p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 9 6 0 e9 6 6

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Public Health

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Original Research

Incidence of ischaemic and haemorrhagic stroke and the

association with smoking and smoking cessation: A 10-year
multicentre prospective study in China

L.A. Tse a, X.H. Fang b,*, W.Z. Wang c, H. Qiu a, I.T.S. Yu a

a
Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, PR China
b
Department of Epidemiology and Social Medicine, Xuanwu Hospital, Capital Medical University, Beijing, PR China
c
Department of Neuroepidemiolology, Beijing Neurosurgical Institute, Beijing, PR China

article info summary

Article history: Objectives: To examine the effects of cigarette smoking and smoking cessation on the
Received 10 August 2011 incidence of ischaemic and haemorrhagic stroke in a multicentre prospective cohort study
Received in revised form among Chinese.
11 May 2012 Study design: A multicentre population-based prospective cohort study.
Accepted 31 July 2012 Methods: The incidence of, and deaths from, stroke were monitored among 26,607 partic-
Available online 9 October 2012 ipants (12,560 men and 14,047 women) who were enrolled in 1986 and free from stroke
until 2000. Cox’s proportional hazard model was performed to obtain the hazard ratio (HR)
Keywords: of cigarette smoking for stroke risk after adjustment for major confounders.
Cigarette smoking Results: After an average of 9.5 years of follow-up, 1108 subjects developed stroke. The
Smoking cessation excess risk of all types of stroke (total stroke) among male current smokers [HR 1.39, 95%
Ischaemic stroke confidence interval (CI) 1.15e1.67] was mainly due to a significantly elevated risk of
Haemorrhagic stroke ischaemic stroke (HR 1.49, 95% CI 1.17e1.90). A significantly increased risk for total stroke
Incidence and ischaemic stroke was observed among men who smoked >15 cigarettes/day and men
Cohort studies who had smoked for >25 years. The rate of smoking cessation was very low among Chinese
men (7.2%) and women (1.5%). Smoking cessation did not appear to reduce the risk of
haemorrhagic stroke, but may reduce the risk of ischaemic stroke; however, the possibility
that this result was due to chance cannot be excluded (HR 0.74, 95% CI 0.26e2.08).
Conclusion: This study confirmed that cigarette smoking is a major determinant for the
incidence of ischaemic and haemorrhagic stroke in Chinese men, and emphasizes the need
for improved strategies to help people quit smoking.
ª 2012 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.

Introduction substantially from that in other countries. Two national

surveys carried out in 1996 and 2002 showed that the preva-
Being the largest producer and consumer of cigarettes in the lence of smoking in the Chinese population aged 16e69 years
world, the epidemiology of smoking in China differs was 66.0% and 66.9% in men, and 3.1% and 4.2% in women,

