(Chest. 2004;125:435-438.)
© 2004
American College of Chest Physicians
Comparison of Conservative and Aggressive Smoking Cessation Treatment Strategies Following Coronary Artery Bypass Graft Surgery*
Daniel E. Hilleman, PharmD;
Syed M. Mohiuddin, MD, FCCP and
Kathleen A. Packard, PharmD
* From Creighton University Cardiac Center, Omaha, NE.
Correspondence to: Daniel E. Hilleman, PharmD, Creighton University Cardiac Center, 3006 Webster St, Omaha, NE 68131; e-mail: hilleman{at}creighton.edu
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Abstract
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Purpose: Patients who continue to smoke following coronary artery bypass graft surgery (CABG) have substantially poorer outcomes than patients able to stop smoking after CABG. This study evaluated the effectiveness of two smoking cessation treatment strategies in patients undergoing CABG.
Methods: Two smoking cessation treatment strategies were compared in smokers who underwent CABG. In the conservative treatment strategy, smokers undergoing CABG were followed up prospectively at monthly intervals. Patients who started smoking again at any time in the year following CABG were asked to enroll in an 8-week smoking cessation program. In the aggressive treatment strategy, smokers undergoing CABG were asked to enroll in an 8-week smoking cessation program starting immediately after hospital discharge. The structure and makeup of the smoking cessation program used in the conservative and aggressive treatment strategies were identical. The primary study outcome was smoking status assessed by self-report and confirmed by expired carbon monoxide at 1.5 months, 3 months, 6 months, and 12 months after surgery.
Results: Nineteen patients were enrolled in the conservative treatment strategy, with 2 patients unavailable for follow-up prior to the first follow-up visit. Of the remaining 17 patients, 14 patients (82%) resumed smoking at an average of 10.3 weeks after CABG. Eleven of these 14 patients (79%) agreed to participate in the smoking cessation program. Based on evaluable patients, 10 of the 17 patients (59%) in the conservative strategy group were not smoking at the 12-month follow-up. Twenty patients were enrolled in the aggressive treatment strategy. All patients agreed to participate in the smoking cessation program. All patients were available for follow-up. At the 12-month follow-up, 17 of 29 patients (85%) in this treatment strategy were not smoking. Point prevalence and continuous abstinence cessation rates were significantly greater in the aggressive treatment strategy compared to the conservative treatment strategy at all follow-up intervals after CABG.
Conclusion: Based on our findings in a small number of patients, an aggressive smoking cessation intervention is associated with a superior smoking cessation rate compared to a conservative treatment strategy in smokers undergoing CABG. A larger study will be needed to confirm that an early aggressive smoking cessation intervention should be provided to all smokers undergoing CABG.
Key Words: coronary artery bypass graft surgery • smoking cessation • tobacco
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Introduction
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Patients who continue to smoke following coronary artery bypass graft surgery (CABG) have an increased risk of premature graft closure, postoperative myocardial ischemia and infarction, repeat hospitalization, and death compared to patients who stop smoking.1
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It has been estimated that 25 to 50% of smokers undergoing CABG will stop smoking on their own without the aid of a formal smoking cessation intervention.3
Unfortunately, 50 to 75% of smokers undergoing CABG will resume smoking after their surgery.
The comparative efficacy of different smoking cessation strategies in patients after CABG has not been evaluated. Rigotti et al4
evaluated the efficacy of a brief smoking cessation intervention in smokers after CABG; their intervention failed to improve cessation rates in treated smokers compared to smokers receiving no intervention. There is an obvious need for effective cessation interventions for smokers undergoing CABG surgery. The objective of the present study was to compare a conservative smoking cessation strategy with an aggressive smoking cessation strategy in patients undergoing CABG surgery.
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Materials and Methods
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Patients
This study was conducted at a single university-affiliated cardiology clinic in Omaha, NE. Eligible patients included those undergoing CABG who were currently smoking or who had smoked in the month prior to surgery. Patients had to have smoked a minimum of 10 cigarettes per day for a minimum of 5 years. Subjects with a history of psychiatric illness requiring current treatment with psychoactive medications, a history of dependence on alcohol or a nonnicotine substance in the past year, or current use of tobacco products other than cigarettes were excluded. Subjects were not excluded on the basis of age, ethnic background, or gender. Subjects unwilling to give written informed consent and those not able to speak and read English were also excluded from the study.
