The cardiologist and smoking cessation

Facilitating smoking cessation in patients who smoke: a large-scale cross-sectional comparison of fourteen groups of healthcare providers

Background

Although healthcare providers are well placed to help smokers quit, implementation of smoking cessation care is still suboptimal. The Ask-Advise-Refer tasks are important aspects of smoking cessation care. We examined to which extent a large and diverse sample of healthcare providers expressed the intention to implement smoking cessation care and which barriers they encountered. We moreover examined to which extent the Ask-Advise-Refer tasks were implemented as intended, and which determinants (in interaction) influenced intentions and the implementation of Ask-Advise-Refer.

Methods

Cross-sectional survey among addiction specialists, anaesthesiologists, cardiologists, general practitioners, internists, neurologists, paediatricians, pulmonologists, ophthalmologists, surgeons, youth specialists, dental hygienists, dentists, and midwives (N = 883). Data were analysed using multivariate linear and logistic regression analyses and regression tree analyses.

Results

The Ask-Advice-Refer tasks were best implemented among general practitioners, pulmonologists, midwives, and addiction specialists. Overall we found a large discrepancy between asking patients about smoking status and advising smokers to quit. Participants mentioned lack of time, lack of training, lack of motivation to quit in patients, and smoking being a sensitive subject as barriers to smoking cessation care. Regression analyses showed that the most important determinants of intentions and implementation of Ask-Advise-Refer were profession, role identity, skills, guideline familiarity and collaboration agreements for smoking cessation care with primary care. Determinants interacted in explaining outcomes.

Conclusions

There is much to be gained in smoking cessation care, given that implementation of Ask-Advise-Refer is still relatively low. In order to improve smoking cessation care, changes are needed at the level of the healthcare provider (i.e., facilitate role identity and skills) and the organization (i.e., facilitate collaboration agreements and guideline familiarity). Change efforts should be directed towards the specific barriers encountered by healthcare providers, the contexts that they work in, and the patients that they work with.

[Smoking cessation: A challenge for cardiologists and pulmonologists]

In addition to public health measures that need to be strongly supported politically, smoking is also a major medical issue. Tobacco dependence is a chronic disease, and, given its extremely addictive nature, treatment for tobacco dependence must be addressed actively by all health professionals. Because smoking is a major contributor to many of the pathologies their specialties address, cardiologists and pulmonologists must be at the forefront of this care. In this review we analyse the current state of smoking cessation treatment and its inadequacies, the limiting impact that doctors' own smoking has, as well as the misconceptions held by smokers and sometimes by doctors as well, which act as brakes on smoking cessation. Smoking cessation must become a treatment delivered in real clinical practice and any doctor must know how to manage it fluently. Do not be satisfied with simply advising smokers to quit. Learn how to approach the subject with smokers effectively, know how the various pharmacotherapies are used and know how to organize smoking cessation follow-up, an essential guarantee of success. If optimal management of this major pathological factor is a role for all doctors, it is of course especially so for our two specialties. It's up to us, cardiologists and pulmonologists, to take up this challenge.

"It's on everyone's plate": a qualitative study into physicians' perceptions of responsibility for smoking cessation

BACKGROUND

Little research has investigated in-depth how physicians perceive their role in smoking cessation care. This qualitative study sought to understand physicians' perceptions of responsibility for smoking cessation.

METHODS

Data were collected through individual semi-structured interviews and focus group interviews between June and November 2017 in The Netherlands. We interviewed 5 addiction specialists, 5 anesthesiologist, 4 cardiologists, 8 GPs, 5 internists, 5 neurologists, 2 pediatricians, 6 pulmonologists, 7 surgeons, and 8 youth healthcare physicians (N = 55). Data analysis followed the framework approach.

RESULTS

The analysis showed that three actors were perceived as responsible for smoking cessation: physicians, patients, and the government. Participants perceived physicians as responsible for facilitating smoking cessation -albeit to different extents-, patients as carrying the ultimate responsibility for quitting smoking, and the government as responsible for creating a society in which smoking uptake is more difficult and quitting smoking easier. Perceptions of smoking itself were found to be important for how participants viewed responsibility for smoking cessation. It remained unclear for many participants which healthcare provider is responsible for smoking cessation care.

CONCLUSIONS

The organization of smoking cessation care within health systems should be a focus of intervention, to better define physician roles and perceptions of responsibility. In addition, it seems important to target perceptions of smoking itself on the level of physicians and -as suggested by comments by several participants- the government.

