Burden of total and cause-specific mortality related to tobacco smoking among adults aged ≥ 45 years in Asia: a pooled analysis of 21 cohorts

Projecting the impact of implementation of WHO MPOWER measures on smoking prevalence and mortality in Japan

OBJECTIVE

This study aimed to quantify the long-term impact of implementing the WHO Framework Convention on Tobacco Control (FCTC) compliant tobacco control measures, MPOWER, on smoking prevalence and mortality in men and women aged ≥20 years in Japan.

DESIGN

A Stock-and-Flow simulation model was used to project smoking prevalence and mortality from 2018 to 2050 under eight different scenarios: (1) maintaining the 2018 status quo, (2) implementation of smoke-free policies, (3) tobacco use cessation programmes, (4-5) health warning about the dangers of tobacco (labels, mass media), (6) enforcement of tobacco advertising bans or (7) tobacco taxation at the highest recommended level and (8) all these interventions combined.

RESULTS

Under the status quo, the smoking prevalence in Japan will decrease from 29.6% to 15.5% in men and 8.3% to 4.7% in women by 2050. Full implementation of MPOWER will accelerate this trend, dropping the prevalence to 10.6% in men and 3.2% in women, and save nearly a quarter million deaths by 2050. This reduction implies that Japan will only attain the current national target of 12% overall smoking prevalence in 2033, 8 years earlier than it would with the status quo (in 2041), a significant delay from the national government's 2022 deadline.

CONCLUSIONS

To bring forward the elimination of tobacco smoking and substantially reduce smoking-related deaths, the government of Japan should fulfil its commitment to the FCTC and adopt stringent tobacco control measures delineated by MPOWER and beyond.

Fat intake modifies association between cigarette smoking and lung cancer in a prospective cohort study: A potential explanation for the lung cancer paradox

BACKGROUND & AIMS

It remains unclear why the association between cigarette smoking and lung cancer was substantially stronger in Western countries than in Asian countries. As experimental studies have revealed that fat intake modulates tobacco carcinogen metabolism and the growth of transplanted or carcinogen-induced lung tumors in mice, the present study sought to investigate whether the association between cigarette smoking and lung cancer was modified by intake of total fat and types of fat (saturated, monounsaturated, and polyunsaturated fats) in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.

METHODS

During a median follow-up of 8.9 years, 1,425 cases of lung cancer were documented from 100,864 participants eligible for the present analysis. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

After adjustment for established or suspected confounders, the strength of the association between cigarette smoking and lung cancer was remarkably larger among individuals with high fat intake. HRs (95% CIs) comparing current with never smokers were 23.0 (13.4, 39.6), 32.7 (20.3, 52.8), and 59.8 (30.2, 118.2) for the tertile 1 (≤13.48 g/day), tertile 2 (13.49-21.89 g/day), and tertile 3 (≥21.90 g/day) of saturate fat intake, respectively. A similar pattern of the non-significant interaction was observed when the accumulated amount of cigarette smoking (1-19, 20-39, and ≥40 vs. 0 pack-years) was entered into the regression models.

CONCLUSIONS

The present study showed that lung cancer risk associated with both the status and accumulated amount of cigarette smoking was remarkably stronger in individuals with high intakes of fat, particularly saturated fat. However, this interaction was not statistically significant and thus warrants further investigations in other studies.

Dose-response association between cigarette smoking and gastric cancer risk: a systematic review and meta-analysis

This study aims at providing an accurate and up-to-date quantification of the dose-response association between cigarette smoking and gastric cancer (GC) risk, overall and by subsite. We conducted a systematic review and meta-analysis of case-control and cohort studies on the association between cigarette smoking and GC risk published up to January 2023. We estimated pooled relative risks (RR) of GC and its subsites according to smoking status, intensity, duration, and time since quitting. Among 271 eligible articles, 205 original studies were included in this meta-analysis. Compared with never smokers, the pooled RR for GC was 1.53 (95% confidence interval; CI 1.44-1.62; n = 92) for current and 1.30 (95% CI 1.23-1.37; n = 82) for former smokers. The RR for current compared with never smokers was 2.08 (95% CI 1.66-2.61; n = 21) for gastric cardia and 1.48 (95% CI 1.33-1.66; n = 8) for distal stomach cancer. GC risk nonlinearly increased with smoking intensity up to 20 cigarettes/day (RR:1.69; 95% CI 1.55-1.84) and levelled thereafter. GC risk significantly increased linearly with increasing smoking duration (RR: 1.31; 95% CI 1.25-1.37 for 20 years) and significantly decreased linearly with increasing time since quitting (RR: 0.65; 95% CI 0.44-0.95 for 30 years since cessation). The present meta-analysis confirms that cigarette smoking is an independent risk factor for GC, particularly for gastric cardia. GC risk increases with a low number of cigarettes up to 20 cigarettes/day and increases in a dose-dependent manner with smoking duration.

Frequency of cigarette smoking and its associated factors among men in East Africa: a pooled prevalence analysis of national survey using multinomial regression

BACKGROUND

Despite the harmful effects of smoking, there have been few studies to pinpoint the factors of this habit, and little is known about it in the East African region. For this reason, this study sought to determine the frequency and factors of cigarette smoking among men in the region.

METHODS

Data from recent demographic and health surveys carried out in ten East African countries between 2015 and 2022 were analyzed in this study. Data from 87,022 men was collected. The key factors affecting the smoking rates in the area were investigated using binary and multiple multinomial logistic regression. To ascertain if variables were statistically significant in the final model for binary regression and multiple regression, P values of ≤ 0.2 and < 0.05 were used respectively.

RESULTS

Overall, about 14.69% of people currently smoke cigarettes. Of this about 11.03 (95% CI = 10.82, 11.24) was for daily active tobacco use. As compared to < 26-year-old men, men with an age range of 26-35 years (RRR = 2.17, 95% CI: 2.01,2.34), 36-45 years (RRR = 2.82, 95% CI: 2.60, 3.07), and > 45 years old (RRR = 3.68, 95% CI: 3.38, 4.02), were using cigarettes daily rather than no-smoking cigarettes. Men who had begun their first sexual intercourse at the age of 7-19 years (RRR = 6.27,95% CI, 5.35,7.35), 20-25 years (RRR = 4.01, 95% CI, 3.40,4.72), and greater than 25 years old (RRR = 3.08, 95% CI, 2.55,3.71) have shown a higher relative risk ratio to smoke cigarette daily rather than using not smoke cigarette respectively, married (RRR = 0.86, 95% CI, 0.79,0.93), divorced or widowed (RRR = 2.51, 95% CI, 2.27,2.77), middle wealth index (RRR = 2.11, 95% CI 1.98,2.24), and rich (RRR = 1.44, 95% CI, 1.34,1.54), secondary/higher education (RRR = 0.72, 05% CI, 0.66,0.77), rural men (RRR = 0.69, 95% CI, 0.65,0.73), employed men (RRR = 1.26,95% CI, 1.17,1.36), mass media exposure (RRR = 0.76, 95% CI, 0.73,0.81), men who have one sex partner (RRR = 1.23,95% CI,1.13,1.35), and more than one sex partner (RRR = 1.63, 95% CI, 1.47,1.79) more times as compared to those participants who had no sex partner respectively.

CONCLUSIONS

Men in East African nations were substantially more likely to smoke cigarettes if they were older, had less education, had a higher wealth index, were divorced or widowed, had many sexual relationships, had early sexual activity, resided in an urban area, were employed, or had no media exposure. The identified factors should be considered by policymakers and public health professionals to lower smoking initiation and increase smoking cessation among men.

Lung Cancer Risk Prediction Models for Asian Ever-Smokers

INTRODUCTION

Although lung cancer prediction models are widely used to support risk-based screening, their performance outside Western populations remains uncertain. This study aims to evaluate the performance of 11 existing risk prediction models in multiple Asian populations and to refit prediction models for Asians.

METHODS

In a pooled analysis of 186,458 Asian ever-smokers from 19 prospective cohorts, we assessed calibration (expected-to-observed ratio) and discrimination (area under the receiver operating characteristic curve [AUC]) for each model. In addition, we developed the "Shanghai models" to better refine risk models for Asians on the basis of two well-characterized population-based prospective cohorts and externally validated them in other Asian cohorts.

RESULTS

Among the 11 models, the Lung Cancer Death Risk Assessment Tool yielded the highest AUC (AUC [95% confidence interval (CI)] = 0.71 [0.67-0.74] for lung cancer death and 0.69 [0.67-0.72] for lung cancer incidence) and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Model had good calibration overall (expected-to-observed ratio [95% CI] = 1.06 [0.90-1.25]). Nevertheless, these models substantially underestimated lung cancer risk among Asians who reported less than 10 smoking pack-years or stopped smoking more than or equal to 20 years ago. The Shanghai models were found to have marginal improvement overall in discrimination (AUC [95% CI] = 0.72 [0.69-0.74] for lung cancer death and 0.70 [0.67-0.72] for lung cancer incidence) but consistently outperformed the selected Western models among low-intensity smokers and long-term quitters.

CONCLUSIONS

The Shanghai models had comparable performance overall to the best existing models, but they improved much in predicting the lung cancer risk of low-intensity smokers and long-term quitters in Asia.

