CME – Smoking & PAD: Assessing the Costs

CME – Smoking & PAD: Assessing the Costs
Author Information (click to view)

Sue Duval, PhD, FAHA

Associate Professor of Medicine and Biostatistics
Lillehei Clinical Research Unit
Cardiovascular Division
University of Minnesota Medical School

Sue Duval, PhD, FAHA, has indicated to Physician’s Weekly that she has or has had no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  • Discuss the findings of a study that explored the contribution of tobacco use to short-term healthcare utilization and medical costs in peripheral artery disease.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Sue Duval, PhD, FAHA
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Sue Duval, PhD, FAHA (click to view)

Sue Duval, PhD, FAHA

Associate Professor of Medicine and Biostatistics
Lillehei Clinical Research Unit
Cardiovascular Division
University of Minnesota Medical School

Sue Duval, PhD, FAHA, has indicated to Physician’s Weekly that she has or has had no financial interests to report.

Tobacco use among patients with peripheral arterial disease (PAD) substantially increases the short-term annual risk for PAD-related hospitalizations due to heart and vascular events, with significantly greater costs. Immediate provision of tobacco cessation programs would most likely be cost effective.
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Peripheral artery disease (PAD) is one of the most common cardiovascular diseases among adults in the United States. The risk for developing PAD increases as people age and are exposed to specific atherosclerosis risk factors. Previous published research has linked continued tobacco use to an increasing number of heart attacks and strokes, worsened claudication, increased amputations, aneurysms, exposure to costly medical procedures, and death in people with PAD. Tobacco use has been identified as an important preventable cause of PAD and is a major determinant of adverse clinical outcomes.

Taking a Closer Look

Surprisingly, no prior studies have specifically explored the contribution of tobacco use to short-term healthcare utilization and medical costs in PAD. To address this research gap, Sue Duval, PhD, FAHA, and colleagues evaluated this risk in a large, population-based, cross-sectional study published in the Journal of the American College of Cardiology that analyzed 2011 claims data of more than 22,000 people with PAD. “Our study was designed to define the associated immediate health and economic burden of tobacco use in Minnesota and the United States,” says Dr. Duval. “It represents one of the largest measurements of the impact of PAD on health.”

Claims data used in the study were provided by Blue Cross and Blue Shield of Minnesota, the state’s largest health plan. The total study group included individuals with 12 months of continuous enrollment and one or more PAD-related claims. The authors also queried tobacco cessation pharmacotherapy billing codes in a subgroup of patients with pharmacy benefits in order to better identify current smokers. Outcomes assessed in the study included the annual proportion of members hospitalized, the associated primary discharge diagnoses, and total healthcare costs.

Assessing Admissions & Costs

The investigation identified 9% of the more than 22,000 participants with PAD who were tobacco users. Also, a subgroup of more than 9,000 patients with pharmacy benefits included nearly 13% who were identified as tobacco users. The total cohort experienced 22,220 hospital admissions, while the subgroup of patients with pharmacy benefits experienced more than 8,000 admissions.

“Within 1 year, nearly one-half of patients with PAD who used tobacco were hospitalized,” says Dr. Duval. This figure was 35% higher than that of non-tobacco users in the total cohort and 30% higher in the subgroup of patients with pharmacy benefits. In both cohorts, tobacco users were more frequently admitted to the hospital for peripheral or visceral atherosclerosis, heart disease, stroke, pneumonia, and bronchitis.

Observed costs for the total PAD cohort in the first year were $64,041 for tobacco users compared with $45,918 for non-tobacco users, representing a cost difference of nearly $18,000 (Figure). Costs for tobacco users were consistently higher for professional and facility-based care, a finding that persisted even after adjusting for age, sex, comorbidities, and insurance type.

A Devastating Impact

“Our research clearly illustrates the devastating impact smoking can have for those dealing with PAD,” Dr. Duval says. “It’s been well-established that tobacco hurts health, but our study shows how powerfully detrimental smoking can be to patients with PAD. The cost to patients, society, and health payers is gigantic for both the short and long term.” Considering that Minnesota is a state that is known to be “heart healthy,” the study group noted that the implications of their research and the costs of smoking are likely to be even higher in other areas throughout the U.S.

According to Dr. Duval, clinicians, health systems, and insurers need to make much greater and more consistent efforts to assist patients with PAD to quit smoking. “It has been shown by other major research studies, including those involving people with PAD, that physicians who counsel individuals on smoking cessation and provide comprehensive tools to facilitate each quit attempt can make an important impact on empowering patients to quit the habit,” she says. “We should inform patients with PAD that their risks for heart disease are higher if they smoke and let them know that they’re more likely to be hospitalized within a year if they continue to smoke. A discussion about smoking cessation should be routine during every patient encounter in order to reinforce quit efforts.”

It is known that each comprehensive effort to help a patient quit smoking, including both access to behavioral counseling and pharmacotherapy, costs less than $500. “When compared with the nearly $18,000 per year in added healthcare costs, it is much more cost effective to give patients every tool to quit smoking,” Dr. Duval says. “It’s important for clinicians and quality-focused health systems to treat the causes of disease— not just the consequences—and we should think of smoking cessation a first-line therapy for PAD.” She notes that the study results also suggest that immediate provision of tobacco cessation programs may be especially cost effective.

Readings & Resources (click to view)

Duval S, Long KH, Roy SS, et al. The contribution of tobacco use to high health care utilization and medical costs in peripheral artery disease: a state-based cohort analysis. J Am Coll Cardiol. 2015;66:1566-1574. Available at:

Barnes GD, Jackson EA. Tobacco use in peripheral artery disease: an economic drag. J Am Coll Cardiol. 2015;66:1575-1576.

Hennrikus D, Joseph A, Lando HA, Duval S, Kodl M, Ukestad L, Hirsch AT.  Effectiveness of a smoking cessation program for peripheral artery disease patients: A randomized controlled trial.  J Amer Coll Cardiol 2010 Dec 14;56(25):2105-12.

Rooke TW, Hirsch AT, Misra S, et al; American College of Cardiology Foundation Task Force; American Heart Association Task Force. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:1555-1570.

Hirsch AT, Duval S. The global pandemic of peripheral artery disease. Lancet. 2013;382(9901):1312-1314.

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