Implementation of smoking cessation treatment in substance use disorder treatment settings: a review

ABSTRACT

Background: The high prevalence of smoking among individuals receiving treatment for substance use disorder (SUD) has led to repeated calls for integrating smoking cessation treatment into these settings. Objectives: This review summarizes key findings from the research on the implementation of smoking cessation in SUD treatment. Methods: PubMed searches of articles published from 2000 to 2015 yielded 48 empirical studies that focused on the delivery of smoking cessation in the US specialty SUD treatment settings in which organizations and counselors were the unit of analysis. Most studies used observational designs to gather data from organizations and counselors. Organizational studies show that few SUD treatment programs offer cessation counseling or pharmacotherapy. Organizational barriers include limited training, inadequate resources, and cultural norms that do not recognize smoking cessation as part of the organization’s mission. Smoking cessation services are more likely to be available in medically oriented treatment settings, larger treatment programs, those offering a broader array of comprehensive services, and those that are more reliant on fee-for-service reimbursement (e.g., insurance, Medicaid). Surveys of counselors also show very low implementation. Counselors’ personal skills and attitudes, their perceptions of managerial and coworker support for smoking cessation, and the availability of resources and reimbursement to support these services are correlated with implementation. State policies requiring treatment programs to offer tobacco treatment increase both adoption and implementation, yet these services continue to reach only modest percentages of the patients. Conclusions: Few studies have tested specific implementation strategies. Such research is needed to determine how to accelerate the diffusion of these evidence-based practices to the SUD treatment field.     

Exploring perceptions of a rheumatoid arthritis‐specific smoking cessation programme

Aim

Smoking cessation is an important consideration in the management of rheumatoid arthritis (RA). The aim of the present study was to determine which aspects of a novel three‐month smoking cessation intervention were most useful for people with RA, and to identify areas for improvement.

Method

Thirty‐eight current smokers with RA (19 intervention and 19 control) enrolled in a previous randomized controlled trial (RCT) of smoking cessation and two arthritis educators who had provided the intervention were interviewed. The data were analysed thematically using a combination of deductive and inductive approaches to identify themes.

Results

Intervention participants and the educators identified individualized support and advice as the two most important components of the smoking cessation intervention. The generic smoking cessation components and education about the links between smoking and RA were also identified as important. Nicotine replacement therapy was provided to all participants and was the most commonly reported facilitator of smoking cessation. People with RA who reported being ready to quit smoking had more success at smoking cessation. The educators were positive about ongoing provision of the smoking cessation intervention.

Conclusion

The novel RA‐specific smoking cessation intervention that had formed the basis of the previous RCT provided useful and varied options to assist quitting smoking in RA. Successful quitters were ready and motivated to quit smoking regardless of their randomization status, with nicotine replacement therapy an effective aid to quitting. Support offered by the educators was critical in the participants' perspective.     

Hospitalization and emergency department visits among seniors receiving homecare: a pilot study

Background

The objective of this study was to examine the Minimum Data Set (MDS) and Geriatric Depression Scale (GDS) as measures of depression among nursing home residents.

Methods

The data for this study were baseline, pre-intervention assessment data from a research study involving nine nursing homes and 704 residents in Massachusetts. Trained research nurses assessed residents using the MDS and the GDS 15-item version. Demographic, psychiatric, and cognitive data were obtained using the MDS. Level of depression was operationalized as: (1) a sum of the MDS Depression items; (2) the MDS Depression Rating Scale; (3) the 15-item GDS; and (4) the five-item GDS. We compared missing data, floor effects, means, internal consistency reliability, scale score correlation, and ability to identify residents with conspicuous depression (chart diagnosis or use of antidepressant) across cognitive impairment strata.

