Approach to smoking cessation in the patient with vascular disease

Opinion statement: In the patient with vascular disease, cigarette smoking is particularly perilous; the benefits of smoking cessation greatly exceed any risks associated with pharmacologic treatment. The patient with claudication is often uniquely motivated to quit smoking because 1) there is a chance that the leg pain will improve and 2) smoking cessation may prevent disease progression and thus invasive procedures. The first step toward success is a systematic approach with focus on the 5 A's (Ask, Advise, Assess, Assist, and Arrange). Multiple clinical trials have demonstrated the efficacy of pharmacologic therapy for smoking cessation. The most effective medications available are bupropion and varenicline. If the patient is ready to quit, varenicline is typically first-line unless contraindicated. If the patient has concomitant signs or symptoms of depression, bupropion in combination with nicotine replacement therapy is preferred. In parallel with aggressive counseling and pharmacotherapy for smoking cessation, cardiovascular risk reduction is critical. Established atherosclerotic vascular disease (including peripheral artery disease, abdominal aortic aneurysm, or carotid artery disease) plus poorly controlled risk factors, including current smoking, place the patient in the "very high-risk" category, which favors reducing the low-density lipoprotein level to less than 70 mg/dL. The increased cardiovascular risk associated with smoking is tremendous, particularly in the vascular patient. Smoking cessation is critical, and no other health intervention offers such a large potential benefit.