The fraction of ischaemic heart disease and stroke attributable to smoking in the WHO Western Pacific and South-East Asian regions

The 30 Years of Shifting in The Indonesian Cardiovascular Burden-Analysis of The Global Burden of Disease Study

IMPORTANCE

Cardiovascular disease (CVD) remains the leading cause of mortality and morbidity. Compared with disease burden rates in 1990, significant reductions in Disability-Adjusted Life Years (DALYs) burden rates for CVD have been recorded. However, general DALYs rates have not changed in Indonesia in the past 30 years. Thus, assessing Indonesian CVD burdens will be an essential first step in determining primary disease interventions.

OBJECTIVE

To determine the national and province-level burden of CVD from 1990 to 2019 in Indonesia.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective observational study was conducted using data from the Global Burden of Disease (GBD) 2019, provided by the Institute of Health Metrics and Evaluation (IHME), to analyze trends in the burden of CVD, including mortality, morbidity, and prevalence characteristics of 12 underlying CVDs.

EXPOSURES

Residence in Indonesia.

MAIN OUTCOMES AND MEASURES

Mortality, incidence, prevalence, death, and DALYs of CVD.

RESULTS

CVD deaths have doubled from 278 million in 1990 to 651 million in 2019. All CVDs recorded increased death rates, except for rheumatic heart disease (RHD) (- 69%) and congenital heart disease (CHD) (- 37%). Based on underlying diseases, stroke and ischemic heart disease (IHD) are still the leading causes of mortality and morbidity in Indonesia, whereas stroke and peripheral artery disease (PAD) are the most prevalent CVDs. Indonesia has the second worst CVD DALYs rates compared to ASEAN countries after Laos. At provincial levels, the highest CVD DALY rates were recorded in Bangka Belitung, South Kalimantan, and Yogyakarta. In terms of DALYs rate changes, they were recorded in West Nusa Tenggara (24%), South Kalimantan (18%), and Central Java (11%). Regarding sex, only RHD, and PAD burdens were dominated by females.

CONCLUSIONS

CVD mortality, morbidity, and prevalence rates increased in Indonesia from 1990 to 2019, especially for stroke and ischemic heart disease. The burden is exceptionally high, even when compared to other Southeast Asian countries and the global downward trend. GBD has many limitations. However, these data could provide policymakers with a broad view of CVD conditions in Indonesia.

Health-related physical fitness and blood pressure in people with intellectual disabilities in Korea

Hypertension is one critical health issue causing cardiovascular diseases. There has been a common concern among health researchers that the prevalence of hypertension, known as high blood pressure, has been more frequently observed among people with intellectual disabilities, compared to the general population. Thus, this study aims to identify which health-related physical fitness and body composition factors are significantly related to both systolic and diastolic blood pressures among people with intellectual disabilities. The data from 2180 people with intellectual disability who conducted the physical fitness tests from 2019 to 2020 were used for this study. Four physical fitness tests (i.e., 3-min step, grip strength, sit-up, and sit and reach) and two body compositions (i.e., body mass index and body fat %) used as predictors, and two blood pressures (i.e., systolic blood pressure and diastolic blood pressure) were used as outcome variables. A regression analysis was performed to examine the proposed associations. The regression test revealed that 3-min step, body mass index, and body fat % were significantly associated with both systolic blood pressure and diastolic body pressure. This research contributes to our understanding of the roles of body compositions and aerobic endurance in preventing hypertension among people with intellectual disability.

Cigarette Smoking as a Risk Factor for Hematoma Expansion in Primary Intracerebral Hemorrhage: Analysis From a Randomized Clinical Trial

Background Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage. Methods and Results This is a post hoc exploratory analysis of the ATACH (Antihypertensive Treatment at Acute Cerebral Hemorrhage)-2 trial. Patients with intracerebral hemorrhage were randomized into intensive blood pressure lowering (systolic blood pressure, <139 mm Hg) versus standard blood pressure lowering (systolic blood pressure, 140-179 mm Hg) in this study. We compared the demographic characteristics; hematoma size, location, and expansion rate; and clinical outcome based on subjects' smoking status. Of a total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be men. Baseline Glasgow Coma Scale score and initial hematoma size did not vary based on smoking status. Ever smokers had higher rates of thalamic hemorrhage (42% versus 34%) and intraventricular hemorrhage (29% versus 23%); this rate was highest among former smokers versus current smokers (49% versus 35%, respectively). Ever smokers had a higher rate of hematoma expansion in 24 hours (adjusted relative risk [RR] [95% CI], 1.46 [1.08-1.96]) compared with nonsmokers on multivariate analysis. There was no significant difference in the rate of death and disability at 90 days between the 2 groups (adjusted RR [95% CI], 1.18 [0.998-1.40]). Conclusions Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.

Associations Between Indoor Air Pollutants and Risk Factors for Acute Respiratory Infection Symptoms in Children Under 5: An Analysis of Data From the Indonesia Demographic Health Survey

OBJECTIVES

The study investigated the association between indoor air pollution (IAP) and risk factors for acute respiratory infection (ARI) symptoms in children under 5 years of age.

METHODS

A cross-sectional study was conducted using data derived from Indonesia Demographic and Health Survey in 2017. Binary logistic regression modeling was employed to examine each predictor variable associated with ARI among children under 5 years of age in Indonesia.

RESULTS

The study included a total of 4936 households with children. Among children under 5 years old, 7.2% reported ARI symptoms. The presence of ARI symptoms was significantly associated with the type of residence, wealth index, and father's smoking frequency, which were considered the sample's socio-demographic characteristics. In the final model, living in rural areas, having a high wealth index, the father's smoking frequency, and a low education level were all linked to ARI symptoms.

CONCLUSIONS

The results revealed that households in rural areas had a substantially higher level of reported ARI symptoms among children under 5 years old. Furthermore, the father's smoking frequency and low education level were associated with ARI symptoms.

Association between Shift Work Schedules and Cardiovascular Events in a Multi-Ethnic Cohort

BACKGROUND

Shift work is known to increase the risk of cardiometabolic diseases and mortality. We investigate the relationship between shift work schedules and cardiometabolic risk factors (smoking, hypertension, and obesity) and their association with cardiometabolic diseases (diabetes and cardiovascular diseases) in a multi-ethnic population from Singapore.

METHODS

2469 participants from the Singapore-based Multi-Ethnic Cohort underwent physical and clinical assessments. Shift work schedules (morning, evening, night, and mixed) were assessed using a validated questionnaire.

RESULTS

Among shift workers, night shift workers had a significantly higher prevalence of smoking (54.5%), diabetes (27.3%), and cardiovascular events (14.1%). Compared to non-shift workers, workers in the night (OR = 2.10, 95%CI: 1.26-3.41) and mixed (OR = 1.74, 95%CI: 1.22-2.48) shift groups were more likely to be current smokers. A significant association between shift duration and smoking (OR = 1.02, 95%CI: 1.00-1.03) was also observed, with longer shift duration (in years) leading to an increase in smoking behavior. No significant associations were found between shift work schedules and hypertension, obesity (BMI), diabetes, and cardiovascular disease, as well as other cardiometabolic risk factors and diseases.

