Monaldi Arch Chest Dis
2012; 78: 85-88
Smoking cessation interventions after Acute
Coronary Syndromes. Results of a cross-sectional
survey in the Lazio Region of Italy
Complete cessation of active tobacco smoking
is associated with a significant 30-40% reduction
in the relative risk of death after acute coronary
syndromes (ACS) [1, 2]. In light of these major
benefits, active in-hospital and post-discharge in-
terventions are currently recommended to assist
smokers in quitting after ACS . However, smok-
ing cessation interventions appear to be largely un-
derutilized in cardiovascular institutions providing
acute care to ACS patients . As a consequence,
smoking relapse rates among smokers who have
become abstinent during an admission for ACS
may exceed 60% at 12 months from discharge .
Given the limited recent research on hospital
smoking care practices, a survey was undertaken to
describe the current status of smoking cessation inter-
ventions for ACS patients in a representative sample
of Cardiology Divisions of the Lazio Region of Italy,
which is a large area (17,000 km2) in central Italy
with a resident population of about 5,600,000 .
Interventi per la cessazione del fumo dopo Sindrome
Coronarica Acuta: risultati di uno studio osservazionale
trasversale nella Regione Lazio
Furio Colivicchi1, David Mocini1, Massimo Uguccioni2, Stefano Strano3,
Giuseppe Imperoli4and Massimo Santini1
for the ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri) Lazio
“Smoking Cessation Initiative”
1Cardiovascular Department, San Filippo Neri Hospital, Rome, Italy.
2Cardiology Division, CTO Hospital, Rome, Italy.
3Department of cardiovascular and Respiratory Sciences, “Sapienza” University of Rome.
4Internal Medicine Department, San Filippo Neri Hospital, Rome, Italy.
Corresponding author: Furio Colivicchi; Viale Gorgia da Leontini, 330; 00124, Rome, Italy;
E-mail address: email@example.com; tel. +39.06.3306.2429; fax. +39.06.3306.2489
ABSTRACT: Smoking cessation interventions after Acute
Coronary Syndromes. Results of a cross-sectional survey in
the Lazio Region of Italy. F. Colivicchi, D. Mocini, M. Uguc-
cioni, S. Strano, G. Imperoli and M. Santini for the ANMCO
(Associazione Nazionale Medici Cardiologi Ospedalieri) Lazio
- “Smoking Cessation Initiative”.
Given the limited research on Italian hospital smoking
care practices, a cross-sectional survey was undertaken in
April-May 2011 to describe the current status of smoking
cessation interventions for ACS patients in cardiovascular
institutions of the Lazio Region of Italy. Lazio is a region of
central Italy with a resident population of about 5,600,000.
According to the data of the Regional Health Authority,
about 10.000 patients are admitted for ACS every year in
this region of Italy. Acute cardiac care in the region is cur-
rently provided by 33 Cardiology Divisions. All of these units
were considered as eligible for the survey. The eligible re-
spondent for each unit was the director. A self-report ques-
tionnaire was developed based on previous studies that ex-
amined the specific features of smoking cessation care pro-
vided to hospitalised patients. Questionnaires were forward-
ed by the Lazio Regional Section of the Italian National As-
sociation of Hospital Cardiologists (ANMCO).
Completed questionnaires were received from 22 of the
33 eligible Divisions (66%). These 22 responding units cur-
rently provide acute care to about 70% of all ACS patients
of the region. Responding units were more likely to repre-
sent public non-teaching hospitals (p=0.002), while non-re-
sponders were mostly from private non-teaching institutions
(p=0.04). Response rates were not influenced by the pres-
ence of either interventional catheterization laboratory
(Cathlab)or cardiac surgery within the hospitals.
The survey suggest that most of cardiology units fail to
provide recommended smoking care interventions to ACS pa-
tients. In particular, brief smoking cessation advice before dis-
charge represents the only systematically implemented ap-
proach in clinical practice (22 units; 100%). Smoking cessation
counselling is provided only in 9 units (40%). Specific pharma-
cotherapy is prescribed in selected case only in about one third
of units (7 units; 32%), with varenicline being the preferred
drug. Structural variables and organizational complexity have
no influence on smoking care, as hospitals with Cathlab and
cardiac surgery do not implement more effective strategies.
Overall, this survey shows that the majority of smoking ACS
inpatients may receive inadequate smoking care and that hos-
pitals have considerable opportunity for improvement.
Keywords: Smoking cessation, Acute Coronary Syndromes,
Monaldi Arch Chest Dis 2012; 78: 85-88.
