Ute Mons

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

Objective To investigate the impact of smoking and smoking cessation on cardiovascular mortality, acute coronary events, and stroke events in people aged 60 and older, and to calculate and report risk advancement periods for cardiovascular mortality in addition to traditional epidemiological relative risk measures. Design Individual participant meta-analysis using data from 25 cohorts participating in the CHANCES consortium. Data were harmonised, analysed separately employing Cox proportional hazard regression models, and combined by meta-analysis. Results Overall, 503?905 participants aged 60 and older were included in this study, of whom 37?952 died from cardiovascular disease. Random effects meta-analysis of the association of smoking status with cardiovascular mortality yielded a summary hazard ratio of 2.07 (95% CI 1.82 to 2.36) for current smokers and 1.37 (1.25 to 1.49) for former smokers compared with never smokers. Corresponding summary estimates for risk advancement periods were 5.50 years (4.25 to 6.75) for current smokers and 2.16 years (1.38 to 2.39) for former smokers. The excess risk in smokers increased with cigarette consumption in a dose-response manner, and decreased continuously with time since smoking cessation in former smokers. Relative risk estimates for acute coronary events and for stroke events were somewhat lower than for cardiovascular mortality, but patterns were similar. Conclusions Our study corroborates and expands evidence from previous studies in showing that smoking is a strong independent risk factor of cardiovascular events and mortality even at older age, advancing cardiovascular mortality by more than five years, and demonstrating that smoking cessation in these age groups is still beneficial in reducing the excess risk.

A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements

Objective To study the association of self-reported physical activity level with prognosis in a cohort of patients with coronary heart disease (CHD), with a special focus on the dose–response relationship with different levels of physical activity. Methods Data were drawn from a prospective cohort of 1038 subjects with stable CHD in which frequency of strenuous leisure time physical activity was assessed repeatedly over 10 years of follow-up. Multiple Cox proportional hazards regression models were used to assess the association of physical activity level with different outcomes of prognosis (major cardiovascular events, cardiovascular mortality, all-cause mortality), with different sets of adjustments for potential confounders and taking into account time-dependence of frequency of physical activity. Results A decline in engagement in physical activity over follow-up was observed. For all outcomes, the highest hazards were consistently found in the least active patient group, with a roughly twofold risk for major cardiovascular events and a roughly fourfold risk for both cardiovascular and all-cause mortality in comparison to the reference group of moderately frequent active patients. Furthermore, when taking time-dependence of physical activity into account, our data indicated reverse J-shaped associations of physical activity level with cardiovascular mortality, with the most frequently active patients also having increased hazards (2.36, 95% CI 1.05 to 5.34). Conclusions This study substantiated previous findings on the increased risks for adverse outcomes in physically inactive CHD patients. In addition, we also found evidence of increased cardiovascular mortality in patients with daily strenuous physical activity, which warrants further investigation.

Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) policy evaluation surveys.

AIMS To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support. DESIGN Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary). SETTINGS Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States. PARTICIPANTS Samples of smokers from 15 countries. MEASUREMENTS Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits. FINDINGS Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available. CONCLUSIONS There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

High-density lipoprotein cholesterol, coronary artery disease, and cardiovascular mortality

AIMS High-density lipoprotein (HDL) cholesterol is a strong predictor of cardiovascular mortality. This work aimed to investigate whether the presence of coronary artery disease (CAD) impacts on its predictive value. METHODS AND RESULTS We studied 3141 participants (2191 males, 950 females) of the LUdwigshafen RIsk and Cardiovascular health (LURIC) study. They had a mean ± standard deviation age of 62.6 ± 10.6 years, body mass index of 27.5 ± 4.1 kg/m², and HDL cholesterol of 38.9 ± 10.8 mg/dL. The cohort consisted of 699 people without CAD, 1515 patients with stable CAD, and 927 patients with unstable CAD. The participants were prospectively followed for cardiovascular mortality over a median (inter-quartile range) period of 9.9 (8.7-10.7) years. A total of 590 participants died from cardiovascular diseases. High-density lipoprotein cholesterol by tertiles was inversely related to cardiovascular mortality in the entire cohort (P = 0.009). There was significant interaction between HDL cholesterol and CAD in predicting the outcome (P = 0.007). In stratified analyses, HDL cholesterol was strongly associated with cardiovascular mortality in people without CAD [3rd vs. 1st tertile: HR (95% CI) = 0.37 (0.18-0.74), P = 0.005], but not in patients with stable [3rd vs. 1st tertile: HR (95% CI) = 0.81 (0.61-1.09), P = 0.159] and unstable [3rd vs. 1st tertile: HR (95% CI) = 0.91 (0.59-1.41), P = 0.675] CAD. These results were replicated by analyses in 3413 participants of the AtheroGene cohort and 5738 participants of the ESTHER cohort, and by a meta-analysis comprising all three cohorts. CONCLUSION The inverse relationship of HDL cholesterol with cardiovascular mortality is weakened in patients with CAD. The usefulness of considering HDL cholesterol for cardiovascular risk stratification seems limited in such patients.

