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CMAJ Commentary Helping smokers with cardiac disease to abstain from tobacco after a stay in hospital Nancy A. Rigotti MD @@ See related research article by Smith and Burgess, page 1297 C igarette smoking is a major risk factor for cardiovas- Key points cular disease. Quitting smoking clearly benefits smokers, including those who quit even after cardio- • Smoking cessation is a critical but often neglected compo- vascular disease has developed. In a meta-analysis of nent of the secondary prevention of cardiovascular disease. 20 studies, people who stopped smoking after a heart attack • Smokers who are admitted to hospital for cardiovascular disease benefit from smoking-cessation counselling that or cardiac surgery had a 36% risk reduction for subsequent begins in hospital and continues for more than 1 month cardiovascular mortality compared with those who did not after discharge. stop smoking.1 These data illustrate why addressing the use • Interventions for smoking cessation initiated in hospital need of tobacco should be a cornerstone of the secondary preven- to be translated from research into routine clinical practice. tion of cardiovascular disease. Unfortunately, smoking re- ceives far less attention from cardiologists than other cardio- vascular risk factors.2,3 In this issue, a study by Smith and the hospital without sustained contact after discharge did not Burgess4 provides further evidence that this should change. improve long-term smoking cessation rates over usual care. This study builds on a classic study from 1990 by Taylor Despite the similarities between the trials, the new trial by and colleagues5 at Stanford Medical School. Their random- Smith and Burgess differs from the original trial in several ized controlled trial demonstrated the efficacy of a nurse- ways. First, Smith and Burgess showed that the program was based counselling program for smoking cessation among pa- effective not only for patients admitted because of MI but tients admitted to hospital for myocardial infarction (MI) and also for smokers who were admitted for coronary artery by- who wanted to stop smoking. A trained nurse provided pass graft surgery. Second, few patients in the original trial cognitive-behavioural counselling at the patient’s bedside and had used smoking-cessation medications, whereas one-third made up to 6 scheduled telephone calls in the 4 months after of the patients in the trial by Smith and Burgess used these discharge. The program nearly doubled the smoking cessation medications, reflecting the greater use of and expanding op- rate at 1 year after hospital discharge, from 32% in the usual tions for pharmacotherapy over the intervening decades. care group to 61% in the intervention group. Paradoxically, smokers in both arms of the new trial who This landmark study was followed by other trials that col- used pharmacotherapy had lower cessation rates than those lectively established hospital-based interventions for smoking who did not use such medications. This apparent contradiction cessation as “best practice” for patients after MI. In a meta- has been observed in other studies in which smokers choose analysis of 18 randomized controlled trials involving smokers whether or not to use pharmacotherapy.7 The findi
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