Waterpipe tobacco smoking and risk of all-cause mortality: a prospective cohort study

BACKGROUND

Despite an increasing proportion of smokers who use non-cigarette products, the harmfulness of these is inconsistent. This study aimed to evaluate the impact of waterpipe tobacco (WTP) smoking on all-cause mortality.

METHODS

A prospective cohort study followed up on 35 646 participants from 2007 to 2019 in Northern Viet Nam. Data for each type of cigarette and WTP smoking were collected based on demographic lifestyle and semi-quantitative food frequency questionnaires. Smokers were categorized as current smokers and former smokers who were lifetime ever smokers but stopped smoking >6 months before the interview. Data on all-cause mortality (2449 deaths) were obtained from medical records at the state health facilities. The hazard ratios (HRs) and 95% CIs for mortality were estimated using a Cox proportional-hazards model.

RESULTS

Compared with non-smokers, ever smokers had a higher all-cause mortality risk (HR = 1.29, 95% CI = 1.16-1.43). Current WTP (HR = 1.37, 95% CI = 1.19-1.57), current cigarette (HR = 1.40, 95% CI = 1.22-1.60) and former WTP smokers (HR = 1.39, 95% CI = 1.10-1.76) showed an elevated risk of dying. The mortality risk was significantly elevated in dual smokers using WTP and cigarettes (HR = 1.55, 95% CI = 1.35-1.79) and exclusive WTP smokers (HR = 1.38, 95% CI = 1.21-1.57). Elevated risk was observed for the main targeted attractions of cancer, diabetes and heart diseases. Smoking cessation of >10 years decreased the risk of all-cause mortality (HR = 0.61, 95% CI = 0.44-0.85) and cancer (HR = 0.24, 95% CI = 0.11-0.52).

CONCLUSIONS

WTP smoking increases the risk of all-cause mortality. A unique programme to control exposure to WTP should be a high priority in Viet Nam and other countries.

Longitudinal Changes in Smoking Behaviors and Cancer-Related Mortality Risk in Middle-Aged Korean Women

PURPOSE

This study investigated association between smoking habit change and cancer-related mortality risk in Korean women.

MATERIALS AND METHODS

Study population were women aged ≥ 40 years who underwent two biennial cancer screenings during 2009-2012 and were followed up until 2020. Participants were grouped into sustained nonsmokers, sustained quitters, new quitters, relapsers/smoking initiators, and sustained smokers. Outcomes included all-cause and cancer-related deaths. Cox regression and competing risk analysis was used to assess association between smoking habit change and mortality risk.

RESULTS

Of 2,892,590 women, 54,443 death cases were recorded (median follow-up of 9.0 years). Compared with sustained nonsmokers, mortality risk from all causes and cancer-related causes increased in all other smoking groups. Cancer-related risk increased 1.22-fold among sustained quitters (95% confidence interval [CI], 1.10 to 1.36), 1.56-fold (95% CI, 1.40 to 1.75) in new quitters, 1.40-fold (95% CI, 1.21 to 1.62) in relapsers/smoking initiators, and 1.61-fold (95% CI, 1.46 to 1.78) in sustained smokers compared with sustained nonsmokers. Women who were sustained smokers with higher smoking intensity had a higher mortality risk in terms of hazard ratios compared to nonsmokers (< 5 pack-years 2.12-fold, 5-10 pack-years 2.15-fold, and > 10 pack-years 2.27-fold).

CONCLUSION

Quitting smoking earlier is critical for preventing death from all causes and cancer among female smokers.

Tobacco smoke and all-cause mortality and premature death in China: a cohort study

BACKGROUND

Tobacco smoke is associated with several diseases, and identified as the second leading risk factor for death from any cause worldwide. The relationship of tobacco smoke to mortality or premature death is not yet available from contemporary cohorts after 2010 in China. This study aimed to investigate the smoking behavior and the relationship of tobacco smoke to mortality and premature death among a nationally representative cohort starting from 2011 in China.

METHODS

The nationally representative datasets (China Health and Retirement Longitudinal Study, CHARLS, 2011-2012) was employed and linked with follow-up data (2013). CHARLS was an ongoing nationally representative survey, which longitudinally followed up subjects aged over 45 years. Smoking status (non-smoker, ex-smoker, smoker, pack-years of smoking, age at starting and ceasing smoking) was used as independent variable, and all-cause mortality, premature death (defined as mortality before age 72.7 years in men and 76.9 years in women) were used as dependent variables. The Cox's proportional hazards regression mode was used to estimate the effect of tobacco smoke and pack-years of smoking on all-cause mortality and premature death.

RESULTS

A total of 16,701 subjects were included. The association between tobacco smoker (hazard ratio [HR] = 1.37, 95%CI = 1.02, 1.83) / ex-smoker (HR = 1.75, 95%CI = 1.24, 2.46) and all-cause mortality was significant. Tobacco smoker (HR = 1.58, 95%CI = 1.04, 2.39) and ex-smoker (HR = 2.25, 95%CI = 1.38, 3.66) was associated with increase in the risk of premature death. Pack-years of smoking ≥ 30 was associated with increased risk of premature death compared with non-smokers in total (HR = 1.59, 95%CI = 1.03, 2.43) and women (HR = 3.38, 95%CI = 1.22, 9.38). Additionally, our results also revealed that there was a linear trend between pack-years of smoking and premature death in total (P = 0.002) and women (P = 0.010).

CONCLUSION

This study found a negative effect of smoking status on all-cause mortality and premature death among a contemporary and nationally representative data in China. The correlation between pack-years of smoking and premature death and the trend of pack-years of smoking with premature death was also identified.

Dose-response Relationships Between Cigarette Smoking and Breast Cancer Risk: A Systematic Review and Meta-analysis

BACKGROUND

The possible association between cigarette smoking and breast cancer risk has been quite controversial.

METHODS

We conducted a systematic review and meta-analysis of all available observational studies published on the issue up to January 2020. Random-effects models were used to compute pooled relative risks (RRs) for cigarette smoking status and dose-risk relationships were evaluated using one-stage random-effects dose-response models.

RESULTS

A total of 169 studies were selected, providing a pooled RR for breast cancer of 1.07 (95% confidence interval [CI], 1.05-1.10) for current, 1.08 (95% CI, 1.06-1.10) for former, and 1.09 (95% CI, 1.07-1.11) for ever smokers, compared to never smokers. Results were consistent in case-control and cohort studies. No meaningful differences were observed across strata of most covariates considered, nor according to relevant genetic mutations and polymorphisms (ie, BRCA mutation, N-acetyltransferase and glutathione S-transferase genotypes, and P53). Breast cancer risk increased linearly with intensity of smoking (RR 1.12; 95% CI, 1.08-1.16 for 20 cigarettes/day and 1.26; 95% CI, 1.17-1.36 for 40 cigarettes/day), and with increasing duration of smoking (RR 1.05; 95% CI, 1.03-1.08 for 20 years of smoking and 1.11; 95% CI, 1.06-1.16 for 40 years of smoking).

CONCLUSION

The present large and comprehensive meta-analysis-conducted using an innovative approach for study search-supports the evidence of a causal role of tobacco smoking on breast cancer risk.

Dose-risk relationships between cigarette smoking and cervical cancer: a systematic review and meta-analysis

OBJECTIVE

Cervical cancer (CC) is the fourth most frequent cancer worldwide. Cigarette smoking has been shown to influence CC risk in conjunction with human papillomavirus (HPV) infection. The aim of this study is to provide the most accurate and updated estimate of this association and its dose-response relationship.

METHODS

Using an innovative approach for the identification of original publications, we conducted a systematic review and meta-analysis of studies published up to January 2021. Random effects models were used to provide pooled relative risks (RRs) of CC for smoking status. Dose-response relationships were evaluated using one-stage random effects models with linear or restricted cubic splines models.

RESULTS

We included 109 studies providing a pooled RR of invasive CC and preinvasive lesions, respectively, of 1.70 [95% confidence interval (CI), 1.53-1.88] and 2.11 (95% CI, 1.85-2.39) for current versus never smokers, and, respectively, 1.13 (95% CI, 1.02-1.24) and 1.29 (95% CI, 1.15-1.46) for former versus never smokers. Considering HPV does not alter the positive association or its magnitude. Risks of CC sharply increased with few cigarettes (for 10 cigarettes/day, RR = 1.72; 95% CI, 1.34-2.20 for invasive CC and RR = 2.13; 95% CI, 1.86-2.44 for precancerous lesions). The risk of CC increased with pack-years and smoking duration and decreased linearly with time since quitting, reaching that of never smokers about 15 years after quitting.

CONCLUSION

This comprehensive review and meta-analysis confirmed the association of smoking with CC, independently from HPV infection. Such association rose sharply with smoking intensity and decreased after smoking cessation.

The spread of heated tobacco product (HTP) use across various subgroups during 2015-16 and 2017-18 in Japan

BACKGROUND

Heated tobacco product (HTP) use has increased substantially between 2016 and 2017 in Japan. This study aims to clarify how HTP use (IQOS, Ploom, and glo) spread across the different combustible cigarette smoking statuses during 2015-16 and 2017-18 in Japan.

METHODS

We compared the two periods of (i) 2015 to 2016 (N = 5,366) and (ii) 2017 to 2018 (N = 3,422) from a longitudinal study randomly sampling members from the Japan "Society and New Tobacco" Internet Survey (JASTIS). Multivariable logistic regression models for current HTP use in the previous 30 days by combustible cigarette smoking status in the previous year were used adjusting for socio-demographic factors.

