title: Impact of Smoking on Health-Related Quality of Life After Percutaneous Coronary Revascularization Stress, social support, and stopping smoking after myocardial infarction in England. Risk factors for a major coronary event after myocardial infarction in the Scandinavian Simvastatin Survival Study (4S). Impact of predicted risk on the benefit of cholesterol-lowering treatment. Smoking and cardiac events after venous coronary bypass surgery. A 15-year follow-up study. Mortality in relation to smoking: 50 years' observations on male British doctors The role of risk factors in heart attacks occurring in men with pre-existing ischaemic heart disease. Haematological prognostic indices after myocardial infarction: evidence from the diet and reinfarction trial (DART). Early discharge following acute myocardial infarction. Long-term follow-up of randomized patients. Short- and long-term prognosis after coronary artery bypass grafting in relation to smoking habits. Stopping smoking and long-term mortality after acute myocardial infarction. Smoking and myocardial infarction: secondary prevention. Effects of cardiac rehabilitation after myocardial infarction: changes in coronary risk factors and long-term prognosis. Risk of New Myocardial Infarction in Middle‐aged Men with Manifest Coronary Heart Disease GIVING UP SMOKING AND THE RISK OF HEART ATTACKS: A report from The British Regional Heart Study Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients. Effect of aspirin use on death and recurrent myocardial infarction in current and former cigarette smokers. Program on the Surgical Control of the Hyperlipidemias Group. The recurrent coronary prevention project. Some preliminary findings. Quitting and restarting smoking: cohort study of patients with angina in primary care Reinfarction after thrombolytic therapy for acute myocardial infarction followed by conservative management: incidence and effect of smoking. The relationship of smoking cessation to coronary heart disease and lung cancer in the Multiple Risk Factor Intervention Trial (MRFIT). Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study. Effect of smoking habits and timolol treatment on mortality and reinfarction in patients surviving acute myocardial infarction. Smoking cessation following admission to a coronary care unit Beneficial effect of stopping smoking on future cardiac events in male smokers with previous myocardial infarction. Biochemical evidence of persistent heavy smoking after a coronary diagnosis despite self-reported reduction: analysis from the Scottish Heart Health Study. Cigarette smoking status and outcome among patients with acute coronary syndromes without persistent ST-segment elevation: effect of inhibition of platelet glycoprotein IIb/IIIa with eptifibatide. The PURSUIT trial investigators. Smoking Status and Risk for Recurrent Coronary Events after Myocardial Infarction A comparison of nursing interventions for smoking cessation in adults with cardiovascular health problems. Effect of cigarette smoking on survival of patients with angiographically documented coronary artery disease. Report from the CASS registry.
abstract: Background PTCA is performed primarily to improve health-related quality of life ( HRQOL ) in patients with symptomatic coronary artery disease . In patients undergoing PTCA , smoking has been shown to increase risks of late myocardial infa rct ion and death . Whether smoking also affects HRQOL after PTCA is currently unknown . Methods and Results We examined the relation between smoking status and HRQOL among 1432 patients who underwent PTCA as part of 2 multicenter clinical trials . HRQOL was assessed with the use of the Medical Outcomes Study SF-36 question naire . Patients were classified as smokers ( n=301 ) , quitters ( n=141 ) , or nonsmokers ( n=990 ) on the basis of their smoking status at the time of their index procedure and during the first year of follow-up . For the overall population , HRQOL improved significantly after PTCA for all scales except general health perception , with improvements ranging from 5.5 points for mental health to 23.2 points for role-physical functioning . After adjustment for baseline characteristics and initial HRQOL , nonsmokers had gains at 6 months that were larger than those of smokers for all health domains : physical function ( 15.4 versus 10.4 points ) , role-physical ( 24.5 versus 13.9 ) , pain ( 18.4 versus 13.3 ) , general health perception ( 1.7 versus −4.5 ) , vitality ( 11.0 versus 4.7 ) , social function ( 12.8 versus 3.5 ) , role-emotional ( 13.5 versus 6.7 ) , and mental health ( 6.8 versus 0.8;P < 0.02 for all comparisons ) . Quitters had 6-month HRQOL improvements that were greater than those in smokers for all domains as well . Findings were similar at 1 year . Conclusions Quality -of-life benefits of PTCA are diminished by continued smoking . Efforts to promote smoking cessation at the time of PTCA may substantially improve the health outcomes of these procedures STUDY OBJECTIVE --To examine the effect on mortality of stopping smoking after myocardial infa rct ion and the psychosocial factors that influence the decision to stop . DESIGN -- Analysis of smokers in a large prospect i ve study . Self completed question naires provided information on psychosocial factors . SETTING --Coronary care units at six English hospitals participating in a multicentre clinical trial . SUBJECTS -- These comprised consenting myocardial infa rct ion survivors who had been identified as smokers and who completed question naires within seven days of infa rct at six hospitals participating in the Anglo-Sc and inavian study of early thrombolysis . The 532 patients identified have been followed for over five and a half years . The main outcome measure was five year all cause mortality . MAIN RESULTS --Smokers who stopped within one month showed significantly reduced mortality compared with those who persisted , adjusting for other prognostic indicators ( odds ratio 0.56 , 95 % confidence interval 0.33 , 0.98 ) . Overall , 74 % stopped smoking . Being married , low life stress levels before infa rct , and higher social class were associated with stopping smoking but the differentials were small . Of the clinical variables , a final diagnosis of definite myocardial infa rct ion was associated with stopping smoking . All associations remained after multiple logistic regression . CONCLUSION --Smoking cessation can halve the smokers ' odds of dying after myocardial infa rct ion and psychosocial factors play a small but important role in the important decision to stop smoking . Health professionals should continue to stress the importance of stopping smoking to all patients as there is little evidence to support specific directing of advice to relatively " stress or " socially isolated " groups AIMS To analyse ( 1 ) the prognostic importance of clinical findings and lipids in patients with a previous myocardial infa rct ion and ( 2 ) the relative and absolute benefit of simvastatin in patients at low , medium and high predicted risk . METHODS The 4S was a double-blind , r and omized , clinical trial of long-term treatment with