While all of us see patients who smoke in their 70s or 80s, due to their limited lifespan from COPD, DM, malignancy, etc., and their expressed wishes to continue tobacco, we keep our admonitions to a minimum. We accept our patient has become learned enough through life to make their own decisions and accept whatever fate has in store. We may disagree, but such is life. As I always say, patients are the pilots, and we are the co-pilots in their health journey.
But what of people under 50 years of age—hospitalized with a severe event related to tobacco? Do they see abstinence in a different light? Will they give up tobacco more readily when they appreciate decades of potential life ahead? As providers, we probably would say yes.
Even though we all cannot escape present bias, would the harms of the Marlboros or Camels be so omnipresent when a doc says, “If you don’t give up smoking, you risk cutting your life short and leaving your spouse and kids without help,” the pack of smokes would go automatically go in the trash can?
A new study out in JAMA attempts to answer that question. I was shocked.
Association of Smoking Cessation and Survival Among Young Adults With Myocardial Infarction in the Partners YOUNG-MI Registry
Question: Is smoking cessation associated with lower mortality among young adults after an initial myocardial infarction (MI)?
The study was a retrospective cohort analysis, and the investigators established smoking status at the time of presentation and one year later. The study population included ~2K individuals who had a MI at 50 years of age or younger between 2000-2016. The researchers used propensity score-adjusted Cox proportional hazards modeling to evaluate the link between smoking cessation and all-cause and cardiovascular mortality.
Not surprisingly, given the age of the cohort, many of the participants were smokers at the time of hospitalization (>50%). This cohort of 900 or so participants was further broken down into a persistent smoking (n=540) group and a cessation group (n=336) after one year following their MI. Those who quit smoking showed a statistically significant reduction in the rate of all-cause mortality (HR=0.35; 95% CI, 0.19 to 0.63; P?<0.001) and cardiovascular mortality (HR=0.29; 95% CI, 0.11 to 0.79; P=0.02). The associations remained statistically significant following propensity-score adjustment (HR=0.30; 95% CI, 0.16 to 0.56; P<0.001) for all-cause mortality and for cardiovascular mortality (HR=0.19; 95% CI, 0.06 to 0.56; P=0.003).
The hazard ratios make a persuasive case for kicking the habit. But I don’t think the patients needed to know the exact percentages. The only right answer is quit.
But how many of the group was still smoking at one year? You can do the math: 540/910 = 60%
That is jaw-dropping. I would have guessed the answer might be a third to a quarter.
Investigators pointed out their study had certain limitations. They included the retrospective nature of the analysis, inability to assess smoking status beyond 1 year of follow-up, and the possibility of unmeasured lifestyle factors impacting results. I will still take the findings as a massive blinking red light despite those weaknesses.
If you asked 100 thirty-year-olds in a room how many of them began to smoke AFTER the age of 21, I would bet you might see three to four hands go up. People continue to smoke not because they want to but because of nicotine, the 800-pound gorilla, and a host of social and economic factors (stress and life circumstances).
It’s not just about willpower–something I wrongly believed when I finished training. Think about it. Most people who have heart attacks DON’T WANT TO SMOKE ANY LONGER. They know the risks and they want to live a long life. The pull of tobacco is so great folks continue to use in the presence of the granddaddy and intimidator of them all: the heart attack. However, we do not see it as rational and as a result, we must recast how we view their world given we know little about it, as challenging as that might be.
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