Smoking Cessation Pharmacotherapy Among Smokers Hospitalized for Coronary Heart Disease

Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

INTRODUCTION

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

AREAS COVERED

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

EXPERT OPINION

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

Efficacy and safety of electronic cigarettes as a smoking cessation intervention: A systematic review and network meta-analysis

INTRODUCTION

This systematic review of randomized controlled trials (RCTs) evaluated the efficacy and safety of electronic cigarettes (e-cigarettes, ENDS) in helping people who smoke to achieve abstinence compared with electronic non-nicotine delivery systems (ENNDS, no nicotine) or any smoking cessation comparator treatment or combination of treatments at 24–26 weeks and at 52 weeks.

METHODS

Systematic review techniques involved searches of three databases in February 2020 with update searches run on 14 May 2021, two-person independent screening, two-person independent assessment of bias, formal extraction of data with verification by a second person, a feasibility assessment to decide if meta-analysis was appropriate, and network meta-analysis (NMA) of data at 24–26 weeks. Data at 52 weeks were narratively summarized.

RESULTS

Ten RCTs met the inclusion criteria, eight for efficacy and ten for safety. Eight of the nine RCTs were assessed as at high risk of bias. The sample sizes of the RCTs were 30–2012. Using nicotine replacement therapy (NRT) as the reference treatment, the incidences of smoking cessation at 24–26 weeks were comparable between ENDS and NRT groups (RR=1.17; 95% CrI: 0.66–1.86). Three sensitivity analyses were carried out indicating the main findings for 24–26 weeks were robust to assumptions. The findings at 52 weeks were inconclusive.

CONCLUSIONS

This systematic review and NMA indicates that there is no clear evidence of a difference in effect between nicotine containing e-cigarettes and NRT on incidences of smoking cessation at 24–26 weeks, and substantial uncertainty remains.

Current smoking as a marker of a high-risk behavioral profile after myocardial infarction

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.

Short-Term Safety of Nicotine Replacement in Smokers Hospitalized With Coronary Heart Disease

Background

Little is known about the safety of nicotine replacement therapy (NRT) in smokers hospitalized with coronary heart disease.

Methods and Results

We examined the short‐term safety of NRT use among smokers hospitalized for coronary heart disease in a geographically and structurally diverse sample of US hospitals in the year 2014. We compared smokers who started NRT in the first 2 days of hospitalization with smokers without any exposure to NRT and adjusted for baseline differences through propensity score matching. Outcomes included inpatient mortality, hospital length of stay, and 1‐month readmission. From 270 hospitals, we included 27 459 smokers (mean age, 58 years; 69% men; 56.9% in intensive care unit), of whom 4885 (17.8%) received NRT (97.2% used the nicotine patch, at a median dose of 21 mg/d for 3 days). After propensity matching, covariates were well balanced within each patient group. Among patients with myocardial infarction, compared with patients who did not receive NRT, those who received NRT showed no difference in mortality (2.1% versus 2.3%; P=0.98), mean length of stay (4.4±3.5 versus 4.3±3.3 days; P=0.60), or 1‐month readmission (15.8% versus 14.6%; P=0.31). Results were similar for patients undergoing percutaneous coronary intervention or coronary artery bypass surgery.

Conclusions

Among smokers hospitalized for treatment of coronary heart disease, use of NRT was not associated with any differences in short‐term outcomes. Given the known beneficial effects of NRT in treating nicotine withdrawal, reducing cravings, and promoting smoking cessation after discharge, our findings suggest that NRT is a safe and reasonable treatment option.

Smoking cessation after hospitalization for myocardial infarction or cardiac surgery: Assessing patient interest, confidence, and physician prescribing practices

Background

Prioritizing and managing multiple behavior changes following a cardiac hospitalization can be difficult, particularly among smokers who must also overcome a serious addiction.

Hypothesis

Hospitalized smokers will report a strong interest in smoking cessation (SC) but will receive little assistance from their physicians.

Methods

We asked current smokers hospitalized for an acute cardiac event to prioritize their health behavior priorities, and inquired about their attitude toward SC therapies. We also assessed SC cessation prescriptions provided by their physicians.

