Original Article
Decline in the Risk of Myocardial Infarction among Women Who Stop Smoking
N Engl J Med 1990; 322:213-217January 25, 1990
- Abstract
- Abstract
To assess the relation of smoking cessation to the risk of a first myocardial infarction in women, we compared the smoking habits of 910 patients who had had their first myocardial infarction with those of 2375 controls in a hospital-based case–control study of women from 25 to 64 years of age.
The estimate of relative risk among current smokers as compared with women who had never smoked was 3.6 (95 percent confidence interval, 3.0 to 4.4). Among exsmokers overall, the corresponding estimate of relative risk was 1.2 (95 percent confidence interval, 1.0 to 1.7). Among exsmokers, the estimate of relative risk was significantly elevated among women who had stopped smoking less than two years previously (relative risk, 2.6; 95 percent confidence interval, 1.8 to 3.8). Most of the increase in the risk had dissipated among the women who had stopped smoking two to three years previously, and the estimate of relative risk among the women who had not smoked for three or more years was virtually indistinguishable from that among the women who had never smoked. The same pattern of decline was apparent regardless of the amount smoked, the duration of smoking, the age of the women, or the presence of other predisposing factors.
These data suggest that in women, as in men, the increase in the risk of a first myocardial infarction among cigarette smokers declines soon after the cessation of smoking and is largely dissipated after two or three years. (N Engl J Med 1990; 322:213–7.)
Media in This Article
Figure 1
Estimated Relative Risk of Myocardial Infarction in Women after They Stopped Smoking.Table 1
Relation of the Risk of Myocardial Infarction to Cigarette Smoking in 910 Case Patients and 2375 Controls.Article Activity
- Article
IT is well established that cigarette smoking is a major contributor to the risk of myocardial infarction in both men and women and that the cessation of smoking is followed by a decline in the risk.1 2 3 4 5 6 7 8 9 10 11 12 13 Studies of the effects of smoking cessation have focused on men, and they indicate that most of the increase in the risk attributable to smoking disappears within five years after quitting. Although there is every reason to believe that the pattern of the decline in risk is similar in women, this has not been demonstrated.
The prevalence of smoking has declined markedly in the United States in the past 20 years, but the decline has been less pronounced in women than in men.14 15 16 Women appear more likely than men to smoke the highly promoted "low-yield" brands, possibly because they believe them to be safer than other kinds of cigarettes. Recent evidence indicates, however, that women who smoke low-yield cigarettes have virtually the same risk of myocardial infarction as women who smoke higher-yield brands.17 Perhaps if women smokers were more aware of the cardiovascular hazards of smoking and the benefits of cessation, they would be more inclined to quit than to switch brands.
In the present study, we assessed the relation of smoking cessation to the risk of a first myocardial infarction in women, with particular attention to how soon the risk declines after the cessation of smoking and to the effect of the intensity of smoking, the duration of smoking, and other predisposing factors.
Methods
Data Collection
The data were collected from 1985 to 1988 from women under the age of 65 who were admitted to 71 hospitals in Massachusetts, Rhode Island, Connecticut, and New York. Our central office telephoned the coronary care units of these hospitals each week to identify potential cases of first myocardial infarction. The attending physician was telephoned for details of the diagnosis and for permission to approach the patient. Seventy percent of the case patients were interviewed in person in the hospital during convalescence, and 30 percent were interviewed by telephone after they had been sent home. Women with conditions other than myocardial infarction (potential control subjects) were interviewed in the same hospitals. The rate of participation was 88 percent among eligible case patients and 91 percent among eligible controls.
The interviewers, who were nurses, administered a structured questionnaire to obtain information on risk factors for myocardial infarction, menstrual history, the use of medications for conditions that increase the risk of myocardial infarction (such as antihypertensive drugs), and the use of oral contraceptives and noncontraceptive estrogens. Current cigarette smokers (women who smoked at the time of entry to the hospital) were asked how many cigarettes they smoked a day and how long they had smoked. Exsmokers were asked how long it had been since they quit smoking, how long they had smoked, and how many cigarettes they had smoked per day before quitting.
