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Smoking and Coronary Artery Disease
CORONARY ARTERY DISEASE IN THE ELDERLY
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SMOKING AND CORONARY ARTERY DISEASE Donald D. Tresch, MD, and Wilbert S. Aronow, MD
Tobacco smoking adversely affects the heart, especially the coronary arteries, and is associated with coronary heart disease (CHD). Some of the effects may be direct, noncumulative, and irreversible, whereas others are indirect, cumulative, and readily reversible* (Table 1).Specific effects include alterations in serum lipids with lower HDL levels and higher levels of VLDL cholesterol and triglycerides found in persons who smoke, as compared with nonsmokers. Increases in platelet adhesiveness and fibrogen levels, as well as blood erythrocytes and leukocytes have also been reported in smokers. Platelet sensitivity to the anti-aggregatory prostaglandins, PGE and PGE,, is decreased in both smokers and nonsmokers exposed to tobacco smoke. Some studies have even shown that smoking directly accelerates atherosclerosis and is associated with vascular endothelial cell dysfunction. Effects of toxic material in cigarette smoke have been shown to adversely affect the heart. Carbon monoxide, a gas component of cigarette smoke, has a strong affinity for hemoglobin and displaces oxygen with the result that smokers may lose as much as 15 percent of their oxygen-carrying capacity. Carbon monoxide also has a negative inotropic effect, increases platelet adhesiveness, and has been shown to decrease ventricular fibrillation threshold during episodes of myocardial ischemia. Nicotine, a toxic particulate in cigarette smoke, produces a number of adverse cardiovascular effects. Increased release of epinephrine and norepinephrine is caused by nicotine with associated increase in blood pressure, heart rate, cardiac output, and myocardial oxygen consumption. In addition to the sympathetic effect, nicotine, like carbon monoxide, has been shown to increase platelet adhesiveness and reduce ventricular fibrillation threshold during episodes of myocardial ischemia. *References 1, 7, 9, 10, 14, 25-28, 32-33, 36, 38, 43, and 50.
From the Medical College of Wisconsin, Milwaukee, Wisconsin (DDT); and the Mount Sinai School of Medicine, and Hebrew Hospital Home, Bronx, New York (WSA)
CLINICS IN GERIATRIC MEDICINE
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VOLUME 12. NUMBER I FEBRUARY 1996
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Table 1. PATHOLOGIC EFFECTS OF SMOKING ON THE HEART Component Plasma lipids and lipoproteins Blood cells
Effects Decreased HDL: increased LDL and triglycerides
lncreased erythrocytes and leukocytes; displacement of 0, from hemoglobin lncreased adhesiveness Platelets lncreased levels Fibrinogen Vessel endothelium damage lncreased atherogenesis Sympathoadrenal activation lncreased myocardial 0, demands by increased cardiac output, heart rate, and blood pressure; increased vasoconstriction HDL = high-density lipoprotein; LDL = low-density lipoprotein Adapted frornTresch DD, Carlos M: Smoking as a risk factor for coronary heart disease in the elderly. Cardiology in the Elderly 2:343-348, 1994; with permission.
SMOKING AS A RISK FACTOR FOR CORONARY HEART DISEASE
Because of its adverse effects, cigarette smoke is believed not only to play a role in the development of CHD but also as an accelerator or initiator of coronary events, including angina pectoris, arrhythmias, myocardial infarction, and sudden death, regardless of the degree of coronary atherosclerosis. Cigarette smoking is a powerful predictor of mortality and is the single most important preventable risk factor for cardiovascular disease.47Thirty percent of all CHD deaths in the United States are thought to be attributable to cigarette smoking,5l with the potential for developing CHD in middle-aged men approximately two times greater in cigarette smokers than in nonsmoker^?^,^^ The risk may be less in cigar and pipe smokers and women smokers, although the risk is still significant compared with nonsmoker^.^' In studies57in which nonfatal and fatal myocardial infarction and sudden death have been analyzed separately, it has been found that the relative risk of nonfatal and fatal myocardial infarction is approximately two to three times higher in men who smoke than in men who do not smoke and about 1.5 and 3.0 times more common in women who smoke than in those who do not. The Framingham Studyz4reported that the relative risk for sudden coronary death is 10 times higher in men who smoked than in nonsmoking men and 4.5 times higher in women who smoked than in nonsmoking women. From the results of most studies, it appears that the smoking risk for coronary events is proportionately related to the age at which a person starts smoking, duration of smoking, and the number of cigarettes smoked daily. Any amount of smoking, however, is associated with increased risk of coronary artery events. Studies have demonstrated that neither filtered cigarettes nor low tar cigarettes . . . . nm+octi~.~p: . ,. . .. . ~mokp~ mrhg s tlged !?!tered cirrzrette~F.zd eyen I.icl.er incidence
of C'HD than smokers of nonfiltered cigarette> Furthermore, it h; been demonstrated that the mere proximity to smokers is associated with increased risk of ~,~ a ~recent review of numerous published CHD morbidity and m ~ r t a l i t y ? , 'In prospective studies and by using the newest Environmental Protective Agency procedures for estimating deaths from passive smoking, Wells56estimated that the number of cardiac deaths caused by passive smoking is 40% to 100%higher than that calculated by previous methods. His studies demonstrated that 62,000 deaths from CHD in the United States in 1985 were caused by passive smoking.
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Furthermore, passive smoking appeared to cause a 20% to 70% increase in the risk of CHD among persons who never smoked, an increase not explained by other risk factors. It should be emphasized that as the number of a patient's risk factors increases, so does the patient's risk for CHD-an increasingly important point in elderly smokers who commonly have hypercholesterolemia and are hypertensive. Studhave demonstrated that hypertension, hypercholesterolemia, and smoking ies3,46 interact in a synergistic rather than an arithmetic manner; the combination of two of these risk factors increases the incidence of CHD by as much as nine times and the presence of all three risk factors increases the incidence by as much as 16 times.
