Improving Access, Standardization of Post-Stroke Smoking Cessation Treatments

Neal Parikh, MD, discussed the inconsistencies with access to treatment regimens aimed at improving smoking cessation in post-stroke patients.

This is a 2-part interview. To view part 1, click here.

A nationwide study conducted by Neal Parikh, MD, and colleagues showed that Black stroke survivors had lower smoking quit rates than White stroke survivors, even after accounting for demographics and smoking-related comorbidities. The data, presented at the 2021 American Academy of Neurology (AAN) Annual Meeting, April 17-22, also suggest that expanding and improving access to smoking-cessation interventions may reduce recurrent stroke disparities.

Among 4,374,011 Americans with a history of smoking and any smoking included in the study, the crude quit ratio was 51.4% (95% CI, 49.0-53.7) in Black and 63.2% (95% CI, 62.4%-64.1%) in White stroke survivors. Parikh, assistant professor of neurology at the Weill Cornell Brain and Spine Center, expressed that although this data identifies the problem, or at least suggests the presence of a problem, it can also push clinicians to pay more attention to adapting updated guidelines for recommended smoking cessation therapy.

In the second half of an interview with NeurologyLive, Parikh detailed the gaps in access to smoking cessation interventions, the need for increased patient-clinician transparency of smoking, and where future research on smoking cessation disparities may turn to next.

NeurologyLive: What is the state of access to smoking cessation interventions and post-stroke care in general?

Neal Parikh, MD: Post-stroke care needs to be improved. Over the last couple of decades, we’ve seen tremendous improvement in acute stroke care and hospital-based stroke care. It’s time to shift our attention to also include the post-stroke care and provide comprehensive preventive services to people following a stroke. There are people working on this right now. There’s [Cheryl] Bushnell, MD, who’s leading the COMPASS program, which tries to understand how a multidisciplinary effort can reduce the risk of recurrent stroke and other outcomes. Programs like that, through their design, may try to address disparities in access to care.

Currently, the smoking cessation treatment after stroke and transient ischemic attack is a bit variant right now. There is no gold standard or uniformly agreed upon practice. The guidelines recommend that we counsel patients to quit, and we consider medications to help them to quit. But there are no hard and fast guidelines that introduce metrics that measure doctor’s success or link their compensation to how effectively they’re helping patients deal with the most important vascular risk factors.

How can access to these interventions be more streamlined once out of the acute stroke treatment phase?

Oftentimes, in the hospital setting, a patient’s smoking status is incorrectly stated because the patient has difficulty communicating or the patient is critically ill, and it is not the priority at that moment. It’s a very simple issue that is actually incentivized by meaningful use criteria for electronic health record utilization but including smoking status at every visit after stroke is a great way to start. It’s always surprising to hear that patients had successfully quit, returned to hanging out with their friends in a certain environment, and before they know it, they’re smoking again.

It’s incorrect to assume that once a person has quit, they remained smoke-free. That’s step 1. Step 2 is to develop tremendous comfort and ease with smoking cessation medications. That includes knowing when to transition from 1 medication to the next and understanding the side effects and how to counsel patients about them. Lastly, if an individual doctor or provider is having trouble getting their patient to quit smoking, they should remember that there are other resources out there, including people training specifically in smoking cessation, as well as other tobacco cessation specialists who are certified to do this work. A lot of centers have 1 person on staff, especially centers that are cancer institutes through the National Cancer Institute. People should try to plug their patients into the most effective services available, especially if they find themselves struggling.

Are there any other future research endeavors that interest you regarding disparities in smoking cessation or related topics?

Certainly. These are descriptive data that identifies the problem or at least suggests the presence of a problem. To intervene effectively, the next steps require getting into the trenches and speaking with patients and their doctors and providers and trying to understand what the real-life barriers to effective smoking cessation through plug are and play with variables, and not things that can be easily identified. We have to do this without making assumptions and hypotheses, but rather listening to patients and doctors to figure out what is the true barrier. What are the key barriers and how can we address them? That’s something that I’d like to work on.

It’s also important that we, in the stroke field, figure out how to adapt current guideline recommended smoking cessation therapies, specifically for our patients, in light of the unique challenges that patients with stroke face. That includes disability, dependence on caregivers, and other factors like that which are unique from the general population.

Were you surprised that after adjusting for demographics and smoking-related comorbidities, the results remained similar?

It did not shock me. I think that adjusting for these crude variables like age, gender, and other variables related to income and educational attainment doesn’t fully capture the differences in access to care and other issues. That alone, was not shocking.

Transcript edited for clarity.

REFERENCE
Parikh N, Parasram M, Zhang Y, et al. Nationwide racial disparities in smoking cessation after stroke in the United States. Presented at 2021 American Academy of Neurology Annual Meeting; April 17-22. Abstract S30.005