Association of smoking status with incident cardiovascular disease in the middle-aged and older male populations
-
摘要:
目的 探讨中老年男性吸烟状况与心血管疾病(cardiovascular disease，CVD)及其亚型发生风险的关联性。 方法 本研究选取东风-同济(Dongfeng-Tongji，DFTJ)队列中基线未患冠心病(coronary heart disease，CHD)、中风、癌症、严重心电图异常的13 940名男性为研究对象。研究对象均完成了基线调查，包括问卷调查、体格检查、生化指标检查和血液样本采集。采用Cox比例风险回归模型进行关联性分析，计算风险比(hazard ratio，HR)和95%置信区间(confidence intervals，CI)。 结果 多因素调整后，与从不吸烟者相比，现在吸烟者发生CVD、CHD和中风的风险增加，吸烟指数≥ 40包年者发生CVD、CHD和中风的风险HR值分别为1.49(95%CI：1.32~1.68，Ptrend=0.001)、1.40(95%CI：1.22~1.62，Ptrend=0.026)和1.59(95%CI：1.26~2.00，Ptrend=0.029)，开始吸烟年龄 < 20岁者发生CVD和CHD的风险HR值分别为1.29(95%CI：1.06~1.58，Ptrend=0.007)和1.30(95%CI：1.03~1.64，Ptrend=0.010)；与现在吸烟者相比，戒烟时长≥ 10年者发生CVD和中风的风险显著降低，HR值分别为0.80(95%CI：0.71~0.91，Ptrend=0.017)和0.65(95%CI：0.50~0.84，Ptrend=0.207)。 结论 吸烟能增加CVD、CHD和中风的发生风险，且吸烟指数越大或开始吸烟年龄越小，CVD发生风险越高。戒烟可降低CVD和中风的发生风险。 Abstract:Objective To investigate the association of smoking status with incident cardiovascular disease (CVD) and its subtypes among the middle-aged and older male populations. Methods This study included 13 940 males from Dongfeng-Tongji (DFTJ) cohort who were free of coronary heart disease (CHD), stroke, cancer or severely abnormal electrocardiogram (ECG) at baseline. All participants completed baseline questionnaires, physical examinations, clinical biochemical tests and blood sample collection. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confident intervals (CI) for the association analyses. Results Compared with never smokers, current smokers had significant higher risks of CVD, CHD and stroke, the adjusted HRs of current smokers who smoked for more than 40 pack-years were 1.49 (95% CI: 1.32-1.68, Ptrend=0.001), 1.40 (95% CI: 1.22-1.62, Ptrend=0.026) and 1.59 (95% CI: 1.26-2.00, Ptrend=0.029) for CVD, CHD and stroke, respectively; and the adjusted HRs of current smokers who started smoking before 20 years old were 1.29 (95% CI: 1.06-1.58, Ptrend=0.007) and 1.30 (95% CI: 1.03-1.64, Ptrend=0.010) for CVD and CHD, respectively. Former smokers who had quitted smoking for 10 or more years had significant lower risks of CVD (HR: 0.80, 95% CI: 0.71-0.91, Ptrend=0.017) and stroke (HR: 0.65, 95% CI: 0.50-0.84, Ptrend=0.207) when comparing to current smokers. Conclusions Smoking is significantly associated with higher risks of CVD, CHD and stroke, and greater amount of smoking and earlier age at smoking initiation are associated with a higher risk of CVD. Smoking cessation can reduce the risk of CVD. -
Key words:
- Smoking /
- Cardiovascular disease /
- Prospective cohort study /
- Middle-aged and older males
-
表 1 不同吸烟状态组的基线特征比较
Table 1. Comparison of baseline characteristics of different smoking status groups
