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Wilma Scholte op Reimer, Esther de Swart, Dirk De Bacquer, Kalevi Pyörälä, Ulrich Keil, Jan Heidrich, Jaap W. Deckers, Kornelia Kotseva, David Wood, Eric Boersma, for the EUROASPIRE Investigators, Smoking behaviour in European patients with established coronary heart disease, European Heart Journal, Volume 27, Issue 1, January 2006, Pages 35–41, https://doi.org/10.1093/eurheartj/ehi497
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Abstract
Aims Treatment guidelines for patients with established coronary disease emphasize the importance of smoking cessation. We aimed to study smoking behaviour in European patients, as well as trends in this behaviour over time. We further aimed to evaluate the relation between selected patient characteristics and smoking cessation.
Methods and results We studied patients who were enrolled in the second European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) survey, which was undertaken in 15 European countries during 1999–2000. Consecutive patients, ≤70 years were identified after coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, admission for myocardial infarction, or admission for myocardial ischaemia. Patients were then interviewed, at a median of 1.5 years after the index event. During the interview, data were collected on a broad range of clinical characteristics, including smoking status, which was validated by breath carbon monoxide levels. The prevalence of smoking was compared with data from the first EUROASPIRE survey, which had a similar design, and was conducted during 1995–96. In EUROASPIRE II, 5551 patients attended the interview and 1172 (21%) were (persistent) smokers. No decrease in smoking prevalence was observed similar to the first survey (19%). The proportion of smokers was 39% in patients aged <50, 26% in patients aged 50–60, and 14% in patients aged ≥60. Men and women had similar prevalence. A verbal advice to give up smoking by a medical professional was given to 99% of the 2244 pre-event smokers, and 48% actually stopped. This proportion was relatively high in elderly patients ≥60 years (53%), patients with a university level of education (56%), and patients with a myocardial infarction as the index event (52%). The proportion of stopped smokers was low in patients <50 years (41%) and in patients with myocardial ischaemia as the index event (38%).
Conclusion The prevalence of smoking in European patients with established coronary disease is too high: one out of each five patients smokes, despite a personal advice to stop. Thus, still there is a need for the development of effective smoking cessation programmes.
Introduction
The adverse effects of smoking on coronary heart disease (CHD) and other atherosclerotic diseases are well established. Smoking is strongly related to the development and the progression of CHD, as well as to the incidence of cardiovascular events, including death.1,2 Moreover, several clinical studies have demonstrated that the prognosis of patients with established CHD improves if smoking is stopped.3,4 Therefore, in their joint recommendations on (secondary) CHD prevention, the European Society of Cardiology (ESC), the European Atherosclerosis Society, the European Society of Hypertension, the International Society of Behavioural Medicine, the European Society of General Practice/Family Medicine, and the European Heart Network (the Joint European Societies) emphasize the urgency of smoking cessation in CHD patients.5–7 To motivate patients to stop smoking, the Joint European Societies also stress the importance of a physician's firm advice, which should include a brief reiteration of the cardiovascular and other health hazards of smoking. Additionally, the patient should be provided with appropriate literature, and preferably an agreement should be reached on a specific treatment plan with appropriate follow-up.6
After publication of their recommendations in 1995 and 1999, the Joint European Societies conducted two surveys in 1995–96 and 1999–2000 to evaluate whether their recommendations had influenced the management of CHD patients across Europe.8,9 In general, both surveys revealed a disappointing situation with regard to secondary prevention actions.8–10 The Joint European Societies had to conclude that a substantial potential to reduce the risk of recurrent cardiovascular disease or death still remains.10 This article describes the findings of the second survey with regard to smoking behaviour in more detail. We studied the relation between a broad range of clinical and demographic characteristics and smoking cessation. The findings of both surveys are compared to evaluate whether smoking behaviour in CHD patients has changed over time.11
Methods
Study population
The design of the European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) surveys is described in detail elsewhere.8,9 The first EUROASPIRE survey was conducted during 1995–96 in 21 hospitals in nine selected regions in Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia, and Spain. Twenty of these hospitals also participated in the second EUROASPIRE survey, which was conducted in 1999–2000 in 47 hospitals in 15 European countries (one Italian centre no longer participated). The original sample was extended with 27 hospitals from Belgium, France, Greece, Ireland, Poland, Sweden, and the United Kingdom. Within each hospital, consecutive patients were identified with one of the following diagnoses: first coronary artery bypass graft (CABG); first percutaneous transluminal coronary angioplasty (PTCA) without previous CABG; first or recurrent myocardial infarction without previous CABG or PTCA; and first or recurrent acute myocardial ischaemia without previous CABG, PTCA, or myocardial infarction. Patients with an age of ≥71 years were not included. Information on demographics, cardiac history, and risk factor management was obtained from medical records. A trained research assistant interviewed patients at least 6 months after the index event, in order to obtain information on lifestyle and risk factors.
In EUROASPIRE I, 4863 consecutive patients were identified who satisfied the inclusion criteria. Among the 4576 patients who were contacted and found alive, 3569 agreed to be interviewed, which resulted in a participation rate of 78%. The interviews were performed at a median of 1.5 years after the index event. In EUROASPIRE II, 8181 eligible patients were identified and 5556 were interviewed, which embraces 76% of the 7310 patients who were contacted and found alive. The interviews were performed at a median of 1.4 years after the index event. The present study is based on data of the interviewed patients in the second EUROASPIRE survey. EUROASPIRE I data were only used for the evaluation of smoking behaviour over time.
