ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 adolescent who smokes should be considered potentially engaged in other risky behaviors. 7.2. Strategies in Combating Smoking Initiation 257,258 One way to approach primordial prevention is by age groups, observing for each group five main items (5 As): Group 0 to 4 years: Ask parents and other family members about their smoking habits; advise to keep the environment free of cigarette smoke; the message should include information about the risks to parents and children, as well as the importance of the parental model; assess willingness to cooperate between parents and other family members; assist parents with trying to quit by informing them about self-help material and/or referring them to their own doctors; make an appointment with clinic within 3 months if a relative is a smoker; check parental progress at each subsequent pediatric visit. 5 to 12 years old group: Ask children about how they feel when someone is smoking nearby and what they do about it if they think it is dangerous to try smoking and if they think they will smoke when they are older, if they have tried smoking or if they have friends who smoke; advise children not to try smoking, praise them for remaining a non-smoker and/or staying away from cigarette smoke; remind children about the short-term negative effects of tobacco, such as reduced ability to smell and athletic capacity, as well as personal health risks (e,g., asthma exacerbation); advise parents to quit smoking and to give clear anti-smoking information to their children; assess the risk factors of smoking initiation or regular smoking progression, including level of experimentation, smoking among friends, depressive symptoms, school performance and adverse experiences; help parents in trying to quit smoking; assist children with developing skills to refuse smoking and exposure to it; assist parents in efforts to prevent tobacco use by their children through parenting and firm anti-smoking messages; make an appointment with clinic within 1-2 months for any child who is smoking or has worrisome risk factors for smoking, refer as necessary cases of social or learning difficulties and mental disorders as well. Group of adolescents and young adults: ask adolescents about smoking behavior, confidentially about friends who smoke and about light cigarettes; advise adolescents to stop smoking, reinforcing personal health risks and danger of addiction; commend adolescents who are not smoking and remind them about the health risks; assess the motivation and symptoms of tobacco dependence among adolescents who are smoking; assess risk factors for smoking initiation among non-smokers; assist adolescents who are smoking with trying to quit, including nicotine replacement and referring if necessary; help parents with their efforts to prevent smoking initiation among their children through parenting and firm anti-smoking information; make an appointment with clinic within one month for each teenager who is smoking, supporting attempts to quit or assessing motivation and barriers to quitting; refer as necessary if risk factors are identified, such as social or learning difficulties, or findings of mental disorders. Primordial Prevention of CVD, in its broadest context, it involves avoiding the establishment of modifiable CVD risk factors, including smoking, and effective strategies for promoting CV health of the individual and the population. Therefore, the joint action of interdiscipline teams (doctors, nurses, psychologists, physical educators, educators, nutritionists, social workers, communicators, managers) and intersectoral (family, school, government, society specialists, university) teams is necessary in a continuous and simultaneous way. 7.3. How to Treat Smoker’s Psychological Dependence Nicotine addiction is a highly complex process that should be addressed by all health professionals. Every healthcare professional, especially the doctor during consultations, as well as the multidisciplinary team, should ask if the patient is a smoker. This question is essential. If the patient is a smoker, two types of approach can be used. Basic approach where the goal is to ask if you smoke, to evaluate the smoker’s profile, to advise to quit smoking, to prepare for cessation and to accompany the smoker to the cessation of smoking. This approach should always be performed by the physician during the routine consultation, with an average duration of 3 (minimum) to 5 (maximum) minutes with each contact the patient makes. The patient should be questioned and asked systematically at each consultation and feedback on the evolution of the cessation process. Suitable for all smokers. Meta-analysis involving 29 studies showed that cessation rates were 19.9% for those who underwent medical intervention. 259 Specific Intensive Approach: performed by health professionals available and trained to make a more in-depth follow-up with the patient, including the doctor. In this case, the professional should have a structured program available to the patient with scheduled sessions (8 group/individual sessions), and will use national reference medication for treatment of smoking, as well as the cognitive behavioral approach. If possible, the patient should be followed up to 1 year of treatment. The cognitive behavioral approach is a psychological approach that is based on working out the automatic thoughts that the smoker has and that lead him/ her to get a cigarette. These thoughts are often accompanied by emotion and behaviors associated with smoking. It is important for the patient to feel welcomed by the doctor, to show empathy, not to judge or condemn because of difficulties in smoking cessation. Another aspect is that the better the smoker knows his/her addiction profile, the easier it is to work on ways to control smoking addiction. 259,260 In the cognitive-behavioral approach it is necessary to: distinguish the patient’s automatic (dysfunctional) thoughts - example: “if I do not smoke I cannot think” - helping him to seek coping strategies for situations other than getting a cigarette. Behavioral techniques most commonly used: self-observation, control of stimuli or triggers that lead to smoking (telephone, computer, alcohol, bathroom, car), identification and learning of functional thinking patterns, relaxation techniques, deep breathing, postponement and breaking of conditioning, assertiveness training (so that one can face situations where there is the temptation to smoke), self-instruction (situations in which patients are taught to argue 822