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Smoking and idiopathic intracranial hypertension: a meta-analysis

Eye (2026)Cite this article

Subjects

Abstract

Purpose

To examine the association between smoking and idiopathic intracranial hypertension (IIH).

Methods

A systematic literature search was conducted on Ovid MEDLINE, Embase, and the Cochrane Library from inception to March 12th, 2025, to identify eligible observational studies evaluating the association between smoking and IIH in adult populations. A random-effects meta-analysis using the Mantel-Haenszel method was conducted to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Leave-one-out sensitivity analyses and subgroup analyses stratified by study continent were performed to assess the robustness of findings. Study quality was appraised using the ROBINS-E tool and the certainty of evidence was evaluated through the GRADE framework. Publication bias was assessed using Egger’s test.

Results

Eleven observational studies comprising 8,098 IIH patients and 90,381 non-IIH controls were included. Patients with IIH exhibited higher odds of current smoking status compared to controls (OR = 1.46, 95%CI = [1.39–1.54], p < 0.001, I2 = 0%). This association remained consistent in the leave-one-out sensitivity analysis and across geographical subgroups: European studies (OR = 1.45, 95%CI = [1.33–1.59], p < 0.001, I2 = 24%) and North American studies (OR = 1.42, 95%CI = [1.21–1.67], p < 0.001, I2 = 0%). Additionally, IIH patients had higher odds of former smoking status compared to controls (OR = 1.13, 95%CI = [1.05–1.21], p < 0.001, I2 = 0%). Quality assessments ranged from some concerns to low risk of bias, with no publication bias (p = 0.59).

Conclusions

Low certainty of evidence suggests that current and former smoking status are associated with IIH. Clinicians should consider smoking history as part of risk assessment in patients with suspected IIH. Further prospective studies with detailed exposure metrics are needed to confirm causality and explore dose-dependent relationships.

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Fig. 1
Fig. 2: Forest plots showing the odds of being a smoker in patients with idiopathic intracranial hypertension compared to controls.
Fig. 3

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Data availability

The data analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Wall M. Idiopathic intracranial hypertension. Neurol Clin. 2010;28:593–617.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Curry WT Jr., Butler WE, Barker FG II. Rapidly Rising Incidence of Cerebrospinal Fluid Shunting Procedures for Idiopathic Intracranial Hypertension in the United States, 1988–2002. Neurosurgery. 2005;57:97–108.

    Article  PubMed  Google Scholar 

  3. Raoof N, Hoffmann J. Diagnosis and treatment of idiopathic intracranial hypertension. Cephalalgia. 2021;41:472–8.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Shaia JK, Sharma N, Kumar M, Chu J, Maatouk C, Talcott K, et al. Changes in Prevalence of Idiopathic Intracranial Hypertension in the United States Between 2015 and 2022, Stratified by Sex, Race, and Ethnicity. Neurology. 2024;102:e208036.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Chen J, Wall M. Epidemiology and risk factors for idiopathic intracranial hypertension. Int Ophthalmol Clin. 2014;54:1–11.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ghaffari-Rafi A, Mehdizadeh R, Ko AWK, Ghaffari-Rafi S, Leon-Rojas J. Idiopathic Intracranial Hypertension in the United States: Demographic and Socioeconomic Disparities. Front Neurol. 2020;11:869.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology. 2013;81:1159–65.

    Article  PubMed  Google Scholar 

  8. Subramaniam S, Fletcher WA. Obesity and Weight Loss in Idiopathic Intracranial Hypertension: A Narrative Review. J Neuroophthalmol. 2017;37:197–205.

    Article  PubMed  Google Scholar 

  9. Passi SF, Butcher R, Orme DR, Warner JEA, Stoddard GJ, Crum AV, et al. Increased Incidence of Pseudotumor Cerebri Syndrome Among Users of Tetracycline Antibiotics. J Neuroophthalmol. 2022;42:323–7.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Adderley NJ, Subramanian A, Nirantharakumar K, Yiangou A, Gokhale KM, Mollan SP, et al. Association Between Idiopathic Intracranial Hypertension and Risk of Cardiovascular Diseases in Women in the United Kingdom. JAMA Neurol. 2019;76:1088–98.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Riise T, Nortvedt MW, Ascherio A. Smoking is a risk factor for multiple sclerosis. Neurology. 2003;61:1122–4.

