Smoking cessation at 5 years after stroke in the North East Melbourne stroke incidence study

Co-Designed Cardiac Rehabilitation for the Secondary Prevention of Stroke (CARESS): A Pilot Program Evaluation

Structured health system-based programs, such as cardiac rehabilitation, may reduce the risk of recurrent stroke. This study aimed to co-design and evaluate a structured program of rehabilitation, developed based on insights from focus groups involving stroke survivors and health professionals. Conducted in Tasmania, Australia in 2019, the 7-week program comprised one hour of group exercise and one hour of education each week. Functional capacity (6 min walk test), fatigue, symptoms of depression (Patient Health Questionnaire), and lifestyle were assessed pre- and post-program, with a historical control group for comparison. Propensity score matching determined the average treatment effect (ATE) of the program. Key themes from the co-design focus groups included the need for coordinated care, improved psychosocial management, and including carers and peers in programs. Of the 23 people approached, 10 participants (70% men, mean age 67.4 ± 8.6 years) completed the program without adverse events. ATE analysis revealed improvements in functional capacity (139 m, 95% CI 44, 234) and fatigue (-5 units, 95% CI -9, -1), with a small improvement in symptoms of depression (-0.8 units, 95% CI -1.8, 0.2) compared to controls. The co-designed program demonstrated feasibility, acceptability, and positive outcomes, suggesting its potential to support stroke survivors.

Patterns of smoked and smokeless tobacco use among multimorbid and non-multimorbid middle-aged and older-aged adults in Karachi, Pakistan: a cross-sectional survey

OBJECTIVES

The objective of this study was to compare the patterns of smoked and smokeless tobacco use among multimorbid and non-multimorbid middle-aged and older-aged individuals in Karachi, Pakistan.

STUDY DESIGN

This was an observational cross-sectional study conducted during 2015-2016.

STUDY SETTING AND PARTICIPANTS

A total of 3250 participants aged 30 years and above, residing in the Gulshan-e-Iqbal town, Karachi, Pakistan were enrolled in the study through systematic random sampling. The selected area of residence represents diverse socioeconomic and ethnic groups of the city. People who could speak and write English or Urdu, and those who provided written informed consent were included in the study.

OUTCOME MEASURES

The primary outcome measure of the study was to determine the differences in patterns of tobacco consumption among multimorbid and non-multimorbid adult individuals.

RESULTS

We found no difference in patterns of smoked (adjusted OR (aOR) 1.15, 95% CI 0.88 to 1.50, p=0.289) or smokeless tobacco (aOR 1.13, 95% CI 0.86 to 1.48, p= 0.379) use among multimorbid and non-multimorbid individuals. Individuals who perceived tobacco as a risk were less likely to consume smokeless tobacco products.

CONCLUSION

There was no difference in tobacco consumption among individuals with and without multimorbidity. Evidenced-based guidelines are required to implement mental and behavioural interventions in patients with multiple chronic diseases to help them modify their behaviours.

Rates, Predictors, and Impact of Smoking Cessation after Stroke or Transient Ischemic Attack: A Systematic Review and Meta-Analysis

BACKGROUND

Smoking cessation after a first cardiovascular event reduces the risk of recurrent vascular events and mortality. This systematic review and meta-analysis aimed to summarize data on the rates, predictors, and the impact of smoking cessation in patients after a stroke or transient ischemic attack (TIA).

METHODS

MEDLINE, EMBASE and Web of Science were searched to identify all published studies providing relevant data through May 20, 2021. Random-effects meta-analysis method was used to pool proportions. Some findings were summarized narratively.

RESULTS

Twenty-five studies were included. The pooled smoking cessation rates were 51.0% (8 studies, n = 1738) at 3 months, 44.4% (7 studies, n = 1920) at 6 months, 43.7% (12 studies, n = 1604) at 12 months, and 49.8% (8 studies, n = 2549) at 24 months or more of follow-up. Increased disability and intensive smoking cessation support programs were associated with a higher likelihood of smoking cessation, whereas alcohol consumption and depression had an inverse effect. Two studies showed that patients who quit smoking after a stroke or a TIA had substantially lower risk of recurrent stroke, death, and a composite of stroke, myocardial infarction, and death.