SMOKING AS A RISK FACTOR OF CORONARY ARTERY DISEASE IN THE ELDERLY
Smoking as a risk factor for CHD is highest in younger persons, and some s t u d i e ~ ~have ' , ~ ~suggested ,~~ that the risk diminishes markedly in elderly smokers. In the Framingham Study,2' smoking in younger persons was an independent predictor of coronary artery disease (CAD), whereas in older persons (over age 65) in whom 33% of men and 23% of women were smokers, the relation disappeared after multivariate analysis. Similar findings were reported by the Boston Collaborative Drug Surveillance Program S t ~ d y .The ~ ' rate ratio for nonfatal acute myocardial infarction was 3.0 for one-pack-a-day cigarette smokers who were 40 to 49 years of age and 1.4 for smokers 50 to 59 years of age. Both rate ratios were highly significant, as compared with rate ratios for nonsmokers. In contrast, the rate ratio of smokers 60 to 69 years of age was insignificant. Similar rate ratios were noted among the age groups when analyzing two-pack-a-day smokers. Because the results of these studies demonstrated a diminished relation of smoking to CHD in older persons, some authorities have questioned whether smoking should be considered a risk factor for CHD in the elderly, and the advisability of urging older persons to stop smoking has been ~ h a l l e n g e dEven .~~ though the prevalence of smoking in the general population has significantly decreased in the last decade, 20% to 30% of elderly persons continued to smoke, and with CHD being so prevalent in this age group and the number one killer, the question of whether elderly should be advised to stop smoking is an important public health issue. In contrast to the results of the Framingham and the Boston Collaborative Drug Surveillance Program studies, other studies have demonstrated smoking to be a significant risk factor for development of CHD in elderly persons, as well as younger persons (Table 2).50The Honolulu Heart Program: which included 1394 men between the ages of 65 and 74, reported a consistent and progressive increase in the CHD incidence rate with increasing levels of smoking in both middle-aged and elderly men. Never-smokers showed the lowest rates of CHD, followed by former smokers, with current smokers exhibiting the highest rates. Multivariate life table regression analysis that included other major risk factors for CHD demonstrated a relative risk of 1.62 for elderly male smokers compared with 1.80 for younger male smokers. The difference in these relative risks between the age groups was not statistically significant.From the perspective of excessive risk for CHD, the difference between current and never-smokers for the elderly men was 3.6 events per 1000 person-years, compared with a difference of 1.9 events between middle-aged smokers and middle-aged men who never smoked.
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Table 2. RELATION OF SMOKING TO CORONARY ARTERY DISEASE AND
MORTALITY IN THE ELDERLY
Study
Harris et aIz1 Miettinen et aI3O Jajich et aIz3 Benfante et aI8' Siegel et a14' LaCroix et aIz6 Aronow et a14 Hermanson et aI2'
Total Points
Age Range (years)
Significant Relationship
End Points
Coronary artery disease Nonfatal acute MI Total mortality Coronary artery disease MI and sudden death Total CV and CHD mortality Coronary artery events Total mortality
No No Yes Yes Yes Yes Yes
CHD = coronary heart disease; CV = cerebrovascular; MI = myocardial infarction AdaptedfromTresch DD, Carlos M: Smoking as a risk factor for coronary heart disease in the elderly. Cardiology in the Elderly 2:343-348; 1994; with permission.
Jajich and associatesz3reported findings from the Chicago Stroke Study similar to those of the Honolulu Heart Study when analyzing CHD death rates in persons 65 through 74 years of age. The CHD mortality was 52%higher in current smokers than in nonsmokers, ex-smokers, and pipe and cigar smokers. A significant increase in all cardiovascular events and major cardiovascular events (myocardial infarction, sudden death, stroke, and left ventricular failure) was also reported in smokers in the Systolic Hypertension in the Elderly Program study," compared with nonsmokers (mean age of participants was 72 years). Moreover, smoking was an independent predictor of the first cardiovascular event in these elderly subjects. The study with one of the largest cohort population of elderly patients in which the relation of smoking to CHD was assessed is the Established Populations for Epidemiologic Studies of the Elderly.26In this study of 7178 people 65 years of age or older, which included 4469 women and people over 75 years of age, the mortality hazards of smoking extended well into later life. The prevalence of smoking in this study, which included people from communities in three states (Iowa, Connecticut, and Massachusetts), was 12.9% among women and 21.2% among men. In both sexes, rates of total mortality and cardiovascular mortality in smokers were twice that found in persons who never smoked. The relative risk of mortality from all cardiovascular causes, including CHD deaths, among current smokers was 1.0 in men and 1.6in women. The relation of current smoking to cardiovascular mortality was not altered by adjustment for other cardiovascular risks, including history of hypertension or diabetes; however, the relative risk of mortality was highest among those who smoked for 40 pack-years or more, lowest in nonsmokers, and intermediate in those who smoked less than 40 pack-years. Aronow and associates," 5,6 in both prospective and retrospective studies of T:=?TT
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and CHD. In a prospective study4 of 192 men and 516 women (average age 82 years), at mean follow up of 41 months, current smoking was found to be an independent risk factor for new coronary events 1.8 times that found in male nonsmokers or ex-smokers and 1.9 times that found in female nonsmokers or exsmokers. Smoking was a significant risk factor in these very elderly persons regardless if there was antecedent CHD prior to smoking. In a study in which coronary angiography was used to assess the presence of CHD, Weintraub and associates55found the number of pack-year cigarettes
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smoked to be a significant independent risk factor for CHD in each age decade from 30 years to 60 years; however, after 70 years the relation was not statistically significant. Current packs of cigarettes smoked, however, was not a significant risk factor at any age. The investigators postulated that smoking accelerates atherogenesis over time, but in those persons over the age of 70, the risk of atherosclerosis is so substantial that smoking history contributed little. In another study of angiographically documented CHD, the Coronary Artery Surgery Study (CASS)22 found that male smokers 55 years or older had a relative risk of 1.7 for mortality and 1.5 for myocardial infarction or death, compared with male nonsmokers. In this study, the hazards of smoking did not diminish with increasing age. BENEFIT OF CESSATION OF SMOKING IN THE ELDERLY
In addition to the issue of whether smoking in elderly persons increases the risk of CHD and death, the other important issue concerning smoking in elderly people is whether cessation is beneficial in this age group. Studies of general populations have found that the risk of CHD reverts to that of nonsmokers when smoking is stopped. Furthermore, the decline in risk for CHD is found to be rapid following cessation of smoking. The Framingham Study2' found the cessation of smoking to cause a decreased risk of CHD within several years to a value similar to that in nonsmokers. Benefits from cessation for smokers who have already demonstrated smoking-related diseases or symptoms have also been shown. Such impressive benefits, however, may not be the case in elderly smokers who stop smoking. Elderly smokers may have too much accumulated smoking history with irreversible cardiac changes to overcome. Also, elderly smokers who have survived may have some resistance to the deleterious effects of smoking and, therefore, benefit less from quitting. Studies addressing the issue of cessation of smoking in elderly smokers, however, have found the benefits to be as encouraging as in younger smokers. In the Established Populations for Epidemiologic Studies for the which included people older than 75 years of age, risks of cardiovascular mortality, including CHD deaths, of former smokers in both sexes were similar to those of the participants who had never smoked, regardless of the number of years since they had last smoked. Ex-smokers in the Chicago Stroke were found to have a risk of CHD mortality no higher than that for nonsmokers. This benefit was noted even in those ex-smokers who had stopped smoking for only a period of 1 to 5 years. In the Coronary Artery Surgery Shtdy,2' the 6-year mortality was higher in continuing smokers than in those who quit smoking during the year before enrollment in the study. Continuing smokers were also at higher risk of either myocardial infarction or death. Furthermore, the benefit of the cessation of smoking did not diminish with age. In addition to these medical health benefits, some studies have demonstrated that after several months of abstinence, former smokers have better psychosocial functioning and are more likely to practice more health promoting and disease preventing behaviors than continuing smokers.16 Such benefits would be especially important in elderly persons who, not infrequently, are bothered by loneliness and mental depression and often have multiple risk factors that require modification. CHANGING TRENDS IN SMOKING HABITS AND SMOKING CESSATION INTERVENTION
