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CMAJ• JUNE 23, 2009 • 180(13)
© 2009 Canadian Medical Association or its licensors
vascular disease has developed. In a meta-analysis of
20 studies, people who stopped smoking after a heart attack
or cardiac surgery had a 36% risk reduction for subsequent
cardiovascular mortality compared with those who did not
stop smoking.1These data illustrate why addressing the use
of tobacco should be a cornerstone of the secondary preven-
tion of cardiovascular disease. Unfortunately, smoking re-
ceives far less attention from cardiologists than other cardio-
vascular risk factors.2,3In this issue, a study by Smith and
Burgess4provides further evidence that this should change.
This study builds on a classic study from 1990 by Taylor
and colleagues5at Stanford Medical School. Their random-
ized controlled trial demonstrated the efficacy of a nurse-
based counselling program for smoking cessation among pa-
tients admitted to hospital for myocardial infarction (MI) and
who wanted to stop smoking. A trained nurse provided
cognitive-behavioural counselling at the patient’s bedside and
made up to 6 scheduled telephone calls in the 4 months after
discharge. The program nearly doubled the smoking cessation
rate at 1 year after hospital discharge, from 32% in the usual
care group to 61% in the intervention group.
This landmark study was followed by other trials that col-
lectively established hospital-based interventions for smoking
cessation as “best practice” for patients after MI. In a meta-
analysis of 18 randomized controlled trials involving smokers
admitted to hospital for cardiovascular disease, bedside coun-
selling followed by more than 1 month of supportive contact
after discharge, usually by telephone, was associated with an
81% increase in the odds of quitting compared with usual care.6
The counselling protocol in the study by Smith and
Burgess consisted of 1 hour of nurse counselling in hospital
followed by 7 telephone calls over 2 months after discharge.
Their protocol resembled the one used in the original trial by
Taylor and colleagues and achieved remarkably similar re-
sults. It is reassuring that the counselling intervention is still
effective decades after the original trial, even though patients
with MI now spend less time in hospital than in the 1980s.
Presumably, the intervention is still effective because so much
of it occurs after hospital discharge. The importance of the
postdischarge component was highlighted by the findings of a
recent meta-analysis of in-hospital interventions for smoking
cessation.6In this analysis, counselling that occurred only in
igarette smoking is a major risk factor for cardiovas-
cular disease. Quitting smoking clearly benefits
smokers, including those who quit even after cardio-
the hospital without sustained contact after discharge did not
improve long-term smoking cessation rates over usual care.
Despite the similarities between the trials, the new trial by
Smith and Burgess differs from the original trial in several
ways. First, Smith and Burgess showed that the program was
effective not only for patients admitted because of MI but
also for smokers who were admitted for coronary artery by-
pass graft surgery. Second, few patients in the original trial
had used smoking-cessation medications, whereas one-third
of the patients in the trial by Smith and Burgess used these
medications, reflecting the greater use of and expanding op-
tions for pharmacotherapy over the intervening decades.
Paradoxically, smokers in both arms of the new trial who
used pharmacotherapy had lower cessation rates than those
who did not use such medications. This apparent contradiction
has been observed in other studies in which smokers choose
whether or not to use pharmacotherapy.7The finding can be
explained if smokers who are less likely to succeed in quitting
because of stronger nicotine dependence are the same smokers
who choose to use cessation medication.7In the trial by Smith
and Burgess, smokers who used pharmacotherapy benefited
more from the counselling intervention (an increase in the ces-
sation rate from 22% to 55%) than did smokers who used no
medication (an increase in the cessation rate from 60% to
76%). This interaction was not statistically significant, owing
in part to the small sample size in the subgroup analysis. How-
ever, these results suggest that a combination of pharma-
cotherapy and counselling may offer hope to some smokers
whose efforts otherwise stand a small chance of success.
Thanks to this and previous trials, strong evidence sup-
Nancy A. Rigotti MD
See related research article by Smith and Burgess, page 1297
Helping smokers with cardiac disease to abstain from
tobacco after a stay in hospital
Nancy A. Rigotti directs the Tobacco Research and Treatment Center of the
Massachusetts General Hospital and is Professor of Medicine at Harvard
Medical School, Boston, USA.
•Smoking cessation is a critical but often neglected compo-
nent of the secondary prevention of cardiovascular disease.
