Summary of Observational Studies

In a meta-analysis of cohort and case-control studies of cigarette smoking and stroke
(Shinton and Beevers 1989). the overall relative risk of stroke among former smokers
was I. 17 compared with never smokers (9Spercent CI. 1.05-l 30). This estimate is
based on a summary of I8 relative risks from 13 studies that separately identified former
smokers (Kahn 1966: Doll and Peto 1976: Abbott et al. 1986: Colditz et al. 1988: Ostfeld
et al. 1974; Kono et al. 1985: Khaw et al. 1984: Vessey. Lawless, Yeates 1984; Bell
and Symon 1979: Bell and Ambrose 1982; Bonitaet al. 1986; Bonita 1986; Taha. Ball.
Illingworth 1982). As observed for the relation between current smoking and stroke.
the risk among former smokers was greater when the analysis was repeated using only
those studies with stroke occurring before age 75 (RR= I .47.95-percent Cl. I. I S-l .X8
compared with never smokers). By comparison. the relative risks for current smokers
were 2.9 for those younger than SS years and I .8 for persons aged 55 to 74 years. Thus,
although a modest elevation in risk persisted among younger former smokers, this
relative risk was substantially less than that which was observed among current
smokers.

Intervention Studies

Intervention trials described above provide little direct evidence relating to change
in risk of stroke after smoking cessation. Only the trial of smoking cessation conducted
among I.445 British men used a single intervention (Rose et al. 1982). During IO years
of followup, five men in the normal care group died because of stroke, and seven men
in the intervention group died because of stroke. The small numbers in each group and
the small difference in smoking cessation rates between the intervention and control
groups limit any conclusion regarding the impact of smoking cessation in this popula-
tion.

Other intervention studies have included management of hypertension and
cholesterol as well as smoking cessation programs.  As discussed under randomized
trials of smoking cessation and CHD. these multiple interventions make drawing
conclusions difficult regarding the relation between smoking cessation and risk of
stroke (Steinbach et al. 1984: Wilhelmsen et al. 1986: MRFIT Research Group 1982.
1986; Salonen, Puska, Mustaniemi 1979; Hjermann 1980; Holme 1982).

In a nonrandomized intervention, Rogers and colleagues (1985) measured changes
in cerebral artery blood flow among volunteers who were encouraged to abstain from
cigarettes. Cerebral perfusion was improved after smoking abstinence.

Influence of Prior Levels of Smoking

Using data from the followup of 248,046 U.S. veterans monitored for I5 years, Rogot
and Murray (1980) reported the mortality ratio for stroke among former cigarette
smokers who stopped smoking for reasons other than a physician's orders according to
the level of prior cigarette smoking. Based on 1,279 strokes among past smokers, the
mortality ratio for stroke among former smokers relative to never smokers increased

75 I


with higher previous daily cigarette consumption from 0.94 for those smohing less than
IO cigarettes per day to I .33 for those smohing 30 cigarettes or more per day compared
with never smokers (Figure 7). Data from ACS CPS-II also address this relationship
(Table X). Within each level of previous smoking. the risk of stroke was clearly lower
for former smokers than for continuing smokers, except among men who smoked 2 I
cigarettes or more per day. Other studies have had too few former smokers to classify
them according to previous number of cigarettes smoked.

~10 cig/day   1 O-20 cig/day  2 l-39 ciglday   ~40 cig/day

O ??????????

m Current Smokers

FIGURE 7.-Mortality ratios for stroke for current smokers and ex-smokers
      compared with never smokers, b> daily cigarette consumption,
      US Veterans Study, 1954-69

Effect of Duration of Abstinence

The relation between duration of abstinence and rish of strohe has been addressed in
only a few studies. In a case<ontrol stud) that included 135 former smohcrs who
suffered strobe. Donnan and coworkers ( 19X9) observed that the relative rish of strohe
declined monotonically over the IO years following quitting: at the end of IO years. a
significant excess rish of strohe was still evident.