In the last two decades, smoking habits of Americans have significantly changed.18,29, 41, 45, 48, 49, 53 The overall population rates of cigarette smoking have
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i
Males
1
Figure 1. Decline of current smokers in the United States. (Adapted from Goldberg RJ: Temporal trends and declining mortality rates from coronary artery disease in the United States. In Ockene S, Ockene JK (eds):Prevention of Coronary Artery Disease. Copyright 0Boston, Little, Brown,and Companv, 1992, p 44; with permissi0n.j
Year
declined from 40% in the adult population in 1965 to 37% in 1970, 33% in 1980, 30% in 1985, and 29% in 1987 (Fig. 1).18 In general, the percentage of Americans who were current smokers declined approximately 30% from 1965 to 1987; and, by 1987 nearly half of all living adults who had ever smoked had quit. The changes in smoking habits have been greater in men, compared to women; in older persons, compared to younger persons; and in Caucasians, compared to African-Americans. The proportion of men over age 18 who were smokers declined from 50% in 1965 to 43% in 1970, to 35% in 1983, and to 32% in 1987. Women smokers declined from 34% in 1965 to 30% in 1970 with a subsequent slight increase in the late 1970s and then a decrease to 27% in 1987. In elderly persons over age 65, a s in the general population, smoking significantly declined since 1965 (see Table 3). Twenty-eight percent of elderly men smoked in 1965 compared with only 18% in 1980; in elderly women, however, the percentage of smokers actually increased from 10% in 1965 to 17% in 1980. Moreover, cigarette smoking quit rates adjusted for differential mortality and smoking initiation have been noted to increase progressively with age cohort. In the late 1960s, men in the seventh decade of life quit smoking at a rate of about 7% per year, while men in their 50s quit at a rate of only 3% per year. In 1965 40% of Caucasians were smoking with the proportion declining to 29% in 1987, whereas among AfricanAmericans, the decline was less marked with the number of smokers decreasing from 43% in 1965 to 34% in 1987. Despite the inability to draw definite conclusions concerning the role of smoking cessation in causing a decline in CHD mortality, there is no doubt that
Table 3. PERCENTAGE OF CURRENT SMOKERS IN THE UNITED STATES Year General adult population Adult women Adult* men Elderlyt men Elderlv women
1965
1976
1980
1987
40 50 34 29 10
36 42 31 23 13
33 37 30 18 17
29 32 27
* Over 18 years or over 20 years of age in + Over 65 years of age.
the various studies.
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the decline in CHD mortality in the United States correlates with the decreasing prevalence of smoking in the general population. Furthermore, the greatest changes in smoking occurred in the second half of the 1970s, which coincides with the greatest observed decline in CHD mortality. Even though modification of all risk factors for CHD occurred during this period, the decline in smoking affected the greatest number of persons; therefore, the decline in CHD may have contributed more to the decline in CHD mortality than to the change in the other risk factors. In comparing the benefits of various CHD risk factors interventions upon survival, Goldman and Cook19estimated a 5% reduction in CHD mortality or 150,000 lives saved between 1968 and 1976 related to the decline in prevalence of smoking. Although the prevalence of current adult smokers in the United States has declined since 1965 and is correlated with a significant decline in CHD and mortality, cigarette smoking continues to be a major health concern. In 1985 the United States spent approximately 65 billion dollars on direct health care and indirect lost productivity related to smoking.58During this same period, even though the number of current smokers decreased, the proportion of heavy smokers (smoking 25 or more cigarettes per day) actually increased, with this trend particularly noted among women.20,29, 53 Between 1965 and 1985, the percent of heavy smokers increased by approximately 29% in men and 77% in women. In the Health Promotion of Disease Prevention Survey of the National Health Interview Survey conducted in 1985,33% of men 18 years or older were smokers and 32% of the smokers were heavy smokers, while 28% of women smoked with 21% of the smokers considered heavy smokers.54Therefore, emphasis on continuing antismoking and smoking cessation programs is necessary. Moreover, since 20% to 30% of elderly persons continue to smoke, and a significant proportion of the health care dollars related to smoking is consumed by this age group, it is necessary that smoking cessation programs involve the elderly population, as well as the younger population. It has been concluded that much of the decline in cigarette smoking in the United States can be attributed to the strong education campaign that has taken place in the United States over the past decades, including the anti-cigarette advertising and smoking cessation programs. The continuation of such programs is required. Over 80% of current smokers indicate that they would like to Interestingly, more than 90% of the 30 million smokers who quit smoking between 1964 and 1982 did not use an organized program to help them stop smoking; and, most smokers who continue to smoke state that they would prefer to stop without the aid of a formal smoking-cessation program.15On the basis of such information it would appear that the individual physician can have a major impact upon smoking cessation. Repeated studies have demonstrated that physicians who intervene with their smoking patients have a significant impact on patients' smoking habit^.'^,^^,^^ Almost any interventional strategy can be effective given a commitment by both the smoker and the physician and realistic expectations of what can be accomplished. The rate of success in quitting smoking has been shown to be related to symptomatic manifestation of the smoking-related diseases.'337Studies have shown a high quit rate (50% to 63%) for smokers who are advised to quit smoking after sustaining a myocardial infarction or when they developed symptoms of angina pectoris. Thus, the physician's encounters in the hospital or office with the symptomatic patient can have a significant role to play in smoking cessation intervention. When assessing patients for smoking cessation intervention, it is important that physicians realize that elderly patients are as interested in quitting as younger patients. Elderly smokers, however, may have special needs that interfere with interventions. They may have poor social support systems and
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have other diseases, such as mental depression, which prevent good adherence to a cessation program. Furthermore, elderly patients are often not aware of the benefits of quitting. Nevertheless, smoking cessation needs to be addressed in elderly smokers, as well as younger smokers, and can be as successful regardless of the patient's age.
CONCLUSION
The findings of studies indicate that the deleterious effects of smoking on the cardiovascular system extend to later life with an increased risk of cardiovascular mortality among elderly men and women who smoke, regardless of their age. The total life consumption of cigarettes is a significant risk factor of CHD and the more a person smokes the greater the risk. The conflicting results of some of the studies of older persons concerning the association of CHD and smoking may be related to the different analytical methods used, possible differences in preventive interventions, and the difference in time periods of the studies. Studies also demonstrate that benefits of quitting smoking are as significant in elderly smokers as younger smokers and the reduced risk of total and CHD mortality are significant even in those elderly persons who stop smoking after 65 years of age. In addition to the benefits of smoking cessation in cardiovascular survival are the known benefits of smoking cessation in other disease, such as cancer and pulmonary disorders. Finally, studies have demonstrated that physicians who intervene with their smoking patients have a significant impact on the patients' smoking habits, regardless of the patient's age. Therefore, it is mandatory that anti-smoking and smoking cessation programs be enthusiastically recommended and initiated by physicians in their daily contact with elderly patients.