CONCLUSION

This study found that shift schedules and shift duration were most strongly associated with smoking status after covariate adjustments (age, gender, ethnicity, socioeconomic status, and work arrangement), with night and mixed shift types being strongly associated with current smoker status. As smoking is a modifiable risk factor for cardiometabolic disease, employers of shift workers should increase work-based health interventions to control smoking and promote a healthier workforce.

Nudging Interventions on Alcohol and Tobacco Consumption in Adults: A Scoping Review of the Literature

Background: The World Health Organization identified alcohol and tobacco consumption as the risk factors with a greater attributable burden and number of deaths related to non-communicable diseases. A promising technique aimed to modify behavioral risk factors by redesigning the elements influencing the choice of people is nudging. Methodology: A scoping review of the literature was performed to map the literature evidence investigating the use of nudging for tobacco and alcohol consumption prevention and/or control in adults. Results: A total of 20 studies were included. The identified nudging categories were increasing salience of information or incentives (IS), default choices (DF), and providing feedback (PF). Almost three-quarters of the studies implementing IS and half of those implementing PF reported a success. Three-quarters of the studies using IS in conjunction with other interventions reported a success whereas more than half of the those with IS alone reported a success. The PF strategy performed better in multi-component interventions targeting alcohol consumption. Only one DF mono-component study addressing alcohol consumption reported a success. Conclusions: To achieve a higher impact, nudging should be integrated into comprehensive prevention policy frameworks, with dedicated education sessions for health professionals. In conclusion, nudge strategies for tobacco and alcohol consumption prevention in adults show promising results. Further research is needed to investigate the use of nudge strategies in socio-economically diverse groups and in young populations.

Sex difference after acute myocardial infarction patients with a history of current smoking and long-term clinical outcomes: Results of KAMIR Registry

BACKGROUND

The contribution of sex as an independent risk factor for cardiovascular disease still remains controversial. The present study investigated the impact of sex on long-term clinical outcomes in Korean acute myocardial infarction (AMI) patients with a history of current smoking on admission after drug-eluting stents (DESs).

METHODS

A total of 12,565 AMI patients (male: n = 11,767 vs. female: n = 798) were enrolled. Major adverse cardiac events (MACEs) comprising all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization were the primary outcomes that were compared between the two groups. Probable or definite stent thrombosis (ST) was the secondary outcome.

RESULTS

After adjustment, the early (30 days) cumulative incidences of MACEs (adjusted hazard ratio [aHR]: 1.457; 95% confidence interval [CI]: 1.021-2.216; p = 0.035) and all-cause death (aHR: 1.699; 95% CI: 1.074-2.687; p = 0.023) were significantly higher in the female group than in the male group. At 2 years, the cumulative incidences of all-cause death (aHR: 1.561; 95% CI: 1.103-2.210; p = 0.012) and Re-MI (aHR: 1.800; 95% CI: 1.089-2.974; p = 0.022) were significantly higher in the female group than in the male group. However, the cumulative incidences of ST were similar between the two groups (aHR: 1.207; 95% CI: 0.583-2.497; p = 0.613).

CONCLUSIONS

The female group showed worse short-term and long-term clinical outcomes compared with the male group comprised of Korean AMI patients with a history of current smoking after successful DES implantation. However, further studies are required to confirm these results.

Assessment of ideal cardiovascular health metrics in refugees, East of Iran

Background

In 2013, there was an estimation of greater than 4.5 million Afghan refugees who had migrated to the least developed countries. Over one million are legally registered in Iran. We assessed the heart health status as described by the American Heart Association (AHA) in the Afghan refugee populace.

Methods

This cross-sectional survey was carried out on 1,634 Afghan refugees, including 746 males (45.7%) and 888 females (54.3%), selected through a convenience sampling method in 2016. The American Heart Association's seven cardiovascular health metrics were evaluated to specify the status of heart health in Afghan refugees. Differences with age and sex were analyzed using the χ² test.

Results

Only one (0.1%) participant met the ideal for all seven cardiovascular health metrics. No significant differences were found between women and men in meeting the ideal criteria for more than five cardiovascular health metrics. As age increased, the proportion of refugees who met the ideal for more than five cardiovascular health metrics declined.

Conclusions

Refugees were not meeting the ideal cardiovascular health for some of the assessed metrics. Intervention to improve and monitor heart health in Afghan refugees is needed.

Associations between smoking habits and major adverse cardiovascular events in patients who underwent coronary computed tomography angiography as screening for coronary artery disease

We analyzed whether smoking was associated with major adverse cardiovascular events (MACE) and the progression of coronary atherosclerosis as assessed by coronary computed tomography angiography (CCTA) as screening for coronary artery disease (CAD). We enrolled 443 patients who had all undergone CCTA and either were clinically suspected of having CAD or had at least one cardiovascular risk factor. We divided the patients into smoking (past and current smoker) and non-smoking groups and into males and females, and evaluated the presence of CAD, severity of coronary atherosclerosis and MACE (cardiovascular death, ischemic stroke, acute myocardial infarction and coronary revascularization) with a follow-up of up to 5 years. %CAD and the severity of coronary atherosclerosis in the smoking group were significantly higher than those in the non-smoking group. %MACE in males and smokers were significantly higher than those in females and non-smokers, respectively. Interestingly, Kaplan-Meier curves also showed that female non-smokers enjoyed significantly greater freedom from MACE than female smokers (p = 0.007), whereas there was no significant difference in freedom from MACE between male non-smokers and male smokers (p = 0.984). Although there were no significant predictors of MACE in all patients according to a multiple logistic regression analysis, smoking was useful for predicting MACE in females, but not males. In conclusion, smoking was significantly associated with MACE in females, but not males, who underwent CCTA as screening for CAD.

Prevalence of Dementia and Associated Risk Factors: A Population-Based Study in the Philippines

BACKGROUND

The Philippines is experiencing rapid demographic aging and with it, the dementia epidemic. Prevalence of dementia and associated risk factors have not been studied in the Philippines.

OBJECTIVES

The study aimed to provide a reliable estimate of dementia prevalence and identify associated risk factors in the Filipino population.

METHODS

1460 participants 60 years and older were randomly selected from the Marikina City's senior registry. A multidisciplinary team (nurse, psychologist, and neurologist) administered a comprehensive assessment to the study population: health history, neurological examination, Geriatric Depression Scale, Neuropsychiatric Inventory, Disability Assessment for Dementia, Alzheimer's Disease 8, and Clinical Dementia Rating Scale. The neurologist analyzed all clinical data to diagnose dementia based on the DSM-IV criteria, Alzheimer's Disease (AD) on the NINCDS-ADRDA criteria, vascular dementia (VaD) on the Hachinski Ischemic Scale, cognitive impairment no dementia (CIND) on a CDR score of 0.5 and not fulfilling DSM-IV criteria for dementia. Risk factors were correlated with dementia prevalence using multivariate binary logistic regression.

RESULTS

1460 persons were randomly selected. 1367 agreed to participate and underwent all assessments. The response rate was 93.6%. Dementia prevalence was found to be 10.6% (95% CI 9.0 to 12.4) with the breakdown 85.5% AD, 11.7% VaD, and 2.7% other dementias. In this population, 82.0% of men and 70.4% of women had at least one cardiovascular risk factor (hypertension, diabetes, dyslipidemia, smoking), which was associated with VaD prevalence but not AD.

CONCLUSION

The prevalence of dementia, CIND, and cardiovascular risk factors are high in the Philippines.

