Quitting, not cutting back, lowers PAD event risk

Clinical takeaway: Encourage patients with peripheral artery disease (PAD) to quit smoking completely rather than simply reduce cigarette consumption, as partial reduction did not translate into meaningful cardiovascular or limb-related benefit.

Smoking is the strongest modifiable risk factor for PAD and is strongly linked to disease progression, cardiovascular events, and limb complications. While smoking cessation is guideline-recommended, evidence has been limited on whether cutting back can provide similar protection.

In this nationwide Korean cohort study, investigators followed 189,545 active smokers newly diagnosed with PAD for about 5 years after assessing postdiagnosis smoking behavior. Overall, 20.6% quit smoking, 20.4% reduced smoking by at least 20%, and 59.0% continued smoking at similar or higher levels.

Compared with continued smokers, patients who quit had a 12% lower risk of major adverse cardiovascular and cerebrovascular events (17.8 vs 20.2 events per 1,000 person-years) and a 17% lower risk of major adverse limb events (1.4 vs 1.8 events per 1,000 person-years). Benefits were seen across most cardiovascular outcomes, with some of the largest reductions observed for myocardial infarction. In contrast, patients who reduced smoking but did not quit had no significant reduction in either cardiovascular or limb event risk.

Dose-response analyses suggested that risk reduction emerged only with near-complete cessation. Even low levels of continued smoking were associated with elevated risks, and findings remained consistent across multiple sensitivity analyses and clinical subgroups, including older adults and patients with diabetes.

Because this observational study relied on self-reported smoking and claims-based PAD definitions, it cannot establish causality and may not fully generalize beyond the screened Korean population. Still, the authors concluded, “partial reduction should not be accepted as sufficient, and clinicians must emphasize complete cessation as the primary therapeutic goal.”

“The objective should not be fewer cigarettes documented in the medical record but durable abstinence from nicotine exposure,” wrote Luciano Delbono, MD, and colleagues in an accompanying editorial, emphasizing that PAD should trigger intensive tobacco-dependence treatment, including pharmacotherapy, counseling, and relapse management.

Source: Kim HK, et al. (2026 Aug 19) JAMA Network Open. Smoking Behavior and Major Cardiovascular and Limb Events in Patients With Peripheral Artery Disease