Smoking and smoking cessation in relation to all-cause mortality and cardiovascular events in 25,464 healthy male Japanese workers

The effect of obesity phenotype changes on cardiovascular outcomes in adults older than 40 years in the prospective cohort of the Tehran lipids and glucose study (TLGS): joint model of longitudinal and time-to-event data

BACKGROUND

Obesity is a worldwide health concern with serious clinical effects, including myocardial infarction (MI), stroke, cardiovascular diseases (CVDs), and all-cause mortality. The present study aimed to assess the association of obesity phenotypes and different CVDs and mortality in males and females by simultaneously considering the longitudinal and survival time data.

METHODS

In the Tehran Lipid and Glucose Study (TLGS), participants older than three years were selected by a multi-stage random cluster sampling method and followed for about 19 years. In the current study, individuals aged over 40 years without a medical history of CVD, stroke, MI, and coronary heart disease were included. Exclusions comprised those undergoing treatment for CVD and those with more than 30% missing information or incomplete data. Joint modeling of longitudinal binary outcome and survival time data was applied to assess the dependency and the association between the changes in obesity phenotypes and time to occurrence of CVD, MI, stroke, and CVD mortality. To account for any potential sex-related confounding effect on the association between the obesity phenotypes and CVD outcomes, sex-specific analysis was carried out. The analysis was performed using packages (JMbayes2) of R software (version 4.2.1).

RESULTS

Overall, 6350 adults above 40 years were included. In the joint modeling of CVD outcome among males, literates and participants with a family history of diabetes were at lower risk of CVD compared to illiterates and those with no family history of diabetes in the Bayesian Cox model. Current smokers were at higher risk of CVD compared to non-smokers. In a logistic mixed effects model, odds of obesity phenotype was higher among participants with low physical activity, family history of diabetes and older age compared to males with high physical activity, no family history of diabetes and younger age. In females, based on the results of the Bayesian Cox model, participants with family history of diabetes, family history of CVD, abnormal obesity phenotype and past smokers had a higher risk of CVD compared to those with no history of diabetes, CVD and nonsmokers. In the obesity varying model, odds of obesity phenotype was higher among females with history of diabetes and older age compared to those with no history of diabetes and who were younger. There was no significant variable associated with MI among males in the Bayesian Cox model. Odds of obesity phenotype was higher in males with low physical activity compared to those with high physical activity in the obesity varying model, whereas current smokers were at lower odds of obesity phenotype than nonsmokers. In females, risk of MI was higher among those with family history of diabetes compared to those with no history of diabetes in the Bayesian Cox model. In the logistic mixed effects model, a direct and significant association was found between age and obesity phenotype. In males, participants with history of diabetes, abnormal obesity phenotype and older age were at higher risk of stroke in the Bayesian Cox model compared to males with no history of diabetes, normal obesity phenotype and younger persons. In the obesity varying model, odds of obesity phenotype was higher in males with low physical activity, family history of diabetes and older age compared to those with high physical activity, no family history of diabetes and who were younger. Smokers had a lower odds of obesity phenotype than nonsmokers. In females, past smokers and those with family history of diabetes were at higher risk of stroke compared to nonsmokers and females with no history of diabetes in the Bayesian Cox model. In the obesity varying model, females with family history of diabetes and older ages had a higher odds of obesity phenotype compared to those with no family history of diabetes and who were younger. Among males, risk of CVD mortality was lower in past smokers compared to nonsmokers in the survival model. A direct and significant association was found between age and CVD mortality. Odds of obesity phenotype was higher in males with a history of diabetes than in those with no family history of diabetes in the logistic mixed effects model.

CONCLUSIONS

It seems that modifications to metabolic disorders may have an impact on the heightened incidence of CVDs. Based on this, males with obesity and any type of metabolic disorder had a higher risk of CVD, stroke and CVD mortality (excluding MI) compared to those with a normal body mass index (BMI) and no metabolic disorders. Females with obesity and any type of metabolic disorder were at higher risk of CVD(, MI and stroke compared to those with a normal BMI and no metabolic disorders suggesting that obesity and metabolic disorders are related. Due to its synergistic effect on high blood pressure, metabolic disorders raise the risk of CVD.

Early smoking lead to worse prognosis of COPD patients: a real world study

BACKGROUND

Smoking remains a major risk factor for the development and progression of chronic obstructive pulmonary disease (COPD). Due to the adolescent smoking associated with worse health state, the age, at which an individual started smoking, might play a key role in shaping the trajectory of COPD development and the severity.

METHODS

We conducted an observational study from September 2016 through January 2023 of eligible patients hospitalized with COPD. Patients who started smoking during the alveolar development stage (ADS, smoking initiation ≤ 24 years old) were defined as early smoking patients, and patients who started smoking after ADS (smoking initiation > 24 years old) were defined as late smoking patients. We collected demographic and clinical data characterizing the patients and documented their condition from hospital discharge to follow-up. The primary endpoints were short-term (within one year), 3-year, and long-term (beyond 3 years) all-cause mortality after discharge.

RESULTS

Among 697 COPD patients, early smoking patients had a lower smoking cessation rate (P < 0.001) and a higher smoking index (P < 0.001) than late smoking patients. Although adjusted smoking index, early smoking patients still had poorer lung function (P = 0.023), thicker left ventricular diameters (P = 0.003), higher frequency of triple therapy use during stable stage (P = 0.049), and more acute exacerbations in the past year before enrollment (P < 0.05). Survival analysis showed that they had a higher risk of death after discharge within three years (P = 0.004) and beyond three years (P < 0.001). Furthermore, even in early smoking COPD patients who quit smoking after adjusting the smoking index had poorer lung function (P < 0.05) and thicker left ventricular diameters (P = 0.003), and survival analysis also showed that they had a higher long-term mortality rate (P = 0.010) and shorter survival time (P = 0.0128).

CONCLUSION

Early smoking COPD patients exhibited multiple adverse clinical outcomes, including heavy cigarette addiction, compromised pulmonary function, augmented left ventricular diameter, and elevated mortality risk. Additional, smoking cessation could not bring enough improvement of health state in early smoking COPD patients as late smoking COPD patients. Consequently, early intervention and specialized cessation approaches for younger smokers are of paramount importance in this context.

Assessment of cognitive function and sleep-wake rhythms in community-dwelling older adults

Disruption of the circadian rhythm and sleep-wake cycles is a consequence of aging and is associated with the cognitive decline and many neurodegenerative conditions. We investigated the bedtime, wake-up time, sleep timing (midpoint between bedtime and wake-up time), and sleep timing standard deviation (SD) using the actigraphy among 80 consecutive volunteers aged ≥ 60 years. Global cognitive function and executive function of detailed cognitive domains were evaluated using the mini-mental state examination (MMSE) and Wisconsin card sorting test (WCST) and subjective daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). The category achievement (CA), total errors (TE), perseverative errors of Nelson (PEN), non-perseverative errors (NPE), and difficulties in maintaining set (DMS) on the WCST were significantly correlated with sleep timing SD (CA: r = - 0.276, p = 0.013, TE: r = 0.311, p = 0.005, PEN: r = 0.241, p = 0.032, NPE: r = 0.250, p = 0.025, DMS: r = 0.235, p = 0.036), but not with the MMSE score. Multiple regression analyses with the stepwise forward selection method including age, ESS score, bedtime, sleep timing, and sleep timing SD, revealed that the ESS score, and sleep timing SD were significant factors related to CA on the WCST (ESS score: β = - 0.322, p = 0.004; sleep timing SD: β = - 0.250, p = 0.022). Assessment of sleep-wake rhythms, daytime sleepiness, and cognitive function using the MMSE and WCST is valuable for the prediction of cognitive decline in the geriatric population.