Gene and environmental interactions according to the components of lifestyle modifications in hypertension guidelines

Risk factors for hypertension consist of lifestyle and genetic factors. Family history and twin studies have yielded heritability estimates of BP in the range of 34–67%. The most recent paper of BP GWAS has explained about 20% of the population variation of BP. An overestimation of heritability may have occurred in twin studies due to violations of shared environment assumptions, poor phenotyping practices in control cohorts, failure to account for epistasis, gene-gene and gene-environment interactions, and other non-genetic sources of phenotype modulation that are suspected to lead to underestimations of heritability in GWAS. The recommendations of hypertension guidelines in major countries consist of the following elements: weight reduction, a healthy diet, dietary sodium reduction, increasing physical activity, quitting smoking, and moderate alcohol consumption. The hypertension guidelines are mostly the same for each country or region, beyond race and culture. In this review, we summarize gene-environmental interactions associated with hypertension by describing lifestyle modifications according to the hypertension guidelines. In the era of precision medicine, clinicians who are responsible for hypertension management should consider the gene-environment interactions along with the appropriate lifestyle components toward the prevention and treatment of hypertension. We briefly reviewed the interaction of genetic and environmental factors along the constituent elements of hypertension guidelines, but a sufficient amount of evidence has not yet accumulated, and the results of genetic factors often differed in each study.

Comparative analysis of recurrent events after presentation with an index myocardial infarction or ischaemic stroke

Aims

Acute myocardial infarction (AMI) and stroke are important causes of mortality and morbidity. Our aims are to determine the comparative epidemiology of AMI and ischaemic stroke; and examine the differences in cardiovascular outcomes or mortality occurring after an AMI or stroke.

Methods and results

The Singapore National Registry of Diseases Office collects countrywide data on AMI, stroke, and mortality. Index events of AMI and ischaemic stroke between 2007 and 2012 were identified. Patients were then matched for occurrences of subsequent AMI, stroke, or death within 1-year of the index event. There were 33 222 patients with first-ever AMI and 20 982 with first-ever stroke. AMI patients were significantly more likely to be men (66.3% vs. 56.9%), non-Chinese (32.1% vs. 24.1%), and smokers (43.1% vs. 38.6%), but less likely to have hypertension (65.6% vs. 79%) and hyperlipidaemia (61.1% vs. 65.5%), compared with stroke patients. In total 6.8% of the AMI patients had recurrent AMI, whereas 4.8% of the stroke patients had recurrent stroke within 1 year; 31.7% of the AMI patients died, whereas 17.1% of the ischaemic stroke patients died within 1 year. Older age, Malay ethnicity, and diabetes mellitus were statistically significant risk factors for all-cause mortality and for the composite endpoint of AMI, stroke, and all-cause mortality, at 1 year.

Conclusions

Risk profiles of patients with AMI and stroke are significantly different. Patients suffer recurrent events in vascular territories similar to the index event. Age and diabetes mellitus are significant predictors of recurrent vascular events and mortality.

Myeloperoxidase mediated HDL oxidation and HDL proteome changes do not contribute to dysfunctional HDL in Chinese subjects with coronary artery disease

High density lipoprotein (HDL) cholesterol levels and cholesterol efflux capacity (CEC) are inversely correlated with coronary artery disease (CAD) risk. Myeloperoxidase (MPO) derived oxidants and HDL proteome changes are implicated in HDL dysfunction in subjects with CAD in the United States; however, the effect of MPO on HDL function and HDL proteome in ethnic Chinese population is unknown. We recruited four matched ethnic Chinese groups (20 patients each): subjects with 1) low HDL levels (HDL levels in men <40mg/dL and women <50mg/dL) and non-CAD (identified by coronary angiography or cardiac CT angiography); 2) low HDL and CAD; 3) high HDL (men >50mg/dL; women >60mg/dL) with no CAD; and 4) high HDL with CAD. Serum cytokines, serum MPO levels, serum CEC, MPO-oxidized HDL tyrosine moieties, and HDL proteome were assessed by mass spectrometry individually in the four groups.

The cytokines, MPO levels, and HDL proteome profiles were not significantly different between the four groups. As expected, CEC was depressed in the entire CAD group but more specifically in the CAD low-HDL group. HDL of CAD subjects had significantly higher 3-nitrotyrosine than non-CAD subjects, but the MPO-specific 3-chlorotyrosine was unchanged; CEC in the CAD low-HDL group did not correlate with either HDL 3-chlorotyrosine or 3-nitrotyrosine levels. Neither 3-chlorotyrosine, which is MPO-specific, nor 3-nitrotyrosine generated from MPO or other reactive nitrogen species was associated with CEC. MPO mediated oxidative stress and HDL proteome composition changes are not the primary cause HDL dysfunction in Chinese subjects with CAD. These studies highlight ethnic differences in HDL dysfunction between United States and Chinese cohorts raising possibility of unique pathways of HDL dysfunction in this cohort.

Prevalence of obesity, diabetes mellitus, hypertension and associated risk factors in a mining workforce, Democratic Republic of Congo

Introduction

The burden of non-communicable diseases (NCDs) is increasing in low and middle-income countries (LMIC). According to the World Health Organization (WHO) the largest increase occurs in Africa. Obesity, diabetes mellitus and hypertension (ODH) are major risk factors for cardiovascular diseases, causing nearly 18 million deaths worldwide. Various risks associated with mining as an occupational activity are implicated in NCDs' occurrence. This study describes the baseline prevalence of ODH and associated risk factors in the workforce of Tenke Fungurume Mining (TFM), in southern Democratic Republic of Congo.

Methods

A cross-sectional study was conducted on a sample of 2,749 employees' and contractor's occupational health examination files for 2010. Socio-demographic, occupational, medical, anthropometric and behavioral characteristics were collected and assessed. Disease status regards ODH was based on WHO criteria. A multivariate logistic regression model was used.

Results

Overall prevalence of ODH was 4.5%, 11.7%, and 18.2% respectively. Proportions of pre-ODH individuals were 19.7%, 16.5%, and 47.8% respectively. Prevalence of ODH increased with age, professional grade, nature of work, gender and reported alcohol use. Smoking 10 or more cigarettes per day increased risk of diabetes and hypertension, while decreasing obesity.

Conclusion

Rates of ODH and associated risk factors are higher in the TFM workforce, than in the general DRC population. This is likely reflective of other mining sites in the country and region. It is evident that ODH are associated with various socio-demographic, occupational, anthropometric, biomedical and behavioral risk factors. A NCD prevention program and close monitoring of disease and risk factors trends are needed in this population.

Prevalence of non-communicable disease risk factors in three sites across Papua New Guinea: a cross-sectional study

Papua New Guinea (PNG) is a culturally, environmentally and ethnically diverse country of 7.3 million people experiencing rapid economic development and social change. Such development is typically associated with an increase in non-communicable disease (NCD) risk factors.

AIM

To establish the prevalence of NCD risk factors in three different regions across PNG in order to guide appropriate prevention and control measures.

METHODS

A cross-sectional survey was undertaken with randomly selected adults (15-65 years), stratified by age and sex recruited from the general population of integrated Health and Demographic Surveillance Sites in West Hiri (periurban), Asaro (rural highland) and Karkar Island (rural island), PNG. A modified WHO STEPS risk factor survey was administered along with anthropometric and biochemical measures on study participants.