RESULTS

HTP use increased by 10 times in the 2017-18 cohort compared with the 2015-16 cohort according to the adjusted odds ratio (95% confidence interval) for current HTP use as 10.2 (7.03-14.8). According to smoking status, significantly higher adjusted ORs (95% CIs) of current HTP use for the after period were observed: 2.60 (1.37-4.94) for never smokers, 7.82 (3.64-16.8) for former smokers, 21.1 (5.73-77.9) for current smokers with intention to quit, and 17.0 (9.58-30.3) for current smokers without intention to quit.

CONCLUSION

During 2015 to 2018 in Japan, HTP use dramatically increased in all subgroups except for never smokers.

Effects of dose and dose-averaged linear energy transfer on pelvic insufficiency fractures after carbon-ion radiotherapy for uterine carcinoma

BACKGROUND AND PURPOSE

The correlation between dose-averaged linear energy transfer (LETd) and its therapeutic or adverse effects, especially in carbon-ion radiotherapy (CIRT), remains controversial. This study aimed to investigate the effects of LETd and dose on pelvic insufficiency fractures after CIRT.

MATERIAL AND METHODS

Among patients who underwent CIRT for uterine carcinoma, 101 who were followed up for > 6 months without any other therapy were retrospectively analyzed. The sacrum insufficiency fractures (SIFs) were graded according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity criteria. The correlations between the relative biological effectiveness (RBE)-weighted dose, LETd, physical dose, clinical factors, and SIFs were evaluated. In addition, we analyzed the association of SIF with LETd, physical dose, and clinical factors in cases where the sacrum D50% RBE-weighted dose was above the median dose.

RESULTS

At the last follow-up, 19 patients developed SIFs. Receiver operating characteristic curve analysis revealed that the sacrum D50% RBE-weighted dose was a valuable predictor of SIF. Univariate analyses suggested that LETd V10 keV/µm, physical dose V5 Gy, and smoking status were associated with SIF. Cox regression analysis in patients over 50 years of age validated that current smoking habit was the sole risk factor for SIF. Therefore, LETd or physical dose parameters were not associated with SIF prediction.

CONCLUSION

The sacrum D50% RBE-weighted dose was identified as a risk factor for SIF. Additionally, neither LETd nor physical dose parameters were associated with SIF prediction.

Differences in medical costs among urban lung cancer patients with different health insurance schemes: a retrospective study

Background

Health insurance plays a significant role in reducing the financial burden for lung cancer patients. However, limited research exists regarding the differences in medical costs for lung cancer patients with different insurance schemes across different cities. We aimed to assess disparities in lung cancer patients’ costs by insurance type and city–specific insurance type.

Methods

Claim data of China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2010 and 2016 were employed to investigate differences in medical costs. This study primarily applied descriptive analysis and a generalized linear model with a gamma distribution and a log link.

Results

In total, 92,856 lung cancer patients with inpatient records were identified, with Renminbi (RMB) 11,276 [6322–20,850] (median [interquartile range]) medical costs for the UEBMI group and RMB 8303 [4492–14,823] for the URBMI group. Out–of–pocket (OOP) expenses for the UEBMI group was RMB 2143 [1108–4506] and RMB 2975 [1367–6275] for the URBMI group. The UEBMI group also had significantly higher drug costs, medical service costs, and medical consumable costs, compared to the URBMI group. Regarding city-specific insurances, medical costs for the UEBMI and the URBMI lung cancer patients in Shanghai were RMB 9771 [5183–16,623] and RMB 9741 [5924–16,067], respectively. In Xianyang, the medical costs for UEBMI and URBMI patients were RMB 11,398 [6880–20,648] and RMB 9853 [5370–24,674], respectively. The regression results showed that the UEBMI group had 27.31% fewer OOP expenses than the URBMI group did, while patients in Xiangyang and Xianyang had 39.53 and 35.53% fewer OOP expenses, respectively, compared to patients in Shanghai.

Conclusions

Compared with the URBMI patients, the UEBMI lung cancer patients obtained more or even better health services and had reduced financial burden. The differences in insurances among cities were greater, compared to those among insurances within cities, and the differences in OOP expenses between cities were greater compared to those between UEBMI and URBMI. Our results called for further reform of China’s fragmented insurance schemes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07957-9.

Association of Marital Status With Total and Cause-Specific Mortality in Asia

IMPORTANCE

Marital status has been shown to be associated with mortality, but evidence in Asian populations is limited.

OBJECTIVE

To examine the association of marital status with total and cause-specific mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included individual participant data from 16 prospective studies in the Asia Cohort Consortium conducted between 1963 and 2015. Asian participants with complete information on marital and vital status were included. Study-specific hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards model and then pooled using a random-effects meta-analysis. The analysis began in February 2021 and ended in August 2021.

EXPOSURES

Marital status.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific mortality.

RESULTS

Of 623 140 participants (326 397 women [52.4%] and 296 743 men [47.6%]; mean [SD] age, 53.7 [10.2] years; mean [SD] follow-up time, 15.5 [6.1] years), 123 264 deaths were ascertained. Compared with married individuals, those who were unmarried had pooled HRs of 1.15 (95% CI, 1.07-1.24) for total mortality, 1.12 (95% CI, 1.03-1.22) for cerebrovascular disease mortality, 1.20 (95% CI, 1.09-1.31) for coronary heart disease mortality, 1.17 (95% CI, 1.07-1.28) for circulatory system diseases mortality, 1.06 (95% CI, 1.01-1.11) for cancer mortality, 1.14 (95% CI, 1.05-1.23) for respiratory diseases mortality, and 1.19 (95% CI, 1.05-1.34) for external causes of death. Positive associations with total mortality were also observed for those who were single (HR, 1.62; 95% CI, 1.41-1.86), separated (HR, 1.35; 95% CI, 1.13-1.61), divorced (HR, 1.38; 95% CI, 1.13-1.69), and widowed (HR, 1.09; 95% CI, 1.04-1.13). In subgroup analyses, the positive association persisted across baseline health conditions, and the risk of death was more pronounced among men or people younger than 65 years.

CONCLUSIONS AND RELEVANCE

This large pooled cohort study of individual participant data provides strong evidence that being unmarried, as well as belonging to the unmarried subcategories, was positively associated with total and cause-specific mortality. Investment of targeted social support services might need to be considered in light of the mortality differences between married and unmarried individuals.

Reducing the Burden of Disease Through Tobacco Taxes in Mongolia: A Health Impact Analysis Using a Dynamic Public Health Model

BACKGROUND/OBJECTIVES

Smoking is the leading risk factor for many chronic diseases. The quantitative analysis of potential health gains from reduced smoking is important for establishing priorities in Mongolia's health policy. This study quantifies the effect of tobacco-tax increases on future smoking prevalence and the associated smoking-related burden of disease in Mongolia.

METHODS

The dynamic model for health impact assessment (DYNAMO-HIA) tool was used. The most recent data were used as input for evaluating tobacco-taxation scenarios. Demographic data were taken from the Mongolian Statistical Information Services. Smoking data came from a representative population-based STEPS survey, and smoking-related disease data were obtained from the health-information database of Mongolia's National Health Center. Simulation was used to evaluate various levels of one-time price increases on tobacco products (25% and 75%) in Mongolia. Conservative interpretation suggests that the population will eventually adjust to the higher tobacco price and return to baseline smoking behaviors.

RESULTS

Over a three-year period, smoking prevalence would be reduced by 1.2% points, corresponding to almost 40 thousand smokers at the population level for a price increase of 75%, compared to the baseline scenario. Projected health benefits of this scenario suggest that more than 137 thousand quality adjusted of life years would be gained by avoiding smoking-related diseases within a population of three million over a 30-year period.

DISCUSSION

Prevention through effective tobacco-control policy could yield considerable gains in population health in Mongolia. Compared to current policy, tax increases must be higher to have a significant effect on population health.

IMPLICATIONS

Tobacco taxation is an effective policy for reducing the harm of tobacco smoking, while benefiting population health in countries where the tobacco epidemic is still in an early stage. Smoking prevalence and smoking behaviors in these countries differ from those in Western countries. Reducing the uptake of smoking among young people could be a particularly worthwhile benefit of tobacco-tax increases.

Mapping of global, regional and national incidence, mortality and mortality-to-incidence ratio of lung cancer in 2020 and 2050

AIM

Lung cancer is the leading cause of cancer deaths worldwide. This study examines the current and future burden of lung cancer at global, regional, and national levels.

METHODS

The estimates of lung cancer incident cases, deaths, and their age-standardized rates are drawn from GLOBOCAN 2020 for 21 regions and 185 countries. Mortality-to-incidence ratio (MIR) is considered as a proxy indicator of 5-year survival rates. Lung cancer burden in 2050 is projected using age-specific incidence and death rates in 2020.

RESULTS

In 2020, there were 2.21 million new cases and 1.8 million deaths due to lung cancer worldwide with age-standardized incidence rate (ASIR) of 22.4/100,000 (male: 31.5; female: 14.6) and age-standardized mortality rates (ASMR) of 18.0/100,000, (male: 25.9; female: 11.2/100,000). Global MIR of lung cancer was 0.82 (males 0.83; females: 0.79), varying from 0.59 (Japan) to 1.0 (Belize). Hungary had the highest age-standardized rates (ASIR: 50.1/100,000; ASMR: 42.4/100,000) and Nigeria (ASIR: 0.88; ASMR: 0.86) had the lowest age-standardized rates in 2020. Both ASIR and ASMR were positively correlated with country-level tobacco smoking prevalence and human development index (HDI), whereas MIR exhibited a negative correlation with HDI. As per our projections, there will be 3.8 million incident cases and 3.2 million deaths globally due to lung cancer in 2050.