Positive association between serum resistin and smoking was strongest in homozygotes of the G-A haplotype at c.-420 C>G and c.-358 G>A in RETN promoter: the Toon Genome Study

Resistin is mainly expressed in human monocytes/macrophages and is associated with insulin resistance, inflammation, and atherosclerosis. Serum resistin is strongly correlated with the G-A haplotype defined by single nucleotide polymorphisms (SNPs) c.-420 C>G (SNP-420) (rs1862513) and c.-358 G>A (SNP-358) (rs3219175) in the promoter region of the human resistin gene (RETN). Smoking is also associated with insulin resistance. We investigated the association between smoking and serum resistin and the effect of the G-A haplotype on this association. Participants were recruited under the Toon Genome Study (an observational epidemiology research in the Japanese population). Of these, 1975 subjects genotyped for both SNP-420 and SNP-358 were analyzed for serum resistin by grouping them based on smoking status and G-A haplotype status. RETN mRNA, isolated from whole blood cells, was evaluated in smokers (n = 7) and age-, sex-, and BMI-matched non-smokers (n = 7) with the G-A haplotype homozygotes. Serum resistin tended to be higher in current smokers who smoked more cigarettes per day (P for trend < 0.0001). The positive association between serum resistin and smoking was strongest in the G-A haplotype homozygotes, followed by heterozygotes and non-carriers (interaction P < 0.0001). This positive association was stronger in the G-A homozygotes than the C-G homozygotes (interaction P < 0.0001). RETN mRNA was 1.40-fold higher in smokers than non-smokers with the G-A homozygotes (P = 0.022). Therefore, the positive association between serum resistin and smoking was strongest in the G-A haplotype homozygotes defined by RETN SNP-420 and SNP-358.

Long-Term Effects of Cigarette Smoking on All-Cause Mortality and Cardiovascular Outcomes in Thai Population: Results From a 30-Year Cohort Study

Despite the overwhelming evidences on the health consequences of smoking, studies in Asian population in low-to-middle income countries are very limited. Baseline data of a prospective cohort study were collected in year 1985. Endpoints regarding all-cause mortality and major adverse cardiovascular events (MACE) were followed for 30 years. Cox proportional hazard models were used for analysis. Participants had an average age of 43 years, 23% were female, and 43% were current smokers. All-cause mortality was significantly higher in ex-smokers (hazard ratio [HR] 1.32) and current smokers (HR 1.70) when compared with never smokers. Participants with any history of smoking had significantly higher risk of developing MACE. Furthermore, all-cause death, cardiovascular death, and MACE increased with increasing pack years. Statistically significant dose-response relationships were established. Therefore, cigarette smoking increased the risk of all-cause mortality, cardiovascular mortality, and MACE in Thai population. Results emphasized the importance of tobacco control in Thailand.

Effects of smoking on the prognosis of anterior circulation acute ischemic stroke with intravenous thrombolysis

OBJECTIVE

This is a single-center retrospective analysis of the clinical data of 516 patients with acute ischemic stroke who underwent intravenous thrombolysis. This study was conducted to compare the therapeutic efficacy of smokers and non-smokers.

METHODS

Univariate analysis was used to analyze and compare the clinical data of smokers and non-smokers. Multivariate analysis was used to assess risk factors affecting the 90-day modified Rankin Scale (mRS) score.

RESULTS

Among the 516 patients, 235 (45.5 %) were smokers. Univariate analysis showed that smokers have a better 90-day prognosis and a lower 90-day mRS score than non-smokers. Multivariate logistic regression analysis showed that smoking is not a protective factor affecting prognosis, while baseline National Institutes of Health Stroke Scale (NIHSS) score was an independent risk factor affecting the 90-day functional outcome. Subgroup analysis did not determine a relationship between the 90-day mRS score and the smoking intensity and duration.

CONCLUSION

Smoking was not associated with a good 90-day prognosis after intravenous thrombolysis (IVT) treatment. The good clinical outcome of smokers in univariate analysis was bound up with their baseline characteristics. Baseline NIHSS score was the independent risk factor that affected the 90-day outcome of AIS patients undergoing IVT.

Cigarette Smoking and Risk of Different Pathologic Types of Stroke: A Systematic Review and Dose-Response Meta-Analysis

Objectives

To quantify the association of cigarette smoking, including cigarettes per day and quitting duration, with the risk of different types of stroke morbidity and mortality in the general population, and to clarify the shape of the dose-response relations.

Study Selection

Prospective cohort studies and reported on the association between smoking, quitting and the incidence or mortality of stroke were included.

Data Extraction and Synthesis

All available data were converted uniformly to odds ratios (ORs) and were pooled using random-effects meta-analysis with inverse variance weighting. A dose-response meta-analysis was performed to explore the quantitative relationship between different smoking characteristics and the risk of different pathologic types of stroke incidence.

Results

Twenty-five studies with 3,734,216 individuals were included. Compared to never smokers, the pooled ORs of stroke morbidity and mortality were 1.45 (1.24–1.70) and 1.44 (1.23–1.67) among ever smokers and 1.90 (1.55–2.34) and 1.70 (1.45–1.98) among current smokers. The risk of different pathologic types of stroke was also increased among ever and current smokers. There was a significant non-linear dose-response association between the number of cigarette smoking and the risk of stroke incidence. Comparing no smoking, the ORs for smoking five and 35 cigarettes per day were 1.44 (1.35–1.53) and 1.86 (1.71–2.02). Other pathologic types of stroke have a similar dose-response relationship. There was also non-linear dose-response association between the length of time since quitting and risk of stroke. The risk of stroke decreased significantly after quitting for 3 years [OR = 0.56 (0.42–0.74)].

Conclusion

The risk of different types of stroke among smokers is remarkably high. Our findings revealed a more detailed dose-response relationship and have important implications for developing smoking control strategies for stroke prevention.

Systematic Review Registration

https://inplasy.com/inplasy-2020-6-0062/, identifier: INPLASY202060062.

Association of Smoking and Smoking Cessation With Overall and Cause-Specific Mortality

INTRODUCTION

Smoking remains a strong risk factor for premature death. This study examines the associations of nondaily smoking, daily smoking, and smoking cessation with the risks of mortality from all causes, cardiovascular disease, and cancer.

METHODS

This study used data from the National Health and Nutrition Examination Survey, a population-based, cross-sectional study. Data analysis was conducted in the U.S. from January to October 2020. Cox proportional hazard regression models were used to obtain adjusted hazard ratios.

RESULTS

During 255,100 person-years of follow-up, 2,008 participants died (347 from cardiovascular diseases and 501 from cancer). A significant increase in the risk of all-cause mortality was observed for nondaily smokers (hazard ratio=1.50, 95% CI=1.08, 2.08) compared with that for those who had never smoked. For daily smokers, the adjusted hazard ratios for all-cause mortality were 1.54 (95% CI=1.24, 1.90) for those smoking <20 cigarettes per day, 2.09 (95% CI=1.65, 2.63) for those smoking 20-40 cigarettes per day, and 2.78 (95% CI=1.75, 4.43) for those smoking ≥40 cigarettes per day. An increased risk of cardiovascular disease and cancer mortality was also observed for daily smokers. Former smokers with ≥5 years since cessation had a lower risk of all-cause mortality than current smokers.

