Smoking Still Common, Tied to Higher Mortality in Young MI Patients

Among young patients who experience MI, slightly more than half are smokers and about two-thirds don’t quit following their event, according to new data from two large Boston hospitals. The findings, researchers say, highlight a significant opportunity for both prevention and better quality of life.

“Generally, if I ask . . . an average clinician what percentage of patients who have an MI under the age of 50 are smokers, I think a lot of people would say 20%, 30%. But finding here that it's actually 50% is really amazing,” senior author Ron Blankstein, MD (Brigham and Women’s Hospital, Boston, MA), told TCTMD. “It's a much higher number than most people realize: that essentially one in every two people that have an MI at a young age are tobacco smokers.”

The results from the YOUNG-MI registry show “that we have an enormous opportunity to do a better job at helping individuals who have an MI at a young age to quit smoking,” he continued. “The fact that 60% are still smoking is simply too high. Not only is it a high number, but if we now look at the outcomes of these individuals, we see that they fare far worse.”

Essentially one in every two people that have an MI at a young age are tobacco smokers. Ron Blankstein

Quinn R. Pack, MD (Baystate Health, Springfield, MA), who commented on the study for TCTMD, said that compared with most other therapies in cardiology, smoking cessation “just takes the cake.”

Quitting smoking is more potent than taking statins, participating in cardiac rehab, and even undergoing bypass surgery, he said. “Same thing with stents, ACE inhibitors, and beta-blockers. Help one person quit smoking, and you could probably do five bypass surgeries for the same effect. So the size of the impact is just remarkable. And the good news in that is that if you're a 40-year-old smoker who has a heart attack and you quit, there's a really good chance that if you do everything right, you'll never have another heart attack.”

Worse Mortality Outcomes

For the study, published online yesterday ahead of print in JAMA Network Open, David W. Biery, AB (Brigham and Women’s Hospital), along with Blankstein and colleagues, looked at 2,072 consecutive patients age 50 or younger (median 45 years) who were hospitalized for MI at Massachusetts General Hospital or Brigham and Women’s Hospital between January 2000 and April 2016. In total, 52.5% were self-reported smokers at the time of their event and 62.3% of those who survived to 1 year remained smokers.

Over a median follow-up period of 11.2 years, the death rate was numerically higher among smokers than nonsmokers (13.3% vs 9.0%; P = 0.08). In a Cox proportional hazard model, those who quit smoking had significantly lower rates of all-cause (HR 0.35; 95% CI 0.19-0.63) and cardiovascular mortality (HR 0.29; 95% CI 0.11-0.79) than those who continued to smoke. The results were similar in a propensity-matched analysis of 309 patients each who quit or continued smoking.

Blankstein said there were no temporal differences in smoking or cessation rates over the study period. These data don’t include e-cigarettes, which likely have increased in use over the last few years, he said.

Given that the Kaplan-Meier curves for mortality continue to separate over time, “the way I think of it is you can show these figures to a patient who just had a heart attack at a young age and say, ‘Okay, you can choose now. If you quit smoking, you're on this curve, and if you continue to smoke, you're on this much steeper curve with a lot more events,’” Blankstein said. “To me, there's a really important opportunity to share this data with individuals who have an MI and reinforce how enormous the benefit is of quitting [smoking] on the day you have your heart attack.”

But the onus of quitting doesn’t belong solely to patients, he added. “All of us as a healthcare system need to think how we can do better in terms of providing better counseling and better maybe options to help with cessation.”

Using the ‘Teachable Moment’

The take-home message from this study, according to Pack, is that there is “obviously an enormous performance gap” in successful smoking cessation following MI. “It's a place where, as a medical society, we are failing to help our patients,” he said, adding that the institutions participating in this study have robust smoking cessation programs. “If they're only managing to pull a 40% 1-year quit rate, can you imagine a small hospital that doesn't emphasize this? It'll be worse. I think this really emphasizes the tremendous opportunity that hospitals have to really make a difference for their patients.”

Help one person quit smoking, and you could probably do five bypass surgeries for the same effect. Quinn Pack

It has long been known that many MI patients in the United States aren’t targeted for smoking cessation, said Pack. “We know that there are medications that really do work for these patients, and we know from this study that smoking cessation makes a huge difference in someone's prognosis. So, my opinion is that every patient should be offered medications and, if at all interested, be prescribed medications to help them quit smoking. There are some patients who refuse and that's fine, that's nothing I can change, but with even just a few minutes of counseling, most of the smokers I talk to are interested in medications.”

Blankstein said the healthcare community is “very good generally” at evaluating patients and starting medications such as lipid-lowering therapies or antiplatelet treatments, but smoking cessation therapies are more important. “When patients have their MI, it is a teachable moment to go over this,” he said. “If you ask people at the time of their MI, a lot of people say, ‘Yes, I'm done smoking. I just had a heart attack.’ But some folks will relapse, and I think continued contact with the patients and continued effort that extends beyond the hospital are key here. A simple conversation at the time of your MI is not going to be sufficient.”

He tells patients that all of the medications they are asked to take post-MI are important, but “if you take the effect of all the medicines that are in your bag . . . quitting [smoking] is more important than all of these put together.” Conveying the risk and educating patients is step one, Blankstein added, but providing them resources like connections to counseling and pharmacotherapy needs to happen as well. “We really need to come up with what I call multipronged approaches to make sure we do a better job as a healthcare system in ensuring that patients remain tobacco free after their MI.”

Smoking and Coronavirus

In light of recent events, Blankstein acknowledged that in theory, smoking can be triggered by stressful situations like the global COVID-19 pandemic. However, “I don't think that people who are stressed, even in the midst of a pandemic, will just take up smoking because they're stressed—they're more likely to not eat well and not exercise and other things,” he said. “But if somebody's actually trying to quit, which requires social support and other resources, perhaps it would be more difficult when times are tough like now.”

Additionally, Blankstein noted that data have shown that smoking is a risk factor for worse complications in people that have COVID-19.

“There is some evidence that smoking is a risk factor for contracting coronavirus, and it is certainly a risk factor for having a worse outcome with coronavirus,” Pack added. “So I think that will help smokers be more motivated to quit. . . . But at the same time, as I have talked with smokers and I've had my ear to the ground, my sense is that the stress of coronavirus and a lot of the isolation has probably made it harder for most people to quit. They're home alone with nothing to do and they're bored, but they still have their cigarettes.”