simvastatin or matching placebo in patients with myocardial infa rct ion or angina pectoris , serum total cholesterol 5.5 - 8.0 mmol x l(-1 ) , and serum triglycerides < or=2.5 mmol x l(-1 ) . The present study only deals with those 3525 patients who had a previous myocardial infa rct ion . End-points comprised coronary death , definite and probable hospital verified myocardial infa rct ion , and resuscitated cardiac arrest . Because there were few women the primary analyses were performed among men . RESULTS A Cox model analysis in the placebo group identified the following independent predictors of coronary events : a history of hypertension ( P=0.023 ) , diabetes ( P=0.0001 ) , smoking after the myocardial infa rct ion ( P=0.010 ) , total cholesterol ( P=0.020 ) , and HDL cholesterol ( P=0.062 ) . The relative reduction of risk by simvastatin treatment in patients at low , medium and high predicted risk was 38 % , 39 % and 42 % , respectively , but the corresponding absolute benefit per 100 patients treated for 6 years increased from 7.9 to 16.2 . CONCLUSION In addition to serum lipids , clinical variables contributed significantly to prediction . The relative benefit from simvastatin treatment was independent of predicted risk , but the absolute benefit increased from low to high risk BACKGROUND The long-term clinical effects of smoking and smoking cessation after  venous coronary bypass surgery  have not been well established . METHODS AND RESULTS Four hundred fifteen patients who underwent venous coronary bypass surgery between April 1976 and April 1977 were followed up prospect ively for 15 years . Multivariate Cox survival analysis revealed that patients who smoked at the time of surgery had no elevated risks for clinical events compared with nonsmokers . However , smoking behavior at 1 and 5 years after surgery appeared to be an important predictor of clinical events during the subsequent follow-up period . Compared with patients who stopped smoking since surgery , smokers at 1 year after surgery had more than twice the risk for myocardial infa rct ion and reoperation . Patients who were still smoking at 5 years after surgery had even more elevated risks for myocardial infa rct ion and reoperation and a significantly increased risk for angina pectoris compared with patients who stopped smoking since surgery and patients who never smoked . Patients who started to smoke again within 5 years after surgery had increased risks for reoperation and angina pectoris . No differences in outcome were found between patients who stopped smoking since surgery and nonsmokers . CONCLUSIONS Our results show that smoking cessation after coronary bypass surgery may have important beneficial effects on clinical events during long-term follow-up Abstract Objective To compare the hazards of cigarette smoking in men who formed their habits at different periods , and the extent of the reduction in risk when cigarette smoking is stopped at different ages . Design Prospect i ve study that has continued from 1951 to 2001 . Setting United Kingdom . Participants 34 439 male British doctors . Information about their smoking habits was obtained in 1951 , and periodically thereafter ; cause specific mortality was monitored for 50 years . Main outcome measures Overall mortality by smoking habit , considering separately men born in different periods . Results The excess mortality associated with smoking chiefly involved vascular , neoplastic , and respiratory diseases that can be caused by smoking . Men born in 1900 - 1930 who smoked only cigarettes and continued smoking died on average about 10 years younger than lifelong non-smokers . Cessation at age 60 , 50 , 40 , or 30 years gained , respectively , about 3 , 6 , 9 , or 10 years of life expectancy . The excess mortality associated with cigarette smoking was less for men born in the 19th century and was greatest for men born in the 1920s . The cigarette smoker versus non-smoker probabilities of dying in middle age ( 35 - 69 ) were 42 % ν24 % ( a twofold death rate ratio ) for those born in 1900 - 1909 , but were 43 % ν 15 % ( a threefold death rate ratio ) for those born in the 1920s . At older ages , the cigarette smoker versus non-smoker probabilities of surviving from age 70 to 90 were 10 % ν 12 % at the death rates of the 1950s ( that is , among men born around the 1870s ) but were 7 % ν 33 % ( again a threefold death rate ratio ) at the death rates of the 1990s ( that is , among men born around the 1910s ) . Conclusion A substantial progressive decrease in the mortality rates among non-smokers over the past half century ( due to prevention and improved treatment of disease ) has been wholly outweighed , among cigarette smokers , by a progressive increase in the smoker ν non-smoker death rate ratio due to earlier and more intensive use of cigarettes . Among the men born around 1920 , prolonged cigarette smoking from early adult life tripled age specific mortality rates , but cessation at age 50 halved the hazard , and cessation at age 30 avoided almost all of it The importance of three risk factors -- serum total cholesterol , systolic blood pressure , and cigarette smoking -- on the risk of new major ischaemic heart disease events in men who already have evidence of ischaemic heart disease was assessed . Data from the initial examination in a large prospect i ve study of cardiovascular disease in middle aged men ( the British Regional Heart Study ) were used to separate 7710 men into three groups on the basis of a resting electrocardiogram , a st and ardised chest pain question naire , and recall of a doctor 's diagnosis of angina or of a previous heart attack : ( group 1 ) no evidence of ischaemic heart disease ( 75 % ) , ( group 2 ) evidence of ischaemic heart disease short of a definite myocardial infa rct ion ( 20 % ) , ( group 3 ) definite myocardial infa rct ion ( 6 % ) . In the average follow up period of 7.5 years , 443 men suffered a new major event caused by ischaemic heart disease ( fatal or non-fatal myocardial infa rct ion or sudden cardiac death  ) . Age st and ardised event rates were determined for each of the three groups for varying levels of the established risk factors . Cigarette smoking is strongly associated with the event rate in group 1 but in men with existing heart disease , especially group 3 , differences in risk between the smoking categories were smaller . The strong relation between systolic blood pressure and event rate persisted in groups 1 and 2 but not in group 3 . The positive association between serum concentration of total cholesterol and the event rate was strongest in group 1 and weaker in groups 2 and 3 , though it remained highly significant . These observations , taken together with the results of previous prospect i ve studies and intervention trials , suggest that the important association between serum total cholesterol and the risk of heart attack persists in men with pre-existing ischaemic heart disease , including myocardial infa rct ion . Therefore , in these men the reduction of serum total cholesterol concentration may be at least as important as it is in men without evidence of