Smoking and Heart Disease

Dateline: 12/06/98

While intuitively it seems that smoking would be strongly implicated in most forms of heart disease, there is precious little scientific data on this important subject. However, what little is available strongly suggests that

• smoking causes heart disease
• stopping smoking reduces the risk of a new cardiac event and improves survival

Smoking and Heart Disease - Difficulty in conducting scientific experiments

Consider this experiment. One group of volunteers would be advised to continue or start smoking a certain number of cigarettes/cigars per day for a specified number of years while a control group would be advised not to. These groups would be examined at periodic intervals for evidence of harmful effects of smoking ! Would such a study be ethically feasible today ?

This explains the lack of hard scientific data on the topic of smoking and heart disease. Most of the evidence is derived from the Framingham study and other similar studies which by their nature contained both smokers and non-smokers.

Life expectancy and smoking

One of the most dramatic study results derives from a paper published by Oster et al in the Journal of the American Medical Association in 1986 where increased life expectancy was related to the age at which smokers quit.

The evidence is clear. Smokers who stop smoking earlier derive a greater benefit in terms of increased life expectancy, but it is never to late to quit with even those who stop smoking at 65 to 69 years of age showing a moderate increase in number of years of expected life. The effect is also more dramatic in men than in women.

Smoking in Survivors of a Heart Attack

Quitting tobacco is one of the most beneficial life-style modifications a survivor of a myocardial infarction can make. In the short term, stopping smoking is extremely effective in reducing morbidity and mortality.

Eugene Braunwald, one of the world's leading cardiologists, in his textbook states that cigarette smoking is an established risk factor for the development of angina and myocardial infarction, and increases the risk for recurrence of infarction and death.

Smokers who continue to smoke have TWICE the risk of another heart attack and sudden cardiac death as those who quit at the time of their first incident.

Even more encouraging is the finding that within just three years of quitting smoking, the risk of a second heart attack reaches the low levels of patients who had never smoked in their lives !

Smoking in patients with proven Coronary Artery Disease (CAD)

Kronmal et al, in their review of the Coronary Artery Surgery Study (CASS) Registry data found that among patients with angiographically demonstrated CAD, cigarette smokers have higher five years mortality and relative risk of myocardial infarction or sudden death than those who have quit smoking. Their study was published in the JAMA in 1986.

Another study published in the prestigious New England Journal of Medicine (NEJM) found that smoking cessation lessens the risk of adverse coronary events in both younger and older persons with CAD.

It was also found that when habitual cigarette smokers who sustained out-of-hospital cardiac arrest stop smoking, a lower incidence of recurrent cardiac arrest was found after three years than those who continued smoking.

A strong association between the risk of a heart attack and smoking was shown by the Framingham Study, one of the largest published studies dealing with heart disease risk factors. Hallston and co-workers, in the Public Health Report published in 1980, also showed such an association from a sixteen year observation of patterns of smoking and causes of death in US veterans.

What affects risk from smoking ?

Risk of a heart attack does not vary with the quantity of nicotine or carbon monoxide in the cigarette. Low tar and less nicotine DO NOT have a corresponding decrease in heart attack risk. People who want to reduce their overall risk of CAD should not rely on any promised advantage of low nicotine cigarettes.

Passive exposure to tobacco smoke itself increases CAD risk. These findings were gleaned from the MRFIT study based on the smoking habits of patient's wives. So, public health measures to protect non-smokers from passive inhalation are required.

Heart disease risk appears related more to the number of cigarettes smoked per day than the actual duration of smoking. Within few years of quitting, the risk of having a heart attack returns to the levels seen in men who NEVER SMOKED !

How does smoking cause heart disease ?

Smoking causes or accelerates heart disease by many different mechanisms. It

• speeds up progression of atherosclerosis
• alters lipid profile, with more LDL and less HDL
• increases heart muscle oxygen demand by 10%
• reduces coronary artery blood flow due to adrenaline release
• diminishes coronary collateral flow reserve
• lowers threshold for angina pain
• interferes with efficacy of anti-anginal medication
• raises blood levels of fibrinogen
• alters the clotting mechanism with aggregation of blood platelets
• causes endothelial cell dysfunction, with reduced ability to produce chemicals that dilate the arteries (like prostacyclin)

Smoking and High Blood Pressure

Large scale studies on patients with high blood pressure - like the Hypertension Detection and Follow Up Program - reveal a worse outcome in smokers with twice the risk of mortality (all-cause cardiovascular deaths) as non-smokers.

Theories of addiction to smoking

1. Physiological - dependence on nicotine is responsible for smoking
2. Psychological - smoking seems to minimise negative emotions like distress, anger and fear, and so becomes a coping mechanism to transfer these negative emotions to socially acceptable behaviour
3. Sociological - smoking is a result of modelling behaviour after parents and peers

Analysis has shown that some factors predict continued smoking even after a cardiac event. These include:

• lower occupational and educational levels
• smoking a greater number of cigarettes
• increasing age
• higher rates of alcohol consumption
• less negative attitude towards smoking
• higher anxiety levels
• low sense of personal control over life events

Breaking the habit

Hospital confinement for a heart attack or bypass surgery (CABG) usually provides time for the psychological manifestations of nicotine withdrawal - irritability, emotionality, lack of concentration, nausea, headache - to resolve. In the face of such a sudden life event, 20-60% of these patients quit.

It is seen that patients who receive strong advice from health professionals to stop smoking are more likely to quit and remain abstinent than those who do not receive such advice. High acute cessation rates are associated with high recidivism. The most effective programs are those that address both the physiological and psychological dependence on cigarettes. With formal programs, long term abstinence rates of upto 70% have been achieved.

Public Health Measures

In view of the findings about passive smoking posing such health hazards, public health measures to protect the non-smoker from passive inhalation are mandatory. Cigarette consumption must also be discouraged by reducing advertising for tobacco products and increasing excise taxes on their sale.

Recommended Reading:

• The Heart Attack Handbook by Joseph S. Alpert
  The Commonsense Guide for Patients and Their Families. Paperback; A useful resource for the family of a victim of heart attack.
• 8 Steps to a Healthy Heart by Robert E. Kowalski
  The Complete Guide to Heart Disease Prevention and Recovery from Heart Attack and Bypass Surgery.
• Guide to Heart Attack Treatment, Recovery, and Prevention by American Heart Association
  The official recommendations of the American Heart Association for treatment and management of a heart attack.

For more resources on smoking and heart disease, visit the resource library.

Go back to the Great American Smoke-out Special homepage.

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You can also review articles in the following interest areas dealing with heart disease:

• Minimally Invasive Heart Surgery
• MICAS website
• Fetal Heart Surgery
• Congenital Heart Disease
• Heart Disease in Women
• Post operative care after heart surgery
• Pregnancy and Heart Disease

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