The Prognostic Effect of Cigarette Smoking on Stroke Severity,

Disability, Length of Stay in Hospital, and Mortality in a Cohort

with Cerebrovascular Disease

Rojiemiahd K. Edjoc, PhD,* Robert D. Reid, PhD, MBA,† Mukul Sharma, MD, FRCPC,‡
and Jiming Fang, PhD,x on behalf of the Registry of the Canadian Stroke Network

Objective: The aim of this study was to determine the prognostic influence of ciga-
rette smoking on stroke severity, disability, length of stay (LOS) in hospital, and mor-
tality in different stroke types. Methods: A cohort separated by smoking status from
the Registry of the Canadian Stroke Network was analyzed using logistic regression
while controlling for key outcomes and clinical and demographic characteristics.
Results: There were 20,523 patients that were included for this study from July
2003 to March 2008. Multivariable analyses revealed that, in general, long-time
smoking had a negative effect on functional outcome at discharge, mortality at
1 year, and LOS in hospital. In general, former smoking had a positive impact in re-
ducing the risk of severe stroke, mortality risk at 30 days, and the LOS in hospital.
Significant differences in clinical and demographics were found between smokers,
nonsmokers, and former smokers with cerebrovascular disease. On average,
smokers had an earlier initial stroke presentation of cerebrovascular disease.
Conclusions: Our results provide empirical evidence regarding the prognostic
influence of cigarette smoking on stroke severity, disability, and LOS in
hospital and mortality, but the magnitude of the effect varied by stroke
type. Key Words: Smoking—epidemiology—stroke severity—disability—length
of stay in hospital—mortality—prevention.
Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of National Stroke
Association. All rights reserved.

From the *Clinical Epidemiology Program, Ottawa Hospital Re-
search Institute, Ottawa, Ontario; †Division of Prevention and Reha-
bilitation, University of Ottawa Heart Institute, Ottawa, Ontario;
‡Population Health Research Institute, McMaster University,
Hamilton, Ontario; and xInstitute of Clinical Evaluative Sciences, Tor-
onto, Ontario, Canada.
Received January 3, 2013; revision received April 24, 2013; accepted
May 1, 2013.
Grant support: The Registry of the Canadian Stroke Network/On-
tario Stroke Registry is funded by the Canadian Stroke Network and
the Ontario Ministry of Health and Long-Term Care. The Institute for
Clinical Evaluative Sciences is supported by an operating grant from
the Ontario Ministry of Health and Long-Term Care.
Address correspondence to Rojiemiahd K. Edjoc, PhD, Centre for
Practice-Changing Research, Ottawa Hospital Research Institute, 501
Smyth Road, Ottawa, Ontario, Canada. E-mail: redjoc@gmail.com.
1052-3057/$ - see front matter
Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of
National Stroke Association. All rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.05.001
Introduction
Cigarette smoking is a well-established risk factor
for initial and recurrent stroke.1-4 Multiple mechanisms
including hypercoagulability and progression of
atherosclerosis are felt to be responsible.5-10
Several studies have suggested clinical and demographic
characteristics may differ between nonsmoking and
smoking patients with a recent cerebrovascular event.11,12
Furthermore, the prognostic influence of cigarette smoking
on important cerebrovascular outcomes is still unclear.
Outcomes such as stroke severity, disability, length of
stay (LOS) in hospital, and mortality have been separately
examined in past studies yielding variable results.13-16 In
general, these studies have demonstrated that cigarette
smoking negatively affects each of these outcomes.13-16
However, these studies have only examined stroke
severity, disability, LOS in hospital, and mortality