    Article  PubMed  Google Scholar 

  12. Wolf PA, D’Agostino RB, Kannel WB, Bonita R, Belanger AJ. Cigarette smoking as a risk factor for stroke. The Framingham Study. Jama. 1988;259:1025–9.

    Article  CAS  PubMed  Google Scholar 

  13. Messner B, Bernhard D. Smoking and cardiovascular disease: mechanisms of endothelial dysfunction and early atherogenesis. Arterioscler Thromb Vasc Biol. 2014;34:509–15.

    Article  CAS  PubMed  Google Scholar 

  14. Cao L, Wang H, Kwapong WR, Wan J, Yan Y, Liu G, et al. Macular exudate in idiopathic intracranial hypertension affects outer retina and visual acuity. BMJ Open Ophthalmol. 2024;9:e001810.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Barke M, Castro HM, Adesina OO, Chuang AZ, Do T, Patel RP, et al. Thinning of the Skull Base and Calvarial Thickness in Patients With Idiopathic Intracranial Hypertension. J Neuroophthalmol. 2022;42:192–8.

    Article  PubMed  Google Scholar 

  16. Deveci Ş, Kabeloğlu V. The Relationship between Idiopathic Intracranial Hypertension and Obstructive Sleep Apnea: Is Obesity the Only Mediating Factor between the Two? Duzce Med J. 2024;26:122–8.

    Article  Google Scholar 

  17. Sander K, Poppert H, Etgen T, Hemmer B, Sander D. Dynamics of intracranial venous flow patterns in patients with idiopathic intracranial hypertension. Eur Neurol. 2011;66:334–8.

    Article  CAS  PubMed  Google Scholar 

  18. Brooke BS, Schwartz TA, Pawlik TM. MOOSE Reporting Guidelines for Meta-analyses of Observational Studies. JAMA Surg. 2021;156:787–8.

    Article  PubMed  Google Scholar 

  19. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj. 2021;372:n71.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Higgins JPT, Morgan RL, Rooney AA, Taylor KW, Thayer KA, Silva RA, et al. A tool to assess risk of bias in non-randomized follow-up studies of exposure effects (ROBINS-E). Environ Int. 2024;186:108602.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Bmj. 2008;336:924–6.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;22:719–48.

    CAS  PubMed  Google Scholar 

  23. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Bmj. 2003;327:557–60.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Bmj. 1997;315:629–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Amikam U, Baghlaf H, Badeghiesh A, Brown R, Dahan MH. Idiopathic intracranial hypertension and obstetric and neonatal outcomes: A 1:20 matched study from a population database. Int J Gynaecol Obstet. 2024;166:1040–6.

    Article  CAS  PubMed  Google Scholar 

  26. Youssef M, Sundaram ANE, Veitch M, Aziz A, Gurges P, Bingeliene A, et al. Obstructive sleep apnea in those with idiopathic intracranial hypertension undergoing diagnostic in-laboratory polysomnography. Sleep Med. 2024;114:279–89.

    Article  PubMed  Google Scholar 

  27. Mollan SP, Subramanian A, Perrins M, Nirantharakumar K, Adderley NJ, Sinclair AJ. Depression and anxiety in women with idiopathic intracranial hypertension compared to migraine: A matched controlled cohort study. Headache. 2023;63:290–8.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Samancı B, Samancı Y, Şen C, Şahin E, Sezgin M, Kocasoy Orhan E, et al. Assessment of the Olfactory Function in Patients With Idiopathic Intracranial Hypertension Using the Sniffin’ Sticks Test: A Case-Control Study. Headache. 2019;59:848–57.

    Article  PubMed  Google Scholar 

  29. Wallentin T, Linnet J, Lichtenstein MB, Hansen NS, Korsbæk JJ, Høgedal L, et al. The impact of eating disorders on idiopathic intracranial hypertension. Cephalalgia. 2024;44:3331024241237237.

    Article  PubMed  Google Scholar 

  30. Ireland B, Corbett JJ, Wallace RB. The search for causes of idiopathic intracranial hypertension. A preliminary case-control study. Arch Neurol. 1990;47:315–20.