CONCLUSIONS

This study suggests that nondaily smokers have a higher risk of all-cause mortality. The association of daily smoking with the risk of mortality increased as the number of cigarettes smoked per day increased. Among former smokers, the risk decreased with longer cessation. Tobacco control efforts should be targeted not only toward daily smokers but also toward nondaily smokers to reduce the risk of premature death owing to smoking.

Effects of long sleep time and irregular sleep-wake rhythm on cognitive function in older people

Sleep disturbances and cognitive decline are common in older adults. We aimed to investigate the effects of the total sleep time (TST) and sleep–wake rhythm on executive function and working memory in older adults. In 63 older participants, we measured the TST, wake after sleep onset (WASO), and sleep timing (midpoint between bedtime and wake-up time) using actigraphy. Executive function was evaluated with the trail making test B (TMT-B) and Wisconsin card sorting test (WCST). The number of back task (N-back task) was used to measure working memory. Participants with a TST ≥ 8 h had a significantly lower percentage of correct answers (% correct) on the 1-back task than those with a TST < 8 h. The % correct on the 1-back task was significantly correlated with the TST, WASO, and sleep timing. Multiple regression analyses revealed that the TST and sleep timing were significant factors of the % correct on the 1-back task. The TMT-B score was significantly correlated with the sleep timing. Category achievement on the WCST was significantly correlated with the standard deviation of the sleep timing. Therefore, a long sleep time and an irregular sleep–wake rhythm could have adverse effects on executive function and working memory in older people.

The clinical characteristics and outcomes of heart failure patient with chronic obstructive pulmonary disease from the Japanese community-based registry

Both heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common diseases, but few studies have assessed the relationship between COPD and outcomes in patients with acute HF, especially in relation to age or ejection fraction (EF). The Kitakawachi Clinical Background and Outcome of Heart Failure Registry was a prospective, multicenter, community-based cohort and enrolled a total of 1,102 patients with acute HF between 2015 and 2017 in this study. The primary endpoint was defined as a composite endpoint that included all-cause mortality and hospitalization for HF. We stratified patients into two groups: those aged ≥ 80 years (elderly) and < 80 years (nonelderly). HF with preserved EF (HFpEF) was defined as EF ≥ 50%, whereas HF with reduced ejection fraction (HFrEF) was defined as EF < 50%. A total of 159 patients (14.4%) with COPD and 943 patients (83.6%) without COPD were included. COPD was found to be independently associated with a higher risk of the composite endpoint (adjusted hazard ratio: 1.42, 95% confidence interval: 1.14-1.77; p = 0.003). During a subgroup analysis, COPD was exposed as an independent risk factor of the composite endpoint in nonelderly patients; however, there was not such a finding observed among elderly patients. Separately, there was a significant association with COPD and the composite endpoint in patients with HFpEF. COPD showed a significantly higher risk of the composite endpoint after discharge in acute HF. However, this heightened risk was observable only in the subgroup of nonelderly patients and those of HFpEF.

Light Cigarette Smoking Increases Risk of All-Cause and Cause-Specific Mortality: Findings from the NHIS Cohort Study

Very few studies have examined the association between light cigarette smoking (i.e., ≤5 cigarettes per day) and mortality. The aim of this study was to examine the association of light cigarette smoking with all-cause and cause-specific mortality among adults in the United States. Data were from 13 waves of the National Health Interview Survey (1997 to 2009) that were linked to the National Death Index records through December 31, 2011. A total of 329,035 participants aged ≥18 years in the United States were included. Deaths were from all cause, cancer, cardiovascular disease (CVD) and respiratory disease and were confirmed by death certification. During a median follow-up of 8.2 years, 34,862 participants died, of which 8415 were from cancer, 9031 from CVD, and 2040 from respiratory disease. Compared with never-smokers, participants who smoked 1–2 (hazard ratios (HR) = 1.94, 95%CI = 1.73–2.16) and 3–5 cigarettes (HR = 1.99, 1.83–2.17) per day were at higher risk of all-cause mortality after adjustment for demographic variables, lifestyle factors and physician-diagnosis of chronic disease. The associations were stronger for respiratory disease-specific mortality, followed by cancer-specific mortality and CVD-specific mortality. For example, the HRs (95% CIs) of smoking 1–2 cigarettes per day were 9.75 (6.15–15.46), 2.28 (1.84–2.84) and 1.93 (1.58–2.36), respectively, for these three cause-specific mortalities. This study indicates that light cigarette smoking increases risk of all-cause and cause-specific mortality in US adults.

Attributable Burden and Expenditure of Cardiovascular Diseases and Associated Risk Factors in Mexico and other Selected Mega-Countries

BACKGROUND

This paper describes the health and economic burden of cardiovascular diseases (CVD) in Mexico and other mega-countries through a review of literature and datasets.

METHODS

Mega-countries with a low (Nigeria), middle (India), high (China/Brazil/Mexico), and very high (the U.S.A./Japan) human development index were included. The review was focused on prevalence of dyslipidemias and CVD economic impact and conducted according to the PRISMA statement. Public datasets of CVD indicators were explored.

RESULTS

Heterogeneity in economic data and limited information on dyslipidemias were found. Hypertriglyceridemia and hypercholesterolemia were higher in Mexico compared with other countries. Higher contribution of dietary risk factors for cardiovascular mortality and greater probability of dying prematurely from CVD were observed in developing countries. From 1990-2016, a greater decrease in cardiovascular mortality in developed countries was registered. In 2015, a CVD expense equivalent to 4% of total health expenditure was reported in Mexico. CVD ranked first in health expenditures in almost all these nations and the economic burden will remain significant for decades to come.

CONCLUSIONS

Resources should be assured to optimize CVD risk monitoring. Educational and medical models must be improved to enhance CVD diagnosis and the prescription and adherence to treatments. Long-term benefits could be attained by modifying the food system.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Derivation and validation of a cardiovascular risk score for prediction of major acute cardiovascular events in non-alcoholic fatty liver disease; the importance of an elevated mean platelet volume

BACKGROUND

Atherosclerotic cardiovascular disease is a key cause of morbidity in non-alcoholic fatty liver disease (NAFLD) but appropriate means to predict major acute cardiovascular events (MACE) are lacking.

AIM

To design a bespoke cardiovascular risk score in NAFLD.

METHODS

A retrospective derivation (2008-2016, 356 patients) and a prospective validation (2016- 2017, 111 patients) NAFLD cohort study was performed. Clinical and biochemical data were recorded at enrolment and mean platelet volume (MPV), Qrisk2 and Framingham scores were recorded one year prior to MACE (Cardiovascular death, acute coronary syndrome, stroke and transient ischaemic attack).

RESULTS

The derivation and validation cohorts were well-matched, with MACE prevalence 12.6% and 12%, respectively. On univariate analysis, age, diabetes, advanced fibrosis, collagen proportionate area >5%, MPV and liver stiffness were associated with MACE. After multivariate analysis, age, diabetes and MPV remained independently predictive of MACE. The "NAFLD CV-risk score" was generated using binary logistic regression: 0.06*(Age) + 0.963*(MPV) + 0.26*(DM¹ ) - 16.44; ¹ Diabetes mellitus: 1: present; 2: absent. (AUROC 0.84). A cut-off of -3.98 gave a sensitivity 97%, specificity 27%, PPV 16%, and NPV 99%. An MPV alone of >10.05 gave a sensitivity 97%, specificity 59%, PPV 24% and NPV 97% (AUROC 0.83). Validation cohort AUROCs were comparable at 0.77 (NAFLD CV-risk) and 0.72 (MPV). In the full cohort, the NAFLD CV-risk score and MPV outperformed both Qrisk2 and Framingham scores.

