The evidence on the use of ENDS as a smok- ing-cessation tool in adults (including pregnant women) and adolescents is insufficientS4.5-23 or The USPSTF recommends that clini- cians direct patients who smoke tobacco to other cessation interventions with established effective- ness and safety. 4. Cigarette smoking remains a strong, indepen- dent risk factor for ASCVD events and premature Even among older adults, tobacco ces- sation is beneficial in reducing excess risk.S4.5-5 The risk of heart failure and death for most for- mer smokers is similar to that of never smokers after >15 years of tobacco cessation.S4.5-25 In the National Health Interview Survey, smoking was strongly associated with ASCVD in young people after adjustment for multiple risk factors,S4.5-26 which is why abstinence from an early age is recommended. 5. Tobacco use dependence is a chronic disease that requires highly skilled chronic disease man- agement. It is a reasonable expectation that every health system or practice should dedicate trained staff to tobacco treatment. Healthcare profes- sionals who receive training in tobacco treatment are more likely to ask about tobacco use, offer advice to quit, provide behavioral interventions, follow up with individuals, and increase the num- ber of tobacco users who quit.S4.5-1 Participants who earn a certificate in tobacco treatment practice demonstrate a nationally recognized level of training and skill acquisition in treating A Tobacco Treatment Specialist is a professional who possesses the skills, knowledge, and training to provide effec- tive, evidence-based interventions for tobacco dependence across a range of intensities.S4.5-28 A list of accredited Tobacco Treatment Specialist programs is available here: http://ctttp.org/ Table 8. Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers* Timing of Behavioral Interventions <3 min of tobacco status assessment with cessation counseling at each clinic encounter >3-10 min of tobacco status assessment with cessation counseling at each clinic encounter >10 min of tobacco status assessment with cessation counseling at each clinic encounter Treatment Dosing Precautions NRT* Patch 21 mg, 14 mg, or 7 mg Starting dose: 21 mg for 10 CPD; 14 mg for <10 CPD Local irritation possible; avoid with skin disorders; may remove for sleep if needed Gum 2 mg or 4 mg Starting dose: 4 mg if first tobacco use is 30 min after waking; 2 mg if first tobacco use is >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d. Chew and park gum* Hiccups/dyspepsia possible; avoid food or beverages 15 min before and after use Lozenge 2 mg or 4 mg Nasal spray 10 mg/mL Starting dose: maximum of 40 doses/d Local irritation possible; avoid with nasal or reactive airway disorders Oral inhaler 10-mg cartridge Starting dose: Puff for 20 min/cartridge every 1-2 h; maximum 16 cartridges/d Cough possible; avoid with reactive airway disorders Other Bupropion (Zyban [GlaxoSmithKline], Wellbutrin SR [GlaxoSmithKline]) 150 mg SR 150 mg once daily (am) for 3 d; then 150 mg twice daily; may use in combination Avoid with history/risk of seizures, eating disorders, MAO inhibitors, or CYP 2D6 inhibitor Varenicline (Chantix [Pfizer]) 0.5 mg or 1 mg 0.5 mg once daily (am) for 3 d; then 0.5 mg twice daily for 4 d; then 1 mg twice daily (use start pack followed by continuation pack) for 3-6 mo Nausea common; take with food. Renal dosing required. Very limited drug interactions; near-exclusive renal clearance. *CPD can guide dosing. 1 CPD is 1-2 mg of nicotine. Note: Use caution with all NRT products for patients with recent ( 2 wk) MI, serious arrhythmia, or angina; patients who are pregnant or breastfeeding; and adolescents. Timing of assessment relates to ICD-10 coding. Dose and duration can be titrated on the basis of response.S4.5-21 The FDA has issued a removal of black box warnings about neuropsychiatric events.S4.5-20,S4.5-21 am indicates morning; CPD, cigarettes smoked per day; FDA, US Food and Drug Administration; ICD-10, International Classification of Diseases, Tenth Revision; MAO, monoamine oxidase; NRT, nicotine replacement; and SR, sustained release. CLINICAL STATEMENTS AND GUIDELINES 6. Secondhand smoke exposure is known to cause in nonsmokers, and it can lead to immediate adverse events.S4.5-30 There is no safe lower limit of exposure to secondhand Even brief exposure to secondhand smoke can trigger an MI.S4.5-30,S4.5-32 Even though exposure to secondhand smoke has steadily decreased over time, certain subgroups remain exposed to secondhand smoke in homes, vehicles, public places, and workplaces. It is estimated that 41000 preventable deaths per year occur in adult nonsmokers as a result of exposure to second- The US Department of Housing and Urban Development prohibited the use of combustible tobacco products in all public hous- ing living units, indoor common areas, and public housing agency administrative office buildings, extending to all outdoor areas up to 25 feet from public housing buildings.S4.5-34 Therefore, the pres- ent writing committee recommends that clinicians advise patients to take precautions against expo- sure to secondhand smoke and aerosol from all tobacco products, such as by instituting smoking restrictions (including ENDS) inside all homes and vehicles and within 25 feet from all entryways, windows, and building vents. 