RESULTS

The prevalence of NCD risk factors was markedly different across the three sites. For example, the prevalences of current alcohol consumption at 43% (95% CI 35 to 52), stress at 46% (95% CI 40 to 52), obesity at 22% (95% CI 18 to 28), hypertension at 22% (95% CI 17 to 28), elevated levels of cholesterol at 24% (95% CI 19 to 29) and haemoglobin A1c at 34% (95% CI 29 to 41) were highest in West Hiri relative to the rural areas. However, central obesity at 90% (95% CI 86 to 93) and prehypertension at 55% (95% CI 42 to 62) were most common in Asaro whereas prevalences of smoking, physical inactivity and low high-density lipoprotein-cholesterol levels at 52% (95% CI 45 to 59), 34% (95% CI 26 to 42) and 62% (95% CI 56 to 68), respectively, were highest in Karkar Island.

CONCLUSION

Adult residents in the three different communities are at high risk of developing NCDs, especially the West Hiri periurban population. There is an urgent need for appropriate multisectoral preventive interventions and improved health services. Improved monitoring and control of NCD risk factors is also needed in all regions across PNG.

Rolling Tobacco in Banana Leaves, Newspaper, or Copybook Paper Associated With Significant Reduction in Lung Function in Vanuatu

In addition to the widespread availability of packaged cigarettes, the inhabitants of island nations of the Southwest Pacific frequently smoke commercially available loose tobacco using manufactured rolling papers, as well as locally grown tobacco rolled in manufactured rolling paper or wrapped in leaves, copybook paper, and newspaper. In this study, Vanuatu men who smoked local tobacco rolled in leaves, copybook paper, or newspaper showed significantly lower forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC ratios than men who smoked packaged cigarettes, store-bought tobacco rolled in manufactured rolling paper, or who smoked locally grown tobacco rolled in manufactured rolling papers. The addition of toxins from these unusual tobacco-wrapping media produces lung function deficits similar to the pattern noted among tobacco smokers who also inhale smoke from burning biomass. Thus, public health initiatives should consider including strategies addressing the use of wrapping media among smokers in South Pacific island societies.

Ischemic heart disease among the general Mongolian population: a review of epidemiological studies

Ischemic heart disease (IHD) is considered to be a pivotal health problem in Mongolia. To summarize the existing epidemiology of IHD in the general Mongolian population is crucial for primary prevention. The present review summarized population-based epidemiological data of IHD in Mongolia. When epidemiological studies were extracted from databases, very limited studies were available. The frequencies of IHD and IHD-attributable death rates appeared to be high and have an increased tendency in Mongolia. This could to be due to a gradually worsening state of potential IHD-related risk factors, such as smoking, hypertension, hypercholesterolemia, obesity and diabetes mellitus. This might indicate an urgent need of strategies for IHD and related risk factors. Anti-IHD strategies, such as more epidemiological studies and campaigns to increase awareness of IHD, at nationwide public health levels would be required in Mongolia for more effective prevention.

Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery

BACKGROUND

Despite the close link between cigarette smoking and the development of gastric cancer, little is known about the effects of cigarette smoking on surgical outcomes after gastric cancer surgery. The aim of this study was to investigate whether preoperative smoking status and the duration of smoking cessation were associated with short-term surgical consequences in gastric cancer surgery.

METHODS

Among 1,489 consecutive patients, 1,335 patients who underwent curative radical gastrectomy at the Samsung Medical Center between January and December 2009 were included in the present study. The smoking status was determined using questionnaires before surgery. Smokers were divided into four groups according to the duration of smoking cessation preoperatively (<2, 2-4, 4-8, and >8 weeks). The primary endpoint was postoperative complications (wound, lung, leakage, and bleeding); secondary endpoints were 3-year recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Five hundred twenty-two patients (39.1 %) were smokers. Smokers had a significantly higher overall incidence of postoperative complications than nonsmokers (12.3 vs. 5.2 %, P < 0.001, respectively), especially in impaired wound healing, pulmonary problems, and leakage. Smokers also had more severe complications than nonsmokers. After adjusting for other risk factors, the odds ratio (95 % CI) for the development of postoperative complications in the subgroups who stopped smoking <2 weeks, 2-4, 4-8, and >8 weeks preoperatively were 3.35 (1.92-5.83), 0.99 (0.22-4.38), 2.18 (1.00-4.76), and 1.32 (0.70-2.48), respectively, compared with the nonsmokers. There were no significant differences in 3-year RFS (P = 0.884) and OS (P = 0.258) between smokers and nonsmokers.

CONCLUSIONS

Preoperative smoking cessation for at least 2 weeks will help to reduce the incidence of postoperative complications in gastric cancer surgery.

Diabetes as risk factor for incident coronary heart disease in women compared with men: a systematic review and meta-analysis of 64 cohorts including 858,507 individuals and 28,203 coronary events

AIMS/HYPOTHESIS

A previous pooled analysis suggested that women with diabetes are at substantially increased risk of fatal CHD compared with affected men. Additional findings from several larger and more contemporary studies have since been published on the sex-specific associations between diabetes and incident CHD. We performed an updated systematic review with meta-analysis to provide the most reliable evidence of any sex difference in the effect of diabetes on subsequent risk of CHD.

METHODS

PubMed MEDLINE was systematically searched for prospective population-based cohort studies published between 1 January 1966 and 13 February 2013. Eligible studies had to have reported sex-specific RR estimates for incident CHD associated with diabetes and its associated variability that had been adjusted at least for age. Random-effects meta-analyses with inverse variance weighting were used to obtain sex-specific RRs and the RR ratio (RRR) (women:men) for incident CHD associated with diabetes.

RESULTS

Data from 64 cohorts, including 858,507 individuals and 28,203 incident CHD events, were included. The RR for incident CHD associated with diabetes compared with no diabetes was 2.82 (95% CI 2.35, 3.38) in women and 2.16 (95% CI 1.82, 2.56) in men. The multiple-adjusted RRR for incident CHD was 44% greater in women with diabetes than in men with diabetes (RRR 1.44 [95% CI 1.27, 1.63]) with no significant heterogeneity between studies (I (2) = 20%).

CONCLUSIONS/INTERPRETATION

Women with diabetes have more than a 40% greater risk of incident CHD compared with men with diabetes. Sex disparities in pharmacotherapy are unlikely to explain much of the excess risk in women, but future studies are warranted to more clearly elucidate the mechanisms responsible for the substantial sex difference in diabetes-related risk of CHD.

Ischemic heart disease and its related factors in Mongolia: a nationwide survey

Ischemic heart disease (IHD) remains one of the most important disorders associated with disability and mortality worldwide, and is one of the major causes of cardiovascular diseases in Mongolia. The objective of the current study was to determine the prevalence of IHD and its related factors in a general population in Mongolia. We conducted a nationwide cross-sectional survey between March and September, 2009. General participants were recruited from urban to rural regions in a multistage random cluster sampling method. The diagnosis of IHD was based on the Rose questionnaire (World Health Organization) and electrocardiographic findings. A total of 369 (16.2 %) subjects with IHD were diagnosed among 2,280 participants. The prevalence of subjects with IHD was significantly increased by age: from 9.9 % in individuals age 40-44 years compared to 17.7 % in those over 60 years. Smoking habits (former and current) and non-frequent intake of fruits and vegetables were significantly positively associated with IHD in men, while heavy alcohol drinking habits and lower education period of time were significantly positively associated with IHD in women. IHD was found to be prevalent, especially among people aged over 40 years, in Mongolia. Statistical factors related to IHD were found to be significantly different based on sex. The current data may provide relevant information to prevent IHD in the Mongolian population.

