Cigarette smoking, tar yields, and non-fatal myocardial infarction: 14,000 cases and 32,000 controls in the United Kingdom. The International Studies of Infarct Survival (ISIS) Collaborators

Family history, socioeconomic factors, comorbidities, health behaviors, and the risk of sudden cardiac arrest

Genetic, environment, and behaviour factors have a role in causing sudden cardiac arrest (SCA). We aimed to determine the strength of the association between various risk factors and SCA incidence. We conducted a multicentre case-control study at 17 hospitals in Korea from September 2017 to December 2020. The cases included out-of-hospital cardiac arrest aged 19-79 years with presumed cardiac aetiology. Community-based controls were recruited at a 1:1 ratio after matching for age, sex, and urban residence level. Multivariable conditional logistic regression analysis was conducted. Among the 1016 cases and 1731 controls, 948 cases and 948 controls were analysed. A parental history of SCA, low educational level, own heart disease, current smoking, and non-regular exercise were associated with SCA incidence (Adjusted odds ratio [95% confidence interval]: 2.51 [1.48-4.28] for parental history of SCA, 1.37 [1.38-2.25] for low edication level, 3.77 [2.38-5.90] for non-coronary artery heart disease, 4.47 [2.84-7.03] for coronary artery disease, 1.39 [1.08-1.79] for current smoking, and 4.06 [3.29-5.02] for non-regular exercise). Various risk factors related to genetics, environment, and behaviour were independently associated with the incidence of SCA. Establishing individualised SCA prevention strategies in addition to general prevention strategies is warranted.

The rise and fall of tobacco smoking and associated rise and fall of coronary atherosclerosis the lethal role of tobacco

In this review two new hypotheses are explored, one, that the decline in coronary heart disease is mainly due to a dramatic decline in the prevalence of underlying atherosclerosis and two, that tobacco smoking has been a much greater influence on atherosclerosis than previously estimated. The major outcome of coronary atherosclerosis is myocardial infarction. Between 1900 and 1960 the prevalence of coronary atherosclerosis dramatically rose in young male soldiers. Between 1960 and 2010 the prevalence of coronary atherosclerosis in young US soldiers equally dramatically fell. Understanding the reasons for this rise and fall offers important insights into the causes of atherosclerosis. In 1960 over 50% of US military personnel were tobacco smokers but by 1988 the rate had reduced to 30%. The increased prevalence of coronary atherosclerosis in young soldiers between 1900 and 1960 was mainly due to increased tobacco smoking. An additional influence was an increase in food and sugar consumption. The fall in atherosclerosis between 1960 and 2010 was probably due to a reduction in tobacco smoking and to a lesser extent, control of hypertension and lowering of high serum total cholesterol. In Western populations up to two thirds of the fall in deaths due to myocardial infarction has been shown to be due to declines in the incidence of heart attacks. Based on the data included in this review it is arguable that the main reason for the fall in the incidence of heart attacks is the fall in the prevalence of underlying coronary atherosclerosis. The adverse influences of tobacco have been well documented. However the enormity of these adverse influences has not been recognised. Over 50% of men continue to smoke tobacco in China, Indonesia, Russia and middle eastern countries. Based on the experience of Western countries over half of these men will die of smoking related conditions.

Tobacco cessation by prescription - A 180 degree turn

Utilisation of tobacco is one of the most serious problems affecting human health worldwide, despite the fact that the early fatality caused by tobacco use are growing, regardless of the fact that it is avoidable tobacco consumption is very common, considerable resources have been allocated to this issue. On tobacco prevention, a range of strategies have been tested but the ratio of death due to tobacco and number of tobacco consumers is increasing day by day. Various impediments to tobacco quitting have been recognized, all of which contribute to the failure of various tobacco cessation programs and methodologies. Individuals in the India have attempted or considered quitting smoking at some point in their lives but ended in failure. Existing tobacco cessation programs have not out-turned in a decrease in the figure of tobacco users or deaths, necessitating a new strategy. Tobacco cessation on prescription, developed from physical activity on prescription (PAP), can be a useful method in terms of public health. But yet no studies have ever been conducted over this. Further studies on this can explore results of tobacco quitting after prescription from general physician or other medical practitioner, evaluative beliefs about tobacco consumption and barriers in quitting even after prescription. Hence the present review was done with explore the outcomes for cessation of tobacco based upon utilization of tobacco cessation by prescription (TCP) methodology in Indian scenario. This review paper focuses on TCP as a need for newer approach pertaining to Indian perspective. Future study should look at whether raising the rate of stop attempts are improving the tobacco cessation rate in the general population after the implementation of TCP.

Cost-effectiveness of hypertension therapy based on 2020 International Society of Hypertension guidelines in Ethiopia from a societal perspective

Introduction

There is inadequate information on the cost-effectiveness of hypertension based on evidence-based guidelines. Therefore, this study was conducted to evaluate the cost-effectiveness of hypertension treatment based on 2020 International Society of Hypertension (ISH) guidelines from a societal perspective.

Methods

We developed a state-transition Markov model based on the cardiovascular disease policy model adapted to the Sub-Saharan African perspective to simulate costs of treated and untreated hypertension and disability-adjusted life-years (DALYs) averted by treating previously untreated adults above 30 years from a societal perspective for a lifetime.

Results

The full implementation of the ISH 2020 hypertension guidelines can prevent approximately 22,348.66 total productive life-year losses annually. The incremental net monetary benefit of treating hypertension based was $128,520,077.61 US by considering a willingness-to-pay threshold of $50,000 US per DALY averted. The incremental cost-effectiveness ratio (ICER) of treating hypertension when compared with null was $1,125.44 US per DALY averted. Treating hypertension among adults aged 40–64 years was very cost-effective 625.27 USD per DALY averted. Treating hypertensive adults aged 40–64 years with diabetes and CKD is very cost-effective in both women and men (i.e., 559.48 USD and 905.40 USD/DALY averted respectively).

Conclusion

The implementation of the ISH 2020 guidelines among hypertensive adults in Southern Ethiopia could result in $9,574,118.47 US economic savings. Controlling hypertension in all patients with or with diabetes and or CKD could be effective and cost-saving. Therefore, improving treatment coverage, blood pressure control rate, and adherence to treatment by involving all relevant stakeholders is critical to saving scarce health resources.

An integral perspective of canonical cigarette and e-cigarette-related cardiovascular toxicity based on the adverse outcome pathway framework

BACKGROUND

Nowadays, cigarette smoking remains the leading cause of chronic disease and premature death, especially cardiovascular disease. As an emerging tobacco product, e-cigarettes have been advocated as alternatives to canonical cigarettes, and thus may be an aid to promote smoking cessation. However, recent studies indicated that e-cigarettes should not be completely harmless to the cardiovascular system.

AIM OF REVIEW

This review aimed to build up an integral perspective of cigarettes and e-cigarettes-related cardiovascular toxicity.

KEY SCIENTIFIC CONCEPTS OF REVIEW

This review adopted the adverse outcome pathway (AOP) framework as a pivotal tool and aimed to elucidate the association between the molecular initiating events (MIEs) induced by cigarette and e-cigarette exposure to the cardiovascular adverse outcome. Since the excessive generation of reactive oxygen species (ROS) has been widely approved to play a critical role in cigarette smoke-related CVD and may also be involved in e-cigarette-induced toxic effects, the ROS overproduction and subsequent oxidative stress are regarded as essential parts of this framework. As far as we know, this should be the first AOP framework focusing on cigarette and e-cigarette-related cardiovascular toxicity, and we hope our work to be a guide in exploring the biomarkers and novel therapies for cardiovascular injury.

