Burden of Total and Cause-Specific Mortality Related to Tobacco Smoking among Adults Aged ≥45 Years in Asia: A Pooled Analysis of 21 Cohorts

Background:Tobacco smoking is a major risk factor for many diseases. We sought to quantify the burden of tobacco-smoking-related deaths in Asia, in parts of which men's smoking prevalence is among the world's highest.Methods and Findings:We performed pooled analyses of data from 1,049,929 participants in 21 cohorts in Asia to quantify the risks of total and cause-specific mortality associated with tobacco smoking using adjusted hazard ratios and their 95% confidence intervals. We then estimated smoking-related deaths among adults aged ≥45 y in 2004 in Bangladesh, India, mainland China, Japan, Republic of Korea, Singapore, and Taiwan-accounting for ∼71% of Asia's total population. An approximately 1.44-fold (95% CI = 1.37-1.51) and 1.48-fold (1.38-1.58) elevated risk of death from any cause was found in male and female ever-smokers, respectively. In 2004, active tobacco smoking accounted for approximately 15.8% (95% CI = 14.3%-17.2%) and 3.3% (2.6%-4.0%) of deaths, respectively, in men and women aged ≥45 y in the seven countries/regions combined, with a total number of estimated deaths of ∼1,575,500 (95% CI = 1,398,000-1,744,700). Among men, approximately 11.4%, 30.5%, and 19.8% of deaths due to cardiovascular diseases, cancer, and respiratory diseases, respectively, were attributable to tobacco smoking. Corresponding proportions for East Asian women were 3.7%, 4.6%, and 1.7%, respectively. The strongest association with tobacco smoking was found for lung cancer: A 3- to 4-fold elevated risk, accounting for 60.5% and 16.7% of lung cancer deaths, respectively, in Asian men and East Asian women aged ≥45 y.Conclusions:Tobacco smoking is associated with a substantially elevated risk of mortality, accounting for approximately 2 million deaths in adults aged ≥45 y throughout Asia in 2004. It is likely that smoking-related deaths in Asia will continue to rise over the next few decades if no effective smoking control programs are implemented.Please see later in the article for the Editors' Summary. © 2014 Zheng et al

Body Mass Index and Diabetes in Asia: A Cross-Sectional Pooled Analysis of 900,000 Individuals in the Asia Cohort Consortium

10.1371/journal.pone.0019930PLoS ONE66

The Impact of Tobacco Use and/or Body Composition on Adult Mortality in Urban Developing Country Population. Results from the Mumbai Cohort Study, Mumbai, India, 1991-2003

