Prevention and Treatment of Tobacco Use: JACC Health Promotion Series

Abstract

Tobacco use is the leading preventable cause of death worldwide and is a major risk factor for cardiovascular disease (CVD). Both prevention of smoking initiation among youth and smoking cessation among established smokers are key for reducing smoking prevalence and the associated negative health consequences. Proven tobacco cessation treatment includes pharmacotherapy and behavioral support, which are most effective when provided together. First-line medications (varenicline, bupropion, and nicotine replacement) are effective and safe for patients with CVD. Clinicians who care for patients with CVD should give as high a priority to treating tobacco use as to managing other CVD risk factors. Broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass media campaigns, and restrict tobacco marketing enhance clinicians' actions working with individual smokers.

Keywords: nicotine; smoking; smoking cessation; smoking prevention; tobacco use disorder.

Central Illustration.. Socio-ecological model of factors associated with smoking initiation and continued smoking.

Various individual, interpersonal, community/organizations, and societal/policy factors play a role in why individuals start smoking and continue to smoke. Interventions targeting each of these factors can help to reduce smoking prevalence.

Figure 1.. Per capita cigarette consumption per year among U.S. adults from 1900 to 2012.

Cigarette consumption has been declining since the 1960s, during which time tobacco control policies have been adopted at local and national levels. From: US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department ofHealth and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2014.

Figure 2.. Mechanisms by which smoking causes cardiovascular disease.

The major components of cigarette smoke that contribute to cardiovascular disease include nicotine, carbon monoxide, reactive oxygen species, free radicals, carbonyls (such as acrolein), and particulate matter.

Figure 3.. Risk continuum of nicotine-containing products.

Nicotine comes in many forms with varying degrees of potential harm to users. Medicinal nicotine, such as that contained in nicotine replacement therapy, is least likely to cause harm, while combustible tobacco, such as cigarettes, is most likely to cause harm. It is not known where heat-not-burn tobacco (also known as heated tobacco) products fall on this spectrum given the limited evidence on their health effects.

Figure 4.. The Ask, Assist, Refer tobacco cessation intervention.

Providers can use this tool to screen for tobacco use among all patients, and refer them to appropriate resources to help with smoking cessation.