CONCLUSION

With close to 2 million cases and deaths already in 2020, lung cancer has already become a global public health threat. Even with current risk levels and age-specific rates, lung cancer annual cases are expected to reach 3.8 million in 2050. Until smoking prevalence is reduced and ambient air pollution levels are checked, particularly in low/medium HDI countries, the lung cancer epidemic will continue unfolding.

Reduction in total and major cause-specific mortality from tobacco smoking cessation: a pooled analysis of 16 population-based cohort studies in Asia

BACKGROUND

Little is known about the time course of mortality reduction following smoking cessation in Asians who have smoking behaviours distinct from their Western counterparts. We evaluated the level of reduction in all-cause, cardiovascular disease (CVD) and lung cancer mortality by years since quitting smoking, in Asia.

METHODS

Using Cox regression, we analysed individual participant data (n = 709 151) from 16 prospective cohorts conducted in China, Japan, Korea/Singapore, and India/Bangladesh, separately by cohorts. Cohort-specific hazard ratios (HRs) were combined using a random-effects meta-analysis.

RESULTS

During a mean follow-up of 12.0 years, 108 287 deaths were ascertained-35 658 from CVD and 7546 from lung cancer. Among Asian men, a dose-response relationship of risk reduction in deaths from all causes, CVD and lung cancer was observed with an increase in years after smoking cessation. Compared with never smokers, however, all-cause and CVD mortality among former smokers remained elevated 10-14 years after quitting [multivariable-adjusted HR (95% confidence interval (CI) = 1.25 (1.13-1.37) and 1.20 (1.02-1.41), respectively]. Lung cancer mortality stayed almost 2-fold higher than among never smokers 15-19 years after smoking cessation [1.97 (1.41-2.73)], particularly among former heavy smokers [2.62 (1.71-4.00)]. Women who quitted for ≥5 years retained a significantly elevated mortality from all causes, CVD and lung cancer. Overall patterns of the cessation-mortality associations were similar across countries.

CONCLUSIONS

Our findings suggest that adverse effects of tobacco smoking persist for an extended time period, even for more than two decades, which is beyond the time windows defined in current clinical guidelines for risk assessment of lung cancer and CVD.

Potential Impact of Time Trend of Lifestyle Risk Factors on Burden of Major Gastrointestinal Cancers in China

BACKGROUND & AIMS

China has the largest number of incident liver, esophageal, gastric, and colorectal cancer cases in 2020. Examining the time trend of relevant lifestyle risk factors would help project the trend of these gastrointestinal (GI) cancer incidence in China.

METHODS

We estimated the time trend of the lifestyle factors based on the China Health and Nutrition Survey 1991 to 2011. We applied the comparative risk assessment method to estimate the population attributable fraction of GI cancers attributable to each risk factor. We also projected the prevalence of lifestyle factors and the associated burden of GI cancer from 2011 to 2031.

RESULTS

In 2011, 56.5% of colorectal, 59.8% of gastric, 48.5% of esophageal, and 35.2% of liver cancer in China were attributable to the lifestyle risk factors under study. Smoking, sodium intake, low vegetable intake, and low fruit intake have improved over time but remained far from optimal and are expected to be responsible for 170,000, 35,000, 22,000, and 50,000 GI cancer cases in 2031, respectively. High body mass index, red and processed meat consumption, and low physical activity are expected to contribute increasingly more GI cancer, accounting for 142,000, 185,000, 60,000, and 53,000 cases in 2031, respectively. The estimated population attributable fraction for all risk factors in 2031 is 52.1%.

CONCLUSIONS

Lifestyle risk factors have had an impact on the risk of GI cancer in China, and the impact is projected to increase. If everyone could adhere to the optimal lifestyle, half of all GI cancer events would be prevented by year 2031.

Excess Body Weight and Long-Term Incidence of Lung and Colon Cancer in Men; Follow-Up Study of 43 Years

Most evidence for an association between excess body weight and cancer risk has been derived from studies of relatively short duration with little reference to the effect on tumor site. This study was designed to evaluate the association between categories of body mass index (BMI: <20, 20–25, 25–30, and >30 kg/m²) and the incidence of colon and lung cancer over 43 years of follow-up (1963–2006), in 10,043 men from the Israeli Ischemic Heart Disease (IIHD) prospective cohort (mean age at baseline 49.3 years, mean BMI 25.7 kg/m²). Data from the Israel National Cancer Registry was linked with the IIHD, and the Cox proportional hazards regression model was applied to analyze the relative risks for lung and colon cancer across BMI categories at baseline. Three hundred cases of lung cancer (2.9%) and 328 cases of colon cancer (3.3%) were diagnosed in the total population. Applying a multivariate model adjusted for age, smoking intensity, and total cholesterol, higher BMI category was associated with an increased risk of colon cancer [HR = 1.22 (95% CI 1.02–1.45)], and with a decreased risk for lung cancer [HR = 0.66 (95% CI 0.56–0.77)]. In this long-term follow-up study over four decades, we observed a consistent dose-response pattern between BMI and increased risk for colon cancer, but decreased risk for lung cancer. Specific associations between excess body weight and cancer risk may suggest different patterns of body fat and cancer incidence at a given site.

A systematic review report on tobacco products and its health issues in India

India is the second country in tobacco production in the world. Smoking tobacco products included Hookah, Cohutta, Chillum, Chillum, ganja, Beedi, Mava, Cigarettes, and cigar etc. Various types of smokeless tobacco like betel quid, khaini, mishri, snuff, gutkha are used. Fifty percent of them are addicted to smokeless tobacco. Sixty eight smokeless tobacco products were available in 2010; most of them included the risk of cancer warning except for loose tobacco products. Women mostly prefer 8 out of 29 gutkha brands. Out of these 29 gutkha brands, 15 were loose tobacco packets. India is the second-largest tobacco consumer, comprises of 27.5 crore consumers which altogether greater than the population of Western Europe. From among these 27.5 crore consumers, 16.4 crore people are smokeless tobacco in takers, 6.9 crore people are exclusive smokers and 4.2 crore people are both tobacco in takers and exclusive smokers. If we take this data into consideration early mortality of 45 crore people is expected by 2050 worldwide. Female basically are prone to fewer cigarettes per day as compared to males. On the other hand, a cigarette that is consumed by females has lower nicotine content as compared to males. In developing countries, the female population has less prevalence of smoking because the level of employment is low, socio-cultural norms, and health and beauty concerns. According to the estimation by the South East Asia Region (SEAR) in the year 2000 basically from India, we encounter death of about 18% men and about 3% of women due to tobacco. Various policies have been set up to control the use of tobacco. So that threat to public health is reduced. Policies like tobacco control policy, pro-health policy are set up for this purpose. Talking about the effects on a longer-term usage of water pipe can add up to the risk of getting affected by cancers of lungs, mouth, bladders, atherosclerosis, cardiovascular and pulmonary diseases, tooth extraction, etc.

A Multicenter, Randomized, Double-blind, Parallel, Placebo-controlled Clinical Study to Evaluate the Efficacy and Safety of a Nicotine Mint Lozenge (2 and 4 mg) in Smoking Cessation

OBJECTIVE

To evaluate the efficacy in smoking cessation and safety of 2 and 4 mg nicotine mint lozenges in Chinese adult smokers.

METHODS

This was a multicenter, randomized, stratified, double-blind, placebo-controlled, parallel-group study. The low-dependence stratum included 483 smokers (241 randomized to active 2 mg nicotine lozenge and 242 to placebo lozenge). The high-dependence stratum included 240 smokers (120 randomized to active 4 mg nicotine lozenge and 120 to placebo lozenge). The primary endpoint was successful smoking cessation at 6 weeks postquit, defined as continuous abstinence from smoking for the 28-day period up to and including the 6-week visit (verified by CO measurement). Cochran-Mantel-Haenszel tests were performed to compare quit rates between active nicotine and placebo separately for the high-dependence and low-dependence strata.

RESULTS

The primary analysis showed that in the low-dependence (2 mg) stratum, 59 subjects (24.5%) of 241 in the active nicotine group and 52 subjects (21.5%) of 242 in the placebo group were successful quitters (P = .3851). In the high-dependence (4 mg) stratum, 37 subjects (30.8%) of 120 in the active nicotine group and 24 subjects (20.2%) of 119 in the placebo group were successful quitters (P = .0565).

CONCLUSIONS

The 4 mg nicotine lozenge provided a directionally significant improvement in smoking cessation rates compared with placebo in Chinese adult smokers with high nicotine dependence for the primary endpoint. The 2 mg nicotine lozenge provided higher, but nonsignificant, smoking cessation rates than placebo. Both nicotine lozenges were generally well tolerated in Chinese adult smokers.

Tobacco use and associated factors among adults reside in Arba Minch health and demographic surveillance site, southern Ethiopia: a cross-sectional study

BACKGROUND

Tobacco use is one of the world-leading preventable killers. There was a varied prevalence of tobacco use and cigarette smoking across different areas. The aim of the study was to assess the prevalence and factors associated with current tobacco use among adults residing in Arba Minch health and demographic surveillance site (HDSS).