Comprehensive smoke-free policies attract more support from smokers in Europe than partial policies

BACKGROUND Support for smoke-free policies increases over time and particularly after implementation of the policy. In this study we examined whether the comprehensiveness of such policies moderates the effect on support among smokers. METHODS We analysed two waves (pre- and post-smoke-free legislation) of the International Tobacco Control (ITC) surveys in France, Germany, and the Netherlands, and two pre-legislation waves of the ITC surveys in UK as control. Of 6,903 baseline smokers, 4,945 (71.6%) could be followed up and were included in the analyses. Generalised Estimating Equations (GEE) were used to compare changes in support from pre- to post-legislation to the secular trend in the control country. Multiple logistic regression models were employed to identify predictors of individual change in support. FINDINGS In France, the comprehensive smoking ban was associated with sharp increases in support for a total smoking ban in drinking establishments and restaurants that were above secular trends. In Germany and the Netherlands, where smoke-free policies and compliance are especially deficient in drinking establishments, only support for a total smoking ban in restaurants increased above the secular trend. Notable prospective predictors of becoming supportive of smoking bans in these countries were higher awareness of cigarette smoke being dangerous to others and weekly visiting of restaurants. CONCLUSIONS Our findings suggest that smoke-free policies have the potential to improve support once the policy is in place. This effect seems to be most pronounced with comprehensive smoking bans, which thus might be the most valid option for policy-makers despite their potential for creating controversy and resistance in the beginning.

Smoking-associated DNA methylation biomarkers and their predictive value for all-cause and cardiovascular mortality

Background With epigenome-wide mapping of DNA methylation, a number of novel smoking-associated loci have been identified. Objectives We aimed to assess dose–response relationships of methylation at the top hits from the epigenome-wide methylation studies with smoking exposure as well as with total and cause-specific mortality. Methods In a population-based prospective cohort study in Germany, methylation was quantified in baseline blood DNA of 1,000 older adults by the Illumina 450K assay. Deaths were recorded during a median follow-up of 10.3 years. Dose–response relationships of smoking exposure with methylation at nine CpGs were modeled by restricted cubic spline regression. Associations of individual and aggregate methylation patterns with all-cause, cardiovascular, and cancer mortality were assessed by multiple Cox regression. Results Clear dose–response relationships with respect to current and lifetime smoking intensity were consistently observed for methylation at six of the nine CpGs. Seven of the nine CpGs were also associated with mortality outcomes to various extents. A methylation score based on the top two CpGs (cg05575921 and cg06126421) showed the strongest associations with all-cause, cardiovascular, and cancer mortality, with adjusted hazard ratios (95% CI) of 3.59 (2.10, 6.16), 7.41 (2.81, 19.54), and 2.48 (1.01, 6.08), respectively, for participants with methylation levels in the lowest quartile at both CpGs. Adding methylation at those two CpGs into a model that included the variables of the Systematic Coronary Risk Evaluation chart for fatal cardiovascular risk prediction improved the predictive discrimination. Conclusion The novel methylation biomarkers are highly informative for both smoking exposure and smoking-related mortality outcomes. In particular, these biomarkers may substantially improve cardiovascular risk prediction. Nevertheless, the findings of the present study need to be further validated in additional large longitudinal studies. Citation Zhang Y, Schöttker B, Florath I, Stock C, Butterbach K, Holleczek B, Mons U, Brenner H. 2016. Smoking-associated DNA methylation biomarkers and their predictive value for all-cause and cardiovascular mortality. Environ Health Perspect 124:67–74; http://dx.doi.org/10.1289/ehp.1409020

Air Contamination Due to Smoking in German Restaurants, Bars, and Other Venues—Before and After the Implementation of a Partial Smoking Ban

INTRODUCTION The present study examined the reduction in exposure to tobacco smoke in German hospitality venues following the implementation of a partial smoking ban by measuring the indoor air concentration of PM(2.5) in 2005 and 2009, that is, before and after the legislation was implemented. METHODS The concentration of respirable suspended particles (PM(2.5)) in the indoor air of German hospitality venues was measured using a laser photometer (AM510). The prelegislation sample from 2005 included 80 venues of which 58 could be revisited in 2009. After replenishment, the postlegislation sample consisted of 79 venues. RESULTS Compared with the prelegislation measurement, the concentration of PM(2.5) in hospitality venues was reduced significantly after introduction of the smoke-free legislation. The median mass concentration of PM(2.5) was reduced by 87.1% in coffee bars, by 88.7% in restaurants, by 66.3% in bars, and by 90.8% in discotheques. Notably, legal exemptions to the smoking ban are an issue: At the postlegislation measurement in 2009, the mass concentrations of PM(2.5) were substantially higher in venues allowing smoking in the whole venue or in a designated smoking room than in completely smoke-free venues. CONCLUSIONS The German smoke-free legislation significantly reduced the levels of respirable suspended particles in the indoor air of hospitality venues, benefiting the health of employees and patrons alike. But legal exemptions attenuated the effectiveness of the policy.