特征 吸烟状态 F/χ2 P值 从不吸烟 过去吸烟 现在吸烟 人数(人) 5 284 2 968 5 688 年龄(岁) 66.1±6.9 66.3±6.2 63.5±6.0 290.13 < 0.001 小学及以下教育水平[n(%)] 1 081(20.6) 720(24.4) 1 357(24.0) 22.60 < 0.001 现在饮酒，是[n(%)] 1 461(27.7) 1 359(45.9) 3 297(58.0) 1 030.13 < 0.001 锻炼，是[n(%)] 3 883(73.5) 2 274(76.6) 3 873(68.1) 80.19 < 0.001 腰围(cm) 85.3±8.8 85.9±8.8 84.6±9.0 19.21 < 0.001 BMI(kg/m 2) 24.5±3.1 24.6±3.2 23.9±3.2 61.03 < 0.001 TG(mmol/L) 1.2(0.8~1.7) 1.2(0.8~1.7) 1.2(0.9~1.7) 4.47 0.011 TC(mmol/L) 4.8(4.2~5.5) 4.9(4.3~5.5) 4.8(4.2~5.4) 2.57 0.077 HDL-C(mmol/L) 1.3(1.1~1.6) 1.3(1.1~1.6) 1.3(1.1~1.6) 1.35 0.259 LDL-C(mmol/L) 2.8(2.3~3.3) 2.8(2.3~3.4) 2.8(2.3~3.3) 0.18 0.835 FBG(mmol/L) 5.7(5.3~6.4) 5.8(5.3~6.4) 5.6(5.1~6.2) 18.04 < 0.001 高血脂[n(%)] 2 108(39.9) 1 271(42.8) 2 336(41.1) 6.76 0.034 高血压[n(%)] 3 021(57.2) 1 811(61.0) 2 899(51.0) 89.87 < 0.001 糖尿病[n(%)] 1 030(19.5) 570(19.2) 875(15.4) 37.11 < 0.001 中风家族史[n(%)] 227(4.3) 177(6.0) 260(4.6) 12.43 0.002 CHD家族史[n(%)] 225(4.3) 155(5.2) 258(4.5) 4.08 0.130 CVD家族史[n(%)] 397(7.5) 288(9.7) 465(8.2) 12.12 0.002 
下载: 导出CSV
表 2 吸烟状态与心血管疾病发生风险的关系
Table 2. Association between smoking status and cardiovascular disease
吸烟状态 吸烟指数(包年)a 吸烟指数每增加20包年的HR(95% CI)值a Ptrenda 从不吸烟 过去吸烟 现在吸烟 < 20 20~40 ≥40 CVD 新发病例数/人年 1 077/30 281 692/16 514 1 202/31 426 318/9 485 436/11 920 434/9 710 HR (95% CI)b 1.00 1.16(1.04~1.29) 1.33(1.21~1.46) 1.16(1.02~1.33) 1.34(1.19~1.51) 1.49(1.32~1.68) 1.11(1.05~1.17) 0.001 CHD 新发病例数/人年 782/31 003 527/16 927 863/32 353 233/9 747 313/12 228 308/10 054 HR(95% CI)b 1.00 1.21(1.07~1.37) 1.29(1.15~1.43) 1.15(0.98~1.35) 1.27(1.10~1.46) 1.40(1.22~1.62) 1.10(1.03~1.18) 0.026 ACS 新发病例数/人年 287/29 141 208/15 703 365/30 466 98/9 198 129/11 557 134/9 397 HR(95% CI)b 1.00 1.37(1.12~1.66) 1.50(1.26~1.78) 1.41(1.10~1.80) 1.47(1.17~1.84) 1.70(1.36~2.13) 1.08(0.98~1.20) 0.129 中风 新发病例数/人年 295/32 351 165/17 956 339/33 754 85/10 107 123/12 797 126/10 511 HR(95% CI)b 1.00 0.98(0.79~1.22) 1.37(1.15~1.64) 1.16(0.89~1.51) 1.44(1.14~1.81) 1.59(1.26~2.00) 1.10(1.00~1.22) 0.029 IS 新发病例数/人年 233/32 114 131/17 849 278/33 551 71/10 062 104/12 736 101/10 424 HR(95% CI)b 1.00 1.03(0.81~1.32) 1.45(1.19~1.78) 1.27(0.94~1.70) 1.59(1.23~2.06) 1.68(1.30~2.18) 1.10(0.98~1.23) 0.076 HS 新发病例数/人年 62/31 442 34/17 444 61/32 831 14/9 872 19/12 452 25/10 176 HR(95% CI)b 1.00 0.80(0.49~1.30) 1.09(0.73~1.61) 0.80(0.43~1.50) 0.93(0.54~1.61) 1.27(0.77~2.12) 1.12(0.88~1.43) 0.166 注：a仅纳入现在吸烟者；Ptrend是将各组中吸烟指数的中位数作为连续性变量纳入回归模型计算得出。b按照年龄(5岁一组)分层，并校正教育、饮酒、BMI、锻炼、高血压、高血脂、糖尿病、CVD/CHD/中风家族史和进入队列批次。
下载: 导出CSV
表 3 开始吸烟年龄与心血管疾病发生风险的关系
Table 3. Association between age at smoking initiation and cardiovascular disease