* Corresponding author. Department of Epidemiology and Social Medicine, Xuanwu Hospital, Capital University of Medical Science, #45
Changchun Street, Beijing 100053, PR China. Tel./fax: þ86 10 63153439.
E-mail address: xhfang@public3.bta.net.cn (X.H. Fang).
0033-3506/$ e see front matter ª 2012 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
http://dx.doi.org/10.1016/j.puhe.2012.07.010
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 9 6 0 e9 6 6
respectively.1,2 The rate of smoking cessation remains very
low among Chinese smokers.24 All these figures differ
considerably from those in Western populations and other
Asian countries.5e9
In China, cardiovascular disease was ranked as the second
leading cause of death related to smoking according to
a national survey in 2005.10 In contrast to Western pop-
ulations, stroke is more common than coronary heart disease
in Chinese,11,12 and a higher proportion of cases of haemor-
rhagic stroke was observed.13e15 A positive association has
been observed consistently between cigarette smoking and
the risk of stroke in Western and many Asian populations, but
the results of Chinese studies have been less consistent, and
only one prospective cohort study reported a significant
positive exposureeresponse relationship with increased
cigarette consumption.16 Although the benefits of smoking
cessation on all types of stroke (total stroke) and subtypes
have been ascertained by several studies in Western countries
and Korea,7e9 no relevant studies have been reported in
China.
The ‘7-5 China Stroke Preventive Project’ (a national pro-
gramme for primary prevention of stroke from 1986 to 1990)17
was extended, following the subjects for 10 more years (until
2000) to examine the effects of cigarette smoking and smoking
cessation on the incidence of ischaemic and haemorrhagic
stroke.
Methods
Details of the study design and subject recruitment have been
described in detail elsewhere.18 Briefly, seven cities (Beijing,
Changsha, Harbin, Yinchuan, Zhengzhou, Shanghai and
Changchun) located in the south, north, east and west of
mainland China were invited to participate in the original
study. Two geographically separated communities with
approximately 10,000 residents from each studied city were
selected at random, and those aged 35 years (approximately
2700 in each community) were included in the baseline
survey. However, follow-up data for Shanghai and Changchun
had to be excluded from the data analyses because of a high
rate of loss to follow-up due to rapid city development.
Therefore, 26,607 cohort members from the other five cities
were included in this report.
A standardized questionnaire was used to collect data on
sociodemographics (i.e. age, gender and education), medical
history, alcohol drinking habits and lifetime cigarette
smoking habits from each participant. Smoking habit was
classified as never, former or current smoker. A never smoker
was defined as an individual who had not smoked 20 or more
packs of cigarettes in their lifetime, or one cigarette per day
for 1 year. A current smoker was defined as a subject who had
smoked at least 20 packs of cigarettes in their lifetime, or one
cigarette per day for 1 year or more. A former smoker was
defined as a subject who had quit smoking for 6 months at
the time of the baseline survey. Data on the number of ciga-
rettes smoked per day and age at smoking initiation were
collected for all former and current smokers. Current smokers
were classified according to daily consumption (i.e.
1e15 cigarettes/day or >15 cigarettes/day) and duration of
961
smoking (i.e. 1e25 years or >25 years). Former smokers were
classified into two groups based on the number of years since
smoking cessation: 20 years and >20 years. ‘Twenty years
since quitting smoking’ was used as a cut-off point because
there was no decrease in the risk of stroke for subjects who
had quit smoking <20 years previously. Alcohol drinking
habit was classified into three categories: never, former and
current. A current drinker was defined as an individual who
habitually drank alcohol, while a former drinker was an
individual who had stopped drinking for 6 months at the
time of the baseline survey.
An extensive physical and neurological examination was
performed on each participant in the study clinics. Seated
blood pressure, height and weight were measured using
standardized methods.18 Subjects were considered to be
hypertensive if their baseline systolic blood pressure (SBP)
was 140 mmHg or their diastolic blood pressure (DBP) was
90 mmHg, or they had taken antihypertensive medication
within the 2 weeks preceding the baseline survey. Body mass
index (BMI) was calculated according to the following formula:
body weight (kg)/body height (meters) squared.
An intensive surveillance system was established to
identify new stroke cases and deaths; this has been detailed
elsewhere.18 Briefly, this was a three-tier monitoring and
registration system, consisting of a team of healthcare
workers from community or district hospitals and a group
of neurologists from local medical centres. All new cases of
stroke and deaths due to stroke between 1986 and 2000
were obtained from the three-tier monitoring and regis-
tration system. Each newly identified stroke case was
further verified using: (1) neurologists/neurosurgeons’
physical examinations; (2) hospital records and discharge
notes; and (3) reports from the witnesses (usually the
decedent’s relatives) in the case of deaths at home. To
ensure uniformity of data collection and recording in all the
centres (interpopulation quality control), a meeting
involving all collaborating centres was held annually to
monitor the progress of the project and quality control.
Government records on death certificates were reviewed
annually, blinded to the smoking status of participants, and
efforts were made to identify the occurrence of stroke and
the cause of death for those lost to follow-up. Stroke diag-
noses and classifications were made based on a slightly
modified version of the Atherosclerosis Risk in Communi-
ties (ARIC) Study,19 and International Classification of
Diseases-9 was used to code stroke (430e438). Haemor-
rhagic stroke was coded as 430 and 431, while ischaemic
stroke was coded as 433 and 434. The analysis of intrace-
rebral haemorrhage was not separated from subarachnoid
haemorrhage due to the limited number of cases of
subarachnoid haemorrhage (four cases in males, nine cases
in females). Intracerebral haemorrhage and subarachnoid
haemorrhage were combined in a single group of ‘hae-
morrhagic stroke’ to improve the statistical power. The
project was approved by the human subject review
committee of each collaborating teaching hospital.
