Practice Current

Abstract

People who continue to smoke after ischemic stroke and transient ischemic attack (TIA) are at increased risk for subsequent stroke and cardiovascular events. Although effective smoking cessation strategies exist, smoking rates after stroke remain high. Through case-based discussions with 3 international vascular neurology panelists, this article seeks to explore practice patterns and barriers to smoking cessation for patients with stroke/TIA. We sought to answer these questions: What are the barriers to using smoking cessation interventions for patients with stroke/TIA? Which interventions are most used for hospitalized patients with stroke/TIA? Which interventions are most used for patients who continue smoking during follow-up? Our synthesis of panelists' commentaries is complemented by the preliminary results of an online survey posed to global readership. Together, the interviews and survey results identify practice variability and barriers to smoking cessation after stroke/TIA, suggesting that there is substantial need for research and standardization.

One in 4 strokes is a recurrent stroke, and approximately 13% of patients with minor stroke and transient ischemic attack (TIA) face recurrent stroke, heart attack, or cardiovascular death within 5 years.^1,2 It is thus critical to improve secondary prevention efforts. Cigarette smoking is a known risk factor for ischemic stroke/TIA, and patients who continue to smoke cigarettes after stroke/TIA face a heightened risk of recurrent stroke and cardiovascular events.^3,4 The importance of smoking cessation after stroke/TIA has been emphasized in the stroke secondary prevention guidelines from across the globe.^5-7 In addition, several effective smoking cessation pharmacotherapies have been introduced over the last 25 years, in addition to behavioral interventions such as intensive counseling programs.^8-10

Despite the risks of smoking after stroke/TIA and the availability of guideline-endorsed effective smoking cessation interventions, only approximately 40% of patients quit smoking after stroke/TIA.¹¹ Furthermore, in the United States for example, although the rate of active smoking has decreased overall over the last 20 years, this has not been the case among stroke survivors.¹² Apart from patient-level factors^11,13,14 such as nicotine dependence, lack of motivation to quit smoking, and sociocultural norms, healthcare system-level and provider-level factors may also contribute to low rates of successful smoking cessation.^15-17 There are also disparities in smoking cessation treatment use, whereby Black, Hispanic, and Asian individuals in the United States report less use of smoking cessation medications and counseling than White individuals, as do uninsured individuals.¹⁸

It is increasingly recognized that improving smoking cessation in individuals with complex medical conditions, such as stroke/TIA, requires a tailored approach specific to the individual condition.¹⁹ Yet, optimal strategies for smoking cessation for this at-risk population have not been adequately delineated.^20,21 Understanding variation in practice and perspectives may identify areas for improvement and inform the development of effective smoking cessation strategies specifically for patients with stroke/TIA. Thus, we sought to understand practice patterns and perceptions regarding barriers to smoking cessation in the inpatient and outpatient settings after stroke/TIA. To address these questions, we interviewed leading vascular neurology experts from 3 continents and disseminated a practice survey to readers. In this article, we synthesize these international panelists' opinions and practice pattern survey data to inform future efforts to improve smoking cessation after stroke/TIA.

Expert Opinion

We discussed smoking cessation with vascular neurology panelists from the United States, Western Europe, and India to understand practices and perspectives across diverse healthcare systems and patient populations. The international panelists' opinions include population-specific comments regarding prevalence of tobacco smoking among patients with stroke/TIA, barriers to successful smoking cessation, the inpatient approach to smoking cessation, and the outpatient approach to smoking cessation. The discussions were centered around panelists' approaches to 2 case scenarios (eAppendix 1, links.lww.com/CPJ/A387, for cases and multiple-choice questions). The American Academy of Neurology does not endorse any specific opinion presented below. The questions and cases were also posed to journal readership in an online format. The preliminary results are presented following the panelist commentaries.

In alphabetical order:

Bo Norrving, MD (Sweden)

Prevalence of Smoking and Barriers to Smoking Cessation

The Swedish Stroke Registry captures data from approximately 90% of patients with stroke and includes smoking data from the 3-month mark. In Sweden, 14% of patients with stroke are smokers at the time of their stroke with equal numbers of men and women. There is a lot of missing data when it comes to quality metrics on type of smoking cessation intervention delivered. However, in our registry, approximately 42% of patients will have quit smoking at 3 months. I believe that barriers such as societal traditions, addiction to nicotine, low success rates, low patient engagement, and mental health comorbidities have limited successful smoking cessation among patients with stroke and TIA. Low patient engagement in tobacco cessation is a major barrier. Looking back, it was common for stroke/TIA care responsibility to be transferred to primary care doctors after acute stroke care, which may have limited the involvement of neurologists in smoking cessation interventions. However, it is increasingly routine for patients to follow-up with a neurologist 3–6 months after stroke. Neurologists need to be more involved in antitobacco efforts for individual patients with stroke/TIA and also in public health campaigns more broadly through advocacy.