CONCLUSIONS

The NAFLD CV risk score and MPV accurately predict 1-year risk of MACE, thereby allowing better identification of patients that require optimisation of their cardiovascular risk profile.

Smoking cessation, weight gain, and risk of stroke among postmenopausal women

The relationship between smoking cessation, concurrent weight gain, and stroke events is not yet understood. Thus, we examined the association between smoking cessation and subsequent stroke risk and whether the association was modified by concurrent weight gain. In 2017, we analyzed data from 109,498 postmenopausal US women enrolled in the Women's Health Initiative from 1993 to 1998. Women with a history of cancer or cardiovascular disease events were excluded. The median length of follow-up time was 14.01 years. Variables of primary focus were smoking cessation, weight change, and clinically confirmed incident cases of hemorrhagic and ischemic stroke. Hazard ratios were estimated for stroke incidences (all, ischemic, and hemorrhagic) associated with smoking cessation using Cox regression. The exposure-outcome relationship of smoking cessation and risk of stroke was evaluated for effect modification by weight change. Recent quitters between baseline and year 3 had a significantly lower risk for all stroke and ischemic stroke, but not hemorrhagic stroke, when compared to the reference group of continuing smokers. In the multivariable-adjusted model for ischemic stroke, the hazard ratio for recent quitters was 0.66 (95% CI: 0.46, 0.95). In the model for hemorrhagic stroke, the hazard ratio for recent quitters was 0.76 (95% CI: 0.36, 1.61). The association between recent quitting and stroke risk was not significantly modified by weight change. Smoking cessation was associated with a significant reduction in stroke risk. The benefit of smoking cessation on the risk of stroke was not attenuated by concurrent weight gain.

The interplay of IMRT and transoral surgery in HPV-mediated oropharyngeal cancer: Getting the balance right

Transoral surgery (TOS) and IMRT represent two primary local ablative treatment modalities for oropharyngeal cancer (OPC). The choice of one over the other represents an interplay between the chance of cure vs risk of late sequelae. HPV-mediated (HPV+) OPC patients generally have excellent outcomes, especially in TNM-8 stage I disease. Controversies exist over which treatment has a more favorable toxicity profile and equal efficacy in the management of this population. Non-randomized retrospective data show comparable oncological and functional outcomes between TOS-based vs IMRT-based treatment for this disease. Several de-intensification concepts have been explored in this subset in both primary surgery-based vs primary radiotherapy-based trials. However, no robust mature trial data are available to convincingly guide treatment selection. TOS is often presented as one of the de-intensification options although the majority of series also describe the use of adjuvant treatments which inevitably result in non-negligible toxicities. Patient selection and surgeons' training are paramount. Understanding tumor biology and the prognostic value of traditional 'adverse' features will further guide trial design for refinement of risk tailored approach. In conclusion, comparative data suggests TOS and IMRT are both effective treatment for TNM-8 stage I HPV+ OPC with similar oncological and functional outcomes. TOS as a single modality has potential advantages in mitigating radiation included toxicities. TOS should be avoided in the presence of clinically overt extranodal extension or when negative margins are unlikely to be achieved. TOS is also less ideal for cases with radiological features predicting a high risk of distant metastasis.

Smoking, Smoking Cessation, and Risk of Mortality in a Japanese Working Population - Japan Epidemiology Collaboration on Occupational Health Study

BACKGROUND

The effect of smoking on mortality in working-age adults remains unclear. Accordingly, we compared the effects of cigarette smoking and smoking cessation on total and cause-specific mortality in a Japanese working population. Methods and Results: This study included 79,114 Japanese workers aged 20-85 years who participated in the Japan Epidemiology Collaboration on Occupational Health Study. Deaths and causes of death were identified from death certificates, sick leave documents, family confirmation, and other sources. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated via Cox proportional hazards regression. During a maximum 6-year follow-up, there were 252 deaths in total. Multivariable-adjusted HRs (95% CIs) for total mortality, cardiovascular disease (CVD) mortality, and tobacco-related cancer mortality were 1.49 (1.10-2.01), 1.79 (0.99-3.24), and 1.80 (1.02-3.19), respectively, in current vs. never smokers. Among current smokers, the risks of total, tobacco-related cancer, and CVD mortality increased with increasing cigarette consumption (P_trend<0.05 for all). Compared with never smokers, former smokers who quit <5 and ≥5 years before baseline had HRs (95% CIs) for total mortality of 1.80 (1.00-3.25) and 1.02 (0.57-1.82), respectively.

CONCLUSIONS

In this cohort of workers, cigarette smoking was associated with increased risk of death from all and specific causes (including CVD and tobacco-related cancer), although these risks diminished 5 years after smoking cessation.

The relationship of cigarette smoking in Japan to lung cancer, COPD, ischemic heart disease and stroke: A systematic review

Background:  To present up-to-date meta-analyses of evidence from Japan relating smoking to major smoking-related diseases.  Methods:  We restricted attention to lung cancer, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD) and stroke, considering relative risks (RRs) for current and ex-smokers relative to never smokers.  Evidence by amount smoked and time quit was also considered.  For IHD and stroke only, studies had to provide age-adjusted RRs, with age-specific results considered.  For each disease we extended earlier published databases to include more recent studies.  Meta-analyses were conducted, with random-effects RRs and tests of heterogeneity presented.  Results:  Of 40 studies, 26 reported results for lung cancer and 7 to 9 for each other disease.  For current smoking, RRs (95%CIs) were lung cancer 3.59 (3.25-3.96), COPD 3.57 (2.72-4.70), IHD 2.21 (1.96-2.50) and stroke 1.40 (1.25-1.57).  Ex-smoking RRs were lower.  Data for lung cancer and IHD showed a clear tendency for RRs to rise with increasing amount smoked and decrease with increasing time quit.  Dose-response data were unavailable for COPD and unclear for stroke, where the association was weaker.  Conclusions:  Compared to studies in other Asian and Western countries, current smoking RRs were quite similar for IHD and stroke.  The comparison is not clear for COPD, where the Japanese data, mainly from cross-sectional studies, is limited.  For lung cancer, the RRs are similar to those in other Asian countries, but substantially lower than in Western countries.  Explanations for this are unclear, but less accurate reporting of smoking by Japanese may contribute to the difference.

Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports

OBJECTIVE

To use the relation between cigarette consumption and cardiovascular disease to quantify the risk of coronary heart disease and stroke for light smoking (one to five cigarettes/day).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline 1946 to May 2015, with manual searches of references.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective cohort studies with at least 50 events, reporting hazard ratios or relative risks (both hereafter referred to as relative risk) compared with never smokers or age specific incidence in relation to risk of coronary heart disease or stroke.

DATA EXTRACTION/SYNTHESIS

MOOSE guidelines were followed. For each study, the relative risk was estimated for smoking one, five, or 20 cigarettes per day by using regression modelling between risk and cigarette consumption. Relative risks were adjusted for at least age and often additional confounders. The main measure was the excess relative risk for smoking one cigarette per day (RR1_per_day-1) expressed as a proportion of that for smoking 20 cigarettes per day (RR20_per_day-1), expected to be about 5% assuming a linear relation between risk and consumption (as seen with lung cancer). The relative risks for one, five, and 20 cigarettes per day were also pooled across all studies in a random effects meta-analysis. Separate analyses were done for each combination of sex and disorder.

