Smoking Cessation Recommendations for Smoking Cessation Referenced studies that support recommendations are summarized in online Data Supplements 7 and 8. COR LOE Recommendations In patients with stroke or TIA who smoke tobacco, counseling with or without drug therapy (nicotine replacement, bupropion, or varenicline) is recommended to assist in quit- Patients with stroke or TIA who continue to smoke tobacco should be advised to stop smoking (and, if unable, to reduce their daily smoking) to lower the risk of recurrent In patients with stroke or TIA. avoidance of environmental (passive) tobacco smoke is recommended to reduce risk of recurrent Synopsis Cigarette smoking is an independent, potent, and dose- respondent risk factor for first ischemic stroke147,151,152 and silent cerebral infarction,153 approximately doubling the risk of stroke.18 Environmental tobacco smoke (pas- sive smoking) has been independently associated with increased risk of stroke and mortality.147 149,155 Tobacco use is an addictive behavior, and cessation is difficult. Even after a life-threatening vascular event, roughly one-third of all smokers continue to smoke.146,156 Persis- tent cigarette smoking after stroke or TIA is associated with increased longer-term mortality rates,157 159 and evidence identifies an 2-fold risk of stroke recurrence in persistent smokers compared with nonsmokers143 145 and a dose-response relationship.143 Behavioral and pharmacological interventions for tobacco dependence are evidence based through multiple meta-analy- but not in cerebrovascular disease popu- No RCTs have examined smoking cessation interventions on recurrent events after stroke compared with no intervention; however, encouraging evidence of increased smoking cessation rates after stroke in mul- tibehavioral interventions compared with usual care is Recommendation-Specific Supportive Text 1. 