Intensive Smoking Cessation Intervention

Reduces Mortality in High-Risk Smokers

With Cardiovascular Disease
Syed M. Mohiuddin, Aryan N. Mooss, Claire B. Hunter, Timothy L.
Grollmes, David A. Cloutier and Daniel E. Hilleman
Chest 2007;131;446-452
DOI 10.1378/chest.06-1587

The online version of this article, along with updated information

and services can be found online on the World Wide Web at:
http://chestjournal.org/cgi/content/abstract/131/2/446

CHEST is the official journal of the American College of Chest

Physicians. It has been published monthly since 1935. Copyright 2007
by the American College of Chest Physicians, 3300 Dundee Road,
Northbrook IL 60062. All rights reserved. No part of this article or PDF
may be reproduced or distributed without the prior written permission
of the copyright holder
(http://www.chestjournal.org/misc/reprints.shtml). ISSN: 0012-3692.

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

CHEST

Original Research
SMOKING CESSATION

Intensive Smoking Cessation

Intervention Reduces Mortality in HighRisk Smokers With Cardiovascular
Disease*
Syed M. Mohiuddin, MD, FCCP; Aryan N. Mooss, MD, FCCP;
Claire B. Hunter, MD; Timothy L. Grollmes, MPA; David A. Cloutier, BS; and
Daniel E. Hilleman, PharmD

Purpose: To compare an intensive smoking cessation intervention against usual care in hospitalized high-risk smokers with acute cardiovascular disease.
Methods: A total of 209 hospitalized smokers were randomized to the intensive intervention
(n 109) or to usual care (n 100). Usual care consisted only of counseling and printed
educational material provided prior to hospital discharge. Intensive treatment consisted of a
minimum of 12 weeks of behavior modification counseling and individualized pharmacotherapy
provided at no cost to the participant. Smoking status in all subjects was confirmed biochemically
(ie, by measuring expired carbon monoxide) at 3, 6, 12, and 24 months after randomization.
Outcomes included point prevalence and continuous abstinence smoking cessation rates, hospitalizations, and all-cause mortality.
Results: At each follow-up interval, point prevalence and continuous abstinence smoking
cessation rates were significantly greater in the intensive-treatment group compared to the
usual-care group. At 24 months, continuous abstinence smoking cessation rates were 33% in the
intensive-treatment group and 9% in the usual-care group (p < 0.0001). Over the 2-year
follow-up period, 41 patients in the usual-care group were hospitalized compared to 25 patients
in the intensive-treatment group (relative risk reduction [RRR], 44%; 95% confidence interval
[CI], 16 to 63%; p 0.007). The all-cause mortality rate was 2.8% in the intensive-treatment
group and 12.0% in the usual-care group (RRR, 77%; 95% CI, 27 to 93%; p 0.014). The
absolute risk reduction in mortality was 9.2% with a number needed to treat of 11.
Conclusion: Hospitalized smokers, especially those with cardiovascular disease, should undergo
treatment with a structured intensive cessation intervention. The duration of the initial treatment
should be 3 months.
(CHEST 2007; 131:446 452)
Key words: coronary artery disease; myocardial infarction; smoking
Abbreviations: ARR absolute risk reduction; CI confidence interval; RRR relative risk reduction

evidence clearly links smoking with

E pidemiologic
adverse outcomes in patients with manifest coronary heart disease.1,2 Patients who continue to
smoke after experiencing a myocardial infarction
have a 50% higher risk of recurrent coronary events
compared to nonsmokers.1 In patients who stop
*From the Creighton University Cardiac Center, Omaha, NE.
The authors have reported to the ACCP that no significant
conflicts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Manuscript received June 26, 2006; revision accepted September
12, 2006.

smoking after a myocardial infarction, the risk of

coronary events declines over time so that their risk
is equal to that of nonsmokers by 3 years after
smoking cessation.1
A number of different types of smoking cessation
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Daniel E. Hilleman, PharmD, Creighton
University Cardiac Center, 3006 Webster St, Omaha, NE 68131;
e-mail: [email protected]
DOI: 10.1378/chest.06-1587

