Smoking and the Patient With Cardiovascular Disease

Alan Blum, MD, Department of Family Medicine, Baylor College of Medicine, Houston, Texas


Smoking is the only completely avoidable risk factor for cardiovascular disease; thus, It is critical that family physicians include refreshing approaches to smoking prevention and cessation as important goals in the primary care of our patients.

Prevalence and Risks

At least a quarter of the adult population in the United States smokes, with the percentage climbing to as high as 40% or more in certain segments of the population (Figure 1)1. Furthermore, It is estimated that a third of high-school-age students {34.8%) smoke cigarettes.2 Those who smoke are at a substantially higher risk for cardiovascular disease, among other serious chronic illnesses. Individuals exposed to passive smoke in the home and workplace are also at increased risk for coronary artery disease.

Physiologic Effects on the Cardiovascular System

While the precise mechanisms by which smoking increases cardiovascular disease are still being discovered, it has been shown to exert direct myocardial effects, such as increasing myocardial oxygen demand, lowering the threshold for angina, and Impairing exercise performance (Figure 2).

Indeed, the rate of CHD deaths among those who smoke is double that of nonsmoking individuals.3 Smoking also appears to accelerate the atherosclerotic process itself by adversely affecting the lipid profile, altering blood pressure and hematologic factors, and exerting direct deleterious effects on arterial walls (Figure 3).

Smoking Prevention and Cessation

Motivating people to stop smoking is a formidable challenge, as is the effort to prevent individuals from starting smoking in the first place. Encouragingly, family physicians can begin to exert a positive influence both by serving as a source of information about the effects of tobacco on health as well as by implementing office-based strategies to promote “anti-smoking” attitudes. Attitudinal approaches should be accompanied by simple behavioral modification techniques (eg, relaxation response, oral substitutes) that move beyond the pharmacologic methods of the conventional nicotine addiction model (ie, the patient as an addict) and toward a consumerist approach-“the thinking patient’s technique.”

1978 AHA More Billboards 1

Consumerist Model

The consumerist model (Table 1) places less emphasis on the physiologic aspects of nicotine addiction and related cessation strategies and more emphasis on a linguistic-based approach In which sociocultural factors are considered and the individual who smokes is encouraged to think in new ways about his or her behavior and how it might be modified.4,5 The consumerist approach Includes nonthreatening and nonjudgmental questions from the physician that personalize the problem and point out Immediate health and financial implications of the behavior (Table 2).

Role of the Family Physician

Family physicians will be most successful in helping a patient to stop smoking by individualizing and personalizing the approach. breaking down myths that surround smoking find Its consequences, and by choosing words more carefully (revocabularizing) when discussing cigarettes with the patient (Table 3).

Doctors Ought to Care (DOC)

Since 1977, DOC (Doctors Ought to Care) has been training physicians, medical students, end other health professionals to counteract the promotion of tobacco and other unhealthy products by means of humorous and engaging approaches in the clinic, classroom, and community.

1978 DOC Bus Bench Benson Heartattack


  1. CDC. Cigarette smoking among adults – United States, 1994. MMWR, 1996;45:588-589.
  2. CDC. Tobacco use and usual source of cigarettes among high school students – United States, 1995. MMWR, 1996;45:413-418.
  3. Neaton JD, Wentworth D, for the Multiple Risk Factor Intervention Trial Research Group. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Arch Intern. Med. 1992;152:56-64.
  4. Rakel RE, Blum A. Nicotine addiction. In: Rakel RE, ed, Textbook of Family Practice, 5th ed. Philadelphia, PA: WB Saunders: 1985:chap 58.
  5. Blum A. Consumer advocacy: a crafty approach to counseling. Patient Care. February 28, 1993. pp 80-83.

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