IJE Advance Access originally published online on May 24, 2005
International Journal of Epidemiology 2005 34(5):1036-1045; doi:10.1093/ije/dyi104
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Article |
Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region
Asia Pacific Cohort Studies Collaboration
,*
Writing committee: M Woodward, TH Lam, F Barzi, A Patel, D Gu, A Rodgers, Il Suh. Executive committee: DF Gu, TH Lam, CMM Lawes, SW MacMahon, WH Pan, A Rodgers, I Suh, H Ueshima, M Woodward. Statistical analyses: F Barzi, V Parag, M Woodward. Participating studies and principal collaborators: Aito Town: A Okayama, H Ueshima, H Maegawa; Akabane: N Aoki, M Nakamura, N Kubo, T Yamada; Anzhen02: ZS Wu; Anzhen: CH Yao, ZS Wu; Australian Longitudinal Study of Aging: G Andrews; Australian National Heart Foundation: TA Welborn; Beijing Aging: Z Tang; Beijing Steelworkers: LS Liu, JX Xie; Blood Donors' Health: R Norton, S Ameratunga, S MacMahon, G Whitlock; Busselton: MW Knuiman; Canberra-Queanbeyan: H. Christensen; Capital Iron and Steel Company: XG Wu; CISCH: J Zhou, XH Yu; Civil Service Workers: A Tamakoshi; CVDFACTS: WH Pan; East Beijing: ZL Wu, LQ Chen, GL Shan; EGAT: P Sritara; Fangshan: DF Gu, XF Duan; Fletcher Challenge: S MacMahon, R Norton, G Whitlock, R Jackson; Guangzhou: YH Li; Guangzhou Occupational: TH Lam, CQ Jiang; Hisayama: M Fujishima, Y Kiyohara, H Iwamoto; Hong Kong: J Woo, SC Ho; Huashan: Z Hong, MS Huang, B Zhou; Kinmen: JL Fuh; Konan: H Ueshima, Y Kita, SR Choudhury; KMIC: I Suh, SH Jee, IS Kim; Melbourne: G Giles; Miyama: T Hashimoto, K Sakata; Newcastle: A Dobson; Ohasama: Y Imai, T Ohkubo, A Hozawa; Perth: K Jamrozik, M Hobbs, R Broadhurst; Saitama: K Nakachi; Seven Cities: XH Fang, SC Li, QD Yang; Shanghai Factory Workers: ZM Chen; Shibata: H Tanaka; Shigaraki Town: Y Kita, A Nozaki, H Ueshima; Shirakawa: H Horibe, Y Matsutani, M Kagaya; Singapore Heart: K Hughes, J Lee; Singapore NHS92: D Heng, SK Chew; Six Cohorts: BF Zhou, HY Zhang; Tanno/Soubetsu: K Shimamoto, S Saitoh; Tianjin: ZZ Li, HY Zhang; Western Australia AAA Screenees: P Norman, K Jamrozik; Xi'an: Y He, TH Lam; Yunnan: SX Yao. (The italicized studies provided data used in this paper)
* Corresponding author. Mark Woodward, The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia. E-mail: mwoodward{at}thegeorgeinstitute.org
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Accepted 21 April 2005
Background Although smoking is a major risk factor for cardiovascular disease, it has been suggested that Asians may be less susceptible to the adverse effects of smoking than Caucasians. This may have contributed to the high prevalence of smoking, and the low quitting rates, in Asian men. Worldwide, smoking rates are increasing for women, amongst whom cardiovascular awareness is relatively poor.
Methods An individual participant data analysis of 40 cohort studies was carried out, involving 463 674 Asians (33% female) and 98 664 Australasians (45% female). Cox proportional hazard models, stratified by study and sex where appropriate, were employed.
Results The HR [95% confidence interval (CI)], comparing current smokers with non-smokers, for coronary heart disease (CHD) was 1.60 (1.49–1.72); haemorrhagic stroke 1.19 (1.06–1.33); ischaemic stroke 1.38 (1.24–1.54). There was a clear dose–response relationship between the number of cigarettes smoked per day and both CHD and stroke, with no significant difference (P 
0.20) between populations from Asia and Australia/New Zealand. Although there was no sex difference for stroke in the effect of amount smoked (P = 0.16), for CHD, women tended to have higher hazard ratios than men (P = 0.011). Quitting gave a clear benefit, which was not significantly different between the sexes or regions (P > 0.63). The HR (CI) for ex-smokers compared with current smokers was 0.71 (0.64–0.78) for CHD and 0.84 (0.76–0.92) for stroke.
Conclusions Unless urgent public health measures are put into place, the impact of the smoking epidemic in Asia, and among women, will be enormous. Tobacco control policies that specifically target these populations are essential.