446

Original Research

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

interventions have been evaluated in hospitalized

smokers. The efficacy of these interventions varied
widely with the intensity (ie, frequency and duration)
of patient contact being the strongest predictor of
success.318 Interventions delivered during hospitalization with only brief follow-up have not been
effective
in
increasing
smoking
cessation
rates.3,5,6,13,14,18 Interventions that included patient
contact after hospital discharge for 3 months were
associated with higher cessation rates compared with
usual care.4,712,1517
Despite the success of the higher intensity interventions in achieving smoking cessation, no structured cessation intervention has been shown to
reduce morbidity or mortality. The present study was
a randomized comparison of an intensive smoking
cessation intervention against usual care in smokers
hospitalized with acute cardiovascular disease designed to assess the impact of the intervention on
morbidity and mortality.
Materials and Methods
Patients
Patients aged 30 to 75 years who were admitted to the coronary
care unit at our university-affiliated teaching hospital with a
diagnosis of acute coronary syndrome or decompensated heart
failure were considered for participation in the study. Daily
smokers who had smoked for a minimum of 5 years with a
Fagerstrom score of 7 were eligible to participate.19 Smokers
were excluded if they did not speak and read the English
language. Patients with current alcohol or illicit substance addiction were excluded. The institutional review board of our university approved the study, and participants gave oral and written
informed consent.
Protocol
Prior to hospital discharge, all participants received counseling
(for approximately 30 min), during which unequivocal advice to
stop smoking was given. All participants received the self-help
materials Smart Move: A Stop Smoking Guide from the American
Cancer Society and You Can Quit Smoking (consumer version)
from the Agency for Health Care Policy and Research. This initial
inpatient counseling was standardized and was delivered by one
of the investigators. Eligible participants were asked to enroll in
the study. Consenting patients were then randomly assigned
using simple randomization without block assignment to the
intensive smoking cessation intervention or to usual care.
Smokers who were randomized to the intensive intervention
were asked to meet with a trained tobacco cessation counselor for
approximately 60 min on a weekly basis for a minimum of 3
months. Counseling sessions began the week after patients were
discharged from the hospital. Sessions were typically conducted
with groups of three to six smokers, although counseling for
individuals was used when logistically necessary. Counseling
sessions included behavior modification training, and focused on
relaxation training, contingency contracting, social support, coping skills training, stimulus control, and nicotine fading. In
addition, counseling regarding diet, exercise, and other risk factor
www.chestjournal.org

modification was provided. Smokers in the intensive-intervention

group were also provided with individualized adjuvant pharmacotherapy including nicotine replacement therapy and/or bupropion at no cost. Smokers randomized to the usual-care group
received no additional information beyond the initial inpatient
counseling session. All participants were seen at 3, 6, 12, and 24
months after study enrollment during which a follow-up medical
history was obtained and expired carbon monoxide levels were
measured. Participants were queried regarding smoking, health
status, hospitalization, and adverse clinical events. Participants
randomized to the intensive intervention who relapsed during the
2-year follow-up period were retreated as necessary if they
restarted smoking. Participants were prospectively tracked for
the development of acute coronary syndrome, stroke, coronary
revascularization procedures, hospitalization, and death.
Statistical Analysis
Baseline characteristics of the treatment groups were compared by analysis of variance for continuous variables and 2
analysis for categoric variables. Smoking cessation efficacy based
on an intention-to-treat analysis was reported as both pointprevalence and continuous abstinence rates. For point-prevalence rates, subjects were classified as abstinent if they had
reported not smoking during the previous evaluation period and
this was confirmed by a negative result for the measurement of
expired carbon monoxide. To be classified as continuously abstinent, smokers had to be confirmed as not smoking by their level
of expired carbon monoxide at every visit up to that point in the
study. Participants were dropped from being considered continuously abstinent after they had a positive test result at any point
in time.
Absolute risk reductions (ARRs) and relative risk reductions
(RRRs) were calculated. An RRR was defined as 1 (relative
risk). The number needed to treat to prevent one death over the
follow-up period was calculated as 1/ARR. Probabilities for the
difference in the RRR were calculated using the Fisher exact test.
Mortality and hospitalization functions were computed and compared using the Kaplan-Meier method and log-rank (MantelCox) tests, respectively. The influence of baseline patient characteristics on the outcomes of point prevalence and continuous
abstinence quit rates, mortality, and hospitalization were evaluated using logistic regression analysis. Data were presented as the
mean SD where appropriate. An a priori level of significance
of p 0.05 was considered to be statistically significant.