Hospital doctors' smoking behavior and attitude towards smoking cessation interventions for patients: a survey in an Italian Comprehensive Cancer Centre

PURPOSE

Tobacco control guidelines recommend all healthcare professionals to ask patients about their smoking status and to offer them at least minimal cessation advice. However, few data are available about the daily practice of hospital clinicians who work with smoking cancer patients. This study assesses, in a comprehensive cancer center, the physicians' smoking habit, their clinical practice in offering a smoking cessation intervention to patients who smoke, and the training they received in this field.

METHODS

A Web-based survey was sent to 285 physicians.

RESULTS

The survey response rate was 75%. Sixty-two percent, 24%, and 14% of responders were never, former, and current smokers, respectively. Six percent of all responding physicians have already participated in smoking cessation training and 43% of them declared their willingness to be trained. Eighty-six percent of all responding physicians asked about the patients' smoking status, 50% routinely advised patients to quit smoking, and 32% assessed their motivation to do so. Smoking cessation guidelines were not followed mostly for lack of time, fear to increase patients' stress, and lack of smoking cessation training. Ninety-four percent of responding physicians knew the smoking cessation service for outpatients and 65% referred at least one patient, 66% of responding physicians knew the service for inpatients, and 36% of them asked for at least one intervention in the ward.

CONCLUSIONS

This study pointed out partial adherence of the physicians working in a leading cancer center to the smoking cessation guidelines. The clinicians' smoking habits did not influence the training and the clinical practice in offering patients smoking cessation interventions.

Global tobacco surveys: information for action by cardiologists

Critical to health promotion is surveillance of tobacco use that is a leading risk factor for cardiovascular diseases (CVDs). The objective of this paper is to analyze information from global tobacco surveys as relevant for CVD prevention and, hence, for cardiologists implying their role in clinical and policy settings for advancing tobacco control. This article uses MPOWER strategy as a framework to discuss information available from The Global Tobacco Surveillance System (GTSS) established in 1998. Data underline the need for cardiologists to 1) step up their efforts in promoting and providing cessation services in clinical settings; 2) become tobacco control advocates and support policy implementation in their countries; 3) raise patient and community awareness of harm caused by tobacco use and SHS exposure to health; 4) undertake policy relevant research where required; and 5) support national governments in effective implementation of provisions of the Framework Convention on Tobacco Control (FCTC).

Extended varenicline treatment in a severe cardiopathic cigarette smoker: a case report

INTRODUCTION

Tobacco smoking is the leading cause of cardiovascular morbidity and mortality and quitting tobacco use should be fundamental for cardiovascular patients. Varenicline is a smoking cessation pharmacological therapy able to improve the possibilities to successfully achieve this result. In 2011 the US Food and Drug Administration issued a safety announcement that varenicline may be associated with an increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease. Following studies found no significant increase in cardiovascular serious adverse events associated with varenicline. For the first time in the literature, we describe the case of a cardiopathic hard smoker who received varenicline for 9 months without any side effect. By describing this case we want to underline the safety of varenicline, to illustrate the setting and the method that we used to support him and to underline the importance of promoting smoking cessation in heart patients.

CASE PRESENTATION

Varenicline was used to promote smoking cessation in a 52-year-old Caucasian man who smoked 40 cigarettes per day, despite two ischemic cardiovascular events. He asked for a consultation in a pharmacy's smoking cessation service and after the assessment phase varenicline was prescribed. Due to his difficulty to quit smoking and given his good tolerance of the drug, we extended the treatment with varenicline to 9 months in order to achieve and maintain a complete smoking abstinence; intensive behavioural counselling was combined with the pharmacological therapy. By using exhaled carbon monoxide measurement we assessed smoking abstinence up to 2 years.

CONCLUSIONS

The use of varenicline for a period longer than 6 months has not been described in the literature, particularly in heart patients. The extended varenicline therapy was clinically monitored and allowed the patient to consolidate his abstinence; the intensive behavioural counselling helped him to overcome his strong psychological dependence. Promoting smoking cessation in people who have cardiovascular disease is crucial. Currently available medications, such as varenicline, increase the chances of success and the risk of possible side effects is outweighed by the lifetime benefits and we hope that clinicians use them more frequently and confidently.

The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology

The environment in which the field of cardiology finds itself has been rapidly changing. This supplement, an expansion of a report created for the Board of Trustees, is intended to provide a timely snapshot of the socio-economic, political, and scientific aspects of this environment as it applies to practice both in the United States and internationally. This publication should assist healthcare professionals looking for the most recent statistics on cardiovascular disease and the risk factors that contribute to it, drug and device trends affecting the industry, and how the practice of cardiology is changing in the United States.

