Cigarette smoking is the leading cause of preventable morbidity and mortality among all racial and ethnic groups in the United States (1,2). Tobacco use is the primary cause of lung cancer and is causally linked to other forms of cancer (3,4), heart disease, stroke (5), and chronic obstructive pulmonary disease (6,7), and it is responsible for more than $75 billion in annual health care expenditures (8). Each year in the United States, more than 438,000 deaths are linked to cigarette smoking, and one-third of deaths among former smokers are directly attributable to tobacco use (9). Moreover, environmental tobacco smoke or “secondhand smoke” has been strongly associated with respiratory illness in children and with both cancer and heart disease in adults living with smokers. Approximately 21.6% of U.S. adults are current smokers (10). Although this prevalence is lower than the 22.5% prevalence among U.S. adults in 2002 (11), the rate of decline is not sufficient to meet the national health objective for 2010.

Coronary heart disease is the leading cause of mortality in the United States, accounting for nearly one-third of all deaths (12). Cigarette smoking greatly increases the risk of death from heart disease, and smoking cessation produces marked reductions in cardiovascular risk (6). The experience of hospitalization, particularly for cardiovascular disease, can result in smoking cessation even without intervention (13,14,15). However, cessation rates vary greatly, depending on the reason for hospitaliza-tion, length of stay, and the presence of depressive symptoms (16,17). For example, Rigotti et al found high cessation rates (58%) 1 year after hospitalization among patients having coronary bypass surgery, whereas other studies have shown low cessation rates among smokers immediately after hospitalization (13.7%) and at 1-year follow-up (9.2%) (18,19). Most individuals who quit smoking without intervention will relapse within 6 months (17,20).

Although 70% of smokers visit a physician each year, relatively few doctors use this opportunity to address the patient’s smoking (21,22,23). Physicians practicing in specialties such as cardiology or emergency medicine are less likely to provide smoking cessation interventions than primary care physicians (24). Possible explanations cited for low physician intervention rates include lack of time, deficient training in counseling skills, and an absence of organizational supports (25,26,27,28). This is regrettable because multiple studies have shown that even a brief intervention lasting less than 3 minutes significantly increases the chance that the smoker will quit (22,29). Formal physician training, the use of cues or reminders, pharmacologic aids, follow-up visits, and supplemental educational materials all increase the effectiveness of physician-delivered interventions (22,30). Cardiologists seeing smokers with coronary artery disease, hypertension, or histories of recurrent chest pain can be especially effective because the patient’s illness can be linked directly to smoking. The clinical encounter is an important opportunity to address smoking cessation and should not be missed (31). Many physicians, however, do not feel that they have the counseling skills or training to address the issue of smoking cessation effectively. This chapter provides a well-researched, effective, and simple approach that cardiologists can use to counsel their patients who smoke.

Clinical guidelines have been developed through a joint collaboration between the Centers for Disease Control and the Agency for Healthcare Research and Quality (AHRQ) together with the National Cancer Institute, the National Heart, Lung, and Blood Institute, the National Institute on Drug Abuse, the Robert Wood Johnson Foundation, and the University of Wisconsin Medical School Center for Tobacco Research and Intervention (29). The recommendations made as a result of this extensive, systematic review and analysis of the extant peer-reviewed scientific literature form the basis of the approach taken in this chapter.

The key principles underlying these recommendations are

The best practice model for a brief intervention for smoking cessation is easily summarized by the mnemonic device of the “Five As” (Table 26-1). Each of these—Ask, Advise, Assess, Assist, and Arrange follow-up—is summarized in the following paragraphs (Fig. 26-1).