Cardiologists GUILTY AS CHARGED with PASSIVISM on SMOKING CESSATION-----HELLO--VARENICLINE

   The last paragraph in the editorial in this month's Lancet reads as follows:  "It is time for cardiologists to be less passive about their patients' smoking status and public health approaches to tackle smoking.  After all, a reduction in smoking at the patient and population level would have a  BIGGER IMPACT ON CARDIOVASCULAR DISEASE than ANY OF THE HIGH -TECH INTERVENTIONS  that delegates in Orlando will hear about."

Hallelujah! Somebody else actually gets it and he has a large audience of intellects who might just be a awakened from their long Rip VanWinkle like sleep to find that our country can no longer afford the "business owner's right to choose" mantra that drives teen smoking and morbidity from 2nd hand smoke. Maybe he'll awaken  us from our passivist slumber enough to rummage through the phone book and contact our local city councilmen, congressmen and even use what connections we  have to our new President Obama.    Though a landslide majority of cardiologists (and citizens) want a smoke free nation, a minority of them are politically active enough in anyway to make it happen. Others feel that national legislation will poison local efforts and we'll wind up with weak legislation that will not protect each and every employee and restaurant worker in this nation.  I say, we've reached the tipping point and we need to stop hiding behind our mother's ashtrays and get to work.   

There is damning evidence everywhere  that we as cardiologists are not doing our jobs at the office level. The Pfizer folks are much nicer about this issue than I am.  Larry Samuels , PHD, pharmacologist and senior medical director at Pfizer   indicated that" physicians get reimbursed very little for smoking cessation" as a reason for why it's not discussed more often with our patients.  I checked with my secretary at our office .  The only folks who reimburse are Medicare and it's a paultry $11.00 for a less than 10 minute conversation and $22.00 for a conversation of greater than 10 minutes.  If I billed every minute I spent begging folks to NOT smoke, I could bail out the auto industry, turn Madoff into mother Teresa and build a Taj Mahal for a guest house, plus retire a century ago.   We shouldn't have to be paid to try and engage a smoking cessation discussion but it's a nice gesture.  It's also time well spent which is why Medicare does it.  Smoking cessation pays off more for them than hypertension and lipid mangement. 

Which brings me to the poster presentation on Varenacline today.  In a nutshell, smokers already sickened with tobacco related illness of  stable coronary obstructive disease and cerebrovascular disease were placed on Varenacline in this randomized double blind placebo controlled study where carbon monoxide levels were utilized to confirm continuance abstinence rates (CAR).   Veranacline more than tripled the CAR compared to placebo at the end of the 12 week treatment period and maintained a higher CAR at 52 weeks of follow-up. Further more, for all the tobacco lobbyist die hard "you'll have to pry this cigarette out of my cold dead hands" folks, it was SAFE.  Let me repeat that, IT WAS SAFE. I know I've disappointed the tobacco lobbyists lurking here, but suck it up.  Varenacline works. 

Though this study was only powered to looked at efficacy, there was no increase in all cause mortality  in the Varenacline group .  As a matter of fact, the all cause mortality in the  Varenicline group was 0.6% and the placebo group was 1.4%.  Though not statistically significant at the end of 12 weeks, the trends were definite and predictably will diverge over time.  Every single smoking cessation study in the world demonstrates benefit whether it be from cancer rates, asthma rates, copd admission, stent thrombosis, CABG vein -graft failure,  stroke risk, etc. etc. etc. 

Michael Honan MD Invasive non-interventionalist from Birmingham, Alabama attended the poster presented by Dr Nancy Rigotti.  When someone asked about publicly reported events of suicide and depression with Chantix, he pointed out that in the Nurse's Health Study where women ages 25-50 were followed for 25 years, of the deaths that occurred , around 64% of the deaths were attributed to smoking.  I get it Dr. Honan.  Though they didn't swallow a bottle of pills , to their families they are just as absent  and are left to hurt because their addiction to tobacco trumped the opportunity to participate in their every day lives .  Some call that passive suicide, the rates of which will forever surpass any implied connection to Varenacline in today's prescribing environment. Dr. Riggoti added that we "don't even know with any certainty that varenacline ever increased these events but we DO KNOW FOR CERTAIN that tobacco will kill you".

Dr. John I Stewart of Port Perry Ontario a family practitioner with an interest in Prevention said  that even though the restrictions for pilots and truckers were heavily publicized, his prescribing habits for Champix (Chantix in America)" never decreased."  "To not treat the smoker is to disenfranchise them from the entire prevention arena", he said.    When asked what percentage of his town smokes he replied suprisingly "around 20-30% probably".  "Why is that ?" I inquired.  "You are from Canada".  He explained that the American auto giant  GM has a large presence in his town and that the  blue collar workers (that he obviously cares a lot about) have a high smoking prevalence.  He said that the Varenacline data presented today is "not suprising and actually very reassuring". I overhead him explaining to someone that he's actually starting a smoking cessation clinic and he hopes to track his success over a couple of years. Good luck Dr. Stewart.  Since GM is costing your town so much in death and health care expenditure, perhaps you could ask them to help you as a goodwill gesture.

