Smoking cessation rates among patients with peripheral artery disease (PAD) undergoing lower extremity revascularization (LER) remain low and largely unchanged, according to a new analysis of Vascular Quality Initiative (VQI) data.
The retrospective study, which was published in the Journal of Vascular Surgery (JVS), analyzed LER procedures across three VQI registries to evaluate trends in smoking cessation and identify predictors of continued tobacco use.
Despite a decline in smoking across the general population, findings showed tobacco use remains highly prevalent among patients undergoing vascular intervention. “At least a third of the patients we studied had smoking as one of the risk factors,” said Cassius Iyad Ochoa Chaar, MD, MPH, MS, associate professor of surgery at Yale School of Medicine and senior author on the study. “One of the things we see in clinical practice and that this study shows is that smoking cessation is challenging and rates have been more or less stagnant.”
The study also identified characteristics associated with continued smoking. “Interestingly, younger patients and those with claudication were more likely to continue smoking,” said Chaar. “Prior studies have shown patients who undergo more invasive treatments, such as open bypass, are more likely to quit smoking. We’ve demonstrated here that patients with claudication, who have less serious disease where they have pain with walking but are not necessarily at risk of losing their leg, are more likely to continue smoking.”
Warren Carter, first author on the study, said the findings highlight the need for a more individualized and comprehensive approach to smoking cessation counseling. “The idea of smoking cessation is that you help patients achieve and maintain the internal motivation it takes to stay off cigarettes,” he said. “There are a lot of different factors that will influence someone’s decision to quit smoking and education is one of them. But there’s also factors beyond that that physicians can try and address. One of the interesting ones that came up in this study is the socioeconomic disadvantage.”
He added that understanding these broader influences is critical to improving outcomes. “I think clinicians need to take a more holistic approach to understanding why that patient in front of them is smoking and trying to be more broad about how they can help beyond just educating them that smoking is bad,” he said.
Chaar emphasized that consistent messaging from clinicians remains a cornerstone of smoking cessation efforts. “The importance of smoking cessation should be highlighted at every single encounter,” he said. “This is something that I do in my clinical practice. If I have patients who continue to smoke, whether they come for arterial disease or venous disease, I always try to stress to them that it is a very impactful lifestyle change that can help them with not only their vascular health, but their overall health.”
He also noted that continued smoking is associated with worse procedural and long-term outcomes, even in patients with less severe PAD. “Even in patients with claudication, those who continue smoking have a much higher rate of reintervention or repeated surgery,” said Chaar. “Their likelihood of progressing to more aggressive forms of PAD and ending up with a major amputation is higher. They’re really putting their limb and their life in jeopardy.”
Carter said smoking cessation may be becoming more difficult over time as remaining smokers represent a more resistant population. “With the negative effects of smoking being so well known, we’re going to get more people where that knowledge isn’t enough motivation for them to quit,” he said. “Those are the patients that we’re seeing more of.”
To address this, Chaar said clinicians can incorporate a wide range of strategies, including offering pharmacologic support and emphasizing the health and financial benefits. “There is a clear economic benefit to quitting,” said Chaar. “If you take the average patient, if they stop smoking they could save a couple of thousand dollars a year they can use for other things. That could help a lot of patients who are socioeconomically disadvantaged.”
However, in order to really improve outcomes, Chaar said broader changes are required. “We have a lot of opportunities as physicians to help patients stop smoking,” he said. “When patients get hospitalized or undergo surgery, this is usually a teachable moment that we should all capitalize on. But we need more infrastructure on the inpatient side to help patients. Most patients are not smoking in the hospital and we should leverage that period of almost mandatory cessation to help them transition to quitting when they leave.”
