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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

in abstinence rates at 6 to 12 months.7,39 Table 8 describes behavioral support programs available throughout the United States. NRT and varenicline have been shown to increase the success of smoking cessation in the overall population who smoke daily, including persons with CCD.6,40–46 The effectiveness of NRT is highest when used as a combination of long- and short-acting NRT.45 Adding behavioral therapy to pharmacotherapy increases quit rates.47 In 2011, the FDA issued a warning for possible increased risk of cardiovascular events in persons with CVD who use varenicline. One metaanalysis of trials through 2016 found no increased cardiovascular risk in persons receiving varenicline.48 Subsequently, a trial randomized 8058 persons to bupropion, varenicline, or NRT and found no difference in cardiovascular events among the 3 groups.44 Trials of pharmacotherapy and behavioral therapy for smoking cessation typically enroll persons who smoke cigarettes daily; more research is needed on the efficacy and optimal strategy for smoking cessation among those who smoke intermittently, those who use smokeless tobacco, and those who use e-cigarettes. 4.	 Varenicline is more effective than bupropion or NRT in achieving abstinence from cigarette smoking in meta-analyses of randomized trials, with a pooled estimate from 5 trials (n=5877 persons) showing a relative risk versus bupropion of 1.39 (95% CI, 1.25-1.54), and a pooled estimate of 8 trials (N=6264 persons) showing a relative risk versus NRT of 1.25 (95% CI, 1.14-1.37) for abstinence favoring varenicline.49 One network meta-analysis evaluated the efficacy of RCTs of smoking cessation specifically among those with CVD and concluded that varenicline was more effective than bupropion or NRT, although no trials have compared various agents with each other in patients with CCD.6 The ultimate choice of pharmacotherapy for smoking cessation should incorporate patients’ previous experiences, preferences, and comorbidities (see “2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment” for dosing information and information about pharmacotherapy for smoking cessation).38 No data are available on the efficacy of pharmacologic therapy to support cessation of either e-cigarettes or smokeless tobacco. More research is needed on how to optimize both pharmacologic and behavioral therapy to support cessation of smokeless tobacco and e-cigarettes. 5.	 Twenty-nine RCTs evaluated the efficacy of

e-cigarettes on smoking cessation, including 5 at low risk of bias.9 In meta-analyses, nicotine e-cigarettes appeared to be more effective than NRT for smoking cessation (relative risk, 1.69 [95% CI, 1.25-2.27]), corresponding to a 4% absolute increase in the success rates of smoking cessation compared with NRT.9 Persons using e-cigarettes for smoking cessation are at risk of long-term dependence. In 1 trial, 80% of those assigned to the e-cigarette group who successfully quit smoking were still using the device at 1 year (versus only 9% still using NRT in the NRT arm).10 Nicotine e-cigarettes appear to affect endothelial function, vascular stiffness, and BP less than combustible cigarettes.33,34,36 No data are available on the long-term risks of e-cigarettes on overall health and cardiovascular risk, but physiologic and toxicology studies suggest that e-cigarettes may increase cardiovascular risk.8,30–37 Substantial variability exists in e-cigarette additives, flavorings, and nicotine dose in e-cigarette liquid; the effect on cardiovascular risk is unknown. Because of the lack of long-term safety data and high rates of ongoing use, nicotine e-cigarettes should not be recommended as first-line therapy for smoking cessation. Patients with CCD who use e-cigarettes to support smoking cessation should be warned about the risks of developing long-term dependence and encouraged to quit use of e-cigarettes promptly to avoid potential long-term risks. 6.	 Secondhand smoke exposure has similar deleteri-

ous physiologic effects as active cigarette smoking.50,51 Even low doses of exposure to secondhand smoke exposure are associated with a marked increase in the risk of ischemic heart disease events, including recurrent events in patients with previous MI.11,12,50–52 Many persons are exposed to secondhand smoke exposure via their workplaces and may not individually be able to avoid exposure. For this reason, policy-level interventions are necessary to decrease occupational secondhand smoke exposure. Policies designed to reduce secondhand smoke exposure, such as smoke-free workplaces and restaurant policies, are associated with lower population-level risk of CVD.

4.2.4 Alcohol and Substance Use

Recommendations for Alcohol and Substance Use Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 C-LD 1 Patients with CCD should be routinely asked and

counseled about substance use to reduce ASCVD events.1–5

2a B-NR 2.	 In patients with CCD who consume alcohol,

it is reasonable to limit alcohol intake (≤1 drink/d for women, ≤2 drinks/d for men) to reduce cardiovascular and all-cause death.6–8

3: No Benefit B-NR 3 Patients with CCD should not be advised to

consume alcohol for the purpose of cardiovascular protection. 9,10

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