Factors influencing smoking cessation in patients with coronary artery disease
Introduction
There is a clear relationship between smoking and coronary artery disease (CAD) [1]. Not only has it been linked to the initial development and rate of progression of CAD [2], but continued smoking has been associated both with restenosis after coronary angioplasty [3]and the recurrence of disease in saphenous vein bypass grafts [4]. By contrast, cessation of smoking following a coronary event has almost immediate health benefits including decreased mortality and morbidity relative to individuals who continue to smoke 5, 6, 7, 8.
Although rates of quitting after a cardiac event are relatively high, 35–75% [5], compared to the cessation rate of 8% [8]in the general population, the proportion of those with known CAD who continue to smoke or who relapse is of concern 8, 9. No definitive comprehensive profile of a smoking noncomplier has emerged in the literature 10, 11. Whilst there is some consensus about the sociodemographic and clinical predictors of failure to quit or relapse, the psychological predictors have been less clearly delineated [10].
The purpose of this paper is to review the sociodemographic, clinical, and psychological characteristics which may be potential predictors of difficulty with smoking cessation in individuals with CAD. Nicotine addiction and the patient's readiness to change are also discussed. Identification of those patients at risk of continued or relapsed smoking after a cardiac event may facilitate a more focused or tailored prescription of intervention to decrease this risk [8]. An overview of intervention strategies is provided.
Section snippets
Literature—search and brief critique
To yield a data base for this paper, searches of the medical, allied health and psychological literature were performed, covering a time span from 1970 to 1996. From this, 47 publications have been cited, with 41 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47providing support for one or more of the potential predictors of smoking status considered in this paper as well as the
Age
Older patients are more likely to be exsmokers 8, 10. In their study of the effect of bypass surgery on smoking, Lapsley and others [12]found the mean age of smokers to be 50 years compared to 62 years for nonsmokers. In particular, older patients who have experienced a previous cardiac event or procedure are more likely to have successfully quit smoking. Considered together, these two variables, age and previous experience of a cardiac event, have been found to correctly predict the smoking
Severity of disease
The likelihood of smoking cessation following a cardiac event has been associated with severity of disease 5, 9, 10. Specifically, Wilhelmsson and others [30]found that the patients who remained abstinent for three months following a myocardial infarction were those who had sustained a larger, more severe infarct and who had experienced a more prolonged hospital stay. Frid and others [5]reported a significant relationship between smoking cessation and the extent of CAD, with the percentage of
Psychological predictor variables
Anxiety, depression and anger/hostility have been identified as components of the disease-prone personality [31]. In addition, these three characteristics have been found to be present to a greater extent in current smokers as opposed to those who have never smoked or who have successfully ceased smoking [32].
Nicotine dependence
A factor which requires consideration in an attempt to identify a profile of those individuals likely to experience difficulty with smoking cessation is the addictive nature of tobacco use. Nicotine, the known addictive substance in tobacco, can activate the nicotinic receptors in the brain. Activated nicotinic receptors may in turn stimulate the dopaminergic reward system which has the potential to alter mood and cognition and serves to reinforce the smoking habit [42]. Nicotine is rapidly
Intervention strategies
Successful intervention to facilitate smoking cessation takes on an eclectic approach, comprising intensive education and counselling, behavioral strategies, and pharmacologic therapy [17]. Regarding education and counselling, a positive approach has been found to be more motivational than one which is fear-arousing [26]. The provision of specific advice and encouragement and emphasis of the benefits to be gained from smoking cessation are recommended strategies.
Behavior modification is
Future research
Presumably the factors discussed in this review would not have an equal impact on the difficulty experienced by individuals with CAD in smoking cessation and maintained abstinence. In future research, these potential predictors may best be considered in a multivariate statistical model to determine their unique and combined contributions to this problem. In addition to identifying those individuals who may experience particular difficulty in smoking cessation, such research would be useful in
Conclusion
Smoking cessation is of critical importance to individuals with CAD. However, for many, cessation of smoking can be problematic, with a matrix of factors potentially contributing to difficulty in quitting. These factors may include younger age, female gender, lower socioeconomic status, heavy smoking, lack of social support, more severe disease, anxiety, depression, anger/hostility, and external health locus of control. In addition, nicotine dependence on its own or in combination with these
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