RESULTS

The meta-analysis included 55 publications containing 141 cohort studies. Among men, the pooled relative risk for coronary heart disease was 1.48 for smoking one cigarette per day and 2.04 for 20 cigarettes per day, using all studies, but 1.74 and 2.27 among studies in which the relative risk had been adjusted for multiple confounders. Among women, the pooled relative risks were 1.57 and 2.84 for one and 20 cigarettes per day (or 2.19 and 3.95 using relative risks adjusted for multiple factors). Men who smoked one cigarette per day had 46% of the excess relative risk for smoking 20 cigarettes per day (53% using relative risks adjusted for multiple factors), and women had 31% of the excess risk (38% using relative risks adjusted for multiple factors). For stroke, the pooled relative risks for men were 1.25 and 1.64 for smoking one or 20 cigarettes per day (1.30 and 1.56 using relative risks adjusted for multiple factors). In women, the pooled relative risks were 1.31 and 2.16 for smoking one or 20 cigarettes per day (1.46 and 2.42 using relative risks adjusted for multiple factors). The excess risk for stroke associated with one cigarette per day (in relation to 20 cigarettes per day) was 41% for men and 34% for women (or 64% and 36% using relative risks adjusted for multiple factors). Relative risks were generally higher among women than men.

CONCLUSIONS

Smoking only about one cigarette per day carries a risk of developing coronary heart disease and stroke much greater than expected: around half that for people who smoke 20 per day. No safe level of smoking exists for cardiovascular disease. Smokers should aim to quit instead of cutting down to significantly reduce their risk of these two common major disorders.

Lifestyles and Mortality in Taiwan: An 11-Year Follow-up Study

The associations of modifiable lifestyle-related factors with cardiovascular and all-cause mortality were examined in a population-based sample of older Taiwanese people. A total of 4176 individuals aged 50 years and older, with 11 years of follow-up, were analyzed. Current and former smokers had a higher risk of all-cause mortality compared with never smokers ([HR = 1.33; 95% CI = 1.12, 1.58], [HR = 1.39; 95% CI = 1.16, 1.68]). Low intake of vegetables and fruits was associated with a significantly higher risk of 1.43 (95% CI = 1.13, 1.81) for cardiovascular mortality and 1.22 (95% CI = 1.09, 1.38) for all-cause mortality. The low physical activity group at baseline who became part of the low, moderate, and high physical activity groups during follow-up had the following risks of cardiovascular mortality: ([HR = 2.89; 95% CI = 1.91, 4.36], [HR = 2.17; 95% CI = 1.29, 3.63], [HR = 1.59; 95% CI = 0.90, 2.82]). Similarly, the moderate physical activity group at baseline who became part of the low, moderate, and high physical activity groups during follow-up had the following risks of cardiovascular mortality: ([HR = 3.52; 95% CI = 2.14, 5.80], [HR = 2.25; 95% CI = 1.34, 3.80], [HR = 1.44; 95% CI = 0.78, 2.66]). The same tendencies were found in all-cause mortality. Smoking, diet, and physical activity were significantly modifiable lifestyle-related factors for mortality.Besides, individuals who decreased their physical activity had a significantly higher risk, whereas those who increased their physical activity had a significantly lower risk.

Influence of sleep duration on cortical oxygenation in elderly individuals

AIM

Short sleep duration is a risk factor for cardiovascular diseases. Cerebral blood flow and its regulation are affected by pathological conditions commonly observed in the elderly population, such as dementia, atherosclerosis, diabetes mellitus (DM), stroke, and hypertension. The purpose of this study was to examine the influence of sleep duration on cortical oxygenated hemoglobin (OxyHb) using near-infrared spectroscopy (NIRS).

METHODS

Seventy-three individuals (age, 70.1 ± 3.9 years, 51 men and 22 women) participated in this study. Cortical OxyHb levels were measured with NIRS. We evaluated age, body mass index (BMI), smoking status, alcohol intake, sleep duration, hypertension, DM, and hyperlipidemia using a questionnaire. Blood pressure was measured using plethysmography.

RESULTS

Peak OxyHb and area under the NIRS curve significantly decreased in participants with sleep duration <7 h compared with those with sleep duration ≥7 h (0.136 ± 0.212 mM·mm vs 0.378 ± 0.342 mM·mm, P = 0.001; 112.0 ± 243.6 vs 331.7 ± 428.7, P  = 0.012, respectively). Sleep duration was significantly correlated with peak OxyHb level and area under the NIRS curve (r = 0.378, P  = 0.001; r = 0.285, P  = 0.015, respectively). Multiple regression analysis, including age, BMI, sex, smoking status, alcohol intake, sleep duration, hypertension, DM, and hyperlipidemia revealed that sleep duration was the only significant independent factor associated with peak OxyHb and area under the NIRS curve (β = 0.343, P  = 0.004; β = 0.244, P  = 0.049, respectively), and smoking status was independently correlated with time to the peak OxyHb (β = -0.319, P  = 0.009).

CONCLUSION

Sleep duration may be an important factor that influences cortical oxygenation in the elderly population.

Tobacco Use and its Relationship with Health Complaints Among Employees of Kermanshah Province, Iran

Background:

Identifying the pattern of tobacco use and its related factors in employees is crucial. This study aimed to investigate the pattern of tobacco use and its related factors in employees of Kermanshah Province, Iran.

Methods:

In 2012, 7129 employees were investigated in a cross-sectional study using the census method. Data on tobacco use and on several chronic diseases obtained using a standardized questionnaire on noncommunicable diseases risk factors of the World Health Organization through face-to-face interviews. Statistical analysis was performed based on the Chi-square test and multivariate logistic regression.

Results:

In general, the prevalence of tobacco use, smoking cigarettes, and smoking waterpipe was 9.9%, 8.9%, and 1.2% among the employees, respectively. Tobacco use was significantly higher in the age group over 40 (14.0%), in male gender (13.3%), in married individuals (10.8%) and in those with diploma and lower degree (16.4%), (P < 0.001). At the individual level, the odds ratio of tobacco use was 1.5 (95% confidence interval [CI]: 1.2–1.8) in hypertensive, 1.8 (95% CI: 1.2–2.6) in diabetic employees and 1.7 (95% CI: 1.3–2.3) in those with heart diseases, compared to healthy individuals. After adjusting for age, gender, marital status and educational level, there was not any significant relationship between tobacco use and health complaints and only the demographic variables remained significant.

Conclusions:

Preventive public health policies are mandatory especially in younger ages and male employees to promote their knowledge on disadvantages of tobacco use.

Smoking and Risk of All-cause Deaths in Younger and Older Adults: A Population-based Prospective Cohort Study Among Beijing Adults in China

Cigarette smoking is the leading preventable cause of death worldwide. Few studies, however, have examined the modified effects of age on the association between smoking and all-cause mortality.In the current study, the authors estimated the association between smoking and age-specific mortality in adults from Beijing, China. This is a large community-based prospective cohort study comprising of 6209 Beijing adults (aged ≥40 years) studied for approximately 8 years (1991-1999). Hazard ratios (HRs) and attributable fractions associated with smoking were estimated by Cox proportional hazard models, adjusting for age, sex, alcohol intake, body mass index, systolic blood pressure, hypertension, and heart rate.The results showed, compared with nonsmokers, the multivariable-adjusted HRs for all-cause mortality were 2.7(95% confidence interval (CI):1.56-4.69) in young adult smokers (40-50 years) and 1.31 (95% CI: 1.13-1.52) in old smokers (>50 years); and the interaction term between smoking and age was significant (P = 0.026). Attributable fractions for all-cause mortality in young and old adults were 63% (95% CI: 41%-85%) and 24% (95% CI: 12%-36%), respectively. The authors estimated multivariate adjusted absolute risk (mortality) by Poisson regression and calculated risk differences and 95% CI by bootstrap estimation. Mortality differences (/10,000 person-years) were 15.99 (95% CI: 15.34-16.64) in the young and 74.61(68.57-80.65) in the old. Compared with current smokers, the HRs of all-cause deaths for former smokers in younger and older adults were 0.57 (95% CI: 0.23-1.42) and 0.96 (95% CI: 0.73-1.26), respectively.The results indicate smoking significantly increases the risks of all-cause mortality in both young and old Beijing adults from the relative and absolute risk perspectives. Smoking cessation could also reduce the excess risk of mortality caused by continuing smoking in younger adults compared with older individuals.

