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 with themselves about the situation that tries to induce them to smoke) and problem-solving so that patients are taught about appropriate ways to solve a problem situation. 260-262 Instruments that help in assessing and understanding the patient profile: • Prochaska and Di Clemente Scale for Behavior Change: This scale provides a model that allows one to clearly and objectively evaluate which phase of behavior change the patient is in. Quitting smoking is a dynamic process that repeats over time and has different stages. At each stage, the individual uses different cognitive and behavioral processes. 263 The authors propose five different stages in this process. Pre-contemplation is characterized by the absence of intention to change behavior. The individual does not perceive, in this case, the act of smoking as a problem. Contemplation implies some awareness of the problem. It is perceived, and there is an intention to change, but there is no notion of when, so there is no commitment. Preparation is the pre-action stage. There is a clear intention to change, the individual already has some initiatives regarding change, but the action is not yet effective. Action is already a behavior change to try to solve the problem. The individual spends time looking for treatments and promotes changes that must be sustainable. Maintenance is the stage at which such changes must be consolidated, encompassing all that has been achieved at the action stage. The problem is that these stages do not occur sequentially in the process of change, but rather in a spiral way; that is, the individual may be at an earlier stage, and at some point, for some reason, regresses to an earlier stage. and then evolves again. When he returns to an early stage of pre-contemplation, he may relapse back to his previous smoking pattern. The individual can start the whole process again, and be able to abstain once again. Basic signs that indicate that the smoker is ready for change: has less resistance, asks fewer questions about the problem (addiction), asks more questions about change (what and how to do it), takes a resolving attitude (feels decided), makes more self-motivational claims, talks about life after change (difficulties and benefits), begins to experience some changes (decreased smoking). • Motivational Interviewing: It is a viable alternative in the treatment of dependent behaviors within brief interventions, as the initial impact seems to influence the motivation for behavior change. Motivational interviewing employs a particular way of assisting in recognizing present or potential problems as well as in behavioral change aimed at solving such problems. Motivational Interviewing Strategies: Providing Guidance, Removing Barriers/ Assisting Obstacles, Providing Alternative Smoking Options, Decreasing Undesirable Aspects of Behavior, Practicing Empathy, Giving Feedback , Clarifying Objectives, and Actively Assisting and Taking Care of Relapse Prevention - Coping With Abstinence. 264 • Fagerström Scale: This is an evaluation scale that allows us to determine the degree of physical dependence on nicotine. It should be used in the initial assessment of the smoker on arriving for treatment. If medication is needed, it helps to determine which medication is best and how much to take. 265,266 In this case, it is noteworthy that the use of medication should not be considered only in cases where Fagerström is ≥ 5. It is known today that a very low Fargeström means that psychological dependence is very high and in this case the medication helps in reducing withdrawal symptoms. 260 • Reason for smoking scale: This is a rating scale that allows us to check in which situations the smoker uses the cigarette. It has to do with physical, psychological dependence and conditioning and helps to clarify to smokers the risk situations of their daily life. This scale assesses: stimulation, ritual handling, pleasure in smoking, tension reduction/relaxation, physical dependence, habit/automatism, and social smoking. These items should be worked through throughout the smoker’s intensive approach process. 267 7.4. Pharmacological Treatment of Smoking 7.4.1. Secondary Intervention Smoking The CV effects of smoking are harmful, so CVD is the leading cause of death among smokers. 268 Smokers with CVD should stop smoking. 269 The safety of first-line anti-smoking drugs such as varenicline, bupropion and nicotine replacement has been reiterated by clinical studies designed 270 to answer publication questions that suggested there may be CV risk with the use of anti-smoking medication. 271 The CATS study, 270 among others, proved that there is no such risk. Thus, respecting the contraindications of each product, the use of these drugs should be encouraged so that the patient can really quit smoking, as the drugs increase cessation success rates. 272 The prescription of anti-smoking drugs is essential for improving the effectiveness of smoking treatment, as well as conducting follow-up appointments and encouraging changes in patients’ habits and behavior. 273,274 The main features of first-line anti-smoking drugs are: 1. Nicotine Replacers (Chart 7.1) Nicotine is primarily responsible for cigarette addiction and nicotine replacement therapies (NRT) have been used since 1984 to help smoking cessation. The forms of NRT currently used and available in Brazil are transdermal and oral (lozenges and chewing gums). Both are effective in smoking cessation and are often used in combination and can double the rate of smoking cessation compared with placebo. 268,275 2. Transdermal Nicotine Effectiveness - compared to placebo - RR = 1.9 (95% CI 1.7-2.2). 6-Month abstinence rate - RR= 23.4 (95% CI 21.3-25.8). • Doses: 21 mg; 14 mg; 7 mg. • Presentation: patches for transdermal application. • Route(s) of administration: transdermal application with daily replacement. • Dose schedule: use of each presentation for 4 weeks on average, with gradual dose reduction. e.g.: (21, then 14, then 7 mg/day). 823