A cross-sectional survey of smoking cessation
interventions routinely delivered to ACS patients in
Cardiology Divisions of acute care hospitals of the
Lazio Region of Italy was undertaken in April-May
2011. Eligible services were those Cardiology Units
within hospitals providing acute care to patients
with ACS. The eligible respondent for each unit was
the director, or a senior attending cardiologist.
A self-report questionnaire was developed based
on recommendations included in the US Clinical
Guidelines for Treating Tobacco Use and Depen-
dence , and on previous reports that examined the
specific features of smoking cessation care that can
be provided to hospitalised patients [8, 9].
Smoking cessation interventions were then
1. Systematic behavioural interventions (brief ad-
vice, individual counselling, provision of self-
help materials, group therapy).
2. Post-discharge support and follow-up.
3. Pharmacotherapy (such as nicotine replacement
therapy, bupropion, varenicline)
A senior cardiologist pilot tested the survey
structure and content, resulting in minor revisions
before final distribution. Questionnaires were for-
warded by the Lazio Regional Section of the Italian
National Association of Hospital Cardiologists
(ANMCO), which is the professional association of
cardiologists working in public hospitals of the Ital-
ian National Health Service (www.anmco.it).
The survey assessed current smoking cessation
interventions regarding ACS patients who were
smokers, as well as hospital characteristics. Respon-
dents were asked to complete the survey based on
their knowledge of practices within their unit.
Hospitals were categorised according to the
standard definitions of the Italian Cardiology Net-
1. Group 1 - hospitals with only a coronary care
2. Group 2 - hospitals with CCU and intervention-
al catheterization laboratory (Cathlab),
3. Group 3 - hospitals with CCU, Cathlab and car-
The prevalence of each type of smoking cessa-
tion intervention is reported as a proportion. Differ-
ences in the prevalence of such care strategies be-
tween different types of units were examined by χ2
or Fisher exact test as appropriate.
Logistic regression analysis was used to exam-
ine the potential associations between type of unit
and specific smoking cessation interventions. Data
analysis was performed by using the SPSS statistical
software package (SPSS 12.0). P<0.05 was consid-
ered statistically significant.
Each year, in the Lazio Region of Italy about
10,000 people are hospitalised for ACS . Be-
sides, according to the Regional Health Authority,
acute care for ACS in this administrative area is cur-
rently provided by 33 Cardiology Divisions .
All of these 33 units were considered as eligible for
the survey. Completed questionnaires were received
from 22 of the 33 eligible Cardiology Divisions
(66%). These 22 responding units currently provide
acute care to about 70% of all ACS patients of the
region . Characteristics of responding and non-
responding divisions are provided in Table 1. Re-
sponding units were more likely to represent public
non-teaching hospitals (p=0.002), while non-re-
sponders were mostly from private non-teaching in-
stitutions (p=0.04). Response rates were not influ-
enced by the presence of either Cathlab or cardiac
surgery within the hospitals as assessed by logistic
Table 2 summarises the prevalence of the vari-
ous forms of smoking cessation intervention deliv-
ered to ACS patients in the responding units. Smok-
ing care was not influenced by the presence of either
Cathlab or cardiac Surgery as assessed by logistic
This study reports the prevalence of smoking
cessation interventions routinely delivered to ACS
patients by acute care hospitals of a major Italian re-
F. COLIVICCHI ET AL.
Table 1. - Characteristics of responding and non-responding eligible hospitals (total number = 33)
Public University hospitals - number (%)1 (4) 2 (18)
Private University hospitals - number (%)0 (0)1 (9)
Public non-teaching hospitals - number (%) 18 (82)* 3 (27)
Private non-teaching hospitals - number (%)3 (14) § 5 (46)
CCU only - number (%)10 (45) 6 (55)
CCU and Cathlab - number (%)9 (41) 2 (18)
CCU, Cathlab and Cardiac Surgery - number (%)3 (14) 3 (27)
CCU, coronary care unit; Cathlab, interventional catheterization laboratory, * p=0.002; § p= 0.04
gion. The results suggest that most of cardiology
units fail to provide recommended smoking care in-
terventions to ACS patients. In particular, brief ad-
vice represents the only systematically implemented
approach in clinical practice, while only about 40%
of respondents reported the provision of individual
or group smoking cessation counselling. Further-
more, specific pharmacotherapy is prescribed in se-
lected cases only in about one third of units, with
varenicline being the preferred drug.
Another point of interest in that structural vari-
ables and organizational complexity seem to have
no influence on smoking care, as hospitals with
Cathlab and cardiac surgery do not implement more
The health care system is a key channel for de-
livering interventions to reduce tobacco use,
which is the leading preventable cause of death in
western countries and a major risk factor for car-
diovascular disease. Consequently, a hospitalisa-
tion for a major cardiovascular event should al-
ways be considered a unique opportunity to deliv-
er a structured smoking cessation intervention.
