International Journal of Cardiology 86 (2002) 185–192

www.elsevier.com / locate / ijcard

Cardiovascular disease and the global tobacco epidemic:

a wake-up call for cardiologists

a, b c d
Samer Jabbour *, K. Srinath Reddy , Walinjom F.T. Muna , Aloyzio Achutti
a
Faculties of Health Sciences and Medicine, American University of Beirut, Van Dyck Hall, Beirut, Lebanon
b
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
c
Pan African Society of Cardiology, and University of Yaounde, Yaounde, Cameroon
d
Academy of Medicine of the State of Rio Grande do Sul, Porto Alegre, Brazil

Received 21 January 2002; received in revised form 16 April 2002; accepted 5 May 2002

Abstract

The global tobacco epidemic continues unabated with the recruitment of young people, including women, to join the ranks of smokers.
Even though cardiovascular diseases account for some of the major tobacco-related morbidity and mortality, cardiologists and their
professional societies have lagged behind in the crusade against tobacco. A great opportunity exists for more involvement and leadership
role by cardiologists, especially in countries where tobacco control efforts are not well established. For this to happen, there is a need to
identify barriers to cardiologists’ involvement in tobacco prevention and cessation efforts and to devise locally-relevant strategies to
address them. Also, the areas where the contribution of cardiologists can be most fruitful must be identified. Considering that a substantial
portion of the future burden of cardiovascular disease will occur among current tobacco users, treating tobacco dependence and supporting
tobacco quitters are the most urgent tasks for cardiologists interested in reducing the human toll of tobacco. The cardiovascular
community must consider the variety of needs and available resources to fight tobacco in different regions. Recommendations to involve
more cardiologists in tobacco control, at the clinical, public health and policy levels, are presented.
 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Tobacco; Smoking; Cardiologist(s); Prevention / treatment

1. Introduction diologist’s domain of interest and responsibility. But

If you were to ask someone, lay person or profes-
sional alike, which doctors should be most concerned
with tobacco use, one likely answer would be car-
diologists. Treatment of tobacco-related cardiovascu-
lar diseases, now an epidemic on a global scale [1,2],
is the cardiologist’s daily ‘bread and butter’ and
control of tobacco would obviously be in the car-
*Corresponding author. Tel.: 1961-1-374-374x4600; fax: 1961-1-
744-470.
E-mail address: sjabbour@aub.edu.lb (S. Jabbour).
how much are cardiologists really involved in the
global and local efforts to control tobacco? If you
attended the 11th World Conference on Tobacco or
Health (held in Chicago, USA, in August 2000), your
impression might be ‘not much’. There is little
evidence to suggest that cardiology, as a profession
worldwide, leads or contributes substantially to
tobacco control activities. A recent review in the
journal focused on the biomedical effects of tobacco
and, rightfully, urged cardiologists’ involvement [3].
This paper extends the discussions to address three
main questions: why aren’t cardiologists more in-

