—  Stroke has a major impact on the nation's health.

—  Smoking is a significant risk factor for stroke: about a quarter of all strokes are attributable to smoking.

—  Environmental tobacco smoke is increasingly recognised as a risk factor for stroke.

—  The link between smoking and stroke has received little public attention, leading to an unacknowledged burden of disability attributable to smoking.

1.  WHAT THE STROKE ASSOCIATION DOES

  1.1  The Stroke Association is a charity operating across England and Wales. We provide practical support to people who have had strokes, their families and carers. We campaign, educate and inform to increase knowledge of stroke at all levels of society. We run telephone helplines, provide publications and welfare grants, and offer information and education services. We also fund and promote research which aims to increase knowledge of stroke prevention and treatment, and to spread best practice.

  1.2  The broad scope of the Association's work gives us a unique perspective on stroke issues and the needs of those affected by stroke.

2.  THE IMPACT OF STROKE

  2.1  Each year, over 100,000 people in England and Wales have a first stroke. About 10,000 of these are under retirement age.

  2.2  Stroke is the largest single cause of severe disability in England and Wales. Over 300,000 people are living with such disability as a result of stroke.

  2.3  Stroke is the third most common cause of death in England and Wales, accounting for over 8 per cent of deaths in men and 13 per cent of deaths in women.

  2.4  The suddenness of stroke can have a devastating effect emotionally and financially on those bereaved. The emotional and financial effects on those who survive with disability, and their families, are equally striking. Lost income from carers who have to give up work is alone estimated at £30.5 million a year.

  2.5  The cost of stroke to the NHS and social services is estimated to be £2.3 billion (or around 5.8 per cent of total expenditure), with costs projected to rise in real terms by around 30 per cent by 2023.

3.  TOBACCO SMOKING AND STROKE

  3.1  Stroke has not tended to feature as strongly as heart disease and cancer in the debate about smoking and health. As a consequence, the impact of smoking as a contributor to high levels of disability as well as death has been underestimated in public debates about smoking. Similarly the impact of smoking in terms of lost income for those unable to work after stroke (and those who have to give up work to carry out a caring role) has not featured in such debates. However, there is a good deal of evidence that tobacco smoking contributes substantially to the burden of stroke.

  3.2  Numerous population studies around the world have clearly documented that tobacco smoking increases the risk of stroke by about threefold. Smoking is thought to act through a variety of mechanisms to increase risk of both thrombotic stroke (caused by a clot) and haemorrhagic stroke (caused by a bleed). The mechanisms by which risk increases include an increased tendency for the blood to clot and for furring of the arteries to develop.

  3.3  There is a strong relationship between the number of cigarettes smoked and increased risk. Those smoking less than 10 cigarettes a day have a relative risk of stroke of about 2.5, while those who smoke more than 20 cigarettes a day have a relative risk of about 4. Pipe and cigar smokers have about a two fold increased risk of stroke.

  3.4  Smoking tends to have a multiplicative rather than additive effect with other risk factors. So, an individual who smokes and has hypertension (a major, and common, risk factor for stroke) will be around 14 times more likely to have a stroke than if he or she had neither risk factor.

  3.5  There is also mounting evidence that exposure to environmental tobacco smoke increases stroke risk by 30 to 80 per cent. A recent study suggests that because the link between environmental tobacco smoke and stroke has been largely ignored, the overall adverse impact of smoking may have been underestimated. The World Health Organisation considered that the report "provides compelling evidence about the need to strengthen tobacco control as a powerful means of reducing the high burden of stroke worldwide".

  3.6  The risk of stroke declines rapidly after stopping smoking, which supports the causal relationship. The benefit of stopping smoking is seen most noticeably in light smokers (those smoking less than 20 cigarettes a day), who revert over time to the risk level of those who have never smoked. The risk factor for heavy smokers declines but not to the level of those who have never smoked.

  3.7  While stroke rates in the UK have declined, partly attributed to declining prevalence of tobacco smoking, the public health significance of smoking in terms of stroke remains substantial.

  3.8  It has been estimated that a seven-year programme reducing prevalence of smoking by 1 per cent per year in the USA would eliminate 64,000 hospitalisations for myocardial infarction, 34,000 for stroke and at least 13,000 prehospital deaths, and save US $3.2 billion just in short-term medical costs.

4.  DELIVERING THE GOVERNMENT'S TARGETS FOR HEALTH

  4.1  Stroke is contained in one of the targets in Saving Lives: Our Healthier Nation. The aim is to reduce the death rate from stroke and coronary heart disease among the under 75s by 25 per cent by 2005 and 40 per cent by 2010 (both from a 1995 baseline).

  4.2  About a quarter of all strokes occurring in the population are directly attributable to cigarette smoking. Reducing the take-up of smoking is obviously desirable in the context of the Government's health target for stroke. The Stroke Association supports the Government's initiatives to reduce the take-up of smoking, including the ban on tobacco advertising and sponsorship.

  4.3  However welcome, changing the take-up of smoking has a long lead-time and its results are likely to have a limited impact on the stroke/CHD targets, particularly that set for 2005. Assistance with smoking cessation is more likely to deliver the public health contribution to meeting the interim target, in parallel with the service improvements which the National Service Framework for Older People is intended to deliver.

September 1999

REFERENCES

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  Bosenquet N & Franks P. The Burden of Stroke. The Stroke Association 1998.

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