Case 1: Inpatient Smoking Cessation Interventions

For a patient with stroke/TIA who is actively smoking, the most likely step taken would be to advise the patient to quit smoking. It is uncommon because a neurologist caring for a patient with acute stroke, to use medications, such as nicotine replacement therapy, bupropion, and varenicline. In the uncommon cases where we do recommend a pharmacologic treatment in the hospital, patients may be advised to use nicotine replacement therapy. This is in part due to the higher cost for bupropion and varenicline. Nicotine replacement therapy is subsidized making it free or otherwise easy to acquire for patients (In fact, nicotine replacement therapy was invented in Sweden.²²) Some people in Sweden use snus, which is a moist pouch of tobacco placed under the lip, instead of smoking. We do have specialized smoking practices with over a 1,000 trained smoking cessation counselors in Sweden,^23,24 but, in my practice, it is uncommon to recommend that a patient visit a smoking cessation practice immediately after their hospitalization for ischemic stroke or TIA. Rather, I focus on providing effective cessation counseling.

Case 2: Outpatient Smoking Cessation Interventions

As I said, in Sweden, routine follow-up with neurology 3–6 months after stroke is becoming increasingly common. If a patient is still smoking at this time, intensified and personalized advice is given to help encourage that the patient quit smoking. Advice offered to patients should be persuasive, and as doctors, we should learn how to advise tobacco quitting most effectively. Overall, a stepwise approach is most reasonable. Hence, prescribing pharmacologic treatments such as bupropion and varenicline is still rare in the outpatient neurology setting, with cost being a significant barrier. Like patients with hospitalization for stroke, if pharmacotherapy is used in the clinic, it would most likely be nicotine replacement therapy. Unlike the hospital setting, it is more common to refer patients to an antismoking clinic after their neurology clinic visit.

Jeyaraj Pandian, MBBS (India)

Prevalence of Smoking and Barriers to Smoking Cessation

In India, the key risk factors for stroke are diabetes, hypertension, smoking, and obesity. Cigarette smoking is a common risk factor for stroke—20%–30% of patients with stroke in India are active smokers. However, there are considerable regional and cultural differences in smoking behavior. For example, in the Punjab province, where I practice, most individuals are of the Sikh faith, and the Sikh faith prohibits smoking. Those who smoke in the Punjab region are more likely to be migrants or people of non-Sikh background, and they may have different risk factors or barriers to care. There are also differences in the type of tobacco that people use here. In addition to cigarettes, we have many who use bidi (beedi or biri) cigarettes, which are hand rolled, hookah, and chewing tobacco—these are not necessarily lower risk alternatives.²⁵ The regional differences, and difference cultural practices, make it difficult to address smoking.

In addition, doctors are more concerned about controlling blood pressure, lipids, and blood glucose with medications than smoking. Although the Indian stroke guidelines mention smoking, they do not discuss how to help patients most effectively. There is also the issue of how health care is organized, which is that there is no systematic referral system from the hospital to general practitioners. More challenges include poor awareness of smoking treatments among doctors, limited access to all medications due to cost, and the sense among doctors that few people will quit no matter what. Smoking is a neglected issue, and many patients with stroke continue smoking.

Case 1: Inpatient Smoking Cessation Interventions

Approximately 70% of patients get care in private hospitals, and there are also government hospitals. I practice in a tertiary-level, academic private hospital. We generally advise patients with stroke to stop smoking, and for the chronic, motivated smoker, we sometimes give them nicotine gum or a patch. We do not use other smoking drugs, with which we have low familiarity. We rarely refer to a psychiatrist or outside service specially for smoking. A big, related problem is opium use in my region. We often treat opium withdrawal in the hospital in patients with stroke, and sometimes, we see nicotine withdrawal. In that case, we will treat with nicotine replacement. We do provide all patients with a written discharge plan and that includes lifestyle advice such as advice to stop smoking.

