Benefits of Inpatient Smoking Cessation Therapy Post-Myocardial Infarction

Because smoking causes cardiovascular disease,¹ the prevalence of smoking is elevated in individuals who have experienced myocardial infarction (MI) compared with the general population. The time of hospitalization for treatment of MI is an opportunity to treat smoking because of increased motivation to quit among patients, increased opportunity to initiate and monitor treatment in-house, and usual practice of close follow-up for continued treatment after discharge. Without tobacco use treatment, individuals forced to abstain from smoking, such as in hospital settings, almost always relapse after regaining access to smoking, such as after discharge. This is a problem because smoking after MI continues to increase risk for mortality.² But just how often are individuals who smoke treated while hospitalized?

New observational data reported on current practices of starting tobacco use treatment during hospitalization for MI.³ In nearly 37,000 individuals who received treatment for MI at 282 hospitals in 2014, approximately one-quarter of individuals (22.7%) received 1 or more prescriptions for tobacco use treatment (including varenicline, bupropion, and all available nicotine replacement options). The majority of patients received nicotine replacement. Approximately 2.5% of the total sample received a prescription for either bupropion or varenicline. The investigators concluded that hospitalization for treatment of MI represents an opportunity to intervene in smoking often accompanied by increased motivation to quit, but that, unfortunately, few patients are given treatment while hospitalized.

Smoking is a treatable problem. It is possible to interrupt the path of smoking, force abstinence, and avoid a return to smoking after discharge in hospitalized individuals. Nicotine replacement options including transdermal, lozenges, and gum could be considered as treatment, and trials have demonstrated efficacy in individuals post-MI. Nicotine replacement therapy initiated in hospitalized individuals who smoke can have the dual purpose of alleviating withdrawal symptoms and as potential longer-term tobacco use treatment.⁴ Treatment with other medications bupropion or varenicline can also significantly increase quit rates. Initial concerns about varenicline potentially increasing risk for adverse cardiovascular outcomes have been addressed in a randomized controlled trial showing effectiveness and safety in treating smoking in outpatients with cardiovascular disease,⁵ and in a subsequent meta-analysis showing no elevated risk for cardiovascular events among individuals treated with varenicline.⁶

Conversely, a recent randomized controlled trial in 392 individuals hospitalized for acute MI demonstrated a nonsignificant difference in 12-month abstinence rates between patients who received bupropion and patients who received placebo (37% and 32%, respectively). ⁷

An accompanying editorial⁴ suggested strategies for hospital-based initiation of tobacco use treatment including effective counseling, transitioning patients to follow-up care within 1 month, matching treatment with patient preferences, and treating co-occurring conditions such as depression. In addition, the authors described viewing tobacco use treatment as chronic disease treatment, which can include continued patient engagement, regular reassessment of smoking, treating relapse and withdrawal symptoms, and promoting adherence to treatment. Interestingly, a secondary data analysis of this randomized trial⁷ showed those patients who adhered partially or fully to treatment were more likely to achieve abstinence at 12 months.⁸

Perhaps 2 problems deserve more attention: a minority of individuals hospitalized for myocardial infarction receive tobacco use treatment in-house,³ suggesting a need to consider treatment for this risk factor while individuals are hospitalized, and adherence to tobacco use treatment varies,⁷ suggesting a need to promote adherence to tobacco use treatment as part of follow-up care. Hospitalization could be an opportunity for addressing both points of discussing risks and benefits and potentially initiating tobacco use treatment, along with recommendations for close follow-up with outpatient clinicians who can help promote adherence to treatment. Patients could also be educated about smoking quit help lines and other supportive resources. Similar to treatment for other chronic conditions, adherence is associated with more favorable outcomes.

Tobacco use treatment started in-house and linked to outpatient follow-up promoting adherence improves quit rates in hospitalized individuals,⁴ suggesting initiating treatment with close follow-up, including counseling, could improve quit rates among individuals hospitalized for acute MI.

References

1. Jha P, Ramasundarahettige C, Landsman V, et al. 21^st-Century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013;368:341-350.
2. Wilson K, Gibson N, Willan A, Cook D. Effect of smoking cessation on mortality after myocardial infarction. Meta-analysis of cohort studies. Arch Intern Med. 2000;160:939-944.
3.  Pack QR, Priya A, Lagu TC, Pekow PS, Rigotti NA, Linderauer PK. Smoking cessation pharmacotherapy among smokers hospitalized for coronary heart disease [published online August 21, 2017]. JAMA Intern Med. doi: 10.1001/jamainternmed.2017.3489
4. Benowitz NL, Prochaska JJ. Smoking cessation after myocardial infarction. J Am Coll Cardiol. 2013;61:533-535.
5.  Rigotti NA, Pipe AL, Benowitz NL, Arteaga C, Garza D, Tonstad S. Efficacy and safety of varenicline for smoking cessation in patients with cardiovascular disease. A randomized trial. Circulation. 2010;121:221-229.
6.  Prochaska JJ, Hilton JF. Risk of cardiovascular serious adverse events associated with varenicline use for tobacco cessation: systematic review and meta-analysis. BMJ. 2012;344:e2856.
7.  Eisenberg MJ, Grandi SM, Gervais A, et al. Bupropion for smoking cessation in patients hospitalized with acute myocardial infarction. A randomized, placebo-controlled trial. J Am Coll Cardiol. 2013;61:524-532.
8.  Grandi SM, Eisenberg MJ, Joseph L, O’Loughlin J, Paradis G, Filion KN. Cessation treatment adherence and smoking abstinence in patients after acute myocardial infarction. Am Heart J. 2016;173:35-40.