Socioeconomic and country variations in cross-border cigarette purchasing as tobacco tax avoidance strategy. Findings from the ITC Europe Surveys

Background Legal tobacco tax avoidance strategies such as cross-border cigarette purchasing may attenuate the impact of tax increases on tobacco consumption. Little is known about socioeconomic and country variations in cross-border purchasing. Objective To describe socioeconomic and country variations in cross-border cigarette purchasing in six European countries. Methods Cross-sectional data from adult smokers (n=7873) from the International Tobacco Control (ITC) Surveys in France (2006/2007), Germany (2007), Ireland (2006), The Netherlands (2008), Scotland (2006) and the rest of the UK (2007/2008) were used. Respondents were asked whether they had bought cigarettes outside their country in the last 6 months and how often. Findings In French and German provinces/states bordering countries with lower cigarette prices, 24% and 13% of smokers, respectively, reported purchasing cigarettes frequently outside their country. In non-border regions of France and Germany, and in Ireland, Scotland, the rest of the UK and The Netherlands, frequent purchasing of cigarettes outside the country was reported by 2–7% of smokers. Smokers with higher levels of education or income, younger smokers, daily smokers, heavier smokers and smokers not planning to quit smoking were more likely to purchase cigarettes outside their country. Conclusions Cross-border cigarette purchasing is more common in European regions bordering countries with lower cigarette prices and is more often reported by smokers with higher education and income. Increasing taxes in countries with lower cigarette prices, and reducing the number of cigarettes that can be legally imported across borders could help to avoid cross-border purchasing.

Germany SimSmoke: The Effect of Tobacco Control Policies on Future Smoking Prevalence and Smoking-Attributable Deaths in Germany

INTRODUCTION Although Germany has recently implemented some tobacco control policies, there is considerable scope to strengthen policies consistent with the MPOWER guidelines. This article describes the development of a simulation model projecting the effect of future tobacco control policies in Germany on smoking prevalence and associated premature mortality. METHODS Germany SimSmoke-an adapted version of the SimSmoke simulation model of tobacco control policy-uses population, smoking rates, and policy data for Germany. It assesses, individually and in combination, the effect of seven types of policies: taxes, smoke-free air laws, mass media campaigns, advertising bans, warning labels, cessation treatment, and youth access policies. RESULTS With a comprehensive set of policies, smoking prevalence within the first few years can be reduced by about 22.0% relative to the status quo and by 37.9% (40.5%) for males (females) in 30 years. By 2040, 39,548 deaths could be averted in that year alone. Without stronger policies, 700,000 additional smoking-attributable deaths (SADs) would occur in Germany over the next 30 years. CONCLUSIONS The model indicates that the consequences of inaction are considerable; without the implementation of a stronger set of policies, smoking prevalence rates will remain relatively stable, and SADs among women will continue to rise over a 30-year horizon. Significant inroads into reducing smoking prevalence and premature mortality can be achieved through strengthening tobacco control policies in line with MPOWER recommendations.

Smoking and All-cause Mortality in Older Adults: Results From the CHANCES Consortium

INTRODUCTION Smoking is known to be a major cause of death among middle-aged adults, but evidence on its impact and the benefits of smoking cessation among older adults has remained limited. Therefore, we aimed to estimate the influence of smoking and smoking cessation on all-cause mortality in people aged ≥60 years. METHODS Relative mortality and mortality rate advancement periods (RAPs) were estimated by Cox proportional hazards models for the population-based prospective cohort studies from Europe and the U.S. (CHANCES [Consortium on Health and Ageing: Network of Cohorts in Europe and the U.S.]), and subsequently pooled by individual participant meta-analysis. Statistical analyses were performed from June 2013 to March 2014. RESULTS A total of 489,056 participants aged ≥60 years at baseline from 22 population-based cohort studies were included. Overall, 99,298 deaths were recorded. Current smokers had 2-fold and former smokers had 1.3-fold increased mortality compared with never smokers. These increases in mortality translated to RAPs of 6.4 (95% CI=4.8, 7.9) and 2.4 (95% CI=1.5, 3.4) years, respectively. A clear positive dose-response relationship was observed between number of currently smoked cigarettes and mortality. For former smokers, excess mortality and RAPs decreased with time since cessation, with RAPs of 3.9 (95% CI=3.0, 4.7), 2.7 (95% CI=1.8, 3.6), and 0.7 (95% CI=0.2, 1.1) for those who had quit <10, 10 to 19, and ≥20 years ago, respectively. CONCLUSIONS Smoking remains as a strong risk factor for premature mortality in older individuals and cessation remains beneficial even at advanced ages. Efforts to support smoking abstinence at all ages should be a public health priority.