0167-5273 / 02 / $ – see front matter  2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S0167-5273( 02 )00277-2
186 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192
volved in tobacco control efforts? What can be done
to rectify this situation? What are the areas where
cardiologists’ contribution can be most effective?
2. The current and projected human toll of
tobacco use
At the beginning of the 21st century, the threat that
tobacco poses to health globally is greater than ever
before [4–8]. Today, the tobacco epidemic kills at
least 400,000 people in the US and more than 4
million around the world annually. Projected esti-
mates for the future are dim: 10 million deaths a year
worldwide by the year 2015. Of the estimated 1.2
billion currently living smokers, 80% of which live in
poor or middle income countries, 500 million will
eventually die of smoking-related diseases, especially
cancer and cardiovascular disease. During the 20th
century, 100 million fatalities can be attributed to
tobacco; with the current global trend in tobacco use,
this figure may reach one billion in the 21st century.
Many tobacco deaths can be prevented if current
smokers quit [9], but in many countries, especially
poorer ones, quitting is rare [10]. If smoking-related
morbidity and health care costs are considered as
well, the current and future global burden of the
tobacco epidemic can be better appreciated [11,12].
Indeed, tobacco is currently the second largest contri-
butor to the burden of disease, both globally and in
each region of the world, and is one of the largest
causes of premature death and disability [4].
3. Tobacco control in the world today
Despite the gloomy forecast, the momentum for
tobacco control has never been stronger. Worldwide,
there is increasing public awareness of the harmful
effects of smoking and the deceitful tactics of the
tobacco industry. A critical mass of committed
people, organizations, and institutions worldwide
propel the tobacco control movement. In the US, for
example, the coalition of citizen interest and activism,
public health efforts, litigation, and political will has
brought substantial gains in tobacco control [13]. In
many other countries, tobacco control efforts are
underway though at a slower pace.
Opportunities for preventing and treating tobacco
dependence are enormous. We know more about how
cigarettes, and other tobacco vehicles, are engineered
and what they contain; how the tobacco industry
dupes people, especially young ones, to start smoking
and get addicted; what works to reduce tobacco
consumption in a population. Physicians now have an
armamentarium of methods and medications to help
tobacco users kick the habit [14,15]. And they work!
Ample research documents the effectiveness of physi-
cian interventions in reducing tobacco use [16–19].
These interventions are effective in both primary and
secondary prevention and are cost-effective compared
with other preventive measures [20].
Considering the needs and the opportunities, it is
disappointing that cardiologists and their professional
societies have lagged behind. There is little evidence
to suggest that cardiology, as a profession worldwide,
leads or contributes substantially to tobacco control
activities. For example, in the aforementioned Tobac-
co Conference, commonly acknowledged as a gauge
of activism in tobacco control, the relative absence of
cardiologists and their societies from the conference
was all too obvious and disappointing. Very few
major cardiac societies were substantially represented
(e.g. the American Heart Association through its
co-sponsorship but not through presence of its mem-
bership). The impression you come away with after
the conference is that we cardiologists have relegated
tobacco control to someone else.
4. The case for involvement of cardiologists in
tobacco control
Tobacco is a major cardiovascular risk factor with
substantial morbidity and mortality [21], even in
non-smokers [22,23]. Half of the tobacco-related
fatalities are due to cardiovascular diseases. Quitting
tobacco has well-documented cardiovascular health
benefits [24]. It’s all too obvious that the movement
for tobacco control can only be stronger if more
clinicians were to join in [25]. This is especially true
for specialties that have to care for the largest
numbers of tobacco victims, such as cardiology.
Cardiologists have credibility and influence with their
patients and with the public that they can leverage for
tobacco control, thereby contributing to reducing the
human toll of tobacco both in their individual patients
and in their communities. Furthermore, a patient with
 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192
suspected or established heart disease is most inter-
ested in quitting tobacco because of the perceived
health risks and a cardiologist’s effort to help him /
her quit is poised for success. More health benefits
can be expected if treatment of tobacco dependence is
supplemented with preventing tobacco use among
susceptible patients without established heart disease
and their families.
5. How can cardiologists contribute more to
tobacco control efforts?
The main objectives of all tobacco control ac-
tivities are to prevent tobacco use, especially among
young people, and increase tobacco quit rates to
prevent consequent health risks [7,8]. What cardiolog-
ists can contribute to these activities depends on the
social context and the available resources. One can
argue that there is also a common minimum that all
cardiologists can be expected to contribute; that
which relates to promotion of tobacco cessation
among their patients with heart disease and those at
risk for it by virtue of using tobacco.
In many countries where the health consequences
of the tobacco epidemic have been well established,
such as the US, Canada and some European coun-
tries, important mobilization against tobacco is under-
way. Coalitions for tobacco control are well estab-
lished, partnerships of strong medical and public
health institutions are common, and resources for
cessation are widely available to patients and their
physicians. This has proven effective in increasing
quit rates, decreasing overall smoking rates as well as
rates of smoking initiation, especially among young
people to prevent early nicotine addiction which sets
the stage for lifelong dependence on tobacco. How-
ever, the presence of these tobacco control activities
does not obviate the need for active involvement of
cardiologists and their professional societies, espe-
cially because the enormous cardiovascular burden of
smoking continues to this day. In this context,
cardiologists can contribute by joining the main-
stream in many ways: (a) ally themselves with
tobacco control activities; (b) influence the debate on
priorities for tobacco control; (c) use the weight of
cardiovascular societies and foundations to lobby for
tobacco control legislation; and (d) support the
widespread use of smoking cessation efforts.
187
On the other hand, in poorer countries and those
where the full effects of the tobacco epidemic are not
well appreciated or established yet, much remains to
be done in order to build the infrastructure needed for
tobacco control. Coalitions that bring the medical
community, the public health institutions, gover-
nmental bodies, non-governmental organizations, and
the citizenry are still relatively weak in many such
countries. Here, doctors would be welcome, indeed
frequently expected, to play an important role in
promoting the health of the people. This presents an
outstanding opportunity for cardiologists and their
societies to take leadership roles in promoting tobac-
co control at all levels. A priority for future tobacco
control coalitions in these countries is to prevent
tobacco initiation and habitual use among young
people as nicotine addiction is established early [8].
Decreasing tobacco use among the young is a sensi-
tive indicator of the success of tobacco control
activities and is one of the most effective ways to
overcome the scourge of tobacco [7]. This requires
subversion of tobacco industry activities such as
smart advertisement and sponsorship of sport events
aimed at seducing vulnerable young people and
promotion of anti-tobacco activism. Other activities
that coalitions can carry out include, for example,
public education about tobacco through national or
local heart foundations, lobbying for tobacco control
legislation by cardiac societies, and ensuring that
tobacco cessation programs are widely available to
practicing cardiologists and other clinicians and
health workers. By adding smoking cessation to the
other preventive interventions, such as screening and
treatment of hypertension, which cardiologists advo-
cate, opportunities for cardiovascular prevention and
risk reduction are maximized. This is especially
important in countries in sub-Saharan Africa where
the health effects of the tobacco epidemic, such as
cardiovascular disease and cancer, are still relatively
low.
6. Which tobacco control activity is a priority
for cardiologists?
It is not well appreciated that the majority of the
future burden of tobacco will happen among current
smokers [6,7]. Therefore, helping current smokers to
188 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192

