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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 September 10, 2019 e619 CLINICAL STATEMENTS AND GUIDELINES

I A 3.  In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.S4.5-2,S4.5-3

I B-NR 4.  In adults who use tobacco, tobacco abstinence is recommended to reduce ASCVD risk.S4.5-4,S4.5-5

IIa B-R 5.  To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare system.S4.5-1

III: Harm B-NR 6.  All adults and adolescents should avoid secondhand smoke exposure to reduce ASCVD risk.S4.5-6

Synopsis

Tobacco use is the leading preventable cause of disease, disability, and death in the United States.S4.5-7 Smoking and smokeless tobacco (eg, chewing tobacco) use increases the risk of all-cause mortality and is a cause of ASCVD.S4.5-4,S4.5-5 Secondhand smoke is a cause of ASCVD and stroke,S4.5-6 and almost one-third of CHD deaths are attributable to smoking and exposure to secondhand smoke. Even low levels of smoking increase risks of acute MI; thus, reducing the number of cigarettes per day does not totally eliminate risk.S4.5-8 Healthy People 2020 recommends that cessation treatment in clinical care settings be expanded, with access to proven cessation treatment provided to all tobacco users.S4.5-9 Electronic Nicotine Delivery Systems (ENDS), often called e-cigarettes,S4.5-10 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.S4.5-11 Arrhythmias and hypertension with e-cigarette use have also been reported.S4.5-12 Chronic use is associated with persistent increases in oxidative stress and sympathetic stimulation in young, healthy subjects.S4.5-13

Recommendation-Specific Supportive Text

1 On the basis of on the US Public Health Service’s

Clinical Practice Guideline for Treating Tobacco Use and Dependence,S4.5-14,S4.5-15 the USPSTF recommended (Grade A) in 2003 and reaffirmed in 2009 that clinicians ask all adults about tobacco use.S4.5-2 Treating tobacco use status as a vital sign and recording tobacco use status in the health record at every healthcare visit not only increases the rate of tobacco treatment but also improves tobacco abstinence.S4.5-15,S4.5-16 Office-wide screening systems (eg, chart stickers, computer prompts) that expand the vital signs to include tobacco use status (current, former, never) can facilitate tobacco cessation.S4.5-15 Because many people who use tobacco do not report it, using multiple questions to assess tobacco use status may improve accuracy and disclosure. For example, clinicians should ask, “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?” “Have you used any other tobacco product in the past 30 days?” If these questions are answered with “yes,” the patient is considered a current smoker. Clinicians should avoid asking “Are you a smoker?” or “Do you smoke?” because people are less likely to report tobacco use when asked in this way.S4.5-17

2.	Tobacco users are more likely to quit after 6 months when clinicians strongly advise adults to quit using tobacco than when clinicians give no advice or usual care.S4.5-2 To help patients quit, it is critically important to use language that is clear and strong, yet compassionate, nonjudgmental, and personalized, to urge every tobacco user to quit.S4.5-15 For example, “The most important thing you can do for your health is to quit tobacco use. I (we) can help.” The ASCVD benefits of quitting are immediate.S4.5-18 The best and most effective treatments are those that are acceptable to and feasible for an individual patient; clinicians should consider the patient’s specific medical history and preferences and offer to provide tailored strategies that work best for the patient.S4.5-3,S4.5-19

3 In alignment with previous expert consensus

regarding strategies for tobacco cessation,S4.5-19 Table 8 summarizes recommended behavioral interventions and pharmacotherapy for tobacco treatment. There are 7 FDA-approved cessation medications, including 5 forms of nicotine replacement. Note that the black box warnings about neuropsychiatric events have been removed by the FDA.S4.5-20,4.5-21 The net benefit of FDA-approved tobacco-cessation pharmacotherapy and behavioral interventions (even just 3 minutes of practical advice), alone or combined, in nonpregnant adults (≥18 years of age) who smoke is substantial. The net benefit of behavioral interventions for tobacco cessation on perinatal outcomes and smoking abstinence in pregnant women who smoke is substantial. However, the evidence on pharmacotherapy for tobacco cessation in pregnant women is insufficient; the balance of benefits and harms cannot be determined. Among hospitalized adults who use tobacco, intensive counseling with continued supportive follow-up contacts for at least one month after discharge is recommended.S4.5-22

ENDS are not recommended as a tobacco treatment method. The evidence is unclear about

Recommendations for Treatment of Tobacco Use (Continued)

COR LOE Recommendations

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