ischaemic heart disease Data from the Diet and Reinfa rct ion Trial were examined to check the prognostic effects of plasma fibrinogen , plasma viscosity , white blood cell count , haemoglobin and mean platelet volume in 92 deaths among 1755 men who had recently recovered from acute myocardial infa rct ion . All these variables were significantly associated with all-cause mortality over the following 18 months ( haemoglobin negatively , the others positively ) . Those who gave up smoking following their infa rct had a lower mortality than those who continued to smoke ( 4.1 % and 7.9 % respectively ) , and this effect appeared to be mediated by fibrinogen levels . Smoking habit accounted for only part of the prognostic effect of fibrinogen and white blood cell count . Haematological variables have an important prognostic significance after myocardial infa rct ion . Cessation of smoking after myocardial infa rct ion is worthwhile and has a favourable effect on plasma fibrinogen Long-term follow-up was obtained on 138 patients who participated in a prospect i ve , r and omized study comparing two weeks with three weeks of hospitalization following uncomplicated acute myocardial infa rct ion . Follow-up information was available on 123 ( 89 % ) of all r and omized patients . The mean follow-up period was 35 months for those patients who died and 99 months for those who survived . No differences were found between the two groups with respect to survival , cardiac-related deaths , frequency or severity of angina pectoris , subsequent myocardial infa rct ion , incidence of congestive heart failure , number of ventricular aneurysms , or subsequent medical therapy . A significantly greater number of survivors in both groups stopped smoking and had a normal initial heart size than those who died . This long-term follow-up study further supports the conclusions of earlier short-term studies that two weeks of hospitalization is safe in patients with uncomplicated acute myocardial infa rct ion We describe the 2- and 5-year prognoses following coronary artery bypass grafting ( CABG ) in relation to smoking habits among consecutive patients being operated on in western Sweden during a 3-year period . Among the 2,121 patients , 10.2 % admitted smoking at coronary angiography as compared with 7.5 % 2 years after CABG ( NS ) . Among smokers , the mortality during the subsequent 2 years was 8.9 % as compared with 6.5 % for exsmokers and 7.3 % for never smokers ( NS ) . During the 5-year follow-up , smokers had a mortality of 18.8 % as compared with 13.6 % for exsmokers and 12.5 % for never smokers ( p = 0.03 ) . When correcting for dissimilarities in previous history , smoking was a strongly significant independent ( p < 0.0001 ) predictor of 5-year mortality A prospect i ve follow-up study was carried out to investigate the relation between smoking and risk of death after an acute myocardial infa rct ion . The study consisted of male patients under the age of 65 years , who had had an acute myocardial infa rct ion between 1972 and 1975 in North Karelia , Finl and . Of these patients , 888 survived the first six months after the acute infa rct ion and were followed-up for three years after the infa rct ion with regard to their deaths . The cumulative all-causes mortality rate of the patients who were still smoking six months after the acute myocardial infa rct ion was 1.7 times that of the patients who had stopped smoking within the first six months . There was a dose-response relation between the number of cigarettes smoked daily and the mortality . The impact of smoking was greatest in the subgroups of patients with an otherwise good prognosis . We estimated that 28 per cent of the deaths in the whole group of initial smokers was attributable to continuing smoking after the infa rct ion . On the basis of these findings we suggest that the anti-smoking advice should be an important part of the modern comprehensive care of patients with an acute myocardial infa rct ion This prospect i ve study examines the question ' Is it too late to stop smoking cigarettes once you have had a myocardial infa rct ion ? ' One hundred and nineteen cigarette smokers ( 90 men , 29 women ) who survived their first myocardial infa rct ion for one month were followed for five years or until their death if earlier . The age corrected mortality rate of men who continued to smoke cigarettes was 2.2 times the age corrected mortality rate of those who stopped smoking after their infa rct . The women who continued to smoke had 2.4 times the age corrected mortality of those who stopped smoking . The age and sex corrected mortality rates for the combined group of men and women show that those who stopped smoking after their infa rct ion have 55 % of the mortality of those who continued to smoke ( P less than 0.05 ) . These results suggest that smoking is not merely a ' risk factor ' for myocardial infa rct ion but is also a causal factor whose effects can be avoided by both men and women after an initial myocardial infa rct ion Prognosis during 5 years of follow-up after first myocardial infa rct ion ( MI ) in a group of men ( aged 40 to 55 years ) was related to risk factors determined at the time of MI . Progression of coronary artery disease ( CAD ) was measured by the occurrence of severe angina pectoris , recurrent myocardial infa rct ion , and cardiac death . Only smoking and serum cholesterol level influenced prognosis . It was possible to identify a subgroup ( patients smoking less than 20 cigarettes/day and having a cholesterol level of less than 7.0 mmoles/L ) with low risk for progression of CAD . A r and omly applied 6-week rehabilitation program shortly after MI was associated with a 50 % decrease in progressive CAD when compared to the control group . Since only a slight decrease in cholesterol levels was found in the rehabilitation group , a direct effect of the rehabilitation program could thus not be excluded because the second important risk factor , smoking , did not show differences between the two groups . The smoking habits at the time of MI determined the continuation of cigarette smoking and rehabilitation did not influence smoking habits Men incurring coronary heart disease ( CHD ) during surveillance of an employed population were studied for risk factors associated with additional myocardial infa rct ions . The coronaryprone Type A behavior pattern measured by a  test score , number of cigarettes smoked daily , and serum cholesterol  were significant discriminators between the 67 men with recurrent CHD and the 220 with but a single clinical CHD event .  