give up the habit should receive paramount attention 8. Why aren’t cardiologists more involved in
if the cardiovascular burden of smoking is to be tobacco control?
averted or minimized. To achieve this requires
adequate emphasis on maximizing opportunities for If cardiologists don’t pay the needed attention to
smoking cessation and treating tobacco dependence. tobacco, what are the barriers and how can we
Here, the contribution of cardiologists and their address them? Several explanations seem plausible
societies can be most effective. As stated by the and they present opportunities for action (Table 1).
National Cancer Institute: ‘Every physician can and
should become a smoking expert to counter the 1. Institutional responsibility: if cardiac societies
pervasive attempts by the tobacco industry to conv- perceive that someone else is doing the job,
ince smokers and would-be smokers that smoking is they may be less inclined to tackle tobacco
desirable, sexy or fun’ [26]. control. In the US, for example, several organi-
zations, such as the American Medical Associa-
tion and the American Cancer Society, co-spon-
sors of the aforementioned conference, have
7. How well do cardiologists intervene to help long had anti-tobacco programs. This is lacking
tobacco users quit? in many countries. But even if this were the
case, the tobacco control avenue isn’t too
Physicians do not adequately counsel patients narrow to preclude valuable contributions from
about quitting tobacco [27]. Only half of current cardiac societies or other interested professional
smokers report that they have been counseled by their bodies. Indeed, cardiologists and their societies
physicians to quit smoking. While cardiologists may would have much to contribute in strengthening
outperform other specialty physicians in delivering advocacy and extending its outreach.
cardiovascular prevention services, the rate for smok- 2. Physicians’ responsibility: we may perceive that
ing cessation remains inadequate [28]. The likelihood treating tobacco dependence is not in the core
of counseling and helping patients to quit may be realm of our responsibilities and prefer to
even lower in areas where smoking is more common delegate the task to other clinicians or health
and doctors are more likely to smoke. workers. However, this practice is in contrast to