CONCLUSION

Smoking cessation in stroke survivors is associated with reduced recurrent vascular events and death. About half of smokers who experience a stroke or a TIA stop smoking afterwards. Those with low post-stroke disability, who consume alcohol, or have depression are less likely to quit. Intensive support programs can increase the likelihood of smoking cessation.

The experience of continued smoking after stroke in Korean males: A qualitative study

AIM

This study aimed to identify the nature and meaning of continued smoking in male stroke patients based on a deep understanding of their lived experiences.

DESIGN

Phenomenological qualitative methodology.

METHODS

In total, 10 male stroke patients participated in this study. We used purposive sampling for recruitment. Data collection was performed through in-depth interviews and analysis through van Manen's methodology.

RESULTS

Five essential themes were derived from the analyses and described participants' experiences with continued smoking, as follows: "Natural relapse into smoking," "Behaving like a healthy person," "Believing that smoking will not be a problem," "Finding consolation in smoking behaviour," and "Consoling oneself by the rationalization of smoking behaviour."

CONCLUSION

The results showcased the need for the development of a smoking cessation educational programme tailored for male stroke patients who have perceptions towards being "like healthy people" after early recovery and who think that smoking is not a problematic behaviour. Participants' reports underpinned the necessity for these programmes to have contents focused on the transformation of patients' awareness toward their own health status.

Symptoms of depression and active smoking among survivors of stroke and myocardial infarction: An NHANES analysis

Historic concerns about the cardiovascular and neuropsychiatric side effects of smoking-cessation pharmacotherapy have in part limited their use. We sought to evaluate whether depressive symptoms are associated with active smoking among survivors of stroke and myocardial infarction (MI). To do this, we performed a cross-sectional analysis using data from the National Health and Nutrition Examination Survey (2005-2016). We included participants ≥20 years old with prior stroke or MI and any history of smoking. Symptoms of depression, at survey participation, were ascertained using the Patient Health Questionnaire-9. Active smoking was defined using self-report and, secondarily, with cotinine measures. We used logistic regression to evaluate the association between depression and active smoking after adjusting for demographics, smoking-related medical conditions, and health-related behaviors. We found that, among stroke and MI survivors with any history of smoking, 37.9% (95% CI, 34.5-41.3%) reported active smoking and 43.8% (95% CI, 40.3-47.3%) had biochemical evidence of smoking. Rates of active smoking were similar for stroke and MI survivors. Twenty-one percent screened positive for depression. In adjusted models, depression was associated with active smoking in the combined group of stroke and MI survivors (odds ratio, 2.28; 95% CI, 1.24-4.20) and in stroke survivors (odds ratio, 2.97; 95% CI, 1.20-7.38). Tests of heterogeneity by event type did not reveal an interaction. Findings were similar when using cotinine measures. We conclude that symptoms of depression were associated with active smoking among stroke and MI survivors. Stroke and MI survivors with symptoms of depression may require targeted smoking-cessation interventions.

Impact of Smoking Status on Stroke Recurrence

Background

Smoking is a well‐established risk factor of stroke and smoking cessation has been recommended for stroke prevention; however, the impact of smoking status on stroke recurrence has not been well studied to date.