Case 2: Outpatient Smoking Cessation Interventions

A critical issue in India is the lack of a referral system to general practitioners, who are anyways typically reluctant to manage a poststroke patient. Patients who have stroke often get attached to the stroke team and call the stroke doctors for future problems. However, we do not have a standardized follow-up schedule, and it is uncommon for a neurologist to address smoking after the patient leaves the hospital. It would be challenging to add more medications because the cost of medications means that many patients do not continue taking their cholesterol or diabetes medications. Last, I think that currently our focus on stroke in India is acute stroke intervention infrastructure. Some parts of prevention are in the hands of the public health officials and government, patients, and their families.

Anjail Sharrief, MD, MPH (United States)

Prevalence of Smoking and Barriers to Smoking Cessation

I work at the UT Health Houston as a stroke neurologist and oversee a transitions clinic for secondary prevention. Here, 10%–20% of patients with stroke are active smokers. This is a high-risk population, at risk for recurrent events and cardiovascular events. There is great room for improvement in the stroke population because there are commonly missed opportunities in the inpatient and outpatient setting to address this. It is important that this is an area where disparities in care may also exist. There are patient barriers and provider/system barriers. Key patient-level barriers are addiction-related, smokers in the home, and mood disorders. Patients with untreated depression and other mood disorders often pose challenges in helping them quit smoking. On the systems level, there is the lack of an organized and consistent, comprehensive approach to smoking cessation. Individual providers have varying levels of interest and enthusiasm about treating nicotine addiction. Certainly, perceptions of patients' willingness to quit influences their care. Last, although guidelines discuss smoking cessation, there is a paucity of research on best practices on how to quit smoking for patients with stroke. Thus, it is difficult to implement best practices or precise guideline-directed care. There needs to be more research on best practices on how to quit specifically for patients with stroke.

Case 1: Inpatient Smoking Cessation Interventions

In the inpatient setting, we have what we call a cardiac rehabilitation program, which includes motivational counseling for smoking cessation by a trained professional. We typically place a referral order so that our patients who smoke can benefit from motivation counseling, although referrals are not as frequent as we would like. We typically do not give medications for smoking cessation in the hospital. On occasion, we will provide a nicotine replacement patch, but rarely or never do we use varenicline, bupropion, or nicotine gum. For patients with stroke who are active smokers, my most likely course of action is to advise the patient to quit smoking and refer the patient to a formal or dedicated tobacco cessation program, and sometimes follow-up with another provider for smoking-cessation management.

Case 2: Outpatient Smoking Cessation Interventions

Our patients are followed in the outpatient setting after stroke and TIA. We will evaluate in the clinic to see whether the patient has continued to smoke. For patients who have continued to smoke, we will counsel patients on smoking cessation and we will most likely start by prescribing bupropion. Varenicline is typically the second-line medication. We might also refer the patient to an outpatient cardiac rehabilitation program, including a pharmacist-led clinic with a smoking cessation counsellor. I have noticed that many patients do not want to go see an additional doctor or provider. More patients are interested in me giving them a nicotine replacement patch than going to another appointment, or even rather than going to the cardiac rehabilitation program. Although we do begin targeted interventions for smoking cessation in the clinic, we uncommonly bring a patient back for a scheduled clinic visit specifically for smoking cessation. Perhaps we address smoking cessation in a less structured or intentional way than we address blood pressure or lipids. I think that interventions at the system or provider level may be impactful in improving our smoking cessation efforts, in the long term.

Preliminary Survey Results (November 28, 2022): Section Editor: Aravind Ganesh, MD, DPhil, FRCPC

We collected a total of 116 complete responses and 128 partial responses between August 1, 2022 and November 28, 2022. Respondents were primarily attending or faculty-level physicians (72.0%) treating adult patients in the inpatient setting (92.8%). Overall, 88.8% reported spending more than half of their time in the care of patients with neurological conditions, and 83.2% reported caring for patients with stroke as their primary area of clinical responsibility; 67.2% reported that more than half of their clinical volume consisted of patients with stroke and TIA. Indeed, 60.8% identified as vascular neurologists, whereas 24.8% identified as general neurologists, and the rest had other subspecialties. A variety of experience levels were represented: 33.6% reported having been in practice for 10 or more years, 48.8% for less than 10 years, and 17.6% were still in training. A variety of world regions were captured: 72.0% of respondents were from North America (68.0% from the United States), 12.8% from Europe, 9.6% from South America, 3.2% from Asia, and 2.4% from Australia.

