Electronic Cigarette Use and Cigarette-Smoking Cessation Attempts Among Stroke Survivors in the US

Quitting cigarette smoking after stroke reduces the risk of stroke recurrence.¹ The rate of smoking among stroke survivors has not declined over the past 20 years.² Electronic cigarette (e-cigarette) use is increasingly common, and e-cigarettes are being investigated for their role in cigarette-smoking cessation.³ However, there are few data regarding the use of e-cigarettes in stroke survivors. We estimated the prevalence of e-cigarette use among actively smoking stroke survivors in the US and evaluated its association with at least 1 cigarette-smoking cessation attempt in the past year.

We performed a cross-sectional analysis using pooled data from the 2016-2018 US Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS) surveys. The US BRFSS is an annual, nationally representative health-related telephone survey.⁴ Respondents are asked about health conditions and health-related behaviors, including e-cigarette use. The Weill Cornell Medicine institutional review board deemed this analysis exempt from review, and informed consent was not required. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Our study population consisted of respondents who reported a prior stroke and active tobacco cigarette smoking. Respondents were asked about active e-cigarette use and smoking cessation (“During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?”).⁴ This measure is commonly assessed as an indicator of motivation to quit and is targeted in nationwide health initiatives.⁵ We used logistic regression to evaluate the association between e-cigarette use and a cigarette-smoking cessation attempt within the past year. Models were adjusted for demographic characteristics and comorbidities, as tabulated in BRFSS, that may influence engagement in smoking cessation. Complete case analysis was performed; missingness ranged from 0% to 3.5% for all variables except income (16.0%). We used interaction testing and subgroup analyses to investigate effect-modifying factors (age of 60 years or younger vs older than 60 years, sex, race/ethnicity, insurance, number of smoking-related comorbidities, and residence in the Stroke Belt⁶). The Wald test was used to calculate 2-sided P values for interaction terms. A sensitivity analysis restricted to 2017 was adjusted for additional covariates collected that year. We used survey-specific procedures to generate nationally weighted frequencies, prevalence estimates, and regressions using SAS version 9.4 (SAS Institute). The level of confidence was set at P < .05.

Among 6 867 786 stroke survivors, 23.6% (95% CI, 22.7-24.5) were active cigarette smokers. The mean (SD) age of actively smoking stroke survivors was 59.6 (11.9) years, 49.2% (95% CI, 47.0-51.3) were women, 22.2% (95% CI, 20.7-23.8) lived in the Stroke Belt, 65.7% (95% CI, 63.5-68.0) were White, 18.4% (95% CI, 16.5-20.4) were Black, and 15.8% (95% CI, 14.0-17.6) reported other race/ethnicity. Diabetes was present in 27.9% (95% CI, 25.9-29.9) of survivors and hypertension in 65.6% (95% CI, 61.9-69.2). The prevalence of active e-cigarette use was 13.5% (95% CI, 11.8-15.3). Overall, 62.3% (95% CI, 60.2-64.4) reported having attempted to quit smoking within the past year. e-Cigarette users were more likely to have attempted to quit cigarette smoking than those not using e-cigarettes (73.0% [95% CI, 67.2-78.9] vs 60.7% [95% CI, 58.5-62.9]; odds ratio, 1.63; 95% CI, 1.21-2.19) (Table). This association persisted across subgroups and was stronger in stroke survivors older than 60 years, those living in the Stroke Belt, and those with more smoking-related comorbidities (Figure).

Actively smoking stroke survivors in the US appear motivated to quit, with more than 3 of 5 having made a cessation attempt in the past year. Approximately 14% of actively smoking stroke survivors use e-cigarettes, and e-cigarette users were more likely to have attempted to quit smoking in the past year. Actively smoking stroke survivors may be vulnerable to the poorly understood deleterious effects of combustible tobacco and e-cigarette co-use.³ Thus, patients should be queried about e-cigarette use, and patients using e-cigarettes as a smoking-cessation aide should be encouraged to instead use guideline-recommended therapies.³

Limitations of this analysis include the cross-sectional observational design and reliance on self-reported data. Efficacy and safety studies of e-cigarettes for smoking cessation will ideally include stroke survivors. In the meantime, inquiring about e-cigarette use may present clinicians with an opportunity to engage patients in smoking cessation.

Accepted for Publication: February 18, 2021.

Published Online: April 12, 2021. doi:10.1001/jamaneurol.2021.0636

Corresponding Author: Neal S. Parikh, MD, MS, Department of Neurology, Weill Cornell Medicine, 420 E 70th St, 4th Floor, New York, NY 10021 (nsp2001@med.cornell.edu).

Author Contributions: Dr Parikh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Parikh, Kamel.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Parikh.

Critical revision of the manuscript for important intellectual content: Navi, Merkler, Kamel.

Statistical analysis: Parikh.

Study supervision: Kamel.

Conflict of Interest Disclosures: Dr Parikh has received grants from the Leon Levy Foundation Fellowship in Neuroscience outside the submitted work. Dr Merkler has received grants from the American Heart Association and Weill Cornell Medicine as well as personal fees from Medico-legal Consulting outside the submitted work. Dr Kamel serves as a principal investigator for the National Institutes of Health—funded ARCADIA trial, serves as Deputy Editor for JAMA Neurology, serves as a steering committee member of Medtronic’s Stroke AF trial (uncompensated), and serves on an end point adjudication committee for a trial of empagliflozin for Boehringer Ingelheim. No other disclosures were reported.

Funding/Support: Dr Parikh is supported by grants from the New York State Empire Clinical Research Investigator Program and Florence Gould Foundation Discovery in Stroke fund.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Kamel is Deputy Editor of JAMA Neurology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.