Tobacco Use Still Rampant Among CVD Patients Who Know Better

Despite knowing the ramifications of smoking, more than one in four patients with cardiovascular disease in the United States continue to use tobacco and few enroll in formal cessation programs, according to new data.

“These findings indicate that public policies and interventions are needed to address these preventable leading causes of death and disability, not just in the US but also around the world,” co-lead author Cristian Zamora, MD (Albert Einstein College of Medicine, Bronx, NY), told TCTMD. “We need a strong commitment from a multidisciplinary team, not just including primary care but also social workers, psychologists, and cardiologists to provide smoking cessation therapies for these people who are high risk.”

To this end, a joint opinion statement published recently in the European Heart Journal, also calls for a comprehensive, collaborative approach.

We need a strong commitment from a multidisciplinary team, not just including primary care but also social workers, psychologists, and cardiologists to provide smoking cessation therapies for these people who are high risk. Cristian Zamora

For the study of US tobacco use, published online today in the Journal of the American Heart Association, Lindsay M. Reynolds, PhD (Wake Forest School of Medicine, Winston-Salem, NC), along with Zamora and colleagues reviewed survey responses from 2,615 adults enrolled in the national Population Assessment of Tobacco and Health (PATH) study who had a self-reported history of MI, stroke, heart failure, or other cardiovascular disease. Participants completed four surveys over 5 years beginning in wave 1 (2013-2014) and ending with wave 4 (2016-2018).

At the outset, 28.9% respondents reported tobacco use, which translates to about 6.2 million US adults who use tobacco in spite of having a history of CVD. Fully 95.9% said they believed that smoking can cause heart disease. Cigarettes were the most common tobacco product (82.8%), followed by cigars (23.7%) and e-cigarettes (23.3%). Notably, very few respondents used e-cigarettes as their sole tobacco product (1.1%). Tobacco use was most common in men, younger patients, and those with less education.

Cigarette usage dropped over the course of the study by only about 5%, while e-cigarette usage increased by 0.5%. Also, only 10% were in formal tobacco cessation programs, and this percentage did not increase between waves 1 and 4.

Zamora said he was surprised at how few patients enrolled in smoking cessation programs but cited several challenges associated with starting people on this path. “[It] is difficult to change beliefs,” he said. “We know to get [patients into] smoking cessation programs can be sometimes very difficult, not just because of lack of knowledge but also insurance and also authorization. Maybe if we can work harder on those topics, maybe we can have better outcomes, because it's well documented in various studies that these therapies will help decrease the amount of smoking, especially in this population.”

‘Pulling Out All the Stops’

Getting to the “tobacco endgame” will take a multipronged approach, according to the joint opinion statement from the American College of Cardiology, American Heart Association (AHA), European Society of Cardiology, and the World Heart Federation.

“Together and with other global partners, we continue to monitor and draw attention to tobacco industry practices that promote its addictive and deadly products,” Jeffrey Willett, PhD (American Heart Association), and colleagues write. “Recognizing the tremendous toll that combustible tobacco products have on global health, we call for stronger government actions that more rapidly reduce the use of combustible tobacco products. Towards this aim, we support lowering nicotine concentrations in all combustible tobacco products while ensuring the next generation is not addicted to new nicotine delivery products.”

AHA President Mitchell Elkind MD (Columbia University, New York, NY), who served as senior author for the statement, told TCTMD that a big challenge for clinicians is that “of course people know a lot of things are bad for them and do them anyway. Behavior control or behavior modification is really difficult.”

The time to end tobacco use is now, he continued. “We're not making the kind of headway that we think we should be and in some ways, things have moved backwards with e-cigarettes and other forms of tobacco that are even increasing in the market in some populations. And so it's time for, as we say, getting to the endgame by pulling out all the stops and doing everything that we can to put an end to tobacco use.”

Of course, people know a lot of things are bad for them and do them anyway. Mitchell Elkind

There are some public misconceptions about potential benefits of e-cigarettes, Elkind said, but these need to be rectified. “Nicotine itself in e-cigarettes is dangerous for the heart and the brain, especially in young people. So, I think it's a battle really between public health and profits. We have to push the needle toward the public health side.”

In addition to compounded education, both following a cardiovascular event and during ongoing follow-up, clinicians should be providing drugs and counseling opportunities to enable their patients to quit tobacco use, he said, adding that insurance companies also need to be reminded to cover these treatments.

Also, Elkind stressed the inequities seen, with tobacco use being prevalent in certain more vulnerable populations. “In the US, the Black population, for example, has a more than 10% higher likelihood of smoking despite having cardiovascular disease,” he said. “We know that for decades the tobacco industry has promoted flavored, especially menthol-flavored, tobacco products in the Black community, and that's had a devastating effect. It's made it that much harder for that group of people to avoid starting and to quit smoking. And so I think we need to fight that kind of marketing with clever marketing and educational strategies around smoking cessation.”

Future research in this space should focus on behavioral risk factor control, according to Elkind. “We need to better understand how to motivate leaders in the youth community to educate their peers not to begin smoking,” he said. “It's not going to be traditional medical research. I don't think we're going to come up with a miracle drug that's going to get people to quit smoking immediately—it's going to be psychological research, it's going to be marketing research, it's going to be understanding how to get people to change their behaviors.”