Intervention against smoking and its relationship to general practitioners' smoking habits

A postal survey was carried out in June and July 1980 to find out if there was any relationship between smoking habits of general practitioners and their reported intervention against smoking among their patients. Responses from 342 general practitioners in London and Kent indicated that there was a relationship: general practitioners who smoked cigarettes (13 per cent of the sample) were less likely to advise or help their patients to stop smoking than general practitioners who smoked a pipe or cigars or who did not smoke at all. The survey also yielded an estimate of smoking prevalence among general practitioners which indicated that prevalence has continued to decline, and that fewer general practitioners are being recruited to smoking.     

Risk factors for coronary heart disease: a study in inner London.

A survey was carried out among 281 men and women aged between 30 and 64 years randomly selected from five general practices located in the inner London borough of Tower Hamlets, to determine the prevalence of risk factors for coronary heart disease. Smoking and obesity were both more pronounced in Tower Hamlets than in comparable national studies: 51% of men and 44% of women were smokers and 57% of these were smoking 20 or more cigarettes per day. A body mass index of 30 or more was present in 18% of men and 10% of women and a body mass index of 25 or more in 71% of men and 49% of women. Two or more risk factors for coronary heart disease (smoking and/or hypertension and/or raised cholesterol levels) were present in 25% of men and 22% of women. For every person known by their general practitioner to have established cardiovascular disease, there were an additional two people also at risk on the basis of multiple risk factors. In this inner city population the prevalence of cardiovascular risk, for women as well as men, has major resource and organizational implications for primary care. A strategy for change requires action based on graded multiple risks for both men and women.     

Depression and smoking amongst older general practice patients

BACKGROUND: Cerebrovascular disease is associated with depression in later life. Smoking is a known risk factor for cerebrovascular disease and, as a consequence, may contribute to the development of depression in the elderly. This study was designed to investigate the association between smoking and depression in people aged 60 years or over. METHODS: Cross-sectional survey of older adults attending a representative sample of general practitioners in Western Australia. Subjects were divided into four groups according to their smoking status: never smoked, ex-light smoker, ex-heavy smoker (>20 cigarettes/day), and current smoker. Depressive symptoms were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D). CES-D score of 22 or more was used to define the presence of clinically significant depression. RESULTS: 1030 completed the assessment. Their age ranged from 60 to 101 years and 57.2% were female. The mean+/-S.D. CES-D score was 10.5+/-8.1, 10.6+/-8.3, 12.5+/-10.2 and 13.1+/-11.0 for never smokers, ex-light smokers, ex-heavy smokers and current smokers respectively (p=0.037), with 7.7%, 8.5%, 13.8% and 17.2% having CES-D > or =22 (p=0.016). Current or past heavy smoking was associated with increased risk of clinically significant depression when compared to never or past light smoking (OR=1.58, 95%CI=1.01-2.48-after adjustments were made for age, gender, place of birth, social isolation, self-perceived health and harmful or hazardous drinking). CONCLUSION: Past heavy smoking and current smoking are associated with increased frequency and severity of depression. Smoking cessation may play an important role in reducing the burden of depression in later life, but the success of smoking cessation interventions in decreasing the incidence and prevalence of depression might be predicated on the timing of the intervention; i.e., before the psychobiological changes associated with smoking become irreversible.     

Correlates of quality of life in patients with asthma.

BACKGROUND: Health-related quality of life (HRQOL) is a major outcome in asthma, but the relationships among HRQOL, characteristics of asthma, type of supervision, and sociodemographic characteristics of patients have not been thoroughly explored. OBJECTIVE: To identify major correlates of HRQOL in a survey of patients with asthma. METHODS: Patients with asthma were identified by their usual caregivers, either general practitioners or respiratory physicians. In a standardized interview, data were collected on patients' sociodemographic characteristics, medical history, medical resource use in the past 12 months, and asthma QOL. Intensity of asthma therapy was evaluated from the use of inhaled controllers and oral corticosteroids in the past 12 months, and number of asthma attacks during the same period was used as an indicator of level of asthma symptoms. RESULTS: Ninety-nine patients with asthma were identified (median age, 36 years; 62.6% women). In multivariate analysis, major correlates for lower HRQOL scores were having at least 5 asthma attacks and the number of medical visits in the past 12 months (P < .001 for both). Other significant positive associations were unemployment (P = .01) and female sex (P = .05), but not intensity of therapy, age, or type of asthma supervision (general practitioner vs respiratory physician). CONCLUSIONS: In this survey, HRQOL scores seem to be primarily related to asthma symptoms, as indicated by the number of attacks experienced by the patients and the frequency of medical contacts in a previous period. The relationships among HRQOL, therapy, and the determinants of control should be investigated in prospective studies.     