Smoking, smoking cessation, and 7-year mortality in a cohort of Thai adults

Background

Smoking is a strong risk factor for mortality in both the developed and the developing world. However, there is still limited research to examine the impact of smoking cessation and mortality in middle-income Southeast Asian populations.

Methods

We use longitudinal data from a large Thai cohort of adult Open University students residing nationwide, linked with official death records to assess the association of smoking status and mortality risks during a 7-year follow-up. The log-rank test was used to evaluate the statistical probability of differential survival according to baseline smoking status. Multivariate hazard ratios (HR) were reported for smoking status and all-cause and cause-specific mortality.

Results

From 2005 baseline to 2012, current smokers were more likely to die than cohort members who ceased smoking and never smokers (1.9 vs 1.3 vs 0.6 %, p < 0.05). The hazard of all-cause mortality increased with the daily amount of cigarette consumption among both current and former smokers. Cause of death analyses showed that current male smokers had a significantly increased risk of cardiovascular disease related mortality (HR 3.9 [95 % CI 1.8–8.1]). Former male smokers had a moderate increase in risk of dying from cardiovascular diseases compared to never smokers (HR 1.6 [95 % CI 0.7–3.4]). Current male smokers between 2005 and 2009 experienced highest subsequent mortality hazards during the period 2009–2012 compared to never smokers (HR 2.1 [95 % CI 1.4–3.4]). The higher risk of dying reduced if people quit smoking during the 2005–2009 follow-up period (HR 1.5 [95 % CI 0.7–3.3]). Risk for mortality fell even further among long-term quitters (HR 1.4 [95 % CI 0.9–2.2]).

Conclusion

Among a large nationwide cohort of Thai adults, current smokers were at a significantly and substantially higher risk of all-cause mortality, especially cardiovascular-related mortality. The higher risk of dying fell if people quit smoking and the risk for mortality was even lower among long-term quitters. Promotion of smoking cessation will contribute substantially to the reduction in avoidable mortality in Thailand.

Comparison of Prevalence- and Smoking Impact Ratio-Based Methods of Estimating Smoking-Attributable Fractions of Deaths

Background

Smoking is a major modifiable risk factor for premature mortality. Estimating the smoking-attributable burden is important for public health policy. Typically, prevalence- or smoking impact ratio (SIR)-based methods are used to derive estimates, but there is controversy over which method is more appropriate for country-specific estimates. We compared smoking-attributable fractions (SAFs) of deaths estimated by these two methods.

Methods

To estimate SAFs in 2012, we used several different prevalence-based approaches using no lag and 10- and 20-year lags. For the SIR-based method, we obtained lung cancer mortality rates from the Korean Cancer Prevention Study (KCPS) and from the United States-based Cancer Prevention Study-II (CPS-II). The relative risks for the diseases associated with smoking were also obtained from these cohort studies.

Results

For males, SAFs obtained using KCPS-derived SIRs were similar to those obtained using prevalence-based methods. For females, SAFs obtained using KCPS-derived SIRs were markedly greater than all prevalence-based SAFs. Differences in prevalence-based SAFs by time-lag period were minimal among males, but SAFs obtained using longer-lagged prevalence periods were significantly larger among females. SAFs obtained using CPS-II-based SIRs were lower than KCPS-based SAFs by >15 percentage points for most diseases, with the exceptions of lung cancer and chronic obstructive pulmonary disease.

Conclusions

SAFs obtained using prevalence- and SIR-based methods were similar for males. However, neither prevalence-based nor SIR-based methods resulted in precise SAFs among females. The characteristics of the study population should be carefully considered when choosing a method to estimate SAF.

Using the Negative Exponential Model to Describe Changes in Risk of Smoking-Related Diseases following Changes in Exposure to Tobacco

Recently published analyses for four smoking-related diseases show that the declining excess relative risk by time quit is well fitted by the negative exponential model. These analyses estimated the half-life of this excess, that is, the time after quitting when the excess relative risk reaches half that for continuing smokers. We describe extensions of the simple model. One quantifies the decline following an exposure reduction. We show that this extension satisfactorily predicts results from studies investigating the effect of reducing cigarette consumption. It may also be relevant to exposure reductions following product-switching. Another extension predicts changes in excess relative risk occurring following multiple exposure changes over time. Suitable published epidemiological data are unavailable to test this, and we recommend its validity to be investigated using large studies with data recorded on smoking habits at multiple time points in life. The basic formulae described assume that the excess relative risk for a continuing smoker is linearly related to exposure and that the half-life is invariant of age. We describe model adaptations to allow for nonlinear dose-response and for age-dependence of the half-life. The negative exponential model, though relatively simple, appears to have many potential uses in epidemiological research for summarizing variations in risk with exposure changes.

Smoking is Not a Good Prognostic Factor following First-Ever Acute Ischemic Stroke

Background and Purpose

There is evidence that smoking increases stroke risk; however, the effect of smoking on functional outcome after stroke is unclear. The aim of this study was to explore the effect of smoking status on outcome following acute ischemic stroke.

Methods

We assessed 1,117 patients with first-ever acute cerebral infarction and no prestroke disability whose functional outcome was measured after three months. A poor outcome was defined as a modified Rankin Scale score of ≥2. Smoking within one month prior to admission was defined as current smoking. Our analysis included demographics, vascular risk factors, initial National Institutes of Health Stroke Scale (NIHSS) score, stroke subtype, onset-to-admission time, thrombolytic therapy, initial blood pressure, and prognostic blood parameters as covariates.

Results

At baseline, current smokers were predominantly male, approximately 10 years younger than non-smokers (mean age, 58.6 vs. 68.3 years), and less likely to have hypertension and atrial fibrillation (53.9% vs. 65.4% and 8.7% vs. 25.9%, respectively), with a lower mean NIHSS score (4.6 vs. 5.7). The univariate analyses revealed that current smokers had a better functional outcome and significantly fewer deaths at three months follow-up when compared with non-smokers (functional outcome: 64.0% vs. 58.4%, P=0.082; deaths: 3.0% vs. 8.4%, P=0.001); however, these effects disappeared after adjusting for covariates (P=0.168 and P=0.627, respectively).

Conclusions

In this study, smoking was not associated with a good functional outcome, which does not support the paradoxical benefit of smoking on functional outcome following acute ischemic stroke.