Methods and Results

Patients with first‐ever stroke were enrolled and followed in the NSRP (Nanjing Stroke Registry Program). Smoking status was assessed at baseline and reassessed at the first follow‐up. The primary end point was defined as fatal or nonfatal recurrent stroke after 3 months of the index stroke. The association between smoking and the risk of stroke recurrence was analyzed with multivariate Cox regression model. At baseline, among 3069 patients included, 1331 (43.4%) were nonsmokers, 263 (8.6%) were former smokers, and 1475 (48.0%) were current smokers. At the first follow‐up, 908 (61.6%) patients quit smoking. After a mean follow‐up of 2.4±1.2 years, 293 (9.5%) patients had stroke recurrence. With nonsmokers as the reference, the adjusted hazard ratios for stroke recurrence were 1.16 (95% CI, 0.75–1.79) in former smokers, 1.31 (95% CI, 0.99–1.75) in quitters, and 1.93 (95% CI, 1.43–2.61) in persistent smokers. Among persistent smokers, hazard ratios for stroke recurrence ranged from 1.68 (95% CI, 1.14–2.48) in those who smoked 1 to 20 cigarettes daily to 2.72 (95% CI, 1.36–5.43) in those who smoked more than 40 cigarettes daily (P for trend <0.001).

Conclusions

After an initial stroke, persistent smoking increases the risk of stroke recurrence. There exists a dose–response relationship between smoking quantity and the risk of stroke recurrence.

Effect of Lifestyle Changes after Percutaneous Coronary Intervention on Revascularization

Objective

Whether optimal cardiovascular health metrics may reduce the risk of cardiovascular events in secondary prevention is uncertain. The study was conducted to evaluate the influence of lifestyle changes on clinical outcomes among the subjects underwent percutaneous coronary intervention (PCI).

Methods

The study group consists of 17,099 consecutive PCI patients. We recorded data on subject lifestyle behavior changes after their procedure. Patients were categorized as ideal, intermediate, or poor CV health according to a modified Life's Simple 7 score (on body mass, smoking, physical activity, diet, cholesterol, blood pressure, and glucose). Multivariable COX regression was used to evaluate the association between CV health and revascularization event. We also tested the impact of cumulative cardiovascular health score on reoccurrence of cardiovascular event.

Results

During a 3-year median follow-up, 1,583 revascularization events were identified. The observed revascularization rate was 8.0%, 9.3%, and 10.6% in the group of patients with optimal (a modified Life's Simple 7 score of 11–14), average (score = 9 or 10), or inadequate (less or equal than 8) CV health, respectively. After multivariable analysis, the adjusted hazard ratios were 0.83 (95% CI: 0.73–0.94) and 0.89 (95% CI: 0.79–0.99) for patients with optimal and average lifestyle changes comparing with the inadequate tertile (P for trend = 0.003). In addition, each unit increase in above metrics was associated with a decrease risk of revascularization (HR, 0.96; 95% confidence interval, 0.93–0.98; P for trend = 0.003). In addition, each unit increase in above metrics was associated with a decrease risk of revascularization (HR, 0.96; 95% confidence interval, 0.93–0.98;

Conclusion

Ideal CV health related to lower incidence of cardiovascular events, even after the percutaneous coronary intervention. Revascularization can be reduced by lifestyle changes. The cardiovascular health metrics could be extrapolated to secondary prevention and need for further validation.

Biological and Psychological Factors Associated With Smoking Abstinence Six Years Post-Stroke

Introduction

Tobacco use is a public health problem causing high morbidity and mortality, including stroke. This study evaluates predictive factors of smoking cessation in the long term after stroke.

Methods

We followed a cohort of 110 consecutive smokers with stroke for up to 6 years. Sociodemographic variables, stroke severity, insular involvement, stage of change in smoking habit before stroke and disruption of addiction variable (smoking cessation, absence of relapses, having stopped smoking without difficulties and not having had urge) were evaluated.

Results

Twenty patients died during follow-up and two patients were lost leaving a final cohort of 88 patients. The prevalence of smoking cessation in the remaining population was 65.9% post-stroke, 54.9% at 3-6 months, 40.9% at 1 year and 37.5% at 6 years. Prevalence was significantly higher in patients with insular involvement during the first year of follow-up, but not at 6 years. Disruption immediately after stroke (OR = 10.1; 95% CI = 2.5 to 40.1) and intention to change before having the stroke (OR = 4.8; 95% CI = 1.0 to 23.0) were predictors of abstinence at 6 years after adjusting for age, sex and stroke severity at baseline. When tobacco abstinence at the 1 year follow-up was included in the model, this factor was the best predictor of tobacco abstinence at 1 year (OR = 10.5; 95% CI = 2.2 to 49.4).