Impacto sanitario de la prohibición total de publicidades de tabaco en argentina

Health impact of the total ban on advertising of tobacco productsThe objective was to estimate the health impact of the total ban on advertising of tobacco products in terms of avoided cardiovascular events in those over 35 years of age in Argentina.The Cardiovascular Disease Policy Model (CVDPM) was used, which is a Markov simulation model used to represent and project mortality and morbidity due to cardiovascular disease (CVD) in the population aged 35 or over. It constitutes a demographic-epidemiological model, which represents the population between 35 and 95 years of age and uses a logistic regression model based on the Framingham equation to estimate the annual incidence of cardiovascular disease. We assumed that implementing a complete ban on the advertising of tobacco products would lead to a 9% reduction in tobacco consumption.The complete ban on advertising could prevent 15,164 deaths over a period of 10 years, of which 2610 would be the result of coronary heart disease and 747 due to stroke. These reductions would mean an annual decrease of 0.46% of total deaths, 0.60% of deaths from coronary heart disease and 0.33% in deaths from stroke. In addition, during the same period, it would avoid 6630 acute myocardial infarctions and 2851 strokes (reductions of 1.35% and 0.40%, respectively).We hope that these findings might contribute to the strengthening of sanitary tobacco control policies in Argentina based on the remarkable benefits of banning the advertising of tobacco products in full and in line with current global recommendations.

Societal economic burden of hypertension at selected hospitals in southern Ethiopia: a patient-level analysis

OBJECTIVES

There is inadequate information on the economic burden of hypertension treatment in Ethiopia. Therefore, this study was conducted to determine the societal economic burden of hypertension at selected hospitals in Southern Ethiopia.

METHODS

Prevalence-based cost of illness study from a societal perspective was conducted. Disability-adjusted life years (DALYs) were determined by the current WHO's recommended DALY valuation method. Adjustment for comorbidity and a 3% discount was done for DALYs. The data entry, processing and analysis were done by using SPSS V.21.0 and Microsoft Excel V.2013.

RESULTS

We followed a cohort of 406 adult patients with hypertension retrospectively for 10 years from September 2010 to 2020. Two hundred and fifty (61.6%) of patients were women with a mean age of 55.87±11.03 years. Less than 1 in five 75 (18.5%) of patients achieved their blood pressure control target. A total of US$64 837.48 direct cost was incurred due to hypertension. A total of 11 585 years and 579.57 years were lost due to hypertension-related premature mortality and morbidity, respectively. Treated and uncontrolled hypertension accounted for 50.83% (6027) of total years lost due to premature mortality from treated hypertension cohort. Total productivity loss due to premature mortality and morbidity was US$449 394.69. The overall economic burden of hypertension was US$514 232.16 (US$105.55 per person per month).

CONCLUSION

Societal economic burden of hypertension in Southern Ethiopia was substantial. Indirect costs accounted for more than 8 out of 10 dollars. Treated and uncontrolled hypertension took the lion's share of economic cost and productivity loss due to premature mortality and morbidity. Therefore, designing and implanting strategies for the prevention of hypertension, early screening and detection, and improving the rate of blood pressure control by involving all relevant stakeholders at all levels is critical to saving scarce health resources.

Trends and risk factors for non-communicable diseases mortality in Nairobi slums (2008-2017)

INTRODUCTION

Tracking progress in reaching global targets for reducing premature mortality from non-communicable diseases (NCDs) requires accurately collected population based longitudinal data. However, most African countries lack such data because of weak or non-existent civil registration systems. We used data from the Nairobi Urban Health and Demographic Surveillance System (NUDSS) to estimate NCD mortality trends over time and to explore the determinants of NCD mortality.

METHODS

Deaths identified in the NUHDSS were followed up with a verbal autopsy to determine the signs and symptoms preceding the death. Causes of death were then assigned using InSilicoVA algorithm. We calculated the rates of NCD mortality in the whole NUHDSS population between 2008 and 2017, looking at how these changed over time. We then merged NCD survey data collected in 2008, which contains information on potential determinants of NCD mortality in a sub-sample of the NUHDSS population, with follow up information from the full NUHDSS including whether any of the participants died of an NCD or non-NCD cause. Poisson regression models were used to identify independent risk factors (broadly categorized as socio-demographic, behavioural and physiological) for NCD mortality, as well as non-NCD mortality.

RESULTS

In the total NUHDSS population of adults age 18 and over, 23% were assigned an NCD as the most likely cause of death. There was evidence that NCD mortality decreased over the study period, with rates of NCD mortality dropping from 1.32 per 1000 person years in 2008-10 (95% CI: 1.13-1.54) to 0.93 per 1000 person years in 2014-17 (95% CI: 0.80-1.08). Of 5115 individuals who participated in the NCD survey in 2008, 421 died during the follow-up period of which 43% were attributed to NCDs. Increasing age, lower education levels, ever smoking and having high blood pressure were identified as independent determinants of NCD mortality in multivariate analyses.

CONCLUSION

We found that NCDs account for one-quarter of mortality in Nairobi slums, although we document a reduction in the rate of NCD mortality over time. This may be attributed to increased surveillance and introduction of population-wide NCD interventions and health system improvements from research activities in the slums. To achieve further decline there is a need to strengthen health systems to respond to NCD care and prevention along with addressing social factors such as education.

A Low-Cost, High-Throughput Digital Image Analysis of Stain Patterns on Smoked Cigarette Filter Butts to Estimate Mainstream Smoke Exposure

Standard machine smoking protocols provide useful information for examining the impact of design parameters, such as filter ventilation, on mainstream smoke delivery. Unfortunately, their results do not accurately reflect human smoke exposure. Clinical research and topography devices in human studies yield insights into how products are used, but a clinical setting or smoking a cigarette attached to such a device may alter smoking behavior. To better understand smokers' use of filtered cigarette products in a more natural environment, we developed a low-cost, high-throughput approach to estimate mainstream cigarette smoke exposure on a per-cigarette basis. This approach uses an inexpensive flatbed scanner to scan smoked cigarette filter butts and custom software to analyze tar-staining patterns. Total luminosity, or optical staining density, of the scanned images provides quantitative information proportional to mainstream smoke-constituent deliveries on a cigarette-by-cigarette basis. Duplicate sample analysis using this new approach and our laboratory's gold-standard liquid chromatography/tandem mass spectrometry (LC/MS/MS) solanesol method yielded comparable results (+7% bias) from the analysis of 20 commercial cigarettes brands (menthol and nonmentholated). The brands varied in design parameters such as length, filter ventilation, and diameter. Plots correlating the luminosity to mainstream smoked-nicotine deliveries on a per-cigarette basis for these cigarette brands were linear (average R2 > 0.91 for nicotine and R2 > 0.83 for the tobacco-specific nitrosamine NNK), on a per-brand basis, with linearity ranging from 0.15 to 3.00 mg nicotine/cigarette. Analysis of spent cigarette filters allows exposures to be characterized on a per-cigarette basis or a "daily dose" via summing across results from all filter butts collected over a 24 h period. This scanner method has a 100-fold lower initial capital cost for equipment than the LC/MS/MS solanesol method and provides high-throughput results (~200 samples per day). Thus, this new method is useful for characterizing exposure related to filtered tobacco-product use.

Low-intensity daily smoking and cause-specific mortality in Mexico: prospective study of 150 000 adults

Background

Research is needed to determine the relevance of low-intensity daily smoking to mortality in countries such as Mexico, where such smoking habits are common.

Methods

Prospective study of 159 755 Mexican adults recruited from 1998–2004 and followed for cause-specific mortality to 1 January 2018. Participants were categorized according to baseline self-reported smoking status. Confounder-adjusted mortality rate ratios (RRs) at ages 35–89 were estimated using Cox regression, after excluding those with previous chronic disease (to avoid reverse causality).

Results

Among 42 416 men and 86 735 women aged 35–89 and without previous disease, 18 985 men (45%) and 18 072 women (21%) reported current smoking and 8866 men (21%) and 53 912 women (62%) reported never smoking. Smoking less than daily was common: 33% of male current smokers and 39% of female current smokers. During follow-up, the all-cause mortality RRs associated with the baseline smoking categories of <10 cigarettes per day (average during follow-up 4 per day) or ≥10 cigarettes per day (average during follow-up 10 per day), compared with never smoking, were 1.17 (95% confidence interval 1.10–1.25) and 1.54 (1.42–1.67), respectively. RRs were similar irrespective of age or sex. The diseases most strongly associated with daily smoking were respiratory cancers, chronic obstructive pulmonary disease and gastrointestinal and vascular diseases. Ex-daily smokers had substantially lower mortality rates than those who were current daily smokers at recruitment.

