Neal S. Parikh, MD, on Smoking Rates Among Survivors of Acute Ischemic Stroke

In this podcast, Dr Parikh discusses the findings of his recent study, which indicated that smoking rates have not decreased over the past 2 decades among survivors of acute ischemic stroke, unlike the general population. He also reviews pharmacologic and nonpharmacologic interventions that may aid smoking cessation efforts among stroke survivors.

Reference:

• Parikh NS, Chatterjee A, Díaz I, et al. Trends in active cigarette smoking among stroke survivors in the United States, 1999 to 2018. Stroke. 2020;51(6). doi:10.1161/STROKEAHA.120.029084

Neal S. Parikh, MD, MS, is an assistant professor of neurology in the Clinical and Translational Neuroscience Unit in the Brain and Mind Research Institute and the Department of Neurology at Weill Cornell Medicine in New York.

TRANSCRIPT:

Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. Today, I’m joined by Dr Neal Parikh, who is an assistant professor in the Clinical and Translational Neuroscience Unit in the Brain and Mind Research Institute and the Department of Neurology at Weill Cornell Medicine in New York. Thank you for joining me today, Dr. Parikh.

Dr Parikh: Thank you. I'm so happy to join you and to talk to your listeners about smoking cessation after stroke–a topic that's near and dear to my heart.

Christina Vogt: Today, we’ll be discussing his recent study, “Trends in Active Cigarette Smoking Among Stroke Survivors in the United States, 1999 to 2018,” which was published in the journal Stroke. So first, what prompted you to conduct this study on trends and smoking rates among stroke survivors?

Dr Parikh: So, we know that, among people who have ischemic stroke in the United States, about 1 in 5 is a recurrent stroke, and I think the ultimate goal of many stroke neurologists is to reduce the rate of recurrent stroke and cardiovascular disease after stroke to 0.

Effectively, as a clinician, if my patient has a second stroke after they've entered my care, I wonder if my efforts were adequate or not. And, we do a lot to prevent a second stroke with optimization of blood thinners, cholesterol, and blood pressure, but my sense was that, although there had been advances in smoking cessation treatment science, generally those advances hadn't permeated into clinical practice and stroke neurology.

And that was my sense, but I wanted to test that formally and explore that with data. And so, the purpose of this study was to see whether these rates and smoking prevalence among stroke survivors have decreased or not. The underlying motivation was to demonstrate that we could potentially be doing better if data borne out the hypothesis.

Christina Vogt: Your study indicated that the prevalence of active smoking among stroke survivors has not decreased during the past few decades. Why do you think this was the case?

Dr Parikh: There are several possible explanations. One possible explanation is just that the people who are having a stroke are changing over time, and we know that that's the case. Younger and younger people are having a stroke, and it’s possible that their health-related habits have changed over time as well. However, we attempted to account for the changes in demographics of strokes in our analysis, leaving it possible that the reason that the prevalence hasn't decreased is because we have not been adequately aggressive with our smoking cessation efforts in these patients.

Christina Vogt: What interventions both, pharmacologic and nonpharmacologic, are important for stroke survivors in particular for smoking cessation?

Dr Parikh: It's been well demonstrated that aggressive counseling, intensive counseling, and behavioral modification, in combination with pharmacological therapy, is the most effective approach for smoking cessation. And so, in terms of those nonpharmacological interventions, it's important that patients be told time and time again by the nurses or doctors in the hospital and in the clinic after discharge from the hospitalization that smoking cessation is a key component of their secondary stroke prevention, and that patients be told that there are several pharmacological interventions to help them along with that. And specifically, there are several FDA-approved pharmacological therapies, including nicotine replacement therapy, varenicline, and buproprion.

Currently, these interventions have not specifically been tried in randomized clinical trials in the stroke survivor population, but there aren’t very many compelling data to tell us that we shouldn’t be using these treatments with our patients. And in fact, the American Heart Association Acute Stroke Care Guidelines, published in 2019, suggested that in-hospital initiation of nicotine replacement and potentially even varenicline may be reasonable for certain patients.

Christina Vogt: What key takeaways do you hope to leave with neurologists on this topic?

Dr Parikh: I hope that neurologists will take this issue more seriously and pay as much attention to patients’ behavioral health-related habits as their antiplatelet regimen, statin regimen. and the antihypertensive treatment. I hope that neurologists feel empowered to address patients’ smoking habits aggressively with nonpharmacological treatments, with the prescription of pharmacological smoking cessation aids, and referral to tobacco cessation specialists when needed.

Christina Vogt: And lastly, what is the next step in terms of future research in this area?

Dr Parikh: That's a great question. I think that a key priority going forward is figuring out, what is the most effective way to get stroke survivors to quit smoking? Although there have been many advances in smoking cessation treatment science for the general population, it's not clear that all of that knowledge applies to stroke survivors, who have some special considerations related to their disability to mood disorder after stroke. And so, we need to develop tailored smoking cessation programs, prove that they work for stroke survivors, and then scale them up so that clinicians across the country feel comfortable using them, just as they feel comfortable prescribing antiplatelet and lipid-lowering medications.

Christina Vogt: Thanks again for joining me today, Dr Parikh.

Dr Parikh: Thank you for having me.