e446 Journal of Stroke and Cerebrovascular Diseases, Vol. 22, No. 8 (November), 2013: pp e446-e454
THE PROGNOSTIC EFFECT OF SMOKING STATUS ON STROKE PATIENTS
separately in relation to cigarette smoking and only in
specific stroke types. Therefore, the impact of cigarette
smoking on these outcomes and in different stroke
types is still poorly understood.13-16
The aim of this study was to determine the prognostic
influence of cigarette smoking on stroke severity, disabil-
ity, LOS in hospital, and mortality in different stroke types.
Methods
The Registry of the Canadian Stroke Network (RCSN)
contains data for over 50,000 strokes in Canada.17 Partici-
pating sites include all Ontario acute care institutions, ex-
cluding children’s and mental health care hospitals and
those with fewer than 10 stroke or transient ischemic at-
tack (TIA) separations per year. The inclusion factors in-
clude: all patients seen in emergency departments or
admitted to hospital with a most responsible diagnosis
of stroke or TIA.17 Diagnoses are identified from the Dis-
charge Abstract Database and the National Ambulatory
Care Reporting System databases that are maintained
by the Canadian Institute for Health Information. The col-
lected data focus on intervals between stroke onset and
the delivery of care including thrombolysis and include
information on patient demographics, stroke type, stroke
risk factors, premorbid conditions, brain imaging, treat-
ments (including medications), and the utilization of
stroke protocols/units.17
We analyzed a distinct cohort of patients from the
RCSN grouped by their smoking status (long-time
smoker, former smoker, and nonsmoker). Covariates of
interest included: age (12-39, 40-59, 60-79, 801), sex
(male or female), type of stroke (ischemic stroke, TIA,
and or intracerebral hemorrhage [ICH]), ethnicity, living
arrangements (live with someone or alone), admission
type (Emergency Medical Service [EMS] versus not),
and medical history (depression, diabetes, dyslipidemia,
hypertension, atrial fibrillation, family history of stroke,
dementia, alcohol consumption). Outcomes of interest
included: mortality (30 days, 90 days, and at 1 year),
LOS in hospital, modified Rankin Scale (mRS) score that
measured disability at discharge, and the Canadian
Neurological Scale (CNS) that measured stroke severity.
From July 2003 to March 2008, a total of 33,119
patients were identified. Those with an in-hospital stroke
(n 5 849); having other diagnoses other than ischemic,
TIA, or ICH (n 5 8523); patients missing a CNS score
(n 5 463), mRS score (n 5 195), or LOS (n 5 5); not having
a valid patient identifier (n 5 764); not being their first
event (n 5 1791); and those who were less than 12 years
(n 5 7) were excluded from this analysis yielding a total
sample size of 20,523. There were 15.7% missing smoking
data from the study cohort.
For the purposes of calibrating the CNS scale, we
based our categorization of this outcome on a study by
O’Donnell et al.18 They dichotomized stroke severity
e447
into severe/moderate versus mild stroke (CNS: #7 ver-
sus .7). The mRS was dichotomized into poor functional
outcome versus nonpoor functional outcome (mRS score:
$3 versus 0-2) at discharge.
Statistical Analysis
Characteristics of long-time smoker, former smoker,
and nonsmoking patients were compared using indepen-
dent one-way analysis of variance for continuous vari-
ables and chi-square tests for categorical variables.
Univariate and multivariable logistic regression was
used to examine the association between smoking status
(long-time smoker versus nonsmoker [reference category]
and former smoker versus nonsmoker [reference cate-
gory]) and CNS (severe/moderate versus mild stroke),
mRS (poor functional outcome at discharge versus non-
poor functional outcome at discharge), and mortality
(dead versus alive at 30 days, 90 days, and 1 year) in 3
stroke types (ischemic, TIA, ICH). Long-term smoking
was defined as those patients who have been smoking
within the last 5 years or longer. They are also those
who have been smoking 6 months before their cerebro-
vascular event. Former smoking was defined as those pa-
tients who have quit smoking in the past. They are also
those who have not been a smoker within the last
6 months before their cerebrovascular event. Univariate
and multivariable Poisson linear regression analyses
were used to determine the association between smoking
status (long-time smoker versus nonsmoker [reference
category] and former smoker versus nonsmoker [refer-
ence category]) and LOS in hospital. Independent vari-
ables included all significant covariates from the
univariate analyses (P , .05).
All the analyses were conducted with the use of SAS
software (version 9.2; SAS Institute Inc., Cary, NC). All
reported P values are 2 sided.
Results
A cohort of 20,523 patients was selected for this study
from the RCSN. Patients were included if they: (1) had
a confirmed diagnosis for stroke/TIA/ICH, (2) had a con-
firmed stroke severity (CNS) and disability (mRS) score,
and (3) had an LOS and mortality report. Characteristics
of this cohort can be found in Table 1. Of this sample,
17.7% were reported long-time smokers and had a re-
ported mean age of initial stroke at 61.8 (613.17), which
was significantly younger than nonsmokers (73.2 6
14.03). Smokers were largely men (64.4%) and had pre-
dominantly ischemic strokes (66.2%) compared with
TIA (23.2%) and ICH (10.6%). Comorbidities such as de-
pression (7.2% versus 4.9%) and alcohol consumption
(.2 drinks/d: 16.1% versus 2.4%) were more common
in smokers compared with nonsmokers. Diabetes
(22.9% and 25.8%), hypertension (65.8% and 70.9%),
atrial fibrillation (16.9% and 15.3%), family history of
e448 R.K. EDJOC ET AL.

