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Factors Associated With Continued Smoking in Lebanese Patients With Acute Coronary Syndrome

Noureddine, Samar, PhD, RN, FAHA, FAAN; Massouh, Angela, PhD, RN

doi: 10.1097/JCN.0000000000000514
ARTICLES: Smoking in ACS

Background: Smoking in patients with acute coronary syndrome (ACS) increases their risk for recurrent events and death.

Objectives: The aim of this study was to describe the smoking trajectory among patients hospitalized with ACS and associated factors.

Methods: Forty patients with ACS who were smokers were interviewed in the hospital about smoking history, nicotine dependence, depression, self-efficacy, and social support. Phone interviews at 1, 3, 6, and 12 months after discharge assessed smoking status and related factors.

Results: Most patients (≥80%) were middle-aged married men, with high nicotine dependence (52.5%) and low self-efficacy for smoking cessation (mean [SD], 38.3 [27.19]) at baseline. Although 85% intended to quit after discharge, 62.5% continued smoking after 1 year. Persistent smoking was associated with lower self-efficacy (P < .01) and higher depression (P = .025).

Conclusion: Smoking cessation intervention must start in the hospital and continue for 6 months. The program must target self-efficacy, manage depression, and involve the patient’s family.

Samar Noureddine, PhD, RN, FAHA, FAAN Professor, Hariri School of Nursing, American University of Beirut, Lebanon.

Angela Massouh, PhD, RN Assistant Professor, Hariri School of Nursing, American University of Beirut, Lebanon.

The authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Correspondence Samar Noureddine, PhD, RN, FAHA, Hariri School of Nursing, American University of Beirut, Maamari St, Beirut 1107 2020, Lebanon (

Smoking is a major risk factor for coronary artery disease (CAD), accounting for 20% of mortality in patients with CAD.1 In Lebanon, the prevalence of tobacco smoking among adults is 43% in men and 34% in women.2 Cigarettes and water pipe smoking, which have similar effects on health, are prevalent in Lebanon, and many people smoke both. Moreover, 50% to 60% of patients with an acute coronary syndrome (ACS) continue smoking after discharge from the hospital.3,4 In a study that documented a 30% recurrence rate of ACS within 3 months of discharge, smoking rates did not differ between patients with first-time ACS and those with recurrent events.4 In Lebanon, the smoking ban law (Decree #174) is not fully enforced and nicotine replacement therapy is not consistently accessible, because it is provided by only 1 pharmacy at a high cost. Moreover, there are no smoking cessation programs in Lebanon.

Smoking cessation significantly reduces the risk of death and new coronary events by 2- to 3-fold in patients with ACS.5,6 For a smoking cessation program to be effective, trends in smoking after hospitalization and associated factors must be identified so they can be targeted accordingly. A tertiary medical center in Beirut was planning to initiate a smoking cessation program and requested information on the smoking trajectory of patients to help plan the intervention. Thus, the aim of this study was to provide preliminary evidence for the development of this program by exploring patients’ smoking trajectories after hospitalization for ACS and by identifying factors associated with continued smoking.

Many factors influence the success of quitting in patients admitted with CAD. Demographic characteristics of patients were found to predict smoking after discharge in some studies but not in others.7,8 For example, some investigators reported that men, older adults, and those with higher education were more likely to quit smoking after a cardiac event than others. Moreover, history of previous myocardial infarction predicted persistent smoking in patients with CAD, whereas higher disease severity and treatment with coronary artery bypass graft surgery predicted smoking cessation.9,10

Relapse in those who quit smoking after an ACS event often occurs within 3 months after discharge.10 Predictors of relapse and persistent smoking included nonparticipation in a smoking cessation program, use of antidepressants, history of a cerebrovascular accident or chronic obstructive lung disease, high nicotine dependence, and low self-efficacy to quit.7,11,12 Anxiety, depression, lack of motivation, and craving for cigarettes predicted smoking after a cardiac event in many studies.10,13,14 On the other hand, abstinence 1 year after an ACS event was predicted by lack of history of myocardial infarction, low nicotine dependence, self-efficacy, and family support.15,16 In brief, the literature shows that some variables such as self-efficacy and depressive symptoms consistently predict smoking cessation in cardiac patients, whereas others do not yield consistent results. In the current study, we examined smoking status after discharge of smokers admitted for ACS, elective coronary artery bypass graft surgery, or elective angioplasty and factors associated with continued smoking in Lebanon. The framework for this study was inspired by the transtheoretical model of behavior change.17

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Design, Sample, and Procedures

A descriptive, observational, longitudinal design was used, with baseline data collected by face-to-face interviews of patients in the hospital and follow-up data collected by phone interviews after discharge. Forty consecutive adult patients hospitalized with ACS at a tertiary medical center in Lebanon were recruited. Inclusion criteria included (1) age of 30 years and older; (2) admission diagnosis of ACS, elective coronary artery bypass graft surgery, or elective percutaneous intervention, thus all participants having either myocardial infarction or unstable angina; (3) current cigarette smoker as documented in the medical record; (4) residence in Lebanon; and (5) ability to understand and speak Arabic. Exclusion criteria included (1) documented cognitive impairment that precluded interviews, (2) hemodynamic instability, (3) mechanical intubation, and (4) those who smoked only water pipe.

