The risk and burden of smoking related heart disease mortality among young people in the United States
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Graduate group in Epidemiology, University of California, Davis, USA
National Human Genome Research Institute, Genomics of Metabolic, Cardiovascular and Inflammatory Disease Branch, Social Epidemiology Research Unit, Bethesda, USA
Program in International and Community Nutrition, University of California, Davis, USA
Department of Public Health Sciences, University of California, Davis, USA
Submission date: 2015-04-07
Acceptance date: 2015-06-12
Publication date: 2015-07-03
Corresponding author
Rumana J. Khan   

Graduate group in Epidemiology, University of California, 5215 VM3A, One Shields Avenue, Davis, CA 95616, USA
Tobacco Induced Diseases 2015;13(July):16
Although cigarette smoking remains the most common risk factor for heart disease among the young, few studies have explored the relationship of smoking with heart disease mortality risk among young people. This prospective study assesses the risk and burden of all heart disease (HD) and coronary heart disease (CHD) mortality associated with smoking among younger adults from a nationally representative sample of the United States.

National Health Interview Survey respondents’ data from 1997–2004 were linked to their death records through 2006. The analyses were restricted to individuals 18 to 44 years of age during follow up (n = 121,284). Cox proportional hazard ratios (HR) were estimated with adjustment for sample weights and design effects. Attributable fractions (AF) of smoking were calculated.

After controlling for age, race, body mass index, history of hypertension and diabetes, and leisure time physical activity, current smoking related CHD mortality HR was 14.6 [95 % confidence interval or CI, 3.3–64.9] for females and 3.6 [95 % CI, 1.2–10.4] for males. The HR for all HD mortality was 3.1 [95 % CI, 1.3–7.6] for females and 2.4 [95 % CI, 1.2–4.7] for males. The AF of smoking for CHD deaths for female and male were 0.58 and 0.54 respectively. The AF of all HD mortality was 0.31 for male and 0.32 for female. The mean estimates of all HD deaths attributable to smoking during 1997–2006 among this age group were 52,214, of which 45,147 were CHD deaths.

Even after adjustment for multiple risk factors and without addressing passive smoking, our result showed a strong relationship between smoking and HD and CHD mortality among young adults that is likely causal.

