Effect of Smoking Relapse on Outcome After Acute Coronary Syndromes

doi:10.1016/j.amjcard.2011.04.033

The American Journal of Cardiology

Volume 108, Issue 6, 15 September 2011, Pages 804-808

https://doi.org/10.1016/j.amjcard.2011.04.033 Get rights and content

The aim of the present study was to evaluate the smoking relapse rate among smokers who had become abstinent during admission for acute coronary syndromes. The association between smoking relapse and mortality was also analyzed. A cohort of 1,294 consecutive active smokers who had interrupted smoking after admission for acute coronary syndromes (1,018 men and 276 women, mean age 59.7 ± 12.3 years) was followed up for 12 months after the index admission. All patients received a brief in-hospital smoking cessation intervention consisting of repeated counseling sessions. During follow-up, 813 patients (62.8%) resumed regular smoking (median interval to relapse 19 days, interquartile range 9 to 76). Increasing age (hazard ratio [HR] 1.034 per year, 95% confidence interval [CI] 1.028 to 1.039, p = 0.001) and female gender (HR 1.23, 95% CI 1.09 to 1.42, p = 0.03) were independent predictors of smoking relapse. Patients enrolled in a cardiac rehabilitation program (HR 0.74, 95% CI 0.51 to 0.91, p = 0.02) and those with diabetes (HR 0.79, 95% CI 0.68 to 0.94, p = 0.03) were more likely to remain abstinent. During follow-up, 97 patients died (1-year probability of death 0.075, 95% CI 0.061 to 0.090). Multivariate analysis with the Cox proportional hazard regression method, including smoking relapse as a time-dependent covariate, demonstrated that, after adjustment for patient demographics, the clinical history features and variables related to the index event, the resumption of smoking was an independent predictor of total mortality (HR 3.1, 95% CI 1.3 to 5.7, p = 0.004). In conclusion, smoking relapse after acute coronary syndromes is associated with increased mortality, and counseling interventions should be integrated into the postdischarge support to reduce the negative effects of smoking resumption.

Section snippets

Methods

Consecutive patients discharged from our institution after ACS in a 7.5-year period (January 2001 to June 2008) were prospectively screened for inclusion. Patients with non–ST-segment elevation and ST-segment elevation ACS were considered. Our institution is a 750-bed public hospital providing primary and tertiary care to an urban area with about 250,000 inhabitants. In the prespecified selection period, 5,364 consecutive patients with ACS were discharged from our institution. All patients were

Results

During the 12-month follow-up period, 813 patients (62.8%) resumed regular smoking. The median interval from discharge to smoking relapse was 19 days (interquartile range 9 to 76). The Kaplan-Meier actuarial estimates of smoking relapse in the study population are shown in Figure 1. The main characteristics of the study cohort, as well as unadjusted comparisons between patients who resumed smoking and patients who remained abstinent during the 12-moth follow-up are listed in Table 1.

Discussion

Smoking cessation after ACS could indeed confer a significant mortality benefit, with an expected 30% to 40% reduction of the relative risk of death from any cause.1, 2 Consistent with previous observations, in the present, large, single-center, prospective data set, smoking relapse after ACS was associated with a significant increase in all-cause mortality. Furthermore, smoking resumption early after discharge imparted a greater risk of death compared to a later relapse of tobacco smoking. A

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Cited by (55)