Conclusions

In this Mexican population, low-intensity daily smoking was associated with increased mortality. Of those smoking 10 cigarettes per day on average, about one-third were killed by their habit. Quitting substantially reduced these risks.

Cardiac mortality after radiotherapy, chemotherapy and endocrine therapy for breast cancer: Cohort study of 2 million women from 57 cancer registries in 22 countries

Comparisons of patients receiving different cancer treatments reflect the effects of both treatment and patient selection. In breast cancer, however, if radiotherapy decisions are unrelated to laterality, comparisons of left-sided and right-sided cancers can demonstrate the causal effects of higher-versus-lower cardiac radiation dose. Cardiac mortality was analysed using individual patient data for 1,934,248 women with breast cancer in 22 countries. The median date of diagnosis was 1996 and the interquartile range was 1987-2002. A total of 1,018,505 women were recorded as irradiated, 223,077 as receiving chemotherapy, 317,619 as receiving endocrine therapy and 55,264 died of cardiac disease. Analyses were stratified by time since breast cancer diagnosis, age at diagnosis, calendar year of diagnosis and country. Patient-selection effects were evident for all three treatments. For radiotherapy, there was also evidence of selection according to laterality in women irradiated 1990 or later. In patients irradiated before 1990, there was no such selection and cardiac mortality was higher in left-sided than right-sided cancer (rate ratio [RR]: 1.13, 95% confidence interval 1.09-1.17). Left-versus-right cardiac mortality RRs were greater among younger women (1.46, 1.19, 1.20, 1.09 and 1.08 after cancer diagnoses at ages <40, 40-49, 50-59, 60-69 and 70+ years, 2ptrend =0.003). Left-versus-right RRs also increased with time since cancer diagnosis (1.03, 1.11, 1.19 and 1.21 during 0-4, 5-14, 15-24 and 25+ years, 2ptrend =0.002) while for women who also received chemotherapy, the left-versus-right RR was 1.42 (95% confidence interval 1.13-1.77), compared to 1.10 (1.05-1.16) for women who did not (2pdifference = 0.03). These results show that the relative increase in cardiac mortality from cardiac exposure during breast cancer radiotherapy given in the past was greater in younger women, lasted into the third decade after exposure and was greater when chemotherapy was also given.

The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries

In high-income countries, the biggest cause of premature death, defined as death before 70 years, is smoking of manufactured cigarettes. Smoking-related disease was responsible for about 41 million deaths in the United States, United Kingdom and Canada, cumulatively, from 1960 to 2020. Every million cigarettes smoked leads to one death in the US and Canada, but slightly more than one death in the UK. The 21^st century hazards reveal that smokers who start smoking early in adult life and do not quit lose a decade of life expectancy versus non-smokers. Cessation, particularly before age 40 years, yields large reductions in mortality risk. Up to two-thirds of deaths among smokers are avoidable at non-smoking death rates, and former smokers have about only a quarter of the excess risk of death compared to current smokers. The gap between scientific and popular understanding of smoking hazards is surprisingly large.

Risk of Coronary Heart Disease Among Smokeless Tobacco Users: Results of Systematic Review and Meta-Analysis of Global Data

Background

Use of smokeless tobacco (SLT) products has been linked to multiple adverse effects, especially precancer and cancer of oral cavity. However, the association of SLT use with risk of coronary heart disease (CHD) is shrouded with controversy due to conflicting results in the literature. The present meta-analysis aimed to evaluate the risk of CHD among adult ever-users of SLT products along with sub-group analysis.

Methods

The analysis included studies retrieved from a systematic literature search for published articles assessing risk of CHD with SLT use. Two authors independently extracted risk estimates and study characteristics of the included studies. Summary relative risks were estimated using the random-effect model.

Results

Twenty studies from four WHO regions were included in the analysis. The summary risk of CHD in SLT users was not significantly positive (1.05, 95% CI = 0.96 to 1.15) although a higher risk of fatal CHD was seen (1.10, 95% CI = 1.00 to 1.20). The risk was significant for users in European Region (1.30, 95% CI = 1.14 to 1.47). The results remained unchanged even after strict adjustment for smoking. Product-wise analysis revealed a significant positive association of fatal CHD with snus/snuff use (1.37, 95% CI = 1.14 to 1.61). The SLT-attributable fraction of fatal CHD was calculated to be 0.3%, highest being for European region (5%).

Conclusion

A significant positive association was detected between SLT use and risk of fatal CHD, especially for European users and those consuming snus/snuff. In view of the positive association even after strict adjustment for smoking, these results underscore the need for inclusion of cessation efforts for smokeless tobacco in addition to smoking for control of fatal cardiovascular diseases.

Implications

The present meta-analysis demonstrates a global perspective of association between coronary heart disease (CHD) and use of smokeless tobacco (SLT), especially for fatal cardiac events, even with strict adjustment for smoking. There appears to be some difference in this effect based on the type of SLT product used. These results highlight the independent deleterious effect of SLT products on the outcome of CHD and might help to resolve the long-standing controversy regarding the association of SLT with the risk of CHD. Hence, we propose that in addition to smoking, cessation efforts should be directed towards SLT products as well, for control of cardiovascular diseases.

Smoking and cancer, cardiovascular and total mortality among older adults: The Finrisk Study

Little information is available about the deleterious effect of smoking in older adults The objective of this study was to assess the relationship of smoking habits with cancer, CVD and all-cause mortality in late middle-age (45–64 years) and older (65–74) people. This cohort study of 6516 men and 6514 women studied the relationship of smoking habits with cancer, cardiovascular disease (CVD) and all-cause mortality among middle-aged and older Finnish men and women during 1997–2013. The study cohort was followed up until the end of 2013 (median follow-up time was 11.8 years). Mortality data were obtained from the National Causes of Death Register and data on incident stroke events from the National Hospital Discharge Register. Adjusted Hazard ratios (HR) for total mortality were 2.61 (95% Confidence interval 2.15–3.18) among 45–64 years-old men and 2.59 (2.03–3.29) in 65–74 years-old men. The corresponding HRs for women 45–64 years-of-age were 3.21 (2.47–4.19) and 3.12 (2.09–4.68) for those 65–74 years-old, respectively. Adjusted HRs for CVD mortality in the 45–64 years-old and 65–74 years-old groups were 2.67 (1.92–2.67) and 1.95 (1.33–2.86) in men, and 4.28 (2.29–7.99) and 2.67 (1.28–5.58) in women, respectively. Among men, the risk difference between never and current smokers was 108/100.000 in the age-group 45–64 years, and 324/100.000 in the age group 65–74 years. Among women the differences were 52/100.000 and 196/100.000, respectively. In conclusion, absolute risk difference between never and current smokers are larger among the older age group. Smoking cessation counseling should routinely target also older adults in primary health-care.

Tar level of cigarettes smoked and risk of smoking-related diseases

BACKGROUND

Opinions differ on the relationship between tar level and risk of smoking-related disease. However, except for lung cancer, few reviews have evaluated the epidemiological evidence. Here the relationship of tar level to risk of the four main smoking-related diseases is considered.

METHODS

Papers comparing risk of lung cancer, COPD, heart disease or stroke in smokers of lower and higher tar yield cigarettes were identified from reviews and searches, relative risk estimates being extracted comparing the lowest and highest tar groups. Meta-analyses investigated heterogeneity by various study characteristics.

RESULTS

Twenty-six studies were identified, nine of prospective design and 17 case-control. Two studies grouped cigarettes by nicotine rather than tar. Seventeen studies gave results for lung cancer, 16 for heart disease, five for stroke and four for COPD. Preferring relative risks adjusted for daily amount smoked, where adjusted and unadjusted estimates were available, combined estimates for lowest versus highest tar (or nicotine) groups were 0.78 (95% confidence interval 0.70-0.88) for lung cancer, 0.86 (0.81-0.91) for heart disease, 0.77 (0.62-0.95) for stroke and 0.81 (0.65-1.02) for COPD. Lower risks were generally evident in subgroups by publication period, gender, study design, location and extent of confounder adjustment. Estimates were similar preferring data unadjusted for amount smoked or excluding nicotine-based estimates.