Table 1
Potential barriers to cardiologists’ involvement in tobacco control
Area Argument/example Refuting argument/proposed solution

Institutional responsibility Non-cardiac organizations are doing a good job at tobacco The involvement of cardiac societies can strengthen advocacy
control and participation of cardiac societies is not needed and extend outreach of tobacco control efforts
Physicians’ responsibility Treating tobacco dependence is not a core responsibility Cardiologists should treat tobacco use as aggressively
of cardiologists as they treat all cardiac risk factors
Reimbursement There is little or no reimbursement for treating tobacco Cardiologists need to lobby for better reimbursement
dependence schemes
Perception of tobacco The low success rates of such interventions makes them less attractive Even modest smoking cessation rates offer substantial health benefits.
cessation success compared with interventions for other cardiac risk factors Success rates can be improved with more involvement by physicians
Training There are too many demands on cardiology trainees and Smoking cessation interventions are more cost-effective
smoking cessation is not a priority than many other cardiology practices
Self tobacco use Smoking cardiologists can effectively advise their patients on Smoking cardiologists are less able to treat tobacco dependence
by cardiologists smoking cessation among their patients. Cardiac societies need to pay more
attention to the practices of its own membership
Risk assessment Cardiologists may view smoking in isolation from other risk Global risk assessment would allow understanding of the
factors underestimating the synergism common origin of many risk factors and their synergistic effects
Priorities of the pharmaceutical Tobacco dependence is not a priority for the pharmaceutical More drugs and aids are now available for treating tobacco
industry industry dependence and cardiologists should agitate for more research
and development of more effective interventions
 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192
the approach we take with other major car-
diovascular risk factors, such as hypertension
and dyslipidemia, which we try to aggressively
modify. The result is a missed opportunity for
prevention. Quitting tobacco is one of the most
important, cost-effective, and life-saving health
interventions that we can perform. When doc-
tors take an interest in helping their patients to
quit, tobacco cessation rates are higher
[26,28,29]. As we reconsider our involvement
in tobacco control, we have to reclaim our
responsibility in treating tobacco dependence as
a major cardiovascular risk factor.
3. Reimbursement: adequate reimbursement for
tobacco counseling and treatment are not in
place in many countries. Fortunately, this is
starting to change [30,31]. This should provide
incentives to cardiologists, and other physicians,
to be more pro-active in counseling smokers
and treating tobacco dependence.
4. Perception of tobacco cessation success: some
cardiologists may feel frustrated with providing
smoking cessation services which they may
view as ineffective due to the low success rates
of ,30%. In fact, even these rates can result in
substantial health benefits and cost-savings
when the deleterious effects of smoking are
taken into consideration. The success rates
would be higher if physicians knew more about
tobacco dependence, saw it as a chronic disease,
with common relapses, and gave full-hearted
attempts at counseling and assisting tobacco
cessation efforts by patients [32].
5. Training: proficiency in treating tobacco depen-
dence is not part of the required curriculum in
most cardiology training programs worldwide.
In the US, for example, while smoking cessa-
tion clinics are commonly based within preven-
tive cardiology programs, cardiology trainees
are not required to rotate in these clinics and
may skip them in favor of rotations in special-
ized and technical aspects of cardiology, which
they deem as more relevant, and profitable, to
their careers. For those who elect exposure to
preventive cardiology rotations, there is a need
to insure that they will become proficient in the
skills of promoting smoking cessation.
6. Self tobacco use: physicians, including car-
189
diologists, are not immune to tobacco addiction
and tobacco use among them is not an un-
common phenomenon. Patients of smoking
physicians, for example, tend to have higher
smoking rates, and to have lower success rates
at smoking cessation [29]. The ‘Do as I say, not
as I do’ does not seem to work in this situation.
7. Risk assessment: while ‘global risk assessment’
of a certain patient is gaining favor, cardiolog-
ists still commonly consider risk factors in
isolation. This results in missing the opportunity
for evaluating the synergistic effect of risk
factors, including tobacco use, and their com-
mon origin in attitudes, behaviors, and life
styles.
8. Priorities of the pharmaceutical industry: this
industry, traditionally, has been more interested
in marketing drugs to treat other CVD risk
factors than smoking. This may well be chang-
ing with the increasing availability of a variety
of drugs to aid smoking cessation. Whether this
will translate into more ‘recruitment’ of physi-
cians to join the efforts of treating and prevent-
ing tobacco dependence remains to be seen.
Table 1 expands on the aforementioned barriers by
identifying common arguments and problems that
hinder progress on tobacco control and proposing
refuting arguments and practical solutions.
9. Concrete steps cardiologists can take to
contribute to tobacco control
Of the many actions that can be recommended,
cardiologists can contribute much through the follow-
ing steps (Table 2).
1. Set an example by abstaining from using tobac-
co, a key factor in establishing credibility.
Barriers to stopping should be identified and
addressed. For example, cardiologist smokers
may be too embarrassed to join the same
smoking cessation programs to which they refer
their patients. Cardiac societies would serve
their anti-tobacco goals well by establishing
channels for treating tobacco use among physi-
cians.
190 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192