Results
During the enrollment period from January 2001
though December 2002, approximately 425 patients
who were self-identified current smokers and had
acute coronary syndrome or decompensated heart
failure were admitted to our coronary care unit. Of
these, 330 patients met the inclusion/exclusion criteria. These patients were approached concerning
participation in the study. Of these, 209 patients
agreed to participate in the trial.
A total of 109 smokers were randomized to receive
the intensive intervention and 100 smokers were
randomized to receive usual care. Baseline demographics and clinical characteristics of the two groups
are summarized in Table 1. The treatment groups
CHEST / 131 / 2 / FEBRUARY, 2007

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

447

Table 1Demographics and Clinical Characteristics of

the Two Treatment Groups*
Variables

Intervention Usual Care

(n 109)
(n 100) p Value

Age, yr
54.0 11.1 55.5 10.8
Gender
Male
75 (69)
56 (56)
Female
34 (31)
44 (44)
Ethnic background
White
91 (83)
70 (70)
African American
15 (14)
25 (25)
Latino
1 (1)
1 (1)
Native American
1 (1)
2 (2)
Other
1 (1)
2 (2)
Formal education, yr
10.5 5.4 10.9 5.6
Hospital admission diagnosis
Non-ST elevation ACS
52 (48)
48 (48)
(unstable angina)
Non-ST elevation MI
35 (32)
32 (32)
ST-elevation MI
13 (12)
12 (11)
Anterior
4 (4)
3 (3)
Inferior
9 (8)
9 (9)
Heart failure
9 (8)
9 (9)
Medical history
CAD
78 (72)
70 (72)
MI
14 (13)
15 (15)
Hypertension
29 (27)
31 (31)
CABG
11 (10)
10 (10)
PCI
24 (22)
24 (24)
Heart failure
12 (11)
13 (13)
Stroke
6 (6)
5 (5)
Diabetes
32 (29)
32 (32)
Arrhythmias
12 (11)
10 (10)
ICD
6 (6)
6 (6)
Pacemaker
8 (7)
9 (9)
Previous cancer
4 (4)
5 (5)
Hospital discharge medications
Aspirin/clopidogrel
98 (90)
93 (93)
-blocker
78 (72)
73 (73)
ACE inhibitor/ARB
80 (73)
76 (76)
Statin
71 (65)
63 (63)
Digoxin
21 (19)
20 (20)
Diuretic
37 (34)
36 (36)
Antiarrhythmic
12 (11)
10 (10)
Oral anticoagulant
20 (18)
21 (21)
LVEF
47 11
48 13
Duration of smoking, yr
33 12
34 11
Cigarettes smoked, No./d
26 14
22 12

0.32
0.08

0.03
0.06
1.00
0.61
0.61
0.88
0.97
0.98
0.95

0.80
0.924
0.803
0.583
0.982
0.507
0.818
0.889
0.792
0.991
0.878
0.853
0.895
0.583
0.938
0.785
0.859
0.894
0.868
0.991
0.758
0.882
0.536
0.03

*Values are given as the mean SD or No. (%). ACS acute

coronary syndrome; MI myocardial infarction; CAD coronary
artery disease; CABG coronary artery bypass graft;
PCI percutaneous coronary intervention; ICD implantable
cardioverter defibrillator; ACE angiotension-converting enzyme;
ARB angiotensin receptor blocker; LVEF left ventricular ejection fraction.

were generally well matched with regard to the

admitting diagnosis, medical history, left ventricular
ejection fraction, and hospital discharge medications.
There was significantly greater number of whites in
the intensive-intervention group compared to the
usual-care group (p 0.03). There was also a trend

toward a higher percentage of African-American

patients and women in the usual-care group compared to the intensive-treatment group, but these
differences did not achieve statistical significance.
Smokers in the intensive-treatment group smoked a
significantly greater number of cigarettes per day
than smokers in the usual-care group (p 0.03).
The point prevalence and continuous abstinence
smoking cessation rates for the two treatment groups
are summarized in Table 2. Five patients (4.6%) in
the intensive-treatment group and four patients
(4.0%) in the usual-care group were lost to followup. At the follow-up visits at which these patients
were lost to-follow-up, their data were included as
being positive for smoking. Patients in the intensivetreatment group had significantly higher quit rates
compared to patients in the usual-care group at all
follow-up time intervals for both point-prevalence
and continuous abstinence analyses. At the 2-year
follow-up, 39% of the intensive-treatment patients
were continuously abstinent compared to 9% of the
usual-care patients (RRR, 75%; 95% confidence
interval [CI], 67 to 84%; p 0.0001).
Point prevalence and continuous abstinent quit
rates were stratified by baseline patient characteristics (ie, ethnic background, gender, age, level of
education, and admitting diagnosis) to evaluate the
impact of these variables on the success of smoking
cessation. None of the patient characteristics, other
than assignment to treatment, had a significant effect
on the subsequent success rate for point prevalence
or continuous smoking cessation.
Smokers who were randomized to the intensivetreatment group attended 8.3 5.4 counseling sessions during their initial treatment after hospital
discharge. Adjuvant smoking cessation pharmacotherapy was used by 75% of our intensive-treatment
patients (bupropion, 7%; nicotine replacement ther-