Case Patients
The case patients were women from 25 to 64 years of age who had been admitted for a first myocardial infarction. We were able to examine the discharge summaries of 90 percent of the potential case patients (891 of 993). Ninety-one percent of the potential case patients whose summaries were read (808 of 891) satisfied the World Health Organization's criteria for the diagnosis of myocardial infarction18 (pathologic Q waves with evolution, elevated cardiac enzyme levels together with a typical history of chest pain, or elevated cardiac enzyme levels together with diagnostic electrocardiographic changes with evolution). Women who did not meet the criteria were excluded, as were women with a history of rheumatic valvular disease, cardiomyopathy, or cardiac surgery (e.g., coronary bypass). A total of 910 case patients were included, 97 percent of whom were white, with a median age of 56 years.
Controls
The controls were women from 25 to 64 years of age who had no history of myocardial infarction, rheumatic valvular disease, cardiomyopathy, or cardiac surgery. We selected women who had been admitted for nonmalignant conditions that we judged to be unrelated to cigarette smoking. Thus, for example, patients with peptic ulcer, ulcerative colitis, or respiratory diseases were not included. There were 2375 controls, 95 percent of whom were white, with a median age of 50 years. The controls had been admitted for gastrointestinal and genitourinary disorders (837 patients), vertebral disk and other orthopedic disorders (570), trauma (550), or infections (418). After adjustment to the age distribution of the case patients, the proportions of current smokers across the diagnostic groups were 34 percent, 39 percent, 32 percent, and 33 percent, respectively; the corresponding proportions of exsmokers were 23 percent, 22 percent, 28 percent, and 26 percent.
Statistical Analysis
The relative risks of myocardial infarction were estimated for current and exsmokers as compared with women who had never smoked. Age-adjusted estimates of relative risk from data stratified according to age (<40, 40 to 49, 50 to 59, and 60 to 64) were computed according to the MantelHaenszel method,19 and 95 percent confidence intervals were computed according to Miettinen's method.20 Multivariate estimates of relative risk were derived from multiple logistic-regression analyses in which several potential confounding factors were controlled21: indicator terms were included for age, geographic area, history of drug-treated hypertension, history of drug-treated angina pectoris, history of drug-treated diabetes mellitus, history of elevated serum cholesterol levels, history of myocardial infarction before the age of 60 in a parent or sibling, body-mass index (the weight in kilograms divided by the height in meters squared), age at menopause, number of hours of vigorous exercise per week, Framingham Type A behavior score,22 oral contraceptive use, use of noncontraceptive estrogen, alcohol consumption, coffee consumption, and years of education. The multivariate estimates of relative risk were similar to those adjusted for age alone and have generally not been given. In addition, the results obtained from case patients interviewed in the hospital (70 percent of the case patients) were similar to those obtained from case patients interviewed by telephone (30 percent of the case patients). The results given below are based on data from all the case patients.