For the first case presented regarding inpatient management, 35 (25.9%) respondents said they would simply advise the patient to quit smoking, while 34 (35.2%) said they would additionally prescribe nicotine replacement monotherapy such as a transdermal patch or oral products. Additionally, 25 (18.5%) said they would refer the patient to a formal or dedicated tobacco cessation program. When asked about their typical practices for admitted patients with stroke/TIA who are active smokers, most (n = 90, 72.0%) said they personally advise the patients to quit smoking, and 61 (48.8%) said they often or always recommend nicotine replacement monotherapy. However, most respondents said they never recommend varenicline (n = 64, 51.6%), and rarely or never recommend bupropion (n = 96, 76.8%) or nicotine replacement combination therapies (n = 66, 52.8%).

For the second case presented regarding outpatient management, 31 (24.0%) respondents said they would simply advise the patient to quit smoking; the second and third most common responses were to refer the patient to a formal or dedicated tobacco cessation program (n = 25, 19.4%) and to prescribe nicotine replacement monotherapy (n = 20, 15.5%), respectively. When asked about their typical practices for clinic patients with stroke/TIA who are active smokers, most (n = 81, 74.3%) said they always personally advise the patients to quit smoking, but only 43 (39.4%) said they often or always recommend nicotine replacement monotherapy. Again, most respondents said they rarely or never recommend nicotine replacement combination therapy (n = 65, 59.6%) or bupropion (n = 80, 74.1%), and 59 (54.1%) said they never recommend varenicline. In terms of longitudinal management, 74 (67.9%) said they never schedule the patient for a follow-up visit specifically for smoking.

When asked about barriers to smoking cessation interventions for patients with stroke and TIA, most respondents reported lack of training with available treatments (n = 65, 52.5%) and patient engagement (n = 69, 55.2%) as moderate or major barriers. Nearly all respondents (n = 121, 96%) agreed that smoking cessation is an integral component of secondary prevention after stroke/TIA, and most (n = 115, 91.2%) agreed that helping patients quit smoking in this setting is their responsibility as a neurologist. However, a similar proportion (n = 102, 81%) said this was the primary care provider or general practitioner’s responsibility. Most reported not being appropriately trained to help patients quit smoking (n = 65, 51.6%).

Overall, the survey results demonstrate a major gap between the recognition of smoking cessation as an important component of stroke prevention and the actual adoption of smoking cessation strategies aside from nicotine replacement monotherapy in neurological practice. Importantly, most respondents disclosed not feeling adequately trained regarding smoking cessation treatments.

Discussion

The importance of promoting smoking cessation among stroke survivors is not controversial. However, despite high rates of smoking among stroke survivors in their populations, the responses of our 3 international panelists reveal variability in smoking cessation intervention practices. There are many common barriers to smoking cessation according to our 3 panelists, such as nicotine addiction, perceived or real lack of patient motivation, comorbid conditions, limited provider knowledge of smoking cessation interventions, lack of evidence-based smoking cessation practices, cost of medications, and poor healthcare system organization to ensure smoking cessation is addressed. All 3 panelists discussed uncertainty regarding whether neurologists or other providers should manage smoking cessation among stroke survivors. Still, other barriers to smoking cessation may be unique to certain countries, such as regional and cultural differences in the prevalence of cigarette smoking in India. In the inpatient setting, all 3 panelists emphasized the importance of advising patients who were active smokers at the time of their stroke or TIA about the need to quit smoking. They also agreed that the only inpatient pharmacologic intervention they would typically pursue would be nicotine replacement therapies, but this is not a standard practice. Only one panelist would refer patients who were active smokers at the time of stroke to a dedicated smoking cessation program as an inpatient. In the outpatient setting, it is increasingly common that patients continue to follow with neurologists after their stroke, though may also receive care from general practitioners. Two of the panelists routinely refer patients to smoking cessation programs. Only one panelist routinely prescribes nonnicotine pharmacotherapy, while the other 2 panelists do not prescribe these medications primarily due to concerns about costs. All 3 panelists discussed the needed for public health and system interventions to increase the rates of smoking cessation among stroke survivors. The United States panelist highlighted the need to address smoking cessation in a manner that addresses health disparities. Together, the international panelist interviews and preliminary survey results identify variability in practice patterns and highlight key barriers to smoking cessation after stroke/TIA. Developing targeted strategies for this at-risk population may improve the quality of secondary stroke prevention efforts.

