Content of this journal is licensed under a Abstract
OBJECTIVE:
Persistent smoking after acute myocardial infarction is associated with an increased risk of recurrent cardiovascular events. Our aim was to determine the changes in smoking habits in patients after acute myocardial infarction and evaluate the factors affecting smoking cessation.
MATERIAL AND METHODS:
A total of 322 patients who had an acute myocardial infarction while smoking were included in the study. Participants were asked to fill out a 30-question survey. According to smoking status, 2 groups were identified, those who quit smoking (n = 155) and those who continued smoking (n = 167).
RESULTS:
The rate of smoking cessation among study participants was 48.2% (n = 155). Most of smoker participants had the intention to quit smoking (n = 124, 74.2%). The most common barriers for smoking cessation were nicotine withdrawal symptoms and the cessation rate was over 3 times higher in those with low nicotine dependence (P < .01). Weight gain was another common problem seen in 163 (50.6%) participants; among which the cessation rate was relatively low (43.6%). A total of 231 (71.7%) participants got an advice from their doctor to quit smoking and the probability of quitting was around 5 times higher in this group (P < .01). A total of 174 (54%) participants stated that they were considering quitting whenever they see the pictorial health warnings on cigarette packs and the probability of quitting was doubled in this group (P < .01).
CONCLUSION:
High number of patients continue on smoking after acute myocardial infarction. The most common barriers for smoking cessation are nicotine withdrawal symptoms. Doctors should play an active role in helping the patient quit smoking. Strict regulations of tobacco control can be very helpful in this regard.
Keywords: Acute myocardial infarction, nicotine dependence, smoking cessation, tobacco control
MAIN POINTS
High number of patients continue to smoke cigarettes after having an acute myocardial infarction.
The most common barriers for smoking cessation were nicotine withdrawal symptoms and the cessation rate was highest among those with low nicotine dependence.
Considering its low costs and the proven benefits, smoking cessation should be a primary goal in patients with acute myocardial infarction.
Evidence-based programs supported by behavioral therapy in which the doctors take an active role can make smoking cessation interventions more effective.
Strict tobacco control regulations by the government may be highly beneficial in the efforts to stop smoking.
INTRODUCTION
Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide.1 Smoking is an important risk factor for CAD.2 Smoking causes an increase in oxidative stress, vascular inflammation, vasoconstriction, and platelet reactivity leading to vascular endothelial dysfunction.3 A study showed that half of the nonfatal acute myocardial infarction (AMI) occurring in young and middle-aged people can be attributed to smoking.4 In patients with CAD, persistent smoking was associated with an acceleration of an ongoing atherosclerotic process.5 Studies have shown that smoking cessation after AMI can reduce the risk of recurrent infarctions by half.2 This risk reduction was found to be consistent regardless of age, gender, ethnicity, or the time of diagnosis.6 Therefore, smoking cessation after AMI can be very helpful in decreasing patients’ morbidity and mortality.
Unfortunately, rates of persistent smoking following a diagnosis or hospitalization for CAD are still high.7 Studies showed that around half of those diagnosed with CAD continue on smoking.8,9 Similar results was observed in the EUROASPRE-V study that was conducted by the European Society of Cardiology.10 Many patients struggle while quitting smoking after AMI and on many occasions professional help becomes a necessity. In this study, we aimed to determine the changes in smoking habits after AMI and identify the factors affecting smoking cessation.
MATERIAL AND METHODS
Setting and Participants
Between June 2021 and June 2022, patients who applied to our cardiology outpatient clinic at least 1 year after an AMI were evaluated. Patients who were smoking during the index event (n = 322) was included in this cross-sectional observational study. Nonsmokers or those who started smoking any time after AMI was not included. Any patients with psychotic illness, cognitive impairment, or inability to answer survey questions was also excluded. The sample size analysis was done with a 5% margin of error at 95% CI.
Data Collection
Participants were asked to fill out a 30-question survey prepared specifically for this study. Patients were assigned into 2 groups according to smoking status. The first group consisted of those who continued to smoke after AMI (n = 167), while the second group consisted of those who quitted smoking (n = 155). The sociodemographic characteristics of the participants (including gender, age, body mass index, occupation, and educational level) were documented. The educational level was categorized as primary school, secondary school, high school, or university graduate. Medical records were used to document past medical history and laboratory test results.