Fagerstrom score predicts smoking status six months after hospitalization for acute myocardial infarction: a prospective study
2022, Hellenic Journal of Cardiology
Fagerstrom score is a validated marker of nicotine addiction in smokers.
In a prospective study, we investigated a) the predictive value of Fagerstrom score for the smoking status in patients early after acute myocardial infarction (AMI) and b) the effectiveness of medically assisted smoking cessation programs in the prevention of relapsing to smoking post discharge. In 103 smokers (58 ± 12 years, 79.6% males), we assessed Fagerstrom score during hospitalization for AMI. Patients filled a dedicated questionnaire including data on family, marital and educational status, habits related to smoking and were followed-up at 3 and 6 months after discharge.
Twenty-eight patients (27.2%) did not quit smoking throughout the 6-months follow-up period (Fagerstrom score:8.1 ± 1.6), 39 patients (37.8%) ceased smoking at 3 months but relapsed to smoking at 6 months (score:6.8 ± 2.1), and only 34 patients (33%) had ceased smoking for 6 consecutive months (score:5.2 ± 2 p < 0.05 for all comparisons between subgroups). By multivariate analysis, Fagerstrom score remained a significant predictor of smoking cessation at 6 months (OR: 0.72, 95%CI: 0.60--0.86, p < 0.001). Out of 73 patients who abstained from smoking for the first 3 months post-AMI, those who participated in a smoking cessation program displayed lower rate of relapsing to smoking compared with those who opted to cease smoking without any support (33.3% vs 61.8% p = 0.012).
Fagerstrom score is a useful predictor of smoking cessation 6 months post-AMI. Patients participating in a smoking cessation program display lower relapse rates post-discharge suggesting the need of well-organized smoking cessation clinics for secondary prevention of heart disease.
Symptoms of depression and active smoking among survivors of stroke and myocardial infarction: An NHANES analysis
2020, Preventive Medicine
Citation Excerpt :
Our approach differs from other recent studies, which reported persistent smoking rates as high as 78% after stroke (Bak et al., 2002) and 63% after MI (Colivicchi et al., 2011). Such studies were not population-based and generally had brief duration of follow-up (Dawood et al., 2008; Holtrop et al., 2009; Perez et al., 2008; Suñer-Soler et al., 2018; Bak et al., 2002; Colivicchi et al., 2011; Lim et al., 2017; Suñer-Soler et al., 2012; Sienkiewicz-Jarosz et al., 2009; Ives et al., 2008; Pagidipati et al., 2017; Gall et al., 2009). Our use of complementary self-reported and biochemical smoking-status measures, and the population-based nature of our study sample, support the representativeness of our estimates for the United States.
Historic concerns about the cardiovascular and neuropsychiatric side effects of smoking-cessation pharmacotherapy have in part limited their use. We sought to evaluate whether depressive symptoms are associated with active smoking among survivors of stroke and myocardial infarction (MI). To do this, we performed a cross-sectional analysis using data from the National Health and Nutrition Examination Survey (2005–2016). We included participants ≥20 years old with prior stroke or MI and any history of smoking. Symptoms of depression, at survey participation, were ascertained using the Patient Health Questionnaire-9. Active smoking was defined using self-report and, secondarily, with cotinine measures. We used logistic regression to evaluate the association between depression and active smoking after adjusting for demographics, smoking-related medical conditions, and health-related behaviors. We found that, among stroke and MI survivors with any history of smoking, 37.9% (95% CI, 34.5–41.3%) reported active smoking and 43.8% (95% CI, 40.3–47.3%) had biochemical evidence of smoking. Rates of active smoking were similar for stroke and MI survivors. Twenty-one percent screened positive for depression. In adjusted models, depression was associated with active smoking in the combined group of stroke and MI survivors (odds ratio, 2.28; 95% CI, 1.24–4.20) and in stroke survivors (odds ratio, 2.97; 95% CI, 1.20–7.38). Tests of heterogeneity by event type did not reveal an interaction. Findings were similar when using cotinine measures. We conclude that symptoms of depression were associated with active smoking among stroke and MI survivors. Stroke and MI survivors with symptoms of depression may require targeted smoking-cessation interventions.
Improving Smoking Cessation Outcomes Through Tailored-Risk Patient Messages at a University Hospital Tobacco Cessation Service
2020, Joint Commission Journal on Quality and Patient Safety
Citation Excerpt :
Long-term abstinence is a gold standard outcome, but many hospital patients will relapse and return to smoking within months.19 Because tobacco smoke, and particularly CO, has such immediate and negative effects postdischarge on immune response,3 wound healing,29,30 bone unions,4 and cardiac effort,5–7,28 any period of even a few weeks of abstinence following hospital discharge can improve recovery outcomes.39 A recent study reported that less than half of patients who smoke may be willing to engage in smoking cessation in the hospital and suggested that new ways to engage more patients in treatment are needed.40
Postdischarge follow-up is a critical step for increasing effectiveness of hospital smoking cessation treatment. A quality improvement project was undertaken at an academic medical center tobacco cessation consult service to evaluate whether a tailored message (TM) linking immediate risks of continued smoking—particularly carbon monoxide exposure—to hospital recovery would stimulate more patient interest in the hospital's cessation treatment, including agreement to postdischarge follow-up, compared to patients receiving the usual treatment protocol with a standard message (SM) regarding more general health benefits of abstinence.
Data from 697 smokers ordered/referred for smoking cessation treatment in 2013 who received either the SM (January–April; n = 323) or the TM (April–November; n =374) were analyzed.
Multivariate regression analysis showed that the TM was associated with significantly greater agreement for follow-up (odds ratio [OR] = 10.83, 95% confidence interval [CI] = 3.66–32.04, p < 0.0001) than the SM. Those patients who received the TM were more willing to try to remain abstinent postdischarge (willingness score = 10, p = 0.0052) and engaged in longer consults (consult time > 10 minutes, p = 0.0075) than SM patients. TM patients also self-reported a higher continuous abstinence rate (OR = 2.07, 95% CI = 1.17–3.66, p = 0.0130] at follow-up than SM.
Linking risks of continued smoking, particularly carbon monoxide exposure, to hospital patients’ immediate recovery following discharge in a treatment protocol resulted in longer consult times and increased agreement to follow-up compared to the usual protocol message. The TM was integrated into the hospital tobacco cessation intervention as standard of care.
