Cigarette Smoking and the Risk to Her Heart

The risk of heart disease associated with cigarette smoking is universally recognized, with smokers having a 2- to 4-times higher risk of developing coronary heart disease (CHD) than nonsmokers.1 Cigarette smoking increases heart disease mortality risk by 1.2- to 3-fold2 and is an independent predictor of sudden cardiac death in patients who already have CHD.3 Smoking is more strongly associated with acute myocardial infarction (MI) in women than in men (odds ratios: 9.11 and 3.92, respectively).4 Smoking also adds to the CHD risk conferred by other factors, including hypertension and high cholesterol.5

Despite a greater appreciation of the health risks associated with smoking, more than 400,000 Americans die annually from smoking-related illnesses.6 Approximately 35% of these deaths can be attributed to cardiovascular disease (CVD).6

According to 2005 data, 18.5% of women in the United States are smokers.7 As part of an overall effort toward the prevention of heart disease in women,8 primary care physicians should ensure that their female patients understand the impact of smoking, not only on their risk of developing heart disease but also on their odds of experiencing a heart attack or sudden cardiac death.





Smoking-Associated CHD Risk in Younger Women
  • A study of women 45 years old or younger who had coronary artery disease (CAD) showed that, after family history (67%), smoking was the most prominent cardiac risk factor (55%).10
  • In a study of women smokers and nonsmokers under age 50, the relative risk of MI increased with the number of cigarettes smoked; among the heaviest smokers, the relative risk of MI was higher in younger women (25 to 39 years of age).11
  • In a longitudinal study of nearly 25,000 individuals, the highest risk for MI was in women smokers under the age of 55.12

  • A study of women younger than 44 years of age found that compared with nonsmokers, there was an approximately 2.5-fold higher risk of MI in women who smoked 1 to 5 cigarettes per day, rising to 74.6 for those smoking more than 40 cigarettes per day.13
  • Unfortunately, younger people—aged 18 to 24 years—also have the highest prevalence and the largest increases in smoking.14
    • 34% to 36% of 18- to 24-year-old Caucasians currently smoke
    • Caucasians in this age group had a 10% to 12% increase in smoking from 1990 to 2000

Concomitant Smoking and Oral Contraceptive (OC) Use

  • One study found that the attributable risk of death from CVD associated with OC use in women aged 35 to 44 years is 3.0 per 100,000 nonsmokers and 19.4 per 100,000 smokers.15
  • A multicenter study found that the independent risk of MI among current smokers adjusted for OC use was 7.21; this risk was lower, but still significant, in women smokers who were taking third-generation OCs (3.75).16
  • In a large study of 17,032 women, women who took OCs and smoked 15 or more cigarettes per day had higher ischemic heart disease mortality and twice the all-cause death rate compared with nonsmokers.17
  • Because the risk of MI in women who smoke concomitantly with OC use appears to be age related, it has been recommended that physicians be wary of prescribing OCs to smokers over 34 years old and especially to smokers over 39 years old.18

Benefits of Smoking Cessation
  • Unlike age or a person's family history, cigarette smoking is a modifiable risk factor, and quitting smoking can have a profound impact on CHD risk:
    • In a pooled cohort study that included 8467 women, smoking cessation—but not smoking reduction—over a mean follow-up period of 14 years resulted in a significantly decreased risk of MI (hazard ratio 0.71)19
    • According to a case-control study in 52 countries (INTERHEART), smoking is 1 of 9 easily measured and potentially modifiable risk factors that account for more than 90% of the risk of an initial acute MI20
    • In a study of 7302 women aged 18 to 39 years with favorable levels for 5 major risk factors (blood pressure, serum cholesterol, body mass index, diabetes, and smoking), there was a very low long-term risk of CHD, CVD, and all-cause mortality compared with those who had unfavorable risk factor profiles21
    • Another study that included 6229 women aged 40 to 59 years from the Chicago Heart Association Project in Industry similarly found that those who had low cholesterol levels, low blood pressure, were not current smokers, had no history of diabetes or MI, and no ECG abnormalities had a lower risk of CHD death, CVD death, and all-cause mortality22
    • A study of 84,129 women enrolled in the Nurses' Health Study identified 5 healthy lifestyle factors, including the absence of current smoking, which significantly decreased the long-term risk of CHD9