Study Design
This study was approved by our institutional review board, and patients provided written, informed consent prior to study enrollment. Two smoking cessation treatment strategies were compared. Patients undergoing CABG from July 2000 through December 2000 who met the study inclusion criteria were managed with a conservative treatment strategy. In the conservative strategy, smokers were counseled in the hospital after CABG to stop smoking. Patients were not, however, initially enrolled in a smoking cessation program. These patients were given the self-help materials "Smart Move: A Stop Smoking Guide" from the American Cancer Society and "You Can Quit Smoking" from the Agency for Health Care Policy and Research.5
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These patients were followed up prospectively at monthly intervals using self-reported smoking status and expired carbon monoxide to confirm smoking status. Patients who started smoking again after surgery were encouraged to enroll in an 8-week comprehensive smoking cessation program. The smoking cessation program and pharmacotherapy (nicotine replacement therapy) were offered at no cost to study participants.
Patients undergoing surgery from January 2001 through June 2001 were managed with an aggressive treatment strategy. In the aggressive strategy, all patients undergoing CABG were encouraged to participate in a comprehensive smoking cessation intervention starting immediately after hospital discharge and continuing for 8 consecutive weeks. Participation in the smoking cessation program and pharmacotherapy (nicotine replacement therapy) were offered at no cost to patients.
The comprehensive smoking cessation program used in the two treatment strategies was identical. The program included eight, weekly, 1-h counseling sessions conducted with up to four other smokers. The sessions focused on patient education and behavior modification. Behavior modification training included cue recognition, coping skills, stress management, and relapse prevention skills. Other counseling included information on nutrition, exercise, chemical dependency, and self-management procedures. All patients were offered adjunctive treatment with nicotine replacement therapy at no cost.
Smoking status was judged by self-report and confirmed by expired carbon monoxide (< 10 ppm) at 1.5 months, 3 months, 6 months, and 12 months after surgery. Smoking cessation status was evaluated using both point-prevalence and continuous abstinence rates. For point-prevalence rates, subjects were classified as abstinent if they reported not smoking since the prior visit and had expired carbon monoxide < 10 ppm at the current visit. Subjects considered to be continuously abstinent had to have reported not to be smoking since their CABG and to have had expired carbon monoxide < 10 ppm at every follow-up visit.
Statistical Analysis
The effectiveness of the interventions was determined by comparing smoking cessation rates between the two groups using an intention-to-treat analysis. Patients unavailable for follow-up for any reason were counted as smokers. Differences in baseline and outcome variables were assessed with 
2 and Fisher exact tests for categorical variables and the student t test for continuous variables. Group differences in the duration of smoking abstinence were assessed using the log-rank test. All significance tests were two tailed.
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Results
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A total of 39 smokers were enrolled in the study with a conservative strategy used in 19 smokers and an aggressive strategy used in 20 smokers. Baseline demographic and clinical characteristics of the study participants are summarized in Table 1
. There were no significant differences between the treatment groups with regard to baseline demographics and clinical characteristics.
Of the 19 patients assigned to the conservative strategy, 1 patient died on day 9 postoperatively and 1 patient was unavailable for follow-up prior to the 1.5-month follow-up visit. Of the remaining 17 patients, 14 patients (82%) resumed smoking at a mean of 10.3 weeks following CABG. Of the 14 subjects who restarted smoking, 11 subjects (79%) elected to enter the 8-week intensive smoking cessation program while 3 smokers refused to participate. Of the 17 smokers participating in the smoking cessation program, all elected to use transdermal nicotine. Continuous abstinence and point-prevalence smoking cessation rates in the conservative strategy group at the 1.5-month, 3-month, 6-month, and 12-month follow-up intervals are summarized in Table 2
. At the 12-month follow-up visit, 10 of the 17 patients (59%) assigned to the conservative strategy were not smoking.
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Table 2.. Point Prevalence and Continuous Abstinence Smoking Cessation Rates Based on Intention-to-Treat Analysis*
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Of the 20 smokers assigned to the aggressive strategy, all patients elected to participate in the intensive 8-week comprehensive smoking cessation program with no patients unavailable for follow-up through the 12-month follow-up interval. Of the 20 smokers participating in the smoking cessation program, 19 smokers (95%) elected to use transdermal nicotine. Continuous abstinence and point-prevalence rates for the patients assigned to the aggressive strategy are summarized in Table 2
. At the 12-month follow-up, 17 of the 20 patients (85%) assigned to the aggressive strategy were not smoking. Point-prevalence and continuous abstinence rates significantly greater for patients enrolled in the aggressive strategy compared to patients enrolled in the conservative strategy at all follow-up intervals after CABG.