Results

The GDS and MDS Depression scales were uncorrelated. Nevertheless, both MDS and GDS measures demonstrated adequate internal consistency reliability. The MDS suggested greater depression among those with cognitive impairment, whereas the GDS suggested a more severe depression among those with better cognitive functioning. The GDS was limited by missing data; the DRS by a larger floor effect. The DRS was more strongly correlated with conspicuous depression, but only among those with cognitive impairment.

Conclusions

The MDS Depression items and GDS identify different elements of depression. This may be due to differences in the manifest symptom content and/or the self-report nature of the GDS versus the observer-rated MDS. Our findings suggest that the GDS and the MDS are not interchangeable measures of depression.     

Smoking inside Canadian acute care hospitals

OBJECTIVE:

To assess smoking policies at Canadian acute care hospitals.

METHOD:

A questionnaire was designed, piloted and faxed to all acute care hospitals in Canada. The questionnaire was designed to address the following: what is the current policy regarding patient smoking? Are staff and/or visitors allowed to smoke inside the hospital? Is there a separate policy for psychiatric patients? Are smoking cessation products available at the hospital pharmacy? Is the policy governed by regional or municipal legislation?

RESULTS:

A total of 852 hospitals were included in the study. Of these, 476 responded to the questionnaire, for an overall response rate of 56%. Twenty-seven per cent of respondents allowed patient smoking inside the hospital. While staff smoking was not allowed inside most hospitals (93%), 32% of hospitals in Quebec allowed staff to smoke inside the building. Thirty per cent of hospitals had a separate policy for psychiatric patients, and 27% of hospitals had provisions for visitor smoking. Sixty-seven per cent of hospitals were able to offer patients smoking cessation products while they were in hospital.

CONCLUSIONS:

Many Canadian hospitals continue to allow smoking inside their facilities. There is considerable variation in hospital smoking policies across the country.     

Receipt of Provider Advice for Smoking Cessation and Use of Smoking Cessation Treatments Among Cancer Survivors

BACKGROUND

As the number of cancer survivors increases, the assessment and intervention for smoking among survivors are increasingly important.

OBJECTIVE

This study examined the extent to which cancer survivors reported being asked and advised about smoking by health-care providers and their use of smoking cessation treatments during quit attempts.

DESIGN

The data were drawn from the 2005 National Health Interview Survey, an annual health survey of US adults.

PARTICIPANTS

The participants were 1,825 individuals who reported being diagnosed with cancer at least 1 year previously and provided data regarding their current smoking status.

MEASUREMENTS

Participants completed items assessing demographics, health and health-care factors, and smoking-related variables.

MAIN RESULTS

More than three-quarters of participants (81.0%) reported that their smoking status was known by a health-care provider. Among current smokers (17.6%) who visited a health-care provider in the past year, 72.2% reported being advised to quit smoking by a provider. Factors associated with a higher rate of receiving advice to quit included greater cigarette consumption (P=0.008), more medical comorbidities (P=?0.001), high psychological distress (P=?0.003), and lack of health-care insurance (P?=?0.03). Among current smokers who tried to quit in the last year, 33.5% used pharmacotherapy cessation treatment and 3.8% used an evidence-based behavioral treatment.

CONCLUSIONS

This study reveals considerable missed opportunities for health-care providers to advise cancer survivors about smoking and provide evidence-based interventions. Systematic efforts are needed to increase the provision of smoking cessation advice and use of cessation treatments among cancer survivors.

     

Proactive bedside counseling of smokers hospitalized in cardiac intensive care unit

Aim of the study

To offer routine information on smoking cessation and bedside counseling to smokers admitted in cardiac intensive care unit. The objective is to encourage cessation and/or use of smoking cessation services after discharge.

Population and methods

Thirty-three smokers were admitted in cardiac intensive care unit at the Georges Pompidou European hospital (HEGP) in Paris (France) from 1st March to June 30th 2010. Assessment of tobacco use and offer of counseling and follow-up visits during and after hospital stay. Evaluation of tobacco use by telephone at least six months after discharge.