Table 1. Clinical and demographic characteristics of study cohort

P
Variables All Long-time smoker Former smoker Nonsmoker value

Sociodemographics
Sample size 20,523 3629 3918 12,976
Mean 6 SD (n) 71.15 6 14.11 61.84 6 13.17 72.84 6 11.49 73.24 6 14.03 ,.0001
(20,523) (3629) (3918) (12,976)
Age group
1: 12-39 (%) 2.6 4.9 1.0 2.5 ,.0001
2: 40-59 (%) 18 38 12.7 14.0
3: 60-79 (%) 47.3 48.5 55.1 44.6
4: 801 (%) 32.1 8.6 31.3 38.9
Sex
Female (%) 47.9 35.6 31.3 56.3 ,.0001
Male (%) 52.1 64.4 68.7 43.7
Ethnicity
Aboriginal (%) .5 1.1 .4 .4 ,.0001
African (%) .4 .5 .0 .4
Asian (%) 2.8 1.8 1.9 3.4
Caribbean (%) .7 .7 .8 .6
Caucasian (%) 52.6 53.3 56.7 51.2
East Indian (%) 1.5 .7 .8 1.9
Hispanic (%) .5 .3 .4 .5
Other (%) .6 .5 .5 .7
Pacific Islander (%) .3 .2 .4 .3
Unable to determine (%) 40.1 40.9 38.0 40.6
Living arrangement
Living alone (%) 19.4 22.6 18.9 18.6
Admission type
EMS (%) 65.1 62.7 60.2 67.3
Stroke type
ICH (%) 12.7 10.6 8.8 14.4 ,.0001
Ischemic (%) 60.2 66.2 60.8 58.3
TIA (%) 27.2 23.2 30.4 27.3
CNS groupings
0-4 Severe (%) 14.2 10.6 9.0 16.8 ,.0001
5-7 Moderate (%) 14.8 14.2 13.3 15.4
$8 Mild (%) 71.0 75.2 77.7 67.8

Medications (%) 29.0 24.8 22.3 32.2

Antiplatelet (%) 39.8 33 48.3 39.1 ,.0001
Anticoagulation (%) 11.0 5.3 11.3 12.5
Antithrombotic (%) 48.2 37.1 56.8 48.7
Comorbidities
Depression (%) 5.4 7.2 5.3 4.9 ,.0001
Diabetes (%) 23.1 20.8 25.8 22.9
Hyperlipidemia (%) 33.7 33.4 44.1 30.7
Hypertension (%) 65.4 57.9 70.9 65.8
Atrial fibrillation (%) 14.7 6.3 15.3 16.9
Stroke history (%) 19.0 15.3 21.7 19.3
Dementia (%) 8.0 3.1 6.9 9.3
Alcohol consumption 8.7 14.5 14.4 5.4 ,.0001
,2/d (%) 5.4 16.1 5.4 2.4
.2/d (%) 65.3 52.4 65.5 68.9
(Continued )

stroke (19.3% and 21.7%), and dementia (9.7% and 6.9%) Former smokers were 19.1% of this sample and had a re-
were more common in nonsmokers and former smokers ported mean age of initial stroke at 72.8 (611.49), which
(Table 1). was similar to the age of nonsmokers. This sample were
THE PROGNOSTIC EFFECT OF SMOKING STATUS ON STROKE PATIENTS e449

Table 1. (Continued )

