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PAPERS: Petter Quist-Paulsen and Frode Gallefoss Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease BMJ 2003; 327: 1254 [Abstract] [Full text]

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fear is arrhythmogenic

Christine Bundy   (3 December 2003)

Beware the brief intervention for hospitalised smokers

Hayden McRobbie, Cressida Darwin and Peter Hajek.   (23 December 2003)

Is fear arousal message feasible in helping cardiac patients to stop smoking?

Petter Quist-Paulsen, Frode Gallefoss   (20 June 2006)

fear is arrhythmogenic 3 December 2003
Christine Bundy, Senior Lecturer in Psychological Medicine/Health Psychology University of Manchester, Medical School Send response to journal: Re: fear is arrhythmogenic	I welcome more studies designed to change behaviour in the problem area of smoking among heart disease patients. However, the particular approach used in this study is unscientific, unethical and potentially counterproductive. Patients who are told they are likely to die if they do not give up smoking are likely to experience anxiety at first and if they subsequently cannot quit, depression or anger at this strategy. Each of these emotion states, in particular anger and depression have direct detrimental effects on cardiovascular functioning. Anxiety and fear has been shown to induce arrhythmias in animal studies (Verrier & Lown 1984); human studies (Follick et al 1988) and ischaemia in non-clinical human studies (see Tennant for an editorial review 1996)and CHD populations(Specchia et al 1991). Furthermore, patients with stress induced cardiac dysfunction are more prone to adverse cardiac outcomes over time (Jain et al 1995). These findings are not new. Lethal cardiac arrhythmogenesis is involved with cerebral activity and delivered through autonomic pathways (see Rozanski, Blumenthal & Kaplan 1999 for an excellent review of mechanisms), this is also not new information. The authors write the research showing fear based work is important for stopping smoking but do not review the adverse effects of fear arousal that are well documented in the psychology literature. The evidence base for such a risky intervention is exposed as weak at best. No attempt was made to measure psychological factors and apparently no support was given to those who subsequently failed to quit. The authors should have considered a properly controlled study before embarking on such a complex area. This study underscores the need for cardiologists and others working with patients with heart disease to be familiar with key finding from cardiac psychology. refs: Follick MJ, Gorkin L, Capone RJ, et al (1988) Psychological distress as a predictor of ventricular arrhythmias in a post-myocardial infarction population. Am Heart J 1998; 116:32. Jain D, Burg M, Soufer R & Zaret BL (1995) Prognostic implications mental stress induced silent left ventricular dysfunction in patients with stable angina pectoris. Am J Cardiol 1995;76 (1): 31-5. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation. 1999 Apr 27;99(16):2192-217 SpecchiaG, Falcone C, Traversi E, et al (1991) Mental stress asa provocative test in patients with various clinical syndromes of coronary heart disease. Circulation 1991; 83 (suppl II):II-108-II-114. Tennant C (1996) Experimental stress and cardiac function. Journal of Psychosomatic Research 1996; 40:6. 569-583. Verrier RL & Lown B. (1984) Biobehavioural stress and cardiac arrhythmias. Annu Rev Physiol 1984; 46:155. Competing interests: None declared
Beware the brief intervention for hospitalised smokers 23 December 2003
Hayden McRobbie, Research Fellow Barts and The London, Queen Mary’s School of Medicine & Dentistry E1 2AD, Cressida Darwin and Peter Hajek. Send response to journal: Re: Beware the brief intervention for hospitalised smokers	Quist-Paulsen and Gallefoss report on a controlled trial of a smoking cessation intervention in patients admitted for coronary artery disease (1). In the abstract the authors describe the success of a simple intervention, in this case a booklet, delivered by cardiac nurses with no special smoking cessation training. This produced abstinence rates of 57% in the intervention group compared to 37% in the control. At first glance it appears that this is an extremely simple and effective way of helping smokers to quit. However, on further reading the amount of behavioural support provided throughout this study is substantial. Patients assigned to the intervention group received up to two consultations from a cardiac nurse whilst in hospital. Nicotine replacement treatment use was encouraged in those who experienced withdrawal symptoms, and spouses who smoked were also encouraged to quit. After discharge patients received an average of 8.5 phone calls, and 1.6 outpatient consultations. Overall the entire contact