Get ready for the Great American Smokeout on Nov. 21. Click here to download this infographic from CardioSmart to support conversations with patients.

In the U.S., smoking contributes to one-third of cardiovascular disease-related deaths.¹ While tobacco use has declined, 30 million people continue to smoke, making cessation a focus for cardiovascular clinicians.² The expanding use of e-cigarettes and "vapes" among young people and adults attempting to quit cigarettes is also a concern.

Smoking increases the risk of cardiovascular disease and the likelihood of dying from a heart attack, stroke or heart failure.^3,4 Not only does smoking cessation reduce cardiovascular disease events, it reverses tobacco's damage.^5,6

At five to 10 years after quitting, there's a 60% reduction in peripheral artery disease and a 30-40% reduction in cardiovascular disease vs. smokers.⁵

After 15 years, the risk of coronary heart disease reduces to baseline levels.6 Notably, even shortly after cessation, the risk of cardiovascular disease declines.^6,7

Tobacco-use disorder is a chronic disease with relapsing use of nicotine.² Nicotine stimulates dopaminergic pathways, reinforcing the behavior, making cessation challenging and leading to periods of relapse.⁸

Aligning with other chronic diseases, the ACC's 2018 Expert Consensus Pathway (ECDP) on Tobacco Cessation Treatment describes an "opt out" approach for smoking cessation.² Patients are offered treatment as standard of care, rather than asking if they want to quit or to "opt in" to treatment.

The ECDP details a five-step algorithm addressing tobacco-use disorder.

Ask about patients' tobacco use status. Assess patients' degree of tobacco dependence with validated tests such as the Heaviness of Smoking Index. Give individualized advice to quit based on patients' cardiovascular conditions and potential benefits. Offer treatment with both pharmacologic interventions and behavioral support. Lastly, schedule follow-up encounters to review patients' cessation progress.²

Current treatment options are pharmacological interventions and behavioral support. Behavioral interventions such as counseling and support groups seek to empower individuals to quit smoking, emphasize autonomy, positive habits and resist urges.³

The combined effect of behavioral support and pharmacotherapy is substantial and treatment plans should include both.²

The most common class of pharmacotherapy is nicotine replacement therapy (NRT), available in patches, gums, nasal sprays, oral inhalers and lozenges. NRT offers alternative routes of nicotine to reduce withdrawal symptoms and cravings in a controlled manner.

NRT routes have similar cessation rates, and the type of NRT is based on patient choice or insurance coverage.² Combination NRT therapies are more effective than one and is now the standard of care.^2,9

Another class is medications that do not contain nicotine: buproprion and varenicline. Bupropion, a dopamine reuptake inhibitor, and nicotine antagonist, reduces nicotine withdrawal symptoms.¹⁰ Varenicline, a nicotine acetylcholine receptor partial agonist, reduces cravings.¹¹

While varenicline has demonstrated efficacy for smoking cessation, there are concerns about cardiovascular side effects – and its use is recommended only in patients with stable cardiovascular disease by the ACC's ECDP on Tobacco Cessation.²

A growing area of interest is how e-cigarettes and "vapes" can be used in smoking cessation.² They are battery-powered devices where inhaled vapor is heated rather than combusted. E-cigarettes deliver 25-33% less nicotine than cigarettes, though quantity varies by manufacturer and device.¹²

E-cigarettes can be used for smoking cessation as they maintain the rituals of smoking, with less nicotine.¹³ However, they can prolong nicotine use.¹³ Other concerns are the inhaled effects of flavors and other substances, which remain under investigation.^13,14

A substantial concern is the marketing campaigns of e-cigarettes to youth causing an increase in nicotine exposure in a population that would otherwise be unaffected.^2,14

In the context of smoking cessation, the monitored use of e-cigarettes should be considered for some patients, with some data showing higher quit rates compared with NRT and standard counseling.^13,15 More research is needed on the comparative efficacy among current treatment options.

Despite the availability of treatment options, smoking cessation is difficult. Patients struggle with withdrawal symptoms, cost of treatment, peer influence and a lack of support. Clinicians struggle with time constraints and perceived lack of training and patient readiness. However, clinicians play an instrumental role in starting the conversation and should offer treatment as the standard of care.²

1. Centers for Disease Control and Prevention (CDC). Smoking-attributable mortality, years of potential life lost, and productivity losses--United States, 2000-2004. MMWR Morb Mortal Wkly Rep 2008;57:1226-8.
2. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment. J Am Coll Cardiol 2018;72:3332-65.
3. Banks E, Joshy G, Korda RJ, et al. Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study. BMC Medicine 2019;17:128.
4. Khan SS, Ning H, Sinha A, et al. Cigarette smoking and competing risks for fatal and nonfatal cardiovascular disease subtypes across the life course. J Am Heart Assoc 2021;10:e021751.
5. Ding N, Sang Y, Chen J, et al. Cigarette smoking, smoking cessation, and long-term risk of 3 major atherosclerotic diseases. J Am Coll Cardiol 2019;74:498-507.
6. U.S. Department of Health and Human Services. Public Health Service, Office of the Surgeon General. Smoking Cessation: A Report of the Surgeon General.2020. Available here.
7. Rigotti N, McDermott M. Smoking cessation and cardiovascular disease: it's never too early or too late for action. J Am Coll Cardiol 2019;74:508-11.
8. Benowitz NL. Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annu Rev Pharmacol Toxicol 2009;49:57-71.
9. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;11:CD000146.
10. Warner C, Shoaib M. How does bupropion work as a smoking cessation aid? Addict Biol 2005;10:219-31.
11. Singh J, Budhiraja S. Partial nicotinic acetylcholine (alpha4beta2) agonists as promising new medications for smoking cessation. Indian J Pharmacol 2008;40:191-6.
12. Farsalinos KE, Spyrou A, Tsimopoulou K, et al. Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices. Sci Rep 2014;4:4133.
13. Auer R, Schoeni A, Humair JP, et al. Electronic nicotine-delivery systems for smoking cessation. N Engl J Med 2024;390:601-10.
14. Gentzke AS, Wang TW, Jamal A, et al. Tobacco product use among middle and high school students - United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1881-8.
15. Hartmann-Boyce J, Lindson N, Butler AR, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2022;11:CD010216.

Clinical Topics: Prevention, Smoking

Keywords: Cardiology Magazine, ACC Publications, Tobacco Use Cessation, Nicotine, Electronic Nicotine Delivery Systems, Vaping, Substance Withdrawal Syndrome, Cardiovascular Diseases