Using 5-year intervals. Root and Murra~~ (19X0) reported the mortalit>, ratios for
those who had abstained. Assuming that an individual classified as a former smoher at
the beginning of the study would remain a former smoher throughout the IS Iears of


TABLE S.-Prospective cohort studies of smoking cessation and risk of stroke

Population

OIlreId et al. (lY74)

NomLlra et al. ( 1074)

2.738 Cook Coun1y. Il.
rek.lcnt~ receiving old age
;I\\l\txlce aged 65-74

47.423 Washington Count).
MD rc\itlent~

O.Vlh    I 4 cl)!/`la): I .7v
    IO IV clp/day: 0.x5
     20 cIg/tl:ly. 0.x I
I .03"          0.7')
0.7')          0.X6
I .ot)          I ..I0
O.Y7          I).`)0

Doll and Pet0 (1976)

Brirlxh phykians: 3J.440
men

Ohada et al. ( lY7h)    4. I X6 Jnpanew

20 yr

h)l

NK

NK


TABLE S.--Continued

Relative risk compared with never smoker\"

Reference

Outcome

Former
smokers

Current
smohers

Doll e1 ill. ( IYXO)

British phy\Icl;ms: 6.lY4
vso"lell

Kogot and M way
(IYXO)

FullcreI al. (IYX7)

Whwhall CIVII wrvant\:
I X.403 men aged 40-64

Vea\ey. Lawleh5.     I7.000 l.lK women aged
Yelltea t IYX4)        2% 3Y

Abbott et al. ( I YXh)

Honolulu Heart Study: 7,XYS
men of Japanese orIgIn: hSX
\mokcr\ who quit In first 6 yr

Welin cI al. t IYX7)

7X0 men living In Gothrnhurg.
67X examined

Car\Iensen.
Pwhagen. Eklund
(IYR7)

?S.lSY Swede\

22 yr

IS yr

IO yr

It&l6 yr

l2yr:
6 Yr

IX.5 yr:
I I yr

Ihyr

NK

I.279

34

2
4

I I
3

NK

I24

DeaIh due to cerebral
thromboG%

Stroke ICD 336343
(7th revision)

Strobe mortality

Subarachnoid
NonhemorrhagIc

Thromboembolic
Hemorrhage
Total

Excluded subarachnoid
hemorrhage

Cerehrovascular mortality
ICD 43%43X

I.IX

I .02

I-14q/day:  0.03
14-24 cIg/day:  0.45
225 cig/day:  0. I Y

         I.32

I.52    I-Y rig/day: I .O'
    I%lYcig/day: 2.0
     220 cig/day: 2.3
2..Jh             3.0
I.3               I.4

I .6 (0.7-3.X)         3.00
1.X (0.4-9.0)         6.10
I.5 ( I &2.3)         3.50

I.IXh             1.67

1.10

I-7 g/day: 0.9
X-I 5 g/day: 0.9
>IS g/d/day: I.1


I'S I)tltis (I'JXY)    AC'S (`PS-I (2%St:lle Stud) )     h yr ( I OS--h.! 1     NR


TAHIX X.--Continued

Qwt <I yr 0.27        2.07
tL2yr  1.42
3 ~.s yr I .3Y
h to yr 2.27
II ISyr 2.34
>Ihyr l.Y)2

Qutt <I yr NR         I .77
I-2yr l.Y2
1-s yr 0.7')
h-t 0 yr 0.5')
t ILtsyyr 1.23
Zlhyr O.Y3


TABLE K-Continued


follo~up. the\e investigator\ reported mortalit> ratios clo\e to I .O for all durations
except for 5 to 9 years after quitting.

Based on 26 ye;irs of\tud!,ing 4.35 men and u'omttn in the Framingham Study (Wolf
et al. 19X8). the ri& of\troLe among person\ u ho stopped was significantly lower than
that among persons who continued to smohe cigarettes. Furthermore. persons u ho quit
smohing developed strobe at the mte of never smoker\ soon after discontinuing
cigarette smohing (Figure 8). Wolf and coworhers ( 198X) estimated that the risk of
stroke among smokers had decreased significantly ? yean after quitting and reverted
to the level of never smokers within 5 years. The\e results persisted after controlling
for age. blood pressure. serum cholestrol level. relative weight. left ventricular hyper-
trophy on electrocardiogram. and blood glucose level. Thu\. the reduction in risk after
smoking cessation is not attributable to differences in other rish factor\ for stroke
between those who quit and those who continue to smohe.
In the Nurses Health Study (Colditr et al. 198X). B lower ri\h of stroke was ohserved
with increasing time from cesation. Compared with the ri\h among never smokers.
the relative risk was 3.6 among women who had stopped for les\ than 2 j'ears
(95percent Cl. 1.11.7). However. among women who had stopped tbr 2 lears or
more, the relative rish was reduced to I .3 (9S-percent CI. I .O-2.0). Women currentI).
smoking IS to 14 cigarettes per day had ;I relative risk of 2.9 compared with never
smoker\. Again. the elevation of the relative risk during the first 3 year\ after cehation
is consistent with high recidivism among the\e women.
Prospective data from ACS CPS-II \ho\ved that among men who quit smoking. the
risk of \trokc returned to that of never smohers after I I year\ or more of smohing
abstinence for those originally smohing fewer than 2 I cigarette\ per dab. However. for
men who pre\,iousl\ smohed 21 cigarette\ or more per da\. the rish among former
smokers did not return to the level of ne\`er smoker\. even after I6 bears or more of
cessation. Among women who quit. the rate of decrease &;I\ much more rapid: h! 3 to
5 years after cessation. the ri\h of a-ohe wa\ 4milar to that of never smoher\ (Table
8).