Assessment of smoking behaviour
During the interview, patients were asked to answer the following questions: (i) ‘Have you ever smoked?’ Patients who answered ‘yes’ to this question were subsequently asked to answer the following two questions: (ii) Were you smoking in the month prior to the hospital admission for the procedure or acute event? and (iii) Do you smoke now? In patients who answered ‘no’ in response to the third question, the concentration of carbon monoxide in breath was measured using a smoker analyser (Bedfont Scientific, UK, Model EC50). Patients who answered ‘yes’ to question (iii) and those in whom the expired carbon monoxide concentration in breath exceeded 10 p.p.m. were classified as ‘persistent smokers’. Patients who answered ‘yes’ to question (ii), ‘no’ to question (iii), and in whom the expired carbon monoxide concentration was ≤10 p.p.m. were classified as ‘stopped smokers’. The remaining patients were classified as ‘pre-index event non-smokers’ (Table 1). Smoking included cigarettes, cigars, and pipes.
Data quality and data management
To assure the quality of data recording from both the review of medical records and patient interviews, duplicate independent assessment of the first 10 medical records by the principal investigator responsible for data collection was undertaken with each research assistant. Furthermore, duplicate independent assessment of a random sample of 20 case records (five in each diagnostic category) was undertaken over the course of data abstraction. Data were stored electronically onto a notebook computer using a unique identification number for country, hospital, and subject, without any further personal identification. Computer disks were sent on a fortnight basis by each country to the co-ordinating centre, where checks for completeness, internal consistency, and accuracy were performed. All data were stored under the provisions of the United Kingdom Data Protection Act.
Statistical analysis
Data on smoking behaviour prior to the index event and at the time of the interview are presented as absolute numbers and percentages. For patients who were classified as ‘pre-index event smokers’ the relation between selected clinical and demographic characteristics and current smoking behaviour (persisted or stopped smoking at the time of the interview) were analysed by multivariable logistic regression analyses. We adjusted for age, gender, type of index event, and centre of enrolment. Adjusted odds ratios and corresponding 95% confidence intervals are reported. Statistical significance was stated at the classical 0.05 probability level (all tests were two-sided). It should be noticed that the EUROASPIRE surveys were not designed to reveal (baseline) determinants of smoking cessation. Most data items that entered the regression models are determined at the interview, simultaneously with the patient's smoking behaviour. Therefore, we did not aim to develop a ‘full’ multivariable regression model. This is a conceptual study and results should be considered accordingly.
Results
In EUROASPIRE II, information on smoking behaviour was available in 5551 interviewed patients (99.9%). A total of 1172 patients (21%) were (persistent) smokers at the time of the interview (Table 2). This proportion varied from 15% in centres in Slovenia and Italy to 30% in centres in Hungary. There were also differences in the proportion of smokers in relation to the index event and age. The number of smokers at the time of the interview was similar in men and women (22 and 18%, respectively).
The proportion of patients who stopped smoking after the index event was 48% (1072 of the 2244 pre-index event smokers). This proportion was relatively high in elderly patients (53% in those ≥60 years and 41% in those <50 years), patients with higher levels of education, patients who had a myocardial infarction as the index event, obese patients, and patients who were still under care by a hospital cardiologist (Table 3). The proportion of stopped smokers was relatively low in patients who had myocardial ischaemia as index event and in patients with a prior history of CHD. A verbal advice to give up smoking by a medical professional was given to 99% of pre-event smokers, whereas a written advice was only given to 26%. Interestingly, 20% of stopped smokers reported to have received such written advice when compared with 30% of continued smokers.
Figure 1 shows that patients who stopped smoking consistently more often undertook actions to make other favourable lifestyle changes than patients who continued smoking.
As Figure 2 demonstrates, there was no difference in the prevalence of (persistent) smoking among interviewed patients between the EUROASPIRE I and EUROASPIRE II survey cohorts (19 vs. 21%).10 The proportion of pre-index event smokers who actually stopped smoking after the index event was lower in EUROASPIRE II than in EUROASPIRE I, but this difference was not statistically significant (48 vs. 60%, P=0.09).
Discussion
The prevalence of smoking in patients with established CHD did not change in the 5-year period between the two EUROASPIRE surveys and remained at a high level. Although we count the fact that half of the pre-index event smokers discontinued their injurious behaviour, we also realize that this implies that the other half persist. Because smoking is one of the dominant risk factors for the genesis and development of atherosclerotic diseases, as well as other life-threatening diseases, including cancer and chronic obstructive pulmonary disease, time and effort should continuously be spent to support stop smoking in these individuals.
We found a relation between the index event and smoking behaviour. The proportion of stopped smokers was relatively high in patients who were hospitalized for myocardial infarction and low in those hospitalized for ischaemia. A myocardial infarction often is the first manifestation of coronary disease (in our data set it actually was), and physicians are then keen to achieve appropriate risk factor management. In addition, patients themselves may realize the seriousness of their disease, more so than after an episode of ischaemia, and are receptive to accept recommendations for lifestyle changes. In patients who were hospitalized for myocardial ischaemia, the need of smoking cessation might have been underestimated. It should be noticed that long-term mortality rates after myocardial ischaemia and myocardial infarction are similar.12–15 Therefore, the importance of appropriate lifestyle changes, among which smoking cessation, should also be recommended to this category of patients with great emphasis.
