Smoking and Provision of Smoking Cessation Interventions among Inpatients with Acute Coronary Syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project

Guoliang Hu, Mengge Zhou, Jing Liu, Sidney C Smith Jr, Changsheng Ma, Junbo Ge, Yong Huo, Gregg C Fonarow, Yongchen Hao, Jun Liu, Kathryn A Taubert, Louise Morgan, Na Yang, Yuhong Zeng, Yaling Han, Dong Zhao, CCC-ACS Investigators, Guoliang Hu, Mengge Zhou, Jing Liu, Sidney C Smith Jr, Changsheng Ma, Junbo Ge, Yong Huo, Gregg C Fonarow, Yongchen Hao, Jun Liu, Kathryn A Taubert, Louise Morgan, Na Yang, Yuhong Zeng, Yaling Han, Dong Zhao, CCC-ACS Investigators

Abstract

Highlights: Over half of male acute coronary syndrome patients were smokers in China.Smoking was associated with higher risk of critical cardiac symptoms at admission.Only 35.3% of smoking patients received smoking cessation interventions in China.

Background: Smoking cessation is recognized as an effective and cost-effective strategy for improving the prognosis of patients with coronary heart disease. Despite this, few studies have evaluated the smoking prevalence and provision of smoking cessation interventions among patients with acute coronary syndrome (ACS) in China.

Objectives: To evaluate the smoking prevalence, clinical conditions and in-hospital outcomes associated with smoking, and the provision of smoking cessation interventions among ACS patients in China.

Methods: This registry study was conducted using data from the Improving Care for Cardiovascular Disease in China project, a collaborative nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Our study sample comprised 92,509 ACS inpatients admitted between November 2014 and December 2018. A web-based data collection platform was used to report required data.

Results: Smoking prevalence among male and female ACS patients was 52.4% and 8.0%, respectively. Patients younger than 45 years had the highest smoking rate (men: 68.0%; women: 14.9%). Compared with non-smokers, smokers had an earlier onset age of ACS and a greater proportion of severe clinical manifestations at admission, including ST-elevation myocardial infarction (67.8% versus 54.8%; p < 0.001) and substantially elevated myocardial injury markers (86.1% versus 83.0%; p < 0.001). After multivariable adjustment, smoking was associated with higher risk of critical cardiac symptoms at admission (OR = 1.14, 95% CI: 1.08-1.20; p < 0.001) and had no direct association with in-hospital outcomes (OR = 0.93, 95% CI: 0.84-1.02; p = 0.107) of ACS patients. Of 37,336 smokers with ACS, only 35.3% received smoking cessation interventions before discharge. There was wide variation in provision of smoking cessation interventions across hospitals (0%-100%).

Conclusions: Smoking is highly prevalent among ACS patients in China. However, smoking cessation interventions are not widely adopted in clinical practice in China as part of formal treatment strategies for ACS patients, indicating an important target for quality improvement.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.

Keywords: acute coronary syndrome; in-hospital outcome; prevalence; smoke; smoke cessation intervention.

Conflict of interest statement

The authors have no competing interests to declare.

Copyright: © 2020 The Author(s).

Figures

Figure 1
Figure 1
Smoking prevalence among ACS patients by sex and age. Smoking prevalence over the entire study period among different age groups among male ACS patients (blue) and female ACS patients (red). ACS: acute coronary syndrome.
Figure 2
Figure 2
Multivariable analysis of association between smoking and critical cardiac symptoms at admission and in-hospital outcomes among ACS patients. This forest plot shows patients’ critical cardiac symptoms at admission and in-hospital outcomes according to smoking status among all ACS patients, and among patients by subtypes of ACS, using data from the CCC-ACS project. Critical cardiac symptoms at admission included acute heart failure, cardiogenic shock, and cardiac arrest. ACS: acute coronary syndrome; CI: confidence interval; NSTE-ACS: non-ST-elevation acute coronary syndrome; OR: odds ratio; STEMI: ST-elevation myocardial infarction.
Figure 3
Figure 3
Rates of provision of different types of smoking cessation interventions. Rates of provision of different smoking cessation interventions before discharge for the entire study period among all smokers with ACS who survived to discharge. ‡ Provided any two or more above smoking cessation interventions.
Figure 4
Figure 4
Comparison of patients receiving smoking cessation interventions and medications for secondary prevention before discharge. Proportion of patients receiving smoking cessation interventions and other ACS quality of care measures for the entire study period among all smoking ACS patients before discharge. ACEI: angiotensin-converting enzyme inhibitor; ACS: acute coronary syndrome; ARB: angiotensin-receptor blocker.

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