Variations in risks from smoking between high-income, middle-income, and low-income countries: an analysis of data from 179 000 participants from 63 countries.
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Sathish Thirunavukkarasu, Teo Koon K, Britz-McKibbin Philip, Gill Biban, Islam Shofiqul, Paré Guillaume, Rangarajan Sumathy, Duong MyLinh, Lanas Fernando, Lopez-Jaramillo Patricio, Mony Prem K, Pinnaka Lakshmi, Kutty Vellappillil Raman, Orlandini Andres, Avezum Alvaro, Wielgosz Andreas, Poirier Paul, Alhabib Khalid F, Temizhan Ahmet, Chifamba Jephat, Yeates Karen, Kruger Iolanthé M, Khatib Rasha, Yusuf Rita, Rosengren Annika, Zatonska Katarzyna, Iqbal Romaina, Lui Weida, Lang Xinyue, Li Sidong, Hu Bo, Dans Antonio L, Yusufali Afzal Hussein, Bahonar Ahmad, O'Donnell Martin J, McKee Martin, Yusuf Salim
Аннотация
METHODS: We analysed data from 134 909 participants from 21 countries followed up for a median of 11·3 years in the Prospective Urban Rural Epidemiology (PURE) cohort study; 9711 participants with myocardial infarction and 11 362 controls from 52 countries in the INTERHEART case-control study; and 11 580 participants with stroke and 11 331 controls from 32 countries in the INTERSTROKE case-control study. In PURE, all-cause mortality, major cardiovascular disease, cancers, respiratory diseases, and their composite were the primary outcomes for this analysis. Biochemical verification of urinary total nicotine equivalent was done in a substudy of 1000 participants in PURE.
FINDINGS: In PURE, the adjusted hazard ratio (HR) for the composite outcome in current smokers (vs never smokers) was higher in HICs (HR 1·87, 95% CI 1·65-2·12) than in MICs (1·41, 1·34-1·49) and LICs (1·35, 1·25-1·46; interaction p<0·0001). Similar patterns were observed for each component of the composite outcome in PURE, myocardial infarction in INTERHEART, and stroke in INTERSTROKE. The median levels of tar, nicotine, and carbon monoxide displayed on the cigarette packs from PURE HICs were higher than those on the packs from MICs. In PURE, the proportion of never smokers reporting high second-hand smoke exposure (≥1 times/day) was 6·3% in HICs, 23·2% in MICs, and 14·0% in LICs. The adjusted geometric mean total nicotine equivalent was higher among current smokers in HICs (47·2 μM) than in MICs (31·1 μM) and LICs (25·2 μM; ANCOVA p<0·0001). By contrast, it was higher among never smokers in LICs (18·8 μM) and MICs (11·3 μM) than in HICs (5·0 μM; ANCOVA p=0·0001).
INTERPRETATION: The variations in risks from smoking between country income groups are probably related to the higher exposure of tobacco-derived toxicants among smokers in HICs and higher rates of high second-hand smoke exposure among never smokers in MICs and LICs.
FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).