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Smoking Cessation for Individuals with Stroke

5th Edition
2014 UPDATE
December 2014

The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke, 5th Edition 2014 module is published in the International Journal of Stroke (IJS) (Online Open‑Access available December 2014; Printed Journal scheduled for April 2015).

To access the specific recommendations for Smoking Cessation for Individuals with Stroke and all other sections of the Secondary Prevention of Stroke module, please click on this URL which will take you to the recommendations online in the IJS:  http://onlinelibrary.wiley.com/doi/10.1111/ijs.12439/full. For the French version of these recommendations, open the appendix at this link : http://onlinelibrary.wiley.com/store/10.1111/ijs.12439/asset/supinfo/ijs12439-sup-0001-si.pdf?v=1&s=b0ed4fff1d7fc435cf4e2a83ccbcbffbdad767de.

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections below for this additional content.

Rationale

The Quality of Stroke Care in Canada stroke audit report found that among all Canadians who experienced a stroke in 2008-09, 41% were current smokers, and more prominent in younger adult stroke patients (less than 49 years old). The InterStroke study reported that current smokers had increased risk of stroke, with the impact greater on ischemic stroke compared to hemorrhagic stroke, and this risk increased with the number of cigarettes smoked per day. Also the significant impact of smoking on stroke was second only to hypertension. The CAN-ADAPTT working group has reported that approximately 17% of Canadians are current smokers, and a large proportion has been shown to be willing to make a quit attempt. Health care providers have an important role to play in assisting individuals to quit smoking.  Moreover, even brief interventions by providers are known to be effective in increasing the likelihood of a quit attempt by a person who smokes.  Clinical practice guidelines are known to be an important and effective provider tool to close the gap between recommended care and actual care provided. Smoking cessation has been found to reverse/reduce stroke risk as duration of being smoke-free increased. Female patients who have had a stroke are at additional risk for recurrent stroke if they continue to smoke and are taking oral contraception or estrogen-based hormone replacement therapy.

System Implications
  • A focus on cerebrovascular health for paediatric cases–such as diet, exercise, non-smoking, avoidance of drugs that increase stroke risk.
  • Access to risk factor management programs such as smoking cessation programs should be available in all communities, primary healthcare settings and workplaces.
  • Improved access to pharmaceuticals and behaviour counseling for smoking cessation through private and public drug coverage plans.
  • Government action at all levels of government to reduce tobacco use.
  • Coordinated efforts among stakeholders such as Heart and Stroke Foundation, public health agencies, ministries of health and care providers across the continuum to produce patient, family and caregiver education materials with consistent information and messages on risk factor management.
  • Coordinated processes for ensuring access to and awareness of educational materials, programs, activities and other media related to risk factor management by healthcare professionals, patients and caregivers, including promotion of educational material and effective dissemination mechanisms.
  • Access to culturally and ethnically appropriate educational resources in multiple languages for patients with aphasia.
  • Government regulation of e-cigarettes, including prohibiting e-cigarette sales to minors, the use of e-cigarettes in workplaces and public places where smoking is banned by law and e-cigarette sales in locations where tobacco sales are banned; and restriction of e-cigarette advertising and promotion.
Performance Measures
  1. Proportion of patients with documented smoking status recorded on patient record.
  2. Proportion of patients with stroke and TIA with a history of tobacco smoking who are given smoking cessation advice and counseling during acute hospital stay, inpatient and outpatient rehabilitation, and during secondary prevention visits.
  3. Proportion of stroke and TIA patients who participate in a smoking cessation program who are smoke-free at 6 months, one year and two years.

Measurement Notes:

  • Data may be available through chart audit. Documentation data quality should be assessed and comprehensive documentation encouraged.
Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

Summary of the Evidence, Evidence Tables and References

Smoking Cessation Evidence Tables and Reference List

It has been estimated that 18% of all strokes may be attributed to active smoking (Goldstein et al. 2001). There appears to be a dose-response relationship between increased cigarette smoking and stroke risk. The Physician’s Health Study (Robbins et al. 1994), included 22,071 male participants. Compared with those who never smoked, the relative risk of non-fatal stroke occurrence was 2.52 (95% CI 1.75 to 3.61) for those currently smoking ≥20 cigarettes/day, 2.02 (95% CI 1.23 to 3.31) for those currently smoking <20 cigarettes/ day, and 1.20 (95% CI 0.94 to 1.53) for former smokers (test for trend: p<0.001), after adjustment for age and aspirin and beta-carotene use.

