Secondary prevention in coronary artery disease. Achieved goals and possibilities for improvements.

AIM: To describe presence of risk indicators of recurrence 6 months after hospitalisation due to coronary artery disease at a university clinic. METHODS: The presence of risk indicators, including tobacco use, lipid levels, blood pressure and glucometabolic status, including 24-hour blood pressure monitoring and an oral glucose-tolerance test, was analysed. RESULTS: Of 1465 patients who were screened, 402 took part in the survey (50% previous myocardial infarction and 50% angina pectoris). Mean age was 64 years (range 40-85 years) and 23% were women. Present medications were: lipid lowering drugs (statins; 94%), beta-blockers (85%), aspirin or warfarin (100%) and ACE-inhibitors or angiotensin II blockers (66%). Values above target levels recommended in guidelines were: a) low density lipoprotein (LDL) in 40%; b) mean blood pressure (day or night) in 38% and c) smoking in 13%. Of all patients, 66% had at least one risk factor (LDL or blood pressure above target levels or current smoking). An abnormal glucose-tolerance test was found in 59% of patients without known diabetes. If no history of diabetes, 85% had either LDL or blood pressure above target levels, current smoking or an abnormal glucose-tolerance test. However, with treatment intensification to patients with elevated risk factors 56% reached target levels for blood pressure and 79% reached target levels for LDL. CONCLUSION: Six months after hospitalisation due to coronary artery disease, despite the high use of medication aimed at prophylaxis against recurrence, the majority were either above target levels for LDL or blood pressure or continued to smoke.

The effectiveness of brief advice and extended smoking cessation counseling programs when implemented routinely in hospitals.

OBJECTIVE: To evaluate the effectiveness of two in-hospital smoking cessation interventions -- brief advice and extended counseling with follow-up. METHODS: The subjects (n=770) were in-patients who were daily smokers or had stopped smoking 30 days preceding admission to 15 wards in five Swedish hospitals. All wards started with a control period. Thereafter, eight wards treated patients with brief advice by a nurse and seven provided bedside support by a trained counselor plus telephone support for up to 30 days after discharge. RESULTS: The one-year point prevalence self-reported cessation rate of 22% for brief advice and 28% for extended counseling was not significantly better than usual care. The odds ratios were 1.12 (95% CI 0.63, 2.01) and 1.25 (95% CI 0.80, 1.98) respectively. The response rate was 79%. Brief advice was refused by 17% of the patients and extended counseling by 34%. Only half of the brief advice and one third of counseled patients received the complete program, and cessation rates among them were 25% and 38% respectively. CONCLUSION: In a hospital setting, neither brief advice nor extended counseling significantly increased cessation rates. However, patients who received the entire intervention were more successful at quitting. Effective implementation of current interventions may be more productive in reducing smoking than a search for better treatments.

Smoking cessation in patients with diabetes mellitus: results from a controlled study of an intervention programme in primary healthcare in Sweden.

OBJECTIVE: To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare. DESIGN: Regional controlled intervention study. SETTING: Seventeen primary healthcare centres in Sweden. INTERVENTION: In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up. PATIENTS: Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients. MAIN OUTCOME MEASURES: Self-reported smoking habits after one year. RESULTS: In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking. CONCLUSION: A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.

Psychologists and tobacco: attitudes to cessation counseling and patterns of use.

BACKGROUND: Psychologists can play an important role in helping their clients stop using tobacco. The extent to which they do so, or quit themselves, has not been reported previously. The utility of snus in reducing smoking prevalence is also questioned and merits study. METHOD: A 36-item self-completion questionnaire was mailed to a random sample of 1000 Swedish psychologists. RESULTS: The response rate was 85%. Very few psychologists (1%) 'often' helped clients to stop using tobacco. While a majority (72%) believed that quitting tobacco use would improve their client's quality of life, most (75%) thought that it was not their responsibility to help clients stop and 74% felt they lacked the necessary skills. About 8% of psychologists smoked cigarettes daily. Use of snus as an aid to cigarette cessation was common in men, but not women, although overall, the percentage of smokers who had quit smoking (72%) did not differ by gender. CONCLUSIONS: Most Swedish psychologists have stopped smoking, but very few help their clients to quit. Targeted campaigns aimed at encouraging and supporting psychologists to treat nicotine dependence are needed. This could increase cessation rates in the population. Snus helped reduce smoking prevalence among men and is a potentially useful harm reduction tool.

Smoking habits and predictors of continued smoking in patients with acute coronary syndromes.

BACKGROUND: Most patients with acute coronary syndrome quit smoking when hospitalized, although several have been found to relapse and resume smoking within 3 months. AIM: This paper reports a study to identify factors that can predict who will resume smoking after hospitalization for an acute coronary syndrome. METHODS: Patients (n = 1320) below the age of 75 years, admitted to a Swedish university hospital coronary care unit with acute coronary syndromes, between September 1995 and September 1999, were consecutively included. Data were collected from hospital medical records and included information on previous clinical history, former illnesses and smoking. During their hospitalization, an experienced nurse interviewed the patients by using a structured questionnaire to obtain additional information. Patients were followed up 3 months after the discharge. Those who continued to smoke (non-quitters) were compared with those who had stopped (quitters) with regard to age, sex, medical history, clinical course, and intention to quit. To identify factors independently related to continued smoking, a logistical regression in a formal forward stepwise mode was used. RESULTS: Of the patients admitted, 33% were current smokers. Three months after discharge, 51% of these patients were still smoking. There were no significant differences in age, gender or marital status between non-quitters and quitters. In a multivariate analysis, independent predictors of continued smoking were: non-participation in the heart rehabilitation programme (P = 0.0008); use of sedatives/antidepressants at time of admission (P = 0.001); history of cerebral vascular disease (P = 0.002), history of previous cardiac event (P = 0.01); history of smoking-related pulmonary disease (P = 0.03) and cigarette consumption at index (P = 0.03). CONCLUSIONS: Smoking patients who do not participate in a heart rehabilitation programme may need extra help with smoking cessation. The findings may provide means of identifying patients in need of special intervention.