General practice update: chlamydia infection in women.

The prevalence of cervical Chlamydia trachomatis infection in general practice populations ranges between 2% and 12%. Untreated infection can cause pelvic inflammatory disease, tubal infertility and ectopic pregnancy. These risks are increased by cervical invasive procedures, especially termination of pregnancy. However, most women with chlamydia infection have no symptoms. General practitioners and practice nurses carrying out pelvic examinations should have facilities for taking endocervical specimens for chlamydia. Routine chlamydia screening, should be considered if the local prevalence of infection is over 6%. Otherwise chlamydia testing should be offered to women requesting termination of pregnancy and to those who have risk factors: aged less than 25 years, absence of barrier contraception, recent change of sexual partner, vaginal discharge, friable cervix or sterile pyuria. Women found to have chlamydia infection need appropriate antibiotics, advice about contact tracing and referral to a genitourinary medicine clinic. Good communication between general practitioners and genitourinary physicians is essential. Both general practitioners and practice nurses have an important role to play in reducing the prevalence of cervical chlamydia infection and its potentially devastating consequences.     

北京城乡居民人群中的吸烟问题：3000个家庭的流行病学研究

目的：了解９０年代初北京城乡居民吸烟状况及与吸烟有关的因素。方法：采用对３０００户计７０７７人的流行学调查。结果：显示北京市城乡居民的吸烟率为２２５８％，烟草依赖率为６４６％，几乎占吸烟人数的１／３。男性吸烟率为４１４６％，女性吸烟率为５３５％。农村地区吸烟率高于城市（２５９０％和１９７５％）。５０岁以上的女性吸烟率有上升的趋势。每日吸烟达２０支以上的重度吸烟者近于１／２。在对烟草价格选择上，以低廉价格为最多（８６３２％）。有１／３吸烟依赖者戒烟后出现渴求吸烟，焦虑、易怒、瞌睡、头痛及胃肠不适等症状。     

Influence of smoking fewer cigarettes on exposure to tar, nicotine, and carbon monoxide

In the hope of reducing the adverse health consequences of smoking, physicians frequently advise their patients who cannot quit to smoke fewer cigarettes. Habitual smokers may compensate for the reduced number of cigarettes, however, by taking in more smoke per cigarette. We measured the intake of tar (estimated as mutagenic activity of the urine), nicotine, and carbon monoxide during short-term cigarette restriction. With a reduction from an average of 37 cigarettes to an average of 5 cigarettes per day, the intake of tobacco toxins per cigarette increased roughly threefold and daily exposure to tar and carbon monoxide declined only 50 percent. We conclude that smoking fewer cigarettes may reduce exposure to toxins and related adverse health consequences. However, consistent with a tendency to maintain intake of nicotine, the magnitude of the benefit is much less than expected. Whether "oversmoking" persists during long-term restriction of cigarettes requires further investigation.     

