Secondhand Smoke Exposure Predicted COPD and Other Tobacco-Related Mortality in a 17-Year Cohort Study in China

doi:10.1378/chest.11-2884

Chest

Volume 142, Issue 4, October 2012, Pages 909-918

https://doi.org/10.1378/chest.11-2884 Get rights and content

Background

Prospective evidence on the association between secondhand smoke (SHS) and COPD and ischemic stroke is scarce.

Methods

We prospectively examined the relationship between SHS and major tobacco-related deaths, particularly COPD and stroke, in 910 Chinese (439 men, 471 women) who never smoked from a 17-year follow-up study in Xi'an, China. SHS exposure was defined as exposure to another person's tobacco smoke at home or in the workplace.

Results

At baseline among the 910 subjects, 44.2% were exposed to SHS at home, 52.9% in the workplace, and 67.1% at home, work, or both. From March 1, 1994, to July 1, 2011, 249 (150 men, 99 women) died within 14,016 person-years. Those who were exposed to SHS had increased mortality due to coronary heart disease (adjusted relative risk [RR], 2.15; 95% CI, 1.00-4.61), ischemic stroke (RR, 2.88; 95% CI, 1.10-7.55), lung cancer (RR, 2.00; 95% CI, 0.62-6.40), COPD (RR, 2.30; 95% CI, 1.06-5.00), and all causes (RR, 1.72; 95% CI, 1.29-2.20), with significant dose-response relationships between cumulative SHS exposure at home and work and the increased risk of cause-specific and total mortality (P for linear trend ranged from .045 to <.001).

Conclusions

This study shows dose-response relationships between SHS and major tobacco-related mortality and provides new evidence to support causation for COPD and ischemic stroke.

Section snippets

Setting, Screening, and Follow-up

Details of the methods were described previously for a 20-year follow-up study that showed that smoking was a major risk factor for total mortality.¹⁷ Briefly, from March to May 1976, a cross-sectional survey on risk factors and prevalence of CHD was carried out in a machinery factory in Xi'an. We included 1,696 people (1,124 men, 572 women) who had data on birth month and year, sex, marital status, education level, occupation, systolic and diastolic BP, serum cholesterol and triglyceride

Results

The date of entry of all subjects was set at March 1, 1994. Up to July 1, 2011, of the 910 subjects (439 men, 471 women), 661 (289 men, 372 women) were alive, and 249 (150 men, 99 women) died. In 1994, the mean ± SD age was 60.3 ± 5.2 years (range, 51.5-87.8 years). The number of person-years of follow-up was 14,016, and the mean duration was 15.4 years (range, 0.12-17.33 years).

A total of 44.2% (28.9% male, 58.4% female) of subjects were exposed to SHS at home, 52.9% (55.8% men, 50.1% women)

Discussion

China is the largest producer and consumer of tobacco in the world. About one-third of the world's cigarettes were consumed by China's 301 million current smokers in 2010.²³ The prevalence figures of active and passive smoking at baseline in 1994 were quite similar to those in the 1996 National Prevalence Survey, which showed that prevalence of smoking was 66.9% in men and 4.2% in women (56.2% and 12.4%, respectively, in the present cohort), and among nonsmokers, 53.5% reported exposure to

Acknowledgments

Author contributions: Drs Y. He and Lam had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Y. He: contributed to the study design, data collection and field operations, data analysis, and preparation of the manuscript.

Dr Jiang: contributed to the data collection and field operations and preparation of the manuscript.

Dr Liang Shou Li: contributed to the study design, data analysis, and preparation of the

References (32)

H Sezer et al.
A case-control study on the effect of exposure to different substances on the development of COPD
Ann Epidemiol
(2006)
P Yin et al.
Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study
Lancet
(2007)
GH Yang et al.
Findings from 2010 Global Adult Tobacco Survey: implementation of MPOWER policy in China
Biomed Environ Sci
(2010)
US Department of Health and Human Services
The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General
(2006)
US Department of Health and Human Services
How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General
(2010)
C Iribarren et al.
Cohort study of exposure to environmental tobacco smoke and risk of first ischemic stroke and transient ischemic attack
Neuroepidemiology
(2004)
CS Anderson et al.
Active and passive smoking and the risk of subarachnoid hemorrhage: an international population-based case-control study
Stroke
(2004)
PH Whincup et al.
Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement
BMJ
(2004)
AI Qureshi et al.
Cigarette smoking among spouses: another risk factor for stroke in women
Stroke
(2005)
X Zhang et al.
Association of passive smoking by husbands with prevalence of stroke among Chinese women nonsmokers
Am J Epidemiol
(2005)

SM McGhee et al.

