Cardiology Magazine — Spring 2013 Cardiology
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The Cost Of Lighting Up

It is addictive. It is glamorized.It directly and indirectly damages hearts around the globe. Smoking is the common denominator in 40 percent of all cardiovascular disease, according to an environmental scan report published late last year in the Journal of the American College of Cardiology (JACC).

The report, entitled “The Worldwide Environment of Cardiovascular Disease: Prevalence, Diagnosis, Therapy and Policy Issues,” brings to light what many have suspected for decades, and what numerous studies have proven: smoking can diminish the benefits of statins, worsen hypertension, and contribute to cardiovascular disease morbidity and mortality. It is also a major risk factor for stroke, doubling the risk of ischemic stroke and increasing the risk of subarachnoid hemorrhage up to four times. Overall, smoking is a burden on health care systems around the globe.

It is also expensive. According to the American Lung Association, the average retail price of a pack of cigarettes in the U.S. is $5.51. However, the cost to society and state economy averages to more than $18 per pack.1 It is estimated that in 2004, smoking cost the U.S. over $193 billion which averages to $4,260 per adult smoker in just one year.2 In some of the most underprivileged households across the globe, tobacco accounts for more than 10 percent of the total family expenditures.3

However, the good news is that U.S. smoking rates have declined since the 1960s when the Surgeon General first issued a warning about cigarettes and the Federal Trade Commission instituted the requirement of a prominent warning on cigarette packages and advertisements. The JACC environmental scan reports that 41.7 percent of adults smoked in 1965, but by 2010, the number had dropped to 19.3 percent.

While smoking rates among adults in the U.S. have declined significantly over the past few decades, the issue remains a global one. At least 25 percent of residents living in Greece, Chile, Ireland, Hungary, Estonia, Spain and Turkey smoke, according to recent Organization for Economic Cooperation and Development health data published in JACC. The World Health Organization (WHO) predicts that tobacco use will kill upwards of 8 million people each year by the year 20304 if the current smoking trends across the globe continue.

In response to a United Nations declaration made in May 2012 to reduce premature death caused by non-communicable diseases (NCDs) by 25 percent, the ACC joined the NCD Alliance, a global task force that includes representation from the American Heart Association, World Heart Federation, European Heart Network and the European Society of Cardiology. The task force established risk factor reduction targets to be reached by 2025, which include a 30 percent relative reduction in the prevalence of tobacco smoking.

According to the NCD Alliance’s jointly released health policy statement, cardiovascular disease is the leading global cause of death and is attributed to 17.3 million deaths annually. It accounts for nearly half of the 36 million NCDs, which have overtaken communicable diseases as the world’s largest disease burden.

“Collaboration among appropriate stakeholders will be necessary to address this emerging 21st century global health priority and begin to reverse the devastating toll of cardiovascular disease and NCDs in our communities,” note the authors of the statement.

Despite the decline in smoking domestically, smoke-free laws are still a hotly debated topic in the states due to the harmful effects of second-hand smoke. According to the WHO, 600,000 deaths per year across the globe are caused by second-hand smoke and 165,000 of them are among children who – along with women – are largely affected.5

The WHO says that only just over seven percent of the world resides in areas with compre-Hensive smoke-free laws. In the U.S., smoke-free, laws are increasingly prevalent. As of February 2013, 24 states, in addition to Washington, DC, the U.S. Virgin Islands and Puerto Rico, have laws requiring completely smoke-free workplaces, restaurants, and bars. Thanks to these laws, nearly 49 percent of the U.S. population is protected against the effects of second-hand smoking.6,

A number of states also have pending bills, mainly focused on smoking in public places, cars, gaming facilities, and common areas of multiple dwellings. Of note, Utah recently enacted a bill which prohibits smoking in an automobile with passengers under the age of 15. Despite the strong support of the Kentucky Chapter and the governor of Kentucky, Steve Beshear, a bill which would have prohibited smoking in most public places in the state failed to pass. In Minnesota, a cigarette tax increase may be part of a general tax bill later this session.

