p.25 抽出テキスト

September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e620

CLINICAL STATEMENTS AND GUIDELINES Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

whether ENDS are useful or effective for tobacco treatment, and they may be potentially harmful. The evidence on the use of ENDS as a smoking-cessation tool in adults (including pregnant women) and adolescents is insufficientS4.5-23 or limited.S4.5-24 The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety. 4.	Cigarette smoking remains a strong, independent risk factor for ASCVD events and premature death.S4.5-4 Even among older adults, tobacco cessation is beneficial in reducing excess risk.S4.5-5 The risk of heart failure and death for most former smokers is similar to that of never smokers after >15 years of tobacco cessation.S4.5-25 In the National Health Interview Survey, smoking was strongly associated with ASCVD in young people after adjustment for multiple risk factors,S4.5-26 which is why abstinence from an early age is recommended. 5 Tobacco use dependence is a chronic disease

that requires highly skilled chronic disease management. It is a reasonable expectation that every health system or practice should dedicate trained staff to tobacco treatment. Healthcare professionals who receive training in tobacco treatment are more likely to ask about tobacco use, offer advice to quit, provide behavioral interventions, follow up with individuals, and increase the number of tobacco users who quit.S4.5-1 Participants who earn a certificate in tobacco treatment practice demonstrate a nationally recognized level of training and skill acquisition in treating tobacco dependence.s4.5-27 A Tobacco Treatment Specialist is a professional who possesses the skills, knowledge, and training to provide effective, evidence-based interventions for tobacco dependence across a range of intensities.S4.5-28 A list of accredited Tobacco Treatment Specialist programs is available here: http://ctttp.org/ accredited-programs.S4.5-29

Table 8.  Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers*

Timing of Behavioral Interventions† <3 min of tobacco status assessment with cessation counseling at each clinic encounter >3-10 min of tobacco status assessment with cessation counseling at each clinic encounter >10 min of tobacco status assessment with cessation counseling at each clinic encounter Treatment Dosing‡ Precautions NRT* Patch 21 mg, 14 mg, or 7 mg Starting dose: 21 mg for ≥10 CPD; 14 mg for <10 CPD Local irritation possible; avoid with skin disorders; may remove for sleep if needed Gum 2 mg or 4 mg Starting dose: 4 mg if first tobacco use is ≤30 min after waking; 2 mg if first tobacco use is >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d. Chew and park gum*

Hiccups/dyspepsia possible; avoid food or beverages 15 min before and after use Lozenge 2 mg or 4 mg

Nasal spray 10 mg/mL Starting dose: 1-2 doses/h (1 dose=1 spray each nostril); maximum of 40 doses/d Local irritation possible; avoid with nasal or reactive airway disorders Oral inhaler 10-mg cartridge Starting dose: Puff for 20 min/cartridge every 1-2 h; maximum 16 cartridges/d Cough possible; avoid with reactive airway disorders Other§ Bupropion (Zyban [GlaxoSmithKline], Wellbutrin SR [GlaxoSmithKline]) 150 mg SR 150 mg once daily (am) for 3 d; then 150 mg twice daily; may use in combination with NRTS4.5-21 Avoid with history/risk of seizures, eating disorders, MAO inhibitors, or CYP 2D6 inhibitor Varenicline (Chantix [Pfizer]) 0.5 mg or 1 mg 0.5 mg once daily (am) for 3 d; then 0.5 mg twice daily for 4 d; then 1 mg twice daily (use start pack followed by continuation pack) for 3-6 mo Nausea common; take with food. Renal dosing required. Very limited drug interactions; near-exclusive renal clearance. *CPD can guide dosing. 1 CPD is ≈1-2 mg of nicotine. Note: Use caution with all NRT products for patients with recent (≤2 wk) MI, serious arrhythmia, or angina; patients who are pregnant or breastfeeding; and adolescents.

†Timing of assessment relates to ICD-10 coding. ‡Dose and duration can be titrated on the basis of response.S4.5-21 §The FDA has issued a removal of black box warnings about neuropsychiatric events.S4.5-20,S4.5-21 am indicates morning; CPD, cigarettes smoked per day; FDA, US Food and Drug Administration; ICD-10, International Classification of Diseases, Tenth Revision; MAO, monoamine oxidase; NRT, nicotine replacement; and SR, sustained release.

Downloaded from http://ahajournals.org by on October 7, 2026