On the basis of the evidence from several clinical trials,16–20 the Joint European Societies guidelines on CHD prevention indicate that a physician's firm and timely advice to stop smoking is not always sufficient, but should be followed by more intensive interventions.6,7 On one hand, our findings seem to confirm this statement, because an oral advice to stop smoking was provided to virtually all smokers, whereas half of them persisted. On the other hand, we noticed that the proportion of patients who reported to have received a more intensive (written) recommendation was larger in persistent smokers than in stopped smokers. The possibility of information bias should not be ignored in this respect, for these data are based on self-reports. Patients might not remember, or even deny, the fact that they have received a lifestyle advice. In addition, making lifestyle changes is a complex and difficult process from psychological point of view, and evidence exists that only those who are really motivated succeed.21,22 Indeed, our data demonstrated that patients who gave up smoking also took significantly more actions to improve their lifestyle otherwise than persistent smokers. In this context, lifestyle intervention programmes that focus on multiple preventable risk factors simultaneously seemed to be most successful.23,24
Smoking cessation might be stimulated by pharmacotherapy. Evidence exists that the use of nicotine-replacement products (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler, and nicotine sublingual tablets/lozenges) increases smoking cessation rates during long-term follow-up, and the effectiveness of such products appears to be independent of the intensity of additional support provided to the smoker.25,26 Recently, also bupropion, an antidepressant, was associated with improved smoking cessation rates.20 Unfortunately, data on the use of these medications were lacking in our data set. Future surveys should pay attention to this relevant issue.
Our study has several limitations, which should be acknowledged. First, the EUROASPIRE surveys were conducted mainly in (university) hospital settings. We realize, however, that hospital physicians are not the only doctors to treat and follow patients with secondary prevention of CHD. In fact, many patients are being referred to primary health care. Additional surveys are needed to evaluate the management of smoking, among other risk factors, in these settings. Furthermore, only a few hospitals in selected European regions participated in the EUROASPIRE surveys, and one can argue that the observed results may not be representative for individual countries or for Europe as a whole. Indeed, regional variation in smoking prevalence was observed in both surveys. Although this observation provides some evidence for selection bias, it is more likely a chance finding, because regions with a relatively high smoking prevalence in the first survey had a relatively low prevalence in the second, and vice versa. Therefore, possible selection bias does not invalidate our main conclusion: smoking prevalence is still too high in European patients with established coronary disease. Finally, there is a possibility of bias in the selection of pre-index event smokers who were enrolled in our survey. For example, if the symptoms leading to the index event already existed for a period longer than 1 month, then patients could have stopped earlier. This might explain the relatively low proportion of pre-index event smokers when compared with ever smokers.
Conclusion
Preventive cardiology regarding smoking cessation has not improved since 1996. One out of each five patients with established coronary disease smokes, despite a personal advice to stop. Therefore, still there is a need for the development of more intensive, effective smoking cessation programmes. Our study suggests that such programmes might best focus on younger patients, patients with lower levels of education, and those with myocardial ischaemia as the first expression of their disease.
Acknowledgements
We thank the administrative staff, physicians, nurses, and other personnel at the hospitals in which the study was carried out, and all the patients who participated in the study. We also thank Paul Durrington (Manchester Royal Infirmary, UK) and Jouko Sundvall (National Public Health Institute, Helsinki, Finland) for the laboratory comparison of cholesterol estimations from EUROASPIRE I and II. Unrestricted educational grants to the European Society of Cardiology were obtained from Merck, Sharp & Dohme for EUROASPIRE I, and from Astra Zeneca, Bristol-Myers Squibb, Merck, Sharp & Dohme, and Pfizer for EUROASPIRE II.
Conflict of interest: no conflict of interest exists with respect to this manuscript.
Appendix
EUROASPIRE I and II group
Scientific steering/expert committees: K. Pyörälä (Kuopio, Finland, Chairman EUROASPIRE I), G. De Backer (Ghent, Belgium, Chairman EUROASPIRE II), G.B. Ambrosio (Venice, Italy), P. Amouyel (Lille, France), D. Cokkinosb (Athens, Greece), J.W. Deckers (Rotterdam, The Netherlands), L. Erhardtb (Malmö, Sweden), I. Graham (Dublin, Ireland), F. Gutzwillera (Zürich, Switzerland), I. Keberb (Ljubljana, Slovenia), U. Keil (Münster, Germany), S. Lehtob (Kuopio, Finland), E. Östör (Budapest, Hungary), A. Pajakb (Cracow, Poland), S. Sans (Barcelona, Spain), J. Simon (Pilsen, Czech Republic), J. Turka (Ljubljana, Slovenia), D. Wood (London, UK, EUROASPIRE Co-ordinator).
Co-ordinating and data management centre: D.A. Wood, B. Schofield, T. Bowkera, J. Inghama, N. McLennana, K. Kotsevab, M. Gollapallib, R. Valayb (Cardiac Medicine, Clinical Epidemiology Group, National Heart and Lung Institute, Imperial College School of Medicine, London, UK).
Computing and statistical centre: G. De Backer and D. De Bacquer (Department of Public Health, Ghent University, Belgium).
Central laboratories: D. Jamesa (Clinical Research Laboratories Europe, Zaventem, Belgium), M. Macknessb (University Department of Medicine, Manchester Royal Infirmary, UK).
Czech Republic: J. Simon, K. Linhartová, P. Hafmana, O. Mayerb, H. Rosolovab, P. Bocekb (Charles University, Medical Faculty, Pilsen); M. Hrncáreka, P. Lupineka, T. Mareka, M. Plaskovab, Z. Skodovab, R. Cifkovab (Department of Preventive Cardiology, Institute of Clinical Experimental Medicine, Prague).
Finland: K. Pyöräläa, S. Lehtob, R. Lehto, A. Kemppainena, H. Koukkunena, J. Luukkonenb, M. Puhakkab, K. Kärkkäinenb, K. Savolainenb (Kuopio University Hospital).
