Smoking cessation rates after stroke are suboptimal.1 Smoking cessation medications – nicotine replacement therapy (NRT), varenicline, and bupropion – significantly increase the likelihood of successful abstinence, compared to counseling alone.2 We aimed to assess rates and predictors of cessation medication provision after stroke and transient ischemic attack (TIA) in the United States, and hypothesized that patients with hemorrhagic stroke and TIA are less often given such treatments than patients with ischemic stroke.
This is a retrospective, cross-sectional study using data from the Get With The Guidelines® (GWTG)-Stroke registry, an American Heart Association/American Stroke Association initiative (Supplemental Methods). We included active smokers with ischemic stroke, hemorrhagic stroke, and TIA from 2018-2020. We categorized patients as those who received any cessation medication versus none. Multivariable logistic regression assessed factors associated with cessation medication; models included variables significantly associated with provision in univariate analyses after Bonferroni correction.
We included 106,714 smokers with stroke/TIA. The mean age was 60 years (standard deviation, 12) and 42% were women; 81.2% had ischemic stroke, 9.5% hemorrhagic stroke, and 9.2% TIA. Overall, 17.5% were smokers (ischemic stroke: 18.9%; hemorrhagic stroke; 14.9%, TIA: 12.4%). Altogether, cessation medication was provided to 29.8% of patients (NRT: 16.2%, varenicline or bupropion: 13.0%; multiple/other: 2.3%); the remainder received counseling alone (Supplemental Table 1). Proportions differed by event type: ischemic stroke (31.0%), hemorrhagic stroke (26.7%), and TIA (23.6%) (Figure). Patients who received cessation medication versus counseling alone had similar age, sex, and comorbidities (Supplemental Table 2). Stratified analyses and univariate models identified several patient-level and care-level factors associated with cessation medication provision (Supplemental Table 3). In multivariable models, hemorrhagic stroke (OR, 0.81; 95% CI, 0.76-0.86) and TIA (OR, 0.68; 95% CI, 0.64-0.73) were associated with lower odds of cessation medication provision, compared to ischemic stroke. Additionally, Black (OR, 0.78; 95% CI, 0.74-0.82) and Asian (OR, 0.72; 95% CI, 0.58-0.87) patients had lower odds of receiving cessation medication, compared to White patients. Hispanic ethnicity was also associated with lower odds of cessation medication provision (OR, 0.65; 95% CI, 0.56-0.73) (Figure). Additional data for subarachnoid and intracerebral hemorrhage, and analyses addressing missingness, are provided separately (Supplemental Results).
Figure: Smoking Cessation Interventions after Stroke and Transient Ischemic Attack.
Proportions receiving smoking cessation medication varied by event type (A). Results of multivariable model highlighting factors with associations with smoking cessation medication provision (B).
The rates and variability of in-hospital smoking cessation medication provision suggest that optimizing use of these interventions during hospitalization may enhance secondary prevention efforts.
Supplementary Material
Funding:
The GWTG-Stroke program is provided by the American Heart Association/American Stroke Association. GWTG-Stroke is sponsored, in part, by Novartis, Novo Nordisk, AstraZeneca, Bayer, Tylenol and Alexion, AstraZeneca Rare Disease. NSP: research funding from NIH/NIA (K23 AG073524); New York State Empire Clinical Research Investigator Program; Florence Gould Endowment for Discovery in Stroke. This content is solely the responsibility of the authors and does not represent the official views of the NIH.
Disclosures:
NSP: personal compensation for medicolegal consulting. LS: consultant (Genentech, TIMELESS NCT03785678; LifeImage; Massachusetts Dept of Public Health); member, Data Safety Monitoring Boards (Penumbra, MIND NCT03342664; Diffusion Pharma, PHAST-TSC NCT03763929); National PI (Medtronic, Stroke AF NCT02700945); Site PI, StrokeNet Network NINDS (New England Regional Coordinating Center U24NS107243); CME lecturer (PRIME® Education, Boehringer-Ingelheim); member, board of directors (American Heart Association). HK: PI (ARCADIA, NINDS U01NS095869; in-kind study drug [BMS-Pfizer Alliance for Eliquis®]; ancillary study support [Roche Diagnostics]); Deputy Editor (JAMA Neurology); member, clinical trial steering/executive committees (Medtronic, Janssen, Javelin Medical); member, endpoint adjudication committees (AstraZeneca, Novo Nordisk, Boehringer Ingelheim); ownership interest (TETMedical, Inc); consultant (American Medical Association).
Non-standard Abbreviations and Acronyms
- NRT
nicotine replacement therapy
- TIA
transient ischemic attack
- GWTG
Get With The Guidelines
References
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