Research shows that smoking is common among many patients with acute myocardial infarction (AMI) and is an important modifiable risk factor for recurrent cardiac events. Studies show that smoking cessation after AMI decreases the risk of recurrent heart attacks and mortality by 30% to 50%. Efforts to improve smoking cessation after AMI have become important performance measures throughout the United States, but many smokers still will not quit their habit even after suffering an AMI.

Most patient education strategies on smoking cessation focus on the risks from continuing to smoke, but patients may be concerned that quitting will worsen their quality of life. These concerns may lower patients’ motivation and success with quitting. Further compounding the issue is that patients recovering from heart attacks often receive little information about the potential effect of smoking cessation on angina and quality of life.

“It is well known that smoking after AMI increases risks for recurrent heart attacks and mortality, but few studies have looked at how smoking relates to health-related quality of life (HRQOL) in cardiac patients,” says Donna M. Buchanan, PhD. “Understanding the link between smoking cessation and HRQOL could have important implications for smoking prevention and how we treat patients who actively smoke at the time of their AMI.” This information may also improve how clinicians counsel patients to quit smoking after their AMI.

 

Looking Closer

In a study published in Circulation: Cardiovascular Quality & Outcomes, Dr. Buchanan and colleagues assessed more than 4,000 patients who suffered an AMI for smoking and HRQOL. Using data from two large, prospective, observational U.S. multicenter AMI registries, the researchers analyzed smoking and HRQOL at admission and at 1, 6, and 12 months after the AMI. Angina and HRQOL were measured with the Seattle Angina Questionnaire (SAQ) and Short Form-12 (SF-12) Physical and Mental Component Scales.

Smoking was assessed at baseline and each follow-up time point. The investigators classified patients into one of four categories:

  • Never smokers.
  • Former smokers (quit before AMI)
  • Recent quitters (quit after AMI).
  • Persistent smokers.

Patients who were current smokers at baseline were then reclassified based on their 1-year follow-up interview responses. At 1 year, patients reporting that they had quit in the past year were deemed recent quitters and those who continued smoking were designated as persistent smokers.

 

Making Comparisons

Results showed that 29% of patients had never smoked when they were admitted for their AMI. Another 34% quit smoking before their AMI and 37% were active smokers at the time of their AMI. Of these active smokers, 46% were designated as recent quitters, having quit smoking within 1 year after their AMI, whereas 54% were persistent smokers. At each separate time point, there was a gradation of more chest pain and worse disease-specific and generic HRQOL across the four smoking status groups. After adjusting for sociodemographic, clinical, and treatment factors, AMI patients who never smoked or were former smokers had the best HRQOL levels in all domains assessed in the study.

“Patients who had never smoked had the least chest pain and the best disease-specific and general HRQOL and former smokers were surprisingly very similar to never smokers in all domains,” says Dr. Buchanan. Within 1 year, those who quit smoking after their AMI had similar levels of chest pain and mental health as those who had never smoked. Recent quitters also had markedly better general mental health than persistent smokers. Conversely, persistent smokers who suffered an AMI had a 1.5- fold higher risk of having angina and worse HRQOL at 1 year in all domains assessed in the study when compared with never smokers (Figure).

 

Assessing Implications

Findings of the study support previous research indicating that smoking is associated with a lower HRQOL. “The general mental health status of both former and recent quitters was similar to that of never smokers, even after we adjusted for social support and depressive symptoms,” Dr. Buchanan says. “Also, recent quitters had substantially better general mental health than persistent smokers. This further supports the importance of providing effective smoking cessation to patients who suffer an AMI.”

The study provides strong support for not only counseling patients about how smoking cessation reduces future risks of AMI and death but is also associated with better health over time, according to Dr. Buchanan. “This data—showing less chest pain and better mental health for those who quit smoking after a heart attack—may offer current smokers more incentive and motivation for quitting. We need to seize this opportunity to address patient concerns about smoking cessation. Some people may believe that quitting smoking won’t make much of a difference in how they feel or may have detrimental effects on their mental health, but our research proves otherwise. Clinicians should be proactive about these possible concerns and discuss them with patients after they have suffered an AMI.”

References

Buchanan DM, Arnold SV, Gosch KL, et al. Association of smoking status with angina and health-related quality of life after acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2015;8:493-500. Available at: http://circoutcomes.ahajournals.org/content/early/2015/08/25/CIRCOUTCOMES.114.001545.

Jang JS, Buchanan DM, Gosch KL, et al. Association of smoking status with health-related outcomes after percutaneous coronary interventions. Circ Cardiovasc Interv. 2015;8:e002226.

Gerber Y, Rosen LJ, Goldbourt U, Benyamini Y, Drory Y; Israel Study Group on First Acute Myocardial Infarction. Smoking status and longterm survival after first acute myocardial infarction a population-based cohort study. J Am Coll Cardiol. 2009;54:2382-2387.

Dawood N, Vaccarino V, Reid KJ, Spertus JA, Hamid N, Parashar S; PREMIER Registry Investigators. Predictors of smoking cessation after a myocardial infarction: the role of institutional smoking cessation programs in improving success. Arch Intern Med. 2008;168:1961-1967.