METHODS

A community-based cross-sectional study was conducted among adults residing in Arba Minch HDSS in 2017. The estimated sample size was 3368 individuals which were selected by simple random sampling techniques using Arba Minch HDSS dataset. Data collection tools were obtained from the WHO STEPwise. Current use of tobacco, which defined as the current use of smoked and/or smokeless tobacco, was considered as the dependent variable. A binary logistic regression model was used to identify candidate variables for the multivariable logistic regression model. An adjusted odds ratio (AOR) at a p-value of less than 0.05 was used to determine a statistically significant association between independent and dependent variables.

RESULT

The prevalence of tobacco use among adults was 20.2% (95% CI: 18.9-21.6%). The current use of smoked and smokeless tobacco were 17.1% (95%CI: 15.8-18.4%) and 9.7% (95%CI: 8.8-10.8%), respectively. The current use of tobacco was significantly associated with sex (female [AOR 0.54; 95%CI: 0.42-0.68] compared to men), age group (35-44 [AOR 1.57; 95%CI: 1.14-2.17], 45-54 [AOR 1.99; 95%CI: 1.45-2.74], and 55-64 [AOR 3.26; 95%CI: 2.37-4.48] years old compared to 25-35 years old), physical activity (moderate physical activity level [AOR 0.65; 95%CI: 0.44-0.96] compared with low) and residency (highland [AOR 4.39; 95% CI: 3.21-6.01] compared with at lowlander). Also, heavy alcohol consumption (AOR 3.97; 95% CI: 3.07-5.12), and Khat chewing (AOR 3.07(95%CI: 1.64-5.77) were also associated with the use of tobacco among the study participants.

CONCLUSION

Nearly one in five adults used tobacco currently in the study area, which is more than the national reports. Interventions for the reduction of tobacco use need to give due attention to men, older adults, uneducated, poor, and highlanders.

Predictions of mortality related to four major cancers in China, 2020 to 2030

BACKGROUND

Cancer has become a global health problem, and assessments of cancer mortality are important for effective public health policy-making and adequate resource allocation. In this study, we aimed to predict the mortality rates and numbers of deaths related to four common cancers (lung, liver, stomach, and esophagus) in China from 2020 to 2030 and to estimate the corresponding cancer burden caused by population aging and tobacco smoking.

METHODS

Cancer mortality data (2004-2017) were extracted from China's death surveillance datasets, and China's population figures (2020-2030) were obtained from the United Nations population projections. Smoking prevalence data were retrieved from a World Health Organization global report, and relative risks of smoking and cancers were derived from large-scale Asian studies. We predicted the deaths related to the four major cancers and age-standardized mortality rates using joinpoint regression and linear regression models. The tobacco smoking-related burden of these four major cancers was estimated using the population attributable fraction.

RESULTS

Unlike lung cancer mortality which was predicted to continue to increase, the age-standardized mortality rates for digestive cancers (liver, stomach, and esophageal cancers) are predicted to decline over the next decade. The number of deaths caused by the four major cancers is predicted to increase from 1,490,304 in 2020 to 1,823,960 in 2030. The age-specific mortality rates of the four major cancers are predicted to increase with age after 40-45 years, peaking in the age groups of 80-84 and ≥85 years. In 2030, the combined number of deaths from the four examined cancers among adults aged ≥65 years is predicted to be 1,167,153, accounting for 64% of all deaths from these cancers. Tobacco smoking is predicted to contribute to nearly 29% of deaths from these cancers, corresponding to 527,577 deaths.

CONCLUSIONS

The overall trend in the combined total mortality from four major cancers is predicted to decline over the next decade; however, the corresponding death toll is expected to surge, in the context of China's population aging and high smoking prevalence. These estimates provide data-driven evidence for China to implement effective cancer control measures in the future.

Joint effect of alcohol drinking and tobacco smoking on all-cause mortality and premature death in China: A cohort study

BACKGROUND

Tobacco smoking and alcohol drinking are associated with several diseases, and studies on the joint effects of smoking and drinking are rare.

OBJECTIVE

This study investigates the joint effects of tobacco smoking and alcohol drinking on all-cause and premature mortality in a contemporary cohort.

METHODS

The China Health and Retirement Longitudinal Study (CHARLS) is an ongoing nationally representative survey of subjects aged over 45 years in China that was performed every two years for a total of three waves from 2011 to 2015 in China. We used weighted logistic regression models to estimate the joint effects of tobacco smoking and alcohol drinking on all-cause and premature mortality.

RESULTS

After adjusting for prespecified confounders, the odds ratios (ORs) of all-cause mortality were 1.51 (95% CI: 1.09-2.10) and 1.47 (95% CI: 1.03-2.08) in smokers and smokers/drinkers, respectively. Compared with nonsmokers/nondrinkers, the OR of smokers/drinkers for premature death was 3.14 (95% CI: 1.56-6.34). In the female subgroup, there was an approximately 5-fold (OR = 4.95; 95% CI: 2.00-12.27) odds of premature mortality for smokers/drinkers compared to nonsmokers/nondrinkers.

CONCLUSION

This study found a joint effect of tobacco smoking and alcohol drinking on all-cause and premature mortality among a contemporary and nationally representative cohort in China. Our results suggested that the joint effects were more pronounced in women, but further research is needed.

Mean Corpuscular Volume as a Prognostic Factor for Patients With Habitual Alcohol or Tobacco Use After Esophagectomy

BACKGROUND

The goal of this study was to investigate the impact of mean corpuscular volume (MCV) in patients with esophageal squamous cell carcinoma (ESCC) who underwent surgical resection.

METHODS

A total of 615 patients with ESCC who underwent esophagectomy were analyzed. Patients were divided into two groups according to the standard MCV: the high MCV group (>100 fl) and the low MCV group (≤100 fl). Survival analyses were performed to calculate overall survival (OS) and cancer-specific survival (CSS) and investigate the independent prognostic factors.

RESULTS

Fifty-one patients (8.3%) were in the high MCV group, and the other 564 patients (91.7%) were defined as the low MCV group. MCV was significantly correlated with sex, habitual alcohol or tobacco use, tumor length, body mass index, and multiple primary malignancies (P < 0.05). Elevated MCV was significantly correlated with poor survival in univariate and multivariate analyses. However, in subgroup analyses, MCV was found to be correlated with survival only in patients with alcohol or tobacco consumption and not in patients without alcohol or tobacco consumption.

CONCLUSIONS

Pretreatment MCV was correlated with survival in ESCC patients after esophagectomy. However, its prognostic value might only exist in patients with alcohol or tobacco consumption.

Informing policy makers on the efficiency of population level tobacco control interventions in Asia: A systematic review of model-based economic evaluations

BACKGROUND

Economic evaluations of tobacco control interventions support decisions regarding resource allocation in public health policy. Our systematic review was aimed at identifying potential bias in decision models used to estimate the long-term costs and effects of population-based tobacco control interventions in Asia.

METHODS

We included studies conducted in Asian countries and using a modelling technique to evaluate the economic impacts of one or more population-based tobacco interventions in line with the Framework Convention on Tobacco Control (FCTC). We assessed the structure, input parameters, and risk of bias for each model, and performed a narrative synthesis of the included studies.

RESULTS

Nine model-based economic evaluation studies of population-based tobacco interventions were identified. About 60% of the criteria for reporting quality were met in all studies, indicating that reporting generally lacked transparency. The studies were highly heterogeneous in terms of the scope, types, and structures of their models and the quality of input parameters. One-third of the models applied in the studies scored a high risk of bias, with problems mostly falling into the following categories: model type, time horizons, and smoking transition probabilities.

CONCLUSIONS

More data are needed to provide high-quality evidence regarding the cost-effectiveness of tobacco control policies in Asia. Strong evidence at the country level hinges on the availability of accurate estimates of the effects of the interventions, the relative risks of smoking, and the price elasticity of the demand for tobacco. Simple transfers of models built in Western populations do not suffice.

PROTOCOL REGISTRATION

PROSPERO CRD 42019141679.

Smoking and Mental Illness: Prevalence, Patterns and Correlates of Smoking and Smoking Cessation among Psychiatric Patients

This study aims to understand (a) the prevalence and correlates of smoking in a psychiatric population, (b) factors that encourage smoking cessation, and (c) awareness towards cessation programmes. This study captured data (n = 380) through a modified version of the Global Adult Tobacco Survey (GATS). A descriptive analysis of the data was performed. The prevalence of smoking was 39.5% (n = 150) and 52.3% of the smokers were dependent on nicotine. More than half of the smokers had made at least one attempt to quit in the past 12 months and 56% reported no immediate plans to quit smoking. The awareness towards institutional smoking cessation programmes was fair (44%), with 49.7% of smokers having indicated that they were willing to use the service upon referral. Smokers endorsed that increasing the cost of cigarettes, restricting availability, and increasing knowledge of health harms could encourage smoking cessation. Past smokers reported that self-determination/willpower followed by substitution of smoking with other types of foods and drinks were factors that helped them achieve successful cessation. Given that the readiness to quit and awareness towards cessation programmes are low among the smokers, concerted efforts through educational programmes and policy changes are crucial to achieve successful cessation.

