Electronic Cigarette Use and Cigarette-Smoking Cessation Attempts Among Stroke Survivors in the US

Abstract

This cross-sectional study estimates the prevalence of electronic cigarette use among actively smoking stroke survivors in the US and evaluates its association with at least 1 cigarette-smoking cessation attempt in the past year.

Quitting cigarette smoking after stroke reduces the risk of stroke recurrence.¹ The rate of smoking among stroke survivors has not declined over the past 20 years.² Electronic cigarette (e-cigarette) use is increasingly common, and e-cigarettes are being investigated for their role in cigarette-smoking cessation.³ However, there are few data regarding the use of e-cigarettes in stroke survivors. We estimated the prevalence of e-cigarette use among actively smoking stroke survivors in the US and evaluated its association with at least 1 cigarette-smoking cessation attempt in the past year.

Methods

We performed a cross-sectional analysis using pooled data from the 2016-2018 US Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS) surveys. The US BRFSS is an annual, nationally representative health-related telephone survey.⁴ Respondents are asked about health conditions and health-related behaviors, including e-cigarette use. The Weill Cornell Medicine institutional review board deemed this analysis exempt from review, and informed consent was not required. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Our study population consisted of respondents who reported a prior stroke and active tobacco cigarette smoking. Respondents were asked about active e-cigarette use and smoking cessation (“During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?”).⁴ This measure is commonly assessed as an indicator of motivation to quit and is targeted in nationwide health initiatives.⁵ We used logistic regression to evaluate the association between e-cigarette use and a cigarette-smoking cessation attempt within the past year. Models were adjusted for demographic characteristics and comorbidities, as tabulated in BRFSS, that may influence engagement in smoking cessation. Complete case analysis was performed; missingness ranged from 0% to 3.5% for all variables except income (16.0%). We used interaction testing and subgroup analyses to investigate effect-modifying factors (age of 60 years or younger vs older than 60 years, sex, race/ethnicity, insurance, number of smoking-related comorbidities, and residence in the Stroke Belt⁶). The Wald test was used to calculate 2-sided P values for interaction terms. A sensitivity analysis restricted to 2017 was adjusted for additional covariates collected that year. We used survey-specific procedures to generate nationally weighted frequencies, prevalence estimates, and regressions using SAS version 9.4 (SAS Institute). The level of confidence was set at P < .05.

Results

Among 6 867 786 stroke survivors, 23.6% (95% CI, 22.7-24.5) were active cigarette smokers. The mean (SD) age of actively smoking stroke survivors was 59.6 (11.9) years, 49.2% (95% CI, 47.0-51.3) were women, 22.2% (95% CI, 20.7-23.8) lived in the Stroke Belt, 65.7% (95% CI, 63.5-68.0) were White, 18.4% (95% CI, 16.5-20.4) were Black, and 15.8% (95% CI, 14.0-17.6) reported other race/ethnicity. Diabetes was present in 27.9% (95% CI, 25.9-29.9) of survivors and hypertension in 65.6% (95% CI, 61.9-69.2). The prevalence of active e-cigarette use was 13.5% (95% CI, 11.8-15.3). Overall, 62.3% (95% CI, 60.2-64.4) reported having attempted to quit smoking within the past year. e-Cigarette users were more likely to have attempted to quit cigarette smoking than those not using e-cigarettes (73.0% [95% CI, 67.2-78.9] vs 60.7% [95% CI, 58.5-62.9]; odds ratio, 1.63; 95% CI, 1.21-2.19) (Table). This association persisted across subgroups and was stronger in stroke survivors older than 60 years, those living in the Stroke Belt, and those with more smoking-related comorbidities (Figure).

Table. Association of Electronic Cigarette Use With Recent Cigarette-Smoking Cessation Attempt Among Actively Smoking Stroke Survivors in the US^a.

Model	Odds ratio (95% CI)
Unadjusted	1.75 (1.29-2.39)
Adjusted for demographic characteristicsb	1.69 (1.26-2.28)
Adjusted for demographic characteristics and comorbiditiesc	1.63 (1.21-2.19)
Adjusted for additional comorbiditiesd	1.73 (1.05-2.87)

^aLogistic regression models evaluated the association of current electronic cigarette use with having attempted to quit tobacco smoking in the past year using data collected by the US Behavioral Risk Factor Surveillance System.

^bAge, sex, self-reported race/ethnicity, education level (less than high school, high school completion, some college, completed college or more), and income category group (less than $15 000, $15 000-$24 999, $25 000-$34 999, $35 000-$49 999, and greater than $50 000 per year).

^cDiabetes, coronary heart disease, pulmonary disease (chronic obstructive pulmonary disease and asthma), and any cancer.

^dRestricted to 2017; additionally adjusted for hypertension and hyperlipidemia based on availability of these covariates only in this year.

Figure. Subgroup Analyses of Electronic Cigarette Use and Cigarette-Smoking Cessation Attempts Among Actively Smoking Stroke Survivors.

Subgroup analyses were performed for age, sex, race/ethnicity, number of smoking-related comorbidities (from among coronary heart disease, pulmonary disease, and cancer), health insurance, and Stroke Belt residence to determine if these factors modified the association between electronic cigarette use and having made a smoking-cessation attempt.

Discussion

Actively smoking stroke survivors in the US appear motivated to quit, with more than 3 of 5 having made a cessation attempt in the past year. Approximately 14% of actively smoking stroke survivors use e-cigarettes, and e-cigarette users were more likely to have attempted to quit smoking in the past year. Actively smoking stroke survivors may be vulnerable to the poorly understood deleterious effects of combustible tobacco and e-cigarette co-use.³ Thus, patients should be queried about e-cigarette use, and patients using e-cigarettes as a smoking-cessation aide should be encouraged to instead use guideline-recommended therapies.³

Limitations of this analysis include the cross-sectional observational design and reliance on self-reported data. Efficacy and safety studies of e-cigarettes for smoking cessation will ideally include stroke survivors. In the meantime, inquiring about e-cigarette use may present clinicians with an opportunity to engage patients in smoking cessation.