Impact of smoking cessation counseling among acute myocardial infarction patients on post-hospitalization mortality rates:a systematic review

Eya Au Alhaijaa *,Ismael Allishi ,Mohamma Alnaeem ,Jafar Alasa Alshraieh

aPatient Safety and Experience Department.Abdali Medical Center,Amman 9662,Jordan

bAl-Istishari Hospital,Amman 11184,Jordan

cFaculty of Nursing,University of Jordan,Amman 11942,Jordan

dClinical Nursing Department,Faculty of Nursing,University of Jordan,Amman 11942,Jordan

Abstract: Objective:The current systematic review aimed to assess the impact of smoking cessation counseling (SCC) on patients’ short-and long-term mortality after acute myocardial infarction (AMI).Methods:The Cochrane guidelines were used to conduct a systematic review of Medline (PubMed),ScienceDirect,CINAHL Cochrane database,and Google Scholar for studies on the impact of SCC on AMI patients’ mortality.Results:Five studies were found to meet the predefined inclusion criteria.Smoker patients were not routinely counseled to quit smoking during their post-AMI hospital stay.Studies showed a reduction in mortality among AMI patients’ who received SCC compared with patients who did not receive it.Conclusions:SCC during hospitalization and after discharge is a simple and cost-effective intervention that improves AMI patients’survival.

Keywords: acute myocardial infarction ? counseling ? mortality ? nursing ? smoking cessation

1.Introduction

Smoking is a global health problem and the leading cause of death,1resulting in 8 million deaths annually.2The overall mortality rate among smokers was 3 times higher than never-smokers.1Smoking has a significant impact on coronary blood flow,myocardial oxygenation needs,and the risk of thrombosis formation.3Almost 70%of smokers are at risk of developing fatal coronary heart diseases.4The estimated mortality rate among patients with acute myocardial infarction (AMI) is about 30%,in which half of the deaths occur before hospital arrival.Besides,about 10% of AMI patients died within the first year after their attack.1Despite the documented tremendous impact of smoking on health,only a few smokers receive cessation counseling from health care providers.5

Studies have reported a positive impact of smoking cessation on mortality rates of AMI patients.6-8Critchley and Capewell,9in their Cochrane systematic review,reported a mortality risk reduction of 37% for patients who quit smoking after a heart attack.Wilson et al.6and Shah7concluded that smoking cessation significantly reduces the risk of mortality and morbidity of AMI patients.

The patients’ acute illness and symptoms may trigger lifestyle changes,10and smoking cessation counseling (SCC) would become a critical component of patient care planning of health care professionals.11SCC had been endorsed by quality healthcare organizations as one of the quality care measures.12,13The Joint Commission (TJC) has approved SCC during AMI hospitalization in the national quality care measures12and its international library of measures.13However,little is known about the effectiveness of such counseling on mortality rates.The current systematic review aims to assess the impact of SCC on patients’ short and longterm mortality after AMI.

2.Methods

2.1.Data sources and search strategy

The researchers have adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) guideline14to report this study.A systematic review of Medline (PubMed),ScienceDirect,CINAHL,and Google Scholar was conducted for studies on the impact of SCC for AMI patients on mortality rate.Search terms included SCC,smoking quit counseling,tobacco cessation counseling,mortality rate,death rate,AMI,and acute coronary syndrome.No limit on either English language or year of publication was applied.All possible combinations of the keywords were searched,and a manual literature search was further performed by reviewing studies referenced in retrieved papers.As an example of literature search,we can mention the PubMed search forming part of the present study,which was carried out using the following combinations of search terms:((smoking cessation counseling) AND(acute myocardial infarction)) AND (mortality),((smoking cessation counseling) AND (acute coronary syndrome))AND (mortality rate),((((smoking cessation counseling)OR (tobacco cessation counseling)) OR (smoking quit counseling)) AND (mortality rate)) AND (acute myocardial infarction),((((smoking cessation counseling) OR(tobacco cessation counseling)) OR (smoking quit counseling)) AND (mortality rate)) AND (acute coronary syndrome),etc.All possible combinations of word search were done.The literature search yielded 100 abstracts that were further screened for eligibility based on this study’s inclusion criteria.