Conclusions

Intention of change, having the disruption criteria, and abstinence 1 year after stroke were predictors of abstinence at 6 years. An insular lesion in the acute phase of stroke does not determine the tobacco use status at 6 years.

Implications

This study is the first prospective investigation with a cohort of stroke patients to examine the long-term influence of biological and psychological factors on smoking cessation. Tobacco abstinence 1 year after stroke was the strongest predictor of abstinence at 6 years of follow-up. The effect of the insular cortex lesion on tobacco cessation, which had been relevant during the first year, no longer had an influence over the longer period studied here.

Rheumatoid arthritis significantly increased recurrence risk after ischemic stroke/transient ischemic attack

The effect of RA on recurrent stroke is unknown. Therefore, we examined effects of rheumatoid arthritis (RA) on risk of stroke recurrence and investigated the interaction between RA and traditional cardiovascular risk factors on recurrence risk after ischemic stroke (IS) or transient ischemic attack (TIA). Of 3190 patients with IS or TIA recruited in this cohort study, 638 were comorbid with RA and 2552 without RA. Stroke recurrence, RA, lifestyle, lipid variables and other comorbidities were identified through linkage between a nationwide stroke database in Taiwan and the National Health Insurance claims database. Cox proportional hazard models with competing risk adjustment were used to evaluate the relationship between RA and recurrent stroke. Patients with RA showed a significantly increased risk of recurrent stroke, particular in recurrent IS/TIA. The increased risk of recurrent IS/TIA in RA patients may through the changes of triglycerides (TG)/high-density lipoprotein cholesterol (HDL-C) ratio. A positive additive interaction was observed between RA and current smoking on the risk of recurrent IS/TIA. Significantly increased risks for recurrent IS/TIA were observed among RA patients who smoked > 40 years or those who smoked > 20 cigarettes/day. This study provides the first evidence that RA significantly increased recurrence IS/TIA risk. The changes of TG/HDL-C ratio may play some roles in the recurrence IS/TIA risk in RA patients. In addition, our results suggest that smoking increases the risk of recurrent IS/TIA in RA patients and reinforces the need for aggressive smoking cessation efforts in RA patients.

Improving Adherence to Secondary Stroke Prevention Strategies Through Motivational Interviewing: Randomized Controlled Trial

BACKGROUND AND PURPOSE

Stroke recurrence rates are high (20%-25%) and have not declined over past 3 decades. This study tested effectiveness of motivational interviewing (MI) for reducing stroke recurrence, measured by improving adherence to recommended medication and lifestyle changes compared with usual care.

METHODS

Single-blind, prospective phase III randomized controlled trial of 386 people with stroke assigned to either MI treatment (4 sessions at 28 days, 3, 6, and 9 months post stroke) or usual care; with outcomes assessed at 28 days, 3, 6, 9, and 12 months post stroke. Primary outcomes were change in systolic blood pressure and low-density lipoprotein cholesterol levels as indicators of adherence at 12 months. Secondary outcomes included self-reported adherence, new stroke, or coronary heart disease events (both fatal and nonfatal); quality of life (Short Form-36); and mood (Hospital Anxiety and Depression Scale).

RESULTS

MI did not significantly change measures of blood pressure (mean difference in change, -0.2.35 [95% confidence interval, -6.16 to 1.47]) or cholesterol (mean difference in change, -0.0.12 [95% confidence interval, -0.30 to 0.06]). However, it had positive effects on self-reported medication adherence at 6 months (1.979; 95% confidence interval, 0.98-3.98; P=0.0557) and 9 months (4.295; 95% confidence interval, 1.56-11.84; P=0.0049) post stroke. Improvement across other measures was also observed, but the differences between MI and usual care groups were not statistically significant.