Impact of smoking on coronary microcirculatory resistance in patients with coronary artery disease

The aim of this study was to investigate the relationship between coronary microvascular function and smoking using the 3 parameters fractional flow reserve (FFR), coronary flow reserve (CFR(thermo)), and index of microcirculatory resistance (IMR) in patients with coronary artery disease (CAD). A total of 97 CAD patients with 148 intermediate stenotic lesions were divided into two groups: current and former smokers (Smokers: n = 54), and those who had never smoked (Non-smokers: n = 43). Coronary physiology measurements were made following coronary angiography at rest and during hyperemia induced with intravenous adenosine triphosphate. If a patient had several intermediate lesions, the lesion producing the largest IMR value and minimum FFR(myo) and CFR(thermo) value was selected. Averaged over all patients, the FFR(myo), CFR(thermo), and IMR values were 0.86 ± 0.10, 2.66 ± 1.50, and 20.8 ± 10.7, respectively. There was no significant correlation between FFR(myo) and IMR. There were no significant differences between smokers and non-smokers in FFR(myo) value (median: 0.85 [IQR: 0.74-0.90] versus 0.87 [IQR: 0.83-0.90], P = 0.15) and CFR(thermo) value (median: 1.90 [IQR: 1.56-3.16] versus 2.10 [IQR: 1.50-2.67] U, P = 0.95). The IMR value was significantly greater in smokers (median: 24.2 [IQR: 16.8-32.5] U versus 18.5 [IQR: 15.4-27.0] U, P = 0.04). In multivariate analysis, smoking was an independent predictor of increased IMR. Smoking appears to have a detrimental effect on coronary microvascular function as measured by IMR.

Changes in smoking behavior and subsequent mortality risk during a 35-year follow-up of a cohort in Xi'an, China

Prospective evidence of the associations of smoking cessation with chronic obstructive pulmonary disease (COPD) and other causes of death in Asia is scarce. Previous studies, which were mostly based on baseline smoking behavior only, were subject to sick-quitter bias and misclassification resulting from changes in smoking behavior during follow-up. We followed up a cohort for 18 years (1976-1994) to assess changes in smoking behavior and then for an additional 17 years (1994-2011) to examine the relationships of continuing to smoke and new quitting with mortality risk in 1,494 Chinese people (961 men, 533 women). Of the baseline current smokers, 38.7% quit between 1976 and 1994. From 1994 to 2011, a total of 488 persons (359 men, 129 women) died. Ever smokers had increased risks of lung cancer, coronary heart disease, thrombotic stroke, and COPD, with dose-response relationships. For all tobacco-related mortality, the relative risk for new quitters compared with continuing smokers was 0.68 (95% confidence interval: 0.46, 0.99) for those who had quit 2-7 years previously and 0.56 (95% confidence interval: 0.37, 0.85) for those who had quit 8 years or more previously. The corresponding relative risks were 0.69 and 0.45 for lung cancer, 0.78 and 0.51 for coronary heart disease, 0.76 and 0.84 for thrombotic stroke, and 0.89 and 0.61 for COPD, respectively. Smoking increased tobacco-related deaths, and particularly deaths from COPD, in China, whereas quitting at middle age (at approximately 50 years of age) substantially reduced the risks of death from these causes. The benefits of smoking cessation were underestimated in previous studies that did not use repeated measures.

F2RL3 methylation as a biomarker of current and lifetime smoking exposures

BACKGROUND

Recent genome-wide DNA methylation studies have found a pronounced difference in methylation of the F2RL3 gene (also known as PAR-4) in blood DNA according to smoking exposure. Knowledge on the variation of F2RL3 methylation by various degrees of smoking exposure is still very sparse.

OBJECTIVES

We aimed to assess dose-response relationships of current and lifetime active smoking exposure with F2RL3 methylation.

METHODS

In a large population-based study, we quantified blood DNA methylation at F2RL3 for 3,588 participants using matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Associations of smoking exposure with methylation intensity were examined by multiple linear regression, controlling for potential confounding factors and paying particular attention to dose-response patterns with respect to current and lifetime smoking exposure as well as time since cessation of smoking.

RESULTS

F2RL3 methylation intensity showed a strong association with smoking status (p < 0.0001), which persisted after controlling for potential confounding factors. Clear inverse dose-response relationships with F2RL3 methylation intensity were seen for both current intensity and lifetime pack-years of smoking. Among former smokers, F2RL3 methylation intensity increased gradually from levels close to those of current smokers for recent quitters to levels close to never smokers for long-term (> 20 years) quitters.

CONCLUSIONS

F2RL3 methylation is a promising biomarker for both current and long-term past tobacco exposure, and its predictive value for smoking-related diseases warrants further exploration.

Lower Framingham risk score and the absence of hypertension are associated with the morning peak in the circadian variation of ST-elevation myocardial infarction onset

There are few studies analyzing the influences of coronary risk factors on the circadian variation of ST-elevation myocardial infarction (STEMI). Between 2008 and 2011, 293 patients were admitted to Miyazaki Prefectural Nobeoka Hospital with STEMI. The onset time of STEMI was identified in 280 patients (age, 70.5±11.7 years; male subjects, 68%; hypertension (HT), 80%; diabetes mellitus, 28%; current smoking (cSM), 33%; Framingham risk score (FRS), 8.77±3.28). The day was divided into six 4-h periods, with the morning peak between 0800 and 1200 hours. The frequency of HT was significantly lower in the morning incidence group than in the nighttime incidence group. Multivariate logistic regression analysis revealed that the prevalence of HT was the only independent variable associated with the morning peak of STEMI (odds ratio (OR), 0.43; 95% confidence interval (95% CI), 0.23-0.83; P=0.01) and that cSM was significantly associated with the nighttime peak of STEMI (OR, 1.96; 95% CI, 1.01-3.80; P=0.04). A comprehensive evaluation using the FRS showed that the FRS was significantly lower in the morning incidence group than in the nighttime incidence group and the other time incidence group (7.95±3.47 vs. 9.14±2.89 vs. 9.06±3.25, P<0.01), and that having a lower FRS was associated with the morning peak of STEMI (OR, 1.12; 95% CI, 1.02-1.21; P=0.01). A lower FRS and non-HT status are associated with the morning peak in the circadian variation of STEMI onset. The morning incidence of STEMI might be affected by pathogenic factors other than the classic coronary risk factors.

Effects of cigarette smoking intensity on the mucociliary clearance of active smokers

BACKGROUND

Smoking impairs mucociliary clearance and increases respiratory infection frequency and severity in subjects with and without smoking-related chronic lung diseases.

OBJECTIVE

This study evaluated the effects of smoking intensity on mucociliary clearance in active smokers.

METHODS

Seventy-five active smokers were grouped into light (1-10 cigarettes/day; n = 14), moderate (11-20 cigarettes/day; n = 34) and heavy smokers (≥21 cigarettes/day; n = 27) before starting a smoking cessation programme. Smoking behaviour, nicotine dependence, pulmonary function, carbon monoxide in exhaled air (exCO), carboxyhaemoglobin (COHb) and mucociliary clearance measured by the saccharin transit time (STT) test were all evaluated. An age-matched non-smoker group (n = 24) was assessed using the same tests.

RESULTS

Moderate (49 ± 7 years) and heavy smokers (46 ± 8 years) had higher STT (p = 0.0001), exCO (p < 0.0001) and COHb (p < 0.0001) levels compared with light smokers (51 ± 15 years) and non-smokers (50 ± 11 years). A positive correlation was observed between STT and exCO (r = 0.4; p < 0.0001), STT and cigarettes/day (r = 0.3, p = 0.02) and exCO and cigarettes/day (r = 0.3, p < 0.01).

CONCLUSION

Smoking impairs mucociliary clearance and is associated with cigarette smoking intensity.

A prospective study of tobacco smoking and mortality in Bangladesh

Background

Limited data are available on smoking-related mortality in low-income countries, where both chronic disease burden and prevalence of smoking are increasing.

Methods

Using data on 20, 033 individuals in the Health Effects of Arsenic Longitudinal Study (HEALS) in Bangladesh, we prospectively evaluated the association between tobacco smoking and all-cause, cancer, and cardiovascular disease mortality during ∼7.6 years of follow-up.

