The impact of smoking on mortality after acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: a retrospective cohort outcome study at 3 years

  • Lloyd Steele
  • James Palmer
  • Amelia Lloyd
  • James Fotheringham
  • Javaid Iqbal
  • Ever D. GrechEmail author


The “smoker’s paradox”, where smokers have improved survival post-myocardial infarction, was predominantly observed in the thrombolytic era. However, evidence for the smoker’s paradox in the current era of PCI therapy is both limited and inconsistent. We aimed to examine the effect of smoking status on survival in unselected ST-elevation myocardial infarction (STEMI) patients managed by primary percutaneous coronary intervention (PCI). Data were collected for all patients with acute STEMI undergoing primary PCI at The South Yorkshire Cardiothoracic Centre, UK over a 5-year period between 2009 and 2014. Differences in survival by smoking status were assessed before and after adjustment for differences in baseline variables using a Kaplan–Meier curve and a Cox regression analysis, respectively. A total of 3133 STEMI patients were included in the study. After adjustment for differences in baseline variables, smoking was associated with a significantly increased mortality (hazard ratio 1.35 (95% CI 1.04–1.74)) compared to never smokers after 3 years. The risk for ex-smokers (hazard ratio 0.99 (0.76–1.28)) was similar to never smokers. There were no significant differences in survival by smoking status at 30 days and 1 year. In this large registry of STEMI patients managed by primary PCI, smokers had a significantly higher 3-year mortality than non-smokers. This study is the first to not only dispel the existence of the smoker’s paradox, but to highlight a high-risk subgroup who may warrant tailored secondary prevention treatment, including smoking cessation.


Smoker’s paradox Smoking cessation Tobacco use disorder Acute coronary syndromes Acute myocardial infarction 



Second Danish Multicenter Trial in Acute Myocardial Infarction


National Health Service Research Ethics Committee


Office for National Statistics



We thank Dr. Dawn Teare for providing statistical advice.

Author contributions

All authors were involved in the preparation of the manuscript, have read the manuscript, agree with the analyses of the data and the conclusions reached in the manuscript, and are accountable for all aspects of the work.


This study received no specific funding, and was carried out as a University of Sheffield degree project.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Supplementary material

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Supplementary material 1 (SAV 1202 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.The University of SheffieldSheffieldUK
  2. 2.The School of Health and Related Research (ScHARR)University of SheffieldSheffieldUK
  3. 3.The South Yorkshire Cardiothoracic CentreNorthern General HospitalSheffieldUK

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