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111
iulig-ieiiii iiediiii idle iaciiiiy.
j idruiui bi'.>io->LC,
i7ob
7. Auerback 0, Carter HW, Garfinkel L, et al: Cigarette smoking and coronary artery disease: A macroscopic and microscopic study. Chest 70:697-705, 1976 8. Benfante R, Reed D, Frank J: Does cigarette smoking have an independent effect on coronary heart disease incidence in the elderly? Am J Public Health 812397499, 1991 9. Briscetto CS, Connor WE, Connor SL, et al: Plasma lipid and lipoprotein profiles of cigarette smokers from randomly selected families: Enhancement of hyperlipidemia and depression of high density lipoprotein. Am J Cardiol52:675-680, 1983 10. Burghuber 0, Punzengruber C, Sinzinger H, et al: Platelet sensitivity to prostacyclin in smokers and nonsmokers. Chest 90:34-38, 1986
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11. Castelli WP, Garrison RJ, Dawber TR, et al: The filtered cigarette and CHD: The framingham study. Lancet 2:109-113, 1981 12. Cohen SJ, Stookey GK, Katz BP, et al: Encouraging primary care physicians to help smokers quit. Ann Intern Med 110:648-652, 1989 13. Croog SH, Richards WP: Health beliefs and smoking patterns in heart patients and their wives: A longitudinal study. Am J Public Health 67:921-930, 1977 14. Davis J, Shelton L, Eigenberg D, et al: Effects of tobacco and non-tobacco cigarette smoking on endothelium and platelets. Clin Pharmacol Ther 37529-533, 1985 15. Fiore M, Novotny T, Lynn W, et al: Methods Used to Quite Smoking in the United States: Do Cessation Programs Help? JAMA 263:2760-2765, 1990 16. Gerace T, Hollis J, Ockene JK, et al: Relationship of smoking prevalence in the United States: 1955 to 1983. Ann Behav Med 75-8, 1985 17. Glantz S, Parmley W: Passive smoking and heart disease: Epidemiology, Physiology, and Biochemistry. Circulation 83:l-12, 1991 18. Goldberg RJ: Temporal trends and declining mortality rates from coronary artery disease in the United States. In Ockene S, Ockene JK (eds): Prevention of Coronary Artery Disease. Boston, Little, Brown, & Company, 1992, p 44 19. Goldman L, Cook EF: The decline in ischemic heart disease: Comparative effects of medical interventions and changes in lifestyle. Ann Intern Med 101:825-836, 1989 20. Gordon T, Kannel WB, McGee D, et al: Death and coronary attacks in men after giving u p cigarette smoking. Lancet 2:1345-1384, 1974 21. Harris T, Cook EF, Kannel WB, et al: Proportional hazards analysis of risk factors for coronary heart disease in individuals aged 65 or older. J Am Geriatr Soc 36:10231028, 1988 22. Hermanson B, Omen GS, Kronmal RA, et al: Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. N Engl J Med 319:13651369, 1988 23. Jajich CL, Ostfield AM, Freeman DH Jr: Smoking and coronary heart disease mortality in the elderly. JAMA 252:2831-2834, 1984 24. Kannel WB, McGee DL, Castelli WP: Latest perspective on cigarette smoking and cardiovascular disease: The Framingham Study. J Cardiac Rehabil 4:267-277, 1984 25. Kaufman DW, Helmrich SP, Rosenberg L, et al: Nicotine and carbon monoxide content of cigarette smoke and the risk of myocardial infarction in young men. N Engl J Med 308:409-413, 1983 26. LaCroix AZ, Lang J, Scherr P, et al: Smoking and mortality among older men and women in three communities. N Engl J Med 324:1619-1625, 1991 27. McGill HC: Potential mechanisms for the augmentation of atherosclerosis and atherosclerotic disease by cigarette smoking. Prev Med 8:390-403, 1979 28. McGill HC: The cardiovascular pathology of smoking. Am Heart J 115:250-257, 1988 29. McGinnis JM, Shopland D, Brown C: Tobacco and Health: Trends in smoking and smokeless tobacco consumption in the United States. Ann Rev Pub1 Health 8:441467, 1987 30. Miettinen OS, Neff RK, Jick H: Cigarette smoking and nonfatal myocardial infarction: Rate ratio in relation to age, sex, and predisposing conditions. Am J Epidemiol 103:3036, 1976 31. Naeye RL, Truong LD: Effects of cigarette smoking on intramyocardial arteries and arterioles in man. Am J Clin Pathol 68:493-498, 1977 32. Niedermaier ON, Smith ML, Beightol LA, et al: Influence of cigarette smoking on human autonomic function. Circulation 88:562-571, 1963 33. Nowak J, Murray JJ, Oates JA, et al: Biochemical evidence of a chronic abnormality in platelet and vascular function in healthy individuals who smoke cigarettes. Circulation 76:6014, 1987 34. Ockene JK: Physician-delivered interventions for smoking cessation: Strategies for increasing effectiveness. Prev Med 16:723-737, 1987 35. Ockene JK: Smoking Intervention: A Behavioral, educational, and pharmacologic perspective. In Ockene S, Ockene JK (eds): Prevention of Coronary Artery Disease. Boston, Little, Brown, & Company, 1992, pp 201-230 36. Rogers WR, Bass RL, Johnson DE, et al: Atherosclerosis-related responses to cigarette smoking in the baboon. Circulation 61:1188-1193, 1980
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37. Rose G, Hamilton PJS: A randomized controlled trial of the effect on middle-aged men of advise to stop smoking. J Epidemiol Community Health 36102-108, 1982 38. Ross, R: The pathology of atherosclerosis. An update. N Engl J Med 314488-500,1986 39. Russel MAH, Taylor W, Gilbert R, et al: A randomized trial of family physicians intervention for smoking cessation. JAMA 260:1570-1574, 1988 40. Seltzer CC: Smoking and coronary heart disease in the elderly. Am J Med Sci 269:309315,1975 41. Shopland DT, Brown C: Change in cigarette smoking prevalence in the United States: 1955 to 1983. Ann Behav Med 7:5-8,1985 42. Siege1D, Kuller L, Lazarus NB, et al: Predictors of cardiovascular events and mortality in the systolic hypertension in the elderly program pilot project. Am J Epidemiol126:385399, 1987 43. Sinzinger H, Kefalides A: Passive smoking severely decreases platelet sensitivity to antiaggregating prostaglandins. Lancet 2:392-393, 1982 44. Smoking in the Elderly (Editorial).Br Med J 4: 607, 1975 45. Sprafka, JM, Burke GL, Folsom AR, et al: Continued decline in cardiovascular disease risk factors: Results of the Minnesota heart survey: 1980-1982 and 1985-1987. Am J Epidemiol 132489-500, 1990 46. Stamler J, Wentworth D, Neaton JD: Prevalence and prognostic significanceof hypercholesterolemia in men with hypertension. Am J Med 1986, 80(suppl 2A):33-39 47. Stokes J 111, Kannel WB, Wolf PA, et al: The relative importance of selected risk factors for various manifestations of cardiovascular disease among men and women from 35 to 64 years old: 30 years of follow-up in the Framingham Study. Circulation 75(suppl V):V-65-V-73, 1987 48. Sytkowski PA, Kannel WB, D'Agostino RB: Changes in risk factors and the decline in mortalitv from cardiovascular disease: The Framingham Heart Study. N Engl -J Med 332:163i-1641, 1990 49. Thornberg OT, Wilson RW, Golden PM: Health promotion date from the 1990 objectives: Estimates from the National Health Interview Survey Health Promotion and Disease Prevention, United States, 1985. Public Health Service, US National Center for Health Statistics, Advance Data From Vital and Health Statistics, no. 126. USDHHS publ. no. (PHs) 86-1250, Sept. 19,1986 50. Tresch DD, Carlos M: Smoking as a risk factor for coronary artery disease in the elderly. Cardiology in the Elderly 2:343-347, 1994 