France: P. Amouyel, M. Montaye, B. Lemaire, S. Daneta, R. Domanievicza, M. Lenoira, S. Beauchantb, A. Dusartb, F. Bonteb, N. Fiévetb, L. Poissonnierb, P. Ledouxb, N. Marécauxb, C. Stécleboutb (Service d'épidémiologie et de santé publique/INSERM U 508, Institut Pasteur de Lille; Hôpital Cardiologique Universitaire, Lille; Hôpital Victor Provo, Roubaix; Hôpital Saint Philibert, Lomme; Hôpital Gustave Dron, Tourcoingb).
Germany: U. Keil, A. Liese, U. Broxtermanna, M. Heimbacha, J. Heidrichb, M. Kalicb (Institut für Epidemiologie und Sozialmedizin, Universität Münster); G. Breithardt, A. Enbergs, S. Kerberb (Medizinische Klinik und Poliklinik für Kardiologie und Angiologie, Universität Münster); H. Scheld, N. Roederb (Klinik und Poliklinik für Thorax-, Herz- und Gefäßchirurgie, Universität Münster); P. Kleine-Katthöfer (St Franziskus Hospital, Münster); G. Assmannb (Institut für Arterioskleroseforschung, Universität Münster).
Hungary: E. Östör, S. Borbás, M. Podmaniczky, T. Ruzsányib (Hungarian Institute of Cardiology, Budapest); A. Jánosi, A. Belatiny-Kenéz, A. Bradáka, Zs Ádámb, Gy Bárczyb, K. Birtalanb, I. Gallaib (Szt János Hospital, Budapest).
Italy: G.B. Ambrosio, C. Leprotti (Department of Internal Medicine, Venice City Hospital); P. Zardini, L. Rossi, A. Galloa, D. Tavellab (Department of Cardiology, Borgo Trento Hospital, Verona); P. Stritoni, A. Pedrocco, F. Perissinottoa (Department of Cardiology, Ca' Foncello Hospital, Treviso); D. Vanuzzoa, L. Pilottoa (Department of Cardiology, SM Misericordia Hospital, Udinea).
The Netherlands: J.W. Deckers, F. Posta, C. Jansenb (Thorax Centre of the Academic Hospital Rotterdam ‘Dijkzigt’); M. Veerhoek, A. Boer, E. Stockx (Sint Franciscus Gasthuis, Rotterdam); R. van de Berga, W.J. Remmea, R. van Vlieta, J. Vosb, M. van der Knaapb (Zuiderziekenhuis, Rotterdam).
Slovenia: J. Turka, I. Keberb, K. Marna, V. Salapuraa, E. Skofb, E. Spanb (University Medical Centre, Ljubljana).
Spain: S. Sans, G. Paluzie, I. Péreza, T. Puiga, C. Varasa, L. Balañáb (Institute of Health Studies, Department of Health and Social Security, Barcelona); F. Navarro López, G. Sanzb, C. Ferrerb (Hospital Clínic i Provincial, Barcelona); A. Bayés de Lunaa, J.M. Caralpsb, M. Domínguezb (Hospital de la Santa Creu i Sant Pau, Barcelona); P. Monrás, M. Reyb (Corporació Sanitària Parc Taulí, Sabadell). aParticipants in EUROASPIRE I only. bParticipants in EUROASPIRE II only.
Interview questions . | Smoker analyser testa . | Classification of smoking behaviour . | Number of patients . | |
---|---|---|---|---|
Were you smoking in the month prior to the hospital admission for the procedure or acute event? . | Do you smoke now? . | |||
Yes | Yes | — | Persistent smoker | 1009 |
Yes | No | Positive | Persistent smoker | 88 |
Yes | No | Negative | Stopped smoker | 1072 |
No | No | Positive | Persistent smoker | 75 |
No | No | Negative | Pre-index event non-smoker | 3307 |
Interview questions . | Smoker analyser testa . | Classification of smoking behaviour . | Number of patients . | |
---|---|---|---|---|
Were you smoking in the month prior to the hospital admission for the procedure or acute event? . | Do you smoke now? . | |||
Yes | Yes | — | Persistent smoker | 1009 |
Yes | No | Positive | Persistent smoker | 88 |
Yes | No | Negative | Stopped smoker | 1072 |
No | No | Positive | Persistent smoker | 75 |
No | No | Negative | Pre-index event non-smoker | 3307 |
aPositive in case of an expired carbon monoxide concentration >10 p.p.m., negative otherwise.
Interview questions . | Smoker analyser testa . | Classification of smoking behaviour . | Number of patients . | |
---|---|---|---|---|
Were you smoking in the month prior to the hospital admission for the procedure or acute event? . | Do you smoke now? . | |||
Yes | Yes | — | Persistent smoker | 1009 |
Yes | No | Positive | Persistent smoker | 88 |
Yes | No | Negative | Stopped smoker | 1072 |
No | No | Positive | Persistent smoker | 75 |
No | No | Negative | Pre-index event non-smoker | 3307 |
Interview questions . | Smoker analyser testa . | Classification of smoking behaviour . | Number of patients . | |
---|---|---|---|---|
Were you smoking in the month prior to the hospital admission for the procedure or acute event? . | Do you smoke now? . | |||
Yes | Yes | — | Persistent smoker | 1009 |
Yes | No | Positive | Persistent smoker | 88 |
Yes | No | Negative | Stopped smoker | 1072 |
No | No | Positive | Persistent smoker | 75 |
No | No | Negative | Pre-index event non-smoker | 3307 |
aPositive in case of an expired carbon monoxide concentration >10 p.p.m., negative otherwise.
