(Author, Department, University,
Corresponding Address and email)
Abstract
Smoking is one of the most hated habits of the present generation. It affects almost every part of the body. Over 16 million people in the U.S. are living with some smoking-related disorder. Among the most important problems arising from smoking, include cardiac problems. Smoking is not only related to myocardial infarction, but smoking behavior could increase the chances of a second myocardial infarction, and these chances increase with increased smoking. Moreover, the number of deaths of people, who stopped smoking after CABG, within 20 years, was less as compared to persistent smokers, i.e. 46% and 64% respectively. On the other hand, survival of patients is prolonged, if they stop smoking after myocardial infarction. Patients of coronary heart disease, who go through PCI, could get approximately 2.1 more years to live after quitting smoking. This paper deals with the effects of smoking, its cessation, and affects of the cessation of smoking on the human body and coronary intervention.
Smoking harms almost every part of the body. It causes a number of health-related problems such as cancers, lung diseases, stroke, cataracts, and heart and blood related problems. One person’s smoking habit also affects the people in the surrounding; they breathe the smoke exhaled by smokers, and may get almost same problems as smokers can get. Estimates show that in 2014, almost 16.8% of adults (estimated 40 million adult people) having 18 years or more of age, smoked cigarettes. Cigarette smoking is among the leading causes of preventable diseases and deaths in the U.S. that is resulting in more than 450,000 deaths annually or about 20% of deaths. Over 16 million people in the U.S. are living with some smoking-related disorder (Centers for Disease Control and Prevention, 2015).
Smoking is one of the most important causes for coronary heart diseases, and risks of mortality are increased because of smoking. It is also an important changeable factor for an adverse prognosis. Research shows that smoking has strong relation to myocardial infarction as well as cardiac death in a population (van Domburg et al., 2000). The media and the government does not lack in providing information on the many untoward effects that smoking puts across. Yet millions of people in America still engage in this deadly vice.
The smoking correlates with instant perioperative morbidity as well as mortality (Voors et al., 1996). Most of the deaths caused by smoking are cardiac related. Some of the problems caused by smoking are myocardial infarctions, Coronary Artery Diseases, Acute Coronary Syndromes, and that are just to name a few. Alongside these medical conditions are costly cardiac interventions that require competent and well-trained cardiologist. Some interventions may go from least invasive such as medical treatment, percutaneous coronary interventions (PCIs) as, for example, percutaneous transluminal coronary angioplasty (PTCA), to the most invasive types like a coronary artery bypass graft (CABG) and revascularization.
On the other hand, cessation of smoking is helpful at any age. Moreover, smoking cessation may be associated with health benefits such as lowered risk for lung cancer and other types of cancer, reduced risk for heart disease, stroke, and peripheral vascular disease, reduced heart disease risk within 1 to 2 years of quitting, reduced respiratory symptoms, such as coughing, wheezing, and shortness of breath and many more. While these symptoms may not disappear, they do not continue to progress at the same rate among people, who quit in comparison with those who continue to smoke (Centers for Disease Control and Prevention, 2016). Considering these facts, it can also be said that smoking cessation could decrease the chances of subsequent mortality.
Background and Significance
Smoking is considered as one of the best modifiable risk factor that a patient may have after coronary artery disease intervention. An aim of this project is to know the trends and the smoking status of a patient after such coronary interventions. Has quality of life improved after quitting smoking? Have frequent hospitalizations been reported after procedure? The project also aims to find out amongst the ones that decided to quit, what smoking cessation techniques have helped them during the process.
An important significance of this project is to be able to yield results that show smoking cessation after coronary interventions will improve mortality rate and quality of life of these cardiac patients. This yields to finding the most effective ways to deliver smoking cessation education to patients. It makes room for more studies to find out what type of smoking cessation advice is effective.
This project could give light to the fact that not only nurses are solely the providers of smoking cessation education. The study may be able to explore on the different ways such as support groups, telephone interviews and one-on-one meetings that can aid someone in quitting smoking.