Groups (never, former and current smoker) were
compared using Chi-squared or ManneWhitney tests for
categorical variables, and two-sample t-tests or analysis
of variance for continuous variables, as appropriate.
962 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 9 6 0 e9 6 6
Person-years of follow-up were calculated from the date of
the baseline survey until the date of stroke occurrence or
death or the end of the study (31st December 2000) for each
subject. The hazard ratio (HR) and the corresponding 95%
confidence interval (95% CI) of stroke risk were estimated
separately in males and females for different smoking cate-
gories using Cox’s proportional hazards regression model,
after adjusting for age, study centre, SBP, BMI, years of
education, treatment status for stroke prevention, previous
disease histories, alcohol drinking habits, and alcohol
consumption. The main effects of smoking and smoking
cessation were presented in this study because the interac-
tion between smoking and drinking status for total stroke
(P ¼ 0.17), ischaemic stroke (P ¼ 0.14) and haemorrhagic
stroke (P ¼ 0.72) was not statistically significant. DBP and
hypertension were not included in the models because these
variables were strongly correlated with SBP (correlation
coefficient 0.77 and 0.72, respectively). In order to examine
the effect of years since smoking cessation, the number of
cigarettes smoked per day and age at smoking initiation were
included in the models, and current smokers were used as
the reference group.
Results
In total, 26,607 subjects (12,560 men and 14,047 women) aged
35 years were included in the baseline survey. Over an
average of 9.5 years of follow-up (median 11.6 years), there
were 1108 (602 male and 506 female cases) stroke events
(including fatal and non-fatal cases). The proportions of
ischaemic, haemorrhagic and ill-defined stroke were 55%, 43%
and 4%, respectively. The rate of loss to follow-up was 21%.
At baseline, there were large differences in smoking prev-
alence between men and women: 55.1% of men and 14.3% of
women were current smokers, and 7.2% of men and 1.5% of
women were former smokers. Compared with current
smokers, male and female former smokers had significantly
higher levels of cardiovascular risk factors (i.e. age, SBP, DBP,
BMI, and prevalence of hypertension/heart disease/diabetes)
and were more likely to be uneducated and former alcohol
drinkers, while current smokers were more likely to be
current alcohol drinkers. All cardiovascular risk factors were
lower among never smokers than ever smokers, with the
exception of BMI where a higher BMI was found among never
smokers (Table 1). Compared with males, females were older
at smoking initiation.
The crude incidence rates (per 1000 person-years) of total
stroke in never, current and former smokers were 5.9, 5.4
and 10.2 in men and 4.0, 6.3 and 7.6 in women, respectively
(Tables 2 and 3). Compared with never smokers, a significantly
higher risk of total stroke was observed in male current
smokers (HR 1.39, 95% CI 1.15e1.67). Significantly higher risks
were found among male smokers who had smoked for >25
years or who smoked more than 15 cigarettes/day. A similar
but slightly stronger trend was suggested for the incidence of
ischaemic stroke, while the positive gradient tended to be
inconsistent for haemorrhagic stroke.
As shown in Table 2, the excess risk of total stroke among
male former smokers (HR 1.35, 95% CI 1.00e1.72) was
attributed to greater risk of haemorrhagic stroke (HR 1.77, 95%
CI 1.14e2.73). Smoking cessation had some effect on reducing
the risk of ischaemic stroke, but it was not possible to rule out
the possibility that this was due to chance (P > 0.05 with
a wide 95% CI); however, smoking cessation for >20 years had
no beneficial effect on reducing the incidence of haemorrhagic
stroke among Chinese males.
By the end of follow-up, there had been 534 deaths from
stroke, accounting for 19.1% of all causes of deaths. There
were 167 deaths from ischaemic stroke, 288 deaths from
haemorrhagic stroke and 79 deaths from ill-defined stroke.
Table 4 summarizes the associations between cigarette
smoking and death from stroke for both genders. Similar to
stroke incidence, a tendency was found for a positive associ-
ation between stroke deaths and daily smoking among
females and years of smoking among men; however, no
significant findings were obtained due to the low number of
stroke deaths. The authors are aware that the small number of
female current and former smokers (Tables 3 and 4) made the
results unstable, and thus avoided any precise interpretations
on the associations between cigarette smoking and the risk of
stroke.
Discussion
This prospective cohort study found that increased cigarette
smoking and years of smoking was associated with increased
incidence of total stroke and ischaemic stroke, while the
tendency for haemorrhagic stroke was inconsistent. The
excess risk of total stroke among current smokers was mainly
due to a significantly elevated risk of ischaemic stroke. These
findings were consistent with another long-term cohort study
in China16 and other studies in Western countries, Japan and
Korea.9,20e23
This study found a significantly higher risk of haemor-
rhagic stroke among male former smokers. This finding was in
contrast to studies by Kawachi et al., Lawlor et al. and Man-
nami et al., which reported a lower risk of total stroke and
ischaemic stroke among former smokers.6,9,22 The present
study compared the amount of alcohol consumption between
different smoking subgroups, and found that former smokers
drank more alcohol (22 drinks per week) than current smokers
(18 drinks per week) and never smokers (13 drinks per week).
Heavy alcohol consumption is known to be an important risk
factor for the occurrence of haemorrhagic stroke24; however,
heavy drinking is less likely to explain the excess risk of
haemorrhagic stroke among the male former smokers in this
study because the effect of alcohol has already been
addressed. A slightly lower risk of haemorrhagic stroke was
found for the subjects who had quit smoking for 20 years
compared with those who had quit for <20 years; this suggests
that a likely reason for smoking cessation among Chinese
men was due to illness, and the higher proportion of cardio-
vascular risk factors among former smokers (as shown in
Table 1) may provide supportive evidence for this hypothesis.
The phenomenon that ‘illness is the most common reason for
quitting smoking’ has been reported in several epidemiolog-
ical studies in China.2,4,25 Nevertheless, interpretations on the
results of the present study should be made with caution
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 9 6 0 e9 6 6 963