Table 2
Steps cardiologists can take to contribute to tobacco control efforts
Identify and treat tobacco dependence among fellow cardiologists and other physicians
Make tobacco use an integral part of vital signs
Become proficient at rapid screening of tobacco use
Become proficient at delivering brief interventions to encourage patients to quit
Add treatment of tobacco dependence to the core curriculum of cardiology training
If not available, agitate for building specialized programs for treating tobacco dependence
Refer patients experiencing difficulty in quitting to tobacco treatment programs
Make ample material on the risks of tobacco and options to quit widely available in offices
and other areas where cardiac services are delivered
Lobby for improved reimbursement for tobacco treatment interventions
Perform periodic surveys to assess cardiologists’ success at treating tobacco dependence
Play a stronger advocacy role, both as individuals and as cardiac societies, within the
broader tobacco control coalitions
Promote research to address unanswered questions relevant to health consequences
and tobacco control policies
Place more emphasis on tobacco in scientific meetings and continuing education programs

2. Include tobacco use status as an integral part of
the vital signs [33]. We should ask whether, and
how much, the patient is using tobacco during
every clinical encounter. This reinforces the
importance of treating tobacco dependence to
the medical and ancillary staff.
3. Emphasize that training of all future cardiolog-
ists should include the development of basic
skills in treating tobacco dependence. This
should include the use of nicotine replacement
therapies, pharmacologic treatment, and non-
pharmacologic interventions, e.g. behavioral
counseling [14]. Every cardiologist should be
able to rapidly screen for tobacco use habits and
to deliver brief interventions to encourage pa-
tients to quit. The so-called ‘5 As’ (Table 3),
can be delivered in less than 5 min and are
effective in increasing quit rates [14]. For the
patients who are not thinking about quitting,
‘motivational interventions’ may prove effective
in helping smokers to consider it (e.g. the ‘5
Rs’—Table 4).
4. Establish pathways for referral of patients ex-
periencing difficulty in quitting to specialists.

Table 3
Quick screening and intervention on tobacco use: the 5 As a
Aspect to emphasize Role of the physician
Ask about tobacco use Identify and document tobacco use status for every patient at every visit
Advise to quit In a clear, strong and personalized manner urge every tobacco user to quit
Assess willingness to make a quit attempt Is the tobacco user willing to make a quit attempt at this time
Assist in quit attempt For the patient willing to make a quit attempt, use counseling and
pharmacotherapy to help him or her quit
Arrange follow-up Schedule follow-up contact, preferably within the first week
after the quit date
a
Adapted from Ref. [14].