The ACC and its state chapters have played a crucial role in supporting local and state-based smoking legislation through letter writing campaigns, testimony, personal meetings with legislators and others. For example, states like Mississippi have taken to working at the county level to pass local smoke-free ordinances rather than tackling the state as a whole. Last year, just one day after the ACC Indiana Chapter’s Legislative Day, Immediate-Past Indiana Chapter President John S. Strobel, MD, FACC, testified before the state Senate Committee on Public Policy in favor of a smoke-free Indiana.The committee ultimately voted in favor of the legislation and after advancing to Senate, the bill (H.B. 1149) was enacted.

“We had no intention of taking away an individual’s right to smoke, but wanted citizens and legislators to know that the effects of second-hand smoke are deadly,” Strobel said. “Studies have shown that the benefits to our citizens and patients of eliminating secondhand smoke are almost immediate.”

Aside from legislation, education is also at the center of the ACC’s mission to improve heart health. The College is tackling the smoking issue head on through its CardioSmart® program. The newly revamped ACC patient portal,, offers digital tools and resources designed to help individuals prevent, treat and manage cardiovascular disease.

A Focus on Prevention at the Committee Level

In order to improve coordination between the many ACC entities working on the prevention end of the College’s mission to transform cardiovascular care and improve heart health, the ACC’s Prevention Committee was recently revitalized. The Committee revised its role and mission in 2012 after receiving the charge from the College’s Clinical Quality Committee. Led by ACC Prevention Committee Chair Vera Bittner, MD, FACC, the group drafted a new charter that focuses on the Committee serving as a prevention resource, voice, mentor, and collaboration contact.

Key goals of the ACC Prevention Committee include:

• Act as a liaison to – and a voice for – preventive cardiovascular specialist members within and on behalf of the College

• Mentor Fellows in Training, early career members, and CCA members interested in prevention

• Serve as ACC’s “access point” for collaborations with other societies and government entities on projects related to prevention, including Million Hearts, prevention guidelines and the National Institutes of Health-led National Program to Reduce Cardiovascular Risk

• Provide input on ACC guidelines and performance measures relating to cardiovascular disease prevention

• Serve as a resource for ACC Advocacy and CardioSmart patient outreach efforts

• Assist in addressing disparities in cardiovascular risk factor incidence, prevalence, awareness and treatment

• Support dedicated resources for prevention specialists, including but not limited to, access to guidelines, point of care reference tools, and quality improvement tools

• Create specific practical and clinical programming and content geared towards cardiovascular disease prevention at the ACC’s Annual Scientific Session and at Chapter meetings

• Work toward recognition as a Council within the ACC

“The ACC Prevention Committee has been tasked with coordinating ‘all things prevention’ within the College,” said Bittner.“The committee is looking forward to member input about ongoing projects, gaps that need to be addressed, and assistance needed in local and regional prevention efforts.”

To provide recommendations for the committee, contact Eva Grace at

“Assisting our patients on becoming tobacco-free is so critical to our mission as cardiologists to improve heart health,” said CardioSmart Chief Medical Expert, JoAnne Foody, MD, FACC.

Under the “Healthy Living” area, users can navigate to the “Stop Smoking” section which provides resources to help patients quit, facts on the effects of smoking and links to other CardioSmart resources, like CardioSmartTXT. By texting QUIT – or DEJA for Spanish – to CARDIO (227346), users can turn their mobile device into a health tool.The texts are designed to help users curb their smoking habits through free, bi-weekly tips, advice and reminders.

ACC’s member committees are stepping up in the areas of prevention and patient-focus as well. The newly revitalized ACC Prevention Committee, along with its list of other duties outlined in its new charter, will coordinate the College’s partnership with the Million Hearts™ Initiative. Million Hearts, jointly managed by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), launched in 2011 as a public private campaign to prevent 1 million cardiovascular events by 2017. The campaign seeks to reach the goal through improved management of the four ABCS indicators: Aspirin, Blood pressure control, Cholesterol management and Smoking cessation. ACC’s State Chapters, including Mississippi and Colorado, have held meetings to brainstorm ways to reach the Million Hearts goal, and bend the curve on public health outcomes in the states.

“Although smoking in the U.S. is lower than many other countries, the ACC is committed to reduce it further for better health, through many initiatives like CardioSmartTXT, Million Hearts, website, and our state Chapter activities,” said Immediate Past ACC President William Zoghbi, MD, MACC. “Such efforts would help further reduce mortality and morbidity from heart disease and bring it down from its number one spot.”



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