Tupakka ja ravitsemus ovat maailmanlaajuisia kansanterveysongelmia ja niiden arvioidaan aiheuttavan noin viidenneksen kaikista kuolemista. Intian suurimmassa kaupungissa Mumbaissa haastateltiin 150 000 aikuista heidän elin- ja tupakointitavoistaan. Heitä seurattiin keskimäärin 5,5 vuotta ja selvitettiin kuolemantapaukset ja niiden syyt. Intiassa tupakkaa käytetään yleisesti ja monessa muodossa. Tupakanpoltto oli tavallista vain miehillä ja muut tupakointimuodot (savuttomat) olivat yleisiä molemmilla sukupuolilla. Intialaiset savukkeet olivat yhtä haitallisia kuin länsimaiset. Myös muut tupakointitavat aiheuttivat huomattavan ylikuolleisuuden. Ravitsemustilaa mitattiin painoindeksillä. Yli- ja alipainoisia oli lähes yhtä paljon, mutta selvä laihuus oli selvää lihavuutta tavallisempaa. Ylipainoisten kuolleisuus oli pienintä ja vasta lihavilla esiintyi ylikuolleisuutta normaalipainoisiin verrattuna. Alipainoisilla kuolleisuus oli suurentunutta ja kasvoi sen mukaan, mitä laihemmista oli kyse. Miehillä tupakoinnin ja laihuuden yhteisvaikutus oli toisiaan voimistavaa, kun taas tupakointi ja lihavuus vaimensivat toistensa vaikutusta. Naisilla yhteisvaikutukset olivat toisiaan vaimentavia mutta tupakan kulutus oli lähinnä savutonta. Ylipainosta on kehittynyt yksi länsimaiden pahimpia terveyden vaaratekijöitä. Intiassa laihuus eli aliravitsemus on edelleen ensisijaisempi. Intia kuitenkin länsimaistuu nopeasti ja on mahdollista, että maassa tulee olemaan kahdensuuntainen eli sekä laihuuteen että lihavuuteen liittyvä terveysongelma, jota yleiset ja monimuotoiset tupakointitavat lisäävät.Worldwide, there are two important risk factors underlying the major causes of death, tobacco use and nutritional status. Of the total 55.9 million global annual deaths, tobacco use and nutritional status, together, account for approximately 20%. Information about excess mortality from different forms of tobacco use other than cigarette smoking (such as bidi smoking and the various forms of smokeless tobacco use), is very limited. Using Mumbai Cohort Study (MCS) data from India, the present study reports on the association of various kinds of tobacco habits that are prevalent in India with all-causes of mortality and with major causes [such as cancers, tuberculosis (TB), etc.]. Nutrition research in India has focused primarily on the problem of undernutrition, particularly among vulnerable women and children. Currently, India is undergoing a rapid economic transition. At this stage in the associated epidemiologic transition, the country is facing the double burden of communicable and non-communicable diseases. In all such transitions, nutrition plays a central role. The joint effect of tobacco use (mainly smoking) and body mass on mortality has not been well characterized, although a body of evidence is accumulating on the individual effect of smoking on the association of body mass and mortality. Using MCS, this was the first such attempt, from a developing country population, where both under- and over- nutrition and tobacco use are major public health concerns. Using the Mumbai electoral role list as the selection frame, a total of 148,173 individuals aged ≥ 35 years were recruited (1991 1997) for a prospective follow-up study. After an average 5.5 years an active house-to-house follow-up (to ascertain vital status) was conducted (1997 2003). At active follow-up, 140,908 (95%) individuals were traced. Among these, 13,261 deaths were recorded, of which 85% occurred within the study area. It was possible to abstract cause of death information from Bombay Municipal Corporation death registers for 9,259 deaths. All forms of tobacco smoking increased the risk of dying in Mumbai. In addition to smoking, different forms of smokeless tobacco use also resulted in excess mortality. Using MCS findings, a total of 24% male and 6% female deaths (aged 35 69 years) were found to be attributable to their tobacco usage. Also, 41.6% of men s and 20.7% of women s cancer deaths were found to be attributable to their tobacco usage. Bidi smoking was found to be as harmful as cigarette smoking and was found to be responsible for around 32% of TB deaths. Therefore, MCS findings provide supportive evidence from the population of a developing country about the association of tobacco usage with increased risk of death; primarily for various cancers and TB. MCS results showed that both chronic underweight and overweight are equally present in an urban population of India. However, the important public health implications for the burden of diseases are associated with only the upper extreme (obese) and all underweight body composition (BC). The results from MCS highlight the immediate need to identify and to address both underweight and obese portions of the distribution in identifying vulnerable targeting interventions. Our study reported that tobacco use is a risk factor for low BMI. Further, tobacco use and low BMI had synergistic effect on mortality in men and antagonistic effect in women, independent of whether additive or multiplicative interaction was assumed. Tobacco use and undernutrition are known to be serious problems in India, and the present study indicates that obesity may emerge as a serious public health problem. However, the effect of obesity on mortality is subject to large random variation in this study. The policy implications for prevention would be that improving the nutritional status of those underweight and preventing use of tobacco results in the immediate highest yield

The Impact of Tobacco Use and/or Body Composition on Adult Mortality in Urban Developing Country Population. Results from the Mumbai Cohort Study, Mumbai, India, 1991-2003

