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Editorial Comment

Smoking Cessation Therapy for

the Patient With Heart Disease*
THOMAS E . KOTTKE, MD, FACC
Rochester, Minnesota

Stopping smoking is a critical intervention for the patient

with coronary heart disease . After a myocardial infarction,
smoking cessation is associated with a doubling of remaining
life expectancy (1 3), and stopping smoking improves outcomes after coronary artery bypass graft surgery (4) . However, unverified reports of patients having an acute myocardial infarction while receiving transdermal nicotine
replacement therapy (5) may have made cardiologists reluctant to prescribe nicotine replacement to help their patients
stop smoking . They have rightly been unsure whether replacing cigarettes with nicotine patches is truly reducing risk
or is simply substituting iatrogenic risk for a risk that
patients have chosen for themselves .
The present study . Benowitz et al . (6) describe in this
issue of the Journal the results of an experiment to determine
whether transdermal nicotine activates platelets in the same
manner as tobacco smoke . For this trial, they recruited 12
healthy male smokers to spend 16 days in a clinical study
center. After abstaining from aspirin and other antiinflammatory drugs for 2 weeks before the study, the subjects were randomized in a crossover design to 5 days of
nicotine patch or 5 days of smoking . Six subjects were
assigned to wear a patch first and six to smoke cigarettes
first . The subjects were then crossed over to the opposite
conditions . After the crossover, all subjects participated in a
5-day placebo patch condition. During the patch treatment
blocks, subjects were carefully checked for evidence of
surreptitious smoking .
During all treatment blocks, urine was collected on days
3 and 4 for measurement of thromboxane and prostacyclin
metabolites. On day 4 of each block, blood samples were
taken at 8 Am and 12 noon for platelet aggregation studies
and measurement of platelet factor 4, beta-thromboglobulin,
Factor VII and fibrinogen concentrations. Red blood cells,
white blood cells and platelets were also counted . On day 5
of each block, blood samples were taken at 4-h intervals for
measurement of plasma nicotine and blood carboxyhemoglobin concentrations.

*Ediloliah published in Jven& qt the Americas College of Cardiology

retied the views of the authors and do not necessarily represent the views of
JACC of the Amesiran College of Cardiology.
Frees the Department of Internet Medicine, Division of Cardiovnsarhu
MUM Mayo CI and Famdations, Rochester. Mimesota.
Thomas E . Kottke, MD, Harwick 6, Mayo
Chest, Rochester, Minnesota 59905.
01499 by we Arnericaa College of Cardiology

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The results indicate that in men without clinical evidence

of coronary artery disease, the nicotine patch has very little
effect on platelet and fibrinogen activation and more strongly
resembles the placebo patch than cigarette smoking . The
authors (6) concluded that "insofar as smoking contributes
to acute coronary events by enhancing platelet activation or
increasing fibrinogen, transdermal nicotine should not be
associated with such a risk." Although the results would be
more satisfying if the study had been performed in subjects
with known coronary artery disease or had addressed potentially negative effects of nicotine not related to platelet
aggregation, the findings of Benowitz et al . should increase
the confidence of cardiologists that nicotine patches can be
safely used in their patients .
However, patches are not a panacea ; without long-term
reinforcement their efficacy is limited (7). Simply neutralizing dependence on nicotine is not enough to make a smoker
quit ; something must happen to make the smoker want to
quit (8). Therefore, once the cardiologist decides to treat a
patient with nicotine replacement, it is important that the
therapy consist not only of nicotine patches but also of a
program to help the patient learn how do deal with urges and
cues to smoke and a reinforcement program to help the
patient maintain the desire to remain abstinent. Few cardiologists have either the time or the desire to personally
provide these services, but there are successful practice
organization models that provide them with minimal physician involvement .
The Mayo Clinic Nicotine Dependence Center. One model
for such a service is the Mayo Clinic Nicotine Dependence
Center consultation service (9) . This service has four components : behavioral therapy, addictive disorders therapy,
adjunctive pharmacologic therapy and relapse prevention .
When a physician or physician-designate initiates the request for consultation, a trained counselor obtains a detailed
smoking history to determine the patient's level of nicotine
dependence, assess the patient's motivational level and
stage of readiness to quit smoking, and utilize specific
strengths of the patient in developing a treatment plan . The
counselor uses therapeutic techniques that include confronting defensiveness; emphasizing negatives associated with
tobacco use ; recognizing loss of control ; bringing unmanageability into focus ; defining consequences of use ; facilitating
acceptance of dependency and need for help ; providing help
through a program combining tools for recovery with hope,
insight and supportive therapy ; developing a plan for stopping; developing aftercare plans with a clear understanding
that recovery is a process that cannot be completed in a
short time; teaching stress management, and identifying
coping skills . Counting all nonresponders to a questionnaire
as smokers, the self-reported rate of smoking cessation for
all 578 patients treated with this strategy by the center in
1988 was 23% . (Because of undefined biases, caution must
be used when comparing this rate with the spontaneous rate
of stopping smoking in the United States . However, it can be
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noted that a 23% cessation rate is more than four times tte
national rate of spontaneous cessation .) This outpatient
consultation service has been translated into an equally
successful inpatient treatment service for profoundly addicted smokers (10) .
A service such as the one at the Mayo Clinic can be
organized to minimize the burden on the physician's time in
much the same way as coronary care units and catheterization laboratories are organized . A physician medical director
makes the medical decisions and provides the inter am
between the treatment unit and the individual physicians
who use its services, and a nurse supervisor oversees the
day-to-day functioning of the service .
Role of the cardiologist . A nicotine dependence treatment
service cannot be effective unless smokers are identified and
referred for care . The effectiveness of the service is also
increased if the smoking cessation message is reinforced
during visits to all health care professionals, not just to those
who are directly affiliated with the nicotine dependence
service . Therefore, each cardiologist needs to take the
following actions to optimize the therapy of his or her
patients who use tobacco:
At each visit, give firm but friendly cessation advice
and offer to help the patient stop smoking . Adding
smoking status to the vital signs collected by the nurse
at every visit reminds the cardiologist to address smoking (11) . Labeling of the charts of nonsmokers saves the
nurse the work of repeatedly asking these patients
about their smoking status (12) .
Reinforce the behavior of patients who have already
quit smoking . Most smoking cessation attempts are
followed by relapse, and reinforcement of cessation
behav ;ur reduces relapse (13) . In addition to helping the
patienr., reinforcing comments remind the cardiologist
that patients actually do quit smoking .
Add a paragraph on the importance of smoking cessation to the report letter to the referring physician.
Failure to mention smoking may lead the referring
physician to believe that smoking is not a problem once
a patient develops heart disease ; a paragraph on smoking informs the referring physician that the cardiologist
recognizes that smoking cessation is important and will
remind the referring physician to support all smoking
cessation interventions . This paragraph can be a standard macro on a secretary's word processor .
Take an activist role to eliminate public smoking in the
community ; cardiologists who are not personally active
can contribute financially to support those who can be
active locally . Reducing opportunities to smoke in
public reduces the likelihood that patients will continue