However, this survey shows that the majority of
smoking ACS inpatients may receive inadequate
smoking care and that hospitals have considerable
opportunity for improvement.
Overall, the results of this survey further suggest
that healthcare providers should take smoking ces-
sation interventions more seriously, as recommend-
ed treatments are not making their way into practice.
As recommended, a successful program to help
ACS patients quit smoking should take a compre-
hensive long-term approach, including individual
counseling, post-discharge support and pharmaco-
1. Wilson K, Gibson N, Willan A, Cook D. Effect of smok-
ing cessation on mortality after myocardial infarction.
meta-analysis of cohort studies. Arch Intern Med 2000;
Critchley JA, Capewell S. Mortality risk reduction asso-
ciated with smoking cessation in patients with coronary
heart disease: a systematic review. JAMA. 2003; 290:
Krumholz HM, Anderson JL, Bachelder BL, et al.
ACC/AHA 2008 performance measures for adults with
ST-elevation and non-ST-elevation myocardial infarction:
a report of the American College of Cardiology/American
SMOKING CESSATION AFTER ACS
Table 2. - Provision of smoking cessation interventions in responding cardiology units
Brief smoking cessation advice - number (%)22 (100)10 (100)9 (100) 3 (100)
Smoking care indications in discharge letter- number (%) 11 (50)4 (40) 4 (45)3 (100)
Counselling for smoking cessation
Individual counselling - number (%)8 (36) 2 (20)4 (45) 2 (66)
With a single session - number (%) 6 (28)2 (20) 4 (45)0 (0)
With multiple sessions - number (%)2 (9)0 (0)0 (0)2 (66)
Delivered by physician - number (%)4 (18) 2 (20)2 (22)0 (0)
Delivered by nurse - number (%)4 (18)1 (10) 1 (11) 2 (66)
Group counselling - number (%)1 (4)0 (0) 1 (11) 0 (0)
Other behavioural interventions
Provision of self-help materials (booklets) - number (%) 4 (18) 2 (20)1 (11) 1 (33)
Follow-up support for smoking cessation after discharge - number (%)7 (32) 2 (20)3 (33)2 (66)
Systematic prescription - number (%)0 (0)0 (0) 0 (0)0 (0)
Prescription in selected cases - number (%)7 (32)2 (20)3 (33) 2 (66)
NRT - number (%)1 (4)1 (10)0 (0)0 (0)
Bupropion - number (%)1 (4)1 (10)0 (0) 0 (0)
Varenicline - number (%) 7 (32)2 (20)3 (33)2 (66)
CCU, coronary care unit; Cathlab, interventional catheterization laboratory; CS, cardiac surgery; NRT, nicotine replacement therapy
Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures
for ST-Elevation and Non-ST-Elevation Myocardial In-
farction). Circulation. 2008; 118: 2598-2648.
Dawood N, Vaccarino V, Reid KJ, Spertus JA, Hamid N,
Parashar S. Predictors of smoking cessation after a my-
ocardial infarction. The role of institutional smoking ces-
sation programs in improving success. Arch Intern Med
Colivicchi F, Mocini D, Tubaro M, Aiello A, Clavario P,
Santini M. Effect of smoking relapse on outcome after Acute
Coronary Syndromes. Am J Cardiol 2011; 108: 804-8.
http://www.regione.lazio.it/statistica/ accessed 15 July
Fiore MC, Jaen CR, Baker TB. Treating tobacco use and
dependence: 2008 update. Clinical practice guideline.
Rockville, MD: U.S. Department of Health and Human
Services. Public Health Service; 2008.
8.Rigotti NA, Munafo MR, Stead LF. Interventions for
smoking cessation in hospitalised patients. Cochrane
Database Syst Rev 2007; CD001837.
Rigotti N, Munafo MR, Stead LF. Smoking cessation in-
terventions for hospitalized smokers: a systematic review.
Arch Intern Med 2008; 168: 1950-60.
Di Chiara A, Fresco C, Savonitto S, et al. Epidemiology
of non-ST elevation acute coronary syndromes in the Ital-
ian cardiology network: the BLITZ-2 study. Eur Heart J
2006; 27: 393-405.
Colivicchi F, Di Roma A, Uguccioni M, et al. Preven-
zione cardiovascolare secondaria dopo sindrome coronar-
ica acuta nella pratica clinica. Documento di Consenso
delle Società Scientifiche di Medicina Cardiovascolare e
Medicina Interna della Regione Lazio. G Ital Cardiol
2010; 11(Suppl 4): 3S-29S.
accessed 9 July 2012.
F. COLIVICCHI ET AL.