ABC | Volume 112, Nº4, April 2019

FSCLP Statement Oliveira et al 2019: Recommendations for reducing tobacco consumption in Portuguese-Speaking countries Arq Bras Cardiol. 2019; 112(4):477-486 Table 3 – Benefits of smoking cessation in the short-, medium-, and long-term • After 2 minutes: BP and HR return to normal. • After 3 weeks: easier breathing and circulation improvement. • After 1 year: the risk of death due to AMI decreases to half, equalizing that of nonsmokers after 15 years. • In 2-5 years: risk of stroke falls by more than 90%, becoming close to the risk of individuals who never smoked. • After 10 years of abstinence: cancer risk is about half of a smoker's risk. • Between 5-10 years: the risk of AMI is equal to that of nonsmokers. • After 20 years: risk of lung cancer is equal to that of nonsmokers. AMI: acute myocardial infarction; BP: blood pressure; HR: heart rate. Adapted from reference. 18 The World Health Organization has launched the MPOWER measures, with proven impact on reducing the consumption of tobacco products: 19-21 M onitoring the epidemic. P rotecting the population against tobacco smoke. O ffering help to quit smoking. W arning about the dangers of tobacco. E nforcing the ban on advertising, promotion, and sponsorship. R aising taxes on tobacco products. These measures have an impact on smoking cessation at a population level, but most smokers require individualized treatment with healthcare professionals, combining a behavioral approach and often medications to quit smoking altogether. New forms of tobacco use New forms of smoking have emerged in the last decade and are advertised as having a reduced or absent risk, like JUUL, popular electronic cigarettes that work as vaporizers of encapsulated nicotine, flavors, and other contents in small replaceable cartridges called “pod mods.” These devices, already in their third generation, associate nicotine with other vaporizing or flavoring substances with effects that are still poorly known, but have the potential of inducing health risks. 13,14 As a result of well-developed marketing campaigns promoting the introduction of new forms of tobacco use, there is currently an intense discussion between the lay society and the scientific community about the inherent risk of electronic cigarettes use as a cause of CVDs and neoplasms. Although the current epidemiological evidence is not extensive and the risk of these new forms of smoking appear to be lower than those of the classic form of smoking, enough evidence is available to claim that their acute consumption causes endothelial dysfunction, DNA damage, oxidative stress, and temporary heart rate increase. As for their chronic use, it seems to increase the risk of myocardial infarction, stroke, and neoplasms of the oral cavity and esophagus. 3,13 Based on the apparent lower risk of use of the new forms of smoking, electronic cigarettes have been promoted as a method to quit smoking, which lacks proof. In 60% of the cases, smokers use both the classic form of smoking and electronic cigarettes, maintaining the existing high risk. In many cases, these new forms of smoking are adopted for a short time, at which point the smoker resumes his previous habit altogether. 13,14 Additionally, electronic cigarettes are considered to be a concern by the scientific community, since they lead youths to nicotine addiction and become a gateway to classic smoking. At the present time, even though we acknowledge that the available scientific evidence is not robust, we recommend any form of smoking to be discontinued or not initiated, including oral tobacco (chewing tobacco, snus, snuff, soluble tobacco, vaping/JUUL), cigarettes, cigars, cigarillos, pipes, or narghile. Secondhand smoke should also be fought, as it exposes to the same risks of smoking, increasing them by 20-30%. 13,14 Approach to smokers Most smokers have the perception and recognize that tobacco is harmful to their health. However, this is not enough for them to give up smoking. Similarly, physicians recognize the harmful effects of smoking but in daily practice tend to prioritize disease treatment instead of prevention. The initial approach to a smoker is to encourage him to start treatment regardless of the type of clinical condition and the stage of his illness. Benefits of quitting smoking must be emphasized to all patients at every appointment with a healthcare professional. As many countries have restrictions on smoking in public settings, it is important to ask systematically about tobacco exposure to nonsmokers who live or cohabit with smokers, especially children and youths who may consider the habit of smoking as normal and not harmful to their health and, as in the case of individuals with asthma, may present acute worsening when exposed to tobacco (Table 4, 5, and 6). Table 7 describes common measures to monitor smoking cessation. Treatment Most patients require cognitive-behavioral therapy (CBT) (Table 8) backed by pharmacological support to cope with the withdrawal syndrome, which typically lasts between 2 and 4 weeks. Nicotine withdrawal syndrome The main signs and symptoms of withdrawal syndrome are shown in Table 9. 480