CONCLUSIONS

Despite evidence that smokers substantially compensate for reduced cigarette yields, the results clearly show lower risks in lower tar smokers. Limitations of the evidence are discussed, but seem unlikely to affect this conclusion.

Smoking and Severe Acute Respiratory Syndrome

In April 2003, rumours spread that smoking protected patients from developing SARS (Severe Acute Respiratory Syndrome). In a case-control study of 447 patients who attended a SARS screening clinic, 63 patients were admitted with SARS. Although a higher proportion of SARS cases were non-smokers than smokers, the adjusted odds of non-smokers with SARS was 1.7 (p=0.54). There is no evidence that smoking protects patients from developing SARS.

Myocardial infarction in the Wisconsin Longitudinal Study: the interaction among environmental, health, social, behavioural and genetic factors

OBJECTIVES

This study examined how environmental, health, social, behavioural and genetic factors interact to contribute to myocardial infarction (MI) risk.

DESIGN

Survey data collected by Wisconsin Longitudinal Study (WLS), USA, from 1957 to 2011, including 235 environmental, health, social and behavioural factors, and 77 single- nucleotide polymorphisms were analysed for association with MI. To identify associations with MI we utilized recursive partitioning and random forest prior to logistic regression and chi-squared analyses.

PARTICIPANTS

6198 WLS participants (2938 men; 3260 women) who (1) had a MI before 72 years and (2) had a MI between 65 and 72 years.

RESULTS

In men, stroke (LR OR: 5.01, 95% CI 3.36 to 7.48), high cholesterol (3.29, 2.59 to 4.18), diabetes (3.24, 2.53 to 4.15) and high blood pressure (2.39, 1.92 to 2.96) were significantly associated with MI up to 72 years of age. For those with high cholesterol, the interaction of smoking and lower alcohol consumption increased prevalence from 23% to 41%, with exposure to dangerous working conditions, a factor not previously linked with MI, further increasing prevalence to 50%. Conversely, MI was reported in <2.5% of men with normal cholesterol and no history of diabetes or depression. Only stroke (4.08, 2.17 to 7.65) and diabetes (2.71, 1.81 to 4.04) by 65 remained significantly associated with MI for men after age 65. For women, diabetes (5.62, 4.08 to 7.75), high blood pressure (3.21, 2.34 to 4.39), high cholesterol (2.03, 1.38 to 3.00) and dissatisfaction with their financial situation (4.00, 1.94 to 8.27) were significantly associated with MI up to 72 years of age. Conversely, often engaging in physical activity alone (0.53, 0.32 to 0.89) or with others (0.34, 0.21 to 0.57) was associated with the largest reduction in odds of MI. Being non-diabetic with normal blood pressure and engaging in physical activity often lowered prevalence of MI to 0.2%. Only diabetes by 65 (4.25, 2.50 to 7.24) and being exposed to dangerous work conditions at 54 (2.24, 1.36 to 3.69) remained significantly associated with MI for women after age 65, while still menstruating at 54 (0.46, 0.23 to 0.91) was associated with reduced odds of MI.

CONCLUSIONS

Together these results indicate important differences in factors associated with MI between the sexes, that combinations of factors greatly influence the likelihood of MI, that MI-associated factors change and associations weaken after 65 years of age in both sexes, and that the limited genotypes assessed were secondary to environmental, health, social and behavioral factors.

Association between Helicobacter pylori infection and angiographically demonstrated coronary artery disease: A meta-analysis

Coronary artery disease (CAD) is a leading cause of mortality globally. However, the etiology and pathogenesis of CAD are not fully understood. The aim of the present meta-analysis was to estimate the association between the risk of CAD and Helicobacter pylori (H. pylori) infection. A literature search was performed to identify eligible studies published prior to August 14, 2014. Fixed or random effect meta-analytical methods were used to pool the data and perform the subgroup analyses. The effect measures estimated were the odds ratios (OR) for dichotomous data reported with 95% confidence intervals (95% CI). Of the 109 studies identified using the search parameters, 26 cross-sectional studies were eligible involving 3,901 CAD patients and 2,751 controls. H. pylori infection was associated with an increased risk of CAD (OR: 1.96, 95% CI: 1.47-2.63, P<0.00001). When the adjusted ORs were used to conduct another meta-analysis, the OR value decreased, but the association remained significant (OR: 1.42, 95% CI: 1.09-1.86, P=0.008). The association between H. pylori infection and CAD risk was stronger in younger individuals than in older individuals (OR: 2.36, 95% CI 1.50-3.73 vs. OR: 1.59, 95% CI: 1.19-2.11). A significant association was observed in studies from Europe (OR: 2.11, 95% CI: 1.54-2.88, P=0.01) and the USA (OR: 1.43, 95% CI: 1.08-1.91, P=0.36). There is a potential association between H. pylori infection and the risk of CAD. The association may be influenced by age and ethnicity.

Tar yield and risk of acute myocardial infarction: pooled analysis from three case-control studies

BACKGROUND

Controversial information is available with reference to the role of type or yield of cigarettes on the risk of cardiovascular disease.

DESIGN

We considered the issue in a combined dataset of three case-control studies of acute myocardial infarction conducted in Italy between 1983 and 2003.

METHODS

Cases were 1990 subjects with a first episode of non-fatal acute myocardial infarction, and controls were 2521 patients in hospital for acute diseases unrelated to smoking or other recognized risk factors for myocardial infarction. The odds ratio and the corresponding 95% confidence interval (CI) were derived by unconditional multiple logistic regression models, including terms for age, sex, and several major risk factors for myocardial infarction.

RESULTS

As compared to never smokers, the multivariate odds ratio was 2.70 (95% CI 2.01-3.63) for smokers of low tar cigarettes (<10 mg), 3.06 (95% CI 2.53-3.70) for intermediate (10-19 mg) and 3.14 (95% CI 2.12-4.64) for high tar yield (> or =20 mg). After further allowance for duration of smoking and number of cigarettes per day, as compared to low tar yield cigarettes, the odds ratio was 1.14 (95% CI 0.85-1.53) for intermediate, and 1.28 (95% CI 0.81-2.02) for high tar yield.

CONCLUSION

Our study confirms that no substantial reduction in acute myocardial infarction risk resulted from the decrease of cigarette tar yield.

Smoking and Adverse Outcomes in Patients With CKD: The Study of Heart and Renal Protection (SHARP)

Background

The absolute and relative importance of smoking to vascular and nonvascular outcomes in people with chronic kidney disease (CKD), as well its relevance to kidney disease progression, is uncertain.

Study Design

Observational study.

Setting & Participants

9,270 participants with CKD enrolled in SHARP.

Predictor

Baseline smoking status (current, former, and never).

Outcomes

Vascular events, site-specific cancer, ESRD, rate of change in estimated glomerular filtration rate (eGFR), and cause-specific mortality.

Results

At baseline, 1,243 (13%) participants were current smokers (median consumption, 10 cigarettes/day); 3,272 (35%), former smokers; and 4,755 (51%), never smokers. Median follow-up was 4.9 years. Vascular event rates were 36% higher for current than never smokers (2,317 events; relative risk [RR], 1.36; 95% CI, 1.19-1.55), reflecting increases in both atherosclerotic (RR, 1.49; 95% CI, 1.26-1.76) and nonatherosclerotic (RR, 1.25; 95% CI, 1.05-1.50) events. Cancer was 37% higher among current smokers (632 events; RR, 1.37; 95% CI, 1.07-1.76), with the biggest RRs for lung (RR, 9.31; 95% CI, 4.37-19.83) and upper aerodigestive tract (RR, 4.87; 95% CI, 2.10-11.32) cancers. For 6,245 patients not receiving dialysis at baseline, ESRD incidence did not differ significantly between current and never smokers (2,141 events; RR, 1.02; 95% CI, 0.89-1.17), nor did estimated rate of change in eGFR (current smokers, −1.77 ± 0.14 [SE]; never smokers, −1.70 ± 0.07 mL/min/1.73 m² per year). All-cause mortality was 48% higher among current smokers (2,257 events; RR, 1.48; 95% CI, 1.30-1.70), with significant increases in vascular (RR, 1.35; 95% CI, 1.07-1.69) and nonvascular (RR, 1.60; 95% CI, 1.34-1.91) causes of death, especially cancer (RR, 2.32; 95% CI, 1.58-3.40) and respiratory (RR, 2.25; 95% CI, 1.51-3.35) mortality.

