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Clinical implications of smoking relapse after acute ischemic stroke Furio Colivicchi, Andrea Bassi*, Massimo Santini, Carlo Caltagirone* Cardiovascular Department, S. Filippo Neri Hospital, Rome, ITALY *Clinical Research Institute, S. Lucia Foundation, Rome, ITALY
Background and Aim of the Study Cigarette smoking is a major risk factor for stroke and healthcare providers should advise every patient with stroke who has smoked in the past year to quit. However, smoking relapse is frequent, even after an admission for a major acute cardiovascular event. Aim of this study was to evaluate the smoking relapse rate among smokers who had become abstinent during admission for ischemic stroke. Moreover, the association between smoking relapse and mortality has also been analysed.
Study Population 921 consecutive active smokers who had completely interrupted smoking since admission for ischemic stroke (584 men and 337 women, mean age 67 ± 16 years) were followed for 12 months after the index event. All patients received a brief in-hospital smoking cessation intervention consisting of repeated counseling sessions lasting 5-20 minutes. No specific post-discharge support was used in any case. No pharmacotherapy for smoking cessation was prescribed in any case
Follow-up A follow-up period of 12 months after the index acute event was planned for all patients. The primary end point of the study was death from any cause within 12 months of discharge. Adherence to recommended lifestyle modifications, including smoking cessation, was assessed by telephone interviews at 1, 6, and 12 months after discharge. The interviews were conducted by a trained nurse. In the case of failure to interview the patient, all relevant data, including survival and smoking status, were collected from primary care physicians, who are responsible for clinical follow-up and prescription refilling in the Italian National Health Service.
Relapsed Smokers (%) Relapse curve showing the occurrence of smoking relapse in the study population. During the 12-month follow-up period 493 patients (53.5%) resumed regular smoking (median interval to relapse 21 days, interquartile range 10 to 84). Time (days)
Study Population Characteristics Total Cohort (n=921) Relapsed Smokers (n=493) Abstinent (n=428) Age (years) 67±16 69±16* 65±15 Women 337 (36%) 216 (44%)* 121 (28%) NIH stroke scale score 9.1±2.7 9.0±2.8 9.1±2.6 Obesity 189 (20%) 98 (20%) 91 (21%) Hypertension 634 (69%) 346 (70%) 288 (68%) Previous Stroke 103 (11%) 59 (12%) 44 (10%) Previous MI 167 (18%) 95 (19%) 72 (16%) Atrial Fibrillation 136 (14%) 74 (15%) 62 (14%) Heart Failure 84 (9%) 50 (10%) 34 (8%) CKD 106 (12%) 65 (13%) 41 (9%) * p<0.001
Smoking Cessation Interventions Total Cohort (n=921) Relapsed Smokers (n=493) Abstinent (n=428) Counseling delivered by nurse 672 (73%) 364 (74%) 308 (71%) Counseling delivered by physician 249 (27%) 129 (26%) 120 (29%) Hospital-based rehabilitation program after stroke 313 (34%) 123 (25%)* 190 (44%) * p<0.001
Smoking Relapse Predictors Independent predictors of relapse by multivariate analysis (Cox proportional hazard regression method): 1. Increasing age (HR 1.048 per year, 95% CI 1.021 to 1.074, p=0.02) 2. Female gender (HR 1.38, 95% CI 1.11 to 1.48, p=0.01) 3. Hospital-based rehabilitation program (HR 0.64, 95% CI 0.49 to 0.87, p=0.01)
12-month Outcome During the 12-month follow-up, 89 patients died (9.6%, 95% CI 4.9 to 8.8). Cardiovascular death in 79 patients (88.7%). Multivariate analysis with the Cox proportional hazard regression method, including smoking relapse as a timedependent covariate, demonstrated that after adjustment (demographics, clinical history, and variables related to the index event), resumption of smoke was an independent predictor of total mortality. An earlier smoking relapse was associated with a greater risk of death.
Multivariable adjusted hazard ratios over time (with horizontal bars representing the 95% confidence intervals) for the association between smoking relapse and all-cause mortality
Conclusions Smoking cessation programs using solely brief individual counseling without post-discharge followup may be associated with a high smoking relapse rate. Post-discharge rehabilitation reduces the risk of smoking relapse (36% RRR). Smoking relapse after ischemic stroke is associated with a significant increase in all-cause mortality. An earlier resumption imparts a greater risk of death compared to a later relapse of tobacco smoking.