Results

Of the 105 patients approached, 81 (77%) completed the survey. Of these, 72.5% ranked SC as their greatest health change priority, surpassing all other behavior changes, including: taking medications, attending cardiac rehabilitation (CR), dieting, losing weight, and attending doctor appointments. Patients felt that SCM (44%), CR (41%), and starting exercise (35%) would increase their likelihood for SC. While most patients agreed that smoking was harmful, 16% strongly disagreed that smoking was related to their hospitalization. At discharge, medication was prescribed to ~32% of patients, with equal frequency among patients who reported interest and those who reported no interest in using medications.

Conclusion

The majority of hospitalized smokers with cardiac disease want to quit smoking, desire help in doing so, and overwhelmingly rate cessation as their highest health behavior priority, although some believe smoking is unrelated to their disease. The period following an acute cardiac event appears to be a time of great receptivity to SC interventions; however, rates of providing tailored, evidence‐based interventions are disappointingly low.

Leverage points to improve smoking cessation treatment in a large tertiary care hospital: a systems-based mixed methods study

OBJECTIVES

To generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment.

DESIGN

Mixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke.

SETTING

Large, tertiary care hospital in the Midwestern United States.

PARTICIPANTS

Group model building: 28 healthcare providers and 22 previously-hospitalised patients; Online survey: 308 healthcare providers; Bedside interviews: 205 hospitalised patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment.

RESULTS

System insights included patients frequently leaving the floor to smoke, which created major workflow disruption. Leverage points included interventions to reduce withdrawal symptoms, and action ideas included nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%-33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking.

CONCLUSIONS

Engaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

Patient Perception of How Smoking Status Influences Cardiac Rehabilitation Attendance After an Acute Cardiac Hospitalization

PURPOSE

Patients hospitalized with a cardiac condition are less likely to attend cardiac rehabilitation (CR) if they are smokers despite the benefits of doing so. The present study sought to investigate how, if at all, a patient's decision to attend CR was influenced by his or her tobacco use post-discharge.

METHODS

We surveyed smokers during their hospitalization for a cardiac condition. Four to 8 wk after discharge, a follow-up survey assessed self-reported CR attendance, smoking cessation (SC), and patient opinion of how their smoking status influenced CR attendance.

RESULTS

Of the 81 patients who completed the baseline survey (68% male, 57 ± 10 y), 62 (77%) completed the follow-up survey. Consistent with prior findings, there was a substantial correlation between SC and CR attendance (OR: 16.0, P < .001) with 36 (44%) patients attending CR overall and 38 (47%) abstaining from smoking. Patients reported a wide variety of reasons for not attending CR, but most patients (n = 39, 63%) reported that their smoking status did not influence their decision to attend CR. However, 5 patients (8%) reported attending CR because they successfully quit smoking, and 5 (8%) attended CR anticipating support with SC.

CONCLUSION

A strong relationship exists between SC and CR attendance following a cardiac hospitalization; however, most patients did not feel that their smoking status was a factor in their decision to attend CR. Regardless of the reason, it appears that success with one behavior may be related to the other and that both SC and CR attendance should be encouraged.

[Smoking cessation: A challenge for cardiologists and pulmonologists]

In addition to public health measures that need to be strongly supported politically, smoking is also a major medical issue. Tobacco dependence is a chronic disease, and, given its extremely addictive nature, treatment for tobacco dependence must be addressed actively by all health professionals. Because smoking is a major contributor to many of the pathologies their specialties address, cardiologists and pulmonologists must be at the forefront of this care. In this review we analyse the current state of smoking cessation treatment and its inadequacies, the limiting impact that doctors' own smoking has, as well as the misconceptions held by smokers and sometimes by doctors as well, which act as brakes on smoking cessation. Smoking cessation must become a treatment delivered in real clinical practice and any doctor must know how to manage it fluently. Do not be satisfied with simply advising smokers to quit. Learn how to approach the subject with smokers effectively, know how the various pharmacotherapies are used and know how to organize smoking cessation follow-up, an essential guarantee of success. If optimal management of this major pathological factor is a role for all doctors, it is of course especially so for our two specialties. It's up to us, cardiologists and pulmonologists, to take up this challenge.