51. U.S. Department of Health, Education, and Welfare: Smoking and health: A report of the surgeon general. Washington, DC, US Government Printing Office, 1979 [DHEW publication no. (PHs) 79-50066.1 52. U.S. Department of Health and Human Services. Health promotion and disease prevention. United States, 1985; data from the National Health Interview Survey, Series 10, #163. USDHHS publ. no. (PHs) 88-1591. Hyattsville, MD, National Center for Health Statistics, 1988 53. U.S. Department of Health and Human Services: Reducing the health consequences of smoking: Twenty-five years of progress. A Report of the Surgeon General. USDHHS publ. no. (CDC) 89-8411,1989 54. U.S. Department of Health and Human Services: The health consequences of smoking: Cardiovascular disease. A Report of the Surgeon General. Washington, DC, U.S. Government Printing Office, 1983 [DHHS publication no. (PHs) 84-50204.1 55. Weintraub WS, Klein LW, Seelaus PA, et al: Importance of total life consumption of cigarettes as a risk factor for coronary artery disease. Am J Cardiol 55:669-672, 1985 56. Wells AJ: Passive smoking as a cause of heart disease. J Am Coll Cardiol24546-554,1994 57. Wilhelman L: Coronary heart disease: Epidemiology of smoking and intervention studies of smoking. Am Heart J 115:242-2Y4, 1Y88 58. Zevallos JC, Chiriboga D, Hebert JR: An international perspective on coronary heart disease and related risk factors. In Ockene S, Ockene JK (eds): Prevention of Coronary Artery Disease. Boston, Little, Brown, & Company, 1992, pp 147-170
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0749-O69O/96 $0.00
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SMOKING AND CORONARY ARTERY DISEASE Donald D. Tresch, MD, and Wilbert S. Aronow, MD
Tobacco smoking adversely affects the heart, especially the coronary arteries, and is associated with coronary heart disease (CHD). Some of the effects may be direct, noncumulative, and irreversible, whereas others are indirect, cumulative, and readily reversible* (Table 1).Specific effects include alterations in serum lipids with lower HDL levels and higher levels of VLDL cholesterol and triglycerides found in persons who smoke, as compared with nonsmokers. Increases in platelet adhesiveness and fibrogen levels, as well as blood erythrocytes and leukocytes have also been reported in smokers. Platelet sensitivity to the anti-aggregatory prostaglandins, PGE and PGE,, is decreased in both smokers and nonsmokers exposed to tobacco smoke. Some studies have even shown that smoking directly accelerates atherosclerosis and is associated with vascular endothelial cell dysfunction. Effects of toxic material in cigarette smoke have been shown to adversely affect the heart. Carbon monoxide, a gas component of cigarette smoke, has a strong affinity for hemoglobin and displaces oxygen with the result that smokers may lose as much as 15 percent of their oxygen-carrying capacity. Carbon monoxide also has a negative inotropic effect, increases platelet adhesiveness, and has been shown to decrease ventricular fibrillation threshold during episodes of myocardial ischemia. Nicotine, a toxic particulate in cigarette smoke, produces a number of adverse cardiovascular effects. Increased release of epinephrine and norepinephrine is caused by nicotine with associated increase in blood pressure, heart rate, cardiac output, and myocardial oxygen consumption. In addition to the sympathetic effect, nicotine, like carbon monoxide, has been shown to increase platelet adhesiveness and reduce ventricular fibrillation threshold during episodes of myocardial ischemia. *References 1, 7, 9, 10, 14, 25-28, 32-33, 36, 38, 43, and 50.
From the Medical College of Wisconsin, Milwaukee, Wisconsin (DDT); and the Mount Sinai School of Medicine, and Hebrew Hospital Home, Bronx, New York (WSA)
CLINICS IN GERIATRIC MEDICINE
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VOLUME 12. NUMBER I FEBRUARY 1996
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Table 1. PATHOLOGIC EFFECTS OF SMOKING ON THE HEART Component Plasma lipids and lipoproteins Blood cells
Effects Decreased HDL: increased LDL and triglycerides
lncreased erythrocytes and leukocytes; displacement of 0, from hemoglobin lncreased adhesiveness Platelets lncreased levels Fibrinogen Vessel endothelium damage lncreased atherogenesis Sympathoadrenal activation lncreased myocardial 0, demands by increased cardiac output, heart rate, and blood pressure; increased vasoconstriction HDL = high-density lipoprotein; LDL = low-density lipoprotein Adapted frornTresch DD, Carlos M: Smoking as a risk factor for coronary heart disease in the elderly. Cardiology in the Elderly 2:343-348, 1994; with permission.
SMOKING AS A RISK FACTOR FOR CORONARY HEART DISEASE
Because of its adverse effects, cigarette smoke is believed not only to play a role in the development of CHD but also as an accelerator or initiator of coronary events, including angina pectoris, arrhythmias, myocardial infarction, and sudden death, regardless of the degree of coronary atherosclerosis. Cigarette smoking is a powerful predictor of mortality and is the single most important preventable risk factor for cardiovascular disease.47Thirty percent of all CHD deaths in the United States are thought to be attributable to cigarette smoking,5l with the potential for developing CHD in middle-aged men approximately two times greater in cigarette smokers than in nonsmoker^?^,^^ The risk may be less in cigar and pipe smokers and women smokers, although the risk is still significant compared with nonsmoker^.^' In studies57in which nonfatal and fatal myocardial infarction and sudden death have been analyzed separately, it has been found that the relative risk of nonfatal and fatal myocardial infarction is approximately two to three times higher in men who smoke than in men who do not smoke and about 1.5 and 3.0 times more common in women who smoke than in those who do not. The Framingham Studyz4reported that the relative risk for sudden coronary death is 10 times higher in men who smoked than in nonsmoking men and 4.5 times higher in women who smoked than in nonsmoking women. From the results of most studies, it appears that the smoking risk for coronary events is proportionately related to the age at which a person starts smoking, duration of smoking, and the number of cigarettes smoked daily. Any amount of smoking, however, is associated with increased risk of coronary artery events. Studies have demonstrated that neither filtered cigarettes nor low tar cigarettes . . . . nm+octi~.~p: . ,. . .. . ~mokp~ mrhg s tlged !?!tered cirrzrette~F.zd eyen I.icl.er incidence
of C'HD than smokers of nonfiltered cigarette> Furthermore, it h; been demonstrated that the mere proximity to smokers is associated with increased risk of ~,~ a ~recent review of numerous published CHD morbidity and m ~ r t a l i t y ? , 'In prospective studies and by using the newest Environmental Protective Agency procedures for estimating deaths from passive smoking, Wells56estimated that the number of cardiac deaths caused by passive smoking is 40% to 100%higher than that calculated by previous methods. His studies demonstrated that 62,000 deaths from CHD in the United States in 1985 were caused by passive smoking.