Mortality associated with passive smoking in Hong Kong

BMJ

(2005)

W Wen et al.

Environmental tobacco smoke and mortality in Chinese women who have never smoked: prospective cohort study

BMJ

(2006)

Y He et al.

Passive smoking and risk of peripheral arterial disease and ischemic stroke in Chinese women who never smoked

Circulation

(2008)

P Vineis et al.

Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study

BMJ

(2005)

MD Eisner et al.

Lifetime environmental tobacco smoke exposure and the risk of chronic obstructive pulmonary disease

Environ Health

(2005)

SK Jindal et al.

A multicentric study on epidemiology of chronic obstructive pulmonary disease and its relationship with tobacco smoking and environmental tobacco smoke exposure

Indian J Chest Dis Allied Sci

(2006)

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Chronic obstructive pulmonary disease in never-smokers: risk factors, pathogenesis, and implications for prevention and treatment
2022, The Lancet Respiratory Medicine
Citation Excerpt :
Heavy maternal smoking (>20 cigarettes per day) during childhood increased the risk of airflow obstruction in middle-aged adults (OR 2·7, 95% CI 1·3–5·7).120 In a study of 910 never-smokers in China, environmental tobacco smoke exposure was associated with increased mortality due to COPD (RR 2·3, 95% CI 1·1–5·0), as well as coronary artery disease, stroke, lung cancer, and all causes.121 A genome-wide study using three Dutch and Swiss cohorts reported a number of interactions between environmental tobacco smoke exposure and single-nucleotide polymorphisms linked to pathways involving apoptosis, p38 mitogen-activated protein kinase (MAPK) activation, and tumour necrosis factor (TNF), indicating the potential contribution of genetic factors to lung injury responses leading to COPD in people who have never smoked.49
Chronic obstructive pulmonary disease (COPD) was traditionally thought to be caused by tobacco smoking. However, recognition of the importance of non-smoking-related risk factors for COPD has increased over the past decade, with evidence on the burden, risk factors, and clinical presentations of COPD in never-smokers. About half of all COPD cases worldwide are due to non-tobacco-related risk factors, which vary by geographical region. These factors include air pollution, occupational exposures, poorly controlled asthma, environmental tobacco smoke, infectious diseases, and low socioeconomic status. Impaired lung growth during childhood, caused by a range of early-life exposures, is associated with an increased risk of COPD. Potential mechanisms for the pathogenesis of COPD in never-smokers include inflammation, oxidative stress, airway remodelling, and accelerated lung ageing. Compared with smokers who develop COPD, never-smokers with COPD have relatively mild chronic respiratory symptoms, little or no emphysema, milder airflow limitation, and fewer comorbidities; however, exacerbations can still be frequent. Further research—including epidemiological, translational, clinical, and implementation studies—is needed to address gaps in understanding and to advance potential solutions to reduce the burden of COPD in never-smokers.
Burden of disease from second-hand tobacco smoke exposure at home among adults from European Union countries in 2017: an analysis using a review of recent meta-analyses
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Smoke-free legislation reduced second-hand smoke (SHS) exposure in public places, and indirectly promoted private smoke-free settings. Nevertheless, a large proportion of adults is still exposed to SHS at home. The aim of this paper is to quantify the burden of disease due to home SHS exposure among adults in the 28-European Union (EU) countries for year 2017.
The burdens by gender from lung cancer, chronic obstructive pulmonary disease (COPD), breast cancer, ischemic heart disease (IHD), stroke, asthma, and diabetes were estimated in an original research analysis using the comparative risk assessment method. Relative risks of death/diseases by gender for adults exposed to SHS at home compared to not exposed ones were estimated updating existing meta-analyses. Prevalence of home SHS exposure by gender was estimated using a multiple imputation procedure based on Eurobarometer surveys. Data on mortality and disability adjusted life years (DALYs) were obtained from the Global Burden of Disease, Injuries and Risk Factors Study.
In 2017, 526,000 DALYs (0.36% of total DALYs) and 24,000 deaths (0.46% of total deaths) were attributable to home SHS exposure in the 28-EU countries, mainly from COPD and IHD. South-Eastern EU countries showed the highest burden, with proportion of DALYs/deaths attributable to SHS exposure on total higher than 0.50%/0.70%, whereas northern EU-countries showed the lowest burden, with proportions of DALYs/deaths lower than 0.25%/0.34%.
The burden from SHS exposure is still significant in EU countries. More could be done to raise awareness of the health risks associated with SHS exposure at home.
Environmental tobacco smoke and cancer risk, a prospective cohort study in a Chinese population
2020, Environmental Research
Few prospective cohort studies have investigated associations between environmental tobacco smoke (ETS) and other cancer sites, in addition to lung cancer. We assessed these associations in a population-based prospective cohort study started from 2008 to 2011 with average of 9.1 years of follow-up, in Minhang district, Shanghai, China. The study included a total of 23,415 participants (8388 men, 15,027 women) and 205,515 person-years. Epidemiological data were collected by a standardized questionnaire including ETS exposure. Newly diagnosed patients with primary cancers and deaths were identified by record linkage system with the Shanghai Cancer Registry and Shanghai Vital Statistics. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were estimated using Cox proportional hazards regression models, adjusting for potential confounders. During the study period, a total of 1462 patients with diagnoses of primary cancers were identified. Among all participants and non-smokers, ETS was associated with an increased risk of all smoking-related cancers (all: adjusted HR: 1.23, 95% CI: 1.05–1.43 and non-smokers: 1.24, 1.02–1.49), lung cancer (1.29, 0.98–1.71 and 1.27, 0.91–1.77), and stomach cancer (1.86, 1.21–2.85 and 1.75, 1.05–2.91), respectively. Furthermore, associations for lung and stomach cancers were the strongest among non-smoking females. The joint effects of both ETS and active smoking were strongest for all cancers, all smoking-related cancers, lung cancer, and stomach cancer. No clear interactions were observed. These results suggest that ETS exposure may increase the risk of smoking-related cancers in a Chinese population. Further studies on the relationship between ETS exposure and specific cancer sites are warranted to replicate our findings.