Efficacy of a tailored tobacco control program on long-term use in a population of U.S. military troops

The authors evaluated the effect of a brief tailored smoking control intervention delivered during basic military training on tobacco use in a population of military personnel (N = 33,215). Participants were randomized to either a tobacco use intervention (smoking cessation, smokeless tobacco use cessation, or prevention depending on tobacco use history) or a health education control condition. Results indicated that smokers who received intervention were 1.16 (95% confidence interval [CI] = 1.04, 1.30) times (7-day point prevalence) and 1.23 (95% CI = 1.07, 1.41) times (continuous abstinence) more likely to be abstinent than controls from smoking cigarettes at the 1-year follow-up (p < .01); the cessation rate difference was 1.60% (31.09% vs. 29.49%) and 1.73% (15.47% vs. 13.74%) for point prevalence and continuous abstinence, respectively. Additionally, smokeless tobacco users were 1.33 (95% CI = 1.08, 1.63) times more likely than controls (p < .01) continuously abstinent at follow-up, an overall cessation rate difference of 5.44% (33.72% vs. 28.28%). The smoking prevention program had no impact on smoking initiation. These results suggest potential for large-scale tobacco control efforts.     

Spreading and impact of the World Health Organization's Allergic Rhinitis and its Impact on Asthma guidelines in everyday medical practice in France. Ernani survey

Objectives The aim of this study was to determine the spreading level of the WHO‐ARIA (World Health Organization's Allergic Rhinitis and its Impact on Asthma) guidelines among the medical community and their influence on medical practices. Methods A cross‐sectional study based on a questionnaire was performed between April and July 2005 on randomly chosen general practitioners (GPs) (943) and ear, nose and throat (ENT) physicians (277). Results About 54.4% of the physicians claimed to know the WHO‐ARIA guidelines and 49.7% said they followed them. These results vary significantly, mainly according to medical specialty (ENT vs. GP). In comparison to those who did not know the guidelines, their patients benefited more frequently (P<0.0001) from allergen search (42.2% vs. 31.7%), a nasal endoscopy (38.3% vs. 26.0%), a follow‐up consultation (64.9% vs. 52.6%) and written information on rhinitis (30.7% vs. 14.1%). Paradoxically, they do not search more frequently for asthma and do not provide different first‐line treatment strategy and duration.     

Prevalence and predictors of metabolic syndrome among HIV-infected and HIV-uninfected women in the Women's Interagency HIV Study

OBJECTIVES: To assess the prevalence of metabolic syndrome (MetSynd) among participants of the Women's Interagency HIV Study and to describe the association of MetSynd with HIV infection, antiretroviral therapies, and sociodemographic factors. METHODS: Prevalence of MetSynd, defined by updated Adult Treatment Panel III guidelines, was assessed among 2393 (1725 seropositive and 668 seronegative) participants from the Women's Interagency HIV Study seen between October 2000 and October 2004. RESULTS: HIV-1 infection was independently associated with MetSynd [33% vs 22%, P<0.0001 in HIV-seropositive compared with HIV-seronegative women; adjusted odds ratio (OR) 1.79 (95% confidence interval 1.48, 2.16)]. HIV-infected women had higher mean triglyceride (154 vs 101 mg/dL, P<0.0001) and lower mean high-density lipoprotein cholesterol levels (46 vs 55 mg/dL, P<0.0001). Most notable factors associated with higher prevalence of MetSynd among HIV-infected women included older age (OR=1.38 per 5 year increase, P<0.0001); higher body mass index; current smoking; HIV-1 RNA (OR=1.36, P=0.019, for >50,000 vs <80 copies/mL); and use of stavudine (OR=1.28, P=0.009). Nevirapine use was protective (OR=0.75, P=0.016). There was no significant association of MetSynd with ritonavir-boosted protease inhibitors (OR=1.15, P=0.134). CONCLUSIONS: MetSynd is more prevalent in HIV-seropositive than HIV-seronegative women. This increased prevalence was due to dyslipidemias rather than higher blood pressure, glucose, or waist circumference.     

Attitudes toward integration of complementary and alternative medicine in primary care: perspectives of patients, physicians and complementary practitioners

OBJECTIVE: Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians' role regarding CAM, and models for CAM referral and treatment. We compared patients' perspectives regarding integration of CAM into primary care with attitudes of primary care physicians (PCPs) and CAM practitioners. METHODS: We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups: a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health maintenance organization in Israel. RESULTS: A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to PCPs' expectations of prescribing CAM (62% vs. 30%; p=0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p<0.0001). Patients supported CAM practitioners providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p<0.0001). CONCLUSION: Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent, that they actually provide CAM treatment themselves. PRACTICE IMPLICATIONS: PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable, skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better collaborate with CAM practitioners to the benefit of their patients.     

