Smoking cessation medication may be underutilized in older patients after MI

Mark J. Eisenberg, MD, MPH

This paper shows that although smoking is being identified in the hospital as a problem, the actual follow-through in terms of treatment with pharmacotherapies is quite low.
As the authors say, words need to be followed by action, so just identifying a post-MI patient as a smoker is not enough, nor is simply referring them to resources or counseling. We need to make a concerted effort to give them a prescription for a smoking cessation pharmacotherapy while they’re in the hospital.

One of our studies was referenced in this article (Eisenberg MJ, et al. Circulation. 2016;doi: 10.1161/CIRCULATIONAHA.115.019634.). Our trial showed that varenicline is effective for smoking cessation in this patient population. From my reading of the literature, typically less than a third of patients quit smoking by 1 year after an MI. In our trial, we were able to increase the quit rates from less than a third to about 50% with varenicline, so even with smoking cessation therapy, 50% of patients are still going to be smoking at 1 year.

There are a couple issues with the study. One is that nicotine replacement therapy could not be studied because it is only available over the counter, so the researchers were only looking at prescriptions for bupropion and varenicline. It’s possible that all the rest of the other patients got nicotine patch, which could not be identified in the database. That’s a potential limitation.

Another limitation is that they don’t know how many patients actually quit smoking. Maybe other patients quit smoking without any therapy, which is very unlikely.

Also, bupropion has been shown in many trials to be effective for smoking cessation in younger, healthy outpatients, but to my knowledge, there have been three trials in post-MI patients with bupropion and it never been shown to be effective for smoking cessation in that particular group. The only drug that I’m aware of that’s been shown to be useful in the post-MI population is varenicline.

I would like to see studies that are using varenicline with more structured behavioral therapy. I wonder whether we should be giving it for a longer period of time. Typically, we give it for 12 weeks. In this study, it appeared the patients were taking varenicline and bupropion for much shorter periods than recommended.

I wonder whether we should be using sequential therapies like give them varenicline, if that does not work, give them bupropion and if that does not work, then give them a nicotine patch. There is a lot of room for research that will push the envelope. These authors have identified that this is a huge problem.

Not only are there a lot of smokers, but they’re not even getting pharmacotherapy, so we need studies to show what the effective mechanisms are for making sure that everybody gets pharmacotherapy, and then if patients fail pharmacotherapy, what do we do afterwards, which is to try another form of pharmacotherapy, behavioral therapy, sequential treatments or synergistic treatments.