CONCLUSIONS

MI improved self-reported medication adherence. All other effects were nonsignificant, though in the direction of a treatment effect. Further study is required to determine whether MI leads to improvement in other important areas of functioning (eg, caregiver burden).

CLINICAL TRIAL REGISTRATION

URL: http://www.anzctr.org.au. Unique identifier: ACTRN-12610000715077.

Diagnosis of diabetes mellitus or cardiovascular disease and lifestyle changes - the Doetinchem cohort study

OBJECTIVE

To study whether being diagnosed with a cardiovascular disease (CVD) or diabetes mellitus (DM) is associated with improvements in lifestyles.

METHODS

We used data from the Doetinchem Cohort Study, a prospective study among 6386 Dutch men and women initially aged 20-59years who were examined four times over 15years (1987-2007). Logistic and linear regression models were used to assess the effect of a self-reported diagnosis of CVD (n=403) or DM (n=221) on smoking, alcohol consumption, weight, diet and physical activity.

RESULTS

Self-reported diagnosis of CVD increased rates of smoking cessation (OR=2.2, 95%CI 1.6 - 3.1). Adults reporting a diagnosis of DM (relatively) decreased weight (3.2%, 95%CI 2.2 - 4.2), (relatively) decreased energy intake (4.2%, 95%CI 0.7 - 7.7), decreased energy percentage from saturated fat (0.4%, 95%CI 0.0 - 0.9) and increased fish consumption (2.8 g/day, 95%CI 0.4 - 5.1). A self-reported diagnosis of CVD or DM was not associated with changes in physical activity.

CONCLUSION

A diagnosis of CVD or DM may act, along with possible effects of medical treatment, as a trigger to adopt a healthier lifestyle in terms of smoking cessation, healthier diet and weight loss.

Factors associated with persistent smoking after the diagnosis of cardiovascular disease

Background

Although cigarette smoking is a major modifiable risk factor for the occurrence of primary and secondary cardiovascular disease (CVD), not all survivors from CVD attacks can successfully stop smoking. However, little is known about the factors associated with the change in smoking behavior after CVD attack.

Methods

Study subjects included 16,807 participants (≥19 years) in the fourth Korean National Health and Nutrition Examination Surveys. From them, we selected 180 persons who had previous CVD diagnosis (angina pectoris, myocardial infarction, or stroke) and were smoking at the time of CVD diagnosis. Then, we categorized the 180 persons into two groups according to change in smoking status after the CVD: quitter and non-quitter. Logistic regression analysis was done to evaluate multivariable-adjusted association.

Results

Even after CVD diagnosis, 63.60% continued to smoke. Fully-adjusted analysis revealed that regular drinking (odds ratio [OR], 4.44) and presence of smokers among family members (OR, 5.86) were significantly (P < 0.05) associated with greater risk of persistent smoking, whereas lower education level (OR, 0.20), larger amount of smoking (OR, 0.95), longer time since diagnosis (OR, 0.88), and diabetes (OR, 0.36) were significantly (P < 0.05) associated with decreased risk of persistent smoking after CVD.

Conclusion

A great proportion of CVD patients tended to continue smoking in the Korean population. In order to reduce smoking rates among CVD patients further, more aggressive efforts towards smoking cessation should be continuously made with consideration of individual socioeconomic, behavioral, and clinical characteristics of CVD patients.

Predictors of smoking patterns after first stroke

Persistent smoking following stroke is associated with poor outcomes including development of secondary stroke and increased mortality risk. This study uses longitudinal data from the U.S. Health and Retirement Study (1992-2008) to investigate whether depression and duration of inpatient hospital care impact smoking outcomes among stroke survivors (N = 745). Longer duration of care was associated with lower likelihood of persistent smoking. Depression was associated with greater cigarette consumption. Interaction effects were also significant, indicating that for survivors who experienced longer inpatient care there was a weaker association between depression and cigarette consumption. Implications for practice and research are discussed.

