Fulltext

Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study

Wang X 1 , Liu X 1 , O'Donnell MJ 2 , McQueen M 2 , Sniderman A 3 , Pare G 2 Show all authors , Hankey GJ 4 , Rangarajan S 2 , Chin SL 2 , Rao-Melacini P 2 , Ferguson J 5 , Xavier D 6 , Zhang H 1 , Liu L 1 , Pais P 4 , Lopez-Jaramillo P 6 , Damasceno A 7 , Langhorne P 8 , Rosengren A 9 , Dans AL 10 , Elsayed A 11 , Avezum A 12 , Mondo C 13 , Judge C 5 , Diener HC 14 , Ryglewicz D 15 , Czlonkowska A 14 , Pogosova N 16 , Weimar C 13 , Iqbal R 17 , Diaz R 18 , Yusoff K 19 , Yusufali A 20 , Oguz A 21 , Penaherrera E 22 , Lanas F 23 , Ogah OS 24 , Ogunniyi A 25 , Iversen HK 26 , Malaga G 27 , Rumboldt Z 28 , Oveisgharan S 29 , Al Hussain F 30 , Nilanont Y 31 , Yusuf S 2 , INTERSTROKE Investigators

Affiliations 

  • 1 Beijing Hypertension League Institute, Beijing, China
  • 2 Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
  • 3 McGill University Health Centre, Montreal, QC, Canada
  • 4 St John's Medical College and Research Institute, Bangalore, India
  • 5 NUI Galway, Galway, Ireland
  • 6 Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
  • 7 Eduardo Mondlane University, Maputo, Mozambique
  • 8 Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK
  • 9 Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
  • 10 College of Medicine, University of Philippines, Manila, Philippines
  • 11 Al Shaab Teaching Hospital, Khartoum, Sudan
  • 12 Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
  • 13 Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
  • 14 Department of Neurology, University Hospital, Essen, Germany
  • 15 Institute of Psychiatry and Neurology, Warsaw, Poland
  • 16 National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
  • 17 Department of Medicine, Aga Khan University Hospitals in Karachi, Pakistan
  • 18 Estudios Clinicos Latinoamerica, Rosario, Argentina
  • 19 UCSI University, Cheras, Kuala Lumpur 56000, Malaysia
  • 20 Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
  • 21 Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
  • 22 Department of Cardiology, Hospital Luis Vernaza, Guayaquil, Ecuador
  • 23 Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
  • 24 Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
  • 25 Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
  • 26 Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
  • 27 Universidad Peruana Cayetano Heredia, Lima, Peru
  • 28 University of Split, Croatia
  • 29 Rush Alzheimer Disease Research Center in Chicago, Chicago, IL, USA
  • 30 University of Limpopo, Pretoria, South Africa
  • 31 Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
EClinicalMedicine, 2024 Apr;70:102515.
PMID: 38516107 DOI: 10.1016/j.eclinm.2024.102515

Abstract

BACKGROUND: Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels.

METHODS: The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined).

FINDINGS: Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50).

INTERPRETATION: There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke.

FUNDING: The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

Similar publications