2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

. Author manuscript; available in PMC: 2017 Sep 21.

Published in final edited form as: Circulation. 2016 Nov 13;135(12):e726–e779. doi: 10.1161/CIR.0000000000000471


Recommendations for Smoking Cessation

COR	LOE	Recommendations

I	A	Patients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit.^170–172

See Online Data Supplements 19 and 20.		Tobacco use is a strong risk factor for the development and progression of PAD.^173,174 Sparse evidence exists with regard to the association of novel tobacco product use, including electronic cigarettes, and PAD.¹⁷⁵ Observational studies suggest that smoking cessation is associated with lower rates of cardiovascular ischemic events, limb-related events, bypass graft failure, amputation, and death in patients with PAD.^{172,176–178} Clinician advice increases quit rates, which supports simple provider-based measures as a component of smoking cessation programs.^22,171,179

I	A	Patients with PAD who smoke cigarettes should be assisted in developing a plan for quitting that includes pharmacotherapy (ie, varenicline, bupropion, and/or nicotine replacement therapy) and/or referral to a smoking cessation program.^{170,180–182}

See Online Data Supplements 19 and 20.		Coordinated smoking cessation interventions that include nonpharmacological and pharmacological approaches have the greatest efficacy. An RCT of a follow-up program and smoking cessation medications provided to hospitalized patients, including those with PAD, demonstrated a modest increase in quit rates.¹⁸¹ In an RCT of patients with PAD specifically, a comprehensive smoking cessation program combining counseling and pharmacological agents increased the rates of smoking cessation to 21.3%, compared with 6.8% with standard advice.¹⁷⁰ Three pharmacological approaches (ie, varenicline, bupropion, and nicotine replacement therapy) used alone or in combination all increase smoking cessation rates.^179,180,182 Two meta-analyses of RCTs of smoking cessation medications showed no evidence of increased cardiovascular event rates with nicotine replacement, bupropion, or varenicline.^183,184 Sparse data suggest that electronic cigarettes have no benefit on smoking cessation rates.¹⁷⁹

I	B-NR	Patients with PAD should avoid exposure to environmental tobacco smoke at work, at home, and in public places.^185,186

See Online Data Supplement 20.		Passive smoke exposure has been associated with the development of PAD.¹⁸⁶ Observational studies have shown lower cardiovascular and cerebrovascular event rates in the general population after enactment of smoke-free legislation.¹⁸⁵ The effects of avoidance of passive smoke exposure on limb-related events are not known.