Trends in COPD mortality and in-patient admissions in men & women: evidence of convergence

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality. Although more prevalent in men, it is anticipated that, due to the convergence in smoking rates, the prevalence rate in women will surpass that of men. There were 14,519 deaths attributable to COPD in the period 2000-2009. Although deaths decreased for both sexes, reduction in deaths was significantly higher among men (test for trend, p<0.01 for men vs. p=0.06 for women). Smoking rates decreased for both sexes from 1980-2009 with the percentage reduction in smoking significantly greater in men (11.5% vs. 7.0%, p<0.001). There has been a convergence in COPD deaths and COPD hospital in-patient discharges for men and women that mirrors the trend in the convergence of male and female smoking rates. This study provides evidence of the need for effective smoking cessation programmes that are targeted at women as well as men.     

Sex differences in subclinical and DSM-IV pathological gambling: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: To examine sex differences in DSM-IV subclinical and pathological gambling in nationally representative data of the US population. METHOD: Data come from a large (n = 43093) representative sample of the adult US population. RESULTS: The lifetime prevalence rate of DSM-IV pathological gambling was 0.64% (95% CI 0.50-0.78) for men and 0.23% (95% CI 0.17-0.29) for women, whereas the lifetime prevalence of subclinical pathological gambling was 6.79% (95% CI 6.32-7.26) for men and 3.26% (95% CI 2.93-3.59) for women. For subclinical pathological gambling, men were significantly (p < 0.01) more likely than women to have smoked more than two packs of cigarettes a day, to be classified as heavy drinkers and to have lifetime diagnoses of alcohol and drug use disorders. Women with subclinical and pathological gambling were significantly more likely than men to have lifetime mood and anxiety disorders. With respect to pathological gambling, women had later ages of onset of the disorder, and were significantly more likely than men to report gambling to relieve depressed mood and to prefer casino gambling. Rates of treatment-seeking for DSM-IV pathological gambling were low for both men and women. CONCLUSIONS: There are important sex differences in the prevalence, symptom pattern, sociodemographic and clinical correlates and course of DSM-IV subclinical and pathological gambling. Results underscore the need to investigate sex differences in the social determinants, neurobiology and treatment response of DSM-IV subclinical and pathological gambling.     

Physician smoking status, attitudes toward smoking, and cessation advice to patients: an international survey

Objective

The smoking status of physicians can impact interactions with patients about smoking. The ‘Smoking: The Opinions of Physicians’ (STOP) survey examined whether an association existed between physician smoking status and beliefs about smoking and cessation and a physician's clinical interactions with patients relevant to smoking cessation, and perceptions of barriers to assisting with quitting.

Methods

General and family practitioners across 16 countries were surveyed via telephone or face-to-face interviews using a convenience-sample methodology. Physician smoking status was self-reported.

Results

Of 4473 physicians invited, 2836 (63%) participated in the survey, 1200 (42%) of whom were smokers. Significantly fewer smoking than non-smoking physicians volunteered that smoking was a harmful activity (64% vs 77%; P < 0.001). More non-smokers agreed that smoking cessation was the single biggest step to improving health (88% vs 82%; P < 0.001) and discussed smoking at every visit (45% vs 34%; P < 0.001). Although more non-smoking physicians identified willpower (37% vs 32%; P < 0.001) and lack of interest (28% vs 22%; P < 0.001) as barriers to quitting, more smoking physicians saw stress as a barrier (16% vs 10%; P < 0.001).

Conclusion

Smoking physicians are less likely to initiate cessation interventions.

Practice implications

There is a need for specific strategies to encourage smoking physicians to quit, and to motivate all practitioners to adopt systematic approaches to assisting with smoking cessation.     