A person’s smoking status after surgery can almost predict the mortality rate of a patient. Smoking cessation is the single most effective action for secondary prevention of coronary heart disease and it significantly reduces the risk of mortality, re-hospitalization and re-occurrence after a coronary event.
Smoking cessation and prognosis for myocardial infarction
It has already been established that smoking behavior is related to myocardial infarction, especially in people having more than 50 years of age. Studies also showed that smoking behavior could increase the chances of a second myocardial infarction in women, and these chances increase with increased smoking. Estimated relative risk for myocardial infarction for smoking people was 2.9 as compared to non-smoking people. In patients of coronary disease, non-quitters have a relative risk of 1.5 for myocardial infarction as compared to quitters. Studies also showed that quitters after first myocardial infarction have only half the rate of nonfatal recurrences as compared to nonquitters. Similarly, the frequency of reinfarction is also reduced in quitters as found in a 10-year follow-up study (Voors et al., 1996).
Patients, who continue to smoke or who start smoking again after coronary bypass surgery have more chances of getting not only myocardial infarction but also recurrent angina pectoris and coronary bypass surgery as compared to patients, who stop smoking after surgery, and patients, who are not smokers. On a further note, the clinical outcomes after surgery of patients, who stop smoking after surgery, is same to that of nonsmokers (Voors et al., 1996).
Smokers have very less chances of remaining free from angina pectoris after 10 years as compared to non-smokers or quitters. Researchers also noted that started the smoking again or continuing smoking after coronary bypass surgery increase the chances of myocardial infarction and the need for coronary bypass surgery. Therefore, smoking cessation after coronary bypass surgery has beneficial effects in long-term cardiac morbidity (Voors et al., 1996).
Smoking cessation and prognosis after CABG
In a study, researchers worked on the relation of mortality with smoking stoppage following coronary artery bypass surgery. It was found that the number of deaths of people, who stopped smoking after CABG, within 20 years, was less as compared to persistent smokers, i.e. 46% and 64% respectively. A cardiac cause of death was observed in less number of quitters as compared to nonquitters, i.e. 62% and 68% respectively. Moreover, persistent smokers have higher chances of dying from all causes as compared to quitters. The smoking habit was found to be the strongest predictor of mortality. Cessation of smoking was also helpful in reducing the chances of further CABG. Repetition of the process of CABG was found in 27% of patients, who had quit smoking after first CABG, as compared to 31% of patients, who were persistent smoker even after the procedure. Similarly, repeat coronary artery revascularization was also more common among nonquitters as compared to quitters (van Domburg et al., 2000).
Researchers also performed a 30-year follow-up study and found that the life expectancy of patients is prolonged for about 3 years after they stop smoking after CABG within first year. Smoking cessation has shown greater benefits in decreasing the chances of mortality after CABG than any other treatment or intervention. The study showed that the mortality is reduced by about 38%, which is almost same or better than the secondary prevention treatments such as aspirin (showing 15% reduction), statins (showing 29% reduction), and angiotensin-converting enzyme inhibitors (showing 23% reduction) (van Domburg, op Reimer, Hoeks, Kappetein, & Bogers, 2008).
Research also shows that after one year of CABG, persistent smokers have two times more chances of getting myocardial infarction and going through reoperation as compared to patients, who stop smoking after surgery. Survival of patients is also prolonged, if they stop smoking after myocardial infarction (van Domburg et al., 2000).
Figure 1: Twenty-year survival from all causes curves for patients who quit smoking after CABG, persistent smokers after CABG and nonsmokers (van Domburg et al., 2000).
Smoking cessation and prognosis after percutaneous coronary intervention (PCI)
Studies are clearly showing that persistent smoking results in adverse long-term prognosis after percutaneous coronary intervention (PCI) (Cohen et al., 2001). Smoking cessation after percutaneous coronary angioplasty (PTCA) may improve clinical outcomes after the procedure, whereas persistent smokers, who continue smoking even after coronary intervention, have more chances of getting atherosclerosis of vein grafts as compared to nonsmokers (van Domburg et al., 2000).
