Alcohol and mortality in Russia: prospective observational study of 151,000 adults.

BACKGROUND: Russian adults have extraordinarily high rates of premature death. Retrospective enquiries to the families of about 50,000 deceased Russians had found excess vodka use among those dying from external causes (accident, suicide, violence) and eight particular disease groupings. We now seek prospective evidence of these associations. METHODS: In three Russian cities (Barnaul, Byisk, and Tomsk), we interviewed 200,000 adults during 1999-2008 (with 12,000 re-interviewed some years later) and followed them until 2010 for cause-specific mortality. In 151,000 with no previous disease and some follow-up at ages 35-74 years, Poisson regression (adjusted for age at risk, amount smoked, education, and city) was used to calculate the relative risks associating vodka consumption with mortality. We have combined these relative risks with age-specific death rates to get 20-year absolute risks. FINDINGS: Among 57,361 male smokers with no previous disease, the estimated 20-year risks of death at ages 35-54 years were 16% (95% CI 15-17) for those who reported consuming less than a bottle of vodka per week at baseline, 20% (18-22) for those consuming 1-2·9 bottles per week, and 35% (31-39) for those consuming three or more bottles per week; trend p<0·0001. The corresponding risks of death at ages 55-74 years were 50% (48-52) for those who reported consuming less than a bottle of vodka per week at baseline, 54% (51-57) for those consuming 1-2·9 bottles per week, and 64% (59-69) for those consuming three or more bottles per week; trend p<0·0001. In both age ranges most of the excess mortality in heavier drinkers was from external causes or the eight disease groupings strongly associated with alcohol in the retrospective enquiries. Self-reported drinking fluctuated; of the men who reported drinking three or more bottles of vodka per week who were reinterviewed a few years later, about half (185 of 321) then reported drinking less than one bottle per week. Such fluctuations must have substantially attenuated the apparent hazards of heavy drinking in this study, yet self-reported vodka use at baseline still strongly predicted risk. Among male non-smokers and among females, self-reported heavy drinking was uncommon, but seemed to involve similar absolute excess risks. INTERPRETATION: This large prospective study strongly reinforces other evidence that vodka is a major cause of the high risk of premature death in Russian adults. FUNDING: UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union, WHO International Agency for Research on Cancer.

Stages of the cigarette epidemic on entering its second century.

OBJECTIVES: A four-stage model of the cigarette epidemic was proposed in 1994 to communicate the long delay between the widespread uptake of cigarette smoking and its full effects on mortality, as had been experienced in economically developed countries where cigarette smoking became entrenched decades earlier in men than in women. In the present work, the question of whether qualitative predictions from the model have matched recent trends in smoking and deaths from smoking in countries at various levels of economic development is assessed, and possible projections to the year 2025 are considered. METHODS: The proportion of all deaths attributed to tobacco was estimated indirectly for 41 high-resource and medium-resource countries from 1950 to the most recent year for which data were available, generally about 2005-2009. The trends in tobacco-attributed mortality in later middle age were then projected forward to 2025, based on recent trends in tobacco-attributed mortality in early middle age. RESULTS: In developed countries the prevalence of smoking has continued to decrease in both sexes, although the rate of decrease has slowed and is less than that predicted by the original version of the model. Over the past 20 years the proportionate contribution of smoking to all deaths has decreased in men while continuing to increase or plateau among women. Although the proportion of all deaths at ages 35-69 that are attributed to smoking is still generally greater in men than in women, the male and female proportions are converging and will probably cross over in some high resource countries. Projections through to 2025 suggest that male and female smoking prevalence and smoking-attributed mortality will decrease in parallel in most developed countries towards lower limits that are not yet defined. In developing countries the model seems generally applicable to men but cannot predict whether or when women will begin smoking in large numbers. Modified criteria that describe the stages of the epidemic separately for men and women would be more generalisable to developing countries. CONCLUSIONS: The four-stage model of the cigarette epidemic still provides a reasonably useful description in many developed countries. Its relevance to developing countries could be improved by describing the stages of the epidemic separately for men and women.

Body mass index and chronic obstructive pulmonary disease-related mortality: a nationally representative prospective study of 220,000 men in China.

BACKGROUND: Low body mass index (BMI) is associated with chronic obstructive pulmonary disease (COPD) in populations where many are overweight. Substantial uncertainty remains about the relationship in populations with lower mean BMI levels, and about the relevance to it of the effects of smoking or of reverse causality. METHODS: A nationally representative prospective cohort study included 221,194 Chinese men aged 40-79 years in 1990-91, who were followed up for 15 years or to the age of 80 years. Hazard ratios for COPD-related mortality vs baseline BMI were adjusted for age, smoking, drinking and other factors. To reduce reverse causality, main analyses excluded all men with prior history of any respiratory diseases or abnormal lung function at baseline, leaving 2960 COPD-related deaths (16% of all deaths). RESULTS: The mean baseline BMI was 21.7 kg/m(2). There was a highly significant inverse association between BMI and COPD-related mortality among men without any apparent impairment of lung function. Approximately 90% of men had a baseline BMI <25 kg/m(2), and among them, 5 kg/m(2) lower BMI was associated with 31% (95% confidence interval 18-45%) higher COPD-related mortality. The excess risk persisted after restricting the analysis to never-smokers or excluding the first 5 years of follow-up. CONCLUSIONS: Low BMI is associated with increased COPD mortality in a relatively lean adult male population in China where COPD is one of the most common causes of death.