Table 1 e Baseline characteristics and person-years of follow-up of a multicentre cohort study in China, stratified by
smoking status and gender.
Male (n ¼ 12,560) Female (n ¼ 14,047)
c
Never Former Current P-value Never Former Current P-valuec
smoker smoker smoker smoker smoker smoker
% (n) % (n) % (n) % (n) % (n) % (n)

37.7 (4741) 7.2 (903) 55.1 (6916) e 84.3 (11,839) 1.5 (205) 14.3 (2003) e
Age (years)a 52.6  11.2 57.6  10.9b 50.3  10.3b <0.001 50.4  11.1 61.8  9.7b 56.3  9.8b <0.001
>60 years 24.2 (1146) 42.6 (385)b 18.8 (1300)b <0.001 19.6 (2316) 58.0 (119)b 34.8 (698)b <0.001
Systolic blood pressure, mmHga 126.7  20.9 130.2  22.9b 125.2  20.7b <0.001 126.2  23.9 139.1  26.3b 130.6  26.0b <0.001
Diastolic blood pressure, mmHga 81.6  11.8 81.7  12.5 80.6  12.0b 0.012 79.4  12.5 83.7  13.4b 80.6  12.9b 0.001
Body mass index (kg/m2)a 23.0  3.1 22.9  3.4 22.3  3.0b <0.001 23.0  3.5 22.9  4.0 22.3  4.0b 0.027
Prevalence of
Heart disease 9.6 (455) 17.4 (157)b 7.4 (509)b <0.001 9.2 (1089) 18.5 (38)b 10.4 (209) <0.001
Diabetes 1.2 (59) 1.3 (12) 0.8 (57) 0.049 1.1 (121) 1.5 (3) 1.0 (21) 0.422
Hypertension 36.4 (1727) 43.7 (394)b 33.3 (2303)b <0.001 35.6 (4215) 60.0 (123)b 41.1(823)b <0.001
Alcohol drinking habits <0.001d <0.001d
Current 23.7 (1124) 45.4 (410) 54.8 (3789) 2.5 (294) 12.2 (25) 13.2 (265)
Former 0.9 (45) 12.1 (109) 3.0 (210) 0.1 (9) 3.9 (8) 0.8(16)
Proportion of uneducated 6.4 (304) 9.5 (86)b 6.2 (429) <0.001 23.8 (2817) 50.5 (103)b 43.4 (869)b 0.060
Age of start smokinga e 23.7  10.8 24.5  8.8 0.015 e 27.1  13.8 29.3  12.3 0.017
Cigarette amount per daya e 15.3  10.3 15.9  8.2 0.031 e 10.0  7.8 10.5  7.0 0.303
Duration of smokinga e 8.9  9.8 25.2  12.1 <0.001 e 10.5  11.7 25.9  14.4 <0.001
Follow-up person-years 38928.4 6654.4 56806.3 e 99134.8 1443.9 15987.2

