Aims: Case-control studies are prone to recall bias, a participant's case-control status influencing their recall of exposure to risk factors. We aimed to demonstrate empirically the scope for this bias.
Methods: Two thousand five hundred and fifty men without coronary heart disease at enrollment to a prospective cohort study underwent two health assessments, about 5 years apart. The association between the development of coronary heart disease in the intervening period and changes in reported stress and cigarette smoking were investigated.
Results: Men admitted to hospital with coronary heart disease reported a greater increase in psychological stress (p=0.032) and greater cessation of smoking (22% vs. 10%; p=0.007) than men not admitted. Consequently, when exposure data are collected at the end rather than at the start of the follow-up period, coronary heart disease is observed to be more strongly associated with psychological stress, and more weakly associated with smoking.
Conclusions: At the time when a case-control study is conducted, levels of exposure to risk factors will have been influenced by disease development. When participants are asked about their level of exposure for a previous time period, recall is likely to be influenced by present outcome and exposure status, especially when psychological states are being investigated.