Keywords Smoking, coronary heart disease, stroke, Asia
Smoking is well known as a major risk factor for cardiovascular disease (CVD).1 However, a question remains regarding the relative strength of the association within ethnic, age, and sex subgroups. Most importantly, there has been some suggestion that Asians may have less excess risk from smoking than Caucasians,2 which may have contributed to the huge percentage of people (largely men) who now smoke in several Asian countries.3 Given that one third of all cigarettes are smoked in China alone,4 reliable data on the risks of smoking in Asia, and how they relate to risks elsewhere, are crucial but currently lacking. Information on age and sex differences are important for targeting health promotion activities, especially as smoking among young females has been on the rise in many populations.4 A related issue is whether smoking has different effects for the three major components of CVD: coronary heart disease (CHD), ischaemic, and haemorrhagic stroke. In terms of total CVD events, Asian populations have a greater percentage of strokes, while among all strokes they have a greater percentage of haemorrhagic strokes than European and North American populations.5
To address these issues we analysed data from the Asia Pacific Cohort Studies Collaboration (APCSC), providing the largest individual participant data meta-analysis from this region to date.
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Methods |
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The Asia Pacific Cohort Studies Collaboration is an overview of cohort studies in the region. As studies were recruited retrospectively, study protocols and conduct differ between studies. Details of study identification, data collection, and event verification are described elsewhere.6,7 All studies in APCSC were conducted prospectively in a population from the Asia-Pacific region, continued follow-up for at least 5000 person-years, and recorded age, sex, and blood pressure at baseline and vital status at the end of the follow-up. Studies were excluded if entry was dependent upon having a particular condition or risk factor. A variety of methods were used to ascertain outcomes, involving monitoring, re-surveying and/or record linkage; in some studies non-fatal, as well as fatal, cardiovascular outcomes were recorded.
All data on cigarette smoking were self-reported at the time when the subject entered the study. All studies included here recorded current cigarette smoking status: yes/no. Some studies additionally recorded whether individuals were current, ex-smokers or never-smokers, and some recorded cigarettes per day for smokers. Most studies additionally measured, at the same time, total cholesterol (from serum) and body mass index [BMI: weight (kg) divided by squared height (m2)]. Studies were classified as Asian if the participants were recruited from mainland China, Hong Kong, Japan, Korea, Singapore, Taiwan or Thailand and as ANZ if the participants were from Australia or New Zealand.
All outcomes were classified, after recoding when necessary, according to the ninth revision of the International Classification of Diseases (ICD): CHD (ICD 410–414); stroke (430–438); haemorrhagic stroke (431.0–432.9); ischaemic stroke (433.0–434.9); and all CVD (390–459). Deaths were ascribed solely to their underlying cause. For studies that collected data on both non-fatal and fatal events, the composite outcome was analysed.
Analyses used individual participant data, and were restricted to individuals aged 20 years at the time of the baseline survey for whom smoking status was recorded. Cox proportional hazards models, stratified by study and (where appropriate) sex, and adjusted for age and systolic blood pressure were used to estimate hazard ratios (approximate relative risks) associated with smoking. In some analyses, further adjustments were made for total cholesterol and BMI, which, unlike blood pressure, were missing for some participants. Homogeneity between groups defined by geographical area (Asia/ANZ), sex, and age groups was investigated by adding interaction terms to the Cox model. Confidence limits for dose–response hazard ratios were calculated using the floating absolute risk method,8 using four ordinal cigarette consumption groups: 0, <20, 20, and >20 cigarettes per day. These groups were chosen so as to provide as near an equal four-way partition as possible (20 cigarettes corresponds to one standard pack). A random effects meta-regression8 was used to relate log hazard ratios from Cox models to follow-up durations using individual study data.
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Results |
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Of the 43 studies in APCSC, 40 (32 in Asia; 8 in ANZ) provided data on current smoking status, of which 33 distinguished ex-smokers from never-smokers and 23 provided data on cigarette consumption for current smokers (Table 1). Total person-years of follow-up were 1.3 million for smokers and 1.7 million for non-smokers in Asia, with corresponding figures of 177 000 and 702 000 in ANZ. Altogether, 8490 deaths from CVD and a further 3972 non-fatal MI or stroke events were recorded (Table 2). As expected, strokes outnumbered CHD only in Asia, whilst haemorrhagic strokes made up a greater percentage of all strokes in Asia compared with ANZ.