Diastolic blood pressure and fasting serum triglycerides were not significant discriminators . Statistical analyses directed to possible sources of bias occasioned by the combined retrospective- prospect i ve study design revealed that these problems are negligible and do not alter the findings observed . Type A score appears relatively unaffected by whether the measure was made before or after the initial CHD event . Multivariable discriminant function equations showed Type A score to be the strongest single predictor of recurrent CHD among the variables available . Number of cigarettes smoked and serum cholesterol accounted for additional variance . Future field trials for the secondary prevention of myocardial infa rct ion would be strengthened by consideration of the possible role of Type A behavior In a prospect i ve study of 7735 middle-aged men , both current and ex-cigarette-smokers had a risk of a major IHD event , within an average 6.2 years of screening , more than twice that in men who had never smoked cigarettes ; men who had given up smoking more than 20 years ago still had an increased risk . This excess risk among ex-smokers is only to a small extent explained by their higher blood pressure , serum total cholesterol , and body-mass index . An increased prevalence of IHD in men who had recently given up smoking also made a small contribution to excess risk . In both current and former cigarette smokers , the number of years a man had smoked cigarettes ( " smoking-years " ) was the clearest indicator of IHD risk due to cigarettes . The major benefit of giving up smoking may lie in halting the accumulation of smoking years OBJECTIVES The purpose of this study was to evaluate the clinical outcome of a large cohort of patients who suffered an acute myocardial infa rct ion with absolutely normal epicardial coronary arteries at the post-myocardial infa rct ion coronary angiogram .  The aetiological and prognostic factors in this population were also analysed . BACKGROUND Few data exist concerning the outcome , and aetiological and prognostic factors , of patients with myocardial infa rct ion and angiographically absolutely normal coronary arteries . METHODS Ninety-one patients ( 34 females/57 males ; mean age 50+/-13 years , range 24 - -78 years ) admitted with an acute myocardial infa rct ion had absolutely normal coronary arteries at the angiogram performed 6.2+/-4 days ( range 1 - -15 days ) after the myocardial infa rct ion , defined by smooth contours and no focal reduction ( NC ) . Of the 91 NC patients , 71 were evaluated prospect ively , alongside a systematic search of all aetiological factors reported in the literature . The NC patients were matched for age , sex , and the same period of myocardial infa rct ion onset with a group of 91 patients with coronary artery stenosis ( > 50 % diameter stenosis ) at the angiogram performed 7.3+/-4 days ( range 1 - -15 days ) after the myocardial infa rct ion ( SC ) . RESULTS The percent of smokers was similar between the two groups ; higher prevalence rates of coronary heart disease family history , obesity , hypertension , hypercholesterolaemia and diabetes mellitus were found in SC ( P=0.043 to 0.0001 ) . In NC , coronary spasm was found in 15.5 % , congenital coagulation disorders in 12.8 % , collagen tissue disorders in 2.2 % , embolization in 2.2 % , and oral contraceptive use in 1.1 % . Left ventricular ejection fraction at hospital discharge was higher in NC ( 60%+/-13 % ) than in SC ( 55%+/-13 % , P=0.04 ) . The mean follow-up was 35 months ( range 1 - -100 months ) . Kaplan-Meier event-free survival , with the combined end-point defined as death , reinfa rct ion , heart failure and stroke was 75 % in NC vs 50 % in SC ( P<0.0001 ) . Survival rate was 94.5 % in NC compared to 92 % in SC ( ns ) . Univariate predictors of events in NC were left ventricular ejection fraction ( P=0.03 ) , age ( P=0.02 ) , diabetes ( P=0.01 ) , and smoking ( P=0.03 ) . Using Cox multivariate analysis , independent predictors of long-term outcome in NC patients were left ventricular ejection fraction ( P=0.003 ) and diabetes ( P=0.004 ) . CONCLUSION Aetiological factors , predominantly coronary spasm and inherited coagulation disorder , can be detected in only one third of the patients with myocardial infa rct ion and absolutely normal coronary angiograms despite a systematic search in a prospect i ve population . Mortality rates are similar but morbidity is lower in myocardial infa rct ion patients with absolutely normal coronary angiography compared with those with coronary artery stenosis . The only two independent factors predictive of poor outcome in myocardial infa rct ion patients with normal coronary arteries are left ventricular function and diabetes The purpose of this study was to examine the effects of aspirin use on mortality and morbidity rates in a subset of the control group of the Program on the Surgical Control of the Hyperlipidemias ( POSCH ) that was stratified by cigarette smoking status at the time of r and omization . The clinical impact of aspirin intake in cigarette smokers and former cigarette smokers has not been well studied . POSCH was a r and omized , controlled , clinical trial design ed to ascertain the effects of lipid modification by the partial ileal bypass operation on clinical end-points and arteriographic changes in postmyocardial infa rct ion subjects with hypercholesterolemia . Cohorts of cigarette smokers in the diet-control group were evaluated for overall and atherosclerotic coronary heart disease ( ACHD ) mortality rates and recurrent confirmed nonfatal myocardial infa rct ion rates .  In current cigarette smokers at baseline ( n = 90 ) with a mean follow-up of 8.3 years , the overall mortality rate was 45.2 % in patients with no aspirin use and 10.4 % in patients who reported even infrequent aspirin use ( relative risk = 4.3 , 95 % confidence interval ( CI ) = 2.4 to 10.6 , p < 0.001 ) . For ACHD mortality in this cohort , the relative risk was 17.1 ( 35.7 % vs 2.1 % , 95 % CI = 1.4 to 125.0 , p < 0.001 ) ; for the combined end-point of ACHD mortality and nonfatal myocardial infa rct ion , the relative risk was 2.4 ( 40.5 % vs 16.7 % , 95 % CI = 1.2 to 5.1 , p = 0.018 ) . ( ABSTRACT TRUNCATED AT 250 WORDS The Recurrent Coronary Prevention Project ( RCPP ) was established as a 5-year clinical trial to examine two basic questions : --1 . Can the recurrence rate of post-coronary subjects be substantially reduced over a 5-year period by means of a programme of behavioural change , in comparison with treatment by cardiologists focussing on medication , diet , exercise and cardiovascular issues , and with subjects who only receive regular care from their own physician ? 2 . Can the Type A behaviour pattern ( TABP ) be changed and do such changes correspond to reduced recurrences of coronary heart disease ( CHD ) over a 5 year period ? To answer these questions , four major treatment groups are currently being compared : --1 . A small group treatment programme ( Section I ) led by cardiologists emphasizing adherence to medication , diet and exercise , and giving cardiovascular and cardiological information . 2 . A behavioural change treatment programme ( Section II ) based primarily on a cognitive social learning model and attempting to alter TABP . 3 . A control group of subjects assessed annually and receiving private medical care from their own physicians . 