A randomized controlled trial of the simple advice given by obstetricians in Guangzhou, China, to non-smoking pregnant women to help their husbands quit smoking

This is a randomized controlled trial to examine the effects of obstetrician's simple advice given to non-smoking pregnant women with the aim to help their husbands to give up smoking. Non-smoking pregnant women who were attending the Guangzhou Women and Children Health Care Centre and whose husbands were smokers were each randomised to an intervention (N = 380) or a control (N = 378) group. The members of the intervention group each received simple advice on encouraging their husbands to give up smoking and an educational booklet at their first antenatal visit, and reminders during subsequent visits, whereas the control group received none, as is the usual practice. Husbands' not smoking for 7 and for 30 days were the main outcomes of the study; other outcomes included husbands' attempts to stop and any decrease in the number of cigarettes smoked. These outcomes were assessed by means of a questionnaire responded to in the last month of pregnancy, which was subjected to 'intention-to-treat' analysis. Results show that more husbands in the intervention group had attempted to stop smoking (30.0% versus 22.2%; p = 0.02), reduced the number of cigarettes smoked (39.7% versus 17.7%; p < 0.0001), and had not smoked any cigarettes for the last 7 days before their wives completed the questionnaire (8.4% versus 4.8%; p = 0.04). The difference between groups in the number of husbands who had abstained from cigarettes for at least 30 days was not significant (6.1% versus 4.2%; p = 0.26). Obstetricians should consider incorporating advice on passive smoking into the antenatal programme for non-smoking pregnant women with smoking husbands.     

Utilization and Perceived Problems of Online Medical Resources and Search Tools Among Different Groups of European Physicians

Background

There is a large body of research suggesting that medical professionals have unmet information needs during their daily routines.

Objective

To investigate which online resources and tools different groups of European physicians use to gather medical information and to identify barriers that prevent the successful retrieval of medical information from the Internet.

Methods

A detailed Web-based questionnaire was sent out to approximately 15,000 physicians across Europe and disseminated through partner websites. 500 European physicians of different levels of academic qualification and medical specialization were included in the analysis. Self-reported frequency of use of different types of online resources, perceived importance of search tools, and perceived search barriers were measured. Comparisons were made across different levels of qualification (qualified physicians vs physicians in training, medical specialists without professorships vs medical professors) and specialization (general practitioners vs specialists).

Results

Most participants were Internet-savvy, came from Austria (43%, 190/440) and Switzerland (31%, 137/440), were above 50 years old (56%, 239/430), stated high levels of medical work experience, had regular patient contact and were employed in nonacademic health care settings (41%, 177/432). All groups reported frequent use of general search engines and cited “restricted accessibility to good quality information” as a dominant barrier to finding medical information on the Internet. Physicians in training reported the most frequent use of Wikipedia (56%, 31/55). Specialists were more likely than general practitioners to use medical research databases (68%, 185/274 vs 27%, 24/88; χ² ₂=44.905, P<.001). General practitioners were more likely than specialists to report “lack of time” as a barrier towards finding information on the Internet (59%, 50/85 vs 43%, 111/260; χ² ₁=7.231, P=.007) and to restrict their search by language (48%, 43/89 vs 35%, 97/278; χ² ₁=5.148, P=.023). They frequently consult general health websites (36%, 31/87 vs 19%, 51/269; χ² ₂=12.813, P=.002) and online physician network communities (17%, 15/86, χ² ₂=9.841 vs 6%, 17/270, P<.001).

Conclusions

The reported inaccessibility of relevant, trustworthy resources on the Internet and frequent reliance on general search engines and social media among physicians require further attention. Possible solutions may be increased governmental support for the development and popularization of user-tailored medical search tools and open access to high-quality content for physicians. The potential role of collaborative tools in providing the psychological support and affirmation normally given by medical colleagues needs further consideration. Tools that speed up quality evaluation and aid selection of relevant search results need to be identified. In order to develop an adequate search tool, a differentiated approach considering the differing needs of physician subgroups may be beneficial.     