The institutional review board of the university approved the study. After consent was obtained, demographic and clinical data were retrieved from medical records. At baseline, the interviews addressed smoking history, nicotine addiction, beliefs about the relationship between smoking and health, self-efficacy for smoking cessation, intention to quit smoking after discharge, and depressive symptoms. On the basis of the literature and given the lack of data on smoking in Lebanese patients, follow-up interviews were done at 1, 3, 6, and 12 months after discharge to identify optimal time targets and duration of the intervention. At follow-up, patients were asked about their smoking status and quit attempts, their seriousness of intent to quit smoking, and time frame for quitting (stage of change). Those who quit and continued smoke free (abstainers) were asked about the reasons and facilitators of quitting. Persistent smokers and quitters who relapsed were asked about the barriers to quitting and triggers of relapse, respectively. Depressive symptoms, social support, self-efficacy, and overall confidence in the ability to quit were asked at various time points, as shown in Table 1. Open questions about smoking are available in the Supplemental Digital Content,



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Nicotine addiction was measured by the 6-item Fagerström Test for Nicotine Dependence, which addresses the time to the first cigarette, number of cigarettes smoked per day, and situations associated with smoking18 and has a test-retest reliability coefficient of 0.88.19 A score of 7 or higher indicates high dependence; 5 to 6, medium; and 4 or lower, low dependence.18

Self-efficacy to avoid smoking in challenging situations was measured at baseline and 6 months of follow-up by the validated 12-item Self-Efficacy Questionnaire rated on a 100-point scale.20 The Self-Efficacy Questionnaire predicted abstinence over time, and its reported test-retest reliability coefficients are 0.81 and 0.93.21 At 1, 3, and 12 months of follow-up, patients were asked how confident they were in their ability to quit smoking, with 1 item rated on a 10-point Likert scale instead of the Self-Efficacy Questionnaire to reduce respondent burden. Mean scores are calculated for the Self-Efficacy and confidence scales (see Table 1).

The 9-item Patient Health Questionnaire (PHQ-9),22 validated in the Arab population,23 was used to screen for depression. The PHQ-9 contains items about the frequency of experiencing 9 depressive symptoms over the past 2 weeks on a 4-point Likert scale. The summative score is categorized as minimal (5–9), mild (10–14), moderate (15–19), and severe (≥20) symptoms. The PHQ showed good agreement with diagnoses made by mental health professionals (κ = 0.84), and its Cronbach α coefficient was .82. A score of 10 or more indicates the need to refer to a mental health professional.22

At baseline, patients were asked whether or not they intend to quit smoking (yes/no). At follow-up, motivation to quit was measured with the Stage of Change Questionnaire that asks whether the person is seriously considering quitting next month, in the coming 6 months, or not at all.24

Availability of social support was measured by the 7-item Enhancing Recovery in Coronary Heart Disease Social Support Inventory,25 which has a maximum summative score of 31. A Cronbach α coefficient of .85 and correlations with the perceived social support scale between 0.63 and 0.62 were reported.25

The questionnaire was evaluated for cultural appropriateness to the Lebanese population by 4 experts in smoking research. The scales were translated into Arabic and then back-translated into English; both English versions were found to be semantically equivalent. Then, 5 smoker cardiac patients were asked for feedback about whether the items were easy to understand, clear, and relevant to them and the feasibility of conducting the interviews by phone. No changes to the questionnaire were mandated by the pilot test.

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Statistical Analyses

SPSS version 24 was used for data entry and analysis. Descriptive statistics, including means and standard deviations for continuous variables, as well as frequency and percentage for categorical variables, were used to describe the sample and summarize the study variables. The Mann-Whitney U, Kruskal-Wallis H, and χ2 tests were used to compare persistent smokers, abstainers, and those who quit and then relapsed. For some analyses, persistent smokers and relapsers were combined in 1 group given the small size of groups.