In a study, researchers worked on the effect of smoking on prognosis in patients having PCI. They were of opinion that reductions in smoking or smoking cessation could help in reducing the chances of adverse effects in patients after PCI. Therefore, they worked on the effect of smoking before and after PCI. They found that smoking cessation whether after or before PCI is helpful for patients in all-cause mortality. Moreover, decrease in cigarettes by five cigarettes per day can reduce the mortality risk by about 72%, especially in persistent smokers (Chen, Li, Wang, Xu, & Guo, 2012).
In another study conducted on patients, who underwent PCI during 1980 to 1985, it was found that smoking cessation gives significant prediction about decreased mortality. Patients, who stopped smoking after PCI, had an estimated life expectancy of about 18.5 years, whereas persistent smokers had an estimated life expectancy of about 16.4 years. Therefore, patients of coronary heart disease, who go through PCI, could get approximately 2.1 more years to live after quitting smoking (de Boer et al., 2013).
It is important to note that smokers and nonsmokers going through the process of PCI are significantly different from each other. However, studies showed mixed results about repeated revascularization after PCI in smokers. Some studies are showing that smokers face less commonly repeated revascularization after the process of PCI as compared to nonsmokers, whereas other studies are either showing no significant association between restenosis and smoking, or showing elevated rates of frequent revascularization in smokers (Cohen et al., 2001).
Smoker’s paradox
Smoking increases the chances of acute myocardial infarction and death because of coronary artery disease. Although active smokers are found to have increased prevalence of acute coronary syndromes, but fibrinolytic therapy can help smokers in decreasing their mortality rate after acute myocardial infarction. This phenomenon is referred to as smoker’s paradox. Researchers reported that current smokers, after primary coronary intervention for acute myocardial infarction, have greater survival as compared to nonsmokers or former smokers. Moreover, reinfarction rates were lower in current smokers even after 1-year follow-up period. This showed the activity of smoker’s paradox in patients going through the process of primary coronary intervention for acute myocardial infarction (Weisz et al., 2005). It was also found that former smokers had a 20% reduction in the need for repeated revascularization during the 1st year of follow-up, whereas persistent smokers had 33% reduction (Cohen et al., 2001).
Researchers reported that improved prognosis in smoking patients of acute myocardial infarction after initial primary coronary intervention could be illustrated by noting the differences in baseline angiographic and clinical features. For example, active smoking patients having acute myocardial infarction were found to be 9 to 11 years younger as compared to nonsmoking patients. Moreover, smoking patients have lower rates of hypertension, diabetes mellitus and hyperlipidemia, which are considered as important factors affecting the longevity after acute myocardial infarction. On a further note, nonsmokers were more likely to be women (Cohen et al., 2001; Weisz et al., 2005).
Smokers also showed less chances of having a history of bypass surgery, but more chances of having a prior myocardial infarction. One possible mechanism behind the differences between smokers and nonsmokers is that smokers would be “less sensitive” to restenosis, and they are less likely to report angina. This is probably due to more prevalence of prior myocardial infarction or some other related factors in smokers, thereby treating their coronary artery and increasing the supply to infarcted and denervated areas (Cohen et al., 2001).
Application of smoking cessation to prolong life of patients
Some researchers such as Mohiuddin et al., (2007) have explored ways to compare a rigorous smoking cessation intervention against usual care in hospitalized high-risk smokers with acute cardiovascular disease. However, presently available management strategies for smoking cessation in patients with coronary heart disease are not sufficient and are not able to convince patients to stop smoking, particularly, if the patient is in outpatient setting. Thoughts about smoking cessation are especially strong at the time of diagnosis of atherothrombotic cardiovascular disease such as an acute myocardial infarction, and in association with an invasive treatment such as CABG or vascular surgery (van Domburg et al., 2008).