4.6. Aspirin Use Recommendations for Aspirin Use Referenced studies that support recommendations are summarized in Online Data Supplements 17 and 18. COR LOE Recommendations IIb A Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding III: Harm B-R Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.S4.6-9 III: Harm C-LD Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of Synopsis For decades, aspirin has been widely administered for ASCVD prevention. By irreversibly inhibiting platelet function, aspirin reduces risk of atherothrombosis but also increases risk of bleeding, particularly in the gas- Aspirin is well established for secondary prevention of ASCVDS4.6-12 and is widely rec- ommended for this indication.S4.6-13 However, in primary prevention, aspirin use is more controversial. Because persons without prior ASCVD are inherently less likely to have future ASCVD events than are those with a prior history, it is more challenging for clinicians and patients to balance benefits and harms of prophylactic aspirin for primary prevention. This uncertainty is re- flected in international guidelines, where, for example, aspirin is not recommended in European guidelines for primary ASCVD preventionS4.6-13 but is recommended in prior US guidelines for selected primary prevention for adults who have elevated risk of ASCVD based on tradi- tional risk factors.S4.6-14,S4.6-15 Adding to this controversy are more recently conducted primary-prevention trials that, in contrast to older trials,S4.6-12 have shown less overall benefit of prophylactic aspirin alongside coad- ministration of contemporary ASCVD preventive treat- ments, such as evidence-based hypertension and cho- Recommendation-Specific Supportive Text 1. To balance the benefits and risks, prior US guide- lines have recommended prophylactic aspirin only in the setting of elevated ASCVD risk (eg, as calculated by risk estimators like the PCE or based on the presence of specific ASCVD risk Meta-regression analyses of his- torical trials show that observed ASCVD risk tracks reasonably well with baseline-estimated ASCVD In contrast, observed bleeding risk on aspirin is less well correlated with baseline-esti- mated ASCVD risk.S4.6-19 (A nonexhaustive list of scenarios associated with increased risk of bleed- ing includes: a history of previous gastrointestinal bleeding or peptic ulcer disease or bleeding from other sites, age >70 years, thrombocytopenia, coagulopathy, CKD, and concurrent use of other medications that increase bleeding risk, such as nonsteroidal anti-inflammatory drugs, steroids, direct oral anticoagulants, and warfarin.) In this context, post hoc study of older trials suggests that the benefit risk ratio for prophylactic aspirin generally becomes more favorable at >10% esti- However, the relative benefits of aspirin, specifically in pre- venting nonfatal MI and perhaps stroke (with a trend to lower mortality) have been less evident in more recent trials.S4.6-9,S4.6-16,S4.6-17,S4.6-20 Similarly, in these recent trials, the estimated ASCVD risk has generally exceeded the actual risk observed during These recent data are the rationale for the lower COR for prophylactic aspirin in the present guideline (Class IIb) and the removal of a specific PCE risk threshold as an inclusion criterion for aspirin consideration. These changes reflect the need to instead consider the totality of available CLINICAL STATEMENTS AND GUIDELINES evidence for ASCVD risk [inclusive, where appro- priate, of risk-enhancing factors, such as strong family history of premature MI, inability to achieve lipid or BP or glucose targets, or significant eleva- tion in coronary artery calcium scoreS4.6-21 ] and to also tailor decisions about prophylactic aspirin to patient and clinician preferences. Depending on risk factors present, a given patient and his/her clinician may decide that lowering the risk of MI (which has potentially serious long-term conse- quences not captured by clinical trials of 5 to 10 years duration) is worth a slight excess risk of seri- ous bleeding. Recent trials show that absolute risk for ASCVD events typically exceeds that of bleed- ing and, although the gap of relative benefit to relative harm for aspirin has narrowed, the num- ber needed to treat to prevent an ASCVD event remains lower than the number needed to harm to cause bleeding. Others may feel that the ben- efit of prophylactic aspirin is comparable to the risk and may instead choose to focus on optimal control of other modifiable ASCVD risk factors. Therefore, a Class IIb recommendation remains more suitable than a Class III recommendation for adults 40 to 70 years of age. Given the nar- row overall balance between benefits and harms of prophylactic aspirin, there is limited justifica- tion to use aspirin at doses >100 mg daily for pri- mary prevention. Indeed, meta-analyses suggest that the ASCVD risk benefit for low-dose aspirin is equivalent to that for high-dose aspirin, but the bleeding risk is higher with high-dose aspi- rin. Recent observational studies motivate future research on the personalization of prophylactic aspirin dose according to patient-specific factors though we note that, regarding weight specifically, there was no evidence low- dose aspirin was any more effective in low-weight individuals than