time amounted to 147 minutes on average. Generic self help materials have been demonstrated to have a limited effect, if any, for smoking cessation (2). The difference in smoking cessation rates between the intervention and control groups in this study can most likely be accounted for by the intensity of behavioural support and use of nicotine replacement therapy. A recent Cochrane Review of interventions for smoking cessation in hospitalised patients concludes that these higher intensity behavioural interventions are an effective way of helping these smokers to stop (3). Although brief interventions may be easier to implement, they are unlikely to have any significant impact in this group of highly dependent smokers (4). Where at all possible, hospitals should provide specialist treatment to hospitalised smokers, including multiple sessions and substantial follow-up, such as was the intervention provided in this study. With the nationwide network of specialist smoking cessation services now in place, such treatments should be available at all hospitals. Hayden McRobbie Research Fellow h.j.mcrobbie@qmul.ac.uk Cressida Darwin Research Health Psychologist Peter Hajek Professor of Clinical Psychology Tobacco Dependence Research & Treatment Centre, Institute of Community Health Sciences, Barts and The London, Queen Mary's School of Medicine & Dentistry, Turner Street, London E1 2AD 1. Quist-Paulsen P, Gallefoss F. Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease. BMJ 2003 Nov 29;327(7426):1254-7. 2. Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database Syst Rev 2002;(3):CD001118. 3. Rigotti NA, Munafo MR, Murphy MF, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2003;(1):CD001837. 4. Hajek P, Taylor TZ, Mills P. Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: randomised controlled trial. BMJ. 2002 Jan 12;324 (7329):87-9. Competing interests: None declared
Is fear arousal message feasible in helping cardiac patients to stop smoking? 20 June 2006
Petter Quist-Paulsen, MD Sørlandet Sykehus Kristiansand, 4604 KRISTIANSAND, NORWAY, Frode Gallefoss Send response to journal: Re: Is fear arousal message feasible in helping cardiac patients to stop smoking?	Quitting smoking is the most effective single action to reduce mortality after a coronary event. Individualised smoking cessation interventions using psychologically based approaches have been shown to increase the cessation rates [1, 2], but such programs may not be applicable in an ordinary clinical setting. We have previously reported that a program based on a fear arousal message had similar efficacy as the more complicated programs [3]. However, the use of fear arousal message is controversial in cardiac patients, and our trial has been criticised [4, 5]. To our knowledge, there are no previous investigations evaluating the feasibility of fear arousal messages in cardiac patients. In our trial, the intervention group received a booklet in which two illustrations showed the differences in mortality between those who continued smoking after myocardial infarction and those who stopped. On the basis of these figures, the participants were told that if they continued smoking their risk of death would be markedly increased, and that they most probably would not reach a high level of age. At 12 months follow up, with a preprinted alternative for answering ranging from very little satisfied (1) to very much satisfied (5), the participants in the intervention group had a mean score of 4.1 compared to 2.9 in the control group, on the level of satisfaction with the help they had got from hospital in quitting smoking (95% CI of the difference 1.0-1.6). This difference was not due to increased cessation rates in the intervention group, as both sustained smokers and quitters scored significantly higher in the intervention group compared to the control group. There were no arrhythmic deaths related to the fear arousal message. We conclude that a smoking cessation program based on a fear arousal message seems both effective and feasible in cardiac patients, with a high level of patient satisfaction and without any indications of unwarranted effects. References 1. Taylor CB, Houston­Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: effects of a nurse­managed intervention. Ann Intern Med 1990;113:118­23. 2. Dornelas EA, Sampson RA, Gray JF, Waters D, Thompson PD. A randomized controlled trial of smoking cessation counselling after myocardial infarction. Prev Med 2000;30:261­8. 3. Quist-Paulsen P, Gallefoss F. Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease. BMJ. 2003; 327: 1254-7. 4. Bundy C. Fear is arrhythmogenic. bmj.com, 3 Dec 2003. 5. Fonteyn M E. A nurse led smoking cessation intervention increased cessation rates after hospital admission for coronary heart disease. Evidence-Based Nursing 2004; 7:46. Competing interests: None declared