Post-stroke smoking and mental health burden: sex-specific analysis of NHIS 2019-2023

Behavioral health factors particularly depression/anxiety and smoking are common after stroke and directly influence secondary stroke prevention, rehabilitation engagement and outcomes, yet they remain under-integrated within routine physical therapy-led stroke care.

To estimate associations between stroke history, smoking, mental health burden and sociodemographic factors and propose pragmatic implications for integrated rehabilitation.

We conducted a cross-sectional analysis of pooled National Health Interview Survey (NHIS) data from 2019-2023 (N = 150,220 adults). Sex-stratified, survey-weighted logistic regression models estimated associations among stroke history, mental health burden, smoking, and sociodemographic factors. Among stroke survivors, models also examined the Covid-19 pandemic period.

Stroke was associated with higher odds of mental health burden (females OR 1.33; males OR 1.57) and current smoking (females OR 1.27; males OR 1.35) versus controls. Among survivors, the pandemic period was associated with increased smoking risk in females (OR 1.38), while Medicaid/public insurance was associated with higher odds of both smoking (females OR 1.77; males OR 1.66) and mental health burden in females (OR 1.33). Partnership conferred protection for mental health burden (females OR 0.70; males OR 0.75) and smoking in males (OR 0.63).

Our study suggests that national patterns support embedding behavioral health screening, smoking and substance use cessation into standard stroke rehabilitation, with prioritization of female, Medicaid-insured survivors, and those without partners, and ensuring continuity during public health crises. Since smoking cessation is central to secondary stroke prevention, embedding behavioral health screening, cessation counseling, and warm handoffs into physical therapy-led rehabilitation offers a concrete, sex-sensitive, and equity-oriented target for improving post-stroke outcomes.