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Review |

Mortality Risk Reduction Associated With Smoking Cessation in Patients With Coronary Heart Disease A Systematic Review

Julia A. Critchley, MSc, DPhil; Simon Capewell, MD, FRCPE
JAMA. 2003;290(1):86-97. doi:10.1001/jama.290.1.86.
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Published online

Context As more interventions become available for the treatment of coronary heart disease (CHD), policy makers and health practitioners need to understand the benefits of each intervention, to better determine where to focus resources. This is particularly true when a patient with CHD quits smoking.

Objective To conduct a systematic review to determine the magnitude of risk reduction achieved by smoking cessation in patients with CHD.

Data Sources Nine electronic databases were searched from start of database to April 2003, supplemented by cross-checking references, contact with experts, and with large international cohort studies (identified by the Prospective Studies Collaboration).

Study Selection Prospective cohort studies of patients who were diagnosed with CHD were included if they reported all-cause mortality and had at least 2 years of follow-up. Smoking status had to be measured after CHD diagnosis to ascertain quitting.

Data Extraction Two reviewers independently assessed studies to determine eligibility, quality assessment of studies, and results, and independently carried out data extraction using a prepiloted, standardized form.

Data Synthesis From the literature search, 665 publications were screened and 20 studies were included. Results showed a 36% reduction in crude relative risk (RR) of mortality for patients with CHD who quit compared with those who continued smoking (RR, 0.64; 95% confidence interval [CI], 0.58-0.71). Results from individual studies did not vary greatly despite many differences in patient characteristics, such as age, sex, type of CHD, and the years in which studies took place. Adjusted risk estimates did not differ substantially from crude estimates. Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, restriction to 6 higher-quality studies had little effect on the estimate (RR, 0.71; 95% CI, 0.65-0.77). Few studies included large numbers of elderly persons, women, ethnic minorities, or patients from developing countries.

Conclusions Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. This risk reduction appears to be consistent regardless of age, sex, index cardiac event, country, and year of study commencement.

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Figure 1. Flow Chart of the Study Selection Process
Graphic Jump Location
Figure 2. Pooled Relative Risks of Mortality Reduction When Patients With CHD Stop Smoking: Random-Effects Meta-analysis of All 20 Studies
Graphic Jump Location
CHD indicates coronary heart disease; RR, relative risk. χ2 for heterogeneity, P = .009.
Figure 3. Begg Funnel Plot
Graphic Jump Location
Log odds ratio vs SE of the log odds ratio for each study are presented. The horizontal solid line indicates the log odds ratio of the pooled estimate; the sloping dashed lines are expected 95% confidence intervals. The funnel plot appears asymmetric and shows that larger, more precise studies with smaller SEs tended to find smaller reductions in risk of mortality on quitting smoking than smaller studies with fewer deaths (P = .006).
Figure 4. Pooled Relative Risks of Reduction in Nonfatal Myocardial Reinfarction When Patients With CHD Stop Smoking: Random-Effects Meta-analysis of 8 Studies
Graphic Jump Location
CHD indicates coronary heart disease; RR, relative risk.

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