Table 2Smokers With Biochemically Validated

Smoking Cessation*

Follow-up
Point prevalence
3 mo
6 mo
12 mo
24 mo
Continuous abstinence
3 mo
6 mo
12 mo
24 mo

Intervention
Group
(n 109)

Usual-Care
Group
(n 100)

p Value

75 (69)
65 (60)
51 (47)
43 (39)

15 (15)
15 (15)
12 (12)
9 (9)

0.0001
0.0001
0.0001
0.0001

75 (69)
60 (55)
43 (39)
36 (33)

15 (15)
13 (13)
11 (11)
9 (9)

0.0001
0.0001
0.0001
0.0001

*Values are given as No. (%), unless otherwise indicated.

448

Original Research

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

apy, 28%; combination, 40%) compared to only 17%

of usual-care patients (bupropion, 1%; nicotine replacement therapy, 5%; combination, 11%;
p 0.0001). At the 3-month visit, 34 patients in the
intensive-treatment group continued to smoke. Of
these, only four patients chose to repeat the treatment intervention. At the 6-month visit, 44 patients
in the intensive-treatment group were smoking.
Twelve patients elected to repeat the treatment
intervention. At the 12-month visit, 58 patients in the
intensive-treatment group were smoking. Twelve
patients elected to repeat the treatment intervention.
At the 24-month visit, 66 patients in the intensivetreatment group were smoking. Retreatment was not
offered to those smokers at that time interval. A total
of 28 smokers in the intensive-treatment group
elected to undergo repeat smoking cessation treatment with a mean of 6.2 9.8 counseling visits per
patient.
Over the 2-year follow-up, 25 patients (23%) in
the intensive-treatment group were hospitalized
compared to 41 patients (41%) in the usual-care
group (RRR, 44%; 95% CI, 16 to 63%; p 0.01)
[Fig 1]. Thirty-seven of the 41 hospitalizations in the
usual-care group (90%) were due to cardiovascular
causes compared to 20 of the 25 hospitalizations in
the intensive-treatment group (80%). Among patients in the usual-care group, cardiac hospitalizations included myocardial infarction in 17 patients,
unstable angina in 14 patients, cardiac arrhythmia in
2 patients, and decompensated heart failure in 4
patients. The noncardiac hospitalizations in the usualcare group were secondary to a diabetic foot infec-

tion complication in one patient, exacerbation of

COPD in two patients, and cancer treatment in a
fourth patient. In patients in the intensive-treatment
group, cardiovascular reasons for hospitalization included myocardial infarction in nine patients, unstable angina in eight patients, cardiac arrhythmia in
one patient, and decompensated heart failure in two
patients. Noncardiac reasons for hospitalization in
the intensive-treatment group included an exacerbation of COPD in three patients, pancreatitis in one
patient, and cancer treatment in one patient.
Over the 2-year follow-up period, 12 of the
usual-care patients (12%) died compared to 3 of
the intensive-treatment patients (2.8%; RRR,
77%; 95% CI, 27 to 93%; p 0.026) [Fig 2]. The
ARR in all-cause mortality was 9.2%. The number
needed to treat to prevent one death over the
course of the 2 years of follow-up was 11. All 3
deaths in the intensive-treatment group were due
to cardiovascular causes compared to 9 of the 12
deaths (75%) in the usual-care group. Of the three
noncardiovascular deaths in the usual-care group,
two were due to respiratory failure and one was
due to cancer.
Hospitalizations and deaths were stratified by
baseline patient characteristics including ethnic
background, age, gender, and admitting diagnosis.
Only age and assignment to a treatment group
significantly affected mortality and hospitalization
rates. Age was not significantly different between the
treatment groups, leaving assignment to a treatment
group as the only variable to significantly impact
clinical outcomes.