Limitations

Smoking status not assessed during follow-up.

Conclusions

In this study of patients with CKD, smoking significantly increased the risks for vascular and nonvascular morbidity and mortality, but was not associated with kidney disease progression. The associations with vascular and neoplastic disease are in keeping with those observed in the general population and are likely modifiable by cessation.

Correlation of Smoking and Myocardial Infarction Among Sudanese Male Patients Above 40 Years of Age

To find an association between smoking and the development of myocardial infarction in male patients above forty years of age presenting at the echocardiology department of Sudan heart center Khartoum. A prospective cohort study was carried out at the echocardiography department of Sudan Heart Center in Khartoum-Sudan between July 2012 and June 2014. The study population comprised a total of 168 adult male patients who underwent cardiac ultrasound scanning. Out of a total of 144 cases, 65% (94) of patients were smokers, 74% of the 94 cases smoked for more than 10 years, and 26% of the 94 cases smoked for less than 10 years. With this study it was concluded that smoking is a risk factor for the development of myocardial infarction. This study showed that patients with myocardial infarction are more likely to have a past history of smoking.

Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes: Clinical Perspectives From the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology

Cardiovascular morbidity and mortality as a result of inhaled tobacco products continues to be a global healthcare crisis, particularly in low- and middle-income nations lacking the infrastructure to develop and implement effective public health policies limiting tobacco use. Following initiation of public awareness campaigns 50 years ago in the United States, considerable success has been achieved in reducing the prevalence of cigarette smoking and exposure to secondhand smoke. However, there has been a slowing of cessation rates in the United States during recent years, possibly caused by high residual addiction or fatigue from cessation messaging. Furthermore, tobacco products have continued to evolve faster than the scientific understanding of their biological effects. This review considers selected updates on the genetics and epigenetics of smoking behavior and associated cardiovascular risk, mechanisms of atherogenesis and thrombosis, clinical effects of smoking and benefits of cessation, and potential impact of electronic cigarettes on cardiovascular health.

Contributions of risk factors and medical care to cardiovascular mortality trends

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

The risk and burden of smoking related heart disease mortality among young people in the United States

PURPOSE

Although cigarette smoking remains the most common risk factor for heart disease among the young, few studies have explored the relationship of smoking with heart disease mortality risk among young people. This prospective study assesses the risk and burden of all heart disease (HD) and coronary heart disease (CHD) mortality associated with smoking among younger adults from a nationally representative sample of the United States.

METHOD

National Health Interview Survey respondents' data from 1997-2004 were linked to their death records through 2006. The analyses were restricted to individuals 18 to 44 years of age during follow up (n = 121,284). Cox proportional hazard ratios (HR) were estimated with adjustment for sample weights and design effects. Attributable fractions (AF) of smoking were calculated.

RESULTS

After controlling for age, race, body mass index, history of hypertension and diabetes, and leisure time physical activity, current smoking related CHD mortality HR was 14.6 [95 % confidence interval or CI, 3.3-64.9] for females and 3.6 [95 % CI, 1.2-10.4] for males. The HR for all HD mortality was 3.1 [95 % CI, 1.3-7.6] for females and 2.4 [95 % CI, 1.2-4.7] for males. The AF of smoking for CHD deaths for female and male were 0.58 and 0.54 respectively. The AF of all HD mortality was 0.31 for male and 0.32 for female. The mean estimates of all HD deaths attributable to smoking during 1997-2006 among this age group were 52,214, of which 45,147 were CHD deaths.

CONCLUSION

Even after adjustment for multiple risk factors and without addressing passive smoking, our result showed a strong relationship between smoking and HD and CHD mortality among young adults that is likely causal.

The Bangladesh Risk of Acute Vascular Events (BRAVE) Study: objectives and design

During recent decades, Bangladesh has experienced a rapid epidemiological transition from communicable to non-communicable diseases. Coronary heart disease (CHD), with myocardial infarction (MI) as its main manifestation, is a major cause of death in the country. However, there is limited reliable evidence about its determinants in this population. The Bangladesh Risk of Acute Vascular Events (BRAVE) study is an epidemiological bioresource established to examine environmental, genetic, lifestyle and biochemical determinants of CHD among the Bangladeshi population. By early 2015, the ongoing BRAVE study had recruited over 5000 confirmed first-ever MI cases, and over 5000 controls "frequency-matched" by age and sex. For each participant, information has been recorded on demographic factors, lifestyle, socioeconomic, clinical, and anthropometric characteristics. A 12-lead electrocardiogram has been recorded. Biological samples have been collected and stored, including extracted DNA, plasma, serum and whole blood. Additionally, for the 3000 cases and 3000 controls initially recruited, genotyping has been done using the CardioMetabochip+ and the Exome+ arrays. The mean age (standard deviation) of MI cases is 53 (10) years, with 88 % of cases being male and 46 % aged 50 years or younger. The median interval between reported onset of symptoms and hospital admission is 5 h. Initial analyses indicate that Bangladeshis are genetically distinct from major non-South Asian ethnicities, as well as distinct from other South Asian ethnicities. The BRAVE study is well-placed to serve as a powerful resource to investigate current and future hypotheses relating to environmental, biochemical and genetic causes of CHD in an important but under-studied South Asian population.

Helicobacter pylori Infection Increase the Risk of Myocardial Infarction: A Meta-Analysis of 26 Studies Involving more than 20,000 Participants

BACKGROUND

Myocardial infarction is a fatal cardiovascular disease and one of the most common death causes all around the world. The aim of the meta-analysis was to quantify the risk of myocardial infarction associated with Helicobacter pylori infection.

METHODS

A literature search was performed to identify studies published before 14 July, 2014, for relevant risk estimates. Fixed and random effect meta-analytical techniques were conducted for myocardial infarction.

RESULTS

Twenty-six case-control studies involving 5829 myocardial infarction patients and more than 16,000 controls were included. Helicobacter pylori infection was associated with an increased risk of myocardial infarction (OR: 2.10, 95%CI: 1.75-2.53, p = .06). We also discovered a significant association between the bacteria and risk of myocardial infarction in young people (OR: 1.93, 95% CI: 1.41-2.66, p = .07), in elder people (OR: 2.02, 95% CI: 1.60-2.54, p = .29), in Caucasians (OR: 2.29, 95% CI: 1.99-2.63, p = .12), and in Asians (OR: 1.75, 95% CI: 1.12-2.73, p = .08).

CONCLUSION

Our meta-analyses suggested a possible indication of relationship between Helicobacter pylori infection and the risk of myocardial infarction. The pathogenicity might not be affected by age and race. More researches should be conducted to explore the mechanisms involved.

Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States

BACKGROUND

Evidence to guide primary prevention in adults aged 75 years or older is limited.

OBJECTIVE

To project the population impact and cost-effectiveness of statin therapy in adults aged 75 years or older.

DESIGN

Forecasting study using the Cardiovascular Disease Policy Model, a Markov model.

DATA SOURCES

Trial, cohort, and nationally representative data sources.

TARGET POPULATION

U.S. adults aged 75 to 94 years.

TIME HORIZON

10 years.

PERSPECTIVE

Health care system.

INTERVENTION

Statins for primary prevention based on low-density lipoprotein cholesterol threshold of 4.91 mmol/L (190 mg/dL), 4.14 mmol/L (160 mg/dL), or 3.36 mmol/L (130 mg/dL); presence of diabetes; or 10-year risk score of at least 7.5%.