Results

It was found that 30.3% of the patients stopped smoking, mostly without specialized help despite heavy smoking prior to hospitalization. They declared being impressed by their hospital stay. Motives for smoking among continuing smokers were mostly automatic smoking and stress relief. They had declined any smoking aid, despite subsequent hospital stays in cardiac intensive care. Three smokers with a severe profile had died at follow-up. Smokers followed-up at HEGP were in need of nicotine replacement therapy. More than six months after hospital discharge, nearly all smokers remembered being offered bedside counseling to stop smoking.

Conclusion

This experience reveals the importance of routine bedside counseling for smoking cessation in cardiac intensive care unit. Smokers in this unit often continue smoking even though smoking hinders cardiac rehabilitation.     

Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers

Background

Current guidelines advise providers to assess smokers’ readiness to quit, then offer cessation therapies to smokers planning to quit and motivational interventions to smokers not planning to quit.

Objectives

We examined the relationship between baseline stage of change (SOC), treatment utilization, and smoking cessation to determine whether the effect of a proactive smoking cessation intervention was dependent on smokers’ level of motivation to quit.

Design

Secondary analysis of a multicenter randomized controlled trial.

Participants

A total of 3006 current smokers, aged 18–80 years, at four Veterans Affairs (VA) medical centers.Interventions: Proactive care included proactive outreach (mailed invitation followed by telephone outreach), offer of smoking cessation services (telephone or face-to-face), and access to pharmacotherapy. Usual care participants had access to VA smoking cessation services and state telephone quitlines.

Main Measures

Baseline SOC measured with Readiness to Quit Ladder, and 6-month prolonged abstinence self-reported at 1 year.

Key Results

At baseline, 35.8 % of smokers were in preparation, 38.2 % in contemplation, and 26.0 % in precontemplation. The overall interaction between SOC and treatment arm was not statistically significant (

Limitations

Mostly male participants limits generalizability. Randomization was not stratified by SOC.

Conclusions

Proactive care increased treatment uptake compared to usual care across all SOC. Proactive care increased smoking cessation among smokers in preparation and contemplation but not in precontemplation. Proactively offering cessation therapies to smokers at all SOC will increase treatment utilization and population-level smoking cessation.

     

Comparing the Functional Independence Measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature

Background

The rehabilitation of older persons is often complicated by increased frailty and medical complexity - these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings - in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems.

Methods

English language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Relevant articles were summarized and charted using the criteria proposed by Streiner. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements.

Results

In total, 66 articles were found that met the inclusion criteria. The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS.

Conclusion

Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and with different client groups.     

Smoking Cessation Among Women with and at Risk for HIV: Are They Quitting?

BACKGROUND

Cigarette smoking is an important risk factor for adverse health events in HIV-infected populations. While recent US population-wide surveys report annual sustained smoking cessation rates of 3.4–8.5%, prospective data are lacking on cessation rates for HIV-infected smokers.

OBJECTIVE

To determine the sustained tobacco cessation rate and predictors of cessation among women with or at risk for HIV infection.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 747 women (537 HIV-infected and 210 HIV-uninfected) who reported smoking at enrollment (1994–1995) in the Women’s Interagency HIV Study (WIHS) and remained in follow-up after 10 years. The participants were mostly minority (61% non-Hispanic Blacks and 22% Hispanics) and low income (68% with reported annual incomes of less than or equal to $12,000).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was defined as greater than 12 months continuous cessation at year 10. Multivariate logistic regression was used to identify independent baseline predictors of subsequent tobacco cessation. A total of 121 (16%) women reported tobacco cessation at year 10 (annual sustained cessation rate of 1.8%, 95% CI 1.6–2.1%). Annual sustained cessation rates were 1.8% among both HIV-positive and HIV-negative women (p = 0.82). In multivariate analysis, the odds of tobacco cessation were significantly higher in women with more years of education (p trend = 0.02) and of Hispanic origin (OR = 1.87, 95% CI = 1.4–2.9) compared to Black women. Cessation was significantly lower in current or former illicit drug users (OR = 0.42 95% CI = 0.24–0.74 and OR = 0.65, 95% CI = 0.49–0.86, respectively, p trend = 0.03) and women reporting a higher number of cigarettes per day at baseline (p trend < 0.001).