Current Guideline Recommendations for CVD Prevention
  • The Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update recommends the following8:

    "Women should not smoke and should avoid environmental tobacco smoke. Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or formal smoking cessation program."
  • Smoking cessation is recommended for women at all CVD risk levels (SOR: A)8

How Do You Help Patients Quit Smoking?
Helping patients to quit smoking may be almost as difficult as quitting yourself. For some important information about discussing smoking with patients in the primary care setting and helping them quit, see the following paper:

Anczak JD, Nogler RA II. Tobacco cessation in primary care: maximizing intervention strategies. Clin Med Res. 2003;1:201-216. Click here to view.

References
1. American Heart Association. Risk factors and coronary heart disease. http://www.americanheart.org/presenter.jhtml?identifier=4726. Accessed May 6, 2009. 2. Novotny TE, Giovino GA. Tobacco use. In: Brownson RC, Remington PL, Davis JR eds. Chronic Disease Epidemiology and Control. 2nd ed. Washington, DC: American Public Health Association; 1998:117-148. 3. Goldenberg I, Jonas M, Tenenbaum A, et al; Bezafibrate Infarction Prevention Study Group. Current smoking, smoking cessation, and the risk of sudden cardiac death in patients with coronary artery disease. Arch Intern Med. 2003;163:2301-2305. 4. Oliveira A, Barros H, Lopes C. Gender heterogeneity in the association between lifestyles and non-fatal acute myocardial infarction. Pub Health Nutr. 2009:1-8. 5. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation. 2002;106:3143-3421. 6. Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 1997-2001. MMWR Morb Mortal Wkly Rep. 2005;54:625-628. 7. Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults: United States, 2004. MMWR Morb Mortal Wkly Rep. 2005;54:1121-1124. 8. Mosca L, Banka CL, Benjamin EJ, et al; for the Expert Panel/Writing Group. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115:1481-1501. http://www.acc.org/qualityandscience/clinical/pdfs/cvdinwomen.pdf. Accessed May 15, 2009. 9. Stampfer MJ, Hu FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343:16-22. 10. De S, Searles G, Haddad H. The prevalence of cardiac risk factors in women 45 years of age or younger undergoing angiography for evaluation of undiagnosed chest pain. Can J Cardiol. 2002;18:945-950. 11. Rosenberg L, Kaufman DW, Helmrich SP, et al. Myocardial infarction and cigarette smoking in women younger than 50 years of age. JAMA. 1985;253:2965-2969. 12. Prescott E, Hippe M, Schnohr P, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ. 1998;316:1043-1047. 13. Dunn NR, Faragher B, Thorogood M, et al. Risk of myocardial infarction in young female smokers. Heart. 1999;82:581-583. 14. Winkleby MA, Cubbin C. Changing patterns in health behaviors and risk factors related to chronic diseases, 1990-2000. Am J Health Promot. 2004;19:19-27. 15. Schwingl PJ, Ory HW, Visness CM. Estimates of the risk of cardiovascular death attributable to low-dose oral contraceptives in the United States. Am J Obstet Gynecol. 1999;180:241-249. 16. Lewis MA, Heinemann LA, Spitzer WO, et al. The use of oral contraceptives and the occurrence of acute myocardial infarction in young women. Results from the Transnational Study on Oral Contraceptives and the Health of Young Women. Contraception. 1997;56:129-140. 17. Vessey M, Painter R, Yeates D. Mortality in relation to oral contraceptive use and cigarette smoking. Lancet. 2003;362:185-191. 18. Keeling D. Combined oral contraceptives and the risk of myocardial infarction. Ann Med. 2003;35:413-418. 19. Godtfredsen NS, Osler M, Vestbo J, et al. Smoking reduction, smoking cessation, and incidence of fatal and non-fatal myocardial infarction in Denmark 1976-1998: a pooled cohort study. J Epidemiol Community Health. 2003;57:412-416. 20. Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937-952. 21. Daviglus ML, Stamler J, Pirzada A, et al. Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality. JAMA. 2004;292:1588-1592. 22. Stamler J, Stamler R, Neaton JD, et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA. 1999;282:2012-2018.

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