Stroke survivors less likely than cancer survivors to quit, with particularly low rates among female, Black, and younger patients

Stroke survivors are far less likely to quit smoking than cancer survivors, and exhibit major demographic and geographic disparities in quit rates, according to results from a cross-sectional analysis.

Notably, the study authors found that the quit ratio among stroke survivors was very similar to that of the general population, whereas the quit ratio among cancer survivors was significantly higher, suggesting that major interventions might be needed to identify and implement treatment strategies specifically for stroke survivors; they pointed to the National Cancer Institute Cancer Moonshot Program’s Cancer Center Cessation Initiative as a potential model for the scale and scope such an intervention would require.

One in four strokes in the U.S. is a recurrent event, highlighting the need to bolster secondary stroke prevention by targeting stroke risk factors, of which tobacco smoking is one of the biggest, Neal S. Parikh, MD, MS, of Weill Cornell Medicine in New York, and colleagues explained in Stroke. However, while cancer survivors, who also face risks from smoking, receive targeted interventions to quit smoking via nationwide initiatives, the same is not true for stroke survivors, and there are few population-based data on smoking cessation after stroke to inform such interventions.

To close that knowledge gap, Parikh and colleagues set out to “comprehensively describe the epidemiology of smoking cessation in stroke survivors in the United States.”

“In this analysis of nationally representative U.S. health survey data, we estimated the smoking quit ratio among stroke survivors to be ≈61%; ≈2 out of 5 stroke survivors with a history of smoking remain active smokers,” they wrote. “The quit ratio varied considerably with respect to demographic and geographic factors, and the quit ratio was lower among stroke survivors than cancer survivors.”

Specifically, Parikh and colleagues found that post-stroke smoking cessation ratios were lower among stroke survivors under 60 years old, women, uninsured patients, and individuals identifying as non-Hispanic Black.

“Race and ethnic disparities in quit ratios have also been observed in the general population, with lower quit ratios in non-Hispanic Black individuals attributed to menthol cigarette use, lower access to cessation treatment, psychosocial stressors, and marketing exposure,” they pointed out. “Additionally, we noted lower quit ratios in rural areas and in the stroke belt, consistent with observations of disparities in stroke care and outcomes in these areas. These data may inform the development and dissemination of smoking cessation interventions for stroke survivors.”

For their analysis, Parikh and colleagues pulled prospectively collected data from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS) from 2013-2019 to identify stroke and cancer survivors who had a history of smoking. Respondents were excluded if they were pregnant or if they failed to provide information about stroke, cancer, and smoking history.

Smoking cessation was assessed using the quit ratio, defined as the proportion of ever smokers (people who smoked at least 100 cigarettes in their lifetime) who have quit smoking. Study authors then stratified quit ratios across demographic and geographic factors, including age (<60 versus ≥60 years), sex, race and ethnicity, and insurance status (insured versus uninsured).

A total of 4,434,604 stroke survivors and 8,488,386 cancer survivors with a history of smoking were included in the analysis; the median age was 68 and 69 years, respectively, and 45% and 56% were women.

“The quit ratio in the overall population of people with a smoking history was 59.5% (95% CI, 59.3%–59.7%),” the study authors found. “The quit ratio for stroke survivors was 60.8% (95% CI, 60.1%–61.6%); 39.2% of stroke survivors continue to be active smokers. Quit ratios varied across demographic and geographic factors. Stroke survivors <60 years old were less likely to have quit than those ≥60 years old (43.3% versus 74.6%; P<0.0001). Men were more likely to have quit smoking than women (63.4% versus 57.8%; P<0.0001), and variation by race and ethnicity was observed (P<0.0001), with higher quit ratios among non-Hispanic White, Hispanic, and Asian or Hawaiian or other Pacific Islander stroke survivors than non-Hispanic Black stroke survivors.”

Parikh and colleagues also took note of a number of geographic disparities:

  • “First, the quit ratio varied between states, ranging from 48.3% in Kentucky to 71.5% in California.
  • “Second, the quit ratio was lower in the stroke belt than in other states (55.7% versus 62.0%, P<0.0001).
  • “Last, the quit ratio was also lower for rural than nonrural stroke survivors (62.7% versus 69.5%, P<0.0001).”

By comparison, the overall quit ratio among cancer survivors was 71.3% (95% CI, 70.9%-71.8%), while 28.7% remained active smokers.

“Compared with cancer survivors, stroke survivors were less likely to have quit (odds ratio, 0.59 [95% CI, 0.56–0.61]),” they wrote. “This remained the case after accounting for differences in demographics, rurality, and smoking-related comorbidities (odds ratio, 0.72 [95% CI, 0.67–0.79]). Results were consistent in a sensitivity analysis adjusted for additional comorbidities. Trends analyses adjusted for demographics and comorbidities suggested that the gap between stroke and cancer survivors’ quit ratios worsened over time (P=0.006 for interaction by time). The odds of having quit among cancer survivors decreased each year (odds ratio, 0.95 [95% CI, 0.93–0.97]) but not among stroke survivors (odds ratio, 1.00 [95% CI, 0.97–1.03]) in adjusted models. However, raw quit ratios appeared stable over time for stroke and cancer survivors.”

Study limitations included the use of cross-sectional data; the inability of the BRFSS to account for institutionalized stroke or cancer survivors, or individuals who died; survey data did not specify whether prior strokes were ischemic or hemorrhagic; and self-reported quit ratios may modestly overestimate true quit ratios.

Despite these limitations, Parikh and colleagues concluded that “these data support the need for interventions to address the substantial proportion of stroke survivors with a smoking history who continues to smoke.”

  1. Stroke survivors were far less likely to quit smoking than cancer survivors, and there are major demographic and geographic disparities in quit rates among stroke survivors, according to results from a cross-sectional analysis.

  2. These findings suggest that interventions are needed to address the large proportion of stroke survivors with a smoking history who continues to smoke.

John McKenna, Associate Editor, BreakingMED™

Parikh has received personal compensation for medicolegal consulting on stroke and research funding from the Leon Levy Foundation and NIH/National Institute on Aging (NIA) (K23AG073524) unrelated to this work. Coauthor Merkler has received personal compensation for medicolegal consulting on stroke and research funding from the American Heart Association unrelated to this work. Coauthor Kamel serves as co-PI for the NIH-funded ARCADIA trial, which receives in-kind study drug from the BMS-Pfizer Alliance and in-kind study assays from Roche Diagnostics, serves as Deputy Editor for JAMA Neurology, serves as a steering committee member of Medtronic’s Stroke AF trial (uncompensated), serves on an end point adjudication committee for a trial of empagliflozin for Boehringer-Ingelheim, and has served on an advisory board for Roivant Sciences related to Factor XI inhibition.

Cat ID: 38

Topic ID: 82,38,730,8,38,143,192,489,925