[Risk factor "smoking" : smoking cessation in patients with cardiovascular diseases]

Smoking is the most frequent cause of avoidable premature death. Annually, almost 6 million people die due to nicotine consumption. Comparing modifiable cardiovascular risk factors, smoking has the strongest impact on cardiovascular mortality. More than 50% of all premature myocardial infarctions are related to nicotine consumption. Even in patients with known coronary disease receiving optimal medical therapy, there is a remarkable additional preventive effect of smoking cessation detectable. Therefore, smoking cessation is an essential component of primary and secondary prevention strategies. Smoking cessation programs applying a combination of behavior therapy and supporting medical treatment have been demonstrated to be the most effective.

Clinical excellence in cardiology

A recent study identified 7 domains of clinical excellence on the basis of interviews with "clinically excellent" physicians at academic institutions in the United States: (1) communication and interpersonal skills, (2) professionalism and humanism, (3) diagnostic acumen, (4) skillful negotiation of the health care system, (5) knowledge, (6) taking a scholarly approach to clinical practice, and (7) having passion for clinical medicine. What constitutes clinical excellence in cardiology has not previously been defined. The author discusses clinical excellence in cardiology using the framework of these 7 domains and also considers the additional domain of clinical experience. Specific aspects of the domains of clinical excellence that are of greatest relevance to cardiology are highlighted. In conclusion, this discussion characterizes what constitutes clinical excellence in cardiology and should stimulate additional discussion of the topic and an examination of how the domains of clinical excellence in cardiology are related to specific patient outcomes.

The Gap between Tobacco Treatment Guidelines, Health Service Organization, and Clinical Practice in Comprehensive Cancer Centres

Smoking cessation is necessary to reach a higher quality of life, and, for a cancer patient, it represents an important step in improving the outcome of both prognosis and therapy. Being a cancer patient addicted to nicotine may be a critical situation. We conducted a survey to monitor how many comprehensive cancer centres in Italy have an outpatient smoker clinic and which kinds of resources are available. We also inquired about inpatient services offering psychological and pharmacological support for smoking cessation, reduction, or care of acute nicotine withdrawal symptoms. What we have witnessed is a significant gap between guidelines and services. Oncologists and cancer nurses are overscheduled, with insufficient time to engage in discussion on a problem that they do not consider directly related to cancer treatment. Furthermore, smoking habits and limited training in tobacco dependence and treatment act as an important barrier and lead to the undervaluation of smokers' needs.

Effect of guideline orientation on the outcomes of peripheral arterial disease in primary care

OBJECTIVE

Peripheral arterial disease (PAD), an established marker of premature death and cardiovascular risk in general, is highly prevalent. We analysed factors associated with poor outcomes in an observational cohort, with particular focus on the effect of guideline orientation in the management of these patients.

METHODS

PACE-PAD is a multicentre, prospective, observational study of PAD patients in primary care. PAD guideline orientation was stated, if patients received the following: exercise training, (if applicable) advice for smoking cessation and diet, therapy for diabetes mellitus, hypertension, hypercholesterolaemia, or antiplatelets/anticoagulants. Multivariate regression models were applied to assess factors associated with all cause death, cardiovascular/cerebrovascular death, or cardiovascular/cerebrovascular/peripheral vascular non-fatal events.

RESULTS

After an 18-month follow-up, of the 5099 PAD patients analysed (mean age 68.0 ± 9.0 years, 68.5% males), only 28.4% of patients met all applicable quality indicators for guideline-oriented treatment. However, most patients were to a large extent managed in line with guidelines. While exercise training was reported in 41.8%, rates were very high for smoking cessation (90.7%), therapy for hypertension (92.5%), diabetes mellitus (82.0%), hypercholesterolemia (83.3%) and antiplatelet therapy (86.7%). Regarding events, there were inhomogeneous results with a statistically significant higher rate of cardiovascular/cerebrovascular deaths and all-cause deaths, but a lower rate of non-fatal vascular events in patients treated according to guidelines compared to those who were not. Limitations of this study include the open, non-controlled design, possible patient selection bias and misclassification of events.

CONCLUSION

Even if the guideline orientation for the various indicators was remarkably stable across the three follow-up visits, the rate of patients comprehensively treated according to the guidelines was relatively low, which calls for optimisation. There was a lack of differentiation between the guideline-oriented and non-guideline-oriented therapy in terms of outcomes, which may be due to patient-related or other factors, and warrants further research.