Healthcare workers and policy makers can use social support, and work on the smoking cessation strategies, particularly, when the patient has been hospitalized after acute myocardial infarction, CABG, and vascular surgery. This strategy could help in prolonging the life of patients by about 3 years, and chances of prolongation of life are highest if the cessation programs are started immediately after coronary intervention (van Domburg et al., 2008).
According to researchers, “Cigarette smoking continues to be the leading cause of preventable morbidity and mortality in the United States. Full implementation of population-based strategies and clinical interventions can educate adult smokers about the dangers of tobacco use and assist them in quitting. In 2008, adults aged ≥25 years with lower educational achievement had the highest prevalence of smoking. Adults with education levels at or below the equivalent of a high school diploma, who comprise approximately half of current smokers, had the lowest quit ratios (2008 range: 39.9% to 48.8%).” (1232) (Dube, Asman, Malarcher, & Carabollo, 2009).
Smoking entrenched a risk factor for coronary artery disease in both men and women. On the review of Health Benefits of Smoking Cessation, a general surgeon stated that smoking cessation decreases the risk of both subarachnoid hemorrhage and stroke compared to a person who continues to smoke. It is important for patients, who are smokers, to know the importance of quitting now before it is too late to realize that he or she had gotten cancer or some heart disease.
Usually, teenagers start smoking, often to impress others, and get addicted as they reach adulthood. There are also some other reasons that need to be addressed as to why people start to smoke. An addiction has set many smokers in red flags for their health. Their results from smoking are irreversible. The vital part of smoking cessation is to provide ten times more educational teachings to help increase non-tobacco use. Some states increased their prices on pack of cigarettes and it is intriguing that smokers still buy them even if the price has increased. Although there are smoking-cessation-pamphlets that are given in the physicians’ office, but most patients ignore them and they end up in the trash. The easier way to get smoking cessation recognized is to be consistent with the teachings we are giving to the patients and to alarm them with the major consequences that they would face in the future.
Historical and Societal Perspective
According to the University of Dayton, “Tobacco is a plant that grows natively in North and South America.” Tobacco growth began in six-thousand B.C. In 1760, Pierre Lorillard established a tobacco processing company in the New York, and now the company is the oldest tobacco company in the U.S. By the mid of the nineteenth century, chewing tobacco was most popular in the U.S. especially among the “cowboys”. In 1913, “Camel”, a cigarette brand, was introduced in the market, and by the year 1923, Camel handled about 45% of the U.S. market. In the year 1939, American Tobacco Company introduced “Pall Mall”, a new brand, that made the company the biggest company in the U.S. In the year 1964, General Surgeon’s report on “Smoking and Health” came out. This was the time when health hazards of smoking were proclaimed (Randall, 1999).
In today’s society, many people choose to smoke in various ways, whether it is a vaporizer or just a simple cigarette. Some states and cities have banned smoking in various areas to prevent second hand smoking. Smokers do not realize the effects they have on people around them while they smoke. Even if they are not smoking, the smell of the tobacco lingers in their clothes, hair, shoes, and in their body and causes harms to kids. A study by Cherukkupalli (2015) stated, “taxation estimate external costs of tobacco use to be low and refrain from recommending large tobacco taxes” (609). Psychological behaviors have a great impact in smoking. Society plays a big role in the tobacco industry. With the commercials and ads that are being shown, tobacco is perceived to be a great habit as advertised. Advertising plays a big role in inviting nonsmokers to smoke. As others watch tobacco advertisements, it causes the audience to see how approving the people look with the cigarette in their mouths.
According to the Global Health Observatory data (GHO), “In 2012, 21% of the global population aged 15 and above smoked tobacco. Men smoked at five times the rate of women; the average rates were 36% and 7% respectively. Smoking among men was highest in the WHO Western Pacific Region, with 48% of men smoking some form of tobacco. Smoking among women was highest in the WHO European Region at 19%.” (World Health Organization, n.d.)