2.2.Ethical consideration

Institutional review board approval was not required for this literature review.The investigation conforms to the principles outlined in the Declaration of Helsinki.14

2.3.Study selection and eligibility

The Population,Issue of interest,Comparison,Outcome,and Timeframe (PICOT) framework guided the question and inclusion criteria.This study review protocol was registered in Prospero during the period of the COVID crisis in 2020.The review protocol was registered automatically (registration No.CRD42020143071).Studies were included in the review if they met the following criteria.The population consists of adult patients with a confirmed diagnosis of AMI;the intervention is smoking or tobacco cessation or quit counseling during hospitalization;the comparison is patients who did not receive the SCC;the outcome is mortality (all-cause,specific cause,immediate and or delayed mortality);and the time is the immediate and delayed mortality of AMI patients.All study designs were included.Two investigators independently screened titles and abstracts identified by the searches to check their eligibility.If there were any disagreements between researchers and titles and abstracts didn’t provide sufficient information,then the full text was reviewed to check if the paper met inclusion criteria.Full texts of all publications that were decided to meet standards potentially were then examined to determine final inclusion.Any disagreement between reviewers was resolved by consensus or a third reviewer.

2.4.Data extraction and synthesis

Each study was reviewed by 2 reviewers.Disagreement regarding data abstraction was resolved by consensus or a third reviewer.Data were summarized using narrative form based on elements of data abstraction.The abstracted data included the study purpose,designs,participants and population,primary and secondary outcomes,definitions of measures,results,and limitations.

3.Results

The study deletion process is shown in Figure 1.Our literature search yielded 233 abstracts,of which 36 were found eligible based on initial screening and therefore underwent full-text review.Of the 36 studies,5 met the inclusion criteria and were included in the final evaluation.The study of Brown et al.15published in 2004 was the first study to address the impact of SSC on mortality rates among patients diagnosed with AMI;it was followed by Houston et al.16in 2005;Mohiuddin et al.17and Van Spall,Chong A,and Tu18in 2007;and Bucholz et al.19in 2016.

Figure 1. Flow of studies through the review process.

Regarding study design,4 were retrospective,cross-sectional studies,15-17,193 sampled the US national cooperative cardiovascular quality improvement project database,15,16,19and 1 tested the Canadian Enhanced Feedback for Effective Cardiac Treatment (EFFECT)project data.18Only 1 randomized controlled study was found,17in which the researchers examined the impact of structured smoking cessation counseling intervention(intensive counseling programs) versus standard smoking cessation counseling (verbal counseling) among patients with cardiovascular disease,including acute myocardial infarction patients.Table 1 presents the reported mortality rates of each study.

3.1.Smoking Cessation Counseling

Smoker patients were not routinely counseled to quit smoking during their post-AMI hospital stay.15,16,18,19The smoking cessation rate ranged between 33.9% and 52.1% in the reviewed studies.Please refer to Table 2 for more details of individual studies.

Table 1. Reported mortality rates in each study.

Table 2. Reported SCC rates.

Studies had reported variation in characteristics of patients who received SCC.Patients who were lesslikely to receive SSC were non-white,15,16,19had diabetes mellitus,heart failure,were older patients,15,16,18,19had hypertension,had stroke,15,19were discharged to a skilled nursing facility,15had a higher APACHE II score,16and were women.15On the other hand,patients who were most likely to receive SCC had a history of chronic obstructive pulmonary disease,15,16,19peripheral vascular disease,19Killip class ＞2,19treatment by revascularization [Percutaneous Coronary Intervention (PCI)/Coronary Artery Bypass Graft(CABG)] within 30 d,aspirin on admission for eligible patients,and beta-blockers on admission for qualified patients and fibrinolytic therapy.19