4 . A dropout comparison group composed of subjects voluntarily discontinuing participation in groups led by cardiologists or in behavioural change groups . Results to date show a significantly reduced rate of recurrence for subjects in the behavioural change group , compared to those in the groups led by cardiologists as well as control and dropout groups . These significantly lower recurrence rates are accompanied by data suggesting that subjects in the behavioural change programme are also altering their TABP as measured by both behavioural question naires and videotaped Type A structured interviews . Clinical impressions suggest that treatment programmes to alter TABP should consider the primary importance of the personal meaning of the TABP and other behaviours to the individual concerned , particularly how basic underlying beliefs set the stage for the TABP . The central role of hostility as a pervasive orientation towards self and others is emphasized , as are issues of excessive controllability related to extreme competitiveness and hyper-arousal . The multiple roles of group leaders , especially as social models for coping , and the impact of the small groups setting s , is also discussed Smoking is the most important modifiable risk factor for coronary heart disease and its reduction is a target for primary health care.1 The participants in most studies of the smoking habits of patients with coronary heart disease are enrolled after acute cardiac events.2 There are few documented studies of the changes in the smoking habits of patients with angina . This study examined variations in self reported smoking habits over a five year period in a primary care cohort of patients diagnosed as having angina . Patients clinical ly diagnosed as having angina at least six months previously were identified from the disease registers of 18 general practice s in the Greater Belfast area . These general practice s were chosen to A group of 456 consecutive patients seen less than or equal to 6 h after the onset of acute myocardial infa rct ion associated with ST segment elevation received thrombolytic therapy and were followed up for 12 months . Intravenous streptokinase was given to 315 patients and recombinant tissue-type plasminogen activator ( rt-PA ) to 141 patients . Reinfa rct ion rate and risk factors for reinfa rct ion were assessed . Management after thrombolysis was conservative ; revascularization procedures were reserved for patients with symptoms refractory to medical therapy or for those with left main coronary artery stenosis .  Coronary artery surgery or angioplasty was performed in only 3.7 % of patients during the first 30 days after thrombolysis and in only 8.6 % by 1 year . Most patients ( 79 % ) underwent coronary arteriography . Twenty-six patients ( 5.7 % ) exhibited signs of threatened reinfa rct ion at 1 month after thrombolytic therapy as did 43 patients ( 9.4 % ) by 1 year . Reinfa rct ion was prevented in four of these patients by early readministration of thrombolytic therapy . Multivariate analysis of possible risk factors for reinfa rct ion identified at the time of initial infa rct ion showed current cigarette smoking to be the only predictive factor ( reinfa rct ion occurred in 12.5 % of smokers versus 6.3 % of nonsmokers , p = 0.04 ) . A second analysis of risk factors identified 3 weeks after initial infa rct ion , including the severity of residual stenosis at coronary arteriography and exercise test variables , again showed continued cigarette smoking to be the only factor predictive of reinfa rct ion . Twenty percent of patients who continued to smoke developed reinfa rct ion compared with 5.1 % of those who stopped ( p less than 0.01 ) . ( ABSTRACT TRUNCATED AT 250 WORDS The impact of smoking cessation on coronary heart disease ( CHD ) and lung cancer was assessed after 10.5 years of follow-up in the 12,866 men in the Multiple Risk Factor Intervention Trial ( MRFIT ) . Those men who died of lung cancer ( n = 119 ) were either cigarette smokers at entry or ex-smokers ; no lung cancer deaths occurred among the 1,859 men who reported never smoking cigarettes . The risk of lung cancer for smokers , adjusted for selected baseline variables using a Cox proportional hazards model , increased as the number of cigarettes smoked increased ( B = 0.0203 , SE = 0.0076 ) . There was not the same grade d response for CHD among smokers at entry . The risk of CHD death was greater among smokers than nonsmokers ( RR = 1.57 ) ( B = -0.0034 , S.E. = 0.0048 ) . After one year of cessation , the relative risk of dying of CHD for the quitters as compared to non-quitters ( RR = 0.63 ) was significantly lower even after adjusting for baseline differences and changes in other risk factors . The relative risk for smokers who quit for at least the first three years of the trial was even lower compared to non-quitters ( RR = 0.38 ) . However , the relative risk for lung cancer for quitters versus non-quitters was close to 1 both for quitters at 12 months and at three years . These data support the benefits of cessation in relation to CHD and are consistent with other epidemiologic studies which suggest that the lag time for a beneficial effect of smoking cessation on lung cancer may be as long as 20 years Risk factors for major ischaemic heart disease ( acute myocardial infa rct ion or sudden death ) have been investigated in a prospect i ve study of 7735 men aged 40 - 59 years drawn from general practice s in 24 British towns . After a mean follow-up of 4.2 years , there have been 202 cases of major ischaemic heart disease . Univariate estimates of the risk of ischaemic heart disease show that serum total cholesterol , HDL-cholesterol and triglyceride concentrations , systolic and diastolic blood pressures , cigarette smoking , and body mass index are all associated with increased risk of ischaemic heart disease . Evidence of ischaemic heart disease at initial examination is also strongly associated with increased risk of subsequent ischaemic heart disease . All these factors were then considered simultaneously using multiple logistic models . Definite myocardial infa rct ion on electrocardiogram and recall of a doctor diagnosis of ischaemic heart disease remained predictive of subsequent major ischaemic heart disease , after allowance for all other risk factors . Serum total cholesterol , blood pressure , and cigarette smoking each remained as highly significant independent risk factors whereas overweight , above average levels of HDL-cholesterol and serum triglyceride were not predictive of risk after allowance for the above factors . Men with and without pre-existing ischaemic heart disease were examined separately in the same way ( using multiple logistic models ) . The strength of association between the principal risk factors and subsequent major ischaemic heart disease was reduced in the men with pre-existing ischaemic heart disease , only age and serum total cholesterol remaining highly significant . Overall the levels of the major risk factors commonly encountered in British men have a marked effect on the risk of ischaemic heart disease . Modification of these risk factors in the general population constitutes an important national priority The Norwegian Multicenter Group Study noted the effect of smoking habits before and after myocardial infa rct ion and their relation to mortality and reinfa rct ion rate