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Current smoking was a significant predictor of all types of cardiovascular events; it was most strongly related to CHD and ischaemic stroke, where smokers had
50% greater risk of an event than non-smokers (Figure 1). There were no significant differences in the relative effect of smoking on CHD or stroke between Asia and ANZ or between women and men, but some evidence of a decline in relative effect with age, leading to small effects in those aged 75 years (Figure 2). Additional adjustments for cholesterol and BMI made no substantive difference to the results (data not shown). The hazard ratio for CHD increased by 1% in both Asia and ANZ after extra adjustment for cholesterol and by 3% in Asia and 4% in ANZ after both adjustments. When Asian studies were subdivided by country, no statistical differences were noted. The hazard ratio (95% CI) relating smoking to CHD was 1.53 (1.30–1.81) in mainland China, 1.45 (1.12–1.87) in Korea, and 1.92 (1.44–2.56) in Japan. Corresponding results for stroke were 1.24 (1.13–1.37), 1.34 (1.17–1.54), and 1.38 (1.16–1.64).
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For those studies that distinguished ex-smokers from never-smokers, the CHD hazard ratio (95% CI) for current compared with never-smoking was 1.75 (1.60–1.90), and for ex-smoking compared with current smoking was 0.71 (0.64–0.78). For stroke, these results were 1.43 (1.32–1.54) and 0.84 (0.76–0.92), respectively. There were no significant differences by region (P = 0.68 for CHD and 0.90 for stroke) or by sex (P = 0.95 for CHD and 0.63 for stroke).
Figures 3 and 4 show a positive dose–response relationship between the number of cigarettes smoked and the hazard ratio for CHD and stroke for each of Asians, those in ANZ, women and men. Although hazard ratios for any level of cigarette smoking, compared with non-smokers, are always lower in Asia than in ANZ, this difference does not reach traditional levels of statistical significance for CHD or stroke (Figure 3). For both CHD and stroke, hazard ratios comparing smokers of 20 cigarettes per day with non-smokers are much higher for women than men (Figure 4). However, the overall sex difference in the risk by smoking amount is only statistically significant (P = 0.011) for CHD. The region and sex comparisons stratified by dose of smoking in Figures 3 and 4 are likely to be more meaningful than those that ignore the amount smoked in Figure 2. The lower mean daily cigarette consumption among female smokers (10 in Asia; 15 in ANZ) compared with male smokers (16 and 20, respectively) explains the contrasting findings in Figure 2 (which shows no sex difference when comparing current smokers with non-smokers) and Figure 4 (which shows greater risk for women with high consumption, when comparing according to amount smoked).
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As a sensitivity analysis, all the results in Figures 1
–4 were reproduced for fatal events only. In every case the hazard ratios were similar and the patterns shown by the plots were unchanged (data not shown). |
Discussion |
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The results from this, the largest ever study of smoking in the Asia-Pacific region, and one of the largest anywhere in the world, confirm that cigarette smoking is a risk factor for both CHD and stroke, independent of the effects of BMI, blood pressure, and cholesterol, with ameliorations of the effects after quitting. Importantly, the results also show that smoking is an independent risk factor for haemorrhagic stroke, the most common type of stroke in Asia and more likely than ischaemic stroke to lead to death within 28 days.5 The large numbers involved make the overall estimates of the relative effects of smoking more precise than those in most previous studies. Our results also show that younger people and women have greater relative risks of CVD from smoking than others. Most importantly, we find that Asians and the predominantly Caucasian Australians and New Zealanders have similar increased proportional cardiovascular risk from smoking cigarettes and similar relative risk reduction from quitting.
Our findings of greater relative risks for CHD from smoking for women than men are in agreement with recent literature.9–13 Although one study from the west of Scotland has shown lack of difference between the sexes,14 it contradicts a national Scottish study of comparable size.11 Past estimates of such differences have rarely been as precise. One study that is larger than ours is the American Cancer Society Cancer Prevention Study II, which showed, both for CHD and stroke, greater relative risks (current vs never-smokers) for women compared with men at all ages, as well as a steady decline in relative risk with age,15 as we find in APCSC. Possibly women experience an anti-oestrogenic effect from smoking, as well as the thrombogenic effect experienced by both men and women.16
The overall lack of regional differences in relative risks, and the moderate differences by sex when comparing all smokers with non-smokers, might be contrasted with the large differences in attributable risks. Taking typical current prevalences3 of smoking across Asia to be 70% in men and 5% in women, the attributable risk for CHD from smoking is 30% in men and 3% in women,8 using the overall age and blood pressure-adjusted hazard ratio for CHD from Figure 1. Equivalent figures for stroke are 18 and 2% for men and women, respectively. In ANZ, assuming 25% current prevalence in men and 20% in women,3 the results for CHD are 13 and 11% for men and women, respectively, and the results for stroke are 7 and 6% for men and women, respectively. Trends in smoking should make numbers converge in the future.
This study has a major advantage of being very large; however, it has a number of disadvantages. Few variables on smoking habits are included in the Collaboration. Relative risks relating to cigarette smoking may vary by type of cigarette smoked (filter/not; black/blond tobacco; hand rolled/manufactured; etc.) and inhalation habits. These may well vary by region, age, and sex.