P
Variables All Long-time smoker Former smoker Nonsmoker value
Rankin score (mRS)
0 (%) 25.1 24.0 28.1 24.6 ,.0001
1 (%) 16.2 17.1 17.6 15.5
2 (%) 12.5 16.7 13.7 11.0
3 (%) 15.2 16.8 16.2 14.5
4 (%) 15.8 15.4 14.6 16.2
5 (%) 4.6 2.9 3.2 5.5
6 (%) 10.5 7.0 6.6 12.6
Severe disability (mRS $ 3) (%)
Length of stay 46.1 42.1 40.6 48.9 ,.0001
Mean 6 SD (n) 9.76 6 18.37 9.68 6 18.62 9.25 6 16.44 9.94 6 18.84 .1130
(20,523) (3629) (3918) (12,976)
Mortality ,.0001
30 d (%) 12.4 8.0 7.7 15.1
90 d (%) 15.6 10.2 11.2 18.5
1 y (%) 21.1 15.2 16.8 24.1

Abbreviations: CNS, Canadian Neurological Scale; ICH, intracerebral hemorrhage; TIA, transient ischemic attack; mRS, modified Rankin
Scale score.

largely men (68.7%) and had predominantly ischemic
strokes (60.8%) compared with TIA (30.4%) and ICH
(8.8%) (Table 1).
Nonsmokers were 63.2% of the sample and had a re-
ported mean age of initial stroke at 73.2 (614.03). This
sample was largely women (43.7%) and had predomi-
nantly ischemic strokes (58.3%) compared with TIA
(27.3%) and ICH (14.4%) (Table 1).
Univariate Analyses
Univariate logistic regression analyses can be found in
Tables 2 and 3. The univariate analyses revealed that
long-time smoking was associated with a reduced risk
of a severe stroke (odds ratio [OR]: .69; 95% confidence in-
terval [CI]: .64-.75), disability (OR: .76; 95% CI: .71-.82),
mortality at 30 days (OR: .49; 95% CI: .43-.56), 90 days
(OR: .50; 95% CI: .44-.56), and at 1 year (OR: .56; 95% CI:
.51-.62). Long-time smoking was associated with a re-
duced LOS in hospital for TIA (2.33 day; 95% CI: 2.45
to 2.21) but not so with ischemic stroke (.06 day; 95%
CI: 2.51 to 2.21) or ICH (.75 day; 95% CI: .30-1.20). For-
mer smoking was associated with a reduced risk of severe
strokes (OR: .61; 95% CI: .56-.66), disability (OR: .71; 95%
CI: .66-.77), risk of death at 30 days (OR: .47; 95% CI:
.42-.54), 90 days (OR: .55; 95% CI: .55-.62), and 1 year

Table 2. Univariate analysis by smoking status and outcomes of interests (stroke severity, disability, and mortality)

Outcomes of interest OR Lower 95% CI Upper 95% CI P value

Long-time smoker versus nonsmoker (reference category)

Stroke severity (severe/moderate versus mild severity) .69 .64 .75 ,.0001
Disability (poor function at discharge versus not) .76 .71 .82 ,.0001
Mortality (dead versus alive)
30 d .49 .43 .56 ,.0001
90 d .50 .44 .56 ,.0001
1y .56 .51 .62 ,.0001
Former smoking versus long-time smoker
Stroke severity (severe/moderate versus mild severity) .61 .56 .66 ,.0001
Disability (poor function at discharge versus not) .71 .66 .77 ,.0001
Mortality (dead versus alive)
30 d .47 .42 .54 ,.0001
90 d .55 .50 .62 ,.0001
1y .64 .58 .70 ,.0001

Abbreviations: CI, confidence interval; OR, odds ratio.

e450 R.K. EDJOC ET AL.

Table 3. Univariate analysis by smoking status and outcome of interest (LOS)

Stroke type Smoking status Outcomes by interest Estimate SE Lower 95% CI Upper 95% CI P value

Ischemic Intercept 12.69 .04 12.61 12.77 ,.0001

Long-time smoker LOS 1.33 .088 21.49 21.18 .47
Former smoker LOS 2.98 .08 21.13 2.82 ,.0001
TIA Intercept 2.22 .03 2.17 2.27 ,.0001
Long-time smoker LOS .33 .06 .21 .45 ,.0001
Former smoker LOS .03 .05 2.07 .12 .67
ICH Intercept 13.42 .08 13.26 13.59 ,.0001
Long-time smoker LOS 1.41 .21 .99 1.83 ,.0001
Former smoker LOS 3.00 .23 2.50 3.42 ,.0001

Abbreviations: CI, confidence interval; ICH, intracerebral hemorrhage; LOS, length of stay; TIA, transient ischemic attack.