从不吸烟 开始吸烟年龄(岁)a 开始吸烟年龄每增加5岁的HR(95% CI)值a Ptrenda < 20 20~24 ≥25 CVD 新发病例数/人年 1 077/30 281 275/6 425 452/11 720 465/13 040 HR(95% CI)b 1.00 1.29(1.06~1.58) 1.26(1.07~1.48) 1.06(0.92~1.22) 0.92(0.88~0.96) 0.007 CHD 新发病例数/人年 782/31 003 199/6 636 324/12 054 333/13 413 HR(95% CI)b 1.00 1.30(1.03~1.64) 1.22(1.01~1.48) 1.03(0.87~1.22) 0.90(0.85~0.95) 0.010 ACS 新发病例数/人年 287/29 141 89/6 258 130/11 361 144/12 606 HR(95% CI)b 1.00 1.89(1.32~2.71) 1.51(1.12~2.03) 1.28(0.99~1.66) 0.86(0.79~0.94) 0.038 中风 新发病例数/人年 295/32 351 76/6 934 128/12 652 132/13 915 HR(95% CI)b 1.00 1.23(0.84~1.80) 1.34(0.99~1.81) 1.13(0.86~1.47) 0.98(0.90~1.06) 0.383 IS 新发病例数/人年 233/32 114 65/6 902 99/12 552 113/13 852 HR(95% CI)b 1.00 1.42(0.94~2.15) 1.37(0.98~1.92) 1.26(0.94~1.70) 1.00(0.92~1.09) 0.650 HS 新发病例数/人年 62/31 442 11/6 717 29/12 319 19/13 545 HR(95% CI)b 1.00 0.62(0.24~1.63) 1.22(0.62~2.41) 0.66(0.34~1.27) 0.85(0.68~1.07) 0.258 注：a仅纳入现在吸烟者；Ptrend是将各组中开始吸烟年龄的中位数作为连续性变量纳入回归模型计算得出。b按照年龄(5岁一组)分层，并校正教育、饮酒、BMI、锻炼、高血压、高血脂、糖尿病、CVD/CHD/中风家族史、进入队列批次和吸烟指数。
下载: 导出CSV
表 4 戒烟时长与心血管疾病发生风险的关系
Table 4. Association between years since quitting and cardiovascular disease
现在吸烟 从不吸烟 戒烟时长(年)a 戒烟时长每增加五年的HR(95%CI)值a Ptrenda < 5 5~10 ≥10 CVD 新发病例数/人年 1 202/31 426 1 077/30 281 156/3 671 127/2 964 390/9 379 HR(95% CI)b 1.00 0.75(0.68~0.82) 1.01(0.85~1.20) 0.95(0.78~1.15) 0.80(0.71~0.91) 0.95(0.90~0.99) 0.017 CHD 新发病例数/人年 863/32 353 782/31 003 118/3 740 97/3 046 299/9 634 HR(95% CI)b 1.00 0.78(0.70~0.87) 1.09(0.89~1.33) 1.02(0.82~1.27) 0.88(0.76~1.01) 0.95(0.90~1.00) 0.056 ACS 新发病例数/人年 365/30 466 287/29 141 47/3 524 37/2 809 122/8 916 HR(95% CI)b 1.00 0.67(0.56~0.79) 1.07(0.78~1.47) 0.98(0.69~1.38) 0.86(0.69~1.08) 0.94(0.86~1.02) 0.274 中风 新发病例数/人年 339/33 754 295/32 351 38/4 047 30/3 210 91/10 179 HR(95% CI)b 1.00 0.73(0.61~0.87) 0.80(0.56~1.15) 0.79(0.53~1.16) 0.65(0.50~0.84) 0.95(0.87~1.05) 0.207 IS 新发病例数/人年 278/33 551 233/32 114 24/4 009 28/3 204 75/10 119 HR(95% CI)b 1.00 0.69(0.56~0.84) 0.66(0.43~1.02) 0.89(0.60~1.34) 0.67(0.51~0.89) 0.96(0.86~1.06) 0.532 HS 新发病例数/人年 61/32 908 62/31 521 14/3 944 2/3 114 16/9 915 HR(95% CI)b 1.00 0.90(0.61~1.34) 1.39(0.72~2.67) 0.31(0.08~1.27) 0.54(0.28~1.05) 0.92(0.73~1.17) 0.104 注：a仅纳入过去吸烟者；Ptrend是将各组中戒烟时长的中位数作为连续性变量纳入回归模型计算得出。b按照年龄(5岁一组)分层，并校正教育、饮酒、BMI、锻炼、高血压、高血脂、糖尿病、CVD/CHD/中风家族史和进入队列批次。
下载: 导出CSV
-
[1] Smith SJ, Collins A, Ferrari R, et al. Our time: a call to save preventable death from cardiovascular disease (heart disease and stroke)[J]. Glob Heart, 2012, 7(4): 297-305. DOI: 10.1016/j.gheart.2012.08.002. [2] 国家心血管病中心. 中国心血管病报告, 2017[M]. 北京: 中国大百科全书出版社, 2017: 190.National Center for Cardiovascular Disease. Report on cardiovascular diseases in China, 2017[M]. Beijing: Encyclopedia of China Publishing House, 2017: 190. [3] GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the global burden of disease study 2015[J]. Lancet, 2017, 389(10082): 1885-1906. DOI: 10.1016/S0140-6736(17)30819-X. [4] Hackshaw A, Morris JK, Boniface S, et al. Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports[J]. BMJ, 2018, 360: j5855. DOI: 10.1136/bmj.j5855. [5] McEvoy JW, Blaha MJ, DeFilippis AP, et al. Cigarette smoking and cardiovascular events: role of inflammation and subclinical atherosclerosis from the multi-ethnic study of atherosclerosis(MESA)[J]. Arterioscler Thromb Vasc Biol, 2015, 35(3): 700-709. DOI: 10.1161/ATVBAHA.114.304562. [6] Huxley RR, Yatsuya H, Lutsey PL, et al. Impact of age at smoking initiation, dosage, and time since quitting on cardiovascular disease in African Americans and whites: the atherosclerosis risk in communities study[J]. Am J Epidemiol, 2012, 175(8): 816-826. DOI: 10.1093/aje/kwr391. [7] Gellert C, Schottker B, Muller H, et al. Impact of smoking and quitting on cardiovascular outcomes and risk advancement periods among older adults[J]. Eur J Epidemiol, 2013, 28(8): 649-658. DOI: 10.1007/s10654-013-9776-0. [8] Mons U, Müezzinler A, Gellert C, et al. Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the chances consortium[J]. BMJ, 2015, 350: h1551. DOI: 10.1136/bmj.h1551. [9] Kenfield SA, Stampfer MJ, Rosner BA, et al. Smoking and smoking cessation in relation to mortality in women[J]. JAMA, 2008, 299(17): 2037-2047. DOI: 10.1001/jama.299.17.2037. [10] Christensen CH, Rostron B, Cosgrove C, et al. Association of cigarette, cigar, and pipe use with mortality risk in the US population[J]. JAMA Intern Med, 2018, 178(4): 469-476. DOI: 10.1001/jamainternmed.2017.8625. [11] Inoue-Choi M, Liao LM, Reyes-Guzman C, et al. Association of long-term, low-intensity smoking with all-cause and cause-specific mortality in the national institutes of health-AARP diet and health study[J]. JAMA Intern Med, 2017, 177(1): 87-95. DOI: 10.1001/jamainternmed.2016.7511. [12] Gellert C, Schottker B, Brenner H. Smoking and all-cause mortality in older people: systematic review and meta-analysis[J]. Arch Intern Med, 2012, 172(11): 837-844. DOI: 10.1001/archinternmed.2012.1397. [13] Chen Z, Peto R, Zhou M, et al. Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies[J]. Lancet, 2015, 386(10002): 1447-1456. DOI: 10.1016/S0140-6736(15)00340-2. [14] Xu L, Schooling CM, Chan WM, et al. Smoking and hemorrhagic stroke mortality in a prospective cohort study of older Chinese[J]. Stroke, 2013, 44(8): 2144-2149. DOI: 10.1161/STROKEAHA.113.001500. [15] 申倩, 祝楠波, 余灿清, 等. 中国成年人吸烟与心血管疾病发病风险的关联及其性别差异分析[J]. 中华流行病学杂志, 2018, 39(1): 8-15. DOI: 10.3760/cma.j.issn.0254-6450.2018.01.002.Shen Q, Zhu NB, Yu CQ, et al. Sex-specific associations between tobacco smoking and risk of cardiovascular diseases in Chinese adults[J]. Chin J Epidemiol, 2018, 39(1): 8-15. DOI: 10.3760/cma.j.issn.0254-6450.2018.01.002. [16] Ji J, Pan E, Li J, et al. Classical risk factors of cardiovascular disease among Chinese male steel workers: a prospective cohort study for 20 years[J]. BMC