    Article  CAS  PubMed  Google Scholar 

  31. Puranik R, Celermajer DS. Smoking and endothelial function. Prog Cardiovasc Dis. 2003;45:443–58.

    Article  CAS  PubMed  Google Scholar 

  32. Tanriverdi H, Evrengul H, Kuru O, Tanriverdi S, Seleci D, Enli Y, et al. Cigarette smoking induced oxidative stress may impair endothelial function and coronary blood flow in angiographically normal coronary arteries. Circ J. 2006;70:593–9.

    Article  CAS  PubMed  Google Scholar 

  33. Sunyer J, Forastiere F, Pekkanen J, Plana E, Kolz M, Pistelli R, et al. Interaction between smoking and the interleukin-6 gene affects systemic levels of inflammatory biomarkers. Nicotine Tob Res. 2009;11:1347–53.

    Article  CAS  PubMed  Google Scholar 

  34. Churg A, Dai J, Tai H, Xie C, Wright JL. Tumor necrosis factor-alpha is central to acute cigarette smoke-induced inflammation and connective tissue breakdown. Am J Respir Crit Care Med. 2002;166:849–54.

    Article  PubMed  Google Scholar 

  35. Tapson VF. The role of smoking in coagulation and thromboembolism in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2005;2:71–7.

    Article  CAS  PubMed  Google Scholar 

  36. Nielsen VG, Hafner DT, Steinbrenner EB. Tobacco smoke-induced hypercoagulation in human plasma: role of carbon monoxide. Blood Coagul Fibrinolysis. 2013;24:405–10.

    Article  CAS  PubMed  Google Scholar 

  37. Masood S, Cappelli C, Li Y, Tanenbaum H, Chou CP, Spruijt-Metz D, et al. Cigarette smoking is associated with unhealthy patterns of food consumption, physical activity, sleep impairment, and alcohol drinking in Chinese male adults. Int J Public Health. 2015;60:891–9.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Eshtiaghi A, Margolin EA, Micieli JA. Idiopathic Intracranial Hypertension and Socioeconomic Status in the Greater Toronto Area, Canada. J Neuroophthalmol. 2023;43:197–201.

    Article  PubMed  Google Scholar 

  39. Hornby C, Mollan SP, Botfield H, OʼReilly MW, Sinclair AJ. Metabolic Concepts in Idiopathic Intracranial Hypertension and Their Potential for Therapeutic Intervention. J Neuroophthalmol. 2018;38:522–30.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Abbott S, Chan F, Tahrani AA, Wong SH, Campbell FEJ, Parmar C, et al. Weight Management Interventions for Adults With Idiopathic Intracranial Hypertension: A Systematic Review and Practice Recommendations. Neurology. 2023;101:e2138–e50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Funding

No funding was received for this work.

Author information

Authors and Affiliations

  1. Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Ryan S. Huang & Andrew Mihalache

  2. Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada

    Brendan K. Tao, Jim S. Xie, Jonathan A. Micieli & Edward A. Margolin

  3. Department of Ophthalmology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada

    Jonathan A. Micieli

  4. Department of Ophthalmology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada

    Edward A. Margolin

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  1. Ryan S. Huang
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Contributions

Ryan S. Huang: Conceptualisation, Methodology, Data curation, Formal analysis, Investigation, Visualisation, Writing – Original draft preparation, Writing – Reviewing and Editing. Andrew Mihalache: Methodology, Data curation, Formal analysis, Visualisation, Writing – Original draft preparation, Writing – Reviewing and Editing. Brendan K. Tao: Conceptualisation, Methodology, Validation, Investigation, Writing – Original draft preparation, Writing – Reviewing and Editing. Jim S. Xie: Conceptualisation, Methodology, Validation, Investigation, Writing – Original draft preparation, Writing – Reviewing and Editing. Jonathan A. Micieli: Conceptualisation, Methodology, Supervision, Project administration, Resources, Writing – Reviewing and Editing. Edward A. Margolin: Conceptualisation, Methodology, Supervision, Project administration, Validation, Resources, Writing – Reviewing and Editing. All authors have equally fulfilled the authorship criteria and contributions outlined by the International Committee of Medical Journal Editors (ICMJE) and approved the current version of the manuscript.

Corresponding author

Correspondence to Edward A. Margolin.

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Huang, R.S., Mihalache, A., Tao, B.K. et al. Smoking and idiopathic intracranial hypertension: a meta-analysis. Eye (2026). https://doi.org/10.1038/s41433-026-04282-x

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