CONCLUSIONS

HIV-infected and at-risk women in this cohort have lower smoking cessation rates than the general population. Given the high prevalence of smoking, the high risk of adverse health events from smoking, and low rates of cessation, it is imperative that we increase efforts and overcome barriers to help these women quit smoking.KEY WORDS: smoking cessation, HIV/AIDS, clinical epidemiology, vulnerable populations     

Nicotine dependence and smoking habits in patients with head and neck cancer

Objective:

To assess smoking habits and nicotine dependence (ND) in patients with head and neck cancer

Methods:

This study involved 71 smokers or former smokers with squamous cell carcinoma in the oral cavity, pharynx, or larynx who were treated at a university hospital in the city of São Paulo between January and May of 2010. We used the Fagerström Test for Nicotine Dependence to evaluate smoking habits and ND in the sample. Data regarding cancer treatment were collected from medical records. Depending on the variables studied, we used the chi-square test, Fisher''s exact test, Student''s t-test, or Spearman''s correlation test.

Results:

Of the 71 patients, 47 (66.2%) presented with high or very high ND, 40 (56.3%) smoked more than 20 cigarettes/day, and 32 (45.1%) smoked their first cigarette within 5 min of awakening. Advanced disease stage correlated significantly with the number of cigarettes smoked per day (p = 0.011) and with smoking history (p = 0.047). We found that ND did not correlate significantly with gender, disease stage, smoking cessation, or number of smoking cessation attempts, nor did the number of cigarettes smoked per day correlate with smoking cessation or gender. Treatment for smoking cessation was not routinely offered.

Conclusions:

In most of the patients studied, the level of ND was high or very high. The prevalence of heavy smoking for long periods was high in our sample. A diagnosis of cancer is a motivating factor for smoking cessation. However, intensive smoking cessation treatment is not routinely offered to smoking patients diagnosed with cancer.     

Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study

BACKGROUND

Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population.

OBJECTIVE

We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers.

DESIGN

Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data.

PATIENTS

Cohort of patients who smoke and who gained Medicaid coverage in 2008–2011 after ≥ 6 months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n?=?4140 matched pairs; 8280 patients).

INTERVENTION

Gaining Medicaid after being uninsured for ≥ 6 months.

MAIN MEASURES

‘Quit’ smoking status (baseline smoking status was ‘current every day’ or ‘some day’ and status change to ‘former smoker’ at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period.

KEY RESULTS

The newly insured had 40 % increased odds of quitting smoking (aOR?=?1.40, 95 % CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR?=?2.94, 95 % CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR?=?2.12, 95 % CI:1.94, 2.32) compared to their uninsured counterparts.

CONCLUSIONS

Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation.

     

Best practices for smoking cessation interventions in primary care

BACKGROUND:

In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity-based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one-half offer adjunct support to patients.

OBJECTIVE:

To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients.

METHODS:

A multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived from international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article.

RESULTS:

The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients’ lives.

CONCLUSION:

Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front-line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.     

Medicare Part D—Lessons Learned and Guidance for Health-care Reform

BACKGROUND

Smoking cessation services in the Department of Veterans Affairs (VA) are currently provided via outpatient groups, while inpatient cessation programs have not been widely implemented.

OBJECTIVE

The objective of this paper is to describe the implementation of the Tobacco Tactics program for inpatients in the VA.

METHODS

This is a pre-/post-non-randomized control study initially designed to teach inpatient staff nurses on general medical units in the Ann Arbor and Detroit VAs to deliver the Tobacco Tactics intervention using Indianapolis as a control group. Coupled with cessation medication sign-off, physicians are reminded to give patients brief advice to quit.