Public Health, 2011, 11: 497. DOI: 10.1186/1471-2458-11-497. [17] Xu T, Bu X, Li H, et al. Smoking, heart rate, and ischemic stroke: a population-based prospective cohort study among Inner Mongolians in China[J]. Stroke, 2013, 44(9): 2457-2461. DOI: 10.1161/STROKEAHA.111.000648. [18] Liu J, Hong Y, D'Agostino RS, et al. Predictive value for the Chinese population of the Framingham CHD risk assessment tool compared with the Chinese multi-provincial cohort study[J]. JAMA, 2004, 291(21): 2591-2599. DOI: 10.1001/jama.291.21.2591. [19] Kelly TN, Gu D, Chen J, et al. Cigarette smoking and risk of stroke in the Chinese adult population[J]. Stroke, 2008, 39(6): 1688-1693. DOI: 10.1161/STROKEAHA.107.505305. [20] Tse LA, Fang XH, Wang WZ, et al. Incidence of ischemic and hemorrhagic stroke and the association with smoking and smoking cessation: a 10-year multicentre prospective study in China[J]. Public Health, 2012, 126(11): 960-966. DOI: 10.1016/j.puhe.2012.07.010. [21] Wang F, Zhu J, Yao P, et al. Cohort profile: the Dongfeng-Tongji cohort study of retired workers[J]. Int J Epidemiol, 201342(3): 731-740. DOI: 10.1093/ije/dys053. [22] Israel RA. International Classification of Diseases (ICD)[M]. John Wiley & Sons, Ltd, 2011, 31-36. [23] Luepker RV, Apple FS, Christenson RH, et al. Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute[J]. Circulation, 2003, 108(20): 2543-2549. DOI:10.1161/01.CIR.0000100560.46946.EA. [24] Yuan Y, Xiao Y, Feng W, et al. Plasma metal concentrations and incident coronary heart disease in Chinese adults: the Dongfeng-Tongji cohort[J]. Environ Health Perspect, 2017, 125(10): 107007. DOI: 10.1289/EHP1521. [25] Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American college of cardiology foundation/American heart association task force on practice guidelines[J]. Circulation, 2013, 127(23): e663-e828. DOI:10.1161/CIR.0b013e31828478ac. [26] Walker AE, Robins M, Weinfeld FD. The national survey of stroke. Clinical findings[J]. Stroke, 1981, 12(Suppl 1): I13-I44. DOI: info:doi/10.1016/S0378-7788(02)00061-0. [27] Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American heart association/American stroke association[J]. Stroke, 2013, 44(7): 2064-2089. DOI: 10.1161/STR.0b013e318296aeca. [28] Nitika, Mishra SS, Lohani P. Lexis expansion: a prerequisite for analyzing time changing variables in a cohort study[J]. Nepal J Epidemiol, 2017, 7(2): 681-684. DOI: 10.3126/nje.v7i2.17974. [29] 赵洁雯, 要鹏韬, 刘黎香. 北京市吸烟人群尼古丁依赖程度影响因素的横断面调查研究[J]. 中华疾病控制杂志, 2018, 22(4): 358-362. DOI: 10.16462/j.cnki.zhjbkz.2018.04.009.Zhao JW, Yao PT, Liu LX. The epidemiological investigation on risk factors of nicotine dependence among the smokers in Beijing[J]. Chin J Dis Control Prev, 2018, 22(4): 358-362. DOI: 10.16462/j.cnki.zhjbkz.2018.04.009. -