Use of and attitudes toward tobacco and alcohol among adults in southern Sri Lanka

The adverse health effects of tobacco and alcohol are well known. Alcohol consumption is increasing in Sri Lanka, but few population studies have been conducted. The objective of this study was to document tobacco and alcohol consumption levels among adults in southern Sri Lanka and to identify the main reasons for using or refraining from alcohol and tobacco products. Tobacco and alcohol use within Sri Lanka is relatively common, particularly among adult males. Reasons given for smoking and drinking frequently relate to social and image-based motivators. Women may be especially susceptible to the influence of peer pressure in social situations. Public health efforts should consider the use of demographic-specific anti-tobacco and anti-alcohol messages, as the motivators driving behavior appear to differ across gender and age groups.

Smoking and hemorrhagic stroke mortality in a prospective cohort study of older Chinese

BACKGROUND AND PURPOSE

Hemorrhagic stroke is more common in non-Western settings and does not always share risk factors with other cardiovascular diseases. The association of smoking with hemorrhagic stroke subtypes has not been established. We examined the association of cigarette smoking with hemorrhagic stroke, by subtype (intracerebral hemorrhage and subarachnoid hemorrhage), in a large cohort of older Chinese from Hong Kong.

METHODS

Multivariable Cox regression analysis was used to assess the adjusted associations of smoking at baseline with death from hemorrhagic stroke and its subtypes, using a population-based prospective cohort of 66 820 Chinese aged>65 years enrolled from July 1998 to December 2001 at all the 18 Elderly Health Centers of the Hong Kong Government Department of Health and followed until May 31, 2012.

RESULTS

After follow-up for an average of 10.9 years (SD=3.1), 648 deaths from hemorrhagic stroke had occurred, of which 530 (82%) were intracerebral hemorrhage. Current smoking was associated with a higher risk of hemorrhagic stroke (hazard ratio, 2.19; 95% confidence interval, 1.49-3.22), intracerebral hemorrhage (1.94; 1.25-3.01), and subarachnoid hemorrhage (3.58; 1.62-7.94), adjusted for age, sex, education, public assistance, housing type, monthly expenditure, alcohol use, and exercise. Further adjustment for hypertension and body mass index slightly changed the estimates.

CONCLUSIONS

Smoking is strongly associated with hemorrhagic stroke mortality, particularly for subarachnoid hemorrhage.

The Asia pacific cohort studies collaboration: a decade of achievements

The Asia Pacific Cohort Studies Collaboration (APCSC) was established in the late 1990s when there was a distinct shortfall in evidence of the importance of risk factors for cardiovascular disease in Asia. With few exceptions, most notably from Japan, most of the published reports on cardiovascular disease in the last century were from Western countries, and there was uncertainty how far etiological associations found in the West could be assumed to prevail in the East. Against this background, APCSC was set up as a pooling project, combining individual participant data (about 600,000 subjects) from all available leading cohort studies (36 from Asia and 8 from Australasia) in the region, to fill the knowledge gaps. In the past 10 years, APCSC has published 50 peer-reviewed publications of original epidemiological research, primarily concerned with coronary heart disease, stroke, and cancer. This work has established that Western risk factors generally act similarly in Asia and in Australasia, just as they do in other parts of the world. Consequently, strategies to reduce the prevalence of elevated blood pressure, obesity, and smoking are at least as important in Asia as elsewhere- and possibly more important when the vast size of Asia is considered. This article reviews the achievements of APCSC in the past decade, with an emphasis on coronary heart disease.

Active smoking and risk of metabolic syndrome: a meta-analysis of prospective studies

Background

Epidemiological evidence suggests that smoking has been associated with emergence of metabolic syndrome. However, data on this issue are inconsistent and controversial. We therefore conducted a meta-analysis to examine the association between smoking and metabolic syndrome.

Methodology and Principal Findings

We searched the Medline, Embase and the Cochrane Library database up to March 2012 to identify prospective cohort studies related to smoking and metabolic syndrome. Reference lists of retrieved articles were also reviewed. Summary effect estimates were derived using a random-effects model and stratified by gender, smoking dose, follow-up duration and geographical area. Primary analysis of 13 studies involving 56,691 participants and 8,688 cases detected a significant positive association between active smoking and risk of metabolic syndrome (pooled relative risk [RR] 1.26, 95% CI: 1.10–1.44). Estimates of effects were substantially consistent in the stratified analyses. In the dose-response analysis, risk of metabolic syndrome was stronger for active male smokers (pooled RR 1.34, 95% CI: 1.20–1.50) than it was for former male smokers (pooled RR 1.19, 95% CI: 1.00–1.42), and greater for heavy smokers (pooled RR 1.42, 95% CI: 1.27–1.59) compared with light smokers (pooled RR 1.10, 95% CI: 0.90–1.35). No evidence of statistical publication bias was found (Egger' s test P = 0.227, Begg' s test P = 0.113).

Conclusions

Active smoking is associated with development of metabolic syndrome. Smoking cessation appears to reduce the risk of metabolic syndrome.

The burden of stroke in the Lao People's Democratic Republic

In the Lao People's Democratic Republic (Laos), stroke is ranked as the third leading cause of death, with a 9·01% mortality rate. To date, neither the prevalence nor the incidence of stroke has been recorded in Laos. This omission may be attributed to a lack of awareness among Laotians of the signs and symptoms of stroke, incomplete data, or insufficient database recording. The only risk factor for stroke that has been studied extensively is cigarette smoking; studies have found that smokers have twice the risk of stroke. Unfortunately, smoking is increasing among youths, adults, and even healthcare professionals. The Southeast Asia Tobacco Control Alliance stated that 42% of hospitalized stroke patients are smokers. Laos is one of the least developed countries in the world, and the country has only one fully trained neurologist for the growing number of stroke cases. The Laos government should seek help from international bodies, such as the World Health Organization, to monitor and rehabilitate stroke patients and prevent stroke occurrence and recurrence.

Infective causes of stroke in tropical regions

Vascular diseases of the brain are the second reason of the death and the first cause of morbidity and disability worldwide. In tropical areas stroke has some particular features related to the nature of torrid zones. There are some special causes of the stroke, mainly infectious, although some of them are non-infectious. The most important etiologies are malaria, tuberculosis, cysticercosis, syphilis, and Chagas' disease. The mean age of the patients with stroke in tropical areas seems to be less than that in developed countries, and the disease is more prevalent in younger adults. Prevention and/or treatment of the classic risk factors as well as factors related to tropical zones are the mainstays of controlling the disease. It has to be mentioned that lack of human as well as financial resources makes it difficult to control and treat the disease properly. Herein, the etiologies and risk factors of the cerebrovascular diseases in tropical regions will be reviewd.