in high-weight individuals in the more recently published ASCEND (A Study of Cardiovascular Events iN Diabetes) trial,S4.6-16 trial. Most importantly, recent clinical trials also teach us that low-dose prophylactic aspirin may be best justified among persons at high ASCVD risk who cannot achieve optimal control of other ASCVD 2. Prophylactic aspirin in primary-prevention adults >70 years of age is potentially harmful and, given the higher risk of bleeding in this age group, dif- ficult to justify for routine use.S4.6-9 In addition, for adults <40 years of age, there is insufficient evidence to judge the risk benefit ratio of rou- tine aspirin for the primary prevention of ASCVD. However, one caveat is that, although routine use is not recommended in these settings, there is also insufficient evidence to comment on whether there may be select circumstances in which physi- cians might discuss prophylactic aspirin with adults <40 years of age or >70 years of age in the con- text of other known ASCVD risk factors (eg, strong family history of premature MI, inability to achieve lipid or BP or glucose targets, or significant eleva- tion in coronary artery calcium score). As inferred from the first recommendation, there is also no justification for the routine administration of low- dose aspirin for the primary prevention of ASCVD among adults at low estimated ASCVD risk. For example, in the recent ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, observed average 10-year ASCVD risk was <10%, and the overall benefits of prophylactic aspirin by intention-to-treat were negligible.S4.6-17 3. The accumulated trial and observational data to date support avoiding prophylactic aspirin in the setting of known risk factors for increased bleeding A nonexhaustive list of conditions associated with increased bleeding risk includes: a history of previous gastrointestinal bleeding or peptic ulcer disease or bleeding at other sites, age >70 years, thrombocytopenia, coagulopathy, CKD, and concurrent use of other medications that increase bleeding risk, such as nonsteroidal anti-inflammatory drugs, steroids, direct oral anti- coagulants, and warfarin.S4.6-10 5. COST AND VALUE CONSIDERATIONS The growing need to consider value stems directly from the goal of achieving the best possible health outcomes with finite healthcare resources in the pri- mary prevention of CVD.S5-1 Value in health care can be defined as the incremental health benefits of a therapy or procedure relative to its incremental net long-term costs. The consideration of cost and value in the guideline development process supports key goals, including: 1) enhancing overall value in the de- livery of cardiovascular care and 2) involving health- care professionals in the challenging care decisions that must be made to increase value in the US health- The integration of value assessments into our na- tional guidelines involves inherent methodological chal- lenges, including: 1) variability in costs across different healthcare settings; 2) variability in costs and benefits across different patient subgroups; 3) variability over time; 4) variability in who bears the burden of the health outcome (ie, typically the individual patient) ver- sus who bears the burden of the healthcare cost (eg, often spread beyond the individual to third-party pay- ers, taxpayers); and 5) an inadequate literature base on which to render a sound, evidence-based assessment of certain specific therapies.S5-1,S5-2 CLINICAL STATEMENTS AND GUIDELINES There are additional challenges specific to the pre- vention realm. As described in the 2011 AHA policy statement, Value of Primordial and Primary Prevention Assessing the value of prevention in appar- ently healthy patients is generally more dif- ficult than evaluating therapy for established disease because the time horizon to the clinical manifestation of disease is generally long many decades in the young. Thus, it is difficult, perhaps impossible, to assess long- term effectiveness in terms of survival or qual- ity-adjusted life-years (QALYs) or associated costs because of increasing uncertainty about outcome the further one tries to look into the future. Furthermore, the principle of discounting, which places relative emphasis on current costs and benefits while deemphasizing downstream costs and benefits, creates disadvantages for prevention because costs of- ten accrue in the present while the benefit may only be fully realized long into the future. These methodologi- cal challenges notwithstanding, prior AHA statements have highlighted the public policies, community ef- forts, and pharmacological interventions that are likely to be cost-effective and, at times, cost-saving preven- tion tactics compared with common benchmarks. For example, robust evidence suggests that both antihy- and statin therapy,S5-7 S5-9 par- ticularly with low-cost generic drug formulations, are high-value interventions across a wide spectrum of risk and age strata. The incorporation of the value category into clini- cal practice guidelines is one of several considerations in medical decision-making and resource allocation. Clinicians, researchers, and policymakers must con- tinue to place cost-effective analyses in the proper context, extracting key value determinations while acknowledging the challenges in fully