Skip to content
naulon
Get started

No retraction, correction or concern found when last checked on Oct 20, 2026.

Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study

Emily Banks, Grace Joshy, Rosemary J. Korda and 7 more

BMC Medicine · 2019 · CC BY

doi:10.1186/s12916-019-1351-4

Abstract

Background. Tobacco smoking is a leading cause of cardiovascular disease (CVD) morbidity and mortality. Evidence on the relation of smoking to different subtypes of CVD, across fatal and non-fatal outcomes, is limited.

Methods. A prospective study of 188,167 CVD- and cancer-free individuals aged ≥ 45 years from the Australian general population joining the 45 and Up Study from 2006 to 2009, with linked questionnaire, hospitalisation and death data up to the end of 2015. Hazard ratios (HRs) for hospitalisation with or mortality from CVD among current and past versus never smokers were estimated, including according to intensity and recency of smoking, using Cox regression, adjusting for age, sex, urban/rural residence, alcohol consumption, income and education. Population-attributable fractions were estimated.

Results. During a mean 7.2 years follow-up (1.35 million person-years), 27,511 (crude rate 20.4/1000 person-years) incident fatal and non-fatal major CVD events occurred, including 4548 (3.2) acute myocardial infarction (AMI), 3991 (2.8) cerebrovascular disease, 3874 (2.7) heart failure and 2311 (1.6) peripheral arterial disease (PAD) events. At baseline, 8% of participants were current and 34% were past smokers. Of the 36 most common specific CVD subtypes, event rates for 29 were increased significantly in current smokers. Adjusted HRs in current versus never smokers were as follows: 1.63 (95%CI 1.56–1.71) for any major CVD, 2.45 (2.22–2.70) for AMI, 2.16 (1.93–2.42) for cerebrovascular disease, 2.23 (1.96–2.53) for heart failure, 5.06 (4.47–5.74) for PAD, 1.50 (1.24–1.80) for paroxysmal tachycardia, 1.31 (1.20–1.44) for atrial fibrillation/flutter, 1.41 (1.17–1.70) for pulmonary embolism, 2.79 (2.04–3.80) for AMI mortality, 2.26 (1.65–3.10) for cerebrovascular disease mortality and 2.75 (2.37–3.19) for total CVD mortality. CVD risks were elevated at almost all levels of current smoking intensity examined and increased with smoking intensity, with HRs for total CVD mortality in current versus never smokers of 1.92 (1.11–3.32) and 4.90 (3.79–6.34) for 4–6 and ≥ 25 cigarettes/day, respectively. Risks diminished with quitting, with excess risks largely avoided by quitting before age 45. Over one third of CVD deaths and one quarter of acute coronary syndrome hospitalisations in Australia aged < 65 can be attributed to smoking.

Conclusions. Current smoking increases the risk of virtually all CVD subtypes, at least doubling the risk of many, including AMI, cerebrovascular disease and heart failure. Paroxysmal tachycardia is a newly identified smoking-related risk. Where comparisons are possible, smoking-associated relative risks for fatal and non-fatal outcomes are similar. Quitting reduces the risk substantially. In an established smoking epidemic, with declining and low current smoking prevalence, smoking accounts for a substantial proportion of premature CVD events.

Electronic supplementary material. The online version of this article (10.1186/s12916-019-1351-4) contains supplementary material, which is available to authorized users.

References 40

  1. 1.
    Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016 · 2017
    No notice
  2. 2.
    Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016 · 2017
    No notice
  3. 3.

    Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328:1519.

    Not in our library10.1136/bmj.38142.554479.ae

  4. 4.

    Thun MJ, Carter BD, Feskanich D, Freedman ND, Prentice R, Lopez AD, Hartge P, Gapstur SM. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368:351-364.

    Not in our library10.1056/nejmsa1211127

  5. 5.

    Pirie K, Peto R, Reeves GK, Green J, Beral V, Million Women Study Collaborators. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-141.

