Intensive smoking-cessation program can double quit rate in cardiac patients

Marlene Busko | Heart Wire

Calgary, AB - Cardiac patients were twice as likely to successfully quit smoking if they received intensive in-hospital counseling plus follow-up support vs only minimal in-hospital counseling, in a recent study [1].

Among patients hospitalized for CABG or MI who were smokers, 54% who received the intensive counseling protocol vs only 35% of patients who received minimal support were confirmed nonsmokers one year after discharge.

Unfortunately, counseling patients about quitting smoking-which research has shown can greatly reduce the risk of a subsequent cardiovascular event-is often neglected by cardiologists, author Dr. Ellen Burgess (University of Calgary, Calgary, ON) told heartwire.

Cardiac patients need help to avoid being lured back into smoking once they leave the hospital, and cardiologists need to be aware of how important it is to talk to patients about quitting smoking when discussing post-MI lifestyle modifications such as following a low-fat diet, she said.

"Providing intensive programs for smoking cessation for patients admitted for CABG or because of acute MI could have a major impact on health and healthcare costs," the authors write.

The study is published in the June 23, 2009 issue of the Canadian Medical Association Journal.

Among cardiac patients, quitting smoking lowers the risk of subsequent CABG by 300% and of subsequent nonfatal MI by 32%, the authors write.

"You only need to reduce readmission to the hospital by six patients per year to pay for the cost of a nurse who would provide smoking cessation counseling," said Burgess.

Despite the huge impact of smoking interventions, they are underused in Canada compared with other efforts-such as taking antihypertensives or statins-for the secondary prevention of cardiovascular disease.

To investigate the efficacy of an intensive smoking-cessation counseling program compared with usual care among patients hospitalized for acute MI or CABG, the researchers randomized 276 patients seen in four cardiac units in Calgary.

Patients in the usual-care group received smoking-cessation advice from a research nurse and from a physician. Patients in the intensive-counseling group also received a one-hour counseling session, a take-home video, and seven scheduled phone calls from a nurse during their first two months after being discharged from the hospital. The follow-up provided patients with strategies to use when they found themselves tempted to relapse.

More patients in the intensive-counseling group reported not smoking at three, six, and 12 months after hospital discharge. Not smoking at 12 months-confirmed by a friend or relative-was twice as likely among patients who received intensive vs minimal intervention (odds ratio 2.0, 95% CI 1.3-3.6).

Having a higher education, smoking restrictions at home, and no history of earlier MI also predicted greater likelihood of abstinence at one year.

Patients who had been admitted for CABG had significantly higher rates of abstinence from smoking than patients admitted for MI.

Patients were free to also use smoking-cessation pharmacotherapy, and 34% of patients in both study arms used it, but these patients had lower quit rates. These patients probably had previous difficulties in quitting, said Burgess.

In an accompanying editorial [2], Dr. Nancy A Rigotti (Harvard Medical School, Boston, MA) writes: "Unfortunately, smoking receives far less attention from cardiologists than other cardiovascular risk factors. [The current study] provides further evidence that this should change."

The protocol and findings were similar to a 1990 study by Taylor and colleagues [3], she writes. In addition, a recent meta-analysis [4] of 18 trials of smokers admitted for cardiovascular disease also found that intensive counseling plus supportive contact after discharge increased the odds of quitting compared with usual care.

Although these studies suggest that widely adopted interventions for smoking cessation could reduce cardiovascular morbidity and mortality, "unfortunately" this type of intervention has not been widely implemented. However, quality standards adopted by hospital accrediting organizations in 2004 in the United States appear to have stimulated hospital-based smoking-cessation counseling efforts, Rigotti notes.

Routine hospital-based smoking counseling for patients with MI is now "well overdue," she concludes.

Commenting on the study for heartwire, Dr. Harlan M Krumholz (Yale University School of Medicine, New Haven, CT) said, "I think we are being shown the path to improving the quit rate. . . . It takes more than what we are usually doing."

However, it remains to be seen whether the healthcare system can be designed to support this type of smoking-cessation intervention that crosses from in-patient counseling to outpatient follow-up, he added.

"We have focused a lot on different aspects of drug treatment, different strategies for heart disease, but we still need to know more about helping people break this very difficult addiction," said Krumholz. "It's really important that we are conducting studies about how best to help people quit smoking."