Study Survey
The survey questions assessed the patient’s desire to quit smoking as well as changes in daily lifestyles following AMI. Those who were still smoking were asked about the reasons for not being able to quit. The advice and guidance they received from their doctors in terms of quitting smoking were asked. Patients were also asked about their thoughts on tobacco control regulations imposed by the government. All the questions were closely reviewed by the authors for clarity, validity, and content after testing with 5 patients to ensure ease of use and comprehensiveness. The final part of the survey contained the Fagerström nicotine dependence test.11 According to test results, addiction levels of the patients were classified as low (0-3 points), medium (4-6 points), and high (≥7 points) based on test results.
All procedures were conducted in accordance with the ethical standards of Helsinki Declaration and the ethical committee approval was obtained from Lokman Hekim University Faculty of Medicine (Doc. no:2021136). The patients were informed about the study and were enrolled after providing informed voluntary consent forms.
Data Management and Statistical Analysis
Descriptive statistics of the continuous variable such as mean and SD is used for summarizing. Percentages and frequencies are used for presenting categorical variables. As a preliminary analysis, the relationships between categorical variables are investigated using the chi-square test. Once relationships are found to be statistically significant with chi-square test, further analyses are conducted with logistic regression. One-way analysis of variance is used for comparing group means. F dependence score is taken as continuous variable of the study. This continuous variable is analyzed with ANOVA F test. Normality assumption of the F test is checked with Shapiro–Wilk test. Equality of variances of the F test is checked with Levene test. All assumptions are satisfied. The statistical analysis was carried out by the Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp.; Armonk, NY, USA).
RESULTS
Among the 322 participants of the study, 51.8% (n = 167) continued smoking after AMI and 48.2% (n = 155) have quitted smoking. There was no significant difference between the 2 groups in terms of basal sociodemographic and clinical characteristics (Table 1). A significant difference was found in the educational level of the 2 groups (P = .04) with smoking cessation rate being highest among university graduates (68.8%) and regression analysis showing a higher probability of quitting in this group (Table 2). On the other hand, no significant association was found between smoking cessation after AMI and other sociodemographic factors (Table 3).
Table 1.
The Basal Clinical Characteristics and Sociodemographic Properties of the Study Participants
| Variable | Nonsmokers, (n = 155) | Smokers, (n = 167) | P |
|---|---|---|---|
| Age, years | 56.7 ± 5.8 | 57.2 ± 4.3 | .38 |
| BMI, kg/m2 | 27.1 ± 3.9 | 26.6 ± 2.8 | .18 |
| Basal HR, b/m | 88.9 ± 7.1 | 87.9 ± 8.8 | .26 |
| Systolic BP, mmHg | 127.7 ± 11.8 | 129.4 ± 11.2 | .19 |
| Diastolic BP, mm Hg | 86.7 ± 12.6 | 87.2 ± 11.3 | .7 |
| Hemoglobin, g/dL | 13.8 ± 1.7 | 14.2 ± 2.6 | .1 |
| TC, mg/dL | 196.2 ± 24.7 | 199.4 ± 32.2 | .32 |
| LDL, mg/dL | 139.6 ± 22.7 | 138.7 ± 33.4 | .78 |
| Triglyceride, mg/dL | 182.6 ± 32.4 | 185.4 ± 41.5 | .5 |
| HDL, mg/dL | 32.8 ± 3.2 | 33.2 ± 4.5 | .36 |
| Calcium, mg/dL | 9.2 ± 0.71 | 9.3 ± 0.82 | .24 |
| Sodium, mEq/L | 140.9 ± 1.5 | 141.1 ± 1.3 | .2 |
| Potassium, mEq/L | 4.1 ± 0.9 | 4.2 ± 0.2 | .16 |
| TSH, mIU/L | 3.3 ± 1.4 | 3.5 ± 0.8 | .11 |
BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein; HR, hazard ratio; LDL, low-density lipoprotein; TC, total cholesterol; TSH, thyroid-stimulating hormone.
Table 2.
Logistic Regression Analysis for the Probability of Smoking Cessation in Relation to Different Variables
| Variables | Standard Error | Odds Ratio | 95% CI | P | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Being a university graduate | 0.236 | 2.076 | 1.3062 | 3.3013 | <.01 |
| Performing regular physical exercise | 0.284 | 2.925 | 1.6742 | 5.1104 | <.01 |
| Having low nicotine dependence | 0.264 | 3.143 | 1.8955 | 5.3536 | <.01 |
| Got a doctor’s advice to quit smoking | 0.271 | 5.185 | 3.0528 | 8.8069 | <.01 |
| Affected by the pictorial health warnings on cigarette packs | 0.269 | 2.061 | 1.2157 | 3.4960 | <.01 |
Table 3.
