Objective: To assess whether being able to quit smoking is an early marker of Parkinson disease (PD) onset rather than tobacco being "neuroprotective," we analyzed information about ease of quitting and nicotine substitute use.Methods: For this case-control study, we identified 1,808 patients with PD diagnosed between 1996 and 2009 from Danish registries, matched 1,876 population controls on sex and year of birth, and collected lifestyle information. We estimated odds ratios and 95% confidence intervals with logistic regression adjusting for matching factors and confounders.Results: Fewer patients with PD than controls ever established a smoking habit. Among former smokers, those with greater difficulty quitting or using nicotine substitutes were less likely to develop PD, with the risk being lowest among those reporting "extremely difficult to quit" compared with "easy to quit." Nicotine substitute usage was strongly associated with quitting difficulty and duration of smoking, i.e., most strongly among current smokers, followed by former smokers who had used nicotine substitutes, and less strongly among former smokers who never used substitutes.Conclusions: Our data support the notion that patients with PD are able to quit smoking more easily than controls. These findings are compatible with a decreased responsiveness to nicotine during the prodromal phase of PD. We propose that ease of smoking cessation is an aspect of premanifest PD similar to olfactory dysfunction, REM sleep disorders, or constipation and suggests that the apparent "neuroprotective" effect of smoking observed in epidemiologic studies is due to reverse causation. Neurology ® 2014;83:1396-1402 GLOSSARY CI 5 confidence interval; GWAS 5 genome-wide association study; OR 5 odds ratio; PD 5 Parkinson disease.According to epidemiologic studies, patients with Parkinson disease (PD) are less likely to smoke.1-3 Also, those who smoke for longer are at lower risk while lengthening time since quitting increases PD risk, causing some to argue that smoking may protect against PD and even prompting nicotine PD prevention trials. 4 While this is counterintuitive given the otherwise adverse health effects of smoking, common biases including confounding, selection, or measurement error do not explain this finding. Alternatively, the possibility exists that biological mechanisms responsible for PD result in smoking avoidance or the ability to quit smoking more easily among those at risk of developing PD. That is, individuals who develop PD may not experience the positive reinforcement from, and possibly the addictive response to, nicotine many years before motor symptom development, and thus are able to quit more easily than smokers who never develop PD. This distinction is important because smoking may either provide leads for treatment/prevention of PD or be plainly no more than an early marker of insidious PD onset. To explore this, we examined difficulty quitting and use of nicotine substitutes in relation to PD risk in the Danish PASIDA (Parkinson...