SMOKING AND CORONARY ARTERY DISEASE
25
Furthermore, passive smoking appeared to cause a 20% to 70% increase in the risk of CHD among persons who never smoked, an increase not explained by other risk factors. It should be emphasized that as the number of a patient's risk factors increases, so does the patient's risk for CHD-an increasingly important point in elderly smokers who commonly have hypercholesterolemia and are hypertensive. Studhave demonstrated that hypertension, hypercholesterolemia, and smoking ies3,46 interact in a synergistic rather than an arithmetic manner; the combination of two of these risk factors increases the incidence of CHD by as much as nine times and the presence of all three risk factors increases the incidence by as much as 16 times.
SMOKING AS A RISK FACTOR OF CORONARY ARTERY DISEASE IN THE ELDERLY
Smoking as a risk factor for CHD is highest in younger persons, and some s t u d i e ~ ~have ' , ~ ~suggested ,~~ that the risk diminishes markedly in elderly smokers. In the Framingham Study,2' smoking in younger persons was an independent predictor of coronary artery disease (CAD), whereas in older persons (over age 65) in whom 33% of men and 23% of women were smokers, the relation disappeared after multivariate analysis. Similar findings were reported by the Boston Collaborative Drug Surveillance Program S t ~ d y .The ~ ' rate ratio for nonfatal acute myocardial infarction was 3.0 for one-pack-a-day cigarette smokers who were 40 to 49 years of age and 1.4 for smokers 50 to 59 years of age. Both rate ratios were highly significant, as compared with rate ratios for nonsmokers. In contrast, the rate ratio of smokers 60 to 69 years of age was insignificant. Similar rate ratios were noted among the age groups when analyzing two-pack-a-day smokers. Because the results of these studies demonstrated a diminished relation of smoking to CHD in older persons, some authorities have questioned whether smoking should be considered a risk factor for CHD in the elderly, and the advisability of urging older persons to stop smoking has been ~ h a l l e n g e dEven .~~ though the prevalence of smoking in the general population has significantly decreased in the last decade, 20% to 30% of elderly persons continued to smoke, and with CHD being so prevalent in this age group and the number one killer, the question of whether elderly should be advised to stop smoking is an important public health issue. In contrast to the results of the Framingham and the Boston Collaborative Drug Surveillance Program studies, other studies have demonstrated smoking to be a significant risk factor for development of CHD in elderly persons, as well as younger persons (Table 2).50The Honolulu Heart Program: which included 1394 men between the ages of 65 and 74, reported a consistent and progressive increase in the CHD incidence rate with increasing levels of smoking in both middle-aged and elderly men. Never-smokers showed the lowest rates of CHD, followed by former smokers, with current smokers exhibiting the highest rates. Multivariate life table regression analysis that included other major risk factors for CHD demonstrated a relative risk of 1.62 for elderly male smokers compared with 1.80 for younger male smokers. The difference in these relative risks between the age groups was not statistically significant.From the perspective of excessive risk for CHD, the difference between current and never-smokers for the elderly men was 3.6 events per 1000 person-years, compared with a difference of 1.9 events between middle-aged smokers and middle-aged men who never smoked.
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TRESCH & ARONOW
Table 2. RELATION OF SMOKING TO CORONARY ARTERY DISEASE AND
MORTALITY IN THE ELDERLY
Study
Harris et aIz1 Miettinen et aI3O Jajich et aIz3 Benfante et aI8' Siegel et a14' LaCroix et aIz6 Aronow et a14 Hermanson et aI2'
Total Points
Age Range (years)
Significant Relationship
End Points
Coronary artery disease Nonfatal acute MI Total mortality Coronary artery disease MI and sudden death Total CV and CHD mortality Coronary artery events Total mortality
No No Yes Yes Yes Yes Yes
CHD = coronary heart disease; CV = cerebrovascular; MI = myocardial infarction AdaptedfromTresch DD, Carlos M: Smoking as a risk factor for coronary heart disease in the elderly. Cardiology in the Elderly 2:343-348; 1994; with permission.
Jajich and associatesz3reported findings from the Chicago Stroke Study similar to those of the Honolulu Heart Study when analyzing CHD death rates in persons 65 through 74 years of age. The CHD mortality was 52%higher in current smokers than in nonsmokers, ex-smokers, and pipe and cigar smokers. A significant increase in all cardiovascular events and major cardiovascular events (myocardial infarction, sudden death, stroke, and left ventricular failure) was also reported in smokers in the Systolic Hypertension in the Elderly Program study," compared with nonsmokers (mean age of participants was 72 years). Moreover, smoking was an independent predictor of the first cardiovascular event in these elderly subjects. The study with one of the largest cohort population of elderly patients in which the relation of smoking to CHD was assessed is the Established Populations for Epidemiologic Studies of the Elderly.26In this study of 7178 people 65 years of age or older, which included 4469 women and people over 75 years of age, the mortality hazards of smoking extended well into later life. The prevalence of smoking in this study, which included people from communities in three states (Iowa, Connecticut, and Massachusetts), was 12.9% among women and 21.2% among men. In both sexes, rates of total mortality and cardiovascular mortality in smokers were twice that found in persons who never smoked. The relative risk of mortality from all cardiovascular causes, including CHD deaths, among current smokers was 1.0 in men and 1.6in women. The relation of current smoking to cardiovascular mortality was not altered by adjustment for other cardiovascular risks, including history of hypertension or diabetes; however, the relative risk of mortality was highest among those who smoked for 40 pack-years or more, lowest in nonsmokers, and intermediate in those who smoked less than 40 pack-years. Aronow and associates," 5,6 in both prospective and retrospective studies of T:=?TT
c!.c!=-!?~=:??sG?z -.-A-AA.o !?.c-c ~ ~ c ~ . ~ o$.????.d ? ? + c57.u-o-.-----...&c?
h-p +-. : / . 7 9 9--.. 3 - - - - - - ~ -0- .