The Associations Between Smoking Cessation With Social and Medical Conditions
| Social and Medical Conditions | Parameters | Still Smoking, n (%) | Total (%) | P | |
|---|---|---|---|---|---|
| Yes (167) | No (155) | ||||
| Gender | Female Male |
79 (54.9) 88 (49.4) |
65 (45.1) 90 (50.6) |
144 (44.7) 178 (55.3) |
.33 |
| Working status | Retired Active worker |
81 (53.3) 86 (50.6) |
71 (46.7) 84 (49.4) |
152 (47.2) 170 (52.8) |
.62 |
| Education level | Primary school Secondary school High school University |
81 (57) 49 (55.1) 27 (45.7) 10 (31.2) |
61 (43) 40 (44.9) 32 (54.3) 22 (68.8) |
142 (44.1) 89 (27.6) 59 (18.3) 32 (10) |
.04 |
| Weight gain | No Yes |
75 (47.2) 92 (56.4) |
84 (52.8) 71 (43.6) |
159 (49.4) 163 (50.6) |
.09 |
| Physical exercise | No Yes |
117 (59.7) 50 (39.6) |
79 (40.3) 76 (60.4) |
196 (60.9) 126 (39.1) |
<.01 |
| Alcohol consumption | No Social drinker Heavy drinker |
119 (49.4) 36 (57.1) 12 (66.6) |
122 (50.6) 27 (42.9) 6 (33.4) |
241 (74.8) 63 (19.6) 18 (5.6) |
.24 |
| Hypertension | No Yes |
112 (51.9) 55 (43.2) |
92 (48.1) 63 (56.8) |
204 (63.4) 118 (36.6) |
.15 |
| Diabetes mellitus | No Yes |
129 (51.2) 38 (54.2) |
123 (48.8) 32 (45.8) |
252 (78.3) 70 (21.7) |
.65 |
| Dyslipidemia | No Yes |
109 (51.2) 58 (53.2) |
104 (48.8) 51 (46.7) |
213 (66.1) 109 (33.9) |
.73 |
| Cerebrovascular disease | No Yes |
162 (52.1) 5 (45.4) |
149 (47.9) 6 (54.6) |
311 (96.6) 11 (3.4) |
.66 |
| Peripheral artery disease | No Yes |
139 (53.7) 28 (44.4) |
120 (46.3) 35 (55.6) |
259 (80.4) 63 (19.6) |
.19 |
| Asthma | No Yes |
142 (52.6) 25 (48) |
128 (47.4) 27 (52) |
270 (83.9) 52 (16.1) |
.55 |
| Chronic obstructive lung disease | No Yes |
152 (52.8) 15 (44.1) |
136 (47.2) 19 (55.9) |
288 (89.4) 34 (10.6) |
.34 |
Most smoker participants had the intention to quit smoking (n = 124, 74.2%) and believed that they would succeed in quitting after AMI (n = 98, 58.7%). The most common difficulty they faced was ‘‘nervous temper’’ in 197 (61.2%) participants (Table 4). Weight gain was another important problem seen in 163 (50.6%) participants among which the rate of smoking cessation was relatively low (43.6%). Physical exercise, on the other hand, was associated with a significant increase in the probability of quitting smoking (P < .01). Nicotine dependence level was low in 154 (47.8%), moderate in 148 (46%), and high in 20 (6.2%) participants. Regression analysis showed that smoking cessation rate was over 3 times higher in the group with low nicotine dependence (P < .01).
Table 4.