Oral Contraceptives and Smoking Cessation

In two studies the risk of subarachnoid hemorrhage was augmented m~ong cigarette
smokers who also take oral contraceptive\ tPetitti and Wingerd IY7X: Collahorati\e
Group for the Study of Strohe in Youn, 17 Women 1975). In the Collaborative Group
Study of stroke among youn, ~7 women ( 1975 1. the cutegot-\ of former smoher\ was not
cleat-l), defined: rather. ;I group of"once regular \moher\" XI\ compared with "never
regular smoker\." In this stud\ there u :I\ no ;t\\oci;ltion between current smoking or
former smoking and risk ofthromhotic strobe. O\,erall. the relutiie rish for hemorrhqic
strobe was I .X among once regular moher\ and 3.3 anon2 current smoker\. Within
the group of once regular hmoher\. uomen currently usins oral contracepti\,e\ had
approximately twice the risk compared u ith women not u\in, ~7 oral contraceptives. The
Royal College of General Practitoner\ \tud! of oral contracepti\,e\ did not separate
former smokers from never smoher\ (Luyde. Beral. Kay I98 I ). Hence, data to address
the relationshipamongoral contraceptive\. smoking cessation. and risk of \ubarachnoid

258


--\
o ? o ? o ?

1        .        I

5     10    15     20     5     10    15     20

        Years of Follow-up

FI(;URE &-survival free of stroke in cigarette smokers (dotted line), never
   smokers (solid line), and former smokers (dashed line), aged 60,
   using 00x proportional hazard regression model. among men and
          women
SOtJK~`E. Wolt'rt al. I IYXX).


hemorrhage are not available from that study. Because oral contraceptive preparations
used today provide substantially lower doses. the risk of cardiovascular disease as-
sociated with their use and their interaction with cigarette smoking may be different
than observed for the early high-dose preparations.

Effect of Smoking Cessation After Stroke

In contrast with CHD. in which the focus after MI is prevention of recurrent disease.
the center of attention after a major cerebrovascular event is rehabilitation. For CHD.
substantial evidence shows the benefits of abstaining from smoking after onset of CHD.
Comparable data are not available on the benefits of abstinence after stroke.

Summary

Risk of stroke resulting from occlusion of the cerebral arteries and from subarachnoid
hemorrhage is increased approximately twofold to fourfold among current smokers
compared with never smokers. After cessation. the excess risk decreases steadily. In
some studies, the rish of stroke among former smokers becomes indistinguishable from
that of never smokers within 5 years: in other studies. this decrease did not occur until
after IO years or more of smoking abstinence. The reduced risk of stroke among persons
who stop smoking is independent of the amount prel iousl) smohed and other knoun
risk factors for stroke. Similar reductions in risk of stroke after cessation are seen
among men and women. but fev. data are available for minority populations.

I Compared with continued smohing. smoking cessation substantially reduces rish ot
coronary heart disease (CHD) among men and women of all ages.
2. The excess risk of CHD caused by smoking is reduced by about half after I qear ot
smoking abstinence and then declines t ~~raduall>. .After I5 years of abstinence. the
risk of CHD is similar to that of persons u ho ha\e never smohed.
3. Among persons u ith diagnosed CHD. smohinf cessation murkedl! reduces the risk
of recurrent infarction and cardiovascular death. In many studies. this reduction in
risk of recurrence or premature death has Hun SO percent or more.
3. Smohing cessation substantialI!, reduces the rish of peripheral artery occluG\e
disease compared M ith continued smoking.
5. Among patients N ith peripheral arter? disease. smohing cessation impro\ es exercise
tolerance. reduces the risk of amputation after peripheral arter! turgq. and
  increases overall survival.

6. Smoking cessation reduces the risk of both ischemic strobe and subarachnoid
hemorrhage compared M ith continued smoking. After smoking cessation. the rish
  of strohe returns to the Iehel of never smohers: in some studies this has occurred
within 5 years. but in others as long as IS bears of abstinence were required.


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          CHAPTER 7
    SMOKING CESSATION AND
NONMALIGNANT RESPIRATORY DISEASES