Mild Depression Predicts Long-Term Mortality After Acute Myocardial Infarction: A 25-Year Follow-Up
2019, Heart Lung and Circulation
Citation Excerpt :
In particular, we have no data concerning resumption of smoking among our patients, given their high rate (53.7%) of smoking upon hospital admission. Continued smoking increases the risk of death after MI significantly [27]. Fourth, we had no information about a past history of depression or depression treatment received during follow-up, both of which have been shown to have prognostic importance [28,29].
Past studies have found that depression is an independent predictor of death in patients after acute myocardial infarction (AMI). Our aim was to investigate whether the adverse effect upon mortality of depression, including mild levels, persisted up to 25 years.
We used an historical design to study patients who had been consecutively admitted to hospital after transmural AMI during the 1980s and enrolled in an exercise training trial. The Beck Depression Inventory (BDI) was administered to 188 patients in the third week after hospital admission. Scores were trichotomised and classified as low (0–5), mild (6–9) or moderate to severe (≥10) depression. The Australian National Death Index was used to determine mortality status. Cox proportional-hazards modelling was undertaken to determine the relationship between the trichotomised BDI-I scores and all-cause mortality over five time periods up to 25 years.
The mean age of patients was 54.15 years. One hundred fourteen (114) (60.4%) had low or no depression, 47 (25.2%) mild depression and 27 (14.3%) moderate to severe depression. The mortality status of 185 (98.4%) patients was established. Depression was a significant predictor of death, independently of age and severity of myocardial infarction, at 5, 10 and 15 years but not at 20 or 25 years. Patients with mild depression had greater mortality than those with low or moderate to severe depression.
Early identification of depression, including milder levels, is important since patients remain at increased risk for many years. They require ongoing monitoring and appropriate treatment.
Smoking cessation: A challenge for cardiologists and pulmonologists
2019, Revue des Maladies Respiratoires
À côté de mesures de santé publique fortement soutenues politiquement, le tabagisme est également un enjeu médical majeur. Véritable maladie chronique, compte tenu de son caractère extrêmement addictif, il doit être pris en charge activement par tous les acteurs de santé. Le tabagisme étant responsable de la majorité des pathologies concernant leurs spécialités, cardiologues et pneumologues sont en première ligne dans cette prise en charge. Sont analysés, dans cette revue, l’état actuel de cette prise en charge et ses insuffisances, l’impact limitant du propre tabagisme des médecins ainsi que les idées fausses véhiculées par les fumeurs et parfois les médecins eux-mêmes, qui sont autant de freins pour un sevrage. Le sevrage tabagique doit en pratique devenir un véritable traitement que tout médecin doit savoir parfaitement gérer : ne pas se contenter du simple conseil d’arrêt, apprendre à aborder efficacement un fumeur, connaître le maniement des différentes aides médicamenteuses souvent indispensables et savoir organiser le suivi du sevrage, gage essentiel de la réussite. Si la gestion optimale de ce facteur pathologique majeur est l’affaire de tous les médecins, c’est bien sûr également celle de nos deux spécialités. À nous, cardiologues et pneumologues, de relever ce défi.
In addition to public health measures that need to be strongly supported politically, smoking is also a major medical issue. Tobacco dependence is a chronic disease, and, given its extremely addictive nature, treatment for tobacco dependence must be addressed actively by all health professionals. Because smoking is a major contributor to many of the pathologies their specialties address, cardiologists and pulmonologists must be at the forefront of this care. In this review we analyse the current state of smoking cessation treatment and its inadequacies, the limiting impact that doctors’ own smoking has, as well as the misconceptions held by smokers and sometimes by doctors as well, which act as brakes on smoking cessation. Smoking cessation must become a treatment delivered in real clinical practice and any doctor must know how to manage it fluently. Do not be satisfied with simply advising smokers to quit. Learn how to approach the subject with smokers effectively, know how the various pharmacotherapies are used and know how to organize smoking cessation follow-up, an essential guarantee of success. If optimal management of this major pathological factor is a role for all doctors, it is of course especially so for our two specialties. It's up to us, cardiologists and pulmonologists, to take up this challenge.
Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking?
2019, Preventive Medicine
Citation Excerpt :
In this large study of smokers recovering from an AMI, we found that participation in OCR was associated with an increased likelihood of smoking cessation during short- and long-term follow-up, after accounting for potential selection bias using propensity score matching. Although hospitalization is a teachable moment for smoking cessation (McBride et al., 2003; Boudreaux et al., 2012), 40–69% of patients with ACS resume smoking, despite the known risks for recurrent coronary events (Attebring et al., 2004; Holtrop et al., 2009; Eisenberg et al., 2016; Minneboo et al., 2017), and most patients who quit relapse within the first few weeks following hospital discharge (Colivicchi et al., 2011). Through its focus on exercise and heart-healthy lifestyle, participation in OCR can reinforce patients' efforts to maintain abstinence from smoking after hospital discharge.
Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20–1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization.

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: This work was entirely supported by the Cardiovascular Department of the “San Filippo Neri Hospital” (Rome, Italy).

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Coronary artery diseaseEffect of Smoking Relapse on Outcome After Acute Coronary Syndromes

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Am J Med

Addict Behav

J Am Coll Cardiol

Lancet

Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies

Arch Intern Med

Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review

JAMA

Circulation

Smoking cessation interventions for hospitalized smokers: a systematic review

Arch Intern Med

Predictors of smoking cessation after a myocardial infarction: the role of institutional smoking cessation programs in improving success

Arch Intern Med

Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: randomised controlled trial

BMJ

Coronary artery disease
Effect of Smoking Relapse on Outcome After Acute Coronary Syndromes