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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 Publisher Pubmed



Sathish T1 ; Teo KK1 ; Britzmckibbin P2 ; Gill B2 ; Islam S1 ; Pare G1, 3 ; Rangarajan S1 ; Duong M1 ; Lanas F4 ; Lopezjaramillo P5 ; Mony PK6 ; Pinnaka L7 ; Kutty VR8 ; Orlandini A9 Show All Authors
Authors
  1. Sathish T1
  2. Teo KK1
  3. Britzmckibbin P2
  4. Gill B2
  5. Islam S1
  6. Pare G1, 3
  7. Rangarajan S1
  8. Duong M1
  9. Lanas F4
  10. Lopezjaramillo P5
  11. Mony PK6
  12. Pinnaka L7
  13. Kutty VR8
  14. Orlandini A9
  15. Avezum A10
  16. Wielgosz A11
  17. Poirier P12
  18. Alhabib KF13
  19. Temizhan A14
  20. Chifamba J15
  21. Yeates K16
  22. Kruger IM17
  23. Khatib R18
  24. Yusuf R19
  25. Rosengren A20, 21
  26. Zatonska K22
  27. Iqbal R23
  28. Lui W24
  29. Lang X24
  30. Li S24
  31. Hu B24
  32. Dans AL25
  33. Yusufali AH26
  34. Bahonar A27
  35. Odonnell MJ1
  36. Mckee M28
  37. Yusuf S1
Show Affiliations
Authors Affiliations
  1. 1. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
  2. 2. Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON, Canada
  3. 3. Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
  4. 4. Internal Medicine Department, Universidad de La Frontera, Temuco, Chile
  5. 5. Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia
  6. 6. Division of Epidemiology & Population Health, St John's Medical College & Research Institute, Bangalore, India
  7. 7. Department of Community Medicine & School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India
  8. 8. Health Action by People, Thiruvananthapuram, Kerala, India
  9. 9. ECLA Foundation, Instituto Cardiovascular de Rosario, Rosario, Argentina
  10. 10. International Research Center, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil
  11. 11. Department of Medicine, University of Ottawa, Ottawa, ON, Canada
  12. 12. Faculty of Pharmacy, Institut universitaire de cardiologie et de pneumologie de Quebec, Universite Laval, Queebec, QC, Canada
  13. 13. Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  14. 14. Cardiology Department, Ankara City Hospital, Ankara, Turkey
  15. 15. Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
  16. 16. Department of Medicine, Queen's University, Kingston, ON, Canada
  17. 17. Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
  18. 18. Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
  19. 19. Department of Life Sciences, Independent University Bangladesh, Dhaka, Bangladesh
  20. 20. Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  21. 21. Region Vastra Gotaland, Sahlgrenska University Hospital, Gothenburg, Sweden
  22. 22. Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  23. 23. Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
  24. 24. Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
  25. 25. Department of Medicine, University of the Philippines College of Medicine, Manila, Philippines
  26. 26. Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
  27. 27. Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  28. 28. Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK, United Kingdom

Source: The Lancet Global Health Published:2022


Abstract

Background: Separate studies suggest that the risks from smoking might vary between high-income (HICs), middle-income (MICs), and low-income (LICs) countries, but this has not yet been systematically examined within a single study using standardised approaches. We examined the variations in risks from smoking across different country income groups and some of their potential reasons. 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). © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license
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