characterizing and incorporating the downstream benefits of a given therapeutic prevention tactic. Further research and methodological advances are needed to comprehen- sively characterize the full spectrum of benefits pro- duced by the prevention approach, thereby rendering cost-effectiveness assessments more consequential to clinical practice. Most ASCVD events are avoidable through primordial prevention (ie, the prevention of risk factor develop- ment) and control of traditional cardiovascular risk fac- tors. Tobacco avoidance is critically important for AS- CVD prevention, and all adults should strive to engage in regular brisk physical activity most days of the week and adhere to a healthy dietary pattern to help lower future ASCVD risk. A diet high in fruits, vegetables, and whole grains is best. Fish, legumes, and poultry are the preferred sources of protein. Minimizing the consumption of trans fats, added sugars (including sugar-sweetened beverages), red meats, sodium, and saturated fats is also important. Clinicians should work in partnership with patients to assess their readiness for sustained lifestyle improvements, identify poten- tial barriers to change, and encourage them to try to achieve measurable goals and continue to monitor Finally, social determinants of ASCVD risk and their impact on the patient s ability to pre- vent or treat risk factors must be taken into account. Clinicians need to consider patients health literacy and education levels and assess patients motivation to im- prove their lifestyle habits. The goal of the clinician is to match the intensity of preventive efforts with an individual s absolute risk of a future ASCVD event and with the individual s willing- ness and capacity to implement preventive strategies. Risk estimation is imperfect and based on group aver- ages that are then applied to individual patients. The clinician must balance an understanding of a patient s estimated ASCVD risk with potential benefits and ad- verse risk from pharmacological therapy in the context of a risk discussion. To determine the appropriateness of pharmacological therapy after quantitative risk esti- mation in cases that are unclear, risk-enhancing factors or selective use of a coronary artery calcium measure- ment can inform decision-making for cholesterol-low- ering or antihypertensive medication use in intermedi- ate-risk individuals. This primary-prevention guideline strives to pro- vide clinicians with the information they need to help their patients reduce their risk of ASCVD and encour- age them to make healthier lifestyle changes when needed. ACC/AHA TASK FORCE MEMBERS Patrick T. O Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Joaquin E. Cigarroa, MD, FACC; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Mark A. Hlatky, MD, FACC, FAHA; John Ikonomidis, MD, PhD, FAHA*; Jos A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAHA; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD * Former Task Force member; current member during the writing effort. CLINICAL STATEMENTS AND GUIDELINES PRESIDENTS AND STAFF American College of Cardiology C. Michael Valentine, MD, FACC, President Timothy W. Attebery, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice Presi- dent, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Educa- tion, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S.D. Getchius, Manager, Guideline Operations American Heart Association Ivor Benjamin, MD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Cammie Marti, PhD, MPH, RN, Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Scientific Publications, Office of Science Operations ARTICLE INFORMATION This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the American Heart Association Executive Committee in February 2019. Supplemental materials are available with this article at https://www. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional. heart.org/). A copy of the document is also available at https://professional.heart. org/statements by selecting the Guidelines & Statements button. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guide- lines development, visit https://professional.heart.org/statements. Select the Guidelines & Statements drop-down menu near the top of the web page, then click Publication Development. Permissions: Multiple copies, modification, alteration, enhancement, and/ or distribution of this document are not permitted without the express permis- sion of the American Heart Association. Instructions for obtaining permission are are located at https://www.heart.org/permissions. A link to the Copyright Permissions Request Form appears in the second paragraph (https://www. heart.org/en/about-us/statements-and-policies/copyright-request-form). REFERENCES S1-1. Weir HK, Anderson RN, Coleman King SM, et al. Heart disease and can- cer deaths trends and projections in the United States, 1969 2020. Prev Chronic Dis. 2016;13:E157. S1-2. Johnson NB, Hayes LD, Brown K, et al. CDC National Health Report: leading causes of morbidity and mortality and associated behavioral risk and protective factors United States, 2005 2013. MMWR Suppl. 2014;63:3 27. S1-3. Xu J, Murphy SL, Kochanek KD, et al. Mortality in the United States, 2015. NCHS Data Brief. 2016:1 8. S1-4. 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