OUTCOME MEASURES

Myocardial infarction (MI), coronary heart disease (CHD) death, disability-adjusted life-years, and costs.

RESULTS OF BASE-CASE ANALYSIS

All adults aged 75 years or older in the National Health and Nutrition Examination Survey have a 10-year risk score greater than 7.5%. If statins had no effect on functional limitation or cognitive impairment, all primary prevention strategies would prevent MIs and CHD deaths and be cost-effective. Treatment of all adults aged 75 to 94 years would result in 8 million additional users and prevent 105 000 (4.3%) incident MIs and 68 000 (2.3%) CHD deaths at an incremental cost per disability-adjusted life-year of $25 200.

RESULTS OF SENSITIVITY ANALYSIS

An increased relative risk for functional limitation or mild cognitive impairment of 1.10 to 1.29 could offset the cardiovascular benefits.

LIMITATION

Limited trial evidence targeting primary prevention in adults aged 75 years or older.

CONCLUSION

At effectiveness similar to that in trials, statins are projected to be cost-effective for primary prevention; however, even a small increase in geriatric-specific adverse effects could offset the cardiovascular benefit. Improved data on the potential benefits and harms of statins are needed to inform decision making.

PRIMARY FUNDING SOURCE

American Heart Association Western States Affiliate, National Institute on Aging, and the National Institute for Diabetes on Digestive and Kidney Diseases.

Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium

OBJECTIVE

To investigate the impact of smoking and smoking cessation on cardiovascular mortality, acute coronary events, and stroke events in people aged 60 and older, and to calculate and report risk advancement periods for cardiovascular mortality in addition to traditional epidemiological relative risk measures.

DESIGN

Individual participant meta-analysis using data from 25 cohorts participating in the CHANCES consortium. Data were harmonised, analysed separately employing Cox proportional hazard regression models, and combined by meta-analysis.

RESULTS

Overall, 503,905 participants aged 60 and older were included in this study, of whom 37,952 died from cardiovascular disease. Random effects meta-analysis of the association of smoking status with cardiovascular mortality yielded a summary hazard ratio of 2.07 (95% CI 1.82 to 2.36) for current smokers and 1.37 (1.25 to 1.49) for former smokers compared with never smokers. Corresponding summary estimates for risk advancement periods were 5.50 years (4.25 to 6.75) for current smokers and 2.16 years (1.38 to 2.39) for former smokers. The excess risk in smokers increased with cigarette consumption in a dose-response manner, and decreased continuously with time since smoking cessation in former smokers. Relative risk estimates for acute coronary events and for stroke events were somewhat lower than for cardiovascular mortality, but patterns were similar.

CONCLUSIONS

Our study corroborates and expands evidence from previous studies in showing that smoking is a strong independent risk factor of cardiovascular events and mortality even at older age, advancing cardiovascular mortality by more than five years, and demonstrating that smoking cessation in these age groups is still beneficial in reducing the excess risk.

Epidemiology and public health policy of tobacco use and cardiovascular disorders in low- and middle-income countries

All forms of tobacco lead to an increased risk of cardiovascular disorders. During the past few decades, the number of people who consume tobacco has increased worldwide because of an overall increase in the global population. It is estimated that close to 80% of the >1.3 billion people who smoke tobacco in the world are in low- and middle-income countries. Smokeless forms of tobacco are also widely consumed in low- and middle-income countries, including chewable and snuffed forms. Lack of targeted and effective strategies to control tobacco consumption contributes to a large burden of cardiovascular disorders in low- and middle-income countries, where cardiovascular disorders have become the leading cause of morbidity and mortality. In this review, we evaluate the epidemiology of tobacco use in low- and middle-income countries and assess the public health policies needed to control tobacco use in such regions for the prevention of cardiovascular disorders and other tobacco-related morbidities and mortality.

Impact of smoking on the quantity and quality of antibodies induced by human papillomavirus type 16 and 18 AS04-adjuvanted virus-like-particle vaccine - a pilot study

Background

The AS04-adjuvanted bivalent L1 virus-like-particle (VLP) vaccine (Cervarix™) against infection with human papillomavirus (HPV) types 16/18 holds great promise to prevent HPV16/18 infections and associated neoplasias, but it is important to rule out significant co-factors of the neoplasias like smoking.

Methods

We conducted a pilot study to compare the quantity and quality of HPV16/18 antibody response at baseline and 7 months post vaccination in 104 non-smoking and 112 smoking female participants vaccinated at 0, 1 and 6 months with Cervarix™ (55 and 48 study participants) or with Hepatitis A vaccine (HAVRIX™) (48 and 64 participants, respectively). These 216 women were a sub-sample of 4808 baseline 16- to 17-year old Finnish women initially enrolled in the double-blind, randomized controlled phase III PATRICIA trial. Following end-of-study unblinding in 2009 they were randomly chosen out of all the participants of the three major Finnish PATRICIA study sites in the Helsinki metropolitan area (University of Helsinki, N = 535, and Family Federation Finland, N = 432) and Tampere (University of Tampere, N = 428). Following enrolment, serum samples were collected at month 0 and month 7 post 1st vaccination shot, and were analysed for levels and avidity of IgG antibodies to HPV16 and HPV18 using standard and modified (4 M urea elution) VLP ELISAs.

Results

We found that at month 7 post vaccination women who smoked (cotinine level > 20 ng/ml) had levels of anti-HPV16/18 antibodies comparable to those of non-smoking women. Low-avidity HPV16/18 IgG antibodies were observed in 16% of the vaccinated women, and active smoking conferred a three-fold increased risk (95% CI 1.0-9.3) of having the low-avidity antibodies.

Conclusion

Our data suggest that while smoking does not interfere with the quantity of vaccine-induced peak IgG levels, it may affect the avidity of IgG induced by HPV16/18 vaccination.

Coronary heart disease mortality in relation to dietary, lifestyle and biochemical risk factors in the countries of the Seven Countries Study: a secondary dataset analysis

BACKGROUND

The present study explored coronary heart disease (CHD) mortality rates in 2011 in countries that participated in the Seven Countries Study (SCS) in relation to several dietary and anthropometric/biochemical risk factors. Special focus was given to Crete and the Ionian Islands.

METHODS

This was a cross-sectional study of secondary analysis of databases using data from the World Health Organization, the Food and Agriculture Organization database and the Greek National Cadaster and Cartography Organization. Geographically weighted regression was applied to identify the high-risk regions in relation to the significant factors.

RESULTS

Crete, the Ionian Islands and Japan had the lowest mortality rates (28.9, 30.1 and 31.2 deaths/100,000 people, respectively) in contrast to Serbia/Montenegro that presented the highest rates (105.1 deaths/100,000 people). Diet, physical inactivity and hypertension were found to be the most significant factors in the model (P < 0.05). Regions of no risk were Crete, Ionian Islands and Japan (exponent B = 0.65; 95% confidence interval = 0.293-0.942; P < 0.001), whereas Serbia/Montenegro and Finland were identified as high-risk areas with a 2.97-fold higher probability for CHD mortality (95% confidence interval = 1.736-4.028; P < 0.001).

CONCLUSIONS

Observed patterns of CHD mortality and related factors may be helpful for appropriate management by health planners when aiming to reduce its prevalence, particularly in high-risk areas.

Association between genetic variants on chromosome 15q25 locus and objective measures of tobacco exposure

Background

Two single-nucleotide polymorphisms, rs1051730 and rs16969968, located within the nicotinic acetylcholine receptor gene cluster on chromosome 15q25 locus, are associated with heaviness of smoking, risk for lung cancer, and other smoking-related health outcomes. Previous studies have typically relied on self-reported smoking behavior, which may not fully capture interindividual variation in tobacco exposure.

Methods

We investigated the association of rs1051730 and rs16969968 genotype (referred to as rs1051730–rs16969968, because these are in perfect linkage disequilibrium and interchangeable) with both self-reported daily cigarette consumption and biochemically measured plasma or serum cotinine levels among cigarette smokers. Summary estimates and descriptive statistical data for 12 364 subjects were obtained from six independent studies, and 2932 smokers were included in the analyses. Linear regression was used to calculate the per-allele association of rs1051730–rs16969968 genotype with cigarette consumption and cotinine levels in current smokers for each study. Meta-analysis of per-allele associations was conducted using a random effects method. The likely resulting association between genotype and lung cancer risk was assessed using published data on the association between cotinine levels and lung cancer risk. All statistical tests were two-sided.

