For a patient who smoked for 25 years and quit 7 months ago, do I answer yes to smoking on the Atherosclerotic Cardiovascular Disease (ASCVD) calculator?

Smoking Status for ASCVD Risk Calculator After Recent Cessation

For a patient who smoked for 25 years and quit 7 months ago, you should answer "YES" to smoking on the ASCVD risk calculator.

Rationale for Answering "Yes" to Smoking Status

According to the 2019 ACC/AHA Guideline on Primary Prevention of Cardiovascular Disease, smoking status is defined based on use within the past 30 days 1. The guidelines specifically recommend asking patients "Have you smoked any tobacco product in the past 30 days, even a puff?" to determine current smoking status. However, for risk calculation purposes, the residual cardiovascular risk from prior smoking extends well beyond 30 days of abstinence.

Persistence of Cardiovascular Risk After Smoking Cessation

The risk reduction from smoking cessation follows a time-dependent pattern:

• Cardiovascular disease risk begins to decrease immediately after quitting 1
• However, the excess risk persists for years after cessation
• According to evidence from Asian cohorts, it takes 10-14 years for CVD mortality risk to approach that of never-smokers 1
• The 2013 AHA statement on Secondary Prevention of ASCVD in Older Adults notes that benefits of smoking cessation are seen in mortality reduction, but the risk never fully equals that of never-smokers 1

ASCVD Risk Calculator Considerations

The Framingham Stroke Risk Profile, which forms the basis for many cardiovascular risk calculations, includes smoking as a binary variable (yes/no) without accounting for time since cessation 1. This suggests that for risk calculation purposes, recent quitters should still be considered as having elevated risk.

Clinical Implications

• Risk assessment accuracy: Marking "yes" for smoking in a patient who quit only 7 months ago provides a more accurate risk assessment
• Treatment decisions: This approach ensures appropriate intensity of preventive interventions
• Patient education: While acknowledging the patient's significant achievement in quitting, it's important to communicate that cardiovascular risk remains elevated

Duration of Elevated Risk

The European guidelines on cardiovascular disease prevention note that the risk of CVD approaches (but never fully equals) the risk of never-smokers within 10-15 years of cessation 1. This extended timeline for risk normalization supports classifying recent quitters as having elevated risk.

Common Pitfalls to Avoid

1. Underestimating residual risk: Marking "no" for smoking status after only 7 months of cessation would significantly underestimate the patient's ASCVD risk
2. Discouraging quitting efforts: While answering "yes" on the calculator, it's essential to positively reinforce the patient's successful cessation
3. Overlooking the dose-response relationship: The 25-year smoking history represents substantial cumulative exposure that continues to affect risk even after cessation

Conclusion

Based on current guidelines and evidence regarding the persistence of cardiovascular risk after smoking cessation, a patient who smoked for 25 years and quit 7 months ago should be classified as "yes" for smoking status on the ASCVD risk calculator to ensure accurate risk assessment and appropriate preventive interventions.