Referral to an experienced dietitian or to a reputable weight loss program for nutritional counseling and behavioral modification ther- apy can be helpful. The effects of caloric restriction are potentiated by regular aerobic physical activity. Therapy with medications or bariatric surgery may be considered in se- lected patients who are unable to achieve adequate weight loss by conventional lifestyle modifications.649 4.4.1.6. Smoking Cessation Counseling Class I 1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home should be encouraged for all patients with SIHD. Follow-up, referral to special programs, and phar- macotherapy are recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange, Avoid).650 652 (Level of Evidence: B) Observational studies over the past 4 decades have fur- nished incontrovertible evidence that smoking increases the risk of cardiovascular disease events.653,654 A dose response relationship exists between cigarettes smoked and cardiovascular risk, with an RR approaching 5.5 for cardiovascular events among heavy smokers compared with nonsmokers.654 Potential mechanisms by which smoking predisposes to cardiovascular events include ad- verse effects on fibrinogen levels,655 platelet adhesion,656 and endothelial function657; reduced HDL cholesterol lev- els658; and coronary artery vasoconstriction.659 Although RCTs have not been performed in patients with SIHD, results of observational studies strongly suggest that smoking cessation is an effective strategy for secondary prevention of coronary events. A meta-analysis of 20 pros- pective cohort studies found a 30% reduction in RR of mortality for those who quit compared with those who continued smoking, and a similar reduction was noted in nonfatal MIs.650 Some studies suggest that most of the reduction in risk occurs within 2 or 3 years of quitting.660,661 The most effective smoking-cessation therapies include both nonpharmacological and medical interventions. 