Return to smoking after heart attack ups death risk

NEW YORK (Reuters Health) - After a heart attack, quitting smoking may offer a patient more benefits than any medication, but Italian researchers say the flipside is that resuming smoking after leaving the hospital can raise the same patient’s risk of dying as much as five-fold.

A smoker lights a cigarette in downtown Toronto February 19, 2007. REUTERS/J.P. Moczulski

On average, people who started smoking again after being hospitalized for acute coronary syndrome (ACS) -- crushing chest pain that often signals a heart attack -- were more than three times as likely to die within a year as people who successfully quit in a study led by Dr. Furio Colivicchi of San Filippo Neri Hospital in Rome.

“Relapse is a major risk factor for long term survival,” said Dr. David Katz, associate professor of internal medicine at University of Iowa Carver College of Medicine in Iowa City.

Quitting smoking has a similar lifesaving effect for ACS patients as taking recommended drugs to lower blood pressure or cholesterol, added Katz, who was not involved in the new study.

To gauge the effects of resuming smoking after a heart “event,” and to see how many people are likely to relapse, Colivicchi and his colleagues tracked 1294 patients who reported being regular smokers before they were hospitalized with ACS.

All the participants had ceased smoking while in the hospital and declared themselves motivated to continue abstaining once they were released. Patients received a few brief smoking-cessation counseling sessions while in the hospital, but no further counseling, nicotine replacement or other smoking-cessation help was provided after they left the hospital.

The researchers interviewed patients about their smoking status at one, six, and 12 months after their release from the hospital and found that a total of 813 (63 percent) had relapsed by the end of the first year. About half had begun smoking again within 20 days of leaving the hospital.

Within a year, 97 patients died, with 81 of those deaths attributed to cardiovascular causes, according to findings published in the American Journal of Cardiology.

After adjusting for patient ages and other variables, the researchers found that resuming smoking raised a person’s risk of death three-fold compared to patients who didn’t relapse.

The earlier a patient fell off the wagon, the more likely he or she was to die within a year -- those who resumed smoking within 10 days of leaving the hospital were five times as likely to die as those who continued to abstain.

Very few patients relapsed after being smoke-free for six months.

“If you manage to stay off cigarettes for six months, you probably have the addiction beat,” said Dr. Nancy Rigotti, director of the Tobacco Research and Treatment Unit at Massachusetts General Hospital in Boston, who was not involved in the study.

Colivicchi’s group did not measure how often the patients smoked -- an important predictor of relapse and early death, Katz noted.

Nonetheless, the results indicate a need to improve the way doctors help patients quit smoking, said Rigotti.

“People don’t take treating tobacco use seriously in the medical setting,” and recommended treatments have not made their way into practice, she said.

Colivicchi agreed. A successful program to help patients quit should take “a comprehensive long-term approach, including individual counseling, post-discharge support and pharmacological treatment,” he told Reuters Health in an email.

A recent study from Harvard Medical School suggested that a comprehensive anti-smoking counseling program for heart attack patients could save thousands of lives at a relatively low cost.

These findings, along with the results of the Italian study, said Rigotti, suggest that hospitals and insurers should work together to implement comprehensive anti-smoking programs to continue to help patients after they leave the hospital.

SOURCE: American Journal of Cardiology, online July 7, 2011.