Table 4
Strategies to motivate un-motivated tobacco users to quit: the 5 Rs a
Aspect to emphasize Role of the physician is to help the patient:
Relevance Identify the personal relevance of quitting
Risks Recognize the acute, long term and environmental risks to oneself and surroundings
Rewards Identify health and other benefits from quitting
Roadblocks Identify barriers to successful quitting and how to face them
Repetition Repeat this process with every encounter with an unmotivated patient
a
Adapted from Ref. [14].
 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192
For example, some patients may have major
depression which itself can worsen tobacco
dependence and referral to a psychiatrist may be
needed.
5. Make available updated material to patients and
their families about the dangers of tobacco,
including ‘light’ cigarettes and second hand
smoke, and the availability of quitting aids in all
patient encounter areas.
6. Lobby for improving reimbursement for treat-
ment of tobacco dependence, both for counsel-
ing as well as pharmacotherapy. This would
motivate and involve more cardiologists to
deliver such services to their patients.
7. Play a stronger advocacy role, both as indi-
viduals and as associations, for anti-tobacco
efforts. This may require, for example, initiating
and engaging in partnerships and coalitions to
support anti-tobacco legislation and interven-
tions aimed at reducing tobacco initiation
among the young. Interventions aimed at pre-
vention of tobacco use among the young are
especially important in curbing the tobacco
epidemic. Many international initiatives, some
active on the Internet such as GLOBALink
(www.GLOBALink.org), offer a platform for
coalition building and for mainstreaming car-
diologists into the broader movement for tobac-
co control.
8. Participate in research to address critical and
unanswered questions in tobacco control. For
example, in many countries, hubble-bubble
smoking is rising [34]. The social, economic
and health dimensions of this phenomenon need
analysis so appropriate control policies can be
devised.
9. Increase attention to tobacco control issues in
scientific meetings and continuing education
forums.
These recommendations require more than a good
heart. Indeed, the current health care set-up in many
countries must change so that treatment of tobacco
dependence is institutionalized. So should the culture
of medicine change so that clinicians realize that they
are practicing poor-quality medicine if they do not
address tobacco among their patients. Cardiologists,
through their professional societies, need to set
191
targets for achieving the above listed goals. If actual
practice, e.g. smoking cessation rates, lags behind
then resources must be directed towards improving
performance.
10. Conclusions
Tobacco use is a major cardiovascular risk factor
that deserves more attention from cardiologists and
their professional societies. Opportunities are abun-
dant for the involvement of cardiologists in many
tobacco control activities, especially in countries
without well established anti-tobacco coalitions. We
need to set benchmark goals, and measure corre-
sponding performance, in specific areas of tobacco
control. For cardiologists to be effective at helping
their patients to quit tobacco, training and proficiency
in treating tobacco dependence is essential. Research
is needed to assess the knowledge, attitude, and
behaviours of cardiologists with regard to these
issues.
References
[1] The hidden epidemic of cardiovascular disease. Lancet
1998;352:1795.
[2] Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in
developing countries. Circulation 1998;97:596–601.
[3] Milei J, Grana DR. Mortality and morbidity from smoking-induced
cardiovascular diseases: the necessity of the cardiologist’s in-
volvement and commitment. Int J Cardiol 1998;67:95–109.
[4] Murray CJL, Lopez AD, editors, The global burden of disease: a
comprehensive assessment of mortality and disability from diseases,
injuries, and risk factors in 1990 and projected to 2020, Cambridge,
USA: Harvard University Press, 1996.
[5] Peto R, Lopez A, Boreham J, Heath C, Thun M. Mortality from
tobacco in developed countries, 1950–2000. Oxford, UK: Oxford
University Press, 1994.