~-ckb?o
and CHD. In a prospective study4 of 192 men and 516 women (average age 82 years), at mean follow up of 41 months, current smoking was found to be an independent risk factor for new coronary events 1.8 times that found in male nonsmokers or ex-smokers and 1.9 times that found in female nonsmokers or exsmokers. Smoking was a significant risk factor in these very elderly persons regardless if there was antecedent CHD prior to smoking. In a study in which coronary angiography was used to assess the presence of CHD, Weintraub and associates55found the number of pack-year cigarettes
SMOKING AND CORONARY ARTERY DISEASE
27
smoked to be a significant independent risk factor for CHD in each age decade from 30 years to 60 years; however, after 70 years the relation was not statistically significant. Current packs of cigarettes smoked, however, was not a significant risk factor at any age. The investigators postulated that smoking accelerates atherogenesis over time, but in those persons over the age of 70, the risk of atherosclerosis is so substantial that smoking history contributed little. In another study of angiographically documented CHD, the Coronary Artery Surgery Study (CASS)22 found that male smokers 55 years or older had a relative risk of 1.7 for mortality and 1.5 for myocardial infarction or death, compared with male nonsmokers. In this study, the hazards of smoking did not diminish with increasing age. BENEFIT OF CESSATION OF SMOKING IN THE ELDERLY
In addition to the issue of whether smoking in elderly persons increases the risk of CHD and death, the other important issue concerning smoking in elderly people is whether cessation is beneficial in this age group. Studies of general populations have found that the risk of CHD reverts to that of nonsmokers when smoking is stopped. Furthermore, the decline in risk for CHD is found to be rapid following cessation of smoking. The Framingham Study2' found the cessation of smoking to cause a decreased risk of CHD within several years to a value similar to that in nonsmokers. Benefits from cessation for smokers who have already demonstrated smoking-related diseases or symptoms have also been shown. Such impressive benefits, however, may not be the case in elderly smokers who stop smoking. Elderly smokers may have too much accumulated smoking history with irreversible cardiac changes to overcome. Also, elderly smokers who have survived may have some resistance to the deleterious effects of smoking and, therefore, benefit less from quitting. Studies addressing the issue of cessation of smoking in elderly smokers, however, have found the benefits to be as encouraging as in younger smokers. In the Established Populations for Epidemiologic Studies for the which included people older than 75 years of age, risks of cardiovascular mortality, including CHD deaths, of former smokers in both sexes were similar to those of the participants who had never smoked, regardless of the number of years since they had last smoked. Ex-smokers in the Chicago Stroke were found to have a risk of CHD mortality no higher than that for nonsmokers. This benefit was noted even in those ex-smokers who had stopped smoking for only a period of 1 to 5 years. In the Coronary Artery Surgery Shtdy,2' the 6-year mortality was higher in continuing smokers than in those who quit smoking during the year before enrollment in the study. Continuing smokers were also at higher risk of either myocardial infarction or death. Furthermore, the benefit of the cessation of smoking did not diminish with age. In addition to these medical health benefits, some studies have demonstrated that after several months of abstinence, former smokers have better psychosocial functioning and are more likely to practice more health promoting and disease preventing behaviors than continuing smokers.16 Such benefits would be especially important in elderly persons who, not infrequently, are bothered by loneliness and mental depression and often have multiple risk factors that require modification. CHANGING TRENDS IN SMOKING HABITS AND SMOKING CESSATION INTERVENTION
In the last two decades, smoking habits of Americans have significantly changed.18,29, 41, 45, 48, 49, 53 The overall population rates of cigarette smoking have
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TRESCH & ARONOW
i
Males
1
Figure 1. Decline of current smokers in the United States. (Adapted from Goldberg RJ: Temporal trends and declining mortality rates from coronary artery disease in the United States. In Ockene S, Ockene JK (eds):Prevention of Coronary Artery Disease. Copyright 0Boston, Little, Brown,and Companv, 1992, p 44; with permissi0n.j
Year
declined from 40% in the adult population in 1965 to 37% in 1970, 33% in 1980, 30% in 1985, and 29% in 1987 (Fig. 1).18 In general, the percentage of Americans who were current smokers declined approximately 30% from 1965 to 1987; and, by 1987 nearly half of all living adults who had ever smoked had quit. The changes in smoking habits have been greater in men, compared to women; in older persons, compared to younger persons; and in Caucasians, compared to African-Americans. The proportion of men over age 18 who were smokers declined from 50% in 1965 to 43% in 1970, to 35% in 1983, and to 32% in 1987. Women smokers declined from 34% in 1965 to 30% in 1970 with a subsequent slight increase in the late 1970s and then a decrease to 27% in 1987. In elderly persons over age 65, a s in the general population, smoking significantly declined since 1965 (see Table 3). Twenty-eight percent of elderly men smoked in 1965 compared with only 18% in 1980; in elderly women, however, the percentage of smokers actually increased from 10% in 1965 to 17% in 1980. Moreover, cigarette smoking quit rates adjusted for differential mortality and smoking initiation have been noted to increase progressively with age cohort. In the late 1960s, men in the seventh decade of life quit smoking at a rate of about 7% per year, while men in their 50s quit at a rate of only 3% per year. In 1965 40% of Caucasians were smoking with the proportion declining to 29% in 1987, whereas among AfricanAmericans, the decline was less marked with the number of smokers decreasing from 43% in 1965 to 34% in 1987. Despite the inability to draw definite conclusions concerning the role of smoking cessation in causing a decline in CHD mortality, there is no doubt that
Table 3. PERCENTAGE OF CURRENT SMOKERS IN THE UNITED STATES Year General adult population Adult women Adult* men Elderlyt men Elderlv women
1965
1976
1980
1987
40 50 34 29 10
36 42 31 23 13
33 37 30 18 17
29 32 27
* Over 18 years or over 20 years of age in + Over 65 years of age.
the various studies.
SMOKING AND CORONARY ARTERY DISEASE
29
the decline in CHD mortality in the United States correlates with the decreasing prevalence of smoking in the general population. Furthermore, the greatest changes in smoking occurred in the second half of the 1970s, which coincides with the greatest observed decline in CHD mortality. Even though modification of all risk factors for CHD occurred during this period, the decline in smoking affected the greatest number of persons; therefore, the decline in CHD may have contributed more to the decline in CHD mortality than to the change in the other risk factors. In comparing the benefits of various CHD risk factors interventions upon survival, Goldman and Cook19estimated a 5% reduction in CHD mortality or 150,000 lives saved between 1968 and 1976 related to the decline in prevalence of smoking. Although the prevalence of current adult smokers in the United States has declined since 1965 and is correlated with a significant decline in CHD and mortality, cigarette smoking continues to be a major health concern. In 1985 the United States spent approximately 65 billion dollars on direct health care and indirect lost productivity related to smoking.58During this same period, even though the number of current smokers decreased, the proportion of heavy smokers (smoking 25 or more cigarettes per day) actually increased, with this trend particularly noted among women.20,29, 53 Between 1965 and 1985, the percent of heavy smokers increased by approximately 29% in men and 77% in women. In the Health Promotion of Disease Prevention Survey of the National Health Interview Survey conducted in 1985,33% of men 18 years or older were smokers and 32% of the smokers were heavy smokers, while 28% of women smoked with 21% of the smokers considered heavy smokers.54Therefore, emphasis on continuing antismoking and smoking cessation programs is necessary. Moreover, since 20% to 30% of elderly persons continue to smoke, and a significant proportion of the health care dollars related to smoking is consumed by this age group, it is necessary that smoking cessation programs involve the elderly population, as well as the younger population. It has been concluded that much of the decline in cigarette smoking in the United States can be attributed to the strong education campaign that has taken place in the United States over the past decades, including the anti-cigarette advertising and smoking cessation programs. The continuation of such programs is required. Over 80% of current smokers indicate that they would like to Interestingly, more than 90% of the 30 million smokers who quit smoking between 1964 and 1982 did not use an organized program to help them stop smoking; and, most smokers who continue to smoke state that they would prefer to stop without the aid of a formal smoking-cessation program.15On the basis of such information it would appear that the individual physician can have a major impact upon smoking cessation. Repeated studies have demonstrated that physicians who intervene with their smoking patients have a significant impact on patients' smoking habit^.'^,^^,^^ Almost any interventional strategy can be effective given a commitment by both the smoker and the physician and realistic expectations of what can be accomplished. The rate of success in quitting smoking has been shown to be related to symptomatic manifestation of the smoking-related diseases.'337Studies have shown a high quit rate (50% to 63%) for smokers who are advised to quit smoking after sustaining a myocardial infarction or when they developed symptoms of angina pectoris. Thus, the physician's encounters in the hospital or office with the symptomatic patient can have a significant role to play in smoking cessation intervention. When assessing patients for smoking cessation intervention, it is important that physicians realize that elderly patients are as interested in quitting as younger patients. Elderly smokers, however, may have special needs that interfere with interventions. They may have poor social support systems and
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TRESCH & ARONOW
have other diseases, such as mental depression, which prevent good adherence to a cessation program. Furthermore, elderly patients are often not aware of the benefits of quitting. Nevertheless, smoking cessation needs to be addressed in elderly smokers, as well as younger smokers, and can be as successful regardless of the patient's age.
