Persistence of smoking following acute coronary syndrome: insights from a two-year single-center study

Background Smoking cessation after an acute coronary syndrome (ACS) is crucial for secondary prevention, yet early relapse is frequent. Identifying determinants of persistent smoking and evaluating the use of pharmacological cessation therapies may help refine targeted interventions. Methods Consecutive patients admitted with ACS to a tertiary center (2023–2024) who were active smokers at presentation and alive at 12 months were screened. Participants completed a structured telephone questionnaire assessing smoking behavior during the year after discharge, including use of cessation pharmacotherapy. Clinical, behavioral, environmental, therapeutic, and outcome variables were analyzed to identify predictors of persistent smoking at 12 months. Results Among 861 ACS admissions, 254 were active smokers; 236 survived to 12 months, and 184 participated. At one year, 85 patients (46%) remained active smokers. Persistent smokers had higher nicotine dependence (Fagerström score, p<0.001), greater pre-event cigarette consumption (p=0.002), and more frequent household smoking exposure (72% vs 33%; p<0.001). Early relapse strongly predicted long-term persistence: 57% of persistent smokers resumed within 7 days versus 5% of those abstinent at one year (p<0.001). Pharmacological support after discharge was reported by 38% of patients: nicotine replacement therapy (24%), cytisinicline (9%), and bupropion (5%). Structured pharmacotherapy—particularly when initiated during hospitalization—was associated with lower early relapse rates compared with no pharmacological support (29% vs 61%, p<0.001). Nevertheless, nearly two-thirds received no evidence-based pharmacological treatment. Persistent smokers more frequently required unplanned cardiac evaluations or rehospitalizations (20% vs 12%; p=0.048) and repeat coronary assessment (15% vs 8%; p=0.041). No differences were observed in 12-month mortality (p=0.72) or left ventricular function recovery (p=0.31). Multivariable analysis identified smoking within 7 days post-discharge (OR 14.37; 95% CI 3.46–59.68; p<0.001) and household smoking exposure (OR 11.02; 95% CI 2.64–45.94; p=0.001) as independent predictors of persistent smoking. Conclusion Nearly half of smokers hospitalized with ACS remained active at one year. Early relapse and household exposure were the strongest predictors of persistence and were associated with increased subsequent cardiac evaluations. Despite the availability of effective therapies, pharmacological support was underused. These findings underscore the need for immediate, structured cessation strategies with systematic in-hospital initiation of evidence-based pharmacotherapy and early post-discharge reinforcement, particularly for patients exposed to smoking environments.Central figure