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Discussion
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Smoking cessation strategies after CABG have not been well studied. In one retrospective study,2
patients who were able to stop smoking without participation in a formal cessation program following CABG surgery had less progression of vein graft atherosclerosis compared to patients who continued to smoke. Data from the Coronary Artery Surgery Study3
indicate that approximately 25% of smokers undergoing CABG are able to quit on their own and remain abstinent for 5 years. Only one controlled trial4
evaluating the effectiveness of a formal smoking cessation intervention in the patients after CABG has been published.
Rigotti et al4
randomized 87 patients to receive smoking cessation counseling or to a control group. Smoking cessation counseling included three 20-min sessions with a nurse counselor using videotapes and printed materials prior to hospital discharge. One week after discharge, a nurse telephoned patients at home to offer support and brief counseling. Control subjects were advised not to smoke as part of a group lecture on the hazards of smoking. No statistically significant difference in smoking status between the two intervention groups was observed. Cessation rates were identical in the intervention and control groups at 1 year (51%) and at 5.5 years (44%). This brief amount of intervention offered to these patients after CABG appeared to be insufficient to impact smoking behavior. It is important to note, however, that the control group in this study had a relatively high cessation rate.
The results of our study indicate that a smoking cessation intervention directed at patients after CABG early after hospital discharge is significantly more effective than a conservative strategy of watchful waiting and then treating only those patients who resume smoking. In patients treated with the conservative cessation strategy, 41% (7 of 17 patients) were smoking at 1 year following surgery. In contrast, only 15% (3 of 20 patients) in the aggressive treatment strategy were smoking at 1 year following surgery. The 85% cessation rate observed in the aggressive treatment strategy in our study is higher than that reported by Rigotti et al,4
suggesting that a more intensive comprehensive smoking cessation strategy is effective in this population. In addition, our cessation rates of 59% and 85% in the conservative and aggressive treatment groups, respectively, are higher than cessation rates seen with comprehensive smoking cessation interventions in ambulatory, nonsurgical patient populations.7
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Cessation rates in these populations are typically only approximately 30 to 35%. The higher quit rates in our study most likely reflect the combined impact of CABG with the use of a comprehensive cessation intervention.
Even though our study included a small sample size, the limited data concerning smoking cessation interventions in the patient after CABG suggest that an aggressive treatment strategy should be implemented in the early post-hospital discharge period in these patients. A larger study will be needed to confirm that an early aggressive smoking cessation strategy is effective in smokers undergoing CABG.
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Footnotes
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Abbreviation: CABG = coronary artery bypass graft surgery
Received for publication July 30, 2003.
Accepted for publication September 24, 2003.
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References
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- Hermanson, B, Omenn, GS, Kronmal, RA, et al (1988) Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease: results from the CASS registry. N Engl J Med 319,1365-1369[Abstract]
- Solymoss, B, Nadeau, P, Millette, D, et al Late thrombosis of saphenous vein coronary bypass grafts related to risk factors. Circulation 1988;78(Supp 1),140-143
- Vliestra, R, Kronmal, R, Oberman, A, et al Effect of cigarette smoking on survival of patients with angiographically documented coronary artery disease: report from the CASS registry. JAMA 1986;255,1023-1027[Abstract]
- Rigotti, NA, McKool, KM, Shiffman, S Predictors of smoking cessation after coronary artery bypass graft surgery: results of a randomized trial with 5-year follow-up. Ann Intern Med 1994;120,287-293[Abstract/Free Full Text]
- American Cancer Society. Smart move! A stop smoking guide. Publication no. 2515-cc; 1997
- Agency for Health Care Policy and Research. You can quit smoking: consumer version. Clinical practice guideline. Publication no. 96-0695; 1996
- Hurt, R, Sachs, D, Glover, E, et al A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997;337,1195-1202[Abstract/Free Full Text]
- Tonnesen, P, Fryd, V, Hansen, M, et al Effect of nicotine chewing gum in combination with group counseling on the cessation of smoking. N Engl J Med 1988;318,15-18[Abstract]
- Transdermal Nicotine Study Group. Transdermal nicotine for smoking cessation: six-month results from two multicenter controlled clinical trials. JAMA 1991;266,3133-3138[Abstract]
- Sutherland, G, Stapleton, JA, Russell, MA, et al Randomized controlled trial of nasal nicotine spray in smoking cessation. Lancet 1992;340,324-329[CrossRef][ISI][Medline]
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Abstract
Introduction