(OR: .64; 95% CI: .58-.70). Former smoking was associated
with a reduced LOS in hospital for TIA (2.31 day; 95% CI:
2.44 to 2.17) but not so with ischemic stroke (.36 day;
95% CI: .16-.55) or ICH (3.15 day; 95% CI: 2.69-3.63).
Multivariable Analyses
Stroke Severity Analyses
Multivariable logistic regression analyses for the associ-
ation between smoking and stroke severity can be found
in Table 4. After adjusting for sociodemographics, comor-
bidities, and stroke type, long-time smoking was associ-
ated with a reduced risk of severe stroke in ICH
(OR: .68; 95% CI: .53-.88) but not with ischemic stroke
(OR: .92; 95% CI: .82-1.04) or TIA (OR: .76; 95% CI:
.43-1.35) patients. Former smoking was associated with
a reduced risk of severe stroke for ischemic (OR: .76;
95% CI: .68-.85) but not with TIA (OR: 1.03; 95% CI:
.68-1.57) or ICH (OR: .79; 95% CI: .79-1.03) patients. The
National Institutes of Health Stroke Scale equivalents of
CNS scores and of this study’s CNS categorization can
be found in Table 5.
Disability/Poor Functional Outcome at Discharge
Analyses
Multivariable logistic regression analyses for the associ-
ation between smoking and disability/poor functional
outcome at discharge can be found in Table 4. After ad-
justing for sociodemographics, comorbidities stroke
type, and stroke severity, long-time smoking was associ-
ated with poorer functional outcome at discharge in TIA
(OR: 1.53; 95% CI: 1.04-2.33) but not so with ischemic
stroke (OR: 1.07; 95% CI: .95-1.21) or ICH (OR: .81; 95%
CI: .58-1.14) patients. Former smoking was not associated
with a reduced risk in poor functional outcome at dis-
charge in any stroke type.
Mortality Analyses
Results of the multivariable logistic regression analyses
for the association between smoking and mortality can
found in Table 6. After adjustment of sociodemographics,
stroke severity, and comorbidities, long-time smoking
was associated with an increased risk of long-term mor-
tality at 1 year in ischemic (OR: 1.19; 95% CI: 1.02.-1.39)

Table 4. Multivariable analysis by smoking status and outcome of interest (stroke severity and poor functional
outcome at discharge)

Stroke type Smoking status Outcomes of interest OR Lower 95% CI Upper 95% CI P value

Ischemic Long-time smoker Stroke severity* .92 .82 1.04 .17

Former smoker .76 .68 .85 ,.0001
TIA Long-time smoker Stroke severity* .76 .43 1.35 .35
Former smoker 1.03 .68 1.57 .89
ICH Long-time smoker Stroke severity* .68 .53 .88 .0034
Former smoker .79 .61 1.03 .08
Ischemic Long-time smoker Poor functional outcome at dischargey 1.07 .95 1.21 .26
Former smoker .93 .83 1.05 .24
TIA Long-time smoker Poor functional outcome at dischargey 1.56 1.04 2.33 .03
Former smoker 1.24 .90 1.70 .18
ICH Long-time smoker Poor functional outcome at dischargey .81 .58 1.14 .22
Former smoker 1.08 .76 1.55 .66

Abbreviations: CI, confidence interval; ICH, intracerebral hemorrhage; OR, odds ratio; TIA, transient ischemic attack.
*Controlled for sociodemographics and comorbidities.
yControlled for sociodemographics, comorbidities, and stroke severity.
THE PROGNOSTIC EFFECT OF SMOKING STATUS ON STROKE PATIENTS e451