Results
Among the 910 case patients, 570 were current smokers (63 percent), 149 were exsmokers (16 percent), and 191 had never smoked (21 percent). Among the 2375 controls, 885 were current smokers (37 percent), 550 were exsmokers (23 percent), and 940 had never smoked (40 percent) (Table 1Table 1
Relation of the Risk of Myocardial Infarction to Cigarette Smoking in 910 Case Patients and 2375 Controls.). For current smokers, as compared with women who had never smoked, the overall age-adjusted estimate of relative risk was 3.6 (95 percent confidence interval, 3.0 to 4.4), and the multivariate estimate was 3.7. The age-adjusted estimate of relative risk increased with the number of cigarettes smoked, from 2.0 among women who smoked 1 to 14 cigarettes a day, to 2.8 for 15 to 24 a day, 4.7 for 25 to 34 a day, and 7.2 for 35 or more a day (data not shown). For exsmokers as compared with those who had never smoked, the overall age-adjusted estimate of relative risk was 1.2 (95 percent confidence interval, 1.0 to 1.7), and the multivariate estimate was 1.3.Although the overall estimate of relative risk among exsmokers was close to 1.0, the estimates varied considerably depending on how long it had been since they had quit smoking. As shown in Figure 1Figure 1
Estimated Relative Risk of Myocardial Infarction in Women after They Stopped Smoking., among women who had not smoked for 1 to 3 months, 4 to 6 months, 7 to 11 months, and 12 to 23 months, the age-adjusted estimates of relative risk were 3.0, 3.6, 2.3, and 2.0, respectively (the combined estimate for these intervals was 2.6; 95 percent confidence interval, 1.8 to 3.8). Among women who had abstained from smoking for 24 to 35 months, the estimate was 1.3, and among those who had not smoked for more than 35 months, the estimates of relative risk ranged from 0.8 to 1.1.As shown in Table 2Table 2
Relation of the Risk of Myocardial Infarction in Women to the Length of Time since the Cessation of Smoking, According to the Amount Smoked and the Duration of Smoking., the same pattern of decline in the age-adjusted estimates of relative risk after the cessation of smoking was apparent among women who had smoked 1 to 14 cigarettes per day, 15 to 24 per day, or 35 or more per day before quitting. Among women who had smoked 25 to 34 cigarettes a day, the estimate was elevated for women who had abstained from smoking for 5 to 9 years (relative risk, 2.6; 95 percent confidence interval, 1.0 to 7.1) but reduced for women who had abstained for 10 or more years (relative risk, 0). The estimated relative risk was 1.0 for the combined group who had not smoked for at least five years. The pattern of decline was also apparent both among women who had smoked for at least 20 years before quitting and among those who had smoked for less than 20 years before quitting.As shown in Table 3Table 3
Relation of the Risk of Myocardial Infarction in Women to the Length of Time since the Cessation of Smoking, According to Their Potential Risk Factors for Myocardial Infarction., the pattern was present among older women (50 to 64 years) and younger women (25 to 49 years); women with hypertension, elevated cholesterol levels, or angina pectoris; obese women; sedentary women; those with high Type A behavior scores; and those with a family history of myocardial infarction. A similar pattern was also present among exsmokers whose underlying risk of myocardial infarction was otherwise presumably low because of the absence of hypertension, elevated cholesterol levels, and angina pectoris.Discussion
Our results indicate that among current smokers, the risk of a first nonfatal myocardial infarction increases with the amount smoked and is considerably elevated for heavy smokers. The results also indicate that a decline in the risk to a level approximating that among women who have never smoked occurs within three or four years after the cessation of smoking and that it is independent of the amount smoked, the duration of smoking, or the presence of other predisposing factors for myocardial infarction. The findings for exsmokers are highly plausible because a large body of evidence indicates that the risk of a first myocardial infarction, and of reinfarction, declines markedly in men after the cessation of smoking.1 2 3 4 5 6 7 8 9 10 In our earlier case–control study of men, a decline in the risk of a first nonfatal myocardial infarction to a level similar to that among men who had never smoked occurred after two years of abstention.11
The period required for the risk of myocardial infarction to decline to base line after the cessation of smoking has generally been longer in follow-up studies than in case–control studies.1 2 3 4 , 10 , 11 Because of recidivism among exsmokers, case–control studies may have an advantage in the classification of subjects according to smoking status. In follow-up studies that measure smoking status only at entry into the study, coronary events that occur among exsmokers who have resumed smoking are erroneously counted as occurring in exsmokers rather than in current smokers. This tends to inflate the risk among exsmokers and to result in an overestimation of the length of time required for the risk to decline to base line after the cessation of smoking.