[6] Peto R, Lopez AD. Future worldwide health effects of current
smoking patterns. In: Koop CE, Pearson CE, Schwarz MR, editors,
Critical issue in global health, New York: Jossey-Bass, 2000.
[7] Reducing tobacco use: a report of the Surgeon General. Washington,
DC: US Department of Health and Human Services, 2000.
[8] Jha P, Chaloupka FJ. Tobacco control in developing countries.
Oxford, UK: Oxford University Press, 2000.
[9] US Department of Health and Human Services. The health benefits
of smoking cessation, a report of the Surgeon General. Washington,
DC: US Government Printing Office, 1990.
[10] Gupta PC. Survey of sociodemographic characteristics of tobacco
use among 99,598 individuals in Bombay, India, using handheld
computers. Tobacco Control 1996;5:114–20.
192 S. Jabbour et al. / International Journal of Cardiology 86 (2002) 185–192
[11] Hodgson TA. The health care costs of smoking. N Engl J Med
1998;338:470.
[12] Manning WG, Keeler EB, Newhouse JP et al. The taxes of sin: do
smokers and drinkers pay their way? J Am Med Assoc
1989;261:1604–9.
[13] Gottlieb S. US government to sue tobacco companies. Br Med J
1999;319:869.
[14] Fiore MC, Bailey WC, Cohen SJ et al. Treating tobacco use and
dependence. Clinical practice guideline. Rockville, MD: US Depart-
ment of Health and Human Services, Public Health Service, 2000.
[15] Raw M, McNeill A, West R. Smoking cessation: evidence-based
recommendations for the healthcare system. Br Med J
1999;318:182–5.
[16] Manley MW, Epps RP, Glynn TJ. The clinician’s role in promoting
smoking cessation among clinic patients. Med Clin North Am
1992;76:477–94.
[17] Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of
successful smoking cessation interventions in medical practice: a
meta-analysis of 39 controlled trials. J Am Med Assoc
1988;259:2883–9.
[18] Ockene JK, Kristeller J, Goldberg R et al. Increasing the efficacy of
physician-delivered smoking interventions: a randomized clinical
trial. J Gen Intern Med 1991;6:1–8.
[19] Ockene JK, Kristeller J, Pbert L et al. The physician-delivered
smoking intervention projects: can short-term interventions produce
long-term effects for a general outpatient population? Health Psy-
chol 1994;13:278–81.
[20] Deedwania PC. Clinical perspectives on primary and secondary
prevention of coronary atherosclerosis. Med Clin North Am
1995;79:973–98.
[21] Ockene IS, Miller NH. Cigarette smoking, cardiovascular disease,
and stroke: a statement for healthcare professionals from the
American Heart Association. Circulation 1997;96:3243–7.
[22] Glantz SA, Parmley WW. Even a little secondhand smoke is
dangerous. J Am Med Assoc 2001;286:462–3.
[23] Glantz SA, Parmley WW. Passive smoking and heart disease:
mechanisms and risk. J Am Med Assoc 1995;273:1046–53.
[24] Lightwood JM, Glantz SA. Short-term economic and health benefits
of smoking cessation: myocardial infarction and stroke. Circulation
1997;96:1089–96.
[25] Townsend JL. Policies to halve smoking deaths. Addiction
1993;88:43–52.
[26] Tobacco and the clinician. Interventions for medical and dental
practice, Smoking and tobacco control series, Vol. Monograph 5,
National Cancer Institute, 1994, NIH publication no. 94-3693.
[27] Goldstein MG, Niaura R, Willey-Lessne C et al. Physicians counsel-
ing smokers: a population-based survey of patients’ perceptions of
health care provider-delivered smoking cessation interventions. Arch
Int Med 1997;157:1313–9.
[28] Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National
patterns in the treatment of smokers by physicians. J Am Med Assoc
1998;279(8):604–8.
[29] Kotte T, Battista RN, DeFriese GH. Attributes of successful
smoking cessation interventions in medical practice; a meta-analysis
of 39 controlled trials. J Am Med Assoc 1988;259:2882–9.
[30] Addressing tobacco in managed care: building the future piece by
piece. Tobacco Control Suppl 2000;1, March.
[31] Group Health Association of America, Inc. HMO industry profile:
1993 edition. Washington, DC: Group Health Association of
America, 1993.
[32] Fiore MC, Bqker TB. Cessation treatment and the good doctor club.
Am J Pub Health 1995;85:161–3.
[33] Fiore MC. The new vital sign: assessing and documenting smoking
status. J Am Med Assoc 1991;266:3183–4.
[34] Kandela P. Signs of trouble for hubble bubble. Lancet
1997;349:1460.