RESULTS

Approximately 96% (210/219) of inpatient nurses in the Ann Arbor, MI site and 57% (159/279) in the Detroit, MI site have been trained, with an additional 282 non-targeted personnel spontaneously attending. Nurses’ self-reported administration of cessation services increased from 57% pre-training to 86% post-training (p?=?0.0002). Physician advice to quit smoking ranged between 73–85% in both the pre-intervention and post-intervention period in both the experimental and control group. Volunteers made follow-up telephone calls to 85% (n?=?230) of participants in the Ann Arbor site. Hospitalized smokers (N?=?294) in the intervention group are reporting an increase in receiving and satisfaction with the selected cessation services following implementation of the program, particularly in regards to medications (p?

CONCLUSION

A large proportion of inpatient nursing staff can rapidly be trained to deliver tobacco cessation interventions to inpatients resulting in increased provision of services.

     

Effectiveness of a text messaging-based smoking cessation intervention (Happy Quit) in China: a randomised controlled trial

Background

The population of China has the highest proportion of cigarette smokers worldwide, accounting for more than 40% of the world's total cigarette consumption. Despite the acceptability, feasibility, and efficacy of mobile phone-based text messaging interventions for smoking in other countries, there is a lack of smoking cessation services in China. Here we assessed the efficacy of a mobile phone-based smoking cessation intervention (Happy Quit) in China.

Depression,anxiety, stress,and motivation over the course of smoking cessation treatment

Objective:

To evaluate changes in the levels of patient anxiety, depression, motivation, and stress over the course of smoking cessation treatment.

Methods:

This cohort study involved patients enrolled in a smoking cessation program in Cuiabá, Brazil. We selected patients who completed the program in six months or less (n = 142). Patient evaluations were conducted at enrollment (evaluation 1 [E1]); after 45 days of treatment with medication and cognitive-behavioral therapy (E2); and at the end of the six-month study period (E3). Patients were evaluated with a standardized questionnaire (to collect sociodemographic data and determine smoking status), as well as with the University of Rhode Island Change Assessment scale, Beck Anxiety Inventory, Beck Depression Inventory, and Lipp Inventory of Stress Symptoms for Adults. The data were analyzed with the nonparametric Wilcoxon test for paired comparisons. To compare treatment success (smoking cessation) with treatment failure, the test for two proportions was used.

Results:

Among the 142 patients evaluated, there were improvements, in terms of the levels of anxiety, depression, motivation, and stress, between E1 and E2, as well as between E1 and E3. In addition, treatment success correlated significantly with the levels of motivation and anxiety throughout the study period, whereas it correlated significantly with the level of depression only at E2 and E3.

Conclusions:

We conclude that there are in fact changes in the levels of patient anxiety, depression, motivation, and stress over the course of smoking cessation treatment. Those changes appear to be more pronounced in patients in whom the treatment succeeded.     

Reconceptualizing motivation for smoking cessation among people with rheumatoid arthritis as incentives and facilitators

Objectives

Smokers with rheumatoid arthritis (RA) may have different motivations for, and barriers to, quitting. Understanding the motivations of smokers and ex‐smokers with RA will help in the design and implementation of targeted smoking cessation interventions for people with RA that are not based solely on extrapolation from the general population or populations with other chronic illnesses.

Methods

Twenty‐nine smokers and 10 recent ex‐smokers with RA participated in semi‐structured interviews via telephone 18 months after being offered a smoking cessation intervention in Aotearoa/New Zealand. The sample consisted of 27 women and 12 men (age range 32–78 years), of whom 14 had received the intervention, 14 had been in the control group and 11 had declined participation in the trial.