Biography

Bo Norrving, MD is a Professor of Neurology and Chair of the Stroke Policy and Quality Research Group at Lund University, Sweden. Professor Norrving served as the president of the World Stroke Organization (WSO) between 2008 and 2012. He continues to serve the WSO as a member of its Global Policy Committee. Upon graduating from Lund University in 1975, Dr. Norrving remained there as a member of the Neurology Department. He is a distinguished clinical researcher with a focus on stroke epidemiology, stroke syndromes, small vessel disease, ultrasound, quality registers, clinical genetics, and clinical trials. He has contributed to over 300 peer-reviewed articles and has authored or co-authored several books, including The Oxford Textbook on Stroke and Cerebrovascular Disease. He was a member of the Swedish Aspirin Low-Dose Trial (SALT) that was published in The Lancet in 1991. In 1994, he was the founder of Riksstroke, the world's first national stroke registry. He remains actively involved in research using Riksstroke data in his role as Chair of the Stroke Policy and Quality Research Group. He previously served as the European Editor of Stroke from 2005 to 2010 and remained a Senior Consulting Editor until 2015. Since 2016, he has served as the Editor-in-Chief of the European Stroke Journal. He received the WSO leadership in Stroke Medicine Award (2014), Karolinska Stroke Award (2014), and American Heart Association/American Stroke Association Sherman Award (2016), all of which recognize his lifetime contributions to stroke science.

Jeyaraj Pandian, MBBS is a Consultant Neurologist and the Principal (Dean) of the Christian Medical College, Ludhiana. He currently serves as the President of the Indian Stroke Association and Vice-President of the WSO. After receiving his MBBS from Tirunelveli Medical College, Tamil Nadu, Dr. Pandian received a MD in Internal Medicine from Christian Medical College. He then completed a neurology residency at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, followed by a stroke fellowship at the Royal Brisbane and Women's Hospital in Brisbane, Australia. Dr. Pandian has been extensively involved in stroke prevention research and the establishment of surveillance and care infrastructure. His group has trained community health workers called Accredited Social Health Activists in rural areas to identify patients with stroke and help them to receive acute stroke care. He also played a role in the Indian Stroke Clinical Trial Clinical Network, which facilitates small and large clinical trials and research studies to advance acute stroke treatment, stroke prevention, and recovery and rehabilitation after stroke at 30 centers around India. He is the Editor-in-Chief of CHRISMED Journal of Health and Research and Journal of Stroke Medicine. He also serves on the Editorial Board of the International Journal of Stroke, Journal of Stroke, and European Stroke Journal. He has been elected as a Fellow of the Royal Australasian College of Physicians, Royal College of Physicians, European Stroke Organization, World Stroke Organization, and National Academy of Medical Sciences.

Anjail Sharrief, MD, MPH is an Associate Professor of Neurology and the Director of Stroke Prevention for the Institute of Stroke and Cerebrovascular Disease at the McGovern Medical School at UT Health Houston. She is the founder and director of the Stroke Clinic and the Stroke Transitions Education and Prevention (STEP) program at UT Health Houston. Dr. Sharrief completed her medical education at Columbia University's College of Physicians and Surgeons. She then went on to complete neurology residency at Johns Hopkins Hospital. She also holds a Masters of Public Health from the Johns Hopkins Bloomberg School of Public Health. Dr. Sharrief's research focuses on disparities and health outcomes among stroke survivors. She has received grants to work on novel healthcare delivery models for secondary stroke prevention. In 2021, she received a $3.1 million grant from the National Institute on Minority Health and Health Disparities at the NIH to launch a trial testing whether multidisciplinary telehealth intervention can improve racial outcomes among adult stroke survivors.

Appendix. Authors

Study Funding

The authors report no targeted funding.

Disclosure

N.S. Parikh was supported by NIH/NIA (K23 AG073524) and the Florence Gould Foundation, has received personal compensation for medicolegal consulting on stroke, and has received research support from the New York State Empire Clinical Research Investigator Program and Leon Levy Foundation; D. Restifo reports no disclosures relevant to this manuscript; A. Ganesh reports funding from the Wellcome Trust, Canadian Institutes of Health Research, Canadian Cardiovascular Society, Campus Alberta Neuroscience, and Alberta Innovates, consultation fees from Atheneum, MD Analytics, MyMedicalPanel, Creative Research Designs, and DeepBench, and stock options from SnapDx, TheRounds.com, and Advanced Health Analytics (AHA Health Ltd); H. Kamel serves as a PI for the NIH-funded ARCADIA trial (NINDS U01NS095869) which receives in-kind study drug from the BMS-Pfizer Alliance for Eliquis and ancillary study support from Roche Diagnostics, serves as a Deputy Editor for JAMA Neurology, serves as a steering committee member of Medtronic's Stroke AF trial, serves on a trial executive committee for Janssen, and serves on an endpoint adjudication committee for a trial of empagliflozin for Boehringer-Ingelheim. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.