Our study included as case patients only women who had survived their first myocardial infarction. It seems unlikely that the failure to include women who had died either before or soon after admission to the hospital for a first myocardial infarction would have affected the results to any material extent, because the relation of smoking status — whether current or former — to fatal disease appears quite similar to its relation to nonfatal illness.10 , 13
We do not think that distortion from other forms of selection bias is an important concern in our study. The rates of participation among both case patients and controls were high. The selective admission of case patients to the hospital on the basis of their smoking status was unlikely because admission for myocardial infarction is obligatory. The smoking habits of the controls were similar across the diagnostic categories, which included conditions for which admission is obligatory. However, the prevalence of smoking among the controls was higher than that reported in population surveys.15 An overestimate of the prevalence of smoking among controls would have led to an underestimate of the relative risks among smokers. For the results in the exsmokers to have been produced by selection bias, one must postulate that controls who quit less recently were more likely to be admitted than those who had quit recently. This seems highly unlikely.
Confounding factors controlled for in the analysis included the principal known and suspected risk factors for myocardial infarction. If the allowance was incomplete, the risk of myocardial infarction in the period soon after the cessation of smoking could have been overestimated if women at higher risk were more likely to quit smoking. In our data, however, other predisposing factors for myocardial infarction were weakly related to the cessation of smoking. This makes it unlikely that residual uncontrolled sources of confounding distorted the findings to any material extent. In any event, the estimate of relative risk among exsmokers decreased to close to 1.0 among women with other major predisposing factors, as well as among women without such factors.
The present data on women, together with our earlier data on men, clearly indicate that the increase in the risk of myocardial infarction attributable to cigarette smoking is largely reversible within a few years. Women have been relatively less successful than men in quitting smoking14 , 15: whereas the proportion of American men who smoke has decreased by almost half in the past two decades (from 51 percent in 1964 to 29 percent in 1986), the proportion of women who smoke has decreased by less than one third (from 33 percent to 24 percent). The present data underscore the value of smoking cessation for women, as for men, and may give women a convincing motive to quit, even if they have smoked heavily for many years.
Supported by grants (R01 HL30225 and R01 HL32174) from the National Heart, Lung, and Blood Institute, by cooperative agreements (U01 FD01222 and FD-U-000082) from the Food and Drug Administration, and by a grant from Hoffmann—LaRoche, Nutley, N.J.
We are indebted to Jacquelyn Smith, Lynne Schoaf, Rena Leib, Theresa Linehan, Cheryl Smith, Maureeen Maher, Virginia Vida, and Kathleen Rowlings for data collection; to Glenn R. Street and Leonard Gaetano for programming assistance; and to the nurses, staffs, and physicians of the following hospitals: in Massachusetts: Addison—Gilbert, AtlantiCare, Beth Israel, Bon Secours, Brigham and Women's, Brockton, Burbank, Cambridge, Cape Cod, Cardinal Cushing General, Choate Memorial, Charlton Memorial, Emerson, Faulkner, Framingham Union, Glover Memorial, Hale, Harrington Memorial, Henry Heywood Memorial, Hunt Memorial, Jordan, Lawrence General, Lawrence Memorial, Leominster, Leonard Morse, Lowell General, Malden, Marlborough, Massachusetts General, Melrose—Wakefield, Milford—Whitinsville Regional, Morton, Mt. Auburn, New England Deaconess, New England Memorial, Newton—Wellesley, Norwood, Quincy City, Salem, Sancta Maria, Somerville, South Shore, St. John's (Lowell), St. Elizabeth's, St. Joseph's, Sturdy Memorial, Symmes, Tufts—New England Medical Center, University of Massachusetts Medical Center, Waltham, Winchester, and Worcester City; in Rhode Island: Kent County Memorial, Memorial, Rhode Island, and St. Joseph; in Connecticut: Bristol, Danbury, Griffin, John Dempsey, Meriden—Wallingford, Middlesex Memorial, New Britain General, St. Francis, St. Joseph, St. Mary's, St. Raphael, St. Vincent's, Stamford, and Waterbury; and in New York: St. Agnes.
Source Information
From the Slone Epidemiology Unit, Boston University School of Medicine, 1371 Beacon St., Brookline, MA 02146, where reprint requests should be addressed to Dr. Rosenberg.
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