CONCLUSION
The findings of studies indicate that the deleterious effects of smoking on the cardiovascular system extend to later life with an increased risk of cardiovascular mortality among elderly men and women who smoke, regardless of their age. The total life consumption of cigarettes is a significant risk factor of CHD and the more a person smokes the greater the risk. The conflicting results of some of the studies of older persons concerning the association of CHD and smoking may be related to the different analytical methods used, possible differences in preventive interventions, and the difference in time periods of the studies. Studies also demonstrate that benefits of quitting smoking are as significant in elderly smokers as younger smokers and the reduced risk of total and CHD mortality are significant even in those elderly persons who stop smoking after 65 years of age. In addition to the benefits of smoking cessation in cardiovascular survival are the known benefits of smoking cessation in other disease, such as cancer and pulmonary disorders. Finally, studies have demonstrated that physicians who intervene with their smoking patients have a significant impact on the patients' smoking habits, regardless of the patient's age. Therefore, it is mandatory that anti-smoking and smoking cessation programs be enthusiastically recommended and initiated by physicians in their daily contact with elderly patients.
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i7ob
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37. Rose G, Hamilton PJS: A randomized controlled trial of the effect on middle-aged men of advise to stop smoking. J Epidemiol Community Health 36102-108, 1982 38. Ross, R: The pathology of atherosclerosis. An update. N Engl J Med 314488-500,1986 39. Russel MAH, Taylor W, Gilbert R, et al: A randomized trial of family physicians intervention for smoking cessation. JAMA 260:1570-1574, 1988 40. Seltzer CC: Smoking and coronary heart disease in the elderly. Am J Med Sci 269:309315,1975 41. Shopland DT, Brown C: Change in cigarette smoking prevalence in the United States: 1955 to 1983. Ann Behav Med 7:5-8,1985 42. Siege1D, Kuller L, Lazarus NB, et al: Predictors of cardiovascular events and mortality in the systolic hypertension in the elderly program pilot project. Am J Epidemiol126:385399, 1987 43. Sinzinger H, Kefalides A: Passive smoking severely decreases platelet sensitivity to antiaggregating prostaglandins. Lancet 2:392-393, 1982 44. Smoking in the Elderly (Editorial).Br Med J 4: 607, 1975 45. Sprafka, JM, Burke GL, Folsom AR, et al: Continued decline in cardiovascular disease risk factors: Results of the Minnesota heart survey: 1980-1982 and 1985-1987. Am J Epidemiol 132489-500, 1990 46. Stamler J, Wentworth D, Neaton JD: Prevalence and prognostic significanceof hypercholesterolemia in men with hypertension. Am J Med 1986, 80(suppl 2A):33-39 47. Stokes J 111, Kannel WB, Wolf PA, et al: The relative importance of selected risk factors for various manifestations of cardiovascular disease among men and women from 35 to 64 years old: 30 years of follow-up in the Framingham Study. Circulation 75(suppl V):V-65-V-73, 1987 48. Sytkowski PA, Kannel WB, D'Agostino RB: Changes in risk factors and the decline in mortalitv from cardiovascular disease: The Framingham Heart Study. N Engl -J Med 332:163i-1641, 1990 49. Thornberg OT, Wilson RW, Golden PM: Health promotion date from the 1990 objectives: Estimates from the National Health Interview Survey Health Promotion and Disease Prevention, United States, 1985. Public Health Service, US National Center for Health Statistics, Advance Data From Vital and Health Statistics, no. 126. USDHHS publ. no. (PHs) 86-1250, Sept. 19,1986 50. Tresch DD, Carlos M: Smoking as a risk factor for coronary artery disease in the elderly. Cardiology in the Elderly 2:343-347, 1994 51. U.S. Department of Health, Education, and Welfare: Smoking and health: A report of the surgeon general. Washington, DC, US Government Printing Office, 1979 [DHEW publication no. (PHs) 79-50066.1 52. U.S. Department of Health and Human Services. Health promotion and disease prevention. United States, 1985; data from the National Health Interview Survey, Series 10, #163. USDHHS publ. no. (PHs) 88-1591. Hyattsville, MD, National Center for Health Statistics, 1988 53. U.S. Department of Health and Human Services: Reducing the health consequences of smoking: Twenty-five years of progress. A Report of the Surgeon General. USDHHS publ. no. (CDC) 89-8411,1989 54. U.S. Department of Health and Human Services: The health consequences of smoking: Cardiovascular disease. A Report of the Surgeon General. Washington, DC, U.S. Government Printing Office, 1983 [DHHS publication no. (PHs) 84-50204.1 55. Weintraub WS, Klein LW, Seelaus PA, et al: Importance of total life consumption of cigarettes as a risk factor for coronary artery disease. Am J Cardiol 55:669-672, 1985 56. Wells AJ: Passive smoking as a cause of heart disease. J Am Coll Cardiol24546-554,1994 57. Wilhelman L: Coronary heart disease: Epidemiology of smoking and intervention studies of smoking. Am Heart J 115:242-2Y4, 1Y88 58. Zevallos JC, Chiriboga D, Hebert JR: An international perspective on coronary heart disease and related risk factors. In Ockene S, Ockene JK (eds): Prevention of Coronary Artery Disease. Boston, Little, Brown, & Company, 1992, pp 147-170
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Address reprint requests to Donald D. Tresch, MD Medical College of Wisconsin 8700 Wisconsin Avenue Milwaukee, WI 53226