Cox proportional hazards models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) for deaths from all-cause, cancer, CVD, ischemic heart disease (IHD), and stroke, in relation to status, duration, and intensity of cigarette/bidi and hookah smoking.

Results

Among men, cigarette/bidi smoking was positively associated with all-cause (HR 1.40, 95% CI 1.06 1.86) and cancer mortality (HR 2.91, 1.24 6.80), and there was a dose-response relationship between increasing intensity of cigarette/bidi consumption and increasing mortality. An elevated risk of death from ischemic heart disease (HR 1.87, 1.08 3.24) was associated with current cigarette/bidi smoking. Among women, the corresponding HRs were 1.65 (95% CI 1.16 2.36) for all-cause mortality and 2.69 (95% CI 1.20 6.01) for ischemic heart disease mortality. Similar associations were observed for hookah smoking. There was a trend towards reduced risk for the mortality outcomes with older age at onset of cigarette/bidi smoking and increasing years since quitting cigarette/bibi smoking among men. We estimated that cigarette/bidi smoking accounted for about 25.0% of deaths in men and 7.6% in women.

Conclusions

Tobacco smoking was responsible for substantial proportion of premature deaths in the Bangladeshi population, especially among men. Stringent measures of tobacco control and cessation are needed to reduce tobacco-related deaths in Bangladesh.

Serum cotinine levels and prehypertension in never smokers

Background. Few studies have shown that self-reported secondhand smoke exposure in never smokers is associated with high blood pressure. However, there are no studies investigating the relationship between secondhand smoke exposure, measured objectively by serum cotinine levels, and high blood pressure in never smokers. Methods. We examined never smokers (n = 2027) from the National Health and Nutrition Examination Survey 2005–2008. Our exposure of interest was the secondhand smoke exposure estimated by serum cotinine level and our outcome was prehypertension (n = 734), defined as a systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg. Results. We found that, in never smokers, serum cotinine levels were positively associated with prehypertension. Compared to those with cotinine levels in the lowest quartile (≤0.024 ng/mL), the multivariable odds ratio (95% confidence interval) of prehypertension among those with cotinine levels in the highest quartile (≥0.224 ng/mL) was 1.45(1.00, 2.11); P trend = 0.0451. In subsequent subgroup analyses, the positive association was found to be stronger among men, non-Whites, and non-obese subjects. Conclusion. Higher secondhand smoke exposure measured objectively by serum cotinine levels was found to be associated with prehypertension in certain subgroups of a representative sample of the US population.

Impact of smoking and quitting on cardiovascular outcomes and risk advancement periods among older adults

Smoking is an established risk factor for cardiovascular events, such as myocardial infarction, stroke and cardiovascular death. However, most pertinent studies primarily relied on middle aged adults. We aimed to provide empirical evidence on the association of smoking with cardiovascular events and the benefits of smoking cessation in people aged 50 years or older. In a German population-based cohort study detailed information on lifetime smoking history was obtained from 8,807 individuals aged 50-74 years, without previous myocardial infarction (MI) or stroke. Cox proportional hazards regression was applied to estimate the impact of smoking on MI, stroke and cardiovascular death (CVD) as well as on the combined outcome of major cardiovascular events (MI, stroke or CVD). In addition, the impact of smoking and the benefits of smoking cessation were quantified by risk advancement periods (RAP). The cohort included 17.2 % current smokers, 31.7 % former smokers and 51.1 % never smokers. During a mean follow-up of 9.1 years, 261 participants experienced a first MI, 456 had a primary stroke and 274 died of cardiovascular reasons. Compared to never smokers, adjusted hazard ratios (95 % confidence intervals) of current smokers were 2.25 (1.62-3.12), 2.12 (1.65-2.73) and 2.45 (1.76-3.42) and RAPs were 19.3, 9.8 and 8.4 years for MI, stroke and CVD, respectively. Strong dose-response relationships were seen with both current and life-time amount of smoking. Most of the excess risk and risk advancement disappeared within 5 years after smoking cessation. Smoking is a strong risk factor for cardiovascular events even at older age. Smoking cessation is highly and rapidly beneficial also at advanced age.

Association of serum cotinine levels and hypertension in never smokers

Hypertension is a major public health problem. Identifying novel risk factors for hypertension, including widely prevalent environmental exposures, is therefore important. Active smoking is a well-known risk factor for hypertension and cardiovascular diseases. However, there are no studies investigating the relationship between secondhand smoke exposure, measured objectively by serum cotinine, and high blood pressure among never smokers. We examined 2889 never smokers from the National Health and Nutrition Examination Survey 2005-2008. Our exposure of interest was secondhand smoke exposure among never smokers, estimated by serum cotinine level, and our main outcome was hypertension (n=1004). We found that in never smokers, higher serum cotinine levels were positively associated with hypertension. In comparison with those with serum cotinine levels ≤ 0.025 ng/mL, the multivariable odds ratio (95% confidence interval) of hypertension among those with serum cotinine levels ≥ 0.218 ng/mL was 1.44 (1.01-2.04). In addition, higher serum cotinine was positively associated with mean change in systolic blood pressure (odds ratio [95% confidence interval], 3.24 [0.86-5.63]; P=0.0061). However, no association was present with diastolic blood pressure. In conclusion, in never smokers, higher secondhand smoke exposure measured objectively by serum cotinine levels was found to be associated with systolic blood pressure and hypertension independent of age, sex, ethnicity, education, alcohol drinking, body mass index, glycohemoglobin, total cholesterol, and other confounders.

Very low nicotine content cigarettes and potential consequences on cardiovascular disease

Cigarette smoking remains highly prevalent in the U.S. and contributes significantly to cardiovascular disease (CVD). Tobacco control policies, including product regulation, can reduce smoking-related harm. One approach being considered in the U.S. is for the FDA to set a low nicotine standard for cigarettes. Such a standard could result in multiple beneficial outcomes including reduced cardiovascular toxicity related to nicotine, reduced smoking intensity in current smokers, increased cessation rates, decreased development of smoking dependence in youth, and decreased passive smoke exposure. Consequently, CVD risk in the U.S. could be dramatically improved by nicotine reduction in cigarettes. Possible pathways linking nicotine reduction in cigarettes to decreased CVD risk are discussed, while potential unintended consequences that could offset expected gains are also presented. Gaps in the literature, including limited data on CVD biomarkers and long-term CVD outcomes following the use of very low nicotine cigarettes, are discussed to highlight areas for new research.

Using the negative exponential distribution to quantitatively review the evidence on how rapidly the excess risk of ischaemic heart disease declines following quitting smoking

No previous review has formally modelled the decline in IHD risk following quitting smoking. From PubMed searches and other sources we identified 15 prospective and eight case-control studies that compared IHD risk in current smokers, never smokers, and quitters by time period of quit, some studies providing separate blocks of results by sex, age or amount smoked. For each of 41 independent blocks, we estimated, using the negative exponential model, the time, H, when the excess risk reduced to half that caused by smoking. Goodness-of-fit to the model was adequate for 35 blocks, others showing a non-monotonic pattern of decline following quitting, with a variable pattern of misfit. After omitting one block with a current smoker RR 1.0, the combined H estimate was 4.40 (95% CI 3.26-5.95) years. There was considerable heterogeneity, H being <2years for 10 blocks and >10years for 12. H increased (p<0.001) with mean age at study start, but not clearly with other factors. Sensitivity analyses allowing for reverse causation, or varying assumed midpoint times for the final open-ended quitting period little affected goodness-of-fit of the combined estimate. The US Surgeon-General's view that excess risk approximately halves after a year's abstinence seems over-optimistic.