    Not in our library10.1016/s0140-6736(12)61720-6

  6. 6.

    Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, Ockene JK, Prentice RL, Speizer FE, Thun MJ. Smoking and mortality—beyond established causes. N Engl J Med. 2015;372(7):631-640.

    Not in our library10.1056/nejmsa1407211

  7. 7.

    Pujades-Rodriguez M, George J, Shah AD, Rapsomaniki E, Denaxas S, West R, Smeeth L, Timmis A, Hemingway H. Heterogeneous associations between smoking and a wide range of initial presentations of cardiovascular disease in 1937360 people in England: lifetime risks and implications for risk prediction. Int J Epidemiol. 2015;44:129-141.

    Not in our library10.1093/ije/dyu218

  8. 8.

    United States Department of Health and Human Services: The health consequences of smoking—50 years of progress: a report of the surgeon general. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.

    Not in our library

  9. 9.

    Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet. 2011;378:1297-1305.

    Not in our library10.1016/s0140-6736(11)60781-2

  10. 10.

    Thun M, Peto R, Boreham J, Lopez AD. Stages of the cigarette epidemic on entering its second century. Tob Control. 2012;21(2):96-101.

    Not in our library10.1136/tobaccocontrol-2011-050294

  11. 11.

    Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4. 2016.

    Not in our library

  12. 12.

    Banks E, Redman S, Jorm L, Armstrong B, Bauman A, Beard J, Beral V, Byles J, Corbett S, Cumming R, et al. Cohort profile: the 45 and up study. Int J Epidemiol. 2008;37(5):941-947.

    Not in our library10.1093/ije/dym184

  13. 13.

    National Centre for Classification in Health. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM). 2017.

    Not in our library

  14. 14.

    Centre for Health Record Linkage (CHeReL) - Quality assurance. http://www.cherel.org.au/quality-assurance. Accessed 4 June 2019.

    Not in our library

  15. 15.

    Joshy G, Korda RJ, Abhayaratna WP, Soga K, Banks E. Categorising major cardiovascular disease hospitalisations from routinely collected data. Public Health Res Pract. 2015;25:e2531532.

    Not in our library10.17061/phrp2531532

  16. 16.
    Tobacco smoking and all-cause mortality in a large Australian cohort study: findings from a mature epidemic with current low smoking prevalence · 2015
    No notice
  17. 17.

    Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: a method based on the gamma distribution. Stat Med. 1997;16:791-801.

    Not in our library10.1002/(sici)1097-0258(19970415)16:7<791::aid-sim500>3.0.co;2-#

  18. 18.

    Stewart AL. Measuring functioning and well-being: the medical outcomes study approach. 1992.

    Not in our library

  19. 19.

    Australian Bureau of Statistics. National Health Survey: final results 2014–2015. 2015.

    Not in our library

  20. 20.

    Australian Bureau of Statistics. National Health Survey: summary of results, 2004-05. 2006.

    Not in our library

  21. 21.

    Kong KA, Jung-Choi K-H, Lim D, Lee HA, Lee WK, Baik SJ, Park SH, Park H. Comparison of prevalence- and smoking impact ratio-based methods of estimating smoking-attributable fractions of deaths. J Epidemiol. 2016;26(3):145-154.

    Not in our library10.2188/jea.je20150058

  22. 22.

    Tanuseputro P, Manuel DG, Schultz SE, Johansen H, Mustard CA. Improving population attributable fraction methods: examining smoking-attributable mortality for 87 geographic regions in Canada. Am J Epidemiol. 2005;161(8):787-798.

    Not in our library10.1093/aje/kwi093

  23. 23.

    General Record of Incidence of Mortality (GRIM) books. https://www.aihw.gov.au/reports/life-expectancy-death/grim-books/contents/general-record-of-incidence-of-mortality-grim-books. Accessed 4 June 2019.

    Not in our library

  24. 24.

    Australian Institute of Health and Welfare. Australia’s health 2016. 2016.

