The cigarette addiction can be so powerful that smokers who have heart transplants because of heart disease due to smoking often light up again after surgery.

A University of Pittsburgh study found that 38 percent of heart recipients, all of whom had kicked the habit before their transplants, were smoking again three years after surgery, many of them beginning within months of the procedure. The study identified ex-smokers most likely to relapse: those who had quit only a few months before surgery, those who were depressed or anxious following the operation and those who received care from a smoker. A better understanding of these risk factors for smoking relapses could lead to more effective intervention, said Carol Stilley, assistant professor of nursing and psychiatry at the Pitt medical and nursing schools. Stilley will present the study findings today at the International Society for Heart and Lung Transplantation meeting in Washington, D.C. The issue is important because other studies have shown that immunosuppressant drugs, which transplant patients take to prevent organ rejection, drastically increase the risk of developing cancers, some by 100 percent, Stilley said. The risk could be compounded for ex-smokers who resume smoking after transplants. "Transplant surgeons in all different areas are noticing alarmingly high rates of head, neck and lung cancer after transplants," among patients with a history of smoking, Stilley said in an interview. What's not clear is how many of those cancers occurred in patients who had resumed smoking. European studies show that heart transplant patients who smoke have a 37 percent five-year survival rate, compared to 80 percent for nonsmokers. While the Pitt study statistics may be disheartening, they could be worse, said study director Mary Amanda Dew, Pitt professor of psychiatry, psychology and epidemiology. "Among the general population, about 90 percent of those who try to quit will relapse within a year, so in many ways our transplant patients are showing much greater willpower," Dew said. She doesn't believe the results indicate that ex-smokers are bad candidates for transplant surgery. "I think they are still appropriate, the way liver transplants are appropriate for people who have had problems with alcohol," Dew said. "We can't make life-and-death health care decisions because people have bad habits." Rather, the findings will help medical professionals anticipate problems associated with transplants, and develop better interventions, she said. The study followed 202 heart transplant recipients for three years, including 144 ex-smokers whose addictions ranged from two to more than 95 "pack-years." The number of pack-years is calculated by multiplying the number of packs smoked daily by the number of years the person smoked. Researchers interviewed patients, their caregivers and transplant nurses at two, seven, 12 and 36 months after the operations. Some 55 recipients resumed smoking at some point, including 45 who began within the first year, and 26 who started within two months. One nonsmoker took up an occasional cigar. Through the three-year-period, 25 patients smoked 10 or fewer cigarettes a day, nine smoked between 11 and 19 a day and four smoked a pack or more daily. The amount was unknown for 11 patients, mostly cigar smokers, who dropped out of the study. Patients were most likely to resume their habit if they had quit smoking for less than six months before their operations. These patients tended to resume smoking sooner and and to smoke more often. Patients who smoked the most -- more than half a pack a day -- reported being depressed or anxious within two months of surgery. Having smoking caregivers was less significant, but remained a strong predictor of relapse. Twenty-one patients who resumed tobacco use had a smoking caregiver. Researchers are involved in the next leg of the study, which is examining the physical, psychological and overall health of surviving patients who had smoked before transplant, and focusing more closely on their relapse predictors. The study has also been broadened to include lung transplant patients. Dew and her colleagues hope the new study will equip medical professionals with a broad range of information so interventions could be developed to prolong life.

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