Cigarette smoking and coronary heart disease: risks and management

Tobacco smoking is the leading preventable cause of death in the United States and an important cause of CHD. The effect of smoking on the cardiovascular system and coronary risk factors is pervasive. Unfavorable effects include acute increases in blood pressure and coronary vascular resistance, reduction in oxygen delivery, enhancement of platelet aggregation, increased fibrinogen, and depression of HDL cholesterol. Smoking cessation reduces cardiovascular morbidity and mortality rates relatively rapidly, even among individuals who stop smoking only after the age of 65 or after developing the clinical manifestations of CHD including myocardial infarction. Behavioral smoking-cessation programs and nicotine-replacement therapy each have been demonstrated to be effective for the treatment of smoking. The most effective treatment currently available is to combine the two. Nicotine-replacement therapy is safe and effective in patients with stable coronary heart disease. Although the threat or diagnosis of CHD is a powerful stimulus to spontaneous smoking cessation, many smokers continue to smoke after events such as myocardial infarction or CABG surgery. Studies have demonstrated that physician advice to stop smoking, supplemented by brief counseling by a nurse and follow-up, dramatically increases the smoking-cessation rate of patients hospitalized with myocardial infarction and is highly cost effective. In the outpatient setting, physician advice and counseling is also effective in helping smokers with or without CHD to stop smoking. This article outlines a simple protocol that has been demonstrated to be effective for counseling smokers.