The indications for Varenacline use may increase over time with early trials starting with alcoholism.  There have even been hints in the past of food addiction and drug addiction therapy application.  Even though the sales for Varenacline dipped by around 40% last January after the restrictions were placed on pilots, there has been a predictable increase in prescribing in the last few weeks.  "Even doctors who were reluctant to prescribe for a while after that really couldn't recall adverse events", said Dr. Samuels. 

We need to become MORE UNcomfortable with the side effects of smoking which include every negative health effect on the planet, MORE COMFORTABLE with prescribing Chantix, more comfortable with spending the necessary time to  engage each and every one of our smoking patients on each and every office visit and be motivated to run, NOT walk to call our local politicians to start a massive movement toward city, county, state and nation wide smoke free legislation. 

 It's time that cardiologists declare war on our own shameful passivism on the smoking epidemic  in this country.  It's a "just"  war that would save lives, money and generate more happiness than  any QOL scale could ever measure. 

I hope passivism is dead.

Your comments

	Cardiologists GUILTY AS CHARGED with PASSIVISM on SMOKING CESSATION-----HELLO--VARENICLINE
	# 1 of 7	April 1, 2009 04:56 (EDT)
	Imran Virk	Excellent commentary. I agree with your comments: "We need to become MORE UNcomfortable with the side effects of smoking which include every negative health effect on the planet, MORE COMFORTABLE with prescribing Chantix."
	# 2 of 7	April 1, 2009 06:02 (EDT)
	Michael Kretz	Standard of care (does any one still care?) for tobacco use/addicition is counseling and pharmacotherapy.  If physicians are just too busy to do an intervention in the office, they can just tell the patient to call the toll-free National Quit Line at 1-800-QUIT-NOW.  "Cold turkey" cessation rates are 3%.  Using the Quit Line increases cessation rates to 22%.  If $11 is too little, ask them if they smoke, advise them to quit, and assist them with the Quit Line number.
	# 3 of 7	April 2, 2009 08:14 (EDT)
	Melissa	Michael, I agree with you, but the point of this trial was that in patients who had already been diagnosed with heart and cerebrovascular disease, many of which intuitively had already been told of the connection between their habits and their health, amazingly (I'm always amazed by this) continued to smoke.  It was in these patients that there was STILL an increase in quitting success by 3x over the quit rates in those who were given placebo instead of Veranacline.  I am encouraged by the information you provided that quit rates with quitlines are 22%.  That's amazing.  Maybe I can extrapolate that to mean that I'm not wasting my breathe in the office after all. Melissa
	# 4 of 7	April 3, 2009 10:07 (EDT)
	Val Fitzgerald	I was thrilled to learn that at least in one place, TX--the 'smoking age' (buy-tobacco age) has been raised to, I think, 19. Way to go, people!  I was all set to celebrate until I remembered that, alas, the DRINKING AGE has been lowered, also by one year--and sobriety checkpoints are not well tolerated down here either. Doesn't make any sense AT ALL...but who am I to complain?
	# 5 of 7	April 9, 2009 04:55 (EDT)
	Melissa	Thanks for sharing Val.  I just commented today that since the measley 30 cent tobacco tax was passed by our wimpy legislature, quit lines have been jammed (calls increased by 30%) .  Everywhere I go, someone tells me "I've quit". So, a certain state representative, who shall remain nameless was wrong when he told me that "a tax increase won't make any difference to addicts".  I know he meant well, but he was wrong, dead wrong and  the next time we try to increase taxes on this worthless weed, I'm going to gently and respectfully remind him of such.  Melissa
	# 6 of 7	April 12, 2009 06:42 (EDT)
	Frank Tyers	That smoking killed was intuitively obvious to some   thoracic surgeons in the 1930s after they began doing lung resections for cancer. Remarkably some continued to smoke, a measure of the power of this addiction. Currently its something all responsible people can agree on. I refused to do open heart surgery on any patient who continued to smoke and explained to family members that it would be nearly impossible for the patient to stop unless everyone quit. At least in Canada this worked remarkably well in ensuring a high rate of continuing post operative abstinence and many 20 year asymptomatic survivors.  Antismoking lobbying groups have been very active in Canada and a number of years back succeeded in getting taxes hiked very substantially. However this was to limited avail as our cigarette companies sent their death warrants south at low tax rates for smuggling back into Canada, and of course the less expensive US product was also widely available. Thus we need a NAFTA equivalent agreement on uniform relatively high tobacco taxes to limit interregional and inter-country   smuggling; and hopefully to establish a pattern for the Euro zone etc.
	# 7 of 7	April 12, 2009 08:17 (EDT)
	Melissa	Great points Frank.  I remember in the late 1980's, sitting in the amphitheatre for thoracic surgery rounds, the chief of thoracic surgery smoking while the cases were being presented.  That would NEVER happen today, so just when I'm discouraged, I think of how far we have come.  Perhaps the OBAMA administration might consider the NAFTA equivalent before his term is over.  We can only hope. Thanks for sharing, Melissa

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