Author + information
- Electrophysiology Section of the Knight Cardiovascular Institute, Oregon Heath & Science University, Portland, OregonElectrophysiology Section of the Knight Cardiovascular Institute, Oregon Heath & Science University, Portland, Oregon
- ↵∗Address for correspondence:
Dr. Eric C. Stecker, Oregon Health & Science University, Electrophysiology Section, Knight Cardiovascular Institute, UHN-62, 3181 SW Sam Jackson Road, Portland, Oregon 97239.
“…when the only thing at stake is the tissue-thin difference between a thing done well and a thing done ill.”
—John Updike, Hub Fans Bid Kid Adieu (1)
Counseling individual patients to quit smoking is a low-yield endeavor. Physician encouragement and support only results in long-term abstinence 1 of 20 times (2). For this and other reasons, the average cardiovascular specialist does a poor job addressing smoking cessation, even among patients with the greatest potential benefit from quitting (3–5).
But, these statistics do not obviate the fact that smoking is a critical threat to our patients’ health: smoking remains the leading cause of preventable death in the United States; smoking confers a disproportionately high burden of ill health on disadvantaged groups; smoking is second only to hypertension as a leading cause of cardiovascular mortality in the United States; and smoking leads to myriad adverse health outcomes that are highly relevant to a broad range of cardiovascular specialists (6–9).
In this issue of the Journal, Palmer et al. (10) present further evidence of the cardiovascular risk posed by smoking and the benefits offered by smoking cessation. They conducted a population-based analysis (which they termed an “ecological cohort study”) evaluating the influence of smoking on risk of ST-segment elevation myocardial infarction (STEMI) in South Yorkshire, United Kingdom. The investigators coupled individual-level data from a regional STEMI database with population-level demographic and smoking data from the regional subset of a national survey. They found an alarmingly high relative risk of STEMI among people who smoke, particularly young and middle-aged women (relative risk 13× for women under age 50 years). Importantly, the STEMI risk for ex-smokers returned to the age- and sex-matched levels of never-smokers.
This hybrid study design has both the strengths and weaknesses of an ecological study. Ecological research evaluates risk factors and outcomes at the population-level rather than individual-level. Although we often extrapolate the results of other forms of observational research to larger populations based on study inclusion criteria, ecological studies can provide more direct evidence of population-level associations. They also allow for the rapid evaluation of many risk factors in large numbers of people using existing population datasets. But there are limitations. The results of ecological studies may not reflect individual-level risk in the same manner as population-level risk, and unmeasured confounders can result in false associations if disease-specific covariates are not sufficiently captured by population datasets. There are also limitations specific to this study, including that it does not assess other types of acute coronary syndrome such as non-STEMI and unstable angina, and it does not account for death prior to hospital arrival from sudden cardiac arrest complicating acute myocardial infarction. In addition, detailed, population-level comorbidity data are not available, nor is information about duration of smoking cessation and characteristics of individuals who successfully quit smoking.
These limitations add nuance, but they do not diminish the main message of this research. The general results, that smoking increases risk of STEMI and that smoking cessation is associated with a return to the risk of a never-smoker, are consistent with observations of many other health outcomes among individuals and populations (9). Therefore, these conclusions can be reasonably generalized to individuals and populations around the world, with minimal concern about incorrect inference. The more specific findings of this study (magnitude of risk increase, higher relative risk among younger patients and among female patients) are potentially subject to confounding or to ecological design limitations; they require cautious interpretation and validating research. This is particularly important when extrapolating to individuals or to populations dissimilar to South Yorkshire (largely white, with a more working-class and lower-income population than that of the United Kingdom as a whole [11,12]).
This study amplifies the considerable evidence for the cardiovascular health benefits from smoking cessation. Nonetheless, doctors give many reasons for poor engagement in smoking cessation, including lack of time, inadequate expertise, poor financial incentive, lack of coverage of treatments, and recalcitrance of smokers to quitting (13). Although these are legitimate challenges, they do not justify overlooking simple changes that can effectively incorporate smoking cessation into routine cardiovascular care (Figure 1). For example, structured outpatient interventions that use pharmacotherapy increase long-term smoking cessation by up to 3-fold (Figure 2) (14,15); and inpatient interventions that use intensive counseling, pharmacotherapy, and post-discharge follow-up increase long-term cessation by 2-fold (16).
In the end, the likelihood of success should not limit our resolve. In his essay on Ted Williams’ final game, John Updike describes the steadfastness that the legendary home-run hitter applied to his “cherished task,” despite low odds of success (1). Like any at-bat in baseball, one’s approach to an individual who smokes is about taking pride in a thing done well, with the goal of averaging-out respectably for the long season. The work of Palmer et al. (10) underscores the important role that smoking plays in the morbidity and mortality of every cardiologist’s patients, and it reminds us of the great impact we can have if we approach our task with constancy and purpose.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Updike J.
- Law M.,
- Tang J.L.
- Katz D.A.,
- Tang F.,
- Faseru B.,
- Horwitz P.A.,
- Jones P.,
- Spertus J.
- Pagidipati N.J.,
- Hellkamp A.,
- Thomas L.,
- Gulati M.,
- Peterson E.D.,
- Wang T.Y.
- ↵Centers for Disease Control and Prevention. Tobacco-related mortality. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm. Accessed May 14, 2019.
- Centers for Disease Control and Prevention
- Yang Q.,
- Cogswell M.E.,
- Flanders W.D.,
- et al.
- Department of Health and Human Services,
- Public Health Service, Office of the Surgeon General
- Palmer J.,
- Lloyd A.,
- Steele L.,
- et al.
- Nomis: Official Labour Market Statistics
- Nomis: Official Labour Market Statistics
- Schroeder S.A.
- Cahill K.,
- Stevens S.,
- Perera R.,
- Lancaster T.
- Barua R.S.,
- Rigotti N.A.,
- Benowitz N.L.,
- et al.
- Rigotti N.A.,
- Clair C.,
- Munafo M.R.,
- Stead L.F.