Table 5. NIHSS equivalents of CNS scores and study CNS and ICH (.75 day; 95% CI: .30-1.20) patients but not so
categorization with ischemic stroke (.05 day; 95% CI: 2.10 to .21). Former
smoking was associated with a reduced LOS in hospital in
Score ischemic stroke (2.36 day; 95% CI: 2.51 to 2.21) but was
Stroke severity associated with an increased LOS in hospital in ICH
categorization Severe Moderate Mild
(3.16 day; 95% CI: 2.69-3.62).
CNS 0-4 5-7 $8
NIHSS 23-15 13-9 ,7 Discussion
Study CNS CNS NIHSS equivalent
categorization Our primary aim for this study was to determine the
Severe/moderate #7 versus .7 $9 versus ,9 association between cigarette smoking, stroke severity,
versus mild and disability, LOS in hospital, and mortality in various
stroke types. We found that long-time smoking was asso-
Abbreviations: CNS, Canadian Neurological Scale; NIHSS, ciated with an increased risk of poor functional outcome
National Institutes of Health Stroke Scale. at discharge in ischemic stroke patients. We also found
that long-time smoking was associated with an increase
and TIA (OR: 1.64; 95% CI: 1.16-2.33) but not in any other
of mortality risk at 1 year for TIA and ischemic stroke
stroke type in any other time points.
patients. Finally, long-time smoking was associated with
Former smoking was associated with a reduced risk of
an increased LOS in hospital in TIA and ICH patients. For-
mortality at 30 days in ischemic (OR: .74; 95% CI: .62-.80)
mer smoking was associated with a reduced risk of severe
and ICH (OR: .63; 95% CI: .46-.88) but not in TIA
stroke in ischemic patients. Former smoking was found to
(OR: 1.34; 95% CI: .71-2.52) patients. Former smoking
be associated with a reduced risk of mortality at 30 days in
was not associated with mortality in other time points
ischemic and ICH patients. Former smoking was associ-
for any stroke type.
ated with a reduced LOS in ischemic stroke but was asso-
ciated with an increased LOS in hospital for ICH patients.
LOS Analyses
We also found that significant differences in clinical and
Results of the multivariable Poisson linear regression demographics were found between smokers, nonsmokers,
analyses for the association between smoking and LOS and former smokers with cerebrovascular disease. We
in hospital can be found in Table 7. After adjusting for found that on average, smokers had an earlier initial stroke
sociodemographics, comorbidities, stroke severity, and presentation of cerebrovascular disease.
stroke type, long-time smoking was associated with an in- Univariate analyses revealed that smoking seems to
creased LOS in hospital in TIA (.45 day; 95% CI: .34-.56) offer a protective effect on stroke severity, disability,

Table 6. Multivariate analysis by smoking status and outcome of interests (mortality at 30 days, 90 days, and 1 year)

Stroke type Smoking status Outcomes of interest OR Lower 95% CI Upper 95% CI P value

Ischemic Long-time smoker Mortality at 30 d* .96 .78 1.18 .70

Former smoker .74 .62 .8 .0010
TIA Long-time smoker Mortality at 30 d* 1.19 .52 2.72 .68
Former smoker 1.34 .71 2.52 .36
ICH Long-time smoker Mortality at 30 d* 1.05 .76 1.43 .78
Former smoker .63 .46 .88 .006
Ischemic Long-time smoker Mortality at 90 d* 1.07 .89 1.28 .50
Former smoker .90 .77 1.05 .18
TIA Long-time smoker Mortality at 90 d* 1.03 .59 1.79 .91
Former smoker .85 .55 1.32 .47
ICH Long-time smoker Mortality at 90 d* 1.17 .56 1.58 .32
Former smoker .75 .55 1.02 .06
Ischemic Long-time smoker Mortality at 1 y* 1.19 1.02 1.39 .02
Former smoker .95 .83 1.09 .48
TIA Long-time smoker Mortality at 1 y* 1.64 1.16 2.33 .005
Former smoker 1.07 .81 1.42 .62
ICH Long-time smoker Mortality at 1 y* 1.29 .96 1.72 .09
Former smokers .76 .57 1.02 .06

Abbreviations: CI, confidence interval; ICH, intracerebral hemorrhage; OR, odds ratio; TIA, transient ischemic attack; LOS, length of stay.
*Controlled for sociodemographics, comorbidities, and stroke severity.
e452 R.K. EDJOC ET AL.