Coffee Consumption and Lung Cancer Risk: A Prospective Cohort Study in Khon Kaen Thailand

Background:

Lung cancer is a major cause of cancer death worldwide. The incidence of lung cancer in Thailand increasing, but risk factors are rarely reported.

Objective:

To investigate the effect of coffee consumption on lung cancer in Thai population.

Methods:

Between 1990 and 2001, lifestyle and demographic data were collected from 24,528 participants in the Khon Kaen Cohort Study (KKCS), who were followed through 2016, by linking to the Khon Kaen Population-based Cancer Registry. A total of 12,668 eligible participants (68.8% females, mean age 51.0 years at baseline) having complete datasets (239,488 person-years of follow up with 138 incident cases of lung cancer observed) were analyzed using a multi-variable adjusted Cox proportional hazard models.

Results:

Coffee consumption was associated with reduced risk for lung cancer (adj. HR = 0.54; 95% CI: 0.35-0.84) after adjusting for age and gender. Cigarette smoking (adj. HR = 2.76; 95% CI: 1.32-5.78) and family history of cancer (adj. HR = 1.65; 95% CI: 1.10-2.48) were associated with higher risk.

Conclusion:

This study suggests coffee consumption may be a protective factor for lung cancer in among this cohort.

The Epidemiology of Lung Cancer in Lebanon During 2014

Background and aims: Lung cancer is the leading cause of cancer death worldwide. There are no recent data on the lung cancer prevalence in Lebanon, and the available data are based on prediction. Thus, this study aimed to determine the incidence rate of lung cancer during 2014, among patients who were newly diagnosed at Lebanese teaching hospitals. In addition, the study attempted to identify the associated risk factors of lung cancer, the most common presenting symptoms at the diagnosis time, and the stage at which the majority of the patients were diagnosed at the targeted population. Methods: A retrospective cross-sectional study was carried out in many teaching hospitals affiliated to the Lebanese University in Lebanon in 2016. Results: The lung cancer incidence was 221.9 per 100000 in 2014. Most patients aged 60 years and over and as regards gender distribution, the majority of them included men. Further, more than half of the patients had the (COPD) and 97% of patients had symptoms at their presentation. Based on the results, 57.9% of them had stage IV lung cancer, but only 12% were diagnosed at the stage IA. Furthermore, 80.6% and 16.4% of patients had non-small and small cell lung cancer, respectively. Finally, 75.4% and 12.1% of them were treated with chemotherapy and underwent surgery, respectively, while 5.2% of patients had radiotherapy. Conclusion: The findings of our study showed a higher incidence rate of lung cancer since 2008 which was diagnosed more commonly in men and with the patient’s history of COPD. Eventually, the diagnosis was mostly made at a later stage with non-small cell lung cancer that was the most common histology type.

Quantifying the association of low-intensity and late initiation of tobacco smoking with total and cause-specific mortality in Asia

BACKGROUND

Little is known about the health harms associated with low-intensity smoking in Asians who, on average, smoke fewer cigarettes and start smoking at a later age than their Western counterparts.

METHODS

In this pooled analysis of 738 013 Asians from 16 prospective cohorts, we quantified the associations of low-intensity (<5 cigarettes/day) and late initiation (≥35 years) of smoking with mortality outcomes. HRs and 95% CIs were estimated for each cohort by Cox regression. Cohort-specific HRs were pooled using random-effects meta-analysis.

FINDINGS

During a mean follow-up of 11.3 years, 92 068 deaths were ascertained. Compared with never smokers, current smokers who consumed <5 cigarettes/day or started smoking after age 35 years had a 16%-41% increased risk of all-cause, cardiovascular disease (CVD), respiratory disease mortality and a >twofold risk of lung cancer mortality. Furthermore, current smokers who started smoking after age 35 and smoked <5 cigarettes/day had significantly elevated risks of all-cause (HRs (95% CIs)=1.14 (1.05 to 1.23)), CVD (1.27 (1.08 to 1.49)) and respiratory disease (1.54 (1.17 to 2.01)) mortality. Even smokers who smoked <5 cigarettes/day but quit smoking before the age of 45 years had a 16% elevated risk of all-cause mortality; however, the risk declined further with increasing duration of abstinence.

CONCLUSIONS

Our study showed that smokers who smoked a small number of cigarettes or started smoking later in life also experienced significantly elevated all-cause and major cause-specific mortality but benefited from cessation. There is no safe way to smoke-not smoking is always the best choice.

Province-specific smoking-attributable cancer mortality in China 2013

INTRODUCTION

Province-specific initiatives are at the forefront of tobacco control but limited studies have provided province-specific assessment of smoking-attributable cancer burden in China.

METHODS

We estimated the fraction of total and site-specific cancer mortality attributable to tobacco smoking in 31 provinces in mainland China. The population attributable fractions (PAFs) for cancer deaths due to smoking were calculated by Levin's formula using province-specific smoking prevalence data around 1998 (assuming a 15-year latency time) and relative risks from cohort studies and meta-analyses. The 95% confidence intervals (CIs) of PAFs were calculated by a Delta method. Cancer deaths were abstracted from cancer registry data of the 31 provinces in mainland China in 2013.

RESULTS

Overall, smoking contributed to a total of 421566 cancer deaths in mainland China in 2013 (19.46% of all cancer deaths), with 400701 of these deaths occurring in men (29.34%) and 20865 (2.61%) in women. The population attributable fractions ranged from 15.56% (95% CI: 9.12-21.82%) in Tibet to 35.09% (95% CI: 25.68-45.83%) in Guizhou among men, and from 0.28% (95% CI: 0.00-0.64%) in Hainan to 10.44% (95% CI: 4.86-16.32%) in Jilin among women. Cancers of lung and liver were the two main smoking-attributable cancers for both men and women.

CONCLUSIONS

Tobacco smoking was responsible for nearly 20% of all cancer deaths in mainland China, but the proportion of cancer deaths attributable to smoking varied substantially across provinces. More effective programs and innovative new strategies for local tobacco control are warranted to reduce the future burden of smoking-related cancers in all provinces of mainland China.

Trend analysis of lung cancer mortality and years of life lost (YLL) rate from 1999 to 2016 in Tianjin, China: Does the lung cancer burden in rural areas exceed that of urban areas?

BACKGROUND

The aim of this study was to examine the trends in the mortality rate and years of life lost (YLL) rate of lung cancer in Tianjin, China, during the period from 1999 to 2016.

METHODS

Lung cancer death data were obtained from Tianjin residents' all-cause death monitoring system, which covers the whole population of Tianjin. Crude mortality rate, age-standardized mortality rate, truncated rate (35-64 years), YLL and age-standardized YLL rate data were calculated and trends examined.

RESULTS

From 1999 to 2016, a total of 93 358 lung cancer deaths were reported in Tianjin, which accounted for 38.0% of all cancer deaths (93 358/245744). The crude mortality rate of lung cancer had increased 58.5% from 1999 (40.15/100000) to 2016 (63.64/100000), average annual percent change (AACP) = 2.9%, P < 0.01. However, the age-standard YLL rate had decreased to 13.3% in 2016 than in 1999, AACP = -0.8%, P < 0.01, with a stable trend in males (AACP = -0.2%), and noticeable decreasing trend in females (AACP = -1.4%). The lung cancer mortality rate (ASRW) in urban areas was higher than that in rural areas in 1999, with a ratio of 1.99:1. However, it was lower in 2016, with the ratio of 0.98:1. For the truncated rate (35-64 years), it had decreased in urban areas compared with rural areas since the year 2013.

CONCLUSION

Lung cancer remains the most fatal cancer in Tianjin. However, the age-standard YLL rate of lung cancer has decreased considerably accompanied by a decline in smoking rate years ago, especially in women and people living in urban areas. Considerable attention is therefore needed in the rural areas where cases of lung cancer are still rapidly increasing.

Smoking counts: experience of implementing questions on smoking on official death certification systems

We describe our experience in several settings, following a suggestion in 1983 to add questions on the smoking status of the deceased on the UK death certificate as an effective way to monitor the evolution of the smoking epidemic. In South Africa in 1997 and in Tianjin Municipality, China, in 2010, questions about the smoking habits of the deceased were inserted on the official death certificates. In both places a system now exists to routinely collect information on smoking status in relation to causes of death. Results from two million South African and 300 000 Chinese deceased individuals have been reported, and the sample size in both places continues to grow. An unsuccessful attempt was made in 2008 to insert smoking questions on the Australian death notification forms but comments and concerns from the registrars of births, marriages and deaths have international applicability. In both China and South Africa, inserting questions on smoking on the death notification forms was not a trivial task-in each it required, as a minimum, significant commitment from several government agencies. Benefits, however, include a better local understanding of the smoking epidemic and allowing for planning and monitoring of tobacco control programmes. Documenting the varied experiences of collecting information on smoking on death notification forms is useful to those wishing to introduce such questions in their own settings. This is pertinent especially at a time when vital registration systems are being improved, with an aim to monitoring sustainable development goals.

Smoking-attributable burden of lung cancer in Mongolia a data synthesis study on differences between men and women

BACKGROUND

Smoking is widely recognized as one of the most prevalent and preventable causes of many cancer types. This study aimed to quantify the population attributable fraction (PAF) of the lung cancer burden for smoking in Mongolia.