after treatment with timolol in patients surviving acute myocardial infa rct ion . The mean follow up period was 17.3 ( range 12 - 33 ) months . No relation was found between initial smoking habits and risk category after infa rct ion or between initial smoking habits and later outcome . At the time of their first infa rct smokers were seven years younger than non-smokers . One moth after infa rct ion nearly 60 % of the smokers had stopped smoking completely . A significantly lower incidence of early cardiac death and lower total mortality was found in patients treated with timolol  in both those who continued smoking and in the combined non-smoking groups and a significantly lower reinfa rct ion rate among non-smokers . Cessation of smoking alone was associated with a reduced reinfa rct ion rate by 45 % but a non-significant reduction in mortality by 26 % . It is concluded that treatment with timolol and cessation of smoking have an additive effect in reducing mortality and reinfa rct ion rate after myocardial infa rct ion Objective : To determine the impact of an episode of serious cardiovascular disease on smoking behavior and to identify factors associated with smoking cessation in this setting . Design : Prospect i ve observational study in which smokers admitted to a coronary care unit ( CCU ) were followed for one year after hospital discharge to determine subsequent smoking behavior . Setting : Coronary care unit of a teaching hospital . Patients : Preadmission  smoking status was assessed in all 828 patients admitted to the CCU during one year . The 310 smokers surviving to hospital discharge were followed and their smoking behaviors assessed by self-report at six and 12 months . Intervention : None . Measurements and main results : Six months after discharge , 32 % of survivors were not smoking ; the rate of sustained cessation at one year was 25 % . Smokers with a new diagnosis of coronary heart disease ( CHD ) made during hospitalization had the highest cessation rate ( 53 % vs. 31 % , p=0.01 ) . On multivariate analysis , smoking cessation was more likely if patients were discharged with a diagnosis of CHD , had no prior history of CHD , were lighter smokers ( < 1 pack/day ) , and had congestive heart failure during hospitalization . Among smokers admitted because of suspected myocardial infa rct ion ( MI ) , cessation was more likely if the diagnosis was CHD than if it was noncoronary ( 37 % vs. 19 % , p<0.05 ) , but a diagnosis of MI led to no more smoking cessation than did coronary insufficiency . Conclusion : Hospitalization in a CCU is a stimulus to long-term smoking cessation , especially for lighter smokers and those with a new diagnosis of CHD . Admission to a CCU may represent a time when smoking habits are particularly susceptible to intervention . Smoking cessation in this setting should improve patient outcomes because cessation reduces cardiovascular mortality , even when quitting occurs after the onset of CHD UNLABELLED We assessed the effect of stopping smoking on future cardiac events ( cardiac death and non-fatal myocardial infa rct ion ( MI ) ) in 90 male smokers with previous MI by a prospect i ve follow-up study . At the time of enrollment , the patients were divided into 2 groups according to their current smoking status ( Group A : those who had stopped smoking ( n = 60 ) , and Group B : those who were still smoking ( n = 30 ) ) . Follow-up was performed prospect ively by annual postal question naires . During the mean follow-up period of 3.1 + /- 1.4 years , 13 cardiac events ( 11 cardiac deaths and 2 cases of non-fatal MI ) occurred in the 87 evaluable patients . The cardiac event rates in Groups A and B were 8.5 % and 28.6 % , respectively , and the relative risk was 3.4 ( Group A vs B , p less than 0.05 ) by univariate analysis . The relative risk using multivariate analysis ( Cox ) was also statistically significant ( 3.1 , p less than 0.05 ) . HDL-cholesterol was significantly lower in Group B than in Group A , but other coronary risk factors apart from smoking were not significantly different between the two groups . At the end of the follow-up period , 89.8 % of the patients in Group A remained nonsmokers and 21 % of the patients in Group B had stopped smoking . CONCLUSION Stopping smoking significantly reduced the risk of future cardiac events in male smokers with previous MI . This prospect i ve follow-up study demonstrated that a significant reduction in the risk of future cardiac events could be achieved by stopping smoking in this group of patients Data from 9740 Scottish men and women aged 40 - 59 years , selected at r and om in a population survey during 1984 - 86 , were used to compare self-reported smoking habits and biochemical measures of tobacco smoke inhalation in three groups : 625 with diagnosed coronary heart disease ; 1497 undiagnosed , but with suggestive question naire symptoms or electro-cardiographic signs ; and 7618 with no diagnosis or evidence of coronary disease , nor cardiovascular medication . Men and women with a diagnosis of coronary heart disease reported that they had tried to reduce their cigarette consumption or had quit more often than did the two comparison groups , but this effect was considerably greater in men than in women . Men in all groups had a higher cigarette quitting rate , but this may be due to switching to pipes and cigars . However , the biochemical measurement of tobacco smoke inhalation by cotinine showed that those with a coronary diagnosis had the highest overall levels of tobacco smoke inhalation , and the highest level of cotinine per self-reported cigarette , cigar , or ounce ( 30 g ) of pipe tobacco consumed . Self-reporting after a coronary diagnosis is consequently distorted , and an objective measure of smoke inhalation is to be preferred . In both sexes , particularly women , intake of tobacco products remains higher than that in the general population , whether or not it was even higher before they were diagnosed . Those responsible for continuing care of coronary patients need to be aware that health education and compliance are less effective in this group than they should be , both in male patients and , even more so , in women BACKGROUND Studies have shown that cigarette smokers constitute a substantial proportion of patients with acute coronary syndromes ( ACS ) and have platelet-rich coronary thrombi . We characterized the influence of smoking status on outcome of patients with ACS without persistent ST-segment elevation and tested the hypothesis that selective inhibition of the platelet glycoprotein IIb/IIIa receptor with eptifibatide would improve outcomes among cigarette smokers . METHODS The study population included patients enrolled in the PURSUIT trial ( Platelet Glycoprotein IIb/IIIa in Unstable Angina : Receptor Suppression Using Integrilin Therapy ) with known smoking status presenting with ischemic chest pain < /=24 hours and having either ischemic electrocardiographic changes without persistent ST-segment elevation or elevated creatine kinase MB levels . Patients were r and omly assigned to receive a bolus and infusion of either eptifibatide or placebo in addition to st and ard therapy . The primary end point was a composite of death or nonfatal myocardial infa rct ion within 30 days . RESULTS Of the 9406 patients with known smoking status , 2677 were current smokers , 3086 were former smokers , and 3643 were nonsmokers . Cigarette smokers had better 30-day outcomes ( 12.3 % , 16.8 % , and 15.4 % for smokers , former smokers , and nonsmokers , respectively ; P = .001 ) . However , after adjusting for differences in baseline clinical variables , smoking status was not a predictor of 30-day outcome ( P = .45 ) . There was a reduction in the composite end point overall with eptifibatide compared with placebo ( 14.3 % vs 15 . 