All 5 retrospective studies reviewed showed a reduction in AMI patients’ mortality after discharge from hospital among patients who received SCC compared with patients who did not receive SCC.14-18Brown et al.16had sampled 788 AMI smoker patients from 117 North Carolina care facilities in 2005 and reported a reduction of 5 years’ crude mortality among patients who were counseled (relative hazard 0.78,95% confidence interval [CI] 0.63-0.97).16A sample of 16,743 AMI smoker patients from 2971 acute care facilities in the US was studied by Houston et al.17in 2005,and they found an improved 30 d mortality (1%),60 d mortality (1.9%),and 2 years mortality (5%) among patients who received SCC.17

Moreover,Van Spall et al.19investigated the 1-year mortality of AMI patients from 83 teaching and community hospitals in Ontario and a sample size of 9041 AMI patients.The authors documented a significant reduction of the 1-year mortality (hazard ratio 0.63,CI 0.44-0.9)among patients counseled to stop smoking.19Bucholz et al.8conducted a study in 2017 and investigated 13,815 AMI smoker patients from acute care non-governmental hospitals in the US.The investigators reported a lower mortality associated with 30 d (22.6%) and 17 years(7.5%) among patients who received SCC.8

Mohiuddin et al.18conducted a randomized controlled study at a university-affiliated teaching hospital to compare the effect of intensive smoking cessation programs versus the standard smoking cessation counseling before patient discharge on mortality.The total number of participants was 209,among which 109 were categorized into intervention groups and 100 into usual care groups.The interventional group received SCC for 60 min/week for a minimum of 3 months,delivered by a trained tobacco cessation counselor.This study reported that smokers who received intensive counseling programs had a lower mortality rate (2.8%) than AMI smokers who received only verbal counseling upon discharge (12.0%).18Data about the mortality rate risk reduction for each study are presented in Table 3.

The 2-year mortality rate risk reduction was reported only from 1 study and was 8%,with a hazard ratio of(0.92),and a 95% CI of (0.86-0.98).16The 5 years mortality risk reduction was almost the same15,19and was reported as 22%,with a hazard risk of (0.782,0.78),and 95% confidence intervals of (0.744-0.823) and(0.63-0.97) consecutively.At the same time,the longterm mortality of 17 years was only reported as 7.5%,with a hazard ratio of 0.925,and a 95% confidence interval of (0.893-0.959).19Control for possible confounding variables was reported in all studies included in this systematic review.15,16,18,19

3.2.Assessment of risk of bias

Only 1 study included in this review was a randomized controlled trial.The other studies were cross-sectional retrospective reviews,and analyzed data from a national database.The authors have assessed the retrieved studies’ methodological features that might affect the estimates of the mortality rates among AMI patients.The assessment was done in both the study and the outcome.No formal risk of bias assessment was used because only 1 randomized controlled trial was used,and the reviewers’ decision at that time was to proceed with the consensus agreement of the risk of bias,considering the report20that the current biases reporting tools are lacking clear criteria for risk of bias assessment.Overall,all studies have described the sample population,determined the relevant inclusion and exclusion criteria,and defined the criteria of AMI and mortality rates.Only 1 study has detailed the data abstraction techniques adopted and its reliability assessment.Moreover,the randomized controlled trial was a single-center study that lacked a blindness protocol.