a Mean  standard deviation.

b P < 0.05, using never smokers as the reference group for males and females separately.
c P-value between former and current smokers.
d P-value for overall comparison.

because of the insignificant beneficial effect found in this
study; the possibility that these results were due to chance
could not be excluded. Moreover, the unique pattern of ciga-
rette smoking (i.e. a high rate of smoking but low rate of
quitting, as well as a potentially high risk of exposure to
secondhand smoke) in Chinese men may explain the
discrepant findings from other studies in terms of the asso-
ciation between smoking cessation and stroke risk. A survey
by Pan showed that the most important reason for smoking
has long been embedded in social interactions and personal
relationships in mainland China.26 Hopefully, the traditional
friendship culture of sharing cigarettes with guests will start
to be phased out (particularly in large cites in China), and will
be replaced by healthier activities.
Epidemiological studies from the USA, Japan and Korea
revealed that the risk of stroke decreased after quitting
smoking for 2 years, and a further decline was observed after
stopping smoking for >5 years.5e7,22,27 However, such findings
were not observed in the present study, and smoking cessation
was found to have insignificant beneficial effects on reducing
stroke risk. Although data on changes in smoking habits over
the follow-up period were not collected, it is believed that the
smoking habits of the cohort members remained stable
because of a very low rate of smoking cessation among Chinese
adults. This suggests that information bias due to the
misclassification of cigarette smoking should not be a serious
issue in this study. Lawlor et al. reported that the role of
smoking and smoking cessation in the occurrence of intrace-
rebral haemorrhage may differ from that of subarachnoid
haemorrhage,9 but this was not reflected in the present study.
Sensitivity analyses for haemorrhagic stroke were performed
by exclusion of subarachnoid haemorrhage cases (four in men,
nine in women), and found that there were no substantial
changes in the risk estimates. Evaluation on the association of
smoking with stroke risk remains an important topic among
the Chinese population, because there are still gaps in our
knowledge of epidemiology of stroke and cigarette smoking
and the impact of smoking and smoking cessation in Chinese.
Most smoking studies on stroke in China were cross-sectional
surveys, which is not the best way to document the association
between cigarette smoking and the risk of stroke.1e4 Only one
large cohort study with long-term follow-up has been con-
ducted in China to evaluate the association between stroke risk
and smoking status (never vs ever),16 and the present results
were similar to that study in terms of the relationship between
ever smokers (combining former smokers and current
smokers) and the risk of stroke,16 while the present study also
performed a separate analysis for current and former smokers.
To the authors’ knowledge, this is the first study to evaluate the
association between smoking cessation and stroke risk in
mainland China.
As this was a long-term population-based multicentre
cohort study, loss to follow-up is an inevitable concern. The
major risk factors of stroke were compared between the group
lost to follow-up (21%) and the remaining subjects, and
subjects lost to follow-up were more likely to be smokers and
alcohol drinkers. Therefore, loss to follow-up was likely to
yield an underestimate of the effect measures towards null.
Misclassification of the diagnosis of stroke is less likely to be
a concern because all new stroke cases were diagnosed by
neurologists, and the death certificates for all the underlying
causes were rechecked by health professionals and obtained
964 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 9 6 0 e9 6 6

