Background
Many studies have suggested that smoking does not increase mortality in stroke survivors.
Index event bias, a sample selection bias, potentially explains this paradoxical finding.
Therefore, we compared all-cause, cardiovascular disease (CVD), and cancer mortality
by cigarette smoking status among stroke survivors using methods to account for index
event bias.
Methods
Among 5797 stroke survivors of 45 years or older who responded to the National Health
Interview Survey years 1997-2004, an annual, population-based survey of community-dwelling
US adults, linked to the National Death Index, we estimated all-cause, CVD, and cancer
mortality by smoking status using Cox proportional regression and propensity score
analysis to account for demographic, socioeconomic, and clinical factors. Mean follow-up
was 4.5 years.
Results
From 1997 to 2004, 18.7% of stroke survivors smoked. There were 1988 deaths in this
stroke survivor cohort, with 50% of deaths because of CVD and 15% because of cancer.
Current smokers had an increased risk of all-cause mortality (hazard ratio [HR], 1.36;
95% confidence interval [CI], 1.14-1.63) and cancer mortality (HR, 3.83; 95% CI, 2.48-5.91)
compared with never smokers, after controlling for demographic, socioeconomic, and
clinical factors. Current smokers had an increased risk of CVD mortality controlling
for age and sex (HR, 1.29; 95% CI, 1.01-1.64), but this risk did not persist after
controlling for socioeconomic and clinical factors (HR, 1.15; 95% CI, .88-1.50).
Conclusions
Stroke survivors who smoke have an increased risk of all-cause mortality, which is
largely because of cancer mortality. Socioeconomic and clinical factors explain stroke
survivors' higher risk of CVD mortality associated with smoking.
Key Words
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Article info
Publication history
Published online: January 17, 2014
Accepted:
October 24,
2013
Received:
September 4,
2013
Footnotes
Funding: D.A.L. received research support from the National Institutes of Health (NIH; P30DK092926 and K23AG040278). S.R.L. was supported in part by NIH grants NS43992, HL096944, AG040039, NS077378, and NS080377. L.E.S. received research support from the NIH (K23 NS073685).
Conflicts of interest and disclosure: None.
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.10.026
Copyright
Published by Elsevier Inc.
