Smoking cessation appears to be comparable to the use of three targeted drugs in warding off future major cardiovascular events in smokers with atherosclerotic cardiovascular disease (ASCVD), according to a new study.

According to data from six large, prospective randomized trials, patients would gain, on average, 4.8 years free of a myocardial infarction (MI) or stroke by quitting smoking or by taking bempedoic acid, colchicine, and a PCSK9 inhibitor.

"The overall benefits of smoking cessation in patients with atherosclerotic cardiovascular disease are underestimated," study author Tinka J. Van Trier, MD, Amsterdam University Medical Centre, told | Medscape Cardiology.

"The benefits are even greater than we realized, because our study shows that kicking the habit appears to be as effective as taking three medications for preventing heart attacks and strokes in people who have had an MI or a procedure to unblock arteries," she said.

The findings were presented at the recent European Society of Cardiology (ESC) Preventive Cardiology 2022.

"New risk-prediction models estimate treatment benefit in years free of specific cardiovascular outcomes, but we feared that, due to the increasing number of beneficial pharmacological interventions available, the substantial health benefit of smoking cessation may be overlooked, and that is what prompted our current study," Van Trier said.

The investigators pooled individual-level risk factor data from six recent prospective studies: RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V, and HELIUS.

The analysis involved 989 patients 45 years and older who were treated with antiplatelet agents, statins, and antihypertensive drugs but were still smoking at least 6 months after having an MI and/or undergoing stent implantation or coronary bypass surgery.

Average age of the patients was 60 years (range, 52 to 68 years) and 23% were women. The median time since the heart attack or procedure was 1.2 years.

The primary outcome was treatment benefit, defined as gain in years without an MI or stroke, as estimated by the SMART-REACH model.

Smoking cessation resulted in a mean of 4.81 event-free years (95% CI, 4.73 - 4.89), a gain comparable with persistent smoking with the three drugs combined (4.83 event-free years; 95% CI, 4.72 - 4.94).

The average number of event-free years was 0.6 with bempedoic acid alone, 2.2 with colchicine alone, and 2.6 with only a PCSK9 inhibitor.

"We weren't that surprised by our findings because it is very well known that smoking cessation has a major impact on a patient's health and life expectancy," commented Van Trier.

However, "it was new to express this benefit in a comparison to the benefits of medication. For example, PCSK9 [inhibition] is known for its efficacy, but it is also very expensive," she said. "I hope this information motivates healthcare professionals and patients to quit smoking prior to prescribing expensive drugs. It might not even be needed."

A Low-Cost Beneficial Intervention

"This very interesting analysis used data from several large databases to compare the treatment benefits of smoking cessation [with] targeted pharmaceutical interventions," ESC Spokesperson Christi Deaton, PhD, RN, professor of nursing, University of Cambridge School of Clinical Medicine, and fellow of Wolfson College, Cambridge, United Kingdom, .

"Intensifying treatment with the two cholesterol-lowering drugs and the anti-inflammatory drug colchicine resulted in an estimated 4.8 years of event-free life. In contrast, 4.8 years of event-free survival were also estimated simply through smoking cessation," Deaton said.

"A more thorough review of the methods, including SMART-REACH estimates of treatment benefit and the choice of drugs in the analysis, plus sample background pharmacotherapy and characteristics, will need to wait for the full paper," she said. "However, this abstract presents a stark contrast of a beneficial, low-cost intervention — smoking cessation — compared with intensified pharmaceutical therapy to achieve the same benefit."

An Important Reminder for Cardiologists

"This study serves as an important reminder about how we, as cardiologists, are driven to relentlessly work to lower risk of recurrent events in patients with atherosclerotic cardiovascular disease," commented Matthew Tomey, MD, a cardiologist at Mount Sinai Morningside, New York City.