Healthcare Costs and Burdens
Smoking cessation and prognosis after coronary intervention require the provision of intensive counseling, advice, pharmacotherapy, as well as follow-up contact after discharge from hospital. Most of the patients, who quit smoking during their hospitalization are found to have less chances of rehospitalization or to die during their follow-up. However, still many hospitals are unable to provide smoking cessation interventions, partially due to issues about the perceived costs of the programs. Moreover, economic burden of continued smoking to the hospital administration and system is large. Smoking cessation is one of the cost effective strategies in reducing the burden on hospitals, and Medicare is also providing reimbursements for smoking cessation counseling (Black, 2010). A study shows that the costs related to acute myocardial infarction (AMI), heart failure (HF), unstable angina (UA), and chronic obstructive pulmonary disease (COPD) can be reduced by about 0.20% by providing intervention to smokers (Mullen et al., 2014). Study shows that reduced hospitalizations as a result of smoking cessation after AMI could help in saving about $22.1 million in reduced hospitalizations. Moreover, productivity costs as a result of premature death would also decrease by $1.99 billion in a 10-year period (Ladapo, Jaffer, Weinstein, & Froelicher, 2011).
Evidence of support for APRN’s role in solutions
An advanced practice registered nurse (APRN) can help in reducing the smoking habits of patients, thereby helping in reducing not only the burden on hospitals and economy, but also helping in reducing mortality rates. They can help in providing optimal long-term care after PCI, i.e. they can provide help in pharmacotherapy and lifestyle changes including smoking cessation (Stone & Aronow, 2006). Nurse counselors having a good level of experience in every aspect of nicotine dependency as well as smoking cessation can help in improving posthospitalization quit rates and cardiac program performance (Reid, Pipe, & Quinlan, 2006). In a randomized controlled trial, it has been reported that the smoking patients for AMI, UA, and coronary bypass surgery were admitted to a hospital. They were allocated to an intervention led by nurses. The intervention was initiated in hospital and included personalized telephone follow-up for more than five months with one clinic visit at 6 weeks. The intervention was developed on the basis of a booklet emphasizing the healthy outcomes of quitting smoking after some coronary events, focusing on fear arousal, and advising the use of prevention methods including the nicotine replacement therapy. Researchers found that smoking cessation rates were high in patients (Fonteyn, 2004). These studies and literature is clearly showing that nursing support is very helpful in improving health outcomes and decreasing the risk of new cardiac event, thereby decreasing mortality rates in cardiac rehabilitation patients (Καδδά, Μαρβάκη, & Παναγιωτάκος, 2014).
Foundation of PICOt
The PICOt format helps in summarizing the research problem in which the effect of a therapy or intervention is explored. In this format, a specific population is considered for study undergoing through a particular intervention or treatment. This population is then compared to a reference, comparison, or control group and the outcomes are considered in the question to check the efficacy of the intervention. Last but not the least, time for the duration of the data collection is mentioned or described in the question (Riva, Malik, Burnie, Endicott, & Busse, 2012). Therefore, PICOt question for the study is "In patients after underdoing percutaneous coronary intervention what is the trend and predictions of smoking cessation in decreasing mortality rate as compared to people not going through percutaneous coronary intervention?"
Appendix
Black, J. H. (2010). Evidence base and strategies for successful smoking cessation. Journal of vascular surgery, 51(6), 1529-1537.
Centers for Disease Control and Prevention. (2015). Current Cigarette Smoking Among Adults in the United States. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
Centers for Disease Control and Prevention. (2016). What You Need to Know About Quitting Smoking. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/
Chen, T., Li, W., Wang, Y., Xu, B., & Guo, J. (2012). Smoking status on outcomes after percutaneous coronary intervention. Clinical cardiology, 35(9), 570-574.