The Difficulties Faced the Patients While Trying to Quit Smoking
| Difficulties | Parameters | Still Smoking n (%) | Total (%) | P | |
|---|---|---|---|---|---|
| Yes (167) | No (155) | ||||
| Nervous temper | Yes No |
109 (55.3) 58 (46.4) |
88 (44.7) 67 (53.6) |
197 (61.2) 125 (38.8) |
.11 |
| Weight gain | Yes No |
92 (56.4) 75 (47.2) |
71 (43.6) 84 (52.8) |
163 (50.6) 159 (49.4) |
.09 |
| Excessive urge to smoke | Yes No |
33 (47.8) 134 (52.9) |
36 (52.2) 119 (47.1) |
69 (21.4) 253 (78.6) |
.57 |
| Headache | Yes No |
27 (55.1) 140 (51.2) |
22 (44.9) 133 (48.8) |
49 (15.2) 273 (84.8) |
.62 |
| Sleep disturbances | Yes No |
12 (38.7) 155 (53.3) |
19 (61.3) 136 (46.7) |
31 (9.6) 291 (90.4) |
.12 |
| Concentration disturbances | Yes No |
7 (43.7) 160 (52.3) |
9 (56.3) 146 (47.7) |
16 (4.9) 306 (95.1) |
.51 |
| Numbness | Yes No |
7 (46.6) 160 (52.1) |
8 (53.4) 147 (47.9) |
15 (4.6) 307 (95.4) |
.17 |
| Oral ulcers | Yes No |
6 (54.5) 161 (51.8) |
5 (45.5) 150 (48.2) |
11 (3.4) 311 (96.6) |
.03 |
| Constipation | Yes No |
4 (44.6) 163 (52.1) |
5 (55.6) 150 (47.9) |
9 (2.7) 313 (97.3) |
.65 |
The number of patients who received an advice from their doctor to quit smoking was 231 (71.7%) and the probability of quitting smoking was 5 times higher in this group (P < .01). However, the number of those referred to a specialized smoking cessation department was small (n = 68, 21.1%). Most participants stated that they support the government’s strict regulations on tobacco control, believing that it can be effective in decreasing smoking rates (Table 5). More than half of study participants (54%, n = 174) said that they were considering quitting smoking when seeing the pictorial health warnings on cigarette packs and the probability of quitting smoking was doubled in this group (Table 2).
Table 5.
Ratios of Patients Supporting the Government’s Regulations in Controlling Tobacco Industry
| Regulations | Parameters | Still Smoking, n (%) | Total (%) | P | |
|---|---|---|---|---|---|
| Yes (167) | No (155) | ||||
| Supporting the printing of pictorial health warnings on cigarette packs | Yes No |
153 (57.5) 14 (25) |
113 (42.6) 42 (75) |
266 (82.6) 56 (17.4) |
<.01 |
| Believing that the pictorial health warnings can help in quitting smoking | Yes No |
103 (59.2) 64 (43.2) |
71 (40.8) 84 (56.8) |
174 (54) 148 (46) |
<.01 |
| Supporting the law of banning tobacco use indoors and in public places | Yes No |
147 (53.1) 20 (44.4) |
130 (46.9) 25 (55.6) |
277 (86) 45 (14) |
.28 |
| Supporting the law of banning the advertising of tobacco products | Yes No |
131 (49.1) 36 (65.4) |
136 (50.9) 19 (34.6) |
267 (82.9) 55 (17.1) |
.27 |
| Supporting the law of “Plain design for cigarette packs” application | Yes No |
116 (48.9) 51 (60) |
121 (51.1) 34 (40) |
237 (73.6) 85 (26.4) |
.08 |
| Supporting the law of raising the tax on tobacco products | Yes No |
103 (54.5) 64 (48.1) |
86 (45.6) 69 (51.9) |
189 (58.6) 133 (41.4) |
.26 |
| Believing that these laws can help in decreasing smoking rates | Yes No |
83 (48.2) 84 (56) |
89 (51.8) 66 (44) |
172 (53.4) 150 (46.6) |
.17 |
DISCUSSION
The present study evaluated the changes in smoking habits after AMI and aimed to analyze the factors that influence smoking cessation. Study results showed that more than half of the patients continue on smoking after AMI. The most common difficulties standing against their will to quit smoking were nicotine withdrawal symptoms. Self-motivation and desire alone were insufficient to assist the patients to quit smoking but the effects of doctors’ guidance and tobacco control regulations were more effective in this regard.
Smoking is the main cause of preventable diseases and premature deaths worldwide.12 It increases the risk of coronary heart disease and cardiovascular-related morbidity and mortality.13 Patients who continue on smoking after the diagnosis of cardiovascular diseases constitute a high-risk group for the recurrence of major adverse cardiovascular events (MACE).6,14 On the other hand, quitting smoking is associated with a substantial lower risk of such events.15 Even reducing the number of cigarettes smoked per day was found to be beneficial in this regard.16 Large-scale studies conducted in different countries showed high rates of patients who continue on smoking after AMI.8-10 Similarly, in our study, more than half of the patients continued on smoking after AMI.
Studies have revealed that sociodemographic characteristics can affect an individual’s commitment to the smoking cessation path.17 For example, high educational level can be associated with higher confidence in the ability to quit smoking which would increase the likelihood of quitting.18 In our study, the educational level of the participants was also found to be a significant factor as smoking cessation rates were highest among university graduates and lowest among primary school graduates (68.8% vs. 43%, respectively). Additionally, regression analysis showed that the probability of smoking cessation is doubled among university graduates (P < .01). On the other hand, no significant association was found between smoking cessation after AMI and other sociodemographic factors like gender, working status, or alcohol consumption (Table 3).