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KOTTKE
EDITORIAL COMMENT

1169

to smoke . Eliminating public smoking can a1s : be

expected to reduce the rate of myocardial infarction
among nonsmokers (14) . Although it is true that the
tobacco industry is rich and powerful, local tobacco
control initiatives tend to succeed when they receive
the enthusiastic support of the health care community
(15) .
Conclusions. Helping the patient with heart disease to
stop smoking is a critical component of a comprehensive
care plan . The work of Benowitz et al . (6) increases our
confidence that nicotine replacement can be included in the
tools that we bring to bear to treat nicotine dependence .
However, whether or not we choose to prescribe nkotine
patches, implementing therapy for our patients who smoke
remains our obligation .

References
I . Mulcahy R . Influence of cigarette smoking on morbidity and mortality
after myocardial infarction . Br Heart J 1983 ;49:410-5 .
2 . Salonen IT . Stopping smoking and long-terns mortality after at :ute myocardial infarction . Hr Hea .rt J 1980 ;43 :463.9 .
3 . Wilhelmsson C, Vedin JA, Elmfeldt D, Tibblin G . Wilhelmsen L. Smoking and myocardial infarction. Lancet 1975;1 :415-20 .
4 . Hermanson B, Gersh B .I. Frye RL, et al . Beneficial six-year outcome of
smoking cessation in older men and women with coronary artery disease :
Results from the CASS group study registry . N Engl J Med 1988 ;319:
1365-9.
5 . Hwang SL . Waldholz M . Heart attacks reported in patch users still
smoking. Wall Street Journal 1992 ;June 19.
6. Benowitz NL, Fitzgerald GA . Wilson M . Zhang Q. Nicotine effects on
eicosanoid formation and hemostatic function : comparison of transdermal
nicotine and cigarette smoking . J Am Coo Cardiol 1993 :1159-67.
7 . Hun RD, Lauger GG, Offord KP, Kottke TE, Dale LC . N.cotinereplacement therapy with use of a transdermal nicotine patch-a randomized double-blind placebo-controlled trial . Mayo Clin Proc 1990 ;65 :152937 .
8 . Venters MH . Kottke TE, Solberg LI . Brekke ML . Rooney B. Dependency . social factors, and the smoking cessation process : The Doctors
Helping Smokers Study . Am J Prev Mad 1990 ;6:185-93 .
9. Huts RD. Dale LC, McClain FL, et .al . A comprehensive model for the
treatment of nicotine dependence in a medical setting. Med Clin North
Am 1992 ;76:495-514.
10. Hurt RD. Dale LC . Word KP. Bruce BK . McClain SL, Ebennan KM .
Inpatient treatment of severe nicotine dependence . Mayo Clin Proc
1992 :67 :823-8.
11 . Fiore MC. The new vital sign. Assessing and documenting smoking status
(comment) . JAMA 1991 ;266:3183-4.
12 . Solberg LI, Maxwell PL . Kottke TE, Gapner Gi . Brekke ML . A
systematic primary care office-based smoking cessation program . J Fam
Pract 1990;30:647-54 .
13 . Kottke TE, Battista RN . DeFriese GH, Brekke ML. Attributes of
successful smoking cessation interventions in medical practice : a metaanalysis of 39 controlled trials . JAMA 1988 ;259 :288 .
14. Glantz SA, Parmley WW- Passive smoking and heart disease : epidemiology, physiology. and biochemistry. Circulation 1991 :R3a-12.
15 . Samuels B, Glantz SA . The politics of local tobacco control . JAMA
1991 ;266:2110-7 .