    Not in our library

  25. 25.
    Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports · 2018
    Corrected
  26. 26.
    Validity of Myocardial Infarction Diagnoses in Administrative Databases: A Systematic Review · 2014
    No notice
  27. 27.
    Accuracy of Electronic Health Record Data for Identifying Stroke Cases in Large-Scale Epidemiological Studies: A Systematic Review from the UK Biobank Stroke Outcomes Group · 2015
    No notice
  28. 28.
    Algorithms for enhancing public health utility of national causes-of-death data · 2010
    No notice
  29. 29.

    Goldenberg I, Moss AJ, McNitt S, Zareba W, Daubert JP, Hall WJ, Andrews ML, Multicenter Automatic Defibrillator Implantation Trial-II Investigators. Cigarette smoking and the risk of supraventricular and ventricular tachyarrhythmias in high-risk cardiac patients with implantable cardioverter defibrillators. J Cardiovasc Electrophysiol. 2006;17:931-936.

    Not in our library10.1111/j.1540-8167.2006.00526.x

  30. 30.

    Javaheri S, Shukla R, Wexler L. Association of smoking, sleep apnea, and plasma alkalosis with nocturnal ventricular arrhythmias in men with systolic heart failure. Chest. 2012;141:1449-1456.

    Not in our library10.1378/chest.11-1724

  31. 31.

    Engstrom G, Hedblad B, Janzon L, Juul-Moller S. Ventricular arrhythmias during 24-h ambulatory ECG recording: incidence, risk factors and prognosis in men with and without a history of cardiovascular disease. J Intern Med. 1999;246:363-372.

    Not in our library10.1046/j.1365-2796.1999.00509.x

  32. 32.

    Huikuri HV, Castellanos A, Myerburg RJ. Sudden death due to cardiac arrhythmias. N Engl J Med. 2001;345(20):1473-1482.

    Not in our library10.1056/nejmra000650

  33. 33.

    Coughlin S, Neaton J, Sengupta A, Kuller L. Predictors of mortality from idiopathic dilated cardiomyopathy in 356,222 men screened for the Multiple Risk Factor Intervention Trial. Am J Epidemiol. 1994;139:166-172.

    Not in our library10.1093/oxfordjournals.aje.a116978

  34. 34.

    Coughlin SS, Labenberg JR, Tefft MC. Black-white differences in idiopathic dilated cardiomyopathy: the Washington DC dilated Cardiomyopathy Study. Epidemiology. 1993;4:165-172.

    Not in our library10.1097/00001648-199303000-00013

  35. 35.

    Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson RN, McAfee T, Peto R. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013;368(4):341-350.

    Not in our library10.1056/nejmsa1211128

  36. 36.

    Teo KK, Ounpuu S, Hawken S, Pandey M, Valentin V, Hunt D, Diaz R, Rashed W, Freeman R, Jiang L. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:647-658.

    Not in our library10.1016/s0140-6736(06)69249-0

  37. 37.

    Price AJ, Wright FL, Green J, Balkwill A, Kan SW, Yang TO, Floud S, Kroll ME, Simpson R, Sudlow CL. Differences in risk factors for 3 types of stroke: UK prospective study and meta-analyses. Neurology. 2018;90(4):e298-e306.

    Not in our library10.1212/wnl.0000000000004856

  38. 38.
    Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs · 2010
    No notice
  39. 39.

    Rothman KJ, Gallacher JE, Hatch EE. Why representativeness should be avoided. Int J Epidemiol. 2013;42:1012-1014.

    Not in our library10.1093/ije/dys223

  40. 40.

    Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2016: detailed findings. 2017.

    Not in our library

Cited by papers we hold 3

Reads

Read by people on this page

None yet.

Checked or read by AI through naulon

None yet.

A person counts once a day per paper. We keep no cookie and no address: a reader is a hash that changes every day. Any month under five reads shows no number.

Are you an author?

Is this your paper?

Claim it to add your note and be paid when agents cite it. Free.