Smoking cessation after lower extremity revascularization in the Vascular Quality Initiative

Smoking cessation is crucial for managing peripheral arterial disease and remains a high priority in quality improvement for vascular specialists. The Society for Vascular Surgery launched the CAN-DO campaign in 2023 to promote smoking cessation efforts in the vascular community. This study aimed to examine trends in smoking cessation, identify factors associated with continued smoking after lower extremity revascularization (LER), and investigate the impact of post-LER smoking cessation.

Patients who were current smokers at the time of index LER in the Vascular Quality Initiative (VQI) peripheral vascular intervention (PVI), infrainguinal (INFRA), and suprainguinal (SUPRA) bypass registries were identified. Patients in the INFRA and SUPRA modules were combined into lower extremity bypass (LEB) and smoking cessation was captured based on long-term follow-up. Trends in smoking status and cessation were investigated. Characteristics and outcomes between patients who continued smoking at follow-up and patients who stopped smoking were compared. Survival analysis was used to analyze long-term outcomes.

This analysis included 113,757 patients undergoing PVI and 33,490 patients treated with LEB. Current smokers were most prevalent among patients undergoing SUPRA bypass (56%), followed by INFRA bypass (40%) and PVI (35%). Current smokers were more likely to achieve cessation after SUPRA and INFRA bypass compared with PVI (38% and 39% vs 32% respectively; P < .001). From 2010 to 2022, there was a significant decrease in the percentage of active smokers undergoing PVI (37.2% to 33.9%; P = .001) and LEB (from 49.1% to 44.4%; P = .024). Smoking cessation after both PVI and LEB also exhibited a significant decrease. Patients who continued smoking after LER were more likely to be younger, White males from socioeconomically disadvantaged neighborhoods, with chronic obstructive pulmonary disease undergoing elective PVI for claudication. Patients who were smoking at long-term follow-up after LER were significantly less likely to have experienced any perioperative complication after PVI (2.0% vs 3.1%; P < .001) and LEB (12% vs 13%; P = .036). Regression analysis revealed younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99), male sex (OR, 1.08; 95% CI, 1.04-1.13), the most disadvantaged neighborhoods (OR, 1.48; 95% CI, 1.27-1.72), chronic obstructive pulmonary disease (OR, 1.34; 95% CI, 1.28-1.39), elective surgery (OR, 1.25; 95% CI, 1.17-1.35), claudication (OR, 1.17; 95% CI, 1.11-1.22), and an endovascular approach (OR, 1.37; 95% CI, 1.27-1.47) were significantly associated with continued smoking after LER. Survival analysis showed that higher rates of adverse outcomes were noted in patients who were not smoking at the long-term follow-up.

Even though the proportion of smokers undergoing LER is decreasing, achieving smoking cessation has become more challenging. Smoking cessation efforts should particularly focus on younger patients undergoing elective endovascular LER for claudication.