Cherukupalli, R. (2010). A Behavioral Economics Perspective on Tobacco Taxation. American journal of public health, 100(4), 609-615. doi: 10.2105/ajph.2009.160838
Cohen, D. J., Doucet, M., Cutlip, D. E., Ho, K. K., Popma, J. J., & Kuntz, R. E. (2001). Impact of Smoking on Clinical and Angiographic Restenosis After Percutaneous Coronary Intervention Another Smoker’s Paradox? Circulation, 104(7), 773-778.
de Boer, S. P., Serruys, P. W., Valstar, G., Lenzen, M. J., de Jaegere, P. J., Zijlstra, F., . . . to, I. c. o. t. T. (2013). Life-years gained by smoking cessation after percutaneous coronary intervention. The American journal of cardiology, 112(9), 1311-1314.
Dube, S., Asman, K., Malarcher, A., & Carabollo, R. (2009). Cigarette smoking among adults and trends in smoking cessation-United States, 2008. Morbidity and mortality weekly report, 58(44), 1227-1232.
Fonteyn, M. E. (2004). A nurse led smoking cessation intervention increased cessation rates after hospital admission for coronary heart disease. Evidence Based Nursing, 7(2), 46-46.
Καδδά, Ό., Μαρβάκη, Χ., & Παναγιωτάκος, Δ. (2014). The role of nursing education after a cardiac event.
Ladapo, J. A., Jaffer, F. A., Weinstein, M. C., & Froelicher, E. S. (2011). Projected cost-effectiveness of smoking cessation interventions in patients hospitalized with myocardial infarction. Archives of internal medicine, 171(1), 39-45.
Mohiuddin, S. M., Mooss, A. N., Hunter, C. B., Grollmes, T. L., Cloutier, D. A., & Hilleman, D. E. (2007). Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk Smokers With Cardiovascular Disease. Chest, 131(2), 446-452
Mullen, K.-A., Coyle, D., Manuel, D., Nguyen, H. V., Pipe, A. L., & Reid, R. D. (2014). Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada. Tobacco control, tobaccocontrol-2013-051483.
Randall, R. V. (1999). History of Tobacco. Retrieved from http://academic.udayton.edu/health/syllabi/tobacco/history.htm
Reid, R. D., Pipe, A. L., & Quinlan, B. (2006). Promoting smoking cessation during hospitalization for coronary artery disease. Canadian Journal of Cardiology, 22(9), 775-780.
Riva, J. J., Malik, K., Burnie, S. J., Endicott, A. R., & Busse, J. W. (2012). What is your research question? An introduction to the PICOT format for clinicians. J Can Chiropr Assoc, 56(3), 167-171.
Stone, G. W., & Aronow, H. D. (2006). Long-term care after percutaneous coronary intervention: focus on the role of antiplatelet therapy. Paper presented at the Mayo Clinic Proceedings.
van Domburg, R. T., Meeter, K., van Berkel, D. F., Veldkamp, R. F., van Herwerden, L. A., & Bogers, A. J. (2000). Smoking cessation reduces mortality after coronary artery bypass surgery: a 20-year follow-up study. Journal of the American College of Cardiology, 36(3), 878-883.
van Domburg, R. T., op Reimer, W. S., Hoeks, S. E., Kappetein, A. P., & Bogers, A. J. (2008). Three life-years gained from smoking cessation after coronary artery bypass surgery: a 30-year follow-up study. American heart journal, 156(3), 473-476.
Voors, A. A., van Brussel, B. L., Plokker, H. T., Ernst, S. M., Ernst, N. M., Koomen, E. M., . . . Vermeulen, F. E. (1996). Smoking and Cardiac Events After Venous Coronary Bypass Surgery A 15-Year Follow-up Study. Circulation, 93(1), 42-47.
Weisz, G., Cox, D. A., Garcia, E., Tcheng, J. E., Griffin, J. J., Guagliumi, G., . . . Aymong, E. (2005). Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction—the smoker's paradox revisited. American heart journal, 150(2), 358-364.
World Health Organization. (n.d.) Prevalence of tobacco use. Retrieved from http://www.who.int/gho/tobacco/use/en/