Figure 1. Effect of intensive smoking cessation treatment on

hospital admissions.

Figure 2. Kaplan-Meier curves of all-cause mortality in the

intensive-treatment and usual-care groups.

www.chestjournal.org

CHEST / 131 / 2 / FEBRUARY, 2007

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

449

Discussion
The results of our study demonstrate that an
intensive smoking cessation intervention in high-risk
smokers with cardiovascular disease is not only effective in achieving smoking cessation, but also
reduces hospitalizations and total mortality. This
study is the first to demonstrate the effectiveness of
a structured smoking cessation intervention in highrisk smokers with cardiovascular disease that not only
leads to a reduction in smoking but also to an
improvement in the rate of occurrence of adverse
clinical events. Several previous studies318 have
demonstrated the effectiveness of smoking cessation
interventions in reducing rates of smoking in hospitalized smokers, but none of these reported a reduction in morbidity or mortality.
In our trial, the initial treatment period over which
counseling sessions were conducted was 3 months,
with a provision for retreatment if patients relapsed.

Previously published studies evaluating smoking cessation interventions in hospitalized smokers have
found the duration of initial treatment to be closely
linked to the success of the intervention. Smoking
cessation interventions of brief duration or with
infrequent contact with smokers have generally been
no more effective than usual care. Sixteen randomized controlled trials318 evaluating smoking cessation interventions in hospitalized smokers have been
published since 1985 (Table 3).
Smoking cessation treatment significantly improved cessation rates in 10 of these trials.4,712,1517
The duration of treatment after hospital discharge
was 3 months in 9 of these 10 successful trials. In
one of these studies,8 the duration of post-hospital
discharge follow-up was only 1.5 months. In this
trial, which was conducted in the Netherlands at 11
different hospitals in 789 smokers, smoking cessation
was assessed only by self-report at 3 months. In the

Table 3Published Studies Evaluating Hospital Smoking Cessation Interventions*

Drug
Tx

BC
Validation

Rigotti et al3

CABG

87

Taylor et al4

MI

173

Stevens et al5

Hospitalized smokers

1,173

Reid et al6

Hospitalized CAD

254

Feeney et al7

MI

198

Bolman et al8

Hospitalized CAD

11

789

Simon et al9

Hospitalized smokers

223

Dornelas et al10

MI

100

Johnson et al11

Hospitalized CAD

86

Quist-Paulson and Gallefoss12

Hospitalized CAD

240

Hajek et al13

Hospitalized CAD

17

540

Rigotti et al14

Hospitalized smokers

650

Ockene et al15

Hospitalized smokers

261

Taylor et al16

Hospitalized smokers

660

Miller et al17

Hospitalized smokers

990

Strechen et al18

Hospitalized smokers

125

Study

Patient
Type

Hospitals,
No.

Patients,
No.

Duration of
Intervention
1 mo
(1 OP contact)
4 mo
(7 OP contacts)
1 mo
(1 OP contact)
2 mo
(3 OP contacts)
4 mo
(7 OP contacts)
11.5 mo
(1 OP contact)
4 mo
(6 OP contacts)
6 mo
(7 OP contacts)
3 mo
(5 OP contacts)
5 mo
(5 OP contacts)
1 mo
(0 OP contact)
1 mo
(2 OP contacts)
4 mo
(4 OP contacts)
3 mo
(4 OP contacts)
3 mo
(4 OP contacts)
1 mo
(0 OP contact)

Quit Rates,
%
51 vs 51
61 vs 32
14 vs 14
39 vs 36
39 vs 2
43 vs 34
33 vs 20
55 vs 34
46 vs 31
50 vs 37
41 vs 37
8.1 vs 8.7
35 vs 28
31 vs 21
27 vs 20
Not reported
(no difference)

*Tx treatment; BC biochemical; OP outpatient; positive; negative. See Table 1 for abbreviations not used in the text.
Treatment group vs control group.
Statistically significant difference in smoking cessation rate.
450