Results

Pooled per-allele associations showed that current smokers with one or two copies of the rs1051730–rs16969968 risk allele had increased self-reported cigarette consumption (mean increase in unadjusted number of cigarettes per day per allele = 1.0 cigarette, 95% confidence interval [CI] = 0.57 to 1.43 cigarettes, P = 5.22 × 10⁻⁶) and cotinine levels (mean increase in unadjusted cotinine levels per allele = 138.72 nmol/L, 95% CI = 97.91 to 179.53 nmol/L, P = 2.71 × 10⁻¹¹). The increase in cotinine levels indicated an increased risk of lung cancer with each additional copy of the rs1051730–rs16969968 risk allele (per-allele odds ratio = 1.31, 95% CI = 1.21 to 1.42).

Conclusions

Our data show a stronger association of rs1051730–rs16969968 genotype with objective measures of tobacco exposure compared with self-reported cigarette consumption. The association of these variants with lung cancer risk is likely to be mediated largely, if not wholly, via tobacco exposure.

Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies

BACKGROUND

Prevalence of smoking is increasing in women in some populations and is a risk factor for coronary heart disease. Whether smoking confers the same excess risk of coronary heart disease for women as it does for men is unknown. Therefore, we aimed to estimate the effect of smoking on coronary heart disease in women compared with men after accounting for sex differences in other major risk factors.

METHODS

We undertook a systematic review and meta-analysis of prospective cohort studies published between Jan 1, 1966, and Dec 31, 2010, from four online databases. We selected cohort studies that were stratified by sex with measures of relative risk (RR), and associated variability, for coronary heart disease and current smoking compared with not smoking. We pooled data with a random effects model with inverse variance weighting, and estimated RR ratios (RRRs) between men and women.

FINDINGS

We reviewed 8005 abstracts and included 26 articles with data for 3,912,809 individuals and 67,075 coronary heart disease events from 86 prospective trials. In 75 cohorts (2·4 million participants) that adjusted for cardiovascular risk factors other than coronary heart disease, the pooled adjusted female-to-male RRR of smoking compared with not smoking for coronary heart disease was 1·25 (95% CI 1·12-1·39, p<0·0001). This outcome was unchanged after adjustment for potential publication bias and there was no evidence of important between-study heterogeneity (p=0·21). The RRR increased by 2% for every additional year of study follow-up (p=0·03). In pooled data from 53 studies, there was no evidence of a sex difference in the RR between participants who had previously smoked compared with those who never had (RRR 0·96, 95% CI 0·86-1·08, p=0·53).

INTERPRETATION

Whether mechanisms underlying the sex difference in risk of coronary heart disease are biological or related to differences in smoking behaviour between men and women is unclear. Tobacco-control programmes should consider women, particularly in those countries where smoking among young women is increasing in prevalence.

FUNDING

None.

The impact of the aging population on coronary heart disease in the United States

BACKGROUND

The demographic shift toward an older population in the United States will result in a higher burden of coronary heart disease, but the increase has not been quantified in detail. We sought to estimate the impact of the aging US population on coronary heart disease.

METHODS

We used the Coronary Heart Disease Policy Model, a Markov model of the US population between 35 and 84 years of age, and US Census projections to model the age structure of the population between 2010 and 2040.

RESULTS

Assuming no substantive changes in risks factors or treatments, incident coronary heart disease is projected to increase by approximately 26%, from 981,000 in 2010 to 1,234,000 in 2040, and prevalent coronary heart disease by 47%, from 11.7 million to 17.3 million. Mortality will be affected strongly by the aging population; annual coronary heart disease deaths are projected to increase by 56% over the next 30 years, from 392,000 to 610,000. Coronary heart disease-related health care costs are projected to rise by 41% from $126.2 billion in 2010 to $177.5 billion in 2040 in the United States. It may be possible to offset the increase in disease burden through achievement of Healthy People 2010/2020 objectives or interventions that substantially reduce obesity, blood pressure, or cholesterol levels in the population.

CONCLUSIONS

Without considerable changes in risk factors or treatments, the aging of the US population will result in a sizeable increase in coronary heart disease incidence, prevalence, mortality, and costs. Health care stakeholders need to plan for the future age-related health care demands of coronary heart disease.

Smoking effect on ischemic heart disease in young patients

Objective:

To evaluate the effect of tobacco smoking on the risk of nonfatal acute myocardial infarction in young adults (≤45 years).

Patient and Methods:

We conducted a population-based case-control study with 329 incident acute myocardial infarction cases (42 women; 287 men), consecutively admitted to the Cardiology department of hospitals in Aleppo, Syria, and 778 controls (486 women; 292 men), selected within the noninstitutionalized Aleppo population, during 2008-2010. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using unconditional logistic regression.

Results:

The prevalence of current smoking was 80.8% in male cases and 53.8% in male controls (OR = 3.63, 95%CI: 2.50, 5.27) and 59.5% of female cases were smokers compared with 35.8% of controls (OR = 2.64, 95%CI: 1.39, 5.02). No interaction was found between current smoking and gender on myocardial infarction risk (P = 0.401). A dose-effect response was present, the odds favoring myocardial infarction reaching an eight-fold increase for those who smoked >25 cigarettes/day compared with never smokers. The risk estimate for former smokers was similar to never smokers.

Conclusions:

Tobacco smoking is an important independent risk factor for acute myocardial infarction in young adults, with similar strength of association for both genders.

Smoking and cardiovascular health: a review of the epidemiology, pathogenesis, prevention and control of tobacco

The causal associations between cigarette smoking and human diseases are irrefutable. In this review, we focus on the epidemiological pattern of cigarette smoking on cardiovascular risk, the underlying mechanistic process of such a causal link, how to prevent premature cardiovascular morbidity and mortality particularly through smoking cessation, and the health benefits of such cessation measures. Finally, we conclude our review summarizing a few of the proven evidence-based tobacco control strategies and policies from across the globe. We did not conduct a systematic review but followed a similar structure. We abstracted the most relevant published literature on the electronic databases, namely, PubMed, Embase and the Cochrane Library applying specific search terms. We also searched gray literature and consulted experts in the field for cross-references. Smoking has been estimated to cause about 11% of all deaths due to cardiovascular disease. Smoking contributes to the pathogenesis of coronary artery disease and sudden death through a variety of mechanisms, including the promotion of atherosclerosis, the triggering of coronary thrombosis, coronary artery spasm, and cardiac arrhythmias, and through reduced capacity of the blood to deliver oxygen. Smoking cessation also confers substantial benefits on people with serious heart disease. Smoking cessation should be viewed as therapeutic rather than preventive intervention, similar to treating asymptomatic hypertension. Smoking cessation is highly cost-effective relative to other frequently used medical and surgical interventions. Tobacco related illnesses are important public health issues worldwide. It has been estimated that there are 1.1 billion smokers worldwide and 250 million of them live in India.

Association of daily tar and nicotine intake with incident myocardial infarction: results from the population-based MONICA/KORA Augsburg Cohort Study 1984-2002

BACKGROUND

Cigarette smoking has been shown to be one of the most important risk factors for cardiovascular diseases. However, little is known about cumulative effects of daily tar and nicotine intake on the risk of incident myocardial infarction (MI) so far. To bridge this gap, we conducted an analysis in a large prospective study from Southern Germany investigating associations of daily tar and nicotine intake with an incident MI event.

METHODS

The study was based on 4,099 men and 4,197 women participating in two population-based MONICA Augsburg surveys between 1984 and 1990 and followed up within the KORA framework until 2002. During a mean follow-up of 13.3 years, a number of 307 men and 80 women developed an incident MI event. Relative risks were calculated as hazard ratios (HRs) estimated by Cox proportional hazards models adjusted for cardiovascular risk factors.

