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 conventional cigarette. The industry of these products insists on seeing them as “smoking cessation treatment,” arguing that smokers, by replacing the use of ordinary cigarettes with these devices, would reduce the risk of disease by consuming a product with less toxic substances. With this argument, they are investing heavily in marketing, and Phillips Morris, one of the largest conventional cigarette manufacturers in the world, is widely publicizing its strategy to stop producing ordinary cigarettes and replace it with heated cigarettes, also an electronic nicotine-release device, without combustion. 291 The marketing, importation and advertising of any electronic smoking device, including electronic cigarette and heated cigarette, have been banned by Anvisa (National Health Surveillance Agency) since 2009 in Brazil (RDC 46). The agency considers that there is no scientific evidence to aid smoking cessation - meaning cessation as a treatment process for nicotine addiction - or scientific arguments that actually prove reduced morbidity and mortality by tobacco- related diseases in populations that have replaced tobacco use. Although they contain less toxic substances than conventional non-combustion cigarettes, those present are not harmless, and nicotine is a substance known to have CV effects, and perpetuates the addiction condition. 292 The impact of the use of these products on people’s health is not yet known, and although manufacturers are betting on their use as a harm reduction policy, the concern is that there is an epidemic of consumption and a setback in encouraging smoking cessation worldwide. Therefore, WHO does not recognize these devices as a treatment for smoking and warns that they cause nicotine addiction just as much as regular cigarettes, and looks forward to studies evaluating the impact of these products on morbidity and mortality. 293 7.8. Hookah Contrary to popular belief that hookah is less harmful and less addictive than cigarettes, research shows that both carry significant health risks, and may induce nicotine addiction. 294,295 The world panorama shows that the trends of hookah use are alarming and have shifted from being a social phenomenon among young people in some regions to becoming the beginning of a global epidemic. 296 In Brazil, the frequency of hookah use in the Brazilian adult population aged 18 to 59 years was determined in a population-based cross-sectional study using the 2013 National Health Survey (PNS). Of the 60,225 adults interviewed, 15% reported using any tobacco use, with the frequency of hookah use being 1.2% (95% confidence interval 0.8 – 1.6), higher in the male, white and younger age groups, with medium to high schooling, and urban and southern and midwestern residents; Among those who tried hookah, 50% used it sporadically, 12.8% monthly, 27.3% weekly and 6.8% daily. These results point to the need for supervision and educational campaigns on the risks of hookah use. 297 7.9. Conclusion Pharmacological treatment of smoking should be considered as a secondary prevention strategy, mainly aimed at reducing CV injury. Smoking is a chronic degenerative disease, and should be viewed by the cardiologist like the other common illnesses in their care routine, such as hypertension and DM. Defining criteria for choosing which anti-smoking drug will initially be used for patient treatment is still a challenge for treatment guides and guidelines because of the lack of systematization of models to be tested. In clinical practice, the choice of drugs is made on the basis of contraindications, drug availability and price, among other criteria. Therefore, systematically discussing criterion models for this choice becomes relevant and necessary for increasing the efficacy of anti-smoking treatment. The high degree of nicotine dependence 298 could be a factor in decision making, as well as factors that identify subpopulations that benefit from any particular drug, considering gender, age, pharmacogenetics 299 (genetic polymorphism of nicotinic, dopamine and hepatic receptors) among others. These factors are not yet known at this time. Recommendations for addressing adult smokers can be found in Table 7.1 and Charts 7.1, 7.2, 7.3 and 7.4. Table 7.1 – Recomendations for approach for adult smokers Recomendation Recommendation class Level of evidence Reference Routine assessment of smoking for adults at all health professional appointments, recorded in medical records I A 2,10,300 Systematic counseling for all adults on smoking cessatio I A 2,10,300 A combination of behavioral and pharmacological interventions is recommended for all adults to minimize dropout rates I A 2,10,300 Smoking cessation is recommended for all adults to reduce cardiovascular risk I B 2,10,300 A multidisciplinary team should be allocated to facilitate smoking cessation in all health systems IIa B 2,10,300 827