湖南省两地区成瘾物质使用状况调查报告：使用率及相关因素

本文采用整群抽样的方法，对湖南两地区城乡共２３７７人（１５岁以上）的成瘾物质使用状况进行调查，其中男１１７９（４９．６％）人，女１１９９（５０．４％人），平均年龄男女分别为４１．２（ＳＤ＝１７．５）和４３．４（ＳＤ＝１８．６）。结果表明，饮酒率男性为５７．５％，女性为１７．３％，吸烟率男女分别为６８．２％和１１．７％；饮酒者多集中在每月饮１次左右的人群中（男５７．９％，女７７．９％），但吸烟者多集中在每日吸２０支及以上（男５２．４％，女４２．９％）的人群中。除解热镇痛剂外，男性各种精神活性物质的使用频率及剂量皆男高于女性，开始使用的年龄及成瘾的年龄男性低于女性；性别、使用频度、最早使用的年龄、婚姻与饮酒、吸烟量关系最为密切。有１４人使用过鸦片类物质，４人使用过兴奋剂。作者讨论了我国成瘾物质使用的特点，指出经济水平、社会文化背景等因素与我国社会性成瘾物质的使用有密切关系。     

Knowledge and attitudes of children towards cigarette smoking and its damage

The present study reports the results of knowledge and attitudes of 280 children (mean age = 6.9 +/- 0.75 years) towards cigarettes and smoking. Subjects were divided into two groups: (I) children of parents who smoked (n = 178) and (II) children whose parents did not smoke (n = 102). The scoring for knowledge in the topics of cigarettes, smoking and the consequences was similar in the two groups (6.2 +/- 2.2 vs 6.1 +/- 2) (N.S.). The differences between the two groups were obvious and significant (p = 0.001) in their attitude towards smoking and its damage; children in group I displayed tolerant attitudes towards smoking even though they knew its consequences in comparison with the children of group II (6.1 +/- 2.4 vs 7.0 +/- 2.2). Without any exceptions among the children of the two groups, 7.4% believe that even at this young age they will begin to smoke one day. In addition, 2.1% pointed out that it is possible they will belong one day to the smokers' group. Of the population study, 90.2% believe that instruction about smoking damage should be included starting from the first grade of elementary school, and certainly, it should be at the level which will be understandable for them. As the pupils' knowledge about the consequences of smoking was lacking, we could add that the important topic of smoking and the damage it can inflict should be taught in all schools from the level of the first grade and during all subsequent years of study. Pupils should be familiar with all aspects of negative consequences caused by cigarette smoking. This knowledge may have influence upon their attitude towards smoking and smokers. More studies should be done to find what may change the positive attitudes of these pupils towards cigarettes and smoking.     

Cigarette smoking and risk of stroke in middle-aged women

It is known that cigarette smoking is associated with increased risk of both thrombotic and hemorrhagic stroke among men. To test for such an association among women, we examined the incidence of stroke in relation to cigarette smoking in a prospective cohort study of 118,539 women 30 to 55 years of age and free from coronary heart disease, stroke, and cancer in 1976. During eight years of follow-up (908,447 person-years), we identified 274 strokes, comprising 71 subarachnoid hemorrhages, 26 intracerebral hemorrhages, 122 thromboembolic strokes, and 55 strokes about which information was insufficient to permit classification. The number of cigarettes smoked per day was associated positively with the risk of stroke. Compared with the women who had never smoked, those who smoked 1 to 14 cigarettes per day had an age-adjusted relative risk of 2.2 (95 percent confidence interval, 1.5 to 3.3), whereas those who smoked 25 or more cigarettes per day had a relative risk of 3.7 (95 percent confidence interval, 2.7 to 5.1). For women in this latter group, the relative risk of subarachnoid hemorrhage was 9.8 (95 percent confidence interval, 5.3 to 17.9), as compared with those who had never smoked. Adjustment for the effects of relative weight, hypertension, diabetes, history of high cholesterol, previous use of oral contraceptives, postmenopausal estrogen therapy, and alcohol intake did not appreciably alter the association between cigarette use and incidence of stroke. These prospective data support a strong causal relation between cigarette smoking and stroke among young and middle-aged women.