Smoking cessation: how to advise the patient
- Correspondence to Dr Serena Tonstad, Loma Linda University, School of Public Health, Department of Health Promotion & Education, 24951 North Circle Drive, Room 1511, Loma Linda, CA 92350, USA;
Cigarette smoking causes more preventable deaths from cardiovascular disease (CVD) than from any other single disease. Smoking cessation slows disease progression and reduces risk of recurrence and premature death by ∼50% in patients with CVD. Smoking cessation counselling at the time of discharge from hospital for a myocardial infarction is considered a class I mandated behaviour,1 although brief interventions delivered only during hospitalisation may be ineffective.2 3
Observations show that only one third to one half of patients who smoke at the time of myocardial infarction subsequently manage to quit. This indicates that many smokers do not receive optimal medical support for cessation. There is often a gap between hospital discharge and follow-up by the primary care physician. Cardiologists and hospital physicians potentially play a key role in motivating and supporting quitting behaviour and should not assume that primary care physicians will fill the gap. The second European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) survey found that continued care by a hospital based cardiologist versus another physician was associated with increased quit rates.4 Furthermore, by creating a clinical environment that is supportive of treating tobacco dependence, cardiologists may motivate other clinic staff to engage in cessation promoting activities.
The 5 A’s (ask, assess, advise, assist, arrange) have been adopted by the European Society of Cardiology as an effective strategy to promote smoking cessation. Smokers should be identified systematically by hospital and office operating procedures. All notes should include an up to date record of smoking status. When a patient is identified as a smoker, the consultant physician or cardiologist intervenes by: (1) assessing dependence on cigarettes; (2) personalising benefits of cessation; (3) boosting motivation for a quit attempt; (4) recommending and prescribing medication; (5) discussing behavioural changes and setting a quit date; and …