Smoking and Risk of Stroke

Shinton R Beevers G. Meta-analysis of relation between cigarette smoking and stroke. BMJ 1989; 298: 789–794.

Donnan GA You R Thrift A McNeil JJ. Smoking as a risk factor for stroke. Cerebrovasc Dis 1993; 3: 129–138.

Shaper AG Phillips AN Pocock AJ Walker M Macfarlane PW. Risk factors for stroke in middle-aged British men. BMJ 1991; 302: 1111–1115.

Kawachi I Colditz GA Stampfer MJ Willett WC Manson JA Rosner B Smoking cessation and decreased risk of stroke in women. JAMA 1993; 269: 232–236.

The relative risk of stroke among current smokers compared with never smokers was 2.6 (95% CI 2.1–3.2) during 12 years of follow-up of 117 006 white, middle-aged, female nurses. The relative risks differed considerably for subtypes of stroke: subarachnoid haemorrhage, 5.0 (95% CI 3.1–7.9); ischaemic stroke, 2.3 (95% CI 1.7–3.0); and intracerebral haemorrhage, 1.5 (95% CI 0.8–2.8). The risk of stroke increased with the number of cigarettes smoked daily from 1.8 (95% CI 1.3–2.5) among light smokers (1–14 cigarettes/day) to 4.2 (95% CI 3.0–6.0) among heavy smokers (≥ 35 cigarettes/day). A dose-response relationship was particularly prominent for subarachnoid haemorrhage, with relative risks increasing from 3.3 (95% CI 1.0–10) among very light smokers (1–4 cigarettes/day) to 8.3 (95% CI 4.5–15) among very heavy smokers (≥ 35 cigarettes/day). The excess risks among former smokers largely disappeared between 2 and 4 years after cessation. Within 2 years of stopping smoking, the risk of stroke was reduced by 22% compared with continuing smokers, and within 4 years it was reduced by 54%, to become a risk that was only 0.5 (95% CI 0.3–0.9) times that of continuing smokers, and 1.2 (95% CI 0.5–2.2) times the risk of never smokers. This represents about 90% of the full potential of cessation. The benefits of stopping smoking were more readily apparent in reducing the risk of ischaemic stroke. Within 2 years of stopping, the risk of ischaemic stroke was reduced by 46% compared with continuing smokers, which represents about 80% of the potential benefit of stopping smoking. 5 Robbins AS, Manson JE, Lee l-M, Satterfield A, Hennekens CH. Cigarette smoking and stroke in a cohort of U.S. male physicians. Ann Intern Med 1994; 120: 458–462.

Current smoking was significantly associated with an dose-dependent increased risk of ischaemic stroke in 22 071 US male physicians followed for an average of 9.7 years (1–19 cigarettes/day, relative risk 2.0, 95% CI 1.1–3.7; ≥ 20 cigarettes/day, relative risk 2.7, 95% CI 1.8–4.1). There was a trend toward an increased risk of haemorrhagic stroke among smokers of > 20 cigarettes/day (relative risk 2.2, 95% CI 0.96–4.9). Former smokers did not have a significantly increased risk of stroke.

Wannamethee G Shaper AG Whincup PH Walker M. Smoking cessation and the risk of stroke in middle-aged men. JAMA 1995; 274: 155–160.

Current smoking was associated with a nearly four-fold increased relative risk of stroke (relative risk 3.7, 95% CI 2.0–6.9) compared with never smokers during 12.75 years of follow-up of 7735 middle-aged British men. Primary pipe or cigar smokers also produced an increased risk (relative risk 2.2, 95% CI 0.6–8.0). Ex-cigarette smokers had a relative risk of stroke of 1.7 (95% CI 0.9–3.3). The benefit of giving up smoking completely was seen within 5 years of stopping. Light smokers (< 20 cigarettes/day) reverted to the risk level of those who never smoked, whereas heavy smokers (< 20 cigarettes/day) retained a more than two-fold risk compared with never smokers (2.2, 95% CI 1.1–4.3). The risk of stroke among those who stopped smoking during the first 5 years of follow-up was less (relative risk 1.8, 95% CI 0.7–4.6) than that of continuing smokers (relative risk 2.2, 95% CI 1.1–4.3).

Njolstad I Arnesen E Lund-Larsen PG. Body height, cardiovascular risk factors, and risk of stroke in middle-aged men and women. A 14-year follow-up of the Finnmark study. Stroke 1996; 94: 2877–2882.

A population-based study of 13 266 men and women aged 35–49 years who were followed for 14 years, during which 241 people had a first-ever stroke. Daily smoking was an independently significant risk factor for all stroke among men (relative risk 1.6, 95% CI 1.1–2.4) and women (relative risk 2.1, 95% CI 1.4–3.2), and also for fatal stroke (relative risk 3.1, 95% CI 1.7–5.7). Daily smoking was the only variable significantly associated with subarachnoid haemorrhage.

Haheim L Lund Holme I Hjermann I Leren P. Smoking habits and risk of fatal stroke: 18 years follow up of the Oslo Study. J Epidemiol Commun Health 1996; 50: 621–624.

A prospective cohort study of 16 209 men aged 40–49 years who were screened in 1972 and followed-up for 18 years, during which there were 85 fatal strokes. The age-adjusted risk of fatal stroke was increased 3.5-fold (95% CI 2.2–5.7) among daily cigarette smokers. Combined cigarette and pipe or cigar smoking was associated with a higher risk (6.1, 95% CI 3.0–12.5) than smoking cigarettes only (4.1, 95% CI 2.3–7.4), and pipe or cigars only (2.2, 95% CI 0.9–5.5).