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The sample was largely male (80%), middle aged (mean [SD], 58.55 [9.16] years), married (85%), and working (77.5%). Almost half of the sample (43%) was educated up to middle school, and 42.3% had a university education. Most participants (80%) were admitted because of an acute myocardial infarction and had other cardiovascular risk factors including hypertension (55%), hyperlipidemia (47.5%), obesity (41.6%), diabetes (40%), and family history of heart disease (25%). Most patients (65.0%) were treated with angioplasty; and 12.5%, with CABG surgery.

Table 2 shows the baseline characteristics related to smoking. The mean (SD) age patients started smoking was 18.93 (9.16) years, and up to 15% smoked other tobacco products. More than 50% had high nicotine addiction, and only 8 patients reported having attempted quitting in the past year, mostly cold turkey. Only 65% believed that smoking was related to their cardiac health, and 85% intended to quit after discharge; yet, the self-efficacy score was only 38.33% (SD, 27.19%). The mean (SD) depression score at baseline was 14 (4.9), which is positive for depressive symptoms, and the mean (SD) social support score was high at 23.55 (5.55).



At 1-year follow-up, only 13 patients (32.5%) reported complete abstinence, whereas 25 (62.5%) reported persistent smoking, and 2 (5.0%) quit and then relapsed. Nevertheless, the mean (SD) number of cigarettes smoked per day was reduced from 32.4 (19.2) at baseline to 16.57 (12.16) at 1 year. The most frequent barriers to quitting were the engrained habit, life stresses, and the social pressure to smoke. For abstainers, factors that facilitated quitting were their concerns about their health, support from their family, their perseverance and strong will, not smoking for some time, and health warnings by their physicians. Patterns of smoking and the motivation to quit (stage of change) over time are shown in Figures 1 and 2.





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Factors Associated With Smoking

There were no demographic or clinical differences between the smoker groups. At 1 month after discharge, persistent smokers (n = 24) reported significantly lower confidence in being able to quit smoking than those who quit and relapsed (n = 3), with means of 4.27 versus 8.67 (P = .019). Conversely, those who relapsed reported lower social support than the 13 abstainers (19 vs 26.46, P = .016).

At 3 months of follow-up, persistent smokers and relapsers (n = 26) showed significantly lower confidence in their ability to quit smoking compared with the 14 abstainers (means, 4 vs 8.74; P = .003). This trend continued at 1 year, with persistent smokers and relapsers (n = 27) reporting significantly lower confidence compared with the 13 abstainers (1.63 vs 9.0, P = .035).

At 6 months, self-efficacy and depression were significantly associated with smoking. The 26 persistent smokers and relapsers had lower self-efficacy scores (25.65 vs 92.56, P < .001) and higher depression scores (11.69 vs 9.71, P = .008) compared with the 14 abstainers.

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The finding of persistent smoking after hospitalization in patients with ACS in this study is similar to earlier findings in Lebanon.3,4 A high level of nicotine addiction is noted in this sample. The results suggest that the smoking outcome is set mostly at 6 months, as either continued smoking or total abstinence. At 1 year, persistent smokers lose any motivation to quit but reduce the number of cigarettes they smoke. Those who abstain have higher self-efficacy, whereas those who continue smoking have more depressive symptoms. The habit, stress, and the environment, in a country with no smoking cessation programs and where the smoking ban law is not enforced, hinder quit attempts. Conversely, health concerns and family support promote success in quitting. Similar findings (60.7% persistent smoking and 9.6% quit and relapse rates) were reported in Jordan, a country with a similar smoking prevalence, where lack of motivation and craving for cigarettes were identified as the strongest barriers against quitting smoking in outpatients with CAD.14

These findings suggest that a smoking cessation program must cover 6 months after discharge and focus on psychoeducational and cognitive behavioral techniques that strengthen self-efficacy, while emphasizing the hazards of continued smoking. Stress management training must be included to help prevent relapse and support participants’ perseverance in coping with cravings given the high addiction and lack of nicotine replacement therapy. Moreover, depression screening and management are recommended to facilitate quitting. For the program to have a long-term impact, patients’ families need to be involved to provide the needed support and nurses need to be trained in smoking cessation counseling.

The main limitation of this study is the small sample size and recruitment from 1 site, which limits the generalizability of findings. The study needs replication with larger samples from various sites. Yet, in terms of practice, the findings do provide guidance for smoking cessation intervention at the study site.

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What’s New and Important?

  • In resource-limited countries, cost-effective creative smoking cessation interventions are needed.
  • To be effective, smoking cessation programs should extend up to 6 months after discharge, target self-efficacy, manage depression, and elicit the patient’s family for support.
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acute coronary syndrome; adult; depression; self-efficacy; smoking

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