Table 7. Multivariable analysis by smoking status and outcome of interest LOS

Stroke type Smoking status Outcomes of interest Estimate SE Lower 95% CI Upper 95% CI P value

Intercept 10.20 .23 9.75 10.64 ,.0001

Ischemic Long-time smoker LOS* .05 .08 2.10 .21 .47
Former smokers LOS* 2.36 .08 2.51 2.20 ,.0001
Intercept 3.23 .46 2.32 4.14 ,.0001
TIA Long-time smoker LOS* .45 .06 .3424 .56 ,.0001
Former smokers LOS* .04 .05 2.05 .13 .39
Intercept 18.92 .57 17.81 20.03 ,.001
ICH Long-time smoker LOS* .75 .23 .30 1.20 .001
Former smokers LOS* 3.16 .24 2.69 3.62 ,.0001

Abbreviations: CI, confidence interval; ICH, intracerebral hemorrhage; TIA, transient ischemic attack; LOS, length of stay.
*Controlled for sociodemographics, comorbidities, stroke severity.

LOS in hospital, and mortality (Tables 2 and 3). However,
we found that when we adjusted for age and other con-
founders (sex, stroke severity, and comorbidities), the
protective effect of smoking largely disappeared. We
believe that univariate analyses significantly differed
from multivariable analyses because of the effect of age.
There is evidence that the severity of disease is related
to age. Asplund et al19 found that with increasing age,
the risk of stroke increases by 10% and 9% in men and
women, respectively. This is supported by the difference
in mean ages of nonsmokers of 73.2 years (614.03) com-
pared with smokers of 61.8 years (613.17). Nonsmokers
had more severe strokes than smokers (32.2% versus
24.8%) (Table 1).
Multivariable analyses revealed that long-time smok-
ing was not associated with a reduced risk of severe/
moderate stroke in any stroke type (Table 4). In fact, we
observed a protective effect of smoking in ICH patients.
This is a surprising finding as smoking has been
established as an independent risk factor for strokes.
Weng et al14 found that smoking was associated with
higher scores on the National Institutes of Health Stroke
Scale for smoking patients with small-vessel occlusions
than nonsmoking patients. Similarly, Anderson et al15
found that smoking was associated with more severe
hemorrhagic strokes. We offer this explanation for this
finding. We found that there was an imbalance of
comorbidities in particular the proportion of atrial fibril-
lation (a-fib) in long-time smokers. Long-time smokers
had a significantly lower proportion of a-fib (6.3%) com-
pared with former smokers (15.3%) and nonsmokers
(16.9%) (Table 1). A-fib is considered a predictor of more
severe strokes.20 A higher proportion of a-fib in former
and never smokers may have lead to the protective effect
of smoking on stroke severity. These protective effects of
smoking in stroke (and cardiovascular disease) have
been observed in other publications from the RCSN.21
We found that former smoking was associated with a re-
duced risk of moderate/severe stroke in ischemic patients
(Table 4). To our knowledge, we are first to document the
effect of former smoking on stroke severity in ischemic
stroke.
Long-time smoking was associated with an increased
risk of moderate/severe disability in TIA patients
(Table 4). Compared with other studies, there have been
varied results when smoking status and disability were
examined. According to Strum et al22 determinants of dis-
ability did not include current smoking and was nonsig-
nificant in multivariable analyses. Redfern et al23 found
that there were more moderately disabled smokers than
severely disabled smokers using the Barthel index to mea-
sure disability.
In LOS analyses, we found that long-time smoking was
associated with an increase in the LOS in hospital in ICH
and TIA patients (Table 7). Previous studies have identi-
fied that sociodemographics such as age and sex and
comorbidities such as hypertension, claudication, diabe-
tes, ischemic heart disease or lifestyle behaviors such as
smoking, alcohol consumption, and stroke type had no
influence on LOS in hospital.24 However, Chang et al16
found that predictors of LOS in hospital included socio-
demographics as stated above, the Barthel index at
admission, small-vessel occlusion stroke, and smoking.
This previous study found that smoking reduced the
LOS in hospital by 1.2 days.16 Former smoking was asso-
ciated with a decreased LOS in hospital in ischemic
patients. To our knowledge, we are the first to document
a positive impact of former smoking in reducing LOS in
hospital. It was unknown why such variations exist
between these studies regarding the effect of smoking in
LOS in hospital. Perhaps the studied population, different
stroke type mechanisms, and hospital management poli-