. | Number of interviewed patients . | Number of patients who ever smoked (%) . | Number of pre-index event smokers (%) . | Number of persistent smokers (%) . |
---|---|---|---|---|
Country/centre | ||||
BEL/GHE | 260 | 191 (73) | 105 (40) | 59 (23) |
CZE/PP | 410 | 287 (70) | 179 (44) | 79 (19) |
FIN/KUO | 348 | 216 (62) | 105 (30) | 75 (22) |
FRA/LLRT | 365 | 278 (76) | 156 (43) | 88 (24) |
GER/MUNS | 400 | 307 (77) | 131 (33) | 67 (17) |
GRE/ATCI | 390 | 305 (78) | 193 (49) | 98 (25) |
HUN/BUD | 389 | 272 (70) | 173 (44) | 117 (30) |
IRE/DUB | 345 | 258 (75) | 157 (46) | 91 (26) |
ITA/TV | 258 | 181 (70) | 93 (36) | 39 (15) |
NET/ROT | 357 | 309 (86) | 175 (49) | 101 (28) |
POL/CRA | 427 | 337 (79) | 164 (38) | 76 (18) |
SLO/LJU | 446 | 296 (66) | 128 (29) | 65 (15) |
SPA/BAR | 404 | 302 (75) | 174 (43) | 72 (18) |
SWE/MAL | 392 | 295 (75) | 191 (49) | 81 (21) |
UK/HL | 362 | 252 (70) | 120 (33) | 64 (18) |
Gender | ||||
Men | 4235 | 3425 (81) | 1829 (43) | 941 (22) |
Women | 1316 | 661 (50) | 415 (32) | 231 (18) |
Index event | ||||
CABG | 1422 | 4047 (74) | 430 (30) | 230 (16) |
PTCA | 1558 | 1201 (77) | 683 (44) | 352 (23) |
Myocardial infarction | 1461 | 1141 (78) | 782 (54) | 375 (26) |
Ischaemia | 1110 | 697 (63) | 349 (31) | 215 (19) |
Age (years) | ||||
<50 | 802 | 682 (85) | 522 (65) | 310 (39) |
50–59 | 1789 | 110 (79) | 861 (48) | 458 (26) |
≥60 | 2960 | 1994 (67) | 861 (29) | 404 (14) |
All patients | 5551a | 4086 (74) | 2244 (40) | 1172 (21) |
. | Number of interviewed patients . | Number of patients who ever smoked (%) . | Number of pre-index event smokers (%) . | Number of persistent smokers (%) . |
---|---|---|---|---|
Country/centre | ||||
BEL/GHE | 260 | 191 (73) | 105 (40) | 59 (23) |
CZE/PP | 410 | 287 (70) | 179 (44) | 79 (19) |
FIN/KUO | 348 | 216 (62) | 105 (30) | 75 (22) |
FRA/LLRT | 365 | 278 (76) | 156 (43) | 88 (24) |
GER/MUNS | 400 | 307 (77) | 131 (33) | 67 (17) |
GRE/ATCI | 390 | 305 (78) | 193 (49) | 98 (25) |
HUN/BUD | 389 | 272 (70) | 173 (44) | 117 (30) |
IRE/DUB | 345 | 258 (75) | 157 (46) | 91 (26) |
ITA/TV | 258 | 181 (70) | 93 (36) | 39 (15) |
NET/ROT | 357 | 309 (86) | 175 (49) | 101 (28) |
POL/CRA | 427 | 337 (79) | 164 (38) | 76 (18) |
SLO/LJU | 446 | 296 (66) | 128 (29) | 65 (15) |
SPA/BAR | 404 | 302 (75) | 174 (43) | 72 (18) |
SWE/MAL | 392 | 295 (75) | 191 (49) | 81 (21) |
UK/HL | 362 | 252 (70) | 120 (33) | 64 (18) |
Gender | ||||
Men | 4235 | 3425 (81) | 1829 (43) | 941 (22) |
Women | 1316 | 661 (50) | 415 (32) | 231 (18) |
Index event | ||||
CABG | 1422 | 4047 (74) | 430 (30) | 230 (16) |
PTCA | 1558 | 1201 (77) | 683 (44) | 352 (23) |
Myocardial infarction | 1461 | 1141 (78) | 782 (54) | 375 (26) |
Ischaemia | 1110 | 697 (63) | 349 (31) | 215 (19) |
Age (years) | ||||
<50 | 802 | 682 (85) | 522 (65) | 310 (39) |
50–59 | 1789 | 110 (79) | 861 (48) | 458 (26) |
≥60 | 2960 | 1994 (67) | 861 (29) | 404 (14) |
All patients | 5551a | 4086 (74) | 2244 (40) | 1172 (21) |
BEL/GHE, Belgium/Ghent; CZE/PP, Czech Republic/Pilsen, Prague; FIN/KUO, Finland/Kuopio; FRA/LLRT, France/Lille, Lomme, Roubaix, Tourcoing; GER/MÜNS, Germany/Münster; GRE/ATCI, Greece/Athens, Thessaloniki, Crete, Ioannina; HUN/BUD, Hungary/Budapest; IRE/DUB, Ireland/Dublin; ITA/UTV, Treviso, Verona; NET/ROT, The Netherlands/Rotterdam; POL/CRA, Poland, Cracow province; SLO/LJU, Slovenia/Ljubljana; SPA/BAR, Spain, Barcelona and province; SWE/MAL, Sweden/Malmö; UK/HL, United Kingdom/Hull, London.
aInformation on smoking behaviour was missing in five of the 5556 interviewed patients.