METHODS

Lung cancer incidence and lung cancer-related death data came from the population-based national registry covering the period 2007-2016. Smoking prevalence data came from the STEPwise approach (STEP) national survey. The lung cancer-related disease burden was calculated and expressed in Disability Adjusted Life Years (DALYs) lost by gender and by year. This was combined with current smoking and former smoking prevalence data, and relative risks (RR) of lung cancer-related deaths for current smokers and former smokers versus never smokers from region-specific cohort studies to estimate the PAF of lung cancer attributable to "ever-smoking" in Mongolia.

RESULTS

Between 2007 and 2016, lung cancer accounted for the loss of over 63,000 DALYs in Mongolia. The PAF of lung cancer-related deaths attributable to current and former smoking combined was 58.1% (95% IR = 43.1%-72.2%) for men and 8.9% (95% IR = 4.1% -13.5%) for women. Smoking-attributable DALYs loss amounted to 2589 years (95% IR = 1907-3226) in 2016.

CONCLUSIONS

A considerable health loss may be prevented with an effective anti-smoking policy. In Mongolia, more than one third of lung cancer-related DALY loss is attributable to active smoking, and thus is potentially preventable. Furthermore, a gender-specific tobacco control policy may be worthwhile because of the large gender difference in smoking exposure in Mongolia. Next to this, age specific policy, including a smoke-free generation policy for adolescents, with targeted education, and mass media campaigns is needed.

Effectiveness of Text-Only Cigarette Health Warnings in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey

Health warnings are an effective strategy for communicating the health harms of smoking, encouraging quitting, and preventing smoking initiation. This study examines the effectiveness of existing text-only health warnings, identifies key predictors of warning effectiveness, and assesses support for pictorial warnings in Japan. Data are from the 2018 International Tobacco Control (ITC) Japan Survey, a cohort survey of adult cigarette smokers (n = 3306), dual users of cigarettes and heated tobacco products (n = 555), and non-cigarette smokers (n = 823). Weighted multivariable logistic regression models were used to assess predictors of warning effectiveness and support for pictorial warnings. Overall, 15.6% of respondents noticed warnings, and 7.9% read or looked closely at warnings. Overall, 10.3% of smokers and dual users said the warnings stopped them from having a cigarette, and 7.2% avoided warnings. Overall, 27.5% of respondents said the warnings made them think about health risks of smoking, but only 2.7% of smokers and dual users said the warnings made them more likely to quit. Overall, 57.6% of respondents supported pictorial warnings. The weak effectiveness of Japan's text-only warnings is consistent with that in other countries with similar warnings. There is majority support for pictorial warnings in Japan, although the level of support is lower than in other countries.

Public Health Threat of Tobacco and Substance Use in Asia: An Introduction to the Theme Issue

Tobacco and substance use is a great public health concern in Asia. The prevalence of tobacco smoking, while steadily declined in Western countries over past few decades, has increased in many regions of Asia, especially in low- and middle-income countries. And high-income countries in the region have reported rapid growth rates in e-cigarette use in recent years. Furthermore, illicit drugs, specially cannabis, amphetamines, and opioids, have begun to threaten the health of the people in the region like never before. To better understand the landscape of the two primary public health concerns in Asia, tobacco and substance use, this special issue examines cigarette/e-cigarette use and tobacco control policies for five selected countries (Singapore, China, South Korea, Japan, and Laos People's Democratic Republic); and explores substance use related issues focused on prevention, influencing factors, and policies of three countries (Hon Kong, Malaysia, and India). The research, policy, and clinical implications from this issue will contribute to mitigating the global burden of tobacco and substance use-related public health issues in Asia.

Factors affecting cigarette smoking among adolescents in South Korea, Vietnam, and Thailand

PURPOSE

The current study was designed to describe risk and preventive factors related to cigarette smoking among adolescents in South Korea, Vietnam, and Thailand.

DESIGN AND METHODS

A cross-sectional descriptive design was used. Student data were extracted from three national data sets, specifically the Global Youth Tobacco Survey from each country. Complex sampling multinomial logistic regression was performed to find factors related to current smoking.

RESULTS

The prevalence of cigarette smoking was 4.7% in South Korean students, 2.8% in Vietnamese students, and 10.9% in Thai students. Students shared three risk factors related to current smoking: male sex, use of other tobacco products, and susceptibility to smoking. Additionally, only one preventive factor of cigarette smoking was found among South Korean adolescents: exposure to antitobacco advertisements. The findings suggest that personal, familial, social, and public area characteristics are associated with smoking among adolescents from these nations.

PRACTICE IMPLICATIONS

These results could be useful for screening students vulnerable to cigarette smoking and the collaborative planning of interventions to prevent adolescents from smoking in these three Asian countries.

Association between educational level and total and cause-specific mortality: a pooled analysis of over 694 000 individuals in the Asia Cohort Consortium

OBJECTIVE

To study the association of educational level and risk of death from all causes, cardiovascular disease (CVD) and cancer among Asian populations.

DESIGN

A pooled analysis of 15 population-based cohort studies.

SETTING AND PARTICIPANTS

694 434 Asian individuals from 15 prospective cohorts within the Asia Cohort Consortium.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

HRs and 95% CIs for all-cause mortality, as well as for CVD-specific mortality and cancer-specific mortality.

RESULTS

A total of 694 434 participants (mean age at baseline=53.2 years) were included in the analysis. During a mean follow-up period of 12.5 years, 103 023 deaths were observed, among which 33 939 were due to cancer and 34 645 were due to CVD. Higher educational levels were significantly associated with lower risk of death from all causes compared with a low educational level (≤primary education); HRs and 95% CIs for secondary education, trade/technical education and ≥university education were 0.88 (0.85 to 0.92), 0.81 (0.73 to 0.90) and 0.71 (0.63 to 0.80), respectively (ptrend=0.002). Similarly, HRs (95% CIs) were 0.93 (0.89 to 0.97), 0.86 (0.78 to 0.94) and 0.81 (0.73 to 0.89) for cancer death, and 0.88 (0.83 to 0.93), 0.77 (0.66 to 0.91) and 0.67 (0.58 to 0.77) for CVD death with increasing levels of education (both ptrend <0.01). The pattern of the association among East Asians and South Asians was similar compared with ≤primary education; HR (95% CI) for all-cause mortality associated with ≥university education was 0.72 (0.63 to 0.81) among 539 724 East Asians (Chinese, Japanese and Korean) and 0.61 (0.54 to 0.69) among 154 710 South Asians (Indians and Bangladeshis).

CONCLUSION

Higher educational level was associated with substantially lower risk of death among Asian populations.

Tobacco Smoking and Mortality in Asia: A Pooled Meta-analysis

IMPORTANCE

Understanding birth cohort-specific tobacco smoking patterns and their association with total and cause-specific mortality is important for projecting future deaths due to tobacco smoking across Asian populations.

OBJECTIVES

To assess secular trends of tobacco smoking by countries or regions and birth cohorts and evaluate the consequent mortality in Asian populations.

DESIGN, SETTING, AND PARTICIPANTS

This pooled meta-analysis was based on individual participant data from 20 prospective cohort studies participating in the Asia Cohort Consortium. Between September 1, 2017, and March 31, 2018, a total of 1 002 258 Asian individuals 35 years or older were analyzed using Cox proportional hazards regression analysis and random-effects meta-analysis. The pooled results were presented for mainland China; Japan; Korea, Singapore, and Taiwan; and India.

EXPOSURES

Tobacco use status, age at starting smoking, number of cigarettes smoked per day, and age at quitting smoking.

MAIN OUTCOMES AND MEASURES

Country or region and birth cohort-specific mortality and the population attributable risk for deaths from all causes and from lung cancer.

RESULTS

Of 1 002 258 participants (51.1% women and 48.9% men; mean [SD] age at baseline, 54.6 [10.4] years), 144 366 deaths (9158 deaths from lung cancer) were ascertained during a mean (SD) follow-up of 11.7 (5.3) years. Smoking prevalence for men steadily increased in China and India, whereas it plateaued in Japan and Korea, Singapore, and Taiwan. Among Asian male smokers, the mean age at starting smoking decreased in successive birth cohorts, while the mean number of cigarettes smoked per day increased. These changes were associated with an increasing relative risk of death in association with current smoking in successive birth cohorts of pre-1920, 1920s, and 1930 or later, with hazard ratios for all-cause mortality of 1.26 (95% CI, 1.17-1.37) for the pre-1920 birth cohort, 1.47 (95% CI, 1.35-1.61) for the 1920s birth cohort, and 1.70 (95% CI, 1.57-1.84) for the cohort born in 1930 or later. The hazard ratios for lung cancer mortality were 3.38 (95% CI, 2.25-5.07) for the pre-1920 birth cohort, 4.74 (95% CI, 3.56-6.32) for the 1920s birth cohort, and 4.80 (95% CI, 3.71-6.19) for the cohort born in 1930 or later. Tobacco smoking accounted for 12.5% (95% CI, 8.4%-16.3%) of all-cause mortality in the pre-1920 birth cohort, 21.1% (95% CI, 17.3%-24.9%) of all-cause mortality in the 1920s birth cohort, and 29.3% (95% CI, 26.0%-32.3%) of all-cause mortality for the cohort born in 1930 or later. Tobacco smoking among men accounted for 56.6% (95% CI, 44.7%-66.3%) of lung cancer mortality in the pre-1920 birth cohort, 66.6% (95% CI, 58.3%-73.5%) of lung cancer mortality in the 1920s birth cohort, and 68.4% (95% CI, 61.3%-74.4%) of lung cancer mortality for the cohort born in 1930 or later. For women, tobacco smoking patterns and lung cancer mortality varied substantially by countries and regions.

