Currently, there are more than 1 billion smokers worldwide with 80% of them living in low and middle income countries. Each year five million deaths are directly related to smoking with 600,000 additional deaths caused by passive smoking. Furthermore, the amount of healthcare expenditure due to smoking-attributable diseases is similarly significant and increasing, approaching $500 annually in the USA .
Despite the huge reduction in cardiovascular disease (CVD) in the last 30 years, CVD still remains the most common cause of death worldwide. Although the risk factor modification has improved significantly thanks to appropriate public awareness campaigns/programmes, including successful anti-smoking legislation, it is still anticipated that a healthy lifestyle can further prevent in excess of 80% of CVD .
Mechanism by which smoking leads to CVD
Smoking can increase the development of atherosclerosis and superimposed thrombotic phenomena by affecting platelet function, fibrinolysis, endothelial function, oxidative processes, inflammation, lipid oxidation and vasomotor function. In both experimental and human studies, several of these are reversible, even after a short period (a few weeks) of smoking cessation . Atherosclerotic plaque formation however, is not thought to be fully reversible and in terms of CVD, smokers would never be expected to reach the risk level of those who have never smoked , especially if they continue to smoke after the age of 30 .
Life expectancy and smoking
There is ample evidence documenting the risk associated with smoking, and it is well accepted that on average a life-long smoker will die 10 years earlier than a non-smoker, a risk that is halved if smoking is given up at the age of 50 and almost normalised if given up before the age of 30 . This risk is much higher even when compared to patients with severe hypertension, who, on average, die ~3 years younger than people without hypertension . Despite this, many smokers (up to 25% in countries like China) still remain unaware of the cardiovascular risk associated with tobacco use  and hence are unaware of the harm.
Do smokers want to give up?
Certainly more than two thirds of smokers are keen to give up smoking, but, less than 1 in 20 are successful . This is an area where we can help by promoting smoking cessation and supporting the smokers throughout the entire process. Furthermore, the benefit and health of passive smokers should also be reminded in all healthcare promotion campaigns.
Time and ways to give up smoking
It is also known that stopping smoking altogether is the most cost-effective strategy to prevent CVD, and there is strong evidence that short pharmacotherapeutic treatment, with, for example, nicotine replacement therapy, bupropion, varenicline plus ongoing support are very effective. At the moment, it is anticipated that electronic cigarettes might also assist significantly in reducing smoking, but in the absence of long-term data for the time being, they should be covered with the same marketing restrictions as cigarettes.
The first step in facilitating smoking cessation
The very first step is identifying who the smokers are in a community or hospital setting and how dependent on nicotine they are (using the Fagerstrom Test).
The Fagerstrom Test for Nicotine Dependence. 
The "five As" for a smoking cessation strategy for routine practice
By considering the “Five As” as shown in the table below, it is important to consider who would be a suitable candidate for smoking cessation.
|A-ASK||Systematically inquire about smoking status at every oppotunity.|
|A-ADVISE||Unequivocally urge all smokers to quit.|
|A-ASSESS||Determine the person's degree of addiction and readiness to quit.|
|A-ASSIST||Agree on a smoking cessation strategy, including setting a quit date, behavioural counselling
and pharmacological support.
|A-ARRANGE||Arrange a schedule of follow-up.|
Table taken from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice detailing the first steps, the “Five As” in smoking cessation .
Having identified a candidate willing to attempt smoking cessation, in addition to the pharmacotherapeutic and other actions by health professionals (doctors, nurses, councillors) it is also important to look for help from the person’s family (with their consent) as support from the partner and family can be instrumental. The following table details the recommendations for smoking intervention strategies.
Recommendations for smoking intervention strategies
|It is recommended to identify smokers and provide repeated advice on stopping with offers to help, by the use of follow up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination.||I||A||289- 286|
|It is recommended to stop all smoking of tobacco or herbal products, as this is strongly and independently causal of CVD.||I||B||287-291|
|It is recommended to avoid passive smoking.||I||B||292- 293|
CVD: cardiovascular disease
aClass of recommendation
bLevel of evidence
cReference(s) supporting recommendations
Table taken from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice showing the recommendations for smoking cessation intervention .
Recommendations for pharmacotherapy for smoking cessation
The table below illustrates the evidence-based recommendations for pharmacotherapy for smoking cessation .
|Advantages||Many years of experience. High safety. Dose and combination of several different products can be adapted individually|
|Disadvantages||High risk of under-dosing (i.e. no effect)|
|Side effects||Common: palpitations, chest pain, nausea and vomiting, gastrointestinal complaints, insomnia, skin irritation, mouth and throat soreness, mouth ulcers, hiccups and coughing|
|Dosage||Bupropion Starting dose is 150 mg od for 6 days; followed by 150 mg bd for 7 to 9 weeks.|
|Advantages||Easy to dose. Well-known safety profile as the drug has previously been used in psychiatric patients for decades|
|Disadvantages||Many interactions with other types of medicine, e.g. antidepressants, antipsychotics, and type 1c anti-arrhythmics|
|Side effects||Insomnia, headache, dry mouth, dizziness, and nausea are common. Risk exists for serious adverse effects such as seizures|
|Contraindications||History of hypersensitivity to bupropion. Concurrent use of MAO inhibitors. Current or past epilepsy, bulimia, or anorexia nervosa. Alcohol withdrawal or withdrawal from benzodiazepines. Bipolar disorder. Severe liver cirrhosis. Know CNS tumour. Pregnancy|
|Dosage||Varenicline Starting dose is 0.5 mg od for 3 days, followed by 0.5 mg bd for 3 to 4 days, followed by 1 mg bd.|
|Advantages||Highest quit rates. Easy to dose|
|Disadvantages||Neuropsychiatric cautions. Expensive|
|Side effects||Common: nausea, insomnia, headache, abnormal dreams, constipation, flatulence, and abdominal pain. Severe: neuropsychiatric and cardiac adverse events have been reported|
|Contraindications||History of serious hypersensitivity or skin reactions to varenicline. Pregnancy|
Addressing overall cardiovascular risk
In addition to promoting smoking cessation at every opportunity and supporting smokers with this throughout, it should also be remembered that smokers do have a significantly higher CVD risk. Therefore, this should be reviewed and other conditions such as hypertension and hypercholesterolemia should be appropriately managed alongside the smoking cessation strategy.
Patient info - Tips to stop smoking:
Cravings for a cigarette usually last 3 to 5 minutes. If you can get over those few minutes, you are well on the way to not having that cigarette. The 4 D's can help you do that. 
- Delay: wait at least 3 minutes; the urge will pass
- Drink: water or juice
- Distract yourself: move away from the situation, and do something different
- Take deep breaths: breathe slowly and deeply, in through your nose and out through your mouth.
Smoking still results in significant morbidity and mortality in both smokers and passive smokers. With appropriate identification of smokers, education and successful actions for smoking cessation and a healthy lifestyle, the advantages associated with giving up smoking can be seen both at an individual level, but also at a population level.