. | Number of interviewed patients . | Number of patients who ever smoked (%) . | Number of pre-index event smokers (%) . | Number of persistent smokers (%) . |
---|---|---|---|---|
Country/centre | ||||
BEL/GHE | 260 | 191 (73) | 105 (40) | 59 (23) |
CZE/PP | 410 | 287 (70) | 179 (44) | 79 (19) |
FIN/KUO | 348 | 216 (62) | 105 (30) | 75 (22) |
FRA/LLRT | 365 | 278 (76) | 156 (43) | 88 (24) |
GER/MUNS | 400 | 307 (77) | 131 (33) | 67 (17) |
GRE/ATCI | 390 | 305 (78) | 193 (49) | 98 (25) |
HUN/BUD | 389 | 272 (70) | 173 (44) | 117 (30) |
IRE/DUB | 345 | 258 (75) | 157 (46) | 91 (26) |
ITA/TV | 258 | 181 (70) | 93 (36) | 39 (15) |
NET/ROT | 357 | 309 (86) | 175 (49) | 101 (28) |
POL/CRA | 427 | 337 (79) | 164 (38) | 76 (18) |
SLO/LJU | 446 | 296 (66) | 128 (29) | 65 (15) |
SPA/BAR | 404 | 302 (75) | 174 (43) | 72 (18) |
SWE/MAL | 392 | 295 (75) | 191 (49) | 81 (21) |
UK/HL | 362 | 252 (70) | 120 (33) | 64 (18) |
Gender | ||||
Men | 4235 | 3425 (81) | 1829 (43) | 941 (22) |
Women | 1316 | 661 (50) | 415 (32) | 231 (18) |
Index event | ||||
CABG | 1422 | 4047 (74) | 430 (30) | 230 (16) |
PTCA | 1558 | 1201 (77) | 683 (44) | 352 (23) |
Myocardial infarction | 1461 | 1141 (78) | 782 (54) | 375 (26) |
Ischaemia | 1110 | 697 (63) | 349 (31) | 215 (19) |
Age (years) | ||||
<50 | 802 | 682 (85) | 522 (65) | 310 (39) |
50–59 | 1789 | 110 (79) | 861 (48) | 458 (26) |
≥60 | 2960 | 1994 (67) | 861 (29) | 404 (14) |
All patients | 5551a | 4086 (74) | 2244 (40) | 1172 (21) |
. | Number of interviewed patients . | Number of patients who ever smoked (%) . | Number of pre-index event smokers (%) . | Number of persistent smokers (%) . |
---|---|---|---|---|
Country/centre | ||||
BEL/GHE | 260 | 191 (73) | 105 (40) | 59 (23) |
CZE/PP | 410 | 287 (70) | 179 (44) | 79 (19) |
FIN/KUO | 348 | 216 (62) | 105 (30) | 75 (22) |
FRA/LLRT | 365 | 278 (76) | 156 (43) | 88 (24) |
GER/MUNS | 400 | 307 (77) | 131 (33) | 67 (17) |
GRE/ATCI | 390 | 305 (78) | 193 (49) | 98 (25) |
HUN/BUD | 389 | 272 (70) | 173 (44) | 117 (30) |
IRE/DUB | 345 | 258 (75) | 157 (46) | 91 (26) |
ITA/TV | 258 | 181 (70) | 93 (36) | 39 (15) |
NET/ROT | 357 | 309 (86) | 175 (49) | 101 (28) |
POL/CRA | 427 | 337 (79) | 164 (38) | 76 (18) |
SLO/LJU | 446 | 296 (66) | 128 (29) | 65 (15) |
SPA/BAR | 404 | 302 (75) | 174 (43) | 72 (18) |
SWE/MAL | 392 | 295 (75) | 191 (49) | 81 (21) |
UK/HL | 362 | 252 (70) | 120 (33) | 64 (18) |
Gender | ||||
Men | 4235 | 3425 (81) | 1829 (43) | 941 (22) |
Women | 1316 | 661 (50) | 415 (32) | 231 (18) |
Index event | ||||
CABG | 1422 | 4047 (74) | 430 (30) | 230 (16) |
PTCA | 1558 | 1201 (77) | 683 (44) | 352 (23) |
Myocardial infarction | 1461 | 1141 (78) | 782 (54) | 375 (26) |
Ischaemia | 1110 | 697 (63) | 349 (31) | 215 (19) |
Age (years) | ||||
<50 | 802 | 682 (85) | 522 (65) | 310 (39) |
50–59 | 1789 | 110 (79) | 861 (48) | 458 (26) |
≥60 | 2960 | 1994 (67) | 861 (29) | 404 (14) |
All patients | 5551a | 4086 (74) | 2244 (40) | 1172 (21) |
BEL/GHE, Belgium/Ghent; CZE/PP, Czech Republic/Pilsen, Prague; FIN/KUO, Finland/Kuopio; FRA/LLRT, France/Lille, Lomme, Roubaix, Tourcoing; GER/MÜNS, Germany/Münster; GRE/ATCI, Greece/Athens, Thessaloniki, Crete, Ioannina; HUN/BUD, Hungary/Budapest; IRE/DUB, Ireland/Dublin; ITA/UTV, Treviso, Verona; NET/ROT, The Netherlands/Rotterdam; POL/CRA, Poland, Cracow province; SLO/LJU, Slovenia/Ljubljana; SPA/BAR, Spain, Barcelona and province; SWE/MAL, Sweden/Malmö; UK/HL, United Kingdom/Hull, London.
aInformation on smoking behaviour was missing in five of the 5556 interviewed patients.