CONCLUSIONS AND RELEVANCE

In this study, mortality associated with tobacco smoking continued to increase among Asian men in recent birth cohorts, indicating that tobacco smoking will remain a major public health problem in most Asian countries in the coming decades. Implementing comprehensive tobacco-control programs is warranted to end the tobacco epidemic.

2018 APLAR axial spondyloarthritis treatment recommendations

INTRODUCTION

Despite the availability of axial spondyloarthritis (SpA) recommendations proposed by various rheumatology societies, we considered that a region-specific guideline was of substantial added value to clinicians of the Asia-Pacific region, given the wide variations in predisposition to infections and other patient factors, local practice patterns, and access to treatment across countries.

MATERIALS AND METHODS

Systematic reviews were undertaken of English-language articles published between 2000 and 2016, identified from MEDLINE using PubMed, EMBASE and Cochrane databases. The strength of available evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Recommendations were developed through consensus using the Delphi technique.

RESULTS

Fourteen axial SpA treatment recommendations were developed based on evidence summaries and consensus. The first 2 recommendations cover non-pharmacological approaches to management. Recommendations 3 to 5 describe the following: the use of non-steroidal anti-inflammatory drugs as first-line symptomatic treatment; the avoidance of long-term corticosteroid use; and the utility of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) for peripheral or extra-articular manifestations. Recommendation 6 refers to the indications for biological DMARDs (bDMARDs). Recommendation 7 deals specifically with screening for infections endemic to Asia, prior to use of bDMARDs. Recommendations 7 to 13 cover the role of bDMARDs in the treatment of active axial SpA and include related issues such as continuing therapy and use in special populations. Recommendation 14 deals with the utility of surgical intervention in axial SpA.

CONCLUSION

These recommendations provide up-to-date guidance for treatment of axial SpA to help meet the needs of patients and clinicians in the Asia-Pacific region.

Global cancer incidence in older adults, 2012 and 2035: A population-based study

Population ageing has substantially contributed to the rising number of new cancer cases worldwide. We document cancer incidence patterns in 2012 among older adults globally, and examine the changing magnitude of cancer in this age group over the next decades. Using GLOBOCAN 2012 data, we presented the number and proportion of new cancer cases, and the truncated age-standardised incidence rates among adults aged 65 years and older for all cancer sites combined and for the five most common cancer sites by world region. We calculated the incidence in 2035 by applying population projections, assuming no changes in rates. In 2012, 6.7 million new cancer cases (47.5% of all cancers) were diagnosed among older adults worldwide, with marked regional disparities. Nearly 48% of these cases occurred in less developed regions. Lung, colorectal, prostate, stomach and breast cancers represented 55% of the global incidence, yet distinct regional patterns were observed. We predict 14 million new cancer cases by 2035, representing almost 60% of the global cancer incidence. The largest relative increase in incidence is predicted in the Middle East and Northern Africa (+157%), and in China (+155%). Less developed regions will see an increase of new cases by 144%, compared to 54% in more developed regions. The expected increase in cancer incidence at older ages will have substantial economic and social impacts globally, posing considerable and unique challenge to healthcare systems in every world region, especially in those with limited resources and weaker health systems.

Strong excess risk of pancreatic cancer for low frequency and duration of cigarette smoking: A comprehensive review and meta-analysis

AIM

Cigarette smoking is an established risk factor for pancreatic cancer but an updated quantification of the association is lacking. Our aim is to provide the most accurate and updated estimate of the dose-response relationships between cigarette smoking and pancreatic cancer risk.

METHODS

Using an innovative approach for the identification of original publications, we conducted a systematic review and meta-analysis of epidemiological studies published on the issue up to April 2017. Random effects models were used to provide pooled estimates for the cigarette smoking status; dose-risk relationships were evaluated using one-stage random effects models with restricted cubic splines.

RESULTS

Seventy-eight studies were included, providing a pooled relative risk (RR) of pancreatic cancer of 1.8 (95% confidence interval, CI: 1.7-1.9) for the current and 1.2 (95% CI: 1.1-1.2) for the former vs. never smokers. A sharp increase in pancreatic cancer risk was found already with a low number of cigarettes and up to 30 cigarettes/day (RR 2.2, 95% CI: 1.9-2.4). Similarly, the risk of pancreatic cancer steady increased after a few years of smoking up to 30 years (RR 1.8, 95% CI: 1.6-2.0). The risk rapidly decreased with increasing time since quitting and was 0.6 (95% CI: 0.5-0.7, for the former vs. current smokers) after 20 years of quitting.

CONCLUSIONS

The present meta-analysis indicates that pancreatic cancer risk sharply increases with a low number of cigarettes or after a few years of smoking and that it rapidly decreases a few years after cessation, although it takes almost 20 years to reach that of never smokers.

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.

Predictors of Quitting Attempts Among Tobacco Users in Bangladesh After a Communication Campaign to Launch Graphic Warning Labels on Packaging

BACKGROUND

Tobacco use contributes to an estimated 14.6% of male and 5.7% of female deaths in Bangladesh.

AIMS

We examine the determinants of tobacco-related quit attempts among Bangladeshis with and without awareness of the synergized "People Behind the Packs" (PBTP) communication campaign used to support the introduction of pack-based graphic warning labels (GWLs) in 2016.

METHOD

Data from 1,796 adults were collected using multistage sampling and a cross-sectional face-to-face survey. Analyses used a normalized design weight to ensure representativeness to the national population of smokers within Bangladesh.

RESULTS

For the overall sample, the multivariable logistic regression model revealed quit attempts were associated with having seen the pack-based GWLs, recalling ≥1 PBTP campaign message, higher levels of self-efficacy to quit, and recognizing more potential side-effects associated with using tobacco products. Conversely, the likelihood of quitting attempts were lower among dual tobacco users (relative to smokers) and those using tobacco at least daily (vs. less than daily). The hierarchical multivariable logistic regression model among those aware of ≥1 PBTP campaign message indicated quitting attempts were positively associated with recalling more of the campaign messages and discussing them with others.

CONCLUSION

This national evaluation of pack-based GWLs and accompanying PBTP campaign within Bangladesh supports the efficacy of using synergized communication messages when introducing such labels. That quit attempts are more likely among those discussing PBTP campaign messages with others and recalling more PBTP campaign messages highlights the importance of ensuring message content is both memorable and engaging.

High relative risk of all-cause mortality attributed to smoking in China: Guangzhou Biobank Cohort Study

BACKGROUND

Prediction of disease burden in China arising from smoking based on earlier cohorts in the West and China could not reflect the disease burden at the current stage accurately. No cohort studies in China focused specifically on people born since 1950. We examined the risk of all-cause mortality attributed to smoking in adults in Guangzhou, the city with the most rapidly expanding economy in China.

METHODS AND FINDINGS

This population-based prospective cohort included 21,658 women and 8,284 men aged 50+ years enrolled from 2003-2008 and followed until January 2016. During an average follow-up of 8.8 (standard deviation = 1.8) years, 2,986 (1,586 women, 1,400 men) deaths were recorded. After adjustment for confounders, the hazards ratios (95% confidence interval (CI)) of all-cause mortality in current versus never smokers increased from 1.61 (95% CI 1.45-1.80) in those born in 1920-1939 to 2.02 (95% CI 1.74-2.34), and 4.40 (95% CI 3.14-6.17), in those born in the 1940s and 1950s, respectively (P for trend 0.009).

CONCLUSIONS

In smokers born after 1949 in Guangzhou and other areas which have the longest history of smoking, the mortality risk could have reached three fold that of non-smokers, as in the UK, US and Australia. If confirmed, unless China quickly and strictly complies with the WHO Framework Convention on Tobacco Control with massive smoking cessation in the population, this is a more striking warning that China will be facing an even larger disease burden from tobacco use than previous forecasts.

Associations of cigarette smoking and alcohol drinking with stomach cancer survival: A prospective patient cohort study in Japan

Cigarette smoking and alcohol drinking may affect the prognosis of stomach cancer, but evidence has been inconsistent. We investigated the associations between pretreatment smoking and alcohol drinking and the risk of all-cause and stomach cancer death among 1,576 patients with histologically confirmed stomach cancer diagnosed during 1997-2010 at a single hospital in Japan. Histories of smoking and alcohol drinking were assessed using a self-administered questionnaire. The patients were followed until December 31, 2013. The Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). During 9,625.1 person-years, 670 all-cause and 419 stomach cancer deaths were documented. Among the patients overall, ever-drinking was significantly associated with an increased risk of all-cause death (HR: 1.25; 95% CI: 1.03-1.51), but not stomach cancer death. Positive linear associations with the frequency of drinking (p_trend  = 0.02) and the amount of alcohol consumed per day (p_trend  = 0.03) were observed for the risk of all-cause death. Ever-smoking was not related to either the risk of all-cause or stomach cancer death. Conversely, among the patients who underwent curative resection, a significant positive association was found between ever-smoking and the risk of stomach cancer death (HR: 2.44; 95% CI: 1.17-5.08). A positive association was also found for earlier age at start of smoking (p_trend  = 0.0046). Pretreatment smoking and alcohol drinking have significant effects on stomach cancer survival. Lifestyle adjustments throughout life may improve survival.