Smokers who are admitted to hospital for cardiovascular
disease benefit from smoking-cessation counselling that
begins in hospital and continues for more than 1 month
Interventions for smoking cessation initiated in hospital need
to be translated from research into routine clinical practice.
ports the efficacy of smoking interventions for inpatients with
Still, challenges remain. Almost half of the smokers in the
current study resumed smoking within 1 year, despite experi-
encing a serious tobacco-related health consequence, under-
going a period of enforced tobacco abstinence during their
stay in hospital and receiving an intensive hospital-initiated
intervention. The fact that so many patients resumed smoking
is testimony to the addictive nature of tobacco and illustrates
the need for more powerful interventions. One strategy would
be to add pharmacotherapy to the comprehensive hospital-
initiated counselling model. The combination of medication
and counselling is synergistic in outpatients and is the current
standard of care.8Whether this holds for smokers while in
hospital should be explored.
Another challenge is translating the research evidence base
into routine clinical practice. Krumholz and colleagues9found
that the counselling-based intervention used by Taylor and
colleagues5was more cost-effective than other medical thera-
pies considered to be standard care among patients with MI.
More recently, a study that followed for 2 years patients with
MI found that an intensive intervention reduced readmissions
and all-cause mortality.10The results of these studies suggest
that, if widely adopted, interventions for smoking cessation
have the potential to reduce cardiovascular morbidity and mor-
tality at the population level. Unfortunately, almost 20 years
after the original study, widespread implementation has not
occurred. “Best practice” has not yet become “usual care.”
A major problem is that the intervention model does not fit
neatly into the existing delivery system for health care. Imple-
menting the model requires coordinating care from the inpa-
tient to the outpatient setting. Bridging this gap is a challenge
for all chronic diseases. Addiction to tobacco is no exception.
Hospitals do not see care after discharge as their responsibility
and are not eager to bear the cost. Treatment for dependence
on tobacco is not well covered by health insurers and payers,
who are not eager to add new benefits in an era of soaring
health care costs, even if the therapies are cost-effective.
In the United States, change was stimulated when hospital
accrediting organizations adopted new quality-of-care stan-
dards in 2004. These organizations measured whether smok-
ers with acute MI were given advice on smoking cessation or
assistance during their hospital stay. The results are publicly
reported and appear to have stimulated hospital-based coun-
selling efforts. How well these new programs adhere to the
evidence-based models that are needed to achieve long-term
smoking cessation is uncertain, but it is a promising start. Six-
teen years ago, Orleans and Ockene11called routine hospital-
based smoking counselling for patients with MI “an idea
whose time has come.” It is well overdue.
1. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessa-
tion in patients with coronary heart disease: a systematic review. JAMA 2003;290:
2.Erhardt L. Cigarette smoking: an undertreated risk factor for cardiovascular dis-
ease. Atherosclerosis DOI: 10.1016/j.atherosclerosis.2009.01.007. Epub 2009 Jan
15 ahead of print.
3.Cardiologists should be less passive about smoking cessation [editorial]. Lancet
4. Smith P, Burgess ED. Smoking cessation initiated during hospital stay for patients
with coronary artery disease: a randomized controlled trial. CMAJ 2009;180:1297-
5.Taylor CB, Houston-Miller N, Killen JD, et al. Smoking cessation after acute my-
ocardial infarction: effects of a nurse-managed intervention. Ann Intern Med 1990;
6.Rigotti NA, Munafo MR, Stead LF. Smoking cessation interventions for hospital-
ized smokers: a systematic review. Arch Intern Med 2008;168:1950-60.
7.Shiffman S, Brockwell SE, Pillitteri JL, et al. Use of smoking-cessation treatments
in the United States. Am J Prev Med 2008;34:102-11.
8.Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008
update. Clinical practice guidelines. Rockville (MD): US Department of Health
and Human Services, Public Health Service; 2008.
9.Krumholz HM, Cohen BJ, Tsevat J, et al. Cost-effectiveness of a smoking cessa-
tion program after myocardial infarction. J Am Coll Cardiol 1993;22:1697-702.
10.Mohiuddin SM, Mooss AN, Hunter CB, et al. Intensive smoking cessation inter-
vention reduces mortality in high-risk smokers with cardiovascular disease. Chest
11.Orleans CT, Ockene JK. Routine hospital-based quit-smoking treatment for the
postmyocardial infarction patient: an idea whose time has come. J Am Coll Cardiol
Correspondence to: Dr. Nancy A. Rigotti, Tobacco Research and
Treatment Center, Massachusetts General Hospital, 50 Staniford
St., 9th fl., Boston, MA 02114, USA; email@example.com
CMAJ • JUNE 23, 2009 • 180(13)
Competing interests: Nancy Rigotti has received payment and travel expenses
from Pfizer, which makes a smoking-cessation medication, and Free and Clear,
which provides telephone-based counselling for smoking cessation. She has re-
ceived research grants from Pfizer, Sanofi Aventis and Nabi Biopharmaceuti-
cals for studies of approved and investigational smoking cessation products.