Neighborhood greenness associated with chronic obstructive pulmonary disease: A nationwide cross-sectional study in China
2020, Environment International
Differential findings have been reported on the association between neighborhood greenness and chronic obstructive pulmonary disease (COPD). The underlying reasons might be the different types of vegetation and the diagnosis methods used in different studies. In this nationwide cross-sectional study in China, we examined the linkage between neighborhood greenness and COPD prevalence among 66,752 adults aged 40 years and above. Neighborhood greenness was estimated using the normalized difference vegetation index (NDVI) based on satellite imagery within buffers of 100, 300, 500, 1000, 2000, 3000 and 5000 m of residential community of the participants. COPD was defined according to the 2017 Global Initiative for Chronic Obstructive Lung Disease lung function criteria. A two-level logistic regression model was applied to estimate the associations. Finally, 9134 adults were classified as COPD. We observed significant positive associations between neighborhood greenness and COPD prevalence. The odds ratio for each interquartile range increase in NDVI within 100 m buffer was 1.08 (95% CI: 1.01, 1.15) after adjustment for potential confounders. Consistent associations were observed across all other NDVI buffer sizes. Stratified analyses revealed that younger adults (40–65 years) and urban residents might be the vulnerable subpopulations. Further regional analyses found that residents from the Northeastern and Northern China were more likely to have this association. Our results indicated that neighborhood greenness might be one risk factor of COPD prevalence. Our study have important public health implications for allocating the surrounding green spaces among living areas, especially for those with respiratory illness; however, the findings and the underlying mechanisms warrant further examinations in longitudinal settings.
Improving the Management of COPD in Women
2017, Chest
COPD is a highly debilitating disease that represents a substantial and growing health burden in women. There is increasing evidence for sex-related differences in COPD risk, progression, and outcomes. However, the disease receives scant attention as a women’s health issue. Thus, a multifaceted approach is required to address COPD in women, including greater awareness, minimization of risk, and further elucidation of the sex-specific factors (biological and cultural) that affect risk, disease progression, and treatment success. This article reviews the current literature on the topic and provides suggestions for achieving better outcomes for the millions of women with COPD worldwide.
Environmental Tobacco Smoke Exposure and Risk of Stroke in Never Smokers: An Updated Review with Meta-Analysis
2017, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Exceptionally, the estimate of 1.54 (.68-3.47) adjusted for age and 15 variables from the Whincup et al study20 is substantially greater than the estimate of .96 (.49-1.89) adjusted only for age and region. Three studies24,28,31 provided RRs for workplace exposure. One of these31 reported a significantly raised RR (2.34, 95% CI: 1.15-4.76) for all types of stroke, whereas all other estimates were nonsignificant, including dose–response RRs of .47, .95, and .74 corresponding to 1-9, 10-24, and 25+ years of exposure, respectively.24
The study aimed to review the epidemiological evidence relating environmental tobacco smoke exposure to stroke in never smokers.
The study is similar to our review in 2006, with searches extended to March 2016.
Twelve further studies were identified. A total of 28 studies varied considerably in design, exposure indices used, and disease definition. Based on 39 sex-specific estimates and the exposure index current spousal exposure (or nearest equivalent), the meta-analysis gave an overall fixed-effect relative risk estimate of 1.23 (95% confidence interval: 1.16-1.31), with significant (P < .05) heterogeneity. There was no significant heterogeneity by sex, continent, fatality, disease end point, or degree of adjustment for potential confounding factors. Relative risks were less elevated in prospective studies (1.15, 1.06-1.24) than in case-control studies (1.44, 1.22-1.60) or cross-sectional studies (1.40, 1.21-1.61). They also varied by publication year, but with no trend. A significant increase was not seen in studies that excluded smokers of any tobacco (1.07, .97-1.17), but was seen for studies that included pipe- or cigar-only smokers, occasional smokers, or long-term former smokers. No elevation was seen for hemorrhagic stroke. Relative risk estimates were similar using ever rather than current exposure, or total rather than spousal exposure. Eleven studies provided dose–response estimates, the combined relative risk for the highest exposure level being 1.56 (1.37-1.79). Many studies have evident weaknesses, recall bias, and particularly publication bias being major concerns.
Although other reviewers inferred a causal relationship, we consider the evidence does not conclusively demonstrate this. We repeat our call for publication of data from existing large prospective studies.