Influence of smoking combined with another risk factor on the risk of mortality from coronary heart disease and stroke: pooled analysis of 10 Japanese cohort studies

BACKGROUND

In spite of the importance of a multifactorial approach to preventing cardiovascular disease in smokers, most information on the combined adverse effects of smoking and hypertension or high serum cholesterol on cardiovascular disease has been derived from Western populations, and coronary heart disease was often used as the only endpoint. Therefore, the present large-scale pooled analysis attempted to provide reliable information on the adverse effects of the coexistence of smoking and hypertension or high serum cholesterol on the risk of mortality from coronary heart disease and stroke in both, individuals and the entire population in Japan.

METHODS

A total of 27,385 male and 39,207 female participants aged 40-89 years were enrolled from 10 well-qualified Japanese cohort studies with a mean follow-up of 10.1 years. Hazard ratios and their corresponding 95% confidence intervals in smokers who had hypertension or high serum cholesterol were estimated for men and women separately using a Cox proportional hazards regression model that included age, body mass index, cohort and either serum total cholesterol or systolic blood pressure as covariates. Fractions of deaths attributable to the coexistence of these risk factors were also calculated.

RESULTS

The multivariate-adjusted hazard ratios in male and female current smokers with hypertension, compared with those with neither factor were 2.57 (95% confidence intervals, 1.51-4.38) and 6.14 (3.49-10.79) for coronary heart disease, and 3.28 (1.89-5.71) and 1.61 (0.81-3.18) for cerebral infarction, respectively. The fractions of deaths attributable to the coexistence of current smoking and hypertension in men and women were 24.6 and 9.6% for coronary heart disease and 28.1 and 2.0% for cerebral infarction, respectively. Smokers with high serum cholesterol were broadly comparable to hypertensive smokers only with respect to coronary mortality risk; the hazard ratios, compared with those with neither factor were 4.19 (2.33-7.53) for men and 3.90 (1.57-9.67) for women. The fraction of coronary deaths attributable to the coexistence of current smoking and high serum cholesterol was 6.3% in men and 2.2% in women. There was no interaction between smoking habit and blood pressure or serum total cholesterol for these two subtypes in both men and women.

CONCLUSIONS

Particular attention should be given to smokers who have concomitant hypertension or high serum cholesterol for preventing deaths due to cardiovascular disease. From a public health perspective in Japan, priority should be given to hypertensive smokers, since this group makes a large contribution to the burden of both coronary and cerebral infarction deaths.

Prospective care of heart failure in Japan: lessons from CHART studies

There are approximately 23 million patients with heart failure (HF) worldwide. The prognosis of patients with HF is still poor and a prospective approach for preventing and treating HF is necessary. The number of HF patients in Japan has been increasing since 1950 mainly because of a rapidly aging population. Furthermore, westernized dietary pattern, reduced physical activity, and obesity have become prominent, particularly in younger Japanese men. There is an increasing trend of diabetes and dyslipidemia, and the prevalence of smoking and hypertension continues to remain high. One of the largest HF cohorts in Japan, the CHART Studies, showed that coronary artery disease (CAD) was the most frequent etiology of HF currently. Thus, prospective strategies including accurate risk stratification, effective prevention of disease progression through evidence-based treatments, optimally personalized treatment particularly in elderly individuals, and life-long control of CAD risk factors are required to manage HF in Japan.

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.

Primary coronary intervention for ST-elevation myocardial infarction in Indonesia and the Netherlands: a comparison

Background. Although the beneficial effects of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) have been demonstrated in a number of trials, most studies were conducted in Western countries. Experience, logistics and patient characteristics may differ in other parts of the world.Methods. Consecutive patients treated with primary PCI in Cinere Hospital, Jakarta, Indonesia, between January 2008 and October 2008 were compared with those treated in the Isala Clinics, Zwolle, the Netherlands.Results. During the study period, a total of 596 patients were treated by primary PCI, 568 in Zwolle and 28 in Jakarta. Patients in Indonesia were younger (54 vs 63 years), more often had diabetes (36 vs. 12%) and high lipids and were more often smokers (68 vs. 31%). Time delay between symptom onset and admission was longer in Indonesia. Patients from Indonesia more often had signs of heart failure at admission. The time between admission and balloon inflation was longer in Indonesia. At angiography, patients from Indonesia more often had multivessel disease. There was no difference in the percentage of restoration of TIMI 3 flow by primary PCI between the two hospitals.Conclusion. Patients with STEMI in Indonesia have a higher risk profile compared with those in the Netherlands, according to prevalence of coronary risk factors, signs of heart failure, multivessel disease and patient delay. Time delay between admission and balloon inflation was much longer in Indonesia, because of both logistic and financial reasons. (Neth Heart J 2009;17:418-21.).

The population attributable fraction of stroke associated with high blood pressure in the Middle East and North Africa

BACKGROUND

Hypertension and the prevalence of stroke are increasing in the Middle East and North Africa. This study aims to quantify the contribution of hypertension to the development of stroke at the country-level by calculating the sex-specific population attributable fraction (PAFs).

METHODS

The most recent sex-specific prevalence data was used, along with age-adjusted hazard ratio (HR) estimates for ischemic and hemorrhagic stroke associated with hypertension from the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence data were then used to calculate the PAFs for each country in the region with the relevant data.

RESULTS

In the 10 countries with nationally-representative data, the PAFs in men ranged from 16.3% in Kuwait to 60.7% in Morocco for hemorrhagic stroke and 7.2% in Kuwait to 38% in Morocco for ischemic stroke. The equivalent PAFs for stroke deaths related to hypertension in women ranged from 12.4% in United Arab Emirates to 48.6% in Bahrain for hemorrhagic stroke and from 10.3% in UAE to 46% in Morocco for ischemic stroke.

CONCLUSION

Overall, up to 60% of stroke can be attributed to the high blood pressure in the Middle East. Stroke is a preventative disease, with this information and better prevention strategies, this region can aim to lower the prevalence of stroke.

The Epidemiology of Stroke Amongst Women in the Asia–Pacific Region

National data from the Asia–Pacific region suggest that stroke accounts for over 10% of female deaths. With general aging in the region, and longer life expectancies for women than men, action is required to maintain recent improvements in female death rates from stroke. However, local data on incidence and risk factors for stroke amongst women are scarce. Data from 214,032 women in the Asia Pacific Cohort Studies Collaboration were thus used to investigate the risk factors for stroke in the region. Raised systolic blood pressure and diabetes were found to be key risk factors for both ischemic (IS) and hemorrhagic (HS) stroke. After adjustment for other risk factors, every extra 10 mmHg systolic blood pressure increased risk of IS by 36% and HS by 69%, whilst diabetes increased risk of IS by 170% and HS by 147%. Smoking was also an important risk factor for IS and HS; risk was reduced by quitting.