Numerous diseases are linked to smoking; therefore, smokers may suffer from a variety of chronic illnesses. Studies evaluating the association between smoking cessation and the presence of smoking related chronic illnesses such as cardiovascular and pulmonary diseases stated that there is no direct relationship between the 2 conditions.19 Similar results was observed in our study as no significant association was found between smoking cessation after AMI and a prior diagnosis of such comorbidities (Table 3).
Depressive symptoms are common during the hospital stay for an AMI and can reduce the effectiveness of smoking cessation interventions.20 Patients also experience withdrawal symptoms while trying to quit smoking which makes the quitting process more challenging.21 Among the participants of our study, nicotine withdrawal symptoms such as nervous temper, headache, and excessive urge to smoke were the main factors that stood against their will to quit smoking. The degree of nicotine dependence is very important in this regard.21 Our study results showed that the probability of smoking cessation after AMI was over 3 times higher in the group with low nicotine dependence compared to those with high dependence (P < .01). Therefore, smoking cessation programs should be supported by intensive behavioral therapy and, if necessary, psychological pharmacotherapy to make such programs more effective.
Weight changes are another important factor in the smoking cessation process, as quitting increases patients’ appetite and causes weight gain.22 This was seen in 163 (50.6%) participants of our study and demotivated them while trying to quit smoking. Beside its benefits in decreasing cardiovascular morbidity and mortality, physical exercise can help patients with weight problems to quit smoking.23,24 Our study results showed a higher probability of smoking cessation among those who perform physical exercise but the rate of patients who exercise regularly was low (39.1%). This highlights the importance of physical exercise as part of post-AMI therapy and indicates that more efforts should be implemented in this regard.
Patients with AMI can experience high levels of stress during the interventional procedures and hospitalization in intensive care units which can urge and motivate them to quit smoking. This motivation is necessary to start the quitting process but alone is insufficient to maintain smoking cessation. In our study, 74.2% of smoker participants had the intention to quit smoking and 58.7% believed that they would succeed in quitting after AMI. A professional help is needed to boost this motivation as studies showed higher smoking cessation rates among AMI patients who got advice and guidance from healthcare professionals after the index event.25,26 Even a brief verbal physician intervention explaining the harmful effects of smoking can yield a strong influence on the patients.27 Among the 322 patients of our study, 231 (71.7%) patients got an advice to quit smoking from their doctor and the probability of quitting was 5 times higher in this group (P < .01). However, not all patients follow these simple instructions and the cessation process should include a comprehensive consulting program within specialized departments.28 Unfortunately, the number of our study participants who referred to a specialized smoking cessation department was small (n = 68, 21.1%). These results show that there is an increased need for a comprehensive smoking cessation programs to be included within the standard treatment offered to prevent the recurrence of cardiovascular events after AMI.
A public health analysis revealed that strict tobacco control regulations could avert 50 million cardiovascular deaths over the course of the next few decades.29 In our study, patients stated that they support the government’s strict regulations on tobacco control, believing that it can be effective in decreasing smoking rates (Table 5). More than half of our study participants said that they were considering quitting smoking every time they see the pictorial health warnings on cigarette packs and the probability of quitting was doubled in this group (P < .01).
In conclusion, our study results showed that high number of patients continue to smoke cigarettes after having an AMI. Considering its low costs and the proven benefits, smoking cessation should be one of the primary goals in these patients. Evidence-based programs supported by behavioral therapy in which the doctors take an active role can make smoking cessation treatment more effective. More strict tobacco control regulations by the government can be very beneficial in this regard. The main limitation of our study is the relatively small number of participants. Another point is that smoking status was based on patients’ statements, which sometimes can be misleading.
Footnotes
Ethics Committee Approval: The study was approved by the ethical committee of Lokman Hekim University, Faculty of Medicine (Doc. no:2021136).
Informed Consent: Informed consents were obtained from all the participants.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – A.K., O.Y., A.C., M.H.T.; Design – A.K., O.Y., A.C., M.H.T.; Supervision – A.K., M.H.T.; Funding – A.K., O.Y., A.C., M.H.T.; Materials – A.K., O.Y., A.C., M.H.T.; Data Collection and/or Processing – A.K., O.Y., A.C., M.H.T.; Analysis and/or Interpretation – A.K., O.Y., A.C., M.H.T.; Literature Review – A.K., M.H.T.; Writing – A.K.; Critical Review – M.H.T.
Declaration of Interests: The authors have no conflict of interest to declare.
Funding: This study received no funding.
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