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Cigarette Smoking and Stroke in a Cohort of U.S. Male Physicians

Anthony S. Robbins, MD, MPH; JoAnn E. Manson, MD, DrPH; I-Min Lee, MB, BS, ScD; Suzanne Satterfield, MD, DrPH; and Charles H. Hennekens, MD, DrPH
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From Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston; the Harvard School of Public Health, Boston, Massachusetts. Requests for Reprints: Charles H. Hennekens, MD, DrPH, Brigham and Women's Hospital/Harvard Medical School, 900 Commonwealth Avenue East, Boston, MA 02215-1204. Acknowledgments: The authors thank the Steering and End Points Committees and the staff of the Physicians' Health Study, and, in particular, the 22 071 dedicated and conscientious physicians who are participating in this ongoing trial. Grant Support: In part by grants (HL-26490, HL-34595, CA-34944, and CA-40360) from the National Institutes of Health.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(6):458-462. doi:10.7326/0003-4819-120-6-199403150-00002
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Objective: To examine the association between cigarette smoking and the risk for stroke in men.

Design: Prospective cohort study.

Setting: Participants in the Physicians' Health Study, a randomized trial of aspirin and β-carotene among U.S. male physicians.

Patients: 22 071 men, 40 to 84 years of age at entry, free from self-reported myocardial infarction, stroke, and transient ischemic attack; followed for an average of 9.7 years; and classified as never-smokers, current smokers, and former smokers based on self-report.

Measurements: Incidence rates of total, ischemic, and hemorrhagic stroke.

Results: With never-smokers as the reference group (relative risk, 1.00), relative risks (adjusted for age and treatment assignment) for total nonfatal stroke (n = 312) were as follows: former smoking, 1.20 (95% CI, 0.94 to 1.53); currently smoking fewer than 20 cigarettes daily, 2.02 (CI, 1.23 to 3.31); and currently smoking 20 or more cigarettes daily, 2.52 (CI, 1.75 to 3.61) (P for trend, <0.0001). For participants who had total fatal stroke (n = 28), the risk for stroke was not increased with smoking (P > 0.2). In proportional-hazards models that controlled simultaneously for other risk factors, these associations were not materially altered.

Conclusions: Current but not former cigarette smoking was significantly associated with an increased risk for stroke in men. Smoking may account for a substantial amount of stroke-associated morbidity and mortality.


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Figure 1.
Relative risk for total stroke associated with cigarette smoking by level of alcohol consumption.

No strokes were noted among physicians currently smoking fewer than 20 cigarettes per day and rarely or never consuming alcohol (“rarely/never” denotes consuming alcohol less than monthly). Relative risks were adjusted for age (1-year categories), treatment assignment (aspirin alone, β-carotene alone, aspirin and β-carotene, or placebo), and history of angina or coronary revascularization.

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