Table 2 e Incidence rate and hazard ratio (HR) of stroke and the subtypes according to the status, amount and duration of
smoking among Chinese men, using Cox’s proportional hazards models.
Total stroke Ischaemic stroke Haemorrhagic stroke
b b
No. of Crude HR (95% CI) No. of Crude HR (95% CI) No. of Crude HR (95% CI)b
cases ratea cases ratea cases ratea

Smoking habit
Never smokers 229 5.9 1 137 3.5 1 85 2.2 1
Former smokers 68 10.2 1.35 (1.00e1.81) 35 5.3 1.17 (0.78e1.76) 32 4.8 1.77 (1.14e2.73)
Current smokers 305 5.4 1.39 (1.15e1.67) 183 3.2 1.49 (1.17e1.90) 118 2.1 1.29 (0.95e1.76)
Cigarettes smoked by
current smokers,
n/day
1e15 132 5.2 1.20 (0.96e1.51) 75 2.9 1.14 (0.85e1.53) 55 2.2 1.36 (0.95e1.95)
>15 173 5.5 1.61 (1.29e2.01) 108 3.5 1.99 (1.50e2.64) 63 2.0 1.22 (0.85e1.76)
Duration of
smoking of current
smokers, years
1e25 81 2.4 1.01 (0.76e1.34) 49 1.5 1.00 (0.70e1.43) 32 1.0 1.11 (0.71e1.75)
>25 224 9.5 1.57 (1.28e1.92) 134 5.7 1.77 (1.36e2.29) 86 3.6 1.37 (0.98e1.90)
Time since smoking
cessation, yearsc
<20 27 7.7 1.08 (0.72e1.64) 15 4.3 0.86 (0.49e1.51) 12 3.4 1.59 (0.86e2.92)
20 41 13.0 0.86 (0.60e1.22) 20 6.4 0.65 (0.39e1.08) 20 6.4 1.27 (0.76e2.10)

CI, confidence interval.

a Crude incidence rate (per 1000 person-years).
b Adjusted for age (years), study centre, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption,
systolic blood pressure, years of education and treatment status.
c Adjusted for age (years), study centre, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption,
systolic blood pressure, years of education, treatment status, number of cigarettes smoked per day and age at smoking initiation, using current
smokers as the reference group.

Table 3 e Incidence rate and hazard ratio (HR) of stroke and the subtypes according to the status, amount and duration of
smoking among Chinese women, using Cox’s proportional hazards models.
Total stroke Ischaemic stroke Haemorrhagic stroke
b b
No. of Crude HR (95% CI) No. of Crude HR (95% CI) No. of Crude HR (95% CI)b
cases ratea cases ratea cases ratea

Smoking habit
Never smokers 395 4.0 1 200 2.0 1 171 1.7 1
Former smokers 11 7.6 0.86 (0.45e1.65) 6 4.2 1.05 (0.43e2.59) 5 3.5 0.84 (0.31e2.06)
Current smokers 100 6.3 1.34 (1.06e1.69) 53 3.3 1.60 (1.15e2.22) 40 2.5 1.11 (0.77e1.61)
Cigarettes smoked by
current smokers,
n/day
1e15 76 6.1 1.28 (0.99e1.67) 42 3.3 1.54 (1.08e2.21) 28 2.2 1.03 (0.67e1.57)
>15 24 7.0 1.54 (1.00e2.37) 11 3.2 1.83 (0.98e3.43) 12 3.5 1.39 (0.74e2.59)
Duration of
smoking of current
smokers, years
1e25 41 4.8 1.45 (1.04e2.04) 17 2.0 1.31 (0.78e2.21) 23 2.7 1.72 (1.09e2.71)
>25 59 7.9 1.27 (0.95e1.69) 36 4.8 1.78 (1.21e2.60) 17 2.3 0.74 (0.44e1.26)
Time since smoking
cessation, yearsc
<20 5 6.4 0.83 (0.34e2.05) 2 2.5 0.66 (0.16e2.74) 3 3.8 1.16 (0.36e3.78)
20 6 9.1 0.53 (0.21e1.35) 4 6.1 0.65 (0.20e2.11) 2 3.0 0.53 (0.12e2.44)

