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JAMA Netw Open. 2019 Mar 1;2(3):e191474. doi: 10.1001/jamanetworkopen.2019.1474.

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

Author information

1
Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee.
2
Division of Cancer Statistics Integration, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan.
3
Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
4
Healis-Sekhsaria Institute for Public Health, Mahape, Navi Mumbai, India.
5
Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana.
6
Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.
7
State Key Laboratory of Oncogene and Related Genes, Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
8
Duke-NUS Medical School Singapore, Singapore, Republic of Singapore.
9
Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Republic of Singapore.
10
Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
11
Ibaraki Chikusei Public Health Center, Chikusei City, Japan.
12
Radiation Effects Research Foundation, Hiroshima, Japan.
13
Tohoku University Graduate School of Medicine, Sendai, Japan.
14
Division of Molecular and Clinical Epidemiology, Aichi Cancer Center Research Institute, Nagoya, Japan.
15
Department of Epidemiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
16
Graduate School of Medicine, Gifu University, Gifu City, Japan.
17
Academia Sinica, Taipei City, Taiwan.
18
Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
19
Department of Social and Preventive Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
20
Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea.
21
Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, South Korea.
22
Cancer Research Institute, Seoul National University, Seoul, South Korea.
23
Institute of Biomedical Sciences, Academia Sinica, Taipei City, Taiwan.
24
Cancer Foundation of China, Beijing, People's Republic of China.
25
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
26
Taiwan Biobank, Institute of Biomedical Sciences, Academia Sinica, Taipei City, Taiwan.
27
Graduate Institute of Environmental Science, China Medical University, Taichung, Taiwan.
28
School of Medicine, Big Data Research Center, Fu Jen Catholic University, Taipei City, Taiwan.
29
Armed Forces Capital Hospital, Seoul National University College of Medicine, Seoul, South Korea.
30
Cancer Research Center, Department of Health Studies, University of Chicago, Chicago, Illinois.
31
Cancer Research Center, Department of Medicine, University of Chicago, Chicago, Illinois.
32
Cancer Research Center, Department of Human Genetics, University of Chicago, Chicago, Illinois.
33
Icahn School of Medicine at Mount Sinai, New York, New York.
34
Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.
35
Centre for Public Health Research, Massey University, Wellington, New Zealand.
36
Department of Epidemiology, University of Washington, Seattle.

Abstract

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.

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