Changing disease trends in the Asia-Pacific

Recently published data demonstrate major demographic changes and disease trends evolving in the Asia-Pacific. These portentous developments will have far-reaching social and economic implications in terms of income security, social welfare and medical services. The region is now home to more than half of the world's population and includes some of the richest and most developed countries alongside some of the poorest and least developed ones. In the coming decades, the number of older persons (aged 60 years or over) and the number of the oldest-old (aged ≥80 years) in the region will increase rapidly. The Asia-Pacific is first in rank in terms of the number of urban dwellers. Despite persisting levels of underweight in some countries in the Asia-Pacific, overweight and obesity have become endemic for almost the entire region. Hypertension, hyperlipidemia and metabolic syndrome are highly prevalent. The Asia-Pacific has the largest diabetes burden in the world. A smoking epidemic is developing in the region. As a consequence of these exacerbations in cardiovascular risk factors, already half of the world's cardiovascular burden occurs in the Asia-Pacific. Additionally, osteoporosis is becoming a serious public health issue in the Asia-Pacific and dementia is reaching epidemic proportions. The mix of a rapidly increasing, aging and urbanized population and a developing epidemic of chronic diseases will result in an enormous, health, social and economic burden and is threatening to overwhelm the health-care systems of less developed countries in the Asia-Pacific.

Population attributable numbers and fractions of deaths due to smoking: a pooled analysis of 180,000 Japanese

OBJECTIVE

Age- and sex-specific population attributable fraction (PAF) and premature deaths attributable to smoking were estimated from a pooled analysis of cohort studies in Japan.

METHODS

A pooled analysis of individual participant data from 13 well-qualified cohort studies throughout Japan (a total of 183,251 Japanese aged 40-89, 69,502 men and 113,749 women; the baseline years between 1987 and 1995 with average 10 years of follow-up) was performed. Poison regression model was used to estimate age- and sex-specific hazard ratios, and their PAFs of all-cause deaths and number of annual premature deaths attributable to smoking were estimated.

RESULTS

Overall PAF attributable to smoking was 24.6% in men and 6.0% in women. The estimated number of annual premature deaths due to smoking was 121,854 (men: 109,998; women: 11,856) in Japan. The age-specific PAF was largest in men aged 60-69 (47.7%) and in women aged 50-59 (12.2%). In the older group aged 70-79 and 80-89, PAF was 15.4% and 8.0% in men and 3.5% and 1.5% in women, respectively.

CONCLUSIONS

Age-specific PAFs attributable to smoking in Japanese men are much larger than that reported from other Asian countries.

Obesity, smoking, and frontal brain dysfunction

Obesity, smoking, and conduct problems have all been associated with decrements in brain function. However, their additive and interactive effects have rarely been examined. To address the deficiency, we studied P300a and P300b electroencephalographic potentials in 218 women grouped by the presence versus absence of: (1) a BMI > or = 30 kg/m(2); (2) recent smoking; and (3) > or = 2 childhood conduct problems. Analyses revealed smaller P300a and P300b amplitudes over the posterior scalp among recent smokers versus nonsmokers. No corresponding group differences were found in P300 latencies or frontal scalp amplitudes. The most interesting analysis result was an interaction between conduct problems and obesity limited to the frontally generated P300a component: its latency was significantly greater in women with both attributes than in those with either or neither attribute. An exploratory ANOVA, substituting the genotype of a GABRA2 SNP for conduct problems, also demonstrated an interaction with obesity affecting P300a latency. It is hypothesized that conduct problems, and a conduct-problem-associated GABRA2 genotype, decrease the age-of-onset and/or increase the lifetime duration of obesity. As a result, they may potentiate the adverse effects of obesity on frontal white matter and thereby increase P300a latency. Smoking may affect brain function by a different mechanism to reduce posterior scalp P300a and P300b amplitudes while preserving frontal scalp P300a latency and amplitude.

Managing the aging man in Asia: a review

The aging man is becoming a major burden to Asian countries because of the current poor health status of Asian men and the aging Asian population. Life expectancy at birth for men is shorter than women by an average of 4 years in Asian countries and major causes of death are cardiovascular disease, cancers, injuries and infections. However, there are considerable variations between Asian countries because of great disparity in socioeconomic status. Male-specific disorders, such as male sexual health and urological conditions, are other major health burdens because they have a great impact on men's quality of life. More importantly, many risk factors to the causes of mortality and morbidities, such as high-risk behavior and smoking, can be improved with health promotion and early intervention. The current evidence suggests that the poor health status of men is the result of their poor health care utilization, negative health-seeking behavior, the adverse social environment for men and gender-insensitive health care delivery. However, much evidence is still needed as Asian countries have great diversity in culture, societal values and men's needs. Asian time-tested wisdom on a balanced healthy lifestyle to longevity should be explored as potential men's health promotional programs. Taking into account Asian men's health-care needs, a gender-streamlined approach and man-friendly health care delivery should be on the national agenda in managing the aging man.

Population attributable fraction of smoking and metabolic syndrome on cardiovascular disease mortality in Japan: a 15-year follow up of NIPPON DATA90

Background

Smoking and metabolic syndrome are known to be related to cardiovascular diseases (CVD) risk. In Asian countries, prevalence of obesity has increased and smoking rate in men is still high. We investigated the attribution of the combination of smoking and metabolic syndrome (or obesity) to excess CVD deaths in Japan.

Methods

A cohort of nationwide representative Japanese samples, a total of 6650 men and women aged 30-70 at baseline without history of CVD was followed for 15 years. Multivariate-adjusted hazard ratio for CVD death according to the combination of smoking status and metabolic syndrome (or obesity) was calculated using Cox proportional hazard model. Population attributable fraction (PAF) of CVD deaths was calculated using the hazard ratios.

Results

During the follow-up period, 87 men and 61 women died due to CVD. The PAF component of CVD deaths in non-obese smokers was 36.8% in men and 11.3% in women, which were higher than those in obese smokers (9.1% in men and 5.2% in women). The PAF component of CVD deaths in smokers without metabolic syndrome was 40.9% in men and 11.9% in women, which were also higher than those in smokers with metabolic syndrome (7.1% in men and 3.9% in women).

Conclusion

Our results indicated that a large proportion of excess CVD deaths was observed in smokers without metabolic syndrome or obesity, especially in men. These findings suggest that intervention targeting on smokers, irrespective of the presence of metabolic syndrome, is still important for the prevention of CVD in Asian countries.

Medical expenditures of men with hypertension and/or a smoking habit: a 10-year follow-up study of National Health Insurance in Shiga, Japan

Hypertension and smoking are major causes of disability and death, especially in the Asia-Pacific region, where there is a high prevalence of a combination of these two risk factors. We attempted to measure the medical expenditures of a Japanese male population with hypertension and/or a smoking habit over a 10-year period of follow-up. A cohort study was conducted that investigated the medical expenditures due to a smoking habit and/or hypertension during the decade of the 1990s using existing data on physical status and medical expenditures. The participants included 1708 community-dwelling Japanese men, aged 40-69 years, who were classified into the following four categories: 'neither smoking habit nor hypertension', 'smoking habit alone', 'hypertension alone' or 'both smoking habit and hypertension.' Hypertension was defined as a systolic blood pressure of > or =140 mm Hg, a diastolic blood pressure of > or =90 mm Hg or taking antihypertensive medications. In the study cohort, 24.9% had both a smoking habit and hypertension. During the 10-year follow-up period, participants with a smoking habit alone (18,444 Japanese yen per month), those with hypertension alone (21,252 yen per month) and those with both a smoking habit and hypertension (31,037 yen per month) had increased personal medical expenditures compared with those without a smoking habit and hypertension (17,418 yen per month). Similar differences were observed even after adjustment for other confounding factors (P<0.01). Japanese men with both a smoking habit and hypertension incurred higher medical expenditures compared with those without a smoking habit, hypertension or their combination.