7 % , P = .054 ) but no interaction between smoking status and treatment strategy ( P = .68 ) . CONCLUSIONS Among patients with ACS without persistent ST-segment elevation , cigarette smokers had better short-term outcomes because of their more favorable clinical profile . Although prior studies have suggested that smokers more commonly have platelet-rich thrombi than nonsmokers , eptifibatide did not result in more improvement in their outcome compared with former smokers or nonsmokers Background Smoking cessation decreases the risk for myocardial infa rct ion among people without previous coronary disease , but its effect on risk reduction after a first myocardial infa rct ion has not been well studied . Contribution The research ers retrospectively observed relative risk for recurrent coronary events in patients discharged from the hospital after an incident myocardial infa rct ion . Compared to nonsmokers , active smokers were 1.5 times more likely to have reinfa rct ion . Among persons who had stopped smoking , relative risk decreased gradually to the nonsmokers ' level over 36 months . Implication s Physicians should emphasize the proven benefits of smoking cessation to encourage patients to quit after a first myocardial infa rct ion . The Editors Smoking is a risk factor for coronary artery disease ( 1 ) . Among persons without coronary disease who quit smoking , the risk for incident coronary disease decreases and approaches that of nonsmokers within 2 to 3 years after cessation ( 2 , 3 ) . Some studies ( 4 - 17 ) show that quitting smoking after myocardial infa rct ion also seems to reduce the risk for adverse outcomes , including death . However , these studies of persons with established disease generally focused on men 65 years of age or younger , had limited information about possible confounding factors , did not evaluate the time course of the potential benefits of smoking cessation , and did not compare results to those in nonsmokers . In contrast to these studies showing a benefit of smoking cessation after myocardial infa rct ion , some evidence suggests that after infa rct ion , smokers may not have an elevated risk for recurrent events compared with never-smokers , a finding termed the smoker 's paradox ( 18 - 24 ) . We examined the association between smoking status and risk for recurrent coronary events and explored the time course of potential benefits of cessation in a large population -based inception cohort of persons who survived to hospital discharge after an incident myocardial infa rct ion . Methods Setting and Participants The study setting was Group Health Cooperative ( GHC ) , a health maintenance organization with more than 500 000 enrollees , based in western Washington State . The organization 's model of health care delivery is structured so that most routine care for enrollees , including care after myocardial infa rct ion , is provided by personal primary care physicians . Group Health Cooperative employs more than 300 primary care physicians and contracts with more than 500 other physicians . Eligible patients included all GHC enrollees who survived to hospital discharge after a first myocardial infa rct ion during the period from July 1986 ( women ) or July 1989 ( men ) through December 1996 . Patients with incident myocardial infa rct ion were identified by International Classification of Diseases , 9th revision , codes from the computerized discharge abstract s of the two GHC hospitals , bills for out-of-plan services provided by non-GHC physicians and health care facilities , and Washington State death records . A trained records abstract or , assisted by study physicians , vali date d the incident infa rct ions by review ing available inpatient medical records . Previous work ( 25 ) has confirmed the accuracy and completeness of the methods used for ascertainment of myocardial infa rct ion .  Persons were excluded if they were younger than 30 or older than 79 years of age at the time of the incident infa rct ion , had previously had a myocardial infa rct ion , had the incident infa rct ion as a result of surgery or another procedure , died before hospital discharge , or had no information available in the medical record after the incident infa rct ion . A total of 50 patients ( 1.8 % of the total otherwise eligible patients ) were discharged alive from the hospital but had no information in the chart after the incident infa rct ion . Persons were also excluded if they had made fewer than four visits to GHC or had been enrolled in GHC for less than 1 year before the incident infa rct ion . Among persons otherwise eligible for inclusion , 9.3 % were excluded because of inadequate duration of enrollment in GHC . Of the 2677 patients who were initially eligible , 58 were excluded because of indeterminate smoking status , leaving 2619 persons ( 97.8 % of the original cohort ) for analysis . The Human Subjects Review Committees of GHC approved the study . Smoking Status We identified smoking status on the basis of ambulatory care and inpatient records . The GHC ambulatory medical record is an important re source because it serves as the primary method of communication among GHC physicians . It includes not only notes from ambulatory care visits but also discharge summaries of hospitalizations , results of laboratory and diagnostic tests , consultant reports , responses to annual GHC health question naires , and up date d problem lists . Data collection included a review of the entire GHC ambulatory medical record for the period before the first infa rct ion , the period of hospitalization associated with the incident infa rct ion , and the period after the infa rct ion up to a predetermined date in 1996 , 1997 , or 1998 . Patients were classified as nonsmokers ( persons with no history of smoking in the medical record ) , former smokers ( persons who had smoked but had quit before the incident myocardial infa rct ion ) , quitters ( persons who were smoking at the time of the incident myocardial infa rct ion and quit after the infa rct ion ) , and active smokers ( persons who were smoking at the time of the incident myocardial infa rct ion and continued to smoke during follow-up ) . Only those persons who quit smoking after their incident infa rct ion and maintained cessation for the duration of follow-up were classified as quitters . Information about the quit date , number of cigarettes smoked per day , and duration of smoking over time was also