cies regarding who are discharged may explain the varia-
tions between our studies.
Our results demonstrated that long-time smoking was
associated with an increased risk of mortality at 1 year
in ischemic and TIA patients. This finding is in line
with previous investigation that demonstrated the effect
of smoking on long-term mortality risk.25 We also found
that former smoking reduced the mortality risk at
THE PROGNOSTIC EFFECT OF SMOKING STATUS ON STROKE PATIENTS
30 days in ischemic stroke and ICH patients. These results
are in line with previous investigations regarding the
effects of former smoking and the reduction in mortality
risk.26 We believe that our finding that former smoking
has an effect on reducing mortality risk as early as
30 days in ischemic and ICH patients a novel finding.
The mechanisms are unclear to how former smoking
affects each of these outcomes and would require further
study. We speculate that, similar to other investigations,
former smoking reduces atherogenesis and hypercoagu-
bility5-10 and may be related to a reduction in the initial
stroke severity. Long-time smokers compared with
former smokers had more severe strokes (24.8% versus
22.3%) (Table 1), and our multivariable analyses revealed
that former smoking was associated with a reduced risk
stroke severity in ischemic stroke patients (Table 4).
Along this pathway, though the multivariable analyses
for the association between former smoking and dis-
ability was not statistically significant (Table 4), there
was a trend for those who were former smokers to be
less disabled than those who were long-time smokers
(40.6% versus 42.1%) (Table 1). Similarly, those who
were former smokers had a reduced LOS in hospital
compared with those who were long-time smokers
(9.25 6 16.4 versus 9.68 6 18.6) (Table 1) although not
statistically significant.
We did notice that the effects of former smoking in our
study were relatively lower compared with other stud-
ies.27 Unfortunately, we did not have access to the dura-
tion of smoking cessation of our patients. Therefore, we
cannot ascertain how long our patients have stopped
smoking. Literature have shown that the inflammatory
markers do not return to that of a nonsmoker until 5 years
of cessation and may explain the relatively low effects of
former smoking in this cohort.28
Our results revealed significant differences between
long-time smoking, nonsmoking, and former smoking
with a recent cerebrovascular event in all clinical and de-
mographic characteristics. Smokers were younger, suf-
fered more ischemic strokes, were more depressed, and
consumed more alcohol than their non or former smok-
ing counterparts. These characteristics were in line with
previous investigations.12,29 On average, smoking
patients presented with a cerebrovascular event at the
age of 61.8 (613.2) compared with nonsmokers at the
age of 73.2 (614.03) (Table 1). This may have clinical im-
plications in secondary stroke prevention. Smokers are
at risk for a cerebrovascular event at a younger age than
nonsmokers. We suggest further study to ascertain the
cause of this earlier presentation in smokers, but we spec-
ulate the role of multiple mechanisms such as hypercoag-
ulability and progression of atherosclerosis because of
smoking.5-10
In light of these results, we propose several limitations
to our study. Our data were obtained from a registry from
similar hospital settings with homogenous operating pro-
e453
cedures. Therefore, whether these results are generaliz-
able to other hospital settings with different operating
procedures, different time periods and other stroke types
need to be considered. Furthermore, self-report was relied
on for patient’s smoking status and should be interpreted
with caution. While there are recognized biochemical val-
idation techniques, self-report for use in observational
studies such as ours have been found to be valid.13
Conclusion
Our study found that there was a significant prognostic
influence of cigarette smoking on stroke severity, disabil-
ity, LOS in hospital, and mortality but the magnitude var-
ied by stroke type. We also found that significant
differences in clinical and demographics were found
between smokers, nonsmokers, and former smokers
with cerebrovascular disease. On average, smokers had
an earlier initial stroke presentation of cerebrovascular
disease. These results emphasize the need for intensive
public health and secondary prevention measures aimed
at preventing smoking initiation and support for smoking
cessation.
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