Heart Disease Deaths Drop When Smoking Cessation Gets Serious

OMAHA, Neb., Feb. 13 -- A get-tough program with hospitalized cardiac disease patients who smoke has proved to be a life-saver here, cutting mortality by 77% over two years compared with standard smoking cessation programs.

The intensive smoking cessation program targeted at smokers hospitalized for acute cardiovascular disease starts before discharge and continues for three months afterward, reported Daniel E. Hilleman, Pharm.D., of Creighton University Cardiac Center here, and colleagues, in the February issue of Chest.

It involves a combination of frequent behavior modification visits and medication, and reduced the absolute risk of death to 2.8% from 12% compared with those in a standard kick-the-habit program,

Smokers who had been in the coronary care unit for acute coronary syndrome or decompensated heart failure and who went through the intensive program also had significantly fewer rehospitalizations, the investigators reported

"Cessation of smoking results in an almost immediate improvement in the risk of heart attack, and our study proves that intense smoking cessation treatment in high-risk patients is successful and that it saves lives," said Syed M. Mohiuddin, M.D.

The investigators randomly assigned 209 smokers to either an intensive intervention (109 patients) or to usual care (100 patients).

The intensive program consisted of a 30-minute in-hospital session during which they received counseling and self-help materials, followed, after discharge, by 12 weeks of behavior modification counseling and individualized pharmacotherapy, consisting of nicotine replacement and/or Zyban (bupropion). The drugs were provided at no cost to patients.

Patients in the usual care group received only the in-hospital counseling session and self-help material.

The investigators confirmed smoking status in all participants by measuring expired carbon monoxide at three, six, 12, and 24 months after the start of the study, and patients were asked about smoking, health status, hospitalizations, and adverse clinical events.

Patients who had initially been randomized to the intensive intervention and had started smoking again were treated again during the two-year study follow-up period.

All patients were prospectively followed for the development of acute coronary syndrome, stroke, coronary revascularization procedures, hospitalizations, and all-cause mortality.

The authors found that at each follow-up interval, point prevalence and continuous abstinence smoking cessation rates were significantly higher among patients who underwent the intensive cessation program.

After two years, one third (33%) of all patients in the intensive cessation group had managed to remain smoke-free during the entire follow-up period, compared with just 9% of those in the standard care group (P<0.0001).

There were a total of 41 hospitalizations among patients in the usual-care group (41%) compared with 25 hospitalizations in the intensive treatment group (23%). The relative risk reduction for hospitalization among intensive quitters was 44% (95% confidence interval, 16 to 63%, P=0.007).

The all-cause mortality rate was 2.8% in the intensive-treatment group (three patients) compared with 12.0% in the usual-care group (12 patients), translating into a 77% relative risk reduction (95% CI, 27 to 93%, P=0.014).

The three deaths in the intensive treatment group were all due to cardiovascular causes, compared with nine of 12 deaths among patients in the usual care group. Two of the remaining patients in the latter group died from respiratory failure, and the remaining patient died of cancer.

The absolute risk reduction in mortality between the two groups was 9.2%m with a number needed to treat to prevent one death over the two-year follow-up being 11.

The authors concluded unequivocally that "hospitalized smokers, especially those with cardiovascular disease, should undergo treatment with a structured intensive cessation intervention. The duration of the initial treatment should be three months."

The authors said that the relatively small sample size limited their ability to control for other factors that might have affected the study outcome, and noted that in the real world it's unlikely that patients would be given nicotine replacement therapy, Zyban, or other medications at no cost.

They recommended adding intensive smoking cessation programs to other prophylactic measures such as the use of statins, antiplatelet therapies, and ?-blockers.

"The results our study suggest that smoking cessation may be the most effective of all secondary prevention measures in this population of patients," they wrote.