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Can J Cardiol. 2019 Dec;35(12):1842-1850. doi: 10.1016/j.cjca.2019.07.635. Epub 2019 Aug 14.

Prevalence and Effects of Cigarette Smoking, Cannabis Consumption, and Co-use in Adults From 15 Countries With Congenital Heart Disease.

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Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. Electronic address:
School of Psychology and Development in Context, KU Leuven, Leuven, Belgium; Unit for Professional Training and Service in the Behavioural Sciences, University of the Free State, Bloemfontein, South Africa.
Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Canada; Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.
Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Center for Congenital Heart Disease, Inselspital-University Hospital of Bern, University of Bern, Bern, Switzerland.
Division of Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
Department of Adult Congenital Heart Disease, Chiba Cardiovascular Center, Chiba, Japan.
Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Cardiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands.
School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, Ohio, USA.
Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
Adult Congenital Heart Disease Center, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA.
Pediatric Cardiology, Frontier Lifeline Hospital (Dr K.M. Cherian Heart Foundation), Chennai, India.
Division of Cardiology, Hospital de Niños, Córdoba, Argentina.
Adult Congenital Heart Disease Center, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; Adult Congenital Heart Unit, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; Department of Health Sciences, University West, Trollhättan, Sweden; Department of Paediatrics, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
Division of Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Canada.
Monash Heart, Monash Medical Centre, Monash University, Melbourne, Australia.
Department of Cardiology, Mater Dei Hospital, Birkirkara Bypass, Malta.
Adult Congenital Heart Disease Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Department of Congenital Heart Disease, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.
Adult Congenital Heart Disease Program at Stanford, Lucile Packard Children's Hospital and Stanford Health Care, Palo Alto, California, USA.
Adult Congenital Heart Disease Center, Washington University and Barnes Jewish Heart and Vascular Center, University of Missouri, Saint Louis, Missouri, USA.
Clinical Psychology Service, IRCCS Policlinico San Donato, Milan, Italy; Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.
Adult Congenital Heart Disease Center University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, Nebraska, USA; Taussig Heart Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.



The prevalence and effects of cigarette smoking and cannabis use in persons with congenital heart disease (CHD) are poorly understood. We (1) described the prevalence of cigarette smoking, cannabis consumption, and co-use in adults with CHD; (2) investigated intercountry differences; (3) tested the relative effects on physical functioning, mental health, and quality of life (QOL); and (4) quantified the differential effect of cigarette smoking, cannabis use, or co-use on those outcomes.


APPROACH-IS was a cross-sectional study, including 4028 adults with CHD from 15 countries. Patients completed questionnaires to measure physical functioning, mental health, and QOL. Smoking status and cannabis use were assessed by means of the Health Behaviour Scale-Congenital Heart Disease. Linear models with doubly robust estimations were computed after groups were balanced with the use of propensity weighting.


Overall, 14% of men and 11% of women smoked cigarettes only; 8% of men and 4% of women consumed cannabis only; and 4% of men and 1% of women used both substances. Large intercountry variations were observed, with Switzerland having the highest prevalence for smoking cigarettes (24% of men, 19% of women) and Canada the highest for cannabis use (19% of men, 4% of women). Cigarette smoking had a small negative effect on patient-reported outcomes, and the effect of cannabis was negligible. The effect of co-use was more prominent, with a moderate negative effect on mental health.


We found significant intercountry variability in cigarette and cannabis use in adults with CHD. Co-use has the most detrimental effects on patient-reported outcomes.


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