DURHAM, NC — Physicians are good at advising hospitalized smokers who have just had an MI to stop smoking, but they could do more to encourage such patients to fill a prescription for a medication to help them quit smoking, a new study suggests[1].
Filled prescription rates for smoking-cessation medications (SCM) were “woefully low” in a national registry study published as a research letter in JAMA Cardiology, Dr Neha J Pagidipati (Duke University, Durham, North Carolina) told theheart.org | Medscape Cardiology.
“Patients who have just had an MI are in this teachable moment,” she said. If they’re going to quit smoking, they are most likely to do so immediately after the MI, she added, “and this study indicates that maybe we’re not doing everything that we can to take advantage of this window of opportunity.”
Specifically, among more than 9000 older patients (median age 70) who were smokers and had just had an MI, 97% were advised to quit smoking while they were in the hospital, but only 7% filled a prescription for bupropion or varenicline (Chantix/Champix, Pfizer) within 3 months of their MI.
“The results of our study suggest the need for words (smoking-cessation counseling rates are high) to be followed by action (SCM use rates can be higher),” the researchers conclude in their report.
“I agree,” Dr Mark J Eisenberg (McGill University, Montreal, QC) told theheart.org | Medscape Cardiology. Identifying smokers post-MI and hospitalization is a major quality-metric benchmark in the US and Canada, so “we finally have a system in place to identify smokers in the hospital,” he noted, “but that needs to be followed by solid therapy . . . meaning treatment with pharmacotherapy and behavioral therapy in 100% of patients.”
Some caveats are that the study did not capture data about use of other smoking-cessation options like nicotine-replacement patch or behavioral therapy, but its “very unlikely” that all the patients who were not taking varenicline or bupropion were getting these interventions, Eisenberg said.
Study limitations include lack of data about the actual prescription rates, smoking-cessation rates after MI, or the reason for drug prescription or discontinuation, the researchers acknowledge.
Nevertheless, this study identified that older patients, men, and those from counties with lower levels of education were less likely to take smoking-cessation therapies, and “they may represent a key target population for more intensive smoking-cessation assistance,” Pagidipati said.
Post-MI Use of Varenicline, Bupropion
The uptake of smoking-cessation medications among smokers who have just had an MI is unknown, the researchers note. To investigate, Pagidipati and colleagues identified patients age 65 and older who were part of the Acute Coronary Treatment and Intervention Outcomes Network Registry, which is linked to Medicare claims data.
They identified 183,783 patients aged 65 and older who were admitted for an MI during April 2007 to December 2013, and of these, 28,242 patients (15.4%) were current or recent smokers.
After researchers excluded patients who died, were discharged to nursing homes, left, or were not enrolled in Medicare Part D, this left 9193 patients in the current study.
Of these, 8942 patients (97%) had received smoking-cessation counseling during their hospitalization. However, the database does not provide information about the type and length of counseling, which likely varied between hospitals, Pagidipati said.
Only 647 patients (7%) filled a prescription for bupropion or varenicline within 90 days of hospital discharge: 306 patients (47.3%) filled a prescription for bupropion and 341 patients (52.7%) filled one for varenicline.
Moreover, the supplies were for a median of 6.2 weeks for bupropion and a median of 4.3 weeks for varenicline, which is less than the recommended 12 weeks.
The smokers who filled an early prescription for a smoking-cessation medication after an MI were more likely to be women (odds ratio [OR] 1.46), live in counties with a high rate of high school graduation (OR 1.14), and have chronic lung disease (OR 1.47) or PAD (OR 1.23) or have undergone coronary revascularization (OR 1.25), and be younger (OR 1.52 for each 5-year decrease in age).
Next Research Steps
A year after the patients were discharged from the hospital following their MI, only 52.8% had quit smoking, and only 9.4% had currently filled a prescription for one of the two SCMs.
Varenicline use dropped from 12.6% in 2007 to 2.2% in 2013, whereas rates of bupropion rose very slightly from 2.5% to 3.2% but remained low.
During this time, a meta-analysis in CMAJ[2] had suggested that varenicline might be associated with increased cardiovascular events, and there were anecdotal reports of increased psychiatric events with varenicline, Eisenberg explained, but the more recent EAGLES trial[3], which randomized more than 8000 patients to bupropion, varenicline, nicotine patch, or placebo, “could show no association with any of the drugs with either cardiac events or psychiatric events.”
“It behooves us as physicians . . . every time we see a patient either in a hospital or a clinic to assess whether they are smokers or not, ” he said, since “they do not volunteer that they are smokers.”
“What we’re seeing is that these medications are being underused, even though guidelines recommend pharmacotherapy to assist with smoking cessation,” Pagidipati said.
“The next steps are to see,” she said, “whether it is because providers are not prescribing smoking-cessation therapy, or are providers prescribing it, but patients don’t want to take it? Or is it because patients wanted to take it, but the cost was too high or the side effects were too bad?”
The authors disclosed that they have no relevant financial relationships. Eisenberg disclosed that he received funding from Pfizer for the EVITA trial.
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