Results

Thematic analysis led to the formulation of four “incentives” to quit and five “facilitators” of quitting for people with RA. Desiring improvements to health (overall and specific to arthritis), social relationships and avoiding costs were incentives to quit. Coping with stress without smoking, commitment, mental preparedness, willpower and interventions were facilitators of quitting.

Conclusions

Becoming aware of the effects of smoking on arthritis provides an important motivation to quit smoking that may counter RA‐specific barriers to smoking cessation. Further research is needed to test whether similar incentives and facilitators of smoking cessation exist in other chronic illnesses, and how to develop interventions to address these motivational processes.     

Smoking Behavior Changes in the Early Rheumatoid Arthritis Period and Risk of Mortality During Thirty‐Six Years of Prospective Followup

Objective

To investigate whether rheumatoid arthritis (RA) diagnosis influences smoking behavior changes and whether these changes were associated with mortality.

Methods

We identified an incident RA cohort in the Nurses' Health Study (NHS; 1976–2012). Behavioral data were collected through biennial questionnaires. We created a comparison cohort, matching RA cases to women without RA by age and calendar year at the index date of RA diagnosis. To investigate smoking behavior changes in the early RA period, sustained cessation was defined as permanently quitting within 4 years of the RA/index date. We used Cox regression to obtain hazard ratios (HRs) for mortality, comparing sustained smoking cessation to continued smoking.

Results

Among 121,700 women in the NHS, we identified 938 with incident RA matched to 8,951 non‐RA comparators. Among current smokers, 40.0% with RA permanently quit smoking in the early RA period, compared to 36.1% of comparators (odds ratio for sustained cessation 1.18 [95% confidence interval (95% CI) 0.88, 1.58]). There were 313 deaths (33.4%) in the RA cohort and 2,042 (22.8%) among comparators. Compared to continued smoking, sustained cessation was associated with similarly decreased mortality in both the RA (HR 0.58 [95% CI 0.33, 1.01]) and comparison (HR 0.47 [95% CI 0.39, 0.58]) cohorts. Women with RA had higher mortality for >5 post‐RA pack‐years (HR 3.67 [95% CI 2.80, 4.81]) than comparators with >5 post‐index pack‐years (HR 1.88 [95% CI 1.62, 2.17]; P < 0.001 for interaction; reference: ever‐smoker non‐RA women with 0 post‐index pack‐years).

Conclusion

Sustained smoking cessation within 4 years of RA diagnosis reduced mortality risk, with a similar effect observed among non‐RA comparators. Smoking >5 pack‐years after RA diagnosis significantly increased mortality beyond the risk of non‐RA comparators.     

Effect of type D personality on smoking status and their combined impact on outcome after acute myocardial infarction

Background

Smoking cessation is correlated with several psychological, social, biological, and pharmacological aspects. The combined tendency to experience negative emotions and to inhibit the expression of these emotions is indicated as “type D personality,” an independent risk marker for clinical outcome in cardiac disease. Despite this effect of type D personality on cardiovascular disease, it is still unclear whether this personality trait may influence smoking cessation after a myocardial infarction.

Hypothesis

we hypothesized that there is a relationship between type D personality and smoking persistence in acute coronary syndrome patients, and this association may predict a worse long‐term prognosis.

Methods

The study enrolled 231 patients with ST‐segment elevation myocardial infarction, treated with primary percutaneous coronary intervention. Type D scale 14 (ds 14) was administered upon admission to the hospital.

Results

After controlling for demographic and clinical confounders, non–type D patients reported statistically significant higher frequencies of smoking cessation when compared with the type D group. In addition, the presence of this psychological factor anticipates significantly the onset of smoking during adolescence. Furthermore, current type D smokers had a higher incidence of cardiovascular events during long‐term follow‐up.

Conclusions

Type D personality and smoking status increase the risk of cardiac events. An emotionally stressed personality and persistence of smoking after the first cardiac event, and mostly their mutual influence, indicate a population at high cardiovascular risk.