RESULTS

In the present study, male regular smokers consumed on average more cigarettes per day than female regular smokers (20 versus 15) and had a higher tar and nicotine intake per day. In men, the MI risk compared to never-smokers increased with higher tar intake: HRs were 2.24 (95% CI 1.40-3.56) for 1-129 mg/day, 2.12 (95% CI 1.37-3.29) for 130-259 mg/day and 3.01 (95% CI 2.08-4.36) for ≥ 260 mg/day. In women, the corresponding associations were comparable but more pronounced for high tar intake (HR 4.67, 95% CI 1.76-12.40). Similar associations were observed for nicotine intake.

CONCLUSIONS

The present study based on a large population-based sample adds important evidence of cumulative effects of tar and nicotine intake on the risk of incident MI. Even low or medium tar and nicotine intake revealed substantial risk increases as compared to never-smokers. Therefore, reduction of tar and nicotine contents in cigarettes cannot be seen as a suitable public health policy in preventing myocardial infarction.

Smoking habits and the risk of non-fatal acute myocardial infarction in Costa Rica

BACKGROUND

Smoking is a major risk factor for cardiovascular diseases, but there is little information on Latin America.

METHODS

We used data from a case-control study comprising 2094 cases with a first acute non-fatal myocardial infarction (MI) and 2094 matched controls (by age, sex, and area of residence) living in Costa Rica between 1994 and 2004. Relative risks (RRs) were obtained from conditional logistic regression models.

RESULTS

Compared to never smokers, the risk of MI was not higher in ex-smokers, but the RR was 2.71 for current smokers, and increased with the number of cigarettes smoked per day. Smoking ≥25 cigarettes per day was associated with an eight-fold risk of MI. The RR was higher for women (4.39) than for men (2.38). There was no trend in risk with duration and age at starting smoking. RRs were respectively 4.8, 5.6 and 6.1 for smokers of ≥15 cigarettes per day with obesity, diabetes or hypertension compared to non-smokers. Subjects living with a smoker had a 23% higher MI risk. Active and passive smoking accounted for 38% and 8% of MI cases. It explained 25% and 9% of female and 42% and 7% of male cases, 47% and 15% of cases below age 50, and 35% and 5% cases above age 50 years. Stopping smoking reduced the risk of MI already after one year, and after five years the risk approached that of never smokers.

CONCLUSION

In Costa Rica, like elsewhere, inducing smokers to stop is a public health priority.

Effectiveness and cost-effectiveness of blood pressure screening in adolescents in the United States

OBJECTIVE

To compare the long-term effectiveness and cost-effectiveness of 3 approaches to managing elevated blood pressure (BP) in adolescents in the United States: no intervention, "screen-and-treat," and population-wide strategies to lower the entire BP distribution.

STUDY DESIGN

We used a simulation model to combine several data sources to project the lifetime costs and cardiovascular outcomes for a cohort of 15-year-old U.S. adolescents under different BP approaches and conducted cost-effectiveness analysis. We obtained BP distributions from the National Health and Nutrition Examination Survey 1999-2004 and used childhood-to-adult longitudinal correlation analyses to simulate the tracking of BP. We then used the coronary heart disease policy model to estimate lifetime coronary heart disease events, costs, and quality-adjusted life years (QALY).

RESULTS

Among screen-and-treat strategies, finding and treating the adolescents at highest risk (eg, left ventricular hypertrophy) was most cost-effective ($18000/QALY [boys] and $47000/QALY [girls]). However, all screen-and-treat strategies were dominated by population-wide strategies such as salt reduction (cost-saving [boys] and $650/QALY [girls]) and increasing physical education ($11000/QALY [boys] and $35000/QALY [girls]).

CONCLUSIONS

Routine adolescents BP screening is moderately effective, but population-based BP interventions with broader reach could potentially be less costly and more effective for early cardiovascular disease prevention and should be implemented in parallel.

Nordic biological specimen bank cohorts as basis for studies of cancer causes and control: quality control tools for study cohorts with more than two million sample donors and 130,000 prospective cancers

The Nordic countries have a long tradition of large-scale biobanking and comprehensive, population-based health data registries linkable on unique personal identifiers, enabling follow-up studies spanning many decades. Joint Nordic biobank-based studies provide unique opportunities for longitudinal molecular epidemiological research. The Nordic Biological Specimen Banks working group on Cancer Causes and Control (NBSBCCC) has worked out very precise quality assurance principles for handling of the samples, based on the tradition in biobank culture. The aim of this paper is to demonstrate how high standards of quality assurance can also be developed for the data related to the subjects and samples in the biobanks. Some of the practices adopted from the strong Nordic cohort study experience evidently improve quality of nested case-control studies nested in biobank cohorts. The data quality requirements for the standardised incidence ratio calculation offer a good way to check and improve accuracy of person identifiers and completeness of follow-up for vital status, which are crucial in case-control studies for picking up right controls for the cases. The nested case-control design applying incidence-density sampling is recommended as an optimal design for most biobank-based studies. It is demonstrated how some types of biobanks have a period immediately after sampling, when the cancer risk is not comparable with the cancer risk in the base population, and how many of the biobanks never represent the normal average population of the region. The estimates on the population-representativeness of the biobanks assist in interpretation of generalisability of results of the studies based on these samples, and the systematic tabulations of numbers of cancer cases will serve in study power estimations. The well over 130,000 prospective cancer cases registered among subjects in the NBSBCCC biobank cohorts have already offered unique possibilities for tens of strong studies, but for rare exposure-outcome combinations predictions on future numbers of cases improve the chance to select the right moment when the study will have accurate statistical power.

Biobanks and registers in epidemiologic research on cancer

The Nordic countries have a long tradition of register-based epidemiologic studies. Numerous population-based specialized registers offer high-quality data from individuals, and the extensive use of register data further improves the quality of the registers. Unique personal identity codes given to every resident and used in all registers guarantee easy and accurate record linkage. A legislation that makes the use of the existing data possible for purposes that benefit both registered individuals and the society - instead of forcing researchers to use their energy in repeated questionnaire studies, disturbing individuals' privacy and leading to response and recall biases - is a prerequisite for effective epidemiologic research. Biobanks can be considered an additional type of registers. They may offer data from individuals that cannot be reliably collected via questionnaire surveys. In turn, other types of registers are crucial in biobank-based studies (1) in defining for how long the persons in biobank cohorts are at risk of getting the diseases, (2) to get information on cofactors that may modify the relative risk measured by the biomarkers, and (3) to get information on the long-term outcome events. This chapter describes the possibilities of register use mainly in Finland - a typical representative of the Nordic "paradise of register-based epidemiological research" - in research of cancer etiology. The ongoing Nordic research project Changing work life and cancer risk in the Nordic countries (NOCCA) will be described as an example of a massive register use, including both direct linkages on an individual level and indirect group level linkages.

'Maintaining balance and harmony': Javanese perceptions of health and cardiovascular disease

Community intervention programmes to reduce cardiovascular disease (CVD) risk factors within urban communities in developing countries are rare. One possible explanation is the difficulty of designing an intervention that corresponds to the local context and culture.

OBJECTIVES

To understand people's perceptions of health and CVD, and how people prevent CVD in an urban setting in Yogyakarta, Indonesia.

METHODS

A qualitative study was performed through focus group discussions and individual research interviews. Participants were selected purposively in terms of socio-economic status (SES), lay people, community leaders and government officers. Data were analysed by using content analysis.

RESULTS

SEVEN CATEGORIES WERE IDENTIFIED: (1) heart disease is dangerous, (2) the cause of heart disease, (3) men have no time for health, (4) women are caretakers for health, (5) different information-seeking patterns, (6) the role of community leaders and (7) patterns of lay people's action. Each category consists of sub-categories according to the SES of participants. The main theme that emerged was one of balance and harmony, indicating the necessity of assuring a balance between 'good' and 'bad' habits.

CONCLUSIONS

The basic concepts of balance and harmony, which differ between low and high SES groups, must be understood when tailoring community interventions to reduce CVD risk factors.