Powers AR, Struempler BJ, Guarino A, Parmer SM. Effects of a nutrition education program on the dietary behavior and nutrition knowledge of second-grade and third-grade students. J Sch Health. 2005;75(4):129–33.
Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121(7):e46–215.
Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933–44.
Cole JH, Miller 3rd JI, Sperling LS, Weintraub WS. Long-term follow-up of coronary artery disease presenting in young adults. J Am Coll Cardiol. 2003;41(4):521–8.
Barbash GI, White HD, Modan M, Diaz R, Hampton JR, Heikkila J, et al. Acute myocardial infarction in the young–the role of smoking: The investigators of the international tissue plasminogen activator/streptokinase mortality trial. Eur Heart J. 1995;16(3):313–6.
Chen L, Chester M, Kaski JC. Clinical factors and angiographic features associated with premature coronary artery disease. Chest. 1995;108(2):364–9.
Zimmerman FH, Cameron A, Fisher LD, Ng G. Myocardial infarction in young adults: angiographic characterization, risk factors and prognosis (Coronary Artery Surgery Study Registry). J Am Coll Cardiol. 1995;26(3):654–61.
Hbejan K. Smoking effect on ischemic heart disease in young patients. Heart Views. 2011;12(1):1–6.
Panagiotakos DB, Rallidis LS, Pitsavos C, Stefanadis C, Kremastinos D. Cigarette smoking and myocardial infarction in young men and women: a case–control study. Int J Cardiol. 2007;116(3):371–5.
Oliveira A, Barros H, Maciel MJ, Lopes C. Tobacco smoking and acute myocardial infarction in young adults: a population-based case–control study. Prev Med. 2007;44(4):311–6.
Parish S, Collins R, Peto R, Youngman L, Barton J, Jayne K, et al. Cigarette smoking, tar yields, and non-fatal myocardial infarction: 14,000 cases and 32,000 controls in the United Kingdom. The International Studies of Infarct Survival (ISIS) Collaborators. BMJ. 1995;311(7003):471–7.
Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ. 1998;316(7137):1043–7.
Design and estimation for the National Health Interview Survey, 1995–2004. Vital Health Stat 2. 2000(130):1–31.
The principal source of information on the health of the U.S. population, National Health Interview Survey, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics,
Questionnaires, Datasets, and Related Documentation 1997 to the Present, National Health Interview Survey, Centers for Disease Control and Prevention,
Lochner K, Hummer RA, Bartee S, Wheatcroft G, Cox C: The public-use National Health Interview Survey linked mortality files: methods of reidentification risk avoidance and comparative analysis. Am J Epidemiol, 2008; 168(3):336-344.
The National Health Interview Survey 1986 – 2004 Linked Mortality Files, Public-use File Layout. 2010; Accessed 15 May, 2011.
National Health Interview Survey: research for the 1995–2004 redesign. Vital Health Stat 2. 1999(126):1–119.
National Health Interview Survey (1986--2004) Linked Mortality Files, Analytic guidelines. 2010;
Walter SD. The estimation and interpretation of attributable risk in health research. Biometrics. 1976;32(4):829–49.
Pleis JR, Ward BW, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2009. Vital and health statistics, Data from the National Health Survey. 249th ed. 2010.
Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1979–1998: CDC WONDER On-line Database, compiled from Compressed Mortality File CMF 1968–1988. 2003. 15 September 2011.
Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999–2007: CDC WONDER On-line Database, compiled from Compressed Mortality File 1999–2007. 2010. 15 September 2011.
Akbartabartoori M, Lean ME, Hankey CR. Relationships between cigarette smoking, body size and body shape. Int J Obes (Lond). 2005;29(2):236–43.
Williams MJ, Restieaux NJ, Low CJ. Myocardial infarction in young people with normal coronary arteries. Heart. 1998;79(2):191–4.
Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med. 1999;107(3):254–61.
Vriz O, Nesbitt S, Krause L, Majahalme S, Lu H, Julius S. Smoking is associated with higher cardiovascular risk in young women than in men: the Tecumseh Blood Pressure Study. J Hypertens. 1997;15(2):127–34.
Houterman S, Verschuren WM, Kromhout D. Smoking, blood pressure and serum cholesterol-effects on 20-year mortality. Epidemiology. 2003;14(1):24–9.
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;378:1297–305.
Lantz PM. Smoking on the rise among young adults: implications for research and policy. Tobac Contr. 2003;12 Suppl 1:i60–70.
Nelson DE, Mowery P, Asman K, Pederson LL, O'Malley PM, Malarcher A, et al. Long-term trends in adolescent and young adult smoking in the United States: metapatterns and implications. Am J Publ Health. 2008;98(5):905–15.
Schoenborn CA, Adams PE. Health behaviors of adults: United States, 2005–2007. Vital and health statistics Series 10, Data from the National Health Survey. 2010;245):1–132.
Baron JA, La Vecchia C, Levi F. The antiestrogenic effect of cigarette smoking in women. Am J Obstet Gynecol. 1990;162(2):502–14.
Michnovicz JJ, Hershcopf RJ, Naganuma H, Bradlow HL, Fishman J. Increased 2-hydroxylation of estradiol as a possible mechanism for the anti-estrogenic effect of cigarette smoking. N Engl J Med. 1986;315(21):1305–9.
Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731–7.
Miller VT, Muesing RA, LaRosa JC, Stoy DB, Phillips EA, Stillman RJ. Effects of conjugated equine estrogen with and without three different progestogens on lipoproteins, high-density lipoprotein subfractions, and apolipoprotein A-I. Obstet Gynecol. 1991;77(2):235–40.
Kim SG, Apple S, Mintz GS, McMillan T, Canos DA, Maehara A, et al. The importance of gender on coronary artery size: in-vivo assessment by intravascular ultrasound. Clin Cardiol. 2004;27(5):291–4.
Gaemperli O, Liga R, Bhamra-Ariza P, Rimoldi O. Nicotine addiction and coronary artery disease: impact of cessation interventions. Curr Pharm Des. 2010;16(23):2586–97.
Kannel WB. Overview of hemostatic factors involved in atherosclerotic cardiovascular disease. Lipids. 2005;40(12):1215–20.
Alter DA, Naylor CD, Austin PC, Tu JV. Biology or bias: practice patterns and long-term outcomes for men and women with acute myocardial infarction. J Am Coll Cardiol. 2002;39(12):1909–16.
Howe M, Leidal A, Montgomery D, Jackson E. Role of cigarette smoking and gender in acute coronary syndrome events. Am J Cardiol. 2011;108(10)):1382–-6.
Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation. 1997;96(4):1089–96.
Sato I, Nishida M, Okita K, Nishijima H, Kojima S, Matsumura N, et al. Beneficial effect of stopping smoking on future cardiac events in male smokers with previous myocardial infarction. Jpn Circ J. 1992;56(3):217–22.
Gordon T, Kannel WB, McGee D, Dawber TR. Death and coronary attacks in men after giving up cigarette smoking: A report from the Framingham study. Lancet. 1974;2(7893):1345–8.
Dobson AJ, Alexander HM, Heller RF, Lloyd DM. How soon after quitting smoking does risk of heart attack decline? J Clin Epidemiol. 1991;44(11):1247–53.
Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease. JAMA. 2003;290(1):86–97.
Kenfield SA, Wei EK, Rosner BA, Glynn RJ, Stampfer MJ, Colditz GA. Burden of smoking on cause-specific mortality: application to the Nurses’ Health Study. Tobac Contr. 2010;19(3):248–54.
Panagiotakos DB, Chrysohoou C, Pitsavos C, Papaioannou I, Skoumas J, Stefanadis C, et al. The association between secondhand smoke and the risk of developing acute coronary syndromes, among non-smokers, under the presence of several cardiovascular risk factors: The CARDIO2000 case–control study. BMC Publ Health. 2002;2:9.
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