Characteristics . | Number of pre-index event smokers . | Number of stopped smokers (%) . | Odds ratio (95% CI)† . | P-value† . |
---|---|---|---|---|
Age | <0.001 | |||
<50 years | 522 | 212 (40.6) | 1 | |
50–60 years | 861 | 403 (46.8) | 1.3 (1.0–1.6) | |
≥60 years | 861 | 457 (53.1) | 1.6 (1.3–2.1) | |
Gender | 0.33 | |||
Male | 1829 | 888 (48.6) | 1 | |
Female | 415 | 184 (44.3) | 0.9 (0.7–1.1) | |
Highest level of education | <0.001 | |||
University, college, or equivalent | 249 | 140 (56.2) | 1.8 (1.4–2.5) | |
Intermediate school | 280 | 137 (48.9) | 1.6 (1.1–2.2) | |
Secondary school | 784 | 385 (49.1) | 1.3 (1.1–1.6) | |
Primary school | 924 | 410 (44.4) | 1 | |
Index event | <0.001 | |||
CABG | 430 | 200 (46.5) | 1 | |
PTCA | 683 | 331 (48.5) | 1.1 (0.9–1.5) | |
Myocardial infarction | 782 | 407 (52.0) | 1.3 (1.0–1.6) | |
Myocardial ischaemia | 349 | 134 (38.4) | 0.7 (0.5–0.9) | |
History of diabetes mellitus | ||||
Yes | 356 | 168 (47.2) | 0.9 (0.7–1.2) | 0.50 |
No | 1888 | 904 (47.9) | 1 | |
History of hypertension | ||||
Yes | 1027 | 492 (47.9) | 1.0 (0.9–1.2) | 0.66 |
No | 1217 | 580 (47.7) | 1 | |
History of hyperlipidemia | 0.26 | |||
Yes | 1559 | 766 (49.1) | 1.1 (0.9–1.4) | |
No | 685 | 306 (44.7) | 1 | |
Obesity | 0.01 | |||
Yes | 670 | 347 (51.8) | 1.4 (1.1–1.6)) | |
No | 1574 | 725 (46.1) | 1 | |
History of CHD | 0.04 | |||
Yes | 746 | 344 (46.1) | 0.8 (0.6–1.0) | |
No | 1498 | 728 (48.6) | 1 | |
Family history of premature CHD | 0.73 | |||
Yes | 1033 | 481 (46.6) | 0.9 (0.7–1.1) | |
No | 1211 | 591 (48.8) | 1 | |
Care for cardiac condition | <0.001 | |||
Hospital cardiologist | 1066 | 544 (51.0) | 1.4 (1.2–1.8) | |
Other physician | 1178 | 528 (44.8) | 1 |
Characteristics . | Number of pre-index event smokers . | Number of stopped smokers (%) . | Odds ratio (95% CI)† . | P-value† . |
---|---|---|---|---|
Age | <0.001 | |||
<50 years | 522 | 212 (40.6) | 1 | |
50–60 years | 861 | 403 (46.8) | 1.3 (1.0–1.6) | |
≥60 years | 861 | 457 (53.1) | 1.6 (1.3–2.1) | |
Gender | 0.33 | |||
Male | 1829 | 888 (48.6) | 1 | |
Female | 415 | 184 (44.3) | 0.9 (0.7–1.1) | |
Highest level of education | <0.001 | |||
University, college, or equivalent | 249 | 140 (56.2) | 1.8 (1.4–2.5) | |
Intermediate school | 280 | 137 (48.9) | 1.6 (1.1–2.2) | |
Secondary school | 784 | 385 (49.1) | 1.3 (1.1–1.6) | |
Primary school | 924 | 410 (44.4) | 1 | |
Index event | <0.001 | |||
CABG | 430 | 200 (46.5) | 1 | |
PTCA | 683 | 331 (48.5) | 1.1 (0.9–1.5) | |
Myocardial infarction | 782 | 407 (52.0) | 1.3 (1.0–1.6) | |
Myocardial ischaemia | 349 | 134 (38.4) | 0.7 (0.5–0.9) | |
History of diabetes mellitus | ||||
Yes | 356 | 168 (47.2) | 0.9 (0.7–1.2) | 0.50 |
No | 1888 | 904 (47.9) | 1 | |
History of hypertension | ||||
Yes | 1027 | 492 (47.9) | 1.0 (0.9–1.2) | 0.66 |
No | 1217 | 580 (47.7) | 1 | |
History of hyperlipidemia | 0.26 | |||
Yes | 1559 | 766 (49.1) | 1.1 (0.9–1.4) | |
No | 685 | 306 (44.7) | 1 | |
Obesity | 0.01 | |||
Yes | 670 | 347 (51.8) | 1.4 (1.1–1.6)) | |
No | 1574 | 725 (46.1) | 1 | |
History of CHD | 0.04 | |||
Yes | 746 | 344 (46.1) | 0.8 (0.6–1.0) | |
No | 1498 | 728 (48.6) | 1 | |
Family history of premature CHD | 0.73 | |||
Yes | 1033 | 481 (46.6) | 0.9 (0.7–1.1) | |
No | 1211 | 591 (48.8) | 1 | |
Care for cardiac condition | <0.001 | |||
Hospital cardiologist | 1066 | 544 (51.0) | 1.4 (1.2–1.8) | |
Other physician | 1178 | 528 (44.8) | 1 |
†Results of multivariable logistic regression analyses, with adjustment for age, gender, index event and centre were appropriate.