View all citing articles on Scopus

Drs Y. He and Jiang contributed equally to this work.

Funding/Support: This study was supported by research grants from the National Natural Science Foundation of China [81072355], Ministry of Science and Technology of China [2009BAI86B01], and National Department Public Benefit Research Foundation by Ministry of Health of China [201002011]. Dr Y. He was partly supported by the Sun Yat-Sen, Gordon Wu, and Cheng Yu Tung Exchange Professorships in the Li Ka Shing Faculty of Medicine and Sino-British Fellowship Trust at the University of Hong Kong.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Chest

Original ResearchCOPDSecondhand Smoke Exposure Predicted COPD and Other Tobacco-Related Mortality in a 17-Year Cohort Study in China

Background

Methods

Results

Conclusions

Section snippets

Setting, Screening, and Follow-up

Results

Discussion

Acknowledgments

Ann Epidemiol

Lancet

Biomed Environ Sci

The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General

How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General

Cohort study of exposure to environmental tobacco smoke and risk of first ischemic stroke and transient ischemic attack

Neuroepidemiology

Active and passive smoking and the risk of subarachnoid hemorrhage: an international population-based case-control study

Stroke

Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement

BMJ

Cigarette smoking among spouses: another risk factor for stroke in women

Stroke

Association of passive smoking by husbands with prevalence of stroke among Chinese women nonsmokers

Am J Epidemiol

Mortality associated with passive smoking in Hong Kong

BMJ

Environmental tobacco smoke and mortality in Chinese women who have never smoked: prospective cohort study

BMJ

Passive smoking and risk of peripheral arterial disease and ischemic stroke in Chinese women who never smoked

Circulation

Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study

BMJ

Lifetime environmental tobacco smoke exposure and the risk of chronic obstructive pulmonary disease

Environ Health

A multicentric study on epidemiology of chronic obstructive pulmonary disease and its relationship with tobacco smoking and environmental tobacco smoke exposure

Indian J Chest Dis Allied Sci

Original Research
COPD
Secondhand Smoke Exposure Predicted COPD and Other Tobacco-Related Mortality in a 17-Year Cohort Study in China