Approach to smoking cessation in the patient with vascular disease.
In the patient with vascular disease, cigarette smoking is particularly perilous; the benefits of smoking cessation greatly exceed any risks associated with pharmacologic treatment. The patient with claudication is often uniquely motivated to quit smoking because 1) there is a chance that the leg pain will improve and 2) smoking cessation may prevent disease progression and thus invasive procedures. The first step toward success is a systematic approach with focus on the 5 A's (Ask, Advise, Assess, Assist, and Arrange). Multiple clinical trials have demonstrated the efficacy of pharmacologic therapy for smoking cessation. The most effective medications available are bupropion and varenicline. If the patient is ready to quit, varenicline is typically first-line unless contraindicated. If the patient has concomitant signs or symptoms of depression, bupropion in combination with nicotine replacement therapy is preferred. In parallel with aggressive counseling and pharmacotherapy for smoking cessation, cardiovascular risk reduction is critical. Established atherosclerotic vascular disease (including peripheral artery disease, abdominal aortic aneurysm, or carotid artery disease) plus poorly controlled risk factors, including current smoking, place the patient in the "very high-risk" category, which favors reducing the low-density lipoprotein level to less than 70 mg/dL. The increased cardiovascular risk associated with smoking is tremendous, particularly in the vascular patient. Smoking cessation is critical, and no other health intervention offers such a large potential benefit.
Department of Medicine, Division of Cardiology, The Johns Hopkins Center for Vascular Medicine, 10755 Falls Road, Suite 320C, Lutherville, MD, 21093, USA, eratchf1@jhmi.edu.
Elizabeth V
EV
Ratchford
James H
JH
Black
J Vasc Surg. 2005 Jul;42(1):67-74
16012454
Ann Intern Med. 2010 Feb 2;152(3):144-51
20124230
N Engl J Med. 1999 Mar 4;340(9):685-91
10053177
Heart. 2009 Oct;95(19):1635-40
19752210
J Am Coll Cardiol. 2010 May 4;55(18):1988-95
20236788
Circulation. 2006 May 16;113(19):2363-72
16702489
Br J Surg. 1982 Jun;69 Suppl:S24-6
7082968
Lancet Neurol. 2009 Oct;8(10):908-17
19717347
Vasc Med. 1996;1(3):181-6
9546936
Arch Intern Med. 2002 Jun 10;162(11):1267-76
12038945
J Vasc Surg. 2003 Aug;38(2):329-34
12891116
Circulation. 2004 Jul 6;110(1):16-21
15210603
Eur Heart J. 1999 Mar;20(5):344-53
10206381
BMJ. 2004 Jun 26;328(7455):1519
15213107
N Engl J Med. 1997 Oct 23;337(17):1195-202
9337378
J Vasc Surg. 2010 Jun;51(6):1529-37
20223623
N Engl J Med. 2000 Sep 21;343(12):864-9
10995867
MMWR Morb Mortal Wkly Rep. 2010 Sep 10;59(35):1135-40
20829747
Am J Epidemiol. 1992 Feb 15;135(4):331-40
1550087
Med Lett Drugs Ther. 2009 Aug 24;51(1319):65
19696706
N Engl J Med. 2010 Jun 17;362(24):2295-303
20554984
Arch Intern Med. 1999 Sep 27;159(17):2033-8
10510989
J Am Coll Cardiol. 2010 Jun 29;56(1):1-7
20620709
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000146
18253970
Treat Guidel Med Lett. 2008 Sep;6(73):61-6
18719526
Circulation. 1990 Dec;82(6):1925-31
2242518