time.
    • If not willing to try to quit at this time: Focus on motivating the patient to think about quitting.
      • Acknowledge that they are not ready to quit.
      • Identify reasons to quit; stress benefits for personal health.
      • Ask them to learn more about the health effects of smoking – self and family.
      • Consider how smoking fits into their life and values – now and for the future.
      • Consider what would make them quit, barriers they would get in the way.
      • Suggest small changes – cutting back, delaying smoking when the urge hits.
    • If willing to try to quit: proceed with quit plan.

  3. ASSIST with quit plan – in-office comprehensive protocol OR brief counseling with a medication recommendation, followed by referral to an outside resource
    • Comprehensive office protocol:
      • Behavioral counseling (staff) – 1) reasons for quitting, 2) review past attempts and relapses, 3) set quit date, 4) coping with urges, 5) environmental changes, 6) getting support, 7) medications for heavy smokers -- willingness to use
      • Physician review -- overall plan; consider first line medications -- OTC nicotine patch, gum or lozenge OR prescribe varenicline, bupropion SR, nicotine inhaler, or nasal spray OR combination
    • Brief Intervention and referral:
      • Brief message on importance of quitting; discuss medication options
      • Recommend the quitline – 1-800-QUIT NOW begin_of_the_skype_highlighting1-800-QUIT NOWend_of_the_skype_highlighting or On-line program
      • Refer to local program, tobacco treatment specialist, addiction therapist, etc.

  4. ARRANGE follow-up
    • Phone call within first week of quit date – assess how it’s going, including urges, coping, obstacles, environment, support, medication if using.
    • Establish ongoing phone support, visit schedule (more frequent better than less frequent)
    • If using medication, follow-up on safety issues in about 2 weeks (esp regarding bupropion and varenicline black box warnings for behavioral/mental health effects)
    • Anticipate relapses – causes, learning experiences, encourage repeat attempt

A Final Thought
There is no clinical treatment available today that can reduce illness, prevent death, and increase quality of life more than effective tobacco cessation interventions. If the 5A approach seems too much, use a brief intervention and refer. This approach has been called "Ask, Advise and Refer” or "Ask and Act. The point is to always ask if they want to quit, and if the answer is "yes” provide some direction. There are great resources available to supplement the power of a physician recommendation.

Remind patients that no one who starts smoking intends to become hooked, that breaking the addiction will be one of the toughest, but also one of the most rewarding, things they will ever accomplish. Remind them that it is a process, that there may be relapses, but that no one is going to quit trying. Eventually, everyone can beat this addiction. Encourage them to picture the rewards -- feeling better, looking better, living longer, taking care of their family, and saving money.

Remind yourself that no task will bring greater rewards -- to individuals, families, and society -- as increasing the quit rates of smoking patients.

Supporting references and additional information:

Download printable versions of these resources:

For other information and useful links, visit the American College of Preventive Medicine website at www.acpm.org.

Copyright 2009 American College of Preventive Medicine. All Rights Reserved.

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