For active smokers with newly diagnosed peripheral artery disease (PAD), complete smoking cessation lowers the risks of both cardiovascular and limb-specific adverse events, whereas partial smoking reduction offers no benefit, according to a large retrospective cohort study.
Over a mean follow-up of 5 years, major adverse cardiovascular and cerebrovascular events (MACCEs) occurred at 17.8 per 1,000 person-years among individuals who quit smoking (complete cessation group) vs 20.2 per 1,000 years among individuals who continued smoking (reference group). [JAMA Netw Open 2026;9:e2629337]
Similarly, the incidence of major adverse limb events (MALEs) was lower in the complete cessation group than in the reference group, at 1.4 vs 1.8 per 1,000 years.
Compared with continued smoking, complete smoking cessation after a PAD diagnosis was associated with a 12-percent reduction in the risk of MACCEs (hazard ratio [HR], 0.88, 95 percent CI, 0.84–0.91) and a 17-percent decrease in the risk of MALEs (HR, 0.83, 95 percent CI, 0.73–0.94).
In contrast, partial smoking reduction conferred no significant protection against the risks of both outcomes when compared with continued smoking (MACCE: HR, 1.00, 95 percent CI, 0.96–1.04; MALE: HR, 0.92, 95 percent CI, 0.81–1.04).
The association between complete smoking cessation and lower MACCE risk was consistent across most subgroups, including older individuals (≥65 years), those with diabetes, or those with prior myocardial infarction. The association between quitting and MALEs were also similar across most subgroups, except for individuals with prior MACCEs, prior peripheral revascularization, or higher comorbidity burden.
“These findings underscore the importance of complete cessation as the primary therapeutic goal in PAD management,” the authors said.
“Our dose-response analyses showed that risk reduction was evident only for near-complete cessation. Across most of the reduction range, continued smoking at any level remained associated with elevated risk,” they continued.
The authors emphasized, however, that the rate of complete smoking cessation among active smokers with PAD in the cohort was low at 20 percent.
“This rate is lower than that reported in studies of symptomatic patients or patients with PAD undergoing revascularization, potentially reflecting lower perceived disease severity among those with earlier-stage disease or insufficient cessation support in clinical practice,” they noted.
“The association between cessation and lower event rates observed in our cohort provides further justification for developing intensive, tailored cessation programmes for patients with PAD,” the authors said.
For the study, the authors used data from the Korean National Health Insurance Service–National Health Information Database and looked at 189,545 active smokers (mean age 54.2 years, 88.5 percent male) who had a new diagnosis of PAD.
Of the active smokers, 38,952 (20.6 percent) quit smoking, 38,709 (20.4 percent) reduced cigarette consumption (≥20-percent decrease in daily consumption), and 111,884 (59 percent) continued smoking (<20-percent decrease or any increase in daily consumption) post-diagnosis. The median interval from the prediagnosis health examination to PAD diagnosis was 292 days, and the median time from PAD diagnosis to the post-diagnosis examination was 304 days.
Compared with individuals who partially reduced or continued smoking, quitters were older, more likely to be female, and had a higher Charlson comorbidity index, fewer smoking pack-years, lower prediagnosis daily cigarette consumption, and lower rates of alcohol consumption.
MACCEs included all-cause death, myocardial infarction, coronary revascularization, and ischaemic stroke, while MALEs included limb revascularization and major amputation.