Impact of Tobacco Smoking and Smoking Cessation on Cardiovascular Risk and Disease

Christopher Bullen


Expert Rev Cardiovasc Ther. 2008;6(6):883-895. 

In This Article

Smoking Cessation in Patients with Cardiovascular Disease

While cessation is an important disease-prevention strategy in smokers without established cardiovascular disease, smoking cessation in patients with known disease should be accorded the highest priority. Complete cessation of smoking offers the single best opportunity for improving cardiovascular health. As this review has highlighted, merely cutting down may not be sufficient to protect from acute cardiovascular events.[99]

Cessation is also more cost effective than any other preventive cardiology measure. For example, Lightwood estimated the cost for the typical treatment regimen of nicotine replacement therapy, providing gum or patch, and brief physician counseling to be in the range of US$2000–6000 per life-year saved compared with no treatment.[100] This compares very favourably with an estimated US$9000–26,000 cost per life-year saved for the treatment of moderate-to-severe hypertension, or US$50,000–196,000 for the treatment of hyperlipidemia in primary prevention.[101]

Unfortunately smoking cessation is not part of routine practice for many physicians. Tobacco smoking may be regarded simply as a ‘bad habit' or a ‘lifestyle choice' and not as a disorder of dependence requiring treatment. Clinicians may lack confidence in even asking patients if they smoke, let treating smokers, because they have not been trained to do so,[102] or they may claim to have insufficient time.

Without doubt, providing smoking cessation treatment is not easy. Tobacco dependence is a chronic relapsing condition and usually requires repeated interventions, including both pharmacotherapy and counseling, before successful long-term abstinence is achieved.[10] Many patients with cardiovascular disease are highly nicotine dependent, as evidenced by low quit rates seen in most studies of smoking cessation in such patients, even after major cardiovascular interventions.[103] Nevertheless, cardiovascular patients identified as smokers should be offered the most intensive smoking cessation interventions feasible at every visit or admission, including both counseling and pharmacotherapy.

Another argument that can be mounted for treating tobacco dependence quite aggressively in this population is that smoking can affect the action of other cardiovascular medications. For example, it speeds up the metabolism of flecanide and propranolol[104,105] and may lead to a poorer blood pressure response to nonselective β-blockers because of its combined α-and β-adrenergic agonist effects.

The pathophysiology of smoking-induced cardiovascular disease is useful to consider when treating smokers with established cardiovascular disease. For example, treatments that improve endothelial function (such as lipid-lowering drugs and excellent diabetes control) are likely to be especially beneficial in smokers. One might expect that antioxidants could also offer benefit. However, there is mixed epidemiologic evidence as to whether antioxidants protect against coronary heart disease.[106,107] A recent meta-analysis showed no evidence of benefit in preventing or treating patients with cardiovascular disease with antioxidants,[108] but the effect on smokers in particular has not yet been studied. In smokers with AMI one might expect that thrombolysis would be a better option than angioplasty. However, the results of both types of intervention appear to be similar in smokers.[8] Where a smoker who has had an AMI does not quit despite every effort, anticoagulant therapy such as long-term warfarin therapy may be beneficial, in addition to standard aspirin treatment, although there are as yet no empirical data to support this recommendation.[8] Smokers who continue to smoke following percutaneous coronary revascularization or coronary artery bypass graft surgery have a higher likelihood of re-occlusion after AMI and an increased risk of recurrent ischemia.[109] In this group, prolonged anticoagulation and lipid lowering may be even more important than in nonsmokers.[8]


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