CI, confidence interval.

a Crude incidence rate (per 1000 person-years).
b Adjusted for age (years), study centre, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption,
systolic blood pressure, years of education and treatment status.
c Adjusted for age (years), study centre, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption,
systolic blood pressure, years of education, treatment status, number of cigarettes smoked per day and age at smoking initiation, using current
smokers as the reference group.
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 9 6 0 e9 6 6 965

Table 4 e Mortality rate and hazard ratio (HR) of deaths from stroke among Chinese men and women according to the
status, amount and duration of smoking, by Cox’s proportional hazards models.
Men Women
a b
No. of deaths Mortality rate HR (95% CI) No. of deaths Mortality ratea Hazard ratio (95% CI)b

Smoking status
Never smokers 104 2.6 1 197 2.0 1
Ever smokers 36 5.3 1.69 (1.12e2.56) 8 5.5 0.98 (0.45e2.17)
Current smokers 132 2.3 1.24 (0.94e1.64) 57 3.5 1.29 (0.94e1.77)
Cigarettes smoked by current smokers, n/day
1e15 64 2.5 1.38 (1.00e1.91) 37 2.9 1.07 (0.74e1.55)
>15 68 2.1 1.11 (0.79e1.56) 20 5.8 2.05 (1.26e3.34)
Duration of smoking of current smokers, years
1e25 29 0.9 1.04 (0.67e1.63) 24 2.8 1.52 (0.96e2.38)
>25 103 4.3 1.31 (0.97e1.76) 33 4.3 1.17 (0.80e1.72)

CI, confidence interval.

a Crude mortality rate (per 1000 person-years).
b Adjusted for age (years), centre, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption, systolic
blood pressure, years of education and treatment status.

from local hospitals, blinded to the patients’ smoking status.
In addition, the proportion of stroke patients undergoing
computed tomography and magnetic resonance imaging was
68.4% (757 out of all 1108 stroke patients), which largely
reduced the misclassification of stroke. Despite the fact that
data were collected on lipids and family history of stroke, it
was not possible to adjust for these potential confounding
factors in the models because approximately 40% of these
data were missing. This represents a potential limitation of
this study.
In conclusion, this multicentre cohort study found that the
risk of total stroke was positively associated with increasing
number of cigarettes smoked per day and years of smoking
among Chinese men, and the trend was more apparent for
ischaemic stroke. The rate of smoking cessation was very low.
Long-term smoking cessation had less beneficial effect in
reducing the risk of haemorrhagic stroke, while a decreased
(although insignificant) risk of total and ischaemic stroke may
convey an encouraging message to chronic smokers, medical
practitioners and the public that smoking cessation is a valu-
able and wise decision. This study confirmed that cigarette
smoking is a major determinant for the incidence of ischae-
mic and haemorrhagic stroke in Chinese men, and empha-
sizes the need for improved strategies to help people quit
smoking.
Acknowledgements
Ethical approval
The project was approved by the human subject review
committee of the collaborating teaching hospitals in five cities
(Beijing, Changsha, Harbin, Yinchuan and Zhengzhou) in the
People’s Republic of China.
Funding
The study was supported by a grant from the Ministry of
Health of the People’s Republic of China; the funding source
had no role in the study design, data collection, data analysis
or interpretation of the findings.
Competing interests
None declared.
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