Please put out that cigarette, grandpa.

In the industrialised nations stroke is a leading cause of physical disability and its international significance is accelerating rapidly as life expectancy increases around the globe. 1 But stroke has been a much neglected Cinderella of cardiovascular disease, for perhaps at least three reasons. Firstly, in Westernised countries stroke is far less common as a cause of death than is its sister condition, coronary heart disease (CHD). Secondly, stroke is so much a disease of the very old—half of its victims are over the age of 75 years—and it is only relatively recently, with the decline in mortality from infectious diseases in developing countries and from CHD in many developed countries, that the population at high risk of cerebrovascular disease (CeVD) has begun to expand rapidly. 2 Finally, the lack of eVective medical and surgical treatments for acute cerebrovascular events means that stroke tends to induce professional as well as physical paralysis. By contrast, there has been steady development of new treatments for CHD, ranging from aspirin and blockers, through coronary artery bypass surgery, to coronary angioplasty, thrombolytic agents and now ACE (angiotensin converting enzyme) inhibitor drugs. The neglect of CeVD has extended to the examination of the relationships between smoking and stroke, where good evidence of an increased risk of stroke in current smokers took much longer to emerge than the evidence showing that smoking caused heart attacks. For example, the 1983 report on smoking and cardiovascular disease from the United States surgeon general 3 concluded unequivocally that " cigarette smoking is one of the three major independent CHD risk factors " (page 5) but stated only that " numerous prospective mortality studies have shown an association between cigarette smoking and cerebrovascular disease " and that " no consistent dose-response eVect has been demonstrated " (page 171). By 1989, the surgeon general had concluded that a causal relationship existed. 4 This issue of Tobacco Control carries a report from Bonita and colleagues in New Zealand of a new study showing strong and graded relationships between risk of stroke and both current active smoking and time since quitting, as well as associations between stroke and passive smoking. 5 A well-conducted, population-based, case-control study, it adds to a growing body of publications on this topic that has emerged from the later 1980s onwards. Futhermore, Bonita et al demonstrate that use of a reference group consisting of non-smokers who are not exposed …