The Impact of Carotid Plaque Screening on Motivation for Smoking Cessation and Knowledge Retention About Atherosclerosis Nicolas Rodondi, MD, MAS, Reto Auer, MD, Patrick J. Devine, MD, Patrick G. O’Malley, MD, MPH, Daniel Hayoz, MD, Jacques Cornuz, MD, MPH Consultation de Prévention Cardiovasculaire & Consultation des Lipides Policlinique Médicale Universitaire Université de Lausanne

Background (1) Controversy remains about who should be treated with medications for the primary prevention of CVD: the highest-risk patients should be identified to  benefit/cost ratio of treatments The determination of subclinical markers of ATS ability to identify individuals at  risk for CVD outcomes: But the incremental values are often small 1 Main candidates for identifying high-risk persons are 2 : Carotid ultrasound to measure IMT and atherosclerotic plaques EBCT to measure coronary artery calcification 1 PG O’Malley, Arch Intern Med 2006 2 NHLBI subclinical diseas working group 2004

Controversy remains about who should be treated with medications for the primary prevention of CVD: the highest-risk patients should be identified to  benefit/cost ratio of treatments

The determination of subclinical markers of ATS ability to identify individuals at  risk for CVD outcomes:

But the incremental values are often small 1

Main candidates for identifying high-risk persons are 2 :

Carotid ultrasound to measure IMT and atherosclerotic plaques

EBCT to measure coronary artery calcification

Background (2) Little data are available on the health consequences of testing for subclinical CVD: it is unknown whether the use of such testing would improve patient behavior 1,2 . Limited impact of biomedical risk assessment as an aid for smoking cessation 3 : 1 PG O’Malley, Arch Intern Med 2006 2 P Greenland, JAMA 2003 3 R Bize, Cochrane Database 2005

Little data are available on the health consequences of testing for subclinical CVD: it is unknown whether the use of such testing would improve patient behavior 1,2 .

Limited impact of biomedical risk assessment as an aid for smoking cessation 3 :

RCT of carotid US on smoking cessation at 6 months (n=153) P value : (A vs B+C [17.6%]) = 0.031 (A+B vs C) = 0.003 Bovet P et al. , Prev Medicine 2002 Limitations Population with low nicotine dependence (mean daily cigarette use: 10/day) No biochemical validation of smoking cessation No standardized information on CV risk to the control group %

Limitations

Population with low nicotine dependence (mean daily cigarette use: 10/day)

No biochemical validation of smoking cessation

No standardized information on CV risk to the control group

These results require confirmation in western countries Little is known whether testing for subclinical CVD positively affects other aspects of patient behavior and control of other cardiovascular risk factors, such as adherence to: Medications Lifesty interventions Background (3)

These results require confirmation in western countries

Little is known whether testing for subclinical CVD positively affects other aspects of patient behavior and control of other cardiovascular risk factors, such as adherence to:

Medications

Lifesty interventions

Pilot study before a large RCT: Objectives To assess feasibility to study the impact of plaque screening in smokers To assess the comprehension of ATS plaques in smokers

To assess feasibility to study the impact of plaque screening in smokers

To assess the comprehension of ATS plaques in smokers

Methods (1) : Design and participants 2-month observational pre-post pilot study conducted at the University Hospital of Lausanne, Switzerland. 30 first smokers recruited out of 90 responding to a single newspaper advertisement for a smoking-cessation study. Eligible smokers had to smoke ≥10 cigarettes/ day and to be 40-70 years

2-month observational pre-post pilot study conducted at the University Hospital of Lausanne, Switzerland.

30 first smokers recruited out of 90 responding to a single newspaper advertisement for a smoking-cessation study.

Eligible smokers had to smoke ≥10 cigarettes/ day and to be 40-70 years

Methods (2): Intervention All smokers underwent: smoking cessation counseling nicotine replacement therapy (or bupropion if intolerant) a carotid ultrasound a 7-minute PowerPoint educational tutorial on atherosclerosis. Carotid plaques were defined as a focal widening >50% relative to adjacent segment (as defined in the Rotterdam study) 1 and as recommended by the US Task Force on non-invasive atherosclerosis measurement 2 1 Oei HH, J Am Coll Cardiol 2002 2 Redberg RF, J Am Coll Cardiol 2003

All smokers underwent:

smoking cessation counseling

nicotine replacement therapy (or bupropion if intolerant)

a carotid ultrasound

a 7-minute PowerPoint educational tutorial on atherosclerosis.