Baseline Smoking Status and the Long-Term Risk of Death or Nonfatal Vascular Event in People with Stroke

Background and Purpose—

Smoking may exacerbate the risk of death or further vascular events in those with stroke, but data are limited.

Methods—

1589 cases of first-ever and recurrent stroke were recruited between 1996 and 1999 from a defined geographical region in North East Melbourne. Both hospital and nonhospital cases were included. Over a 10-year period, all deaths, recurrent stroke events, and acute myocardial infarctions that were reported at follow-up interviews were validated using medical records. Cox proportional hazards regression was used to assess the association between baseline smoking status (never, ex, and current) and outcome (death, acute myocardial infarction, or recurrent stroke).

Results—

Patients who were current smokers (Hazard Ratio [HR], 1.30; 95% Confidence Interval [CI], 1.06–1.60; P =0.012) at the time of their stroke had poorer outcome when compared with those who had never smoked. Among those who survived the first 28 days of stroke, current smokers (HR, 1.42; 95% CI, 1.13–1.78; P <0.003) and ex-smokers (HR, 1.18; 95% CI, 1.01–1.39; P =0.039) at baseline had poorer outcome than those who had never smoked. Current smokers also had a greater risk of recurrent events than past smokers (HR, 1.23; 95% CI, 1.00–1.50; P =0.050).

Conclusions—

Patients who smoked at the time of their stroke or had smoked before their stroke had greater risk of death or recurrent vascular events when compared with patients who were never smokers. There are benefits of smoking cessation, with ex-smokers appearing to have a lesser risk of recurrent vascular events than current smokers.

Smoking cessation 1 year poststroke and damage to the insular cortex

BACKGROUND AND PURPOSE

Hospitalization as a result of stroke provides an opportunity to stop smoking that is often not taken up. The present study analyzes sociodemographic, psychological, and lesion-related variables to identify associated factors for smoking cessation during the first year after stroke.

METHODS

We conducted a prospective longitudinal study with a 1-year follow-up of a cohort of 110 patients with acute stroke who were smokers at the time of diagnosis and were admitted consecutively between January 2005 and July 2007.

RESULTS

On hospital release, 69.1% had given up smoking but at 1 year, only 40% had stopped smoking. Of the 110 patients, 27 (24.5%) had an acute stroke lesion in the insular cortex, of which 19 (70.3%) were nonsmokers at 1 year. Strongly associated factors in giving up smoking were the location of the lesion in the insular cortex (OR, 5.42; 95% CI, 1.95-15.01; P=0.001) and having the intention of giving up before the stroke, comparing precontemplating patients (without intention of giving up in the near future) with contemplating and prepared patients (intention of stopping in the near future; OR, 7.29; 95% CI, 1.89-28.07; P=0.004).

CONCLUSIONS

Of patients with stroke who were smokers, only 4 of 10 patients had stopped smoking 1 year after admission. Our results show that the variables best predicting smoking cessation in patients with a stroke diagnosis 1 year after hospital discharge are insular damage and the prestroke intention to stop.

[Predictors of smoking cessation after stroke]

Cigarette smoking is a major modifiable risk factor for stroke. Smoking dose dependently increases the risk of stroke, especially in patients below 75 years of age. Although smoking cessation is considered as one of the most effective methods of secondary stroke prevention, little is known about nicotine dependence and predictors of smoking cessation after stroke. Identification of such predictors could facilitate the development of anti-smoking interventions in post-stroke patients. Results of previous studies showed that smoking cessation is determined by the interplay of multiple factors, including sociodemographic (gender, age, race, living conditions, employment), clinical (functional status), psychobiological (nicotine dependence, depressed mood) and environmental (smoking household members) factors. Limitations of most studies were relatively small sample sizes and lack of verification of smoking status with a biochemical marker (e.g. expired CO). The aim of this article is to summarize current knowledge about predictors of smoking cessation after stroke.