As no data were collected on lifetime smoking, we cannot take duration of smoking into account when making comparisons between regions, age groups, or the sexes. Since smoking is generally longer established in ANZ than Asia, in men than women, and in older than younger people, our analyses of current smoking will have relatively underestimated the true relative risk of current smoking for Asians, women, and younger people. Although we have shown no significant difference between the relative risks of smoking on CHD and stroke for Asians and Caucasians, we did find lower relative risks for Asians at each level of cigarette smoking. In APCSC, we can only estimate the effects of differences in smoking duration during follow-up, which is but one component of the overall effect of smoking duration. The median follow-up in Asian APCSC studies (6.3 years) was 2 years shorter than in ANZ studies (8.3 years). From a meta-regression8 of log hazard ratios against median follow-up in APCSC we estimated that the hazard ratio (95% CI) for CHD would be increased by 2.0% (0.02–3.7%) for each extra year of follow-up. Thus, as found in the British Doctors Study,17 relative risks for smoking tend to increase as duration of follow-up increases, and we would expect to find smaller relative risks in our studies from Asia, compared with ANZ, even if the effect of smoking was homogeneous across regions. Furthermore, the immaturity of the smoking epidemic in Asia, compared with ANZ, suggests that Asian smokers may tend to be of relatively high social class compared with smokers in ANZ. Thus we would also expect that adjustments for other cardiovascular risk factors, unmeasured in our study, would reduce the differentials in relative risks for smoking between Asia and ANZ.
No objective measures of tobacco consumption were available in the APCSC database. These have been shown to have important advantages over self-reports in CVD research when there are many self-reported quitters,18 as indeed there are in the ANZ, though not the Asian, cohorts in APCSC (Table 1). Another restriction is that the current analyses only use smoking habits recorded at baseline; changes in habit over the duration of follow-up were available from so few studies that no meaningful analysis could be undertaken. However, when we restricted analyses to 1, 2, and 3 years follow-up, where changes in smoking status would be expected to be relatively few, there were no important differences in the ratio of relative risks, comparing Asia with ANZ.
Finally, differences between studies may have biased the results in some unknown way. The individual studies used different laboratory and physical examination methods, which will compromise the statistical adjustments for blood pressure, cholesterol, and BMI. Furthermore, different methods were used to verify outcomes. In particular, only 57% of fatal strokes were classified by subtype, and, while most strokes should have been verified by imaging or autopsy, we have limited information from many studies.
Our data provide precise estimates of the relative impact of smoking upon cardiovascular health in the Asia-Pacific region, where data previously have been scarce,19 thus avoiding the need for indirect estimation of the public health impact of smoking.20 The Asian results here mainly agree with recent reports from Asia,21–23 except that two Japanese studies have reported a protective effect of smoking for haemorrhagic stroke.24,25 This may possibly be explained by chance findings with smaller sample sizes or differences in the make-up of this heterogeneous disease.5,22,24 Our results underline the observations made by previous authors4,25,26 that if smoking goes unchecked, the impact of smoking upon health in Asia, and particularly China, will be huge.
We found no difference in the reductions in risk of CVD, for those who have stopped smoking, between Asians and Caucasians. Taken together with a recent meta-analysis,27 which showed no ethnic differences in the benefit of quitting among those who had previous coronary disease, this suggests that there will be real benefit, in huge absolute numbers, from campaigns to promote quitting in Asia. Previous evidence of the benefits of quitting among Asians is scarce, largely because it happens so rarely (see, for example, Table 1). Unfortunately, in some parts of Asia there is a common belief that sudden quitting after long-term smoking may be harmful.28 Higher risks among ex-smokers, compared with current smokers, do sometimes occur in observational studies when, as is often the case in Asia, quitting is generally recent. However, this is merely an artefact caused by quitting among those with incident disease,18 and benefits would be expected to appear soon after quitting in disease-free populations.
It is important that tobacco control activities in Asia take account of gender differences, because of the different causes of, and perceptions about, smoking among Asian women and men.29,30 The greater relative impact of cigarette smoking, on women's cardiovascular health, which we have demonstrated is of particular public health concern given that the tobacco epidemic is still spreading among women, with a peak not expected for a few decades. If current trends are not halted, it is estimated that there will be over 530 million female smokers by 2025.31 Furthermore, female smoking generally has a greater impact on family health than does smoking among males.4 We recommend that tobacco control policies should always, in future, include messages specifically targeted at women.
KEY MESSAGES
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Acknowledgments |
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This project has received grants from the National Health and Medical Research Council of Australia, the Health Research Council of New Zealand, and an unrestricted educational grant from Pfizer Inc. The sponsors had no influence on design, analysis, or interpretation of results, and took no part in the writing of this paper.
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