Tupakka ja ravitsemus ovat maailmanlaajuisia kansanterveysongelmia ja niiden arvioidaan aiheuttavan noin viidenneksen kaikista kuolemista. Intian suurimmassa kaupungissa Mumbaissa haastateltiin 150 000 aikuista heidän elin- ja tupakointitavoistaan. Heitä seurattiin keskimäärin 5,5 vuotta ja selvitettiin kuolemantapaukset ja niiden syyt. Intiassa tupakkaa käytetään yleisesti ja monessa muodossa. Tupakanpoltto oli tavallista vain miehillä ja muut tupakointimuodot (savuttomat) olivat yleisiä molemmilla sukupuolilla. Intialaiset savukkeet olivat yhtä haitallisia kuin länsimaiset. Myös muut tupakointitavat aiheuttivat huomattavan ylikuolleisuuden. Ravitsemustilaa mitattiin painoindeksillä. Yli- ja alipainoisia oli lähes yhtä paljon, mutta selvä laihuus oli selvää lihavuutta tavallisempaa. Ylipainoisten kuolleisuus oli pienintä ja vasta lihavilla esiintyi ylikuolleisuutta normaalipainoisiin verrattuna. Alipainoisilla kuolleisuus oli suurentunutta ja kasvoi sen mukaan, mitä laihemmista oli kyse. Miehillä tupakoinnin ja laihuuden yhteisvaikutus oli toisiaan voimistavaa, kun taas tupakointi ja lihavuus vaimensivat toistensa vaikutusta. Naisilla yhteisvaikutukset olivat toisiaan vaimentavia mutta tupakan kulutus oli lähinnä savutonta. Ylipainosta on kehittynyt yksi länsimaiden pahimpia terveyden vaaratekijöitä. Intiassa laihuus eli aliravitsemus on edelleen ensisijaisempi. Intia kuitenkin länsimaistuu nopeasti ja on mahdollista, että maassa tulee olemaan kahdensuuntainen eli sekä laihuuteen että lihavuuteen liittyvä terveysongelma, jota yleiset ja monimuotoiset tupakointitavat lisäävät.Worldwide, there are two important risk factors underlying the major causes of death, tobacco use and nutritional status. Of the total 55.9 million global annual deaths, tobacco use and nutritional status, together, account for approximately 20%. Information about excess mortality from different forms of tobacco use other than cigarette smoking (such as bidi smoking and the various forms of smokeless tobacco use), is very limited. Using Mumbai Cohort Study (MCS) data from India, the present study reports on the association of various kinds of tobacco habits that are prevalent in India with all-causes of mortality and with major causes [such as cancers, tuberculosis (TB), etc.]. Nutrition research in India has focused primarily on the problem of undernutrition, particularly among vulnerable women and children. Currently, India is undergoing a rapid economic transition. At this stage in the associated epidemiologic transition, the country is facing the double burden of communicable and non-communicable diseases. In all such transitions, nutrition plays a central role. The joint effect of tobacco use (mainly smoking) and body mass on mortality has not been well characterized, although a body of evidence is accumulating on the individual effect of smoking on the association of body mass and mortality. Using MCS, this was the first such attempt, from a developing country population, where both under- and over- nutrition and tobacco use are major public health concerns. Using the Mumbai electoral role list as the selection frame, a total of 148,173 individuals aged ≥ 35 years were recruited (1991 1997) for a prospective follow-up study. After an average 5.5 years an active house-to-house follow-up (to ascertain vital status) was conducted (1997 2003). At active follow-up, 140,908 (95%) individuals were traced. Among these, 13,261 deaths were recorded, of which 85% occurred within the study area. It was possible to abstract cause of death information from Bombay Municipal Corporation death registers for 9,259 deaths. All forms of tobacco smoking increased the risk of dying in Mumbai. In addition to smoking, different forms of smokeless tobacco use also resulted in excess mortality. Using MCS findings, a total of 24% male and 6% female deaths (aged 35 69 years) were found to be attributable to their tobacco usage. Also, 41.6% of men s and 20.7% of women s cancer deaths were found to be attributable to their tobacco usage. Bidi smoking was found to be as harmful as cigarette smoking and was found to be responsible for around 32% of TB deaths. Therefore, MCS findings provide supportive evidence from the population of a developing country about the association of tobacco usage with increased risk of death; primarily for various cancers and TB. MCS results showed that both chronic underweight and overweight are equally present in an urban population of India. However, the important public health implications for the burden of diseases are associated with only the upper extreme (obese) and all underweight body composition (BC). The results from MCS highlight the immediate need to identify and to address both underweight and obese portions of the distribution in identifying vulnerable targeting interventions. Our study reported that tobacco use is a risk factor for low BMI. Further, tobacco use and low BMI had synergistic effect on mortality in men and antagonistic effect in women, independent of whether additive or multiplicative interaction was assumed. Tobacco use and undernutrition are known to be serious problems in India, and the present study indicates that obesity may emerge as a serious public health problem. However, the effect of obesity on mortality is subject to large random variation in this study. The policy implications for prevention would be that improving the nutritional status of those underweight and preventing use of tobacco results in the immediate highest yield

