Stroke survivors more likely than cancer survivors to continue cigarette smoking

Stroke survivors were more likely to continue cigarette smoking than cancer survivors, raising the risk that they will have more health problems or die from a subsequent stroke or heart disease, according to new research published today in Stroke, a journal of the American Stroke Association, a division of the American Heart Association.

The motivation for this study was the National Cancer Institute (NCI)'s Moonshot initiative that includes smoking cessation among people with cancer. We were curious to understand smoking among people with stroke and cardiovascular disease. In part to assess whether a similar program is necessary for stroke survivors, our team compared smoking cessation rates between stroke survivors and cancer survivors."

Neal Parikh, M.D., M.S., lead author of the study and neurologist at NewYork-Presbyterian/Weill Cornell Medical Center in New York City

The investigators analyzed data collected between 2013 and 2019 from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, a national health survey that collects information regarding chronic health conditions and health-related behaviors annually.

Researchers analyzed data from 74,400 respondents who reported having a prior stroke and a history of smoking (median age of 68 years; 45% women; 70% non-Hispanic white), and 155,693 respondents who identified as cancer survivors with a history of smoking (median age of 69 years; 56% women; 81% non-Hispanic white). Previous smoker status was defined as having smoked at least 100 cigarettes in their lifetime.

After adjusting for demographic factors and the presence of smoking-related medical conditions, researchers found that:

• Stroke survivors were found to be 28% less likely to have quit smoking compared to people with cancer.
• 61% of stroke survivors reported that they had quit smoking.
• Stroke survivors under the age of 60 were far less likely to have quit smoking (43%) compared to stroke survivors ages 60 and older (75%).

"If you told a stroke neurologist that 40% of their patients don't have their blood pressure controlled or weren't taking their aspirin or their cholesterol-lowering medication, I think they would be very disappointed," said Parikh, who is also an assistant professor of neurology in the Department of Neurology and of neuroscience in the Feil Family Brain and Mind Research Institute at Weill Cornell Medicine. "These results indicate that we should be disappointed – more of our stroke patients need to quit smoking. We can and should be doing a lot better in helping patients with smoking cessation after stroke."

The researchers also found that stroke survivors who live in the Stroke Belt – 8 states in the southeastern United States with elevated stroke rates (North Carolina, South Carolina, Georgia, Tennessee, Alabama, Mississippi, Arkansas and Louisiana) – were around 6% less likely to have quit smoking than stroke survivors in other areas of the U.S. Increasing smoking cessation is one factor than can be addressed to reduce the disproportionately high rates of strokes and stroke deaths in the Stroke Belt.

"Important next steps are devising and testing optimal smoking cessation programs for people who have had a stroke or mini-stroke," said Parikh. "Programs for patients with stroke and cardiovascular disease should be as robust as smoking cessation programs offered to patients with cancer. At NCI-designated sites, smoking cessation programs often include a dedicated, intensive counseling program, a trained tobacco cessation specialist, and health care professionals with specific knowledge about the use of smoking cessation medications. Hospital systems could also adjust care protocols so that every stroke patient receives a consultation with a tobacco cessation specialist and is enrolled in a smoking cessation program with the option to opt out, as opposed to having to seek out a program."

A limitation of the study is that the data in the survey was self-reported – it relied on individuals to indicate if they have ever smoked or are currently smoking. The study population is also limited because it included only people who live independently in the community, rather than those living in a nursing home or other living facility.

Co-authors are Melvin Parasram, D.O., M.S.; Halina White, M.D.; Alexander E. Merkler, M.D., M.S.; Babak B. Navi, M.D., M.S.; and Hooman Kamel, M.D., M.S.

The study was supported by the New York State Department of Health Empire Clinical Research Investigator Program and the Florence Gould Endowment for Discovery in Stroke.