Stroke. 2005;36:e74-e76
Published online before print August 4, 2005,
doi: 10.1161/01.STR.0000177475.30281.7f
(Stroke. 2005;36:e74.)
© 2005 American Heart Association, Inc.
Cigarette Smoking Among Spouses
Another Risk Factor for Stroke in Women
Adnan I. Qureshi, MD;
M. Fareed;
K. Suri, MD;
Jawad F. Kirmani, MD
Afshin A. Divani, PhD
From the Zeenat Qureshi Stroke Research Center, Department of Neurology and Neurosciences, University of Medicine and Dentistry of New Jersey, Newark.
Correspondence to Adnan I Qureshi, MD, Dept of Neurology and Neurosciences, UMDNJ, DOC-8100, 90 Bergen St, Newark, NJ 07103. E-mail aiqureshi{at}hotmail.com
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Abstract
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Background and Purpose It is well known that passive
exposure to cigarette smoking increases the risk of coronary
events, but the effect on the risk of stroke is not well defined.
We performed this study to determine the effect of cigarette
smoking among spouses on the risk of developing stroke and ischemic
stroke among a nationally representative sample of women.
Methods We examined the association between history of smoking among spouses with the incidence of stroke in a national cohort of 5379 women who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study.
Results During a mean follow-up of 8.5 years, the risk was significantly increased for all strokes (relative risk, 5.7; 95% CI, 1.4 to 24) and ischemic stroke (relative risk, 4.8; 95% CI, 1.2 to 20) among cigarette-smoking women with a cigarette-smoking spouse compared with those with a nonsmoking spouse after adjusting for other cardiovascular risk factors.
Conclusion The study provides new evidence linking spousal smoking to stroke.
Key Words: minority groups smoking stroke stroke, ischemic women
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Introduction
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It is well known that passive exposure to cigarette smoking
increases the risk of coronary events,
1 but the effect on the
risk of stroke is not well defined. We performed this study
to determine the effect of cigarette smoking among spouses on
the risk of developing stroke and ischemic stroke among a nationally
representative sample of women.
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Methods
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We used the data from 12 220 participants aged 25 to 74 years
evaluated from 1982 to 1984 as part of the First National Health
and Nutrition Examination Survey Epidemiologic Follow-Up Study
(NHEFS).
2 Of the 12 220 participants, 7279 were women. Subsequently,
1900 were excluded from the analysis because of previous cardiovascular
diseases (n=712), missing follow-up (n=572), spouse smoking
status unknown (n=72), missing values for cholesterol, diabetes
mellitus, blood pressure, or body mass index (n=405), and missing
values for smoking duration (n=139). In the 1982 to 1984 visit,
several questions were inquired, including whether the participant
was actively smoking, daily cigarette consumption, years of
cigarette smoking, and active cigarette smoking among spouses.
We defined incident all stroke cases as study participants who
were hospitalized or died during the 10-year follow-up period
with
International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) codes 431 to 434.9 or 436 to
437.1. The strokes were further categorized as ischemic stroke
(ICD-9-CM codes 433 to 434.9 or 436 to 437.1) and intracerebral
hemorrhage (ICD-9-CM codes 431 to 432). Cardiovascular disease
was defined by either stroke or coronary artery disease (ICD-9-CM
codes 410 to 414). The definitions of stroke and cardiovascular
diseases were consistent with previous reports.
3,4 Potential
confounders in the association in the analyses were age, race/ethnicity
(black, white, other), systolic blood pressure, hyperlipidemia
(serum cholesterol <200 or

200 mg/dL), obesity (body mass
index

30.0 kg/m
2), diabetes mellitus, cigarette smoking (former,
current), average daily cigarette consumption, alcohol consumption
(never, moderate, and heavy) and duration of smoking. All measures
were obtained prospectively during the National Health and Nutrition
Examination Survey I, 1982 to 1984 visit, except serum cholesterol
measurements, which were obtained from baseline interview. Cox
proportional hazards analysis was used to estimate the relative
risk (RR) for stroke and cardiovascular diseases. Because of
significant interaction between smoking status of participant
and spouse, the analysis was performed in cigarette-smoking
and nonsmoking women separately. Annual household income inquired
from 2172 of the 2347 cigarette-smoking and 2759 of 3032 nonsmoking
women was entered as provided in original dataset (<3000;
3000 to 3999; 4000 to 4999; 5000 to 5999; 6000 to 6999; 7000
to 9999; 10 000 to 14 999; 15 000 to 19 999; 20 000 to 24 999;
25 000 to 34 999; 35 000 to 49 999; 50 000 to 74 999; 75 000
to 100 000; >100 000; and missing).
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Results
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Of the 5379 women included in the analysis, women who reported
a cigarette-smoking spouse (n=3727) were more likely to be active
smokers and reported higher cigarette consumption and years
of smoking (
Table 1). The mean follow-up duration (years ±SD)
was 8.5±2.1. The risk of all strokes (RR, 5.7; 95% CI,
1.4 to 24) and ischemic stroke (RR, 4.8; 95% CI, 1.2 to 20)
was increased among cigarette-smoking women with a cigarette-smoking
spouse compared with women with nonsmoking spouses after adjusting
for differences in potential confounders (
Table 2). The increased
risk of all strokes (RR, 5.8; 95% CI, 1.4 to 24) and ischemic
stroke (RR, 4.8; 95% CI, 1.2 to 20) persisted after adjustment
for annual household income. No association between cigarette
smoking in spouses and risk of all strokes or ischemic stroke
was identified among nonsmoking women (
Table 3).
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TABLE 2. Multivariate-Adjusted RRs of Cardiovascular Diseases, Stroke, and Ischemic Stroke Among Cigarette-Smoking Women According to Smoking Status of Spouse
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TABLE 3. Multivariate-Adjusted RRs of Cardiovascular Diseases, Stroke, and Ischemic Stroke Among Nonsmoking Women According to Smoking Status of Spouse
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Discussion
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The present results are derived from a nationally representative
probability sample of the US civilian noninstitutionalized population
and potentially lack the biases observed with longitudinal studies
conducted on selected population samples. Previous studies
5,6 have reported an increased risk for either all stroke or ischemic
stroke among active smokers exposed to environmental tobacco
smoke
5 or spousal smoking.
6 Both studies also reported an increased
risk for nonsmoking participants, unlike our study. However
the relationship has not been consistently observed in longitudinal
studies.
7 Whether this difference is related to the different
design (case control versus cohort) or lack of adjustment for
potential confounders such as serum cholesterol and body mass
index in previous studies is unclear. The possibility that spouses
of nonsmoking women may be more likely to quit or reduce cigarette
smoking during the follow-up period cannot be excluded. Smoke
exposure may also be lower in nonsmoking women because spouses
may avoid smoking in close proximity. Some limitations of the
analyses need to be considered. Because of the small number
of events observed, potential relationships such as those between
spousal smoking and cardiovascular diseases may be underestimated.
Some variables such as dietary intake were not available in
1982 to 1984 interviews and could not be adjusted for in the
model.
Our prospective cohort study suggests that spousal cigarette smoking may be associated with all strokes and particularly ischemic stroke among women.
Received September 3, 2004;
revision received February 24, 2005;
accepted March 3, 2005.
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