Should alternative smoking devices be encouraged or discouraged in patients with lower extremity Peripheral Artery Disease (PAD)?

Electronic Nicotine Delivery Systems in Peripheral Artery Disease

Electronic nicotine delivery systems should be discouraged as a transitional tool to smoking cessation in patients with lower extremity PAD because of the lack of efficacy and safety data in this patient population. 1

Evidence-Based Rationale

The 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease clearly addresses this issue. While the guideline acknowledges that emerging data have demonstrated that electronic nicotine delivery systems have a positive effect on smoking cessation rates in the general population, it specifically notes that long-term health-related outcomes (MACE and MALE) with use of electronic nicotine delivery systems have not been evaluated in PAD patients 1.

The guideline explicitly states: "Additional clinical investigation of electronic nicotine delivery systems in patients with PAD is needed to establish their safety and efficacy for smoking cessation in this patient population" 1. This indicates that without established safety and efficacy data specific to PAD patients, these devices should not be recommended.

Smoking Cessation Recommendations for PAD Patients

The 2024 guideline provides clear recommendations for smoking cessation in PAD patients:

1. Strong recommendation (Class 1, Level A): Patients with PAD who smoke cigarettes or use any other forms of tobacco should be advised at every visit to quit or encouraged to maintain cessation 1.

2. Strong recommendation (Class 1, Level A): Patients should be assisted in developing a plan for quitting that includes:

   • Pharmacotherapy (varenicline, bupropion, and/or nicotine replacement therapies)
   • Counseling
   • Referral to a smoking cessation program 1

3. Strong recommendation (Class 1, Level B-NR): Patients should avoid exposure to secondhand tobacco smoke in all indoor or enclosed spaces 1.

Risks of Smoking in PAD Patients

Cigarette smoking and other forms of tobacco use are strong, dose-responsive risk factors for PAD development and progression. The risk of PAD development remains more than twice as high as that of never-smokers for up to 10-20 years after quitting 1. Observational studies suggest that smoking cessation is associated with lower rates of major adverse limb events (MALE), including bypass graft failure and amputation, as well as death in patients with PAD 1.

Effective Smoking Cessation Approaches for PAD Patients

Instead of electronic nicotine delivery systems, the following evidence-based approaches should be used:

1. Pharmacotherapy options:

   • Varenicline
   • Bupropion
   • Nicotine replacement therapies 1

2. Behavioral interventions:

   • Counseling
   • Referral to smoking cessation programs 1

Clinical Implications and Pitfalls

Key Pitfalls to Avoid:

1. Don't substitute one form of nicotine for another: Electronic nicotine delivery systems still contain nicotine, particulates, and other toxic chemicals, albeit at lower levels than tobacco smoke 1.

2. Don't assume safety in PAD patients: While these devices may have a role in the general population, their safety profile has not been established specifically in PAD patients, who are at higher risk for cardiovascular and limb events 1.

3. Don't miss the opportunity for proven interventions: Clinician advice and encouragement increase cessation rates, supporting simple provider-based measures as a component of smoking cessation programs 1.

Important Clinical Considerations:

• The risk of PAD progression and adverse outcomes is significantly higher in patients who continue to smoke 1, 2.
• Complete smoking cessation should always be the ultimate goal, using proven pharmacological and behavioral approaches 1.
• Physician advice coupled with frequent follow-up achieves significantly higher 1-year smoking cessation rates compared to patients attempting to quit without intervention 1.

In conclusion, while electronic nicotine delivery systems may have a role in smoking cessation for some populations, the current evidence does not support their use in PAD patients due to lack of safety and efficacy data in this high-risk population. Clinicians should instead focus on proven smoking cessation strategies including pharmacotherapy (varenicline, bupropion, nicotine replacement) and behavioral interventions.