Elsevier

American Heart Journal

Volume 154, Issue 2, August 2007, Pages 213-220
American Heart Journal

Curriculum in Cardiology
Inpatient smoking-cessation counseling and all-cause mortality in patients with acute myocardial infarction

This work is dedicated to the memory of Aubrey Ignatius Van Spall, beloved father and friend.
https://doi.org/10.1016/j.ahj.2007.04.012Get rights and content

Background

Smoking cessation is associated with improved health outcomes, but the prevalence, predictors, and mortality benefit of inpatient smoking-cessation counseling after acute myocardial infarction (AMI) have not been described in detail.

Methods

The study was a retrospective, cohort analysis of a population-based clinical AMI database involving 9041 inpatients discharged from 83 hospital corporations in Ontario, Canada. The prevalence and predictors of inpatient smoking-cessation counseling were determined. Associations were drawn between counseling and all-cause 1-year mortality using multivariate Cox proportional hazards regression model and controlling for important validated predictors of post-MI mortality.

Results

A majority of patients with AMI (67.4%) had a history of smoking and 39.0% were current smokers. Current smokers presented with AMI at a much younger average age than former- and never-smokers (mean [±SD] ages 59.0 ± 12.5, 68.9 ± 11.4, and 70.6 ± 12.8 years, respectively). Only 52.1% of current smokers were offered smoking-cessation counseling. Multivariate predictors of counseling included a history of asthma (odds ratio [OR] 1.62, 95% CI 1.15-2.31) and admission to a large hospital (OR 1.74, 95% CI 1.37-2.22). Factors associated with no counseling included increasing patient age (OR 0.69, 95% CI 0.65-0.74), a history of diabetes (OR 0.77, 95% CI 0.63-0.93), and admission under the care of a cardiologist (OR 0.67, 95% CI 0.52-0.85) or internist (OR 0.72, 95% CI 0.58-0.88). After adjustment for predictors of post-MI mortality, counseled smokers had a lower risk of mortality (hazard ratio 0.63, 95% CI 0.44-0.90) than those not counseled.

Conclusions

Post-MI inpatient smoking-cessation counseling is an underused intervention, but is independently associated with a significant mortality benefit. Given the minimal cost and potential benefit of inpatient counseling, we recommend that it receive greater emphasis as a routine part of post-MI management.

Section snippets

Study design

This study was a retrospective analysis of patients presenting with AMI at 83 teaching and community hospitals (103 sites) in Ontario, Canada, between April 1, 1999, and March 31, 2001. The patient population was derived from the EFFECT study, a large initiative to improve the quality of AMI care in Ontario.12 We identified newly admitted patients with a most responsible diagnosis (ie, the principal diagnosis which accounts for most of a patient's length of stay) of AMI using the Canadian

Study population and baseline characteristics

Among the 11 524 patients with AMI in the EFFECT database, 2483 were excluded for prespecified reasons (Figure 1). Thus, 9041 patients who were admitted with an AMI and discharged alive were included in this study.

Table I shows the baseline characteristics of the study population. Of the 9041 patients, 67.1% were male and 32.9% were female. There was no significant difference in the proportion of patients with STEMI and NSTEMI. Among patients admitted with AMI, 67.4% had a history of smoking and

Discussion

Patients who continue to smoke after a diagnosis of coronary artery disease or AMI are at greater risk for death than those who quit smoking.4, 7, 17 This is likely because of the association of cigarette smoking with increased thrombosis, cytokine production, endothelial dysfunction, coronary vasoreactivity, arrhythmogenesis, and sudden cardiac death.5, 6, 18, 19, 20, 21 According to one systematic review, smoking cessation is associated with a relative risk of 0.64 of all-cause mortality

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    The EFFECT study is funded by a Canadian Institutes of Health Research Team Grant in Cardiovascular Outcomes Research. Additional funding for this project came from an operating grant (Grant No. NA 5703) from the Heart and Stroke Foundation of Ontario. Dr Tu is funded by a Canada Research Chair in Health Services Research and a Career Investigator Award from the Heart and Stroke Foundation of Ontario.

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