Carotid plaques were defined as a focal widening >50%

relative to adjacent segment (as defined in the Rotterdam

study) 1 and as recommended by the US Task Force on

non-invasive atherosclerosis measurement 2

Methods (3) : Outcomes Primary outcome: Feasibility of studying the impact of carotid plaque screening in smokers Secondary outcomes: Change in motivation for smoking cessation 7-day point prevalence smoking abstinence at 2 months Atherosclerosis (ATS) knowledge at 2 months (after the tutorial on ATS)

Primary outcome:

Feasibility of studying the impact of carotid plaque screening in smokers

Secondary outcomes:

Change in motivation for smoking cessation

7-day point prevalence smoking abstinence at 2 months

Atherosclerosis (ATS) knowledge at 2 months (after the tutorial on ATS)

Pilot Study: Participant Characteristics (n=30) Variable Mean (± SD) or % Mean age [range], yr 51.7 ± 9.4 [40 – 70] Women 43.3 % Daily cigarette consumption 22.2 ± 9 Pack-year smoking history 38.3 ± 19.3 Previous attempts of smoking cessation 83.3 % By attempters (n=25), number of previous attempts of smoking cessation 3.1 ± 2.2 [1-10] Fagerström score 4.8 ± 2.3

Smoking cessation at two months Motivation for smoking cessation, 1-10 Pre-screening 72.7% 37.5% Smoking cessation at 2 months, % 7.9 No plaque Plaque No plaque (n=8) Plaque (n=22) Pre-screening At 2 months At 2 months P = 0.10 P = 1.0 P = 0.008 7.2 8.7 At 2 months At 2 months N Rodondi et al, Nicotine & Tobacco Research 2008

Baseline At two months P Stress Perceived 4-Item stress scale, 2.0 [0-5] 1.5 [0-3.5] 0.13 range 0-16 Group without carotid plaques 1.0 [0-2.5] 2 [0-3.5] 0.66 Group with carotid plaques 2.5 [1-5.5] 0.5 [0-3.5] 0.04 Anxiety , range 0-14, Prime-MD 4.0 [0-7.5] 2.0 [0-4.0] 0.01 Group without range carotid plaques 4.0 [2.0-5.5] 1.5 [0.5-4.0] 0.11 Group with carotid plaques 3.5 [0-8.0] 2.0 [0-4.0] 0.04 Depression , range 0-27, Prime-MD 4.0 [2.0-6.5] 3.0 [0.5-4.5] 0.02 Group without range carotid plaques 6.0 [4.0-7.5] 3.5 [0.5-5.0] 0.08 Group with carotid plaques 4.0 [2.0-6.0] 3.0 [1.0-4.5] 0.12 Potential harms of screening Range 1-10, median [25%-75%] N Rodondi et al, Nicotine & Tobacco Research 2008

Knowledge Retention About Atherosclerosis 96% responded correctly to  80% of 10 multiple-choice questions regarding atheroslerosis knowledge: at baseline at two months N Rodondi et al, Nicotine & Tobacco Research 2008

96% responded correctly to  80% of 10 multiple-choice questions regarding atheroslerosis knowledge:

at baseline

at two months

N Rodondi et al, Nicotine & Tobacco Research 2008

Limitations The increases in motivation at 2 months might be driven by the close follow-up and not by plaque screening.  RCT needed ! As many smokers relapse to smoking after 2 months, 12 months of follow-up often necessary for long-term efficacy. We could not exclude non-measured confounders or examine combinations of confounders in multivariate analyses, given our sample size.

The increases in motivation at 2 months might be driven by the close follow-up and not by plaque screening.  RCT needed !

As many smokers relapse to smoking after 2 months, 12 months of follow-up often necessary for long-term efficacy.

We could not exclude non-measured confounders or examine combinations of confounders in multivariate analyses, given our sample size.

Design of the ongoing RCT in 530 smokers 530 smokers aged 40-70 y US of the carotids C: Follow-up Plaque B: Follow-up A: Follow-up No plaque No test 1° Outcome: Smoking cessation (validated by cotinine measurement) 2° Outcomes: Risk factor control: LDL-C BP HbA1c (if diabetes) - CRP R Outcomes at 1 year Outcomes at 1 year Abbreviations: US: ultrasound, BP: blood pressure, CRP: C-reactive protein ® = randomization Support This clinical trial is supported by the Swiss National Foundation and the Swiss heart Foundation .

US of the

carotids

C: Follow-up

Plaque

B: Follow-up

A: Follow-up

No

plaque

1° Outcome:

Smoking cessation

(validated by cotinine measurement)

2° Outcomes:

Risk factor control:

LDL-C

BP

HbA1c (if diabetes)

- CRP

Conclusions Screening for carotid plaques may increase short- term motivation for smoking cessation, and might be an additional strategy to increase smoking quit rates. The impact of screening for carotid plaques on long-term smoking cessation and control of other cardiovascular risk factors should be further examined in large randomized controlled trials: Ongoing Caross study in 530 smokers

Screening for carotid plaques may increase short- term motivation for smoking cessation, and might be an additional strategy to increase smoking quit rates.

The impact of screening for carotid plaques on long-term smoking cessation and control of other cardiovascular risk factors should be further examined in large randomized controlled trials:

Ongoing Caross study in 530 smokers

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