The risk of upper aero digestive tract cancer associated with smoking, with and without concurrent alcohol consumption

BACKGROUND

Smoking and alcohol are major causal factors for upper aerodigestive tract cancer, but reliable quantification of the combined impact of smoking and alcohol on this cancer and its major subtypes has not been performed.

METHODS

A meta-analysis of studies that had published quantitative estimates of smoking and upper aerodigestive tract cancer by January 2007 was performed. Pooled estimates of relative risks were obtained. Publication bias was investigated through funnel plots and corrected if found to be present.

RESULTS

Overall, 85 studies with information on 53,940 individuals with upper aerodigestive tract cancer were included. The pooled estimate for the association between smoking and the risk of this cancer was 3.47 (95% confidence interval, 3.06-3.92). The risk remained elevated for a decade after smoking cessation but declined thereafter. Individuals who both smoked and consumed alcohol had double the risk of upper aerodigestive tract cancer in comparison with those who only smoked: the relative risk was 6.93 (95% confidence interval, 4.99-9.62) for the former and 2.56 (95% confidence interval, 2.20-2.97) for the latter (P < 0.001).

CONCLUSIONS

Public health interventions that simultaneously discourage smoking and heavy drinking would have greater benefits than would be expected from those that target only one of these risk factors.

Maternal smoking and acute respiratory infection symptoms among young children in Nepal: multilevel analysis

The association between maternal smoking and adverse child health outcomes has not been systematically explored in less developed countries, especially in Nepal where over a quarter of women of reproductive age smoke tobacco products. This study aims to quantify the effect of maternal smoking on acute respiratory infection (ARI) symptoms among children aged below five years, using the 2001 Nepal Demographic and Health Survey. It is hypothesized that children born to mothers who smoke frequently are at higher risk of developing ARI symptoms. Four-level random intercept logistic regression models were used to disentangle the independent effect of maternal smoking on children's ARI symptoms, controlling for potential biological, socioeconomic, seasonal and spatial variables. Maternal smoking status had a significant effect on children's ARI symptoms; the effects were significantly higher (adjusted OR 1.41; 95% CI 1.02-1.96) among those born to mothers who smoked more frequently than their counterparts. Furthermore, a strong spatial pattern was evident in the prevalence of ARI symptoms, after adjusting for maternal smoking and relevant control variables. The findings underscore the importance of designing exclusive public health intervention measures to prevent tobacco smoking within households, for example through awareness campaigns highlighting the adverse effect of maternal smoking on child health.

Smoking and the risk of upper aero digestive tract cancers for men and women in the Asia-Pacific region

Although smoking is an established causal factor for upper aero digestive tract cancer (UADTC), most of the evidence originates from the West. Thus, we analysed data from 455,409 subjects in the Asia Pacific Cohort Studies Collaboration. Over a median of around six years follow-up, 371 deaths from UADTC were observed. The hazard ratio (95% confidence interval) for current smokers, compared with those who had never smoked, was 2.36 (1.76 – 3.16), adjusted for age and alcohol drinking. Tobacco control policies are urgently required in Asia to prevent millions of deaths from UADTC that smoking will otherwise cause.

An epidemiologic study comparing fetal exposure to tobacco smoke in three Southeast Asian countries

The high prevalence of smoking in Southeast Asia (SEA) means pregnant women face exposure to tobacco smoke that may affect the health of their fetus. This study determined fetal exposure to tobacco smoke by meconium analysis for cotinine in 3 locations in SEA: Bulacan Province, Philippines (N=316), Bangkok, Thailand (N=106) and Singapore City (N=61). Maternal exposure to tobacco smoke was 71.1% (1.3% active; 69.8% passive) in Bulacan, 57.5% (0.9% active; 58.6% passive) in Bangkok and 54.1% (11.5% active; 42.0% passive) in Singapore. Fetal exposure to tobacco smoke (by meconium analysis) was 1.3% (Bulacan), 4.7% (Bangkok) and 13.1% (Singapore); however, a large proportion of infants who tested positive for cotinine (65%) were born to mothers who gave no history of either active or passive exposure to environmental tobacco smoke. Fetal exposure to tobacco smoke is a major health problem.

Costs of heart disease and risk behaviour: implications for expenditure on prevention

AIMS

The objective of this paper is firstly to estimate the healthcare costs attributable to heart disease in Denmark using recently available data for 2002-05. Secondly, to estimate the attributable healthcare costs of lifestyle risk factors among heart patients, in order to inform decision making about prevention programmes specifically targeting patients with heart disease.

METHODS

For a cohort consisting of participants in a national representative health interview survey, register-based information about hospital diagnosis was used to identify patients with heart disease. Healthcare consumption during 2002- 05 among individuals developing heart disease during 2002-05 was compared with individuals free of heart disease. Healthcare costs attributable to heart disease were estimated by linear regression with adjustment for confounding factors. The attributable costs of excess drinking, physical inactivity and smoking among future heart patients were estimated with the same method.

RESULTS

Individuals with heart disease cost the healthcare system on average 3,195 (p<0.0001) per person-year more than individuals without heart disease. The attributable cost of unhealthy lifestyle factors among individuals at risk of heart disease was about 11%-16% of the attributable cost of heart disease.

CONCLUSIONS

Heart disease incurs significant additional costs to the healthcare sector, and more so if heart patients have a history of leading an unhealthy life. Consequently, strategies to prevent or cease unhealthy lifestyle may not only result in cost savings due to avoided heart disease. Additional cost savings may be obtained because heart patients who prior to the disease led a more healthy life consume fewer healthcare resources.

Cigarette smoking and risk of stroke in the chinese adult population

BACKGROUND AND PURPOSE

We studied the relationship between cigarette smoking and stroke incidence and mortality in the Chinese adult population.

METHODS

We conducted a prospective cohort study in a nationally representative sample of 169 871 Chinese men and women aged 40 years and older. Data on cigarette smoking and other covariables were collected at a baseline examination in 1991 using a standard protocol. Follow-up evaluation was conducted in 1999 to 2000, with a response rate of 93.4%.

RESULTS

During an average of 8.3 years follow-up, a total of 6780 stroke events (3979 fatal strokes) were observed. The multivariate-adjusted relative risks (95% confidence interval) of stroke incidence and mortality associated with present cigarette smoking were 1.28 (1.19 to 1.37) and 1.13 (1.03 to 1.25) in men and 1.25 (1.13 to 1.37) and 1.19 (1.04 to 1.36) in women, respectively. The corresponding population attributable risks were 14.2% and 7.1% in men and 3.1% and 2.4% in women. Compared to never-smokers, the multivariate-adjusted relative risks of stroke incidence (95% confidence interval) were 1.21 (1.12 to 1.31), 1.21 (1.11 to 1.32), and 1.36 (1.25 to 1.47) for those who smoked 1 to 9, 10 to 19, and >/=20 cigarettes per day; and 1.18 (1.09 to 1.28), 1.25 (1.15 to 1.35), and 1.34 (1.24 to 1.44) for those who smoked 1 to 11, 12 to 26, and >26 pack-years, respectively (both P<0.0001 for linear trends).

CONCLUSIONS

Our study identified a positive and dose-response relationship between cigarette smoking and risk of stroke. Smoking prevention and cessation programs should be an important strategy for reducing the burden of stroke in Chinese adults.