Characteristics . | Number of pre-index event smokers . | Number of stopped smokers (%) . | Odds ratio (95% CI)† . | P-value† . |
---|---|---|---|---|
Age | <0.001 | |||
<50 years | 522 | 212 (40.6) | 1 | |
50–60 years | 861 | 403 (46.8) | 1.3 (1.0–1.6) | |
≥60 years | 861 | 457 (53.1) | 1.6 (1.3–2.1) | |
Gender | 0.33 | |||
Male | 1829 | 888 (48.6) | 1 | |
Female | 415 | 184 (44.3) | 0.9 (0.7–1.1) | |
Highest level of education | <0.001 | |||
University, college, or equivalent | 249 | 140 (56.2) | 1.8 (1.4–2.5) | |
Intermediate school | 280 | 137 (48.9) | 1.6 (1.1–2.2) | |
Secondary school | 784 | 385 (49.1) | 1.3 (1.1–1.6) | |
Primary school | 924 | 410 (44.4) | 1 | |
Index event | <0.001 | |||
CABG | 430 | 200 (46.5) | 1 | |
PTCA | 683 | 331 (48.5) | 1.1 (0.9–1.5) | |
Myocardial infarction | 782 | 407 (52.0) | 1.3 (1.0–1.6) | |
Myocardial ischaemia | 349 | 134 (38.4) | 0.7 (0.5–0.9) | |
History of diabetes mellitus | ||||
Yes | 356 | 168 (47.2) | 0.9 (0.7–1.2) | 0.50 |
No | 1888 | 904 (47.9) | 1 | |
History of hypertension | ||||
Yes | 1027 | 492 (47.9) | 1.0 (0.9–1.2) | 0.66 |
No | 1217 | 580 (47.7) | 1 | |
History of hyperlipidemia | 0.26 | |||
Yes | 1559 | 766 (49.1) | 1.1 (0.9–1.4) | |
No | 685 | 306 (44.7) | 1 | |
Obesity | 0.01 | |||
Yes | 670 | 347 (51.8) | 1.4 (1.1–1.6)) | |
No | 1574 | 725 (46.1) | 1 | |
History of CHD | 0.04 | |||
Yes | 746 | 344 (46.1) | 0.8 (0.6–1.0) | |
No | 1498 | 728 (48.6) | 1 | |
Family history of premature CHD | 0.73 | |||
Yes | 1033 | 481 (46.6) | 0.9 (0.7–1.1) | |
No | 1211 | 591 (48.8) | 1 | |
Care for cardiac condition | <0.001 | |||
Hospital cardiologist | 1066 | 544 (51.0) | 1.4 (1.2–1.8) | |
Other physician | 1178 | 528 (44.8) | 1 |
Characteristics . | Number of pre-index event smokers . | Number of stopped smokers (%) . | Odds ratio (95% CI)† . | P-value† . |
---|---|---|---|---|
Age | <0.001 | |||
<50 years | 522 | 212 (40.6) | 1 | |
50–60 years | 861 | 403 (46.8) | 1.3 (1.0–1.6) | |
≥60 years | 861 | 457 (53.1) | 1.6 (1.3–2.1) | |
Gender | 0.33 | |||
Male | 1829 | 888 (48.6) | 1 | |
Female | 415 | 184 (44.3) | 0.9 (0.7–1.1) | |
Highest level of education | <0.001 | |||
University, college, or equivalent | 249 | 140 (56.2) | 1.8 (1.4–2.5) | |
Intermediate school | 280 | 137 (48.9) | 1.6 (1.1–2.2) | |
Secondary school | 784 | 385 (49.1) | 1.3 (1.1–1.6) | |
Primary school | 924 | 410 (44.4) | 1 | |
Index event | <0.001 | |||
CABG | 430 | 200 (46.5) | 1 | |
PTCA | 683 | 331 (48.5) | 1.1 (0.9–1.5) | |
Myocardial infarction | 782 | 407 (52.0) | 1.3 (1.0–1.6) | |
Myocardial ischaemia | 349 | 134 (38.4) | 0.7 (0.5–0.9) | |
History of diabetes mellitus | ||||
Yes | 356 | 168 (47.2) | 0.9 (0.7–1.2) | 0.50 |
No | 1888 | 904 (47.9) | 1 | |
History of hypertension | ||||
Yes | 1027 | 492 (47.9) | 1.0 (0.9–1.2) | 0.66 |
No | 1217 | 580 (47.7) | 1 | |
History of hyperlipidemia | 0.26 | |||
Yes | 1559 | 766 (49.1) | 1.1 (0.9–1.4) | |
No | 685 | 306 (44.7) | 1 | |
Obesity | 0.01 | |||
Yes | 670 | 347 (51.8) | 1.4 (1.1–1.6)) | |
No | 1574 | 725 (46.1) | 1 | |
History of CHD | 0.04 | |||
Yes | 746 | 344 (46.1) | 0.8 (0.6–1.0) | |
No | 1498 | 728 (48.6) | 1 | |
Family history of premature CHD | 0.73 | |||
Yes | 1033 | 481 (46.6) | 0.9 (0.7–1.1) | |
No | 1211 | 591 (48.8) | 1 | |
Care for cardiac condition | <0.001 | |||
Hospital cardiologist | 1066 | 544 (51.0) | 1.4 (1.2–1.8) | |
Other physician | 1178 | 528 (44.8) | 1 |
†Results of multivariable logistic regression analyses, with adjustment for age, gender, index event and centre were appropriate.
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