Original Research

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

six trials3,5,6,13,14,18 that failed to demonstrate the

statistically significant effect of the smoking cessation
treatment, the duration of post-hospital discharge
treatment was 1 month in five trials and was 2
months in the sixth trial.6
These studies confirm that smoking cessation interventions with a minimum intervention duration of
3 months following hospital discharge are associated
with a greater likelihood of success compared to
interventions of shorter duration. This is a welldocumented dilemma in providing treatment for
nicotine addiction. Intensive smoking cessation interventions are the most effective in terms of smoking cessation rates, but are also more expensive and
reach a smaller number of smokers. In contrast,
lower intensity smoking cessation interventions (eg,
self-help pamphlets or brochures) can reach a larger
number of smokers at a lower cost, but have lower
smoking cessation success rates.
Another unique aspect of our treatment protocol
was the provision of individualized smoking cessation
pharmacotherapy at no cost to the intensive intervention participants. Adjuvant pharmacotherapy was
used by 75% of the intensive-treatment smokers
(bupropion, 7%; nicotine replacement, 28%; combination, 40%) compared to only 17% of the usual-care
smokers (bupropion, 1%; nicotine replacement, 5%;
combination, 11%; p 0.0001). Of the 16 previously
published trials in hospitalized smokers, only 6 trials4,6,7,8,16,17 included nicotine replacement therapy
as a treatment option. None of these trials included
bupropion as a treatment option. Whether adjuvant
pharmacotherapy was provided at no cost to the
participants in these trials was not stated. It is
unknown what impact the availability of free medication had on the outcome of our study.
Structured smoking cessation treatment interventions have been shown to improve smoking cessation
rates when initiated in hospitalized cardiac patients.
These studies have not previously been shown to
reduce morbidity or mortality in these patients. Our
study demonstrates that a structured smoking cessation intervention administered to hospitalized smokers with cardiovascular disease reduces smoking as
well as clinical event rates and death. We think that
our results can be extrapolated to all patients who are
hospitalized with acute cardiovascular events. Obviously, smokers have to agree to receive treatment for
nicotine addiction. Whether similar results can be
obtained in patients identified in the outpatient
setting is unknown. During hospitalization has been
identified as an opportune time to intervene in
smokers.14 Success in hospitalized patients may be
due in part to the occurrence of an acute illness,
which may motivate patients to seek healthier lifestyles.
www.chestjournal.org

The major limitation of our trial is its relatively

small sample size, which limited our ability to perform multivariate analyses to adjust for the impact of
other factors on the study outcome. In addition, the
provision of adjuvant pharmacotherapy at no cost has
not been previously evaluated. It is unlikely that this
practice, outside of research environments, can be
readily adopted. Whether we could have achieved
the same outcomes if smokers had to purchase their
smoking cessation medications is unknown.
Smoking cessation treatment should be considered in the larger context of an integrated approach
to reducing health risks in the patient with cardiovascular disease. In patients with coronary heart
disease, antiplatelet agents, -blockers, renin-angiotension-aldosterone system-modulating drugs, and
statins have all been shown to reduce cardiovascular
mortality.20 When evaluated individually, these
classes of drugs have been associated with a risk
reduction for vascular events of approximately 25%.
The results our study suggest that smoking cessation
may be the most effective of all secondary prevention
measures in this population of patients.
The American College of Cardiology/American
Heart Association21 have indicated that smokers
recovering from acute coronary syndrome should
receive counseling along with pharmacologic therapy
(ie, nicotine replacement and bupropion) and formal
smoking cessation programs as appropriate. Our data
support this recommendation, with the further finding that a structured intensive smoking cessation
intervention with an initial treatment interval of 3
months be used.

References
1 Rea TD, Heckbert SR, Kaplan RC, et al. Smoking status and
risk for recurrent coronary events after myocardial infarction.
Ann Intern Med 2002; 137:494 500
2 Twardella D, Kupper-Nuybelen J, Rothenbacher D, et al.
Short-term benefit of smoking cessation in patients with
coronary heart disease: estimates based on self-reported
smoking data and serum cotinine measurements. Eur Heart J
2004; 25:21012108
3 Rigotti NA, McKool KM, Shiffman S. Predictors of smoking
cessation after coronary artery bypass graft surgery: results of
a randomized trial with 5-year follow-up. Ann Intern Med
1994; 120:287293
4 Taylor CB, Houston-Miller N, Killen JD, et al. Smoking
cessation after acute myocardial infarction: effects of a nursemanaged intervention. Ann Intern Med 1990; 113:118 123
5 Stevens VJ, Glasgow RE, Hollis JF, et al. Implementation and
effectiveness of a brief smoking-cessation intervention for
hospital patients. Med Care 2000; 38:451 459
6 Reid R, Pipe A, Higginson L, et al. Stepped care approach to
smoking cessation in patients hospitalized for coronary artery
disease. J Cardiopulm Rehab 2003; 23:176 182
7 Feeney GF, McPherson A, Connor JP, et al. Randomized
CHEST / 131 / 2 / FEBRUARY, 2007