recorded . Patients were closely monitored after the incident infa rct ion ; 97.6 % had a clinic visit within 3 months after hospital discharge , and the median number of visits ( physician , nurse , or emergency department visits or hospitalizations ) during the first year after the incident infa rct ion was 9 ( 25th , 75th percentiles : 6 , 14 ) . Clinical and Medication Covariates Trained research assistants review ed the ambulatory care and inpatient medical records to collect information about potential risk factors for coronary disease , such as use of health services ; marital status ; alcohol consumption ; body weight ; height ; and medical conditions such as hypertension , diabetes , and congestive heart failure . Congestive heart failure was determined to have occurred on the basis of the notes of the primary care physician and consultants and the results of diagnostic tests . Hypertension was defined as pharmacologically treated hypertension ; diabetes was defined as diabetes pharmacologically treated with oral hypoglycemic agents or insulin . In addition , laboratory values for r and om serum glucose , total cholesterol , and high-density lipoprotein cholesterol were recorded . Medication use was assessed at the time of hospital discharge after the incident infa rct ion by using information from the discharge summary supplemented with information from the first outpatient visit and the GHC computerized pharmacy data base . The status of the clinical and medication covariates was determined at the time of hospital discharge . Laboratory information was taken from the period before the incident infa rct ion . End Point The outcome of interest was recurrent coronary events , defined as nonfatal myocardial infa rct ion or coronary death . Information on these end points was obtained from the GHC ambulatory medical record , available inpatient records , and the results of matches between Washington State death records and GHC enrollment records . In patients with established coronary disease , if the underlying cause of death was heart disease , heart failure , or arrhythmia , the death was classified as a coronary death . Statistical Analysis Follow-up time began at the date of discharge from the hospital after the incident infa rct ion , and it extended to the date of the first recurrent infa rct ion , coronary death , or censoring . Persons were censored at the date of death from causes other than heart disease , the date of unenrollment from GHC , or the end of the assigned follow-up period . Cox proportional-hazards regression analysis with a time-dependent smoking status variable was used to model the association of smoking status and recurrent coronary events after adjustment for potential confounding factors ( 26 ) . A patient who quit smoking during hospitalization for the incident myocardial infa rct ion was classified as a quitter . For those who quit smoking after discharge , smoking status was modeled with person-years accrued initially as if the patient were an active smoker and then after cessation as if the patient were a quitter . To investigate the risk for recurrent coronary events in relation to the duration of smoking cessation , we divided follow-up time into four mutually exclusive categories of duration of cessation ( 0 to < 6 months , 6 to < 18 months , 18 to < 36 months , and 36 months ) . Because the underlying time scale used in the regression analysis was time since hospital discharge after the first myocardial infa rct ion , the Cox model adjusts for time since infa rct ion , enabling an assessment of the relationship of duration of cessation independent of time since infa rct ion . In addition , because most patients who quit smoking did so very soon after the incident infa rct ion , time since hospital discharge and time since cessation of smoking were similar for many quitters . To help discern whether the change seen among quitters in the hazard ratio over time was due to smoking cessation rather than to any other characteristic of smokers that changed over time after discharge , we also evaluated whether the coronary event hazard ratio among active smokers varied with time since infa rct ion . We calculated the unadjusted rates of recurrent OBJECTIVE To examine the relative effectiveness of three different presentations of a smoking cessation program on the smoking behavior of adults with cardiovascular health problems . DESIGN A 2 x 2 x 2 x 4 experimental design with stratification by sex , smoking history , and a cardiovascular event , and r and omization to Individual , Group , Written , or No Intervention groups . SETTING Six community hospital classrooms . SUBJECTS 255 nonhospitalized adults . THEORETIC FRAMEWORK : Interaction Model of Client Health Behavior . MEASUREMENTS Study Intake : Professional referral form , demographic question naire , smoking habits question naire , health history , perceived threat survey , perceived health status . Follow up : smoking cessation and health question naire , saliva thiocyanate testing .  RESULTS At 12-month follow-up , a  nurse-client interaction  was more effective than written self-help material s ; however , smoking cessation rates were highest in the No Intervention control group , possibly related to having had coronary artery bypass graft surgery . Variables positively related to quitting were being male and married and having a higher income . With baseline factors considered , a quitter was most likely to be male and less than 48 years of age , have a high degree of perceived threat relative to medical diagnosis , and be in the individual intervention group . Only partial support for the study hypotheses was found Through a multicenter registry of patients in the Coronary Artery Surgery Study , we prospect ively evaluated morbidity and mortality in 4,165 smokers with angiographically proved coronary artery disease , 2,675 of whom continued to smoke and 1,490 of whom quit .  At five years , mortality ( adjusted by Cox analysis for baseline differences ) was 22 % for those who continued smoking and 15 % for quitters . The relative risk ( also from the Cox analysis ) for mortality in continuers vs quitters was 1.55 ( 95 % confidence interval , 1.29 to 1.85 ) . The adverse effect of smoking mainly took the form of higher frequencies of myocardial infa rct ion -- associated death and sudden death : the frequencies of these events during follow-up in continuers vs quitters were 7.9 % vs 4.4 % for myocardial infa rct ion -- associated death and 2.8 % vs 1.5 % for sudden death . This study supports the recommendation that patients with coronary artery disease should stop smoking
target: REVIEW ER 'S CONCLUSIONS Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD .
  This 36 % risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years .
  The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events , age , sex , country , and time period .
background: BACKGROUND Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt , the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate .
  OBJECTIVES To estimate the magnitude of risk reduction when a patient with CHD stops smoking .