Smokers who first lit up as teens more likely to smoke after stroke

American Heart Association
Friday, 4 July 2003

Smokers who took up the habit at an early age, and those with a history of depression or alcohol use, are more likely to resume smoking after suffering a "bleeding" stroke, researchers report in today's rapid access issue of Stroke: Journal of the American Heart Association

Continued smoking has been linked with recurrent stroke, so identifying the people most likely to keep smoking may allow for more effective intervention, which may ultimately decrease the risk of recurrent stroke and other cardiovascular events, says lead researcher Stephan A. Mayer, M.D., associate professor of clinical neurology and neurosurgery at Columbia University College of Physicians and Surgeons in New York City.

The study evaluated factors that might predict the someone would resume cigarette smoking after a first subarachnoid hemorrhage (SAH). An SAH occurs when a blood vessel on the brain's surface ruptures and bleeds into the space between the brain and skull. In 30 percent to 50 percent of cases, SAH is fatal. Cigarette smoking is a major risk factor for SAH.

Tobacco use is also a risk factor for an aneurysm – the weakening of a blood vessel's wall – and thus may be a risk factor for recurrent SAH after aneurysm repair, Mayer says. SAH is fatal in 30 percent to 50 percent of cases, he says.

Researchers interviewed 152 SAH survivors ages 23 to 80 three months after their stroke. They found that 37 percent (56 people) had resumed smoking. Overall those who resumed smoking were typically under age 50, black, had begun smoking as a teen, had a prior history of alcohol or cocaine use, and a history of self-reported depression.

Several factors were independent predictors of continued smoking, researchers say. Fifty-one percent of those who began smoking at age 16 or younger resumed smoking compared to 28 percent or those who began smoking at age 17 or older.

"This finding indicates that the addictive properties of nicotine may be especially potent in individuals who begin smoking at a younger age," Mayer says.

Because there was little difference in physical capabilities, quality of life, mental status and emotional health between those who quit smoking and those who continued smoking, Mayer discounted the notion that patients resume smoking to relieve their post-stroke depression or enhance alertness or mental function. Some have hypothesized that patients used nicotine as a stimulant to "self-medicate" for these symptoms.

The researchers acknowledge that their study is limited by the small number of patients included. They also note that because the information was obtained in patient interviews the study may have underestimated cigarette, alcohol and cocaine use.

Mayer recommends that physicians routinely ask when patients began smoking and conduct careful screening for a history of depression or alcohol use as a simple and effective means of identifying SAH patients at high risk of continued smoking.

"Informing patients and their families that they are at high risk to continue smoking after hospital discharge may be an important first step in raising awareness of the problem and may provide extra motivation for some patients to quit," he says.

"There is a need to develop improved psychosocial and medical treatment interventions targeted at smoking cessation after SAH, which should be routinely offered as part of the rehabilitation and ongoing care of these patients."

Despite this finding that more than a third of SAH survivors resume smoking, it is still lower than the one-half to two-thirds of heart attack survivors who resume smoking, Mayer notes.

Co-authors are Jennifer Ballard, B.A.; Kurt T. Kreiter, Ph.D.; Jan Claassen, M.D.; Robert G. Kowalski, B.S.; and E. Sander Connolly, M.D. The research was partly funded by the American Heart Association.

For more information, or to contact American Heart Association, see their website at: www.americanheart.org