4.Discussion

Only 5 studies that connect SCC with AMI mortality were identified,but despite this being so,counseling of AMI patients to stop smoking has been recommended by the United States (US) treating tobacco use and dependence guidelines,8and the European guideline for the management of AMI.21.Out of the 5 studies,4 were retrospective in design,and only 1 used a prospective randomized control trial design.Out of 5 studies,3 were part of the US national cooperative cardiovascular quality improvement project,8,16,17and 1 study was from the EFFECT Canadian project.19

Our review has found that AMI patients are not routinely counseled for smoking cessation during their hospitalization.The documentation of SCC in the reviewed literature ranged from 33.9% to 52.1%.The single available randomized controlled study compared conventional SCC during hospitalization,and an extensive SCC combined with a pharmacological treatment continued after discharge.18The interventional group received SCC for 60 min/week,for a minimum of 3 months,delivered by a trained tobacco cessation counselor.This RCT study reported that smokers who received intensive counseling programs had a lower mortality rate (2.8%)than AMI smokers who received only verbal counseling upon discharge (12.0%).18Our finding is consistent with the 2014 CDC findings that only half of the US smokers received SCC by a healthcare provider.5

White patients were more likely to be counseled to quit smoking than non-whites,8,16,17a finding that has been supported by a US study on racial disparities of SCC by healthcare providers that reported white smokers were around 2.5 times more likely to be counseled than black smokers.5Patients with a history of chronic obstructive pulmonary disease,peripheral vascular disease,and AMI risk stratification of Killip class ＞2,patients who received AMI treatment,younger patients,and patients with low disease severity were more likely to receive SCC.Meanwhile,elderly patients,and patients with a history of DM,heart failure,and HTN were less likely to receive SCC.However,this data should be considered cautiously since all studies were conducted in the US and Canada,and 3 out of 5 studies had sampled the same database.

In general,the mortality rates were better in AMI patients’ who received SCC than patients who did not receive the counseling in the reviewed studies.However,the retrospective nature is the primary concern in most of these studies.The uncertainties regarding AMI smokers’ adherence to smoking cessation are the primary concerns.The highest gain in life was reported within the first year after patient discharge from the hospital (37%).This finding is concurrent with Critchley et al.’s9systematic review findings in 2009,who reported again in life for those who quit smoking compared to those who smoked as about 36%.

The only randomized control study8was a singlecenter study that compared a structured smoking cessation program and standard care of SSC during hospitalization,and reported a mortality risk reduction of 77% in the interventional group than the control group.In this trial,the structured smoking cessation program started during the patient acute illness hospitalization and followed the patients after being discharged home,and included a combination of behavioral and pharmacological intervention.The observed effect was thought to be due to the intensity of the interventional protocol,combining SSC and pharmacological treatment,and following-up patients post-discharge.10,22

5.Conclusions

Smoking cessation counseling is simple,and one of the cost-effective lifestyle changes interventions post AMI,which nurses can carry out or suggest.Smoking cessation counseling of AMI patients during hospitalization and after discharge may independently or in conjunction with other interventions reduce short-and longterm mortality.To maximize SCC programs,counseling should begin straightaway during the AMI hospitalization period and continue to at least 1 month after discharge.We recommend including SCC in the medical and nursing management guidelines of AMI.Prospective studies to investigate the effect of SCC on quitting smoking and mortality are recommended.

Limitations

Our present review has identified several limitations of the included studies.The majority were nonrandomized,observational studies with no control groups,had relied on health provider documentation of patient smoking habits and SCC,and contained no clear definition of smoking.All analyses were in the US and Canada.Moreover,we have searched only Medline (PubMed),ScienceDirect,CINAHL,and Google Scholar in this review.Other possible related publications may be present in other databases or even be not indexed.

Further,this review has focused on a single outcome measure,which is the mortality rate of AMI.One primary outcome of SCC is to quit smoking.However,this was not measured in all reviewed studies,and it was assumed that patients who received SCC were more likely to quit than a patient who didn’t have SCC.

Implications for practice

? Nurses and other healthcare providers caring for AMI patients are encouraged to initiate SCC as part of their care plan.

? Smoking cessation counseling should begin straightaway during the patient’s hospitalization and continue at least 1 month post-discharge.

? Smoking cessation counseling that includes behavioral and pharmacological treatment is superior to conventional routine intervention.

Ethical approval

Ethical issues are not involved in this paper.

Conflicts of interest

All contributing authors declare that no conflicts of interest exist.