Jamrozik K Broadhurst RJ Anderson CS Stewart-Wynne EG. The role of lifestyle factors in the etiology of stroke. A population-based case-control study in Perth, Western Australia. Stroke 1994; 25: 51–59.

A population-based, case–control study of 492 cases of stroke and 931 age- and sex-matched control subjects revealed a significant dose-dependent independent increase in likelihood of any stroke, first-ever stroke, ischaemic stroke, and haemorrhagic stroke.

Whisnant JP Wiebers DO O'Fallon WM Sicks JD Frye RL. A population-based model of risk factors for ischemic stroke: Rochester, Minnesota. Neurology 1996; 47: 1420–1428.

You RX McNeil JJ O'Malley HM Davis SM Thrift AG Donnan GA. Risk factors for stroke due to cerebral infarction in young adults. Stroke 1997; 28: 1913–1918.

Howard G Wagenknecht LE Burke GL Diez-Roux A Evans GW McGovern P , for the ARIC Investigators. Cigarette smoking and progression of atherosclerosis. The Atherosclerosis Risk in Communities (ARIC) Study. JAMA 1998; 279: 119–124.

A population-based cohort study of 10 914 middle-aged adults who were followed-up over 3 years, which found that exposure to active smoke increased carotid artery intimal–medial thickness progression by 50%, and that exposure to ETS was associated with a 20% increase in intimal–medial thickness, an effect similar to that observed among former smokers.

Steenland K Thun M Lally C Heath C. Environmental tobacco smoke and coronary heart disease in the American Cancer Society CPS-II cohort. Circulation 1996; 94: 622–628.

Kawachi I Colditz GA Speizer FE Manson JE Stampfer MJ Willett WC A prospective study of passive smoking and coronary heart disease. Circulation 1997; 95: 2374–2379.

Wells JA. Passive smoking as a cause of heart disease. J Am Coll Cardiol 1994; 24: 546–554.

Bonita R Scragg R Stewart A Jackson R Beaglehole R. Cigarette smoking and risk of premature stroke in men and women. BMJ 1986; 293: 6–8.

Gorelick PB Rodin MB Langenberg P Hier DB Costigan J. Weekly alcohol consumption, cigarette smoking and the risk of ischaemic stroke: results of a case control study at three urban medical centres in Chicago, Illinois. Neurology 1989; 39: 339–343.

You RX McNeil JJ Hurley SF Farish SJ O'Malley HM Quang L Donnan GA. Smoking as a risk factor for cortical ischaemia presumably due to carotid occlusive disease. Neuroepidemiology 1993; 12: 141–147.

Meade TW Imeson J Stirling Y. Effects of changes in smoking and other characteristics on clotting factors and the risk of ischaemic heart diseases. Lancet 1987; II: 986–988.

Wannamethee G Perry IJ Shaper AG. Haematocrit, hypertension, and risk of stroke. J Intern Med 1994; 235: 164–168.

Rogers RL Meyer JS Shaw TG Mortel KP. Abstention from cigarette smoking improves cerebral perfusion among elderly chronic smokers. JAMA 1985; 253: 2970–2974.

Haapanen A Koskenvuo M Kaprio J Kesaniemi YA Heikkila K. Carotid atherosclerosis in identical twins discordant for cigarette smoking. Circulation 1989; 80: 10–16.

Homer D Ingall TJ Baker HL O'Fallon WM Kottke BA Whisnant JP. Serum lipids and lipoproteins are less powerful predictors of extracranial carotid artery atherosclerosis than are cigarette smoking and hypertension. Mayo Clin Proc 1991; 66: 259–267.

Ingall TJ Homer D Baker HL Kottke BA O'Fallon WM Whisnant JP. Predictors of intracranial carotid artery atherosclerosis: duration of cigarette smoking and hypertension are more powerful than serum lipid levels. Arch Neurol 1991; 48: 687–691.

Fine-Edelstein JS Wolf PA O'Leary DH Poehlman H Belanger AJ Kase CS D'Agostino RB. Precursors of extracranial carotid atherosclerosis in the Framingham Study. Neurology 1994; 44: 1046–1050.

Petrik PV Gelabert HA Moore WS Quinones-Baldrich W Law MM. Cigarette smoking accelerates carotid artery intimal hyperplasia in a dose-dependent manner. Stroke 1995; 26: 1409–1414.

Kubota K Yamaguchi T Abe Y Fujiwara T Hatazawa J Matsuzawa T. Effects of smoking on regional cerebral blood flow in neurologically normal subjects. Stroke 1983; 14: 720–724.

Wannamethee G Shaper AG. Haematocrit: relationships with blood lipids, blood pressure and other cardiovascular risk factors. Haemost Thromb 1994; 72: 58–64.

Rose G Hamilton PJS Colwell L Shipley MJ. A randomised controlled trial of anti-smoking advice: 10 year results. J Epidemiol Commun Health 1982; 36: 102–108.

Lightwood JM Glantz SA. Short-term economic and health benefits of smoking cessation. Myocardial infarction and stroke. Circulation 1997; 96: 1089–1096.

Kannel WB. Curbing the tobacco menace [editorial]. Circulation 1997; 96: 1070.