A recent systematic review & meta-analysis (Peters et al. 2013) included the results from 81 prospective cohort studies, which included 3,980,359 persons, reporting sex-specific risk of current smoker vs. nonsmokers. The prevalence of current smoking ranged from 8% to 59% in men and from 1% to 51% in women. Most studies reported higher smoking rates among men. Over the duration of follow up, which ranged from 6-40 years, there were 42,401 strokes. The risk of stroke was higher in current smokers compared with nonsmokers in both women: (RR=1.83, 95% CI 1.58-2.12) and men (RR=1.67, 95% CI 1.49-1.88). The risk of stroke was also higher in former smokers compared with never smokers (women: RR=1.17, 95% CI 1.12-1.22; men: RR=1.08, 95% CI 1.03-1.13). The risk of hemorrhagic, but not ischemic stroke, was significantly increased in women who smoked compared with men who smoked (RR=1.17, 95% CI 1.02-1.34, p=0.02). An increased risk of all stroke (OR=2.09, 95% CI 1.75-2.51), ischemic stroke (OR=2.32, 95% CI 1.91-2.81) and hemorrhagic stroke (OR=1.45, 95% CI 1.07-1.96) was also associated with current smoking in the case-control INTERSTROKE Study (O’Donnell et al. 2010). Results from the Cardiovascular Health Study (Kaplan et al. 2005) including persons over the age of 65 years, indicated that smoking was associated with a significantly increased risk for stroke recurrence (HR, 2.06; 95% CI, 1.39–3.56).

Both pharmacological agents and behavioural intervention strategies have proved effective as smoking cessation interventions. A Cochrane review of reviews authored by Cahill et al. (2013) included the results of 12 Cochrane reviews (including the results from 267 RCTs, 101,804 participants) which examined the effectiveness of pharmacological treatments to promote smoking cessation in adults. Treatments evaluated included nicotine replacement products, such as gums, transdermal patches, nasal sprays or inhalers, the non-tricyclic antidepressant, bupropion and varenicline, a nicotinic receptor partial agonists. Compared with placebo, all forms of therapies significantly increased the odds of sustained smoking cessation (ORs ranged from 1.82-2.88). Varenicline was superior to single forms of nicotine replacement therapy (OR= 1.57, 95% % Credible interval [Cred I] 1.29 to 1.91) and was also superior to bupropion (OR= 1.59, 95% CredI 1.29 to 1.96). The odds of serious adverse events (chest pains and heart palpitations) associated with nicotine replacement therapy were significantly increased (OR= 1.88, 95% CI 1.37- 2.57). The most common side effects associated with bupropion were insomnia, occurring in 30% to 40% of patients, dry mouth (10%) and nausea. The main serious adverse event was seizures. The main adverse event for varenicline was mild-moderate nausea, which subsided over time and was rarely reported. Typical drop-out rates due to adverse events ranged from 7% to 12%.

Non-pharmacological and combination therapy have been shown to be effective in achieving sustained smoking cessation. A recent Cochrane Review, Stead & Lancaster (2012a) evaluated behavioral support with the addition of the availability of pharmacotherapy compared with a control condition receiving usual care or brief advice or less intensive behavioural support. The results from 41 RCTs including participants from both community and healthcare settings, the majority of whom smoked >20 cigarettes/day, were included. Most studies supplied nicotine replacement therapy (provided as patch or gum)while behavioural support was typically provided by specialists in cessation counseling, but was also provided by peer counselors, trained nurses and usual care providers and took the forms of telephone, mail, individual and group sessions. Combination therapy was associated with the greatest chance of cessation of smoking at 6 months (RR=1.82, 95% CI 1.66-2.00, p< 0.0001). In studies that recruited participants from healthcare settings, the probability of success was greater (RR=2.06 vs. 1.53). There was no association between number of sessions provided and success of quitting (1-3 vs. 4-8 vs. >8) or the planned duration of contact (total minutes) (up to 30 vs. 31-90 vs. 91-300 vs. >300).

Motivational interviewing, by itself has also shown to be an effective strategy to achieve sustained smoking cessation. Using the results from 14 RCTs, Lai et al (2010) examined the use of 1-4 sessions (15-45 minutes/session) of motivational interviewing (MI) compared with control groups who received brief advice, or routine care. Motivational interviewing was associated with a significantly increased probability of achieving long-term smoking cessation (RR 1.27, 95% CI 1.14- 1.42). Chances of success were greater when delivered by a general practitioner, compared with a nurse or counselor. While both single compared and multiple sessions were both effective, sessions of >20 minutes duration were more effective compared with shorter sessions (RR= 1.31, 95% CI 1.16 to 1.49 vs. 1.14, 95% CI 0.80 to 1.16).

The use of electronic cigarettes (e-cigarettes) has increased in recent years, and remains controversial. They may be used as an alternative to conventional cigarettes or as an aid in smoking cessation programs. The current practice recommendations make no statements regarding their use. Although the use of e-cigarettes has been shown to significantly reduce the use of conventional cigarettes, in persons who wish to quit smoking (and in those with no desire to quit), data regarding their safety are limited.