This week's special issue, devoted to matters of the heart, will go to the American College of Cardiology's annual meeting in Orlando, Florida (March 29—31), where 30 000 cardiovascular professionals will gather to hear the latest clinical and scientific news in their specialty. Sessions range from advances in atrial fibrillation ablation to updates in device therapy. Preventive cardiology will also feature. As the EUROASPIRE Study Group show in The Lancet today, more effective management of lifestyle risk factors is desperately needed in patients with coronary heart disease. The study, which compared the results of three EUROASPIRE surveys in eight European countries, found that adverse lifestyle trends persisted in patients 1 year after a cardiac event. These trends included smoking; about a fifth of patients continued to smoke and the proportion of young women smoking actually increased.

These findings are perhaps unsurprising. As delegates at the 14th World Conference on Tobacco or Health in Mumbai, India, heard this week, cardiologists often overlook smoking as a risk factor for cardiovascular disease when compared with hypertension and hyperlipidaemia. This is despite the fact that tobacco smoke increases the risk of acute myocardial infarction, sudden cardiac death, aortic aneurysms, and peripheral vascular disease. The lack of attention that smoking cessation receives in some primary and specialist settings is a concern since quitting can reverse the risk of cardiovascular disease from smoking in patients at risk of or with existing disease. For example, in disease-free smokers, much of the risk of acute myocardial infarction dissipates 5 years after quitting. And patients who quit after acute myocardial infarction or cardiac surgery can decrease their risk of death by around a third.

Why then is smoking cessation overlooked? Perhaps the advent of effective high-tech interventions for cardiovascular diseases has drawn attention away from secondary prevention. Some professionals might view smoking as a lifestyle choice rather than an addiction that needs treatment. Others cite a lack of time or lack of training in smoking cessation counselling. But when doctors provide simple brief advice about quitting smoking, the likelihood that patients will quit and remain non-smokers 12 months later is increased. Furthermore, US data suggest that smoking cessation is also more cost effective than other preventive cardiology measures. Nicotine replacement therapy and brief counselling by physicians costs around US$2000—6000 per life-year saved compared with no treatment, whereas treatment of moderate to severe hypertension costs $9000—26 000 per life-year saved.

Promotion of smoking cessation at the population level is also becoming ever more important. The number of smokers worldwide is estimated to reach 1·7 billion by 2025. Even though some developed countries have seen reductions in smoking, a burgeoning epidemic of cardiovascular disease caused by tobacco consumption is expected in low-income and middle-income countries. Public health measures such as increasing taxation on cigarettes and banning smoking in public places need to be implemented globally. Smoke-free policies around the world are already having a positive effect on cardiovascular health. A study by the US Centers for Disease Control and Prevention found that in the city of Pueblo, Colorado, heart attack admissions fell by 27% 18 months after a ban on smoking in public places. In Scotland, the number of hospital admissions for acute coronary syndrome decreased by 17% after the introduction of smoke-free legislation at the end of March, 2006.

Cardiologists should be ardent supporters of such public health measures. They need to engage in debates about important developments in tobacco control. In the USA, for example, big changes are afoot. The Food and Drug Administration (FDA) looks set to gain the power to regulate cigarettes and other tobacco products after legislation was passed by a panel of the US House of Representatives last week. If the full House and the Senate approve the move, the FDA could control the labelling, marketing, and sale of tobacco products. Although some doctors' groups have praised the legislation, others have raised concerns. For example, the bill could be a barrier to the introduction of new smoke-free products, such as low-nicotine lozenges.

It is time for cardiologists to be less passive about their patients' smoking status and public health approaches to tackle smoking. After all, a reduction in smoking at the patient and population level would have a bigger impact on cardiovascular disease than any of the high-tech interventions delegates in Orlando will hear about.