Association of tobacco smoking with risk of death from all causes in selected study populations in Asia.

a<p>Adjusted for age, education, rural/urban resident, marital status, and body mass index; data from participants with <1 y of follow-up are excluded.</p><p>Analyses were conducted among those age 45 y or older.</p>b<p>Including data from mainland China, Taiwan, Singapore, Republic of Korea, and Japan.</p>c<p>Including data from India and Bangladesh.</p

Association of tobacco smoking with risk of cause-specific death by study populations in Asia.

a<p>Number of deaths among ever-smokers/never-smokers are presented.</p>b<p>HRs estimated for ever-smokers compared with never-smokers and adjusted for age, education, rural/urban residence, marital status, and body mass index; data from participants with <1 y of follow-up are excluded.</p><p>Analyses were conducted among those age 45 y or older.</p>c<p>HR not estimated because of small sample size.</p><p>CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease.</p

Smoking prevalence, population attributable risk, and number of deaths due to tobacco smoking in selected Asian populations.

<p>Estimates are provided for populations age 45 y or older.</p>a<p>Because of the small sample size in the current study for these populations, data for smoking prevalence rates were obtained from other sources: Bangladeshi men and women: <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001631#pmed.1001631-Giovino1" target="_blank">[12]</a>, Taiwanese women: <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001631#pmed.1001631-Liaw1" target="_blank">[19]</a>, and Korean women: <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001631#pmed.1001631-Jee1" target="_blank">[34]</a>.</p>b<p>PARs were estimated using HRs derived from all South Asian cohorts combined because of unstable HR estimates using Bangladeshi data alone.</p>c<p>Mortality data for Taiwan were obtained from <a href="http://www.mohw.gov.tw/CHT/Ministry/Index.aspx" target="_blank">http://www.mohw.gov.tw/CHT/Ministry/Index.aspx</a>.</p>d<p>PARs were estimated using weighted HRs and smoking prevalence of the study populations.</p><p>Thus, the number of deaths attributable to smoking in these populations may not be equal to the sum of the numbers of deaths from the countries in the population areas. East Asia: mainland China, Taiwan, Singapore, Republic of Korea, and Japan. South Asia: Bangladesh and India. All populations: all seven countries/regions listed above.</p

Association of tobacco smoking with risk of death from all causes, cardiovascular diseases, cancer, or respiratory diseases in major East Asian female populations.

a<p>Excluding participants with less than 1 y of follow-up.</p>b<p>Adjusted for age, education, rural/urban resident, marital status, and body mass index.</p><p>Analyses were conducted among those age 45 y or older.</p>c<p>Excluding current smokers with missing information on pack-years of smoking.</p