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

451

10

11

12

13

14

controlled trial of two cigarette quit programmes in coronary

care patients after myocardial infarction. Intern Med J 2001;
31:470 475
Bolman C, de Vries H, van Breukelen G. Evaluation of a
nurse-managed minimal-contact smoking cessation intervention for cardiac patients. Health Educ Res 2002; 17:99 116
Simon JA, Carmody TP, Hudes ES, et al. Intensive smoking
cessation counseling versus minimal counseling among hospitalized smokers treated with transdermal nicotine replacement: a randomized trial. Am J Med 2003; 114:555562
Dornelas EA, Sampson RA, Gray JF, et al. A randomized
controlled trial of smoking cessation counseling after myocardial infarction. Prev Med 2000; 30:261268
Johnson JL, Budz B, Mackay M, et al. Evaluation of a
nurse-delivered smoking cessation intervention for hospitalized patients with cardiac disease. Heart Lung 1999; 28:
55 64
Quist-Paulsen P, Gallefoss F. Randomized controlled trial of
smoking cessation intervention after admission for coronary
heart disease. BMJ 2003; 327:1254 1257
Hajek P, Taylor TZ, Mills P. Brief intervention during
hospital admission to help patients to give up smoking after
myocardial infarction and bypass surgery: randomized controlled trial. BMJ 2002; 324:1 6
Rigotti NA, Arnsten JH, McKool KM, et al. Efficacy of a

15
16
17
18
19
20

21

smoking cessation program for hospital patients. Arch Intern

Med 1997; 157:26532660
Ockene J, Kristeller JL, Goldberg R, et al. Smoking cessation
and severity of disease: the coronary artery smoking intervention study. Health Psychol 1992; 11:119 126
Taylor CB, Miller NH, Herman S, et al. A nurse-managed
smoking cessation program for hospitalized smokers. Am J
Public Health 1996; 86:15571560
Miller NH, Smith RM, DeBusk RF, et al. Smoking cessation
in hospitalized patients: results of a randomized trial. Arch
Intern Med 1997; 157:407 415
Strecher VJ, Becker MH, Kirscht JP, et al. Evaluation of a
minimal-contact smoking cessation program in a health care
setting. Patient Educ Couns 1985; 7:395 407
Fagerstrom KO. Measuring degree of physical dependence to
tobacco smoking with reference to individualization of treatment. Addict Behav 1978; 3:235241
Smith SC, Allen J, Blair SN, et al. AHA/ACC guidelines for
secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update; endorsed by
the National Heart, Lung, and Blood Institute. Circulation
2006; 113:23632372
Antmann EM, Anbe DT, Armstrong PW, et al. ACC/AHA
guidelines for the management of patients with ST-elevation
myocardial infarction-executive summary. Circulation 2004;
110:588 636

452

Original Research

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians

Intensive Smoking Cessation Intervention Reduces Mortality in

High-Risk Smokers With Cardiovascular Disease
Syed M. Mohiuddin, Aryan N. Mooss, Claire B. Hunter, Timothy L. Grollmes,
David A. Cloutier and Daniel E. Hilleman
Chest 2007;131;446-452
DOI 10.1378/chest.06-1587
This information is current as of September 22, 2008
Updated Information
& Services

Updated information and services, including

high-resolution figures, can be found at:
http://chestjournal.org/cgi/content/full/131/2/446

References

This article cites 19 articles, 8 of which you can access

for free at:
http://chestjournal.org/cgi/content/full/131/2/446#BIBL

Open Access

Freely available online through CHEST open access

option

Permissions & Licensing

Information about reproducing this article in parts

(figures, tables) or in its entirety can be found online at:
http://chestjournal.org/misc/reprints.shtml

Reprints

Information about ordering reprints can be found online:

http://chestjournal.org/misc/reprints.shtml

Email alerting service

Receive free email alerts when new articles cite this

article sign up in the box at the top right corner of the
online article.

Images in PowerPoint format Figures that appear in CHEST articles can be

downloaded for teaching purposes in PowerPoint slide
format. See any online article figure for directions.

Downloaded from chestjournal.org on September 22, 2008

Copyright 2007 by American College of Chest Physicians