Body mass index and mortality from lung cancer in smokers and nonsmokers: a nationally representative prospective study of 220,000 men in China.

Low body mass index (BMI) has been associated with increased risk of lung cancer. However, the nature of the association, especially in populations with relatively low BMI, is less well characterized, as is the relevance to it of smoking. A nationally representative prospective cohort study included 217,180 Chinese men aged 40-79 years in 1990-91 who had no prior history of cancer and were followed up for 15 years. Standardized hazard ratios (HRs) were calculated for lung cancer mortality by baseline BMI. The mean baseline BMI was 21.7 kg/m(2), and 2,145 lung cancer deaths were recorded during 15 years of follow-up. The prevalence of smoking was strongly inversely associated with BMI, but no apparent relationship was seen between amount smoked (or other measures of smoking intensity) and BMI among smokers. Overall there was a strong inverse association between BMI and lung cancer mortality (p < 0.0001 for trend) after excluding the first 3 years of follow-up. This association appeared to be confined mainly to current smokers, with no apparent relationship in nonsmokers (p < 0.001 for difference between slopes). Among current smokers, the inverse association appeared to be log-linear, with each 5 kg/m(2) lower BMI associated with a 35% (95% confidence interval: 24-46%; p < 0.0001) higher lung cancer mortality, and it persisted after excluding those who had reported poor health status or history of any disease or respiratory symptoms at baseline. In this relatively lean Chinese male population, low BMI was strongly associated with increased risk of lung cancer only among current smokers.

Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48,557 adult deaths.

BACKGROUND: Alcohol is an important determinant of the high and fluctuating adult mortality rates in Russia, but cause-specific detail is lacking. Our case-control study investigated the effects of alcohol consumption on male and female cause-specific mortality. METHODS: In three Russian industrial cities with typical 1990s mortality patterns (Tomsk, Barnaul, Biysk), the addresses of 60,416 residents who had died at ages 15-74 years in 1990-2001 were visited in 2001-05. Family members were present for 50,066 decedents; for 48,557 (97%), the family gave proxy information on the decedents' past alcohol use and on potentially confounding factors. Cases (n=43,082) were those certified as dying from causes we judged beforehand might be substantially affected by alcohol or tobacco; controls were the other 5475 decedents. Case versus control relative risks (RRs; calculated as odds ratios by confounder-adjusted logistic regression) were calculated in ever-drinkers, defining the reference category by two criteria: usual weekly consumption always less than 0.5 half-litre bottles of vodka (or equivalent in total alcohol content) and maximum consumption of spirits in 1 day always less than 0.5 half-litre bottles. Other ever-drinkers were classified by usual weekly consumption into three categories: less than one, one to less than three, and three or more (mean 5.4 [SD 1.4]) bottles of vodka or equivalent. FINDINGS: In men, the three causes accounting for the most alcohol-associated deaths were accidents and violence (RR 5.94, 95% CI 5.35-6.59, in the highest consumption category), alcohol poisoning (21.68, 17.94-26.20), and acute ischaemic heart disease other than myocardial infarction (3.04, 2.73-3.39), which includes some misclassified alcohol poisoning. There were significant excesses of upper aerodigestive tract cancer (3.48, 2.84-4.27) and liver cancer (2.11, 1.64-2.70). Another five disease groups had RRs of more than 3.00 in the highest alcohol category: tuberculosis (4.14, 3.44-4.98), pneumonia (3.29, 2.83-3.83), liver disease (6.21, 5.16-7.47), pancreatic disease (6.69, 4.98-9.00), and ill-specified conditions (7.74, 6.48-9.25). Although drinking was less common in women, the RRs associated with it were generally more extreme. After correction for reporting errors, alcohol-associated excesses accounted for 52% of all study deaths at ages 15-54 years (men 8182 [59%] of 13968, women 1565 [33%] of 4751) and 18% of those at 55-74 years (men 3944 [22%] of 17,536, women 1493 [12%] of 12 302). Allowance for under-representation of extreme drinkers would further increase alcohol-associated proportions. Large fluctuations in mortality from these ten strongly alcohol-associated causes were the main determinants of recent fluctuations in overall mortality in the study region and in Russia as a whole. INTERPRETATION: Alcohol-attributable mortality varies by year; in several recent years, alcohol was a cause of more than half of all Russian deaths at ages 15-54 years. Alcohol accounts for most of the large fluctuations in Russian mortality, and alcohol and tobacco account for the large difference in adult mortality between Russia and western Europe. FUNDING: UK Medical Research Council, Cancer Research UK, British Heart Foundation, International Agency for Research on Cancer, and European Commission Directorate-General for Research.

Alcohol poisoning is a main determinant of recent mortality trends in Russia: evidence from a detailed analysis of mortality statistics and autopsies.

BACKGROUND: The changes in Russian mortality rates during the last two decades are unprecedented in a modern industrialized country. Although these fluctuations have attracted much interest, trends for major groups of causes of death have been analysed while trends in specific causes of death might shed light on the underlying determinants. METHODS: We analysed trends in total and cause-specific mortality in Russia for 1991-2006. The records of 24 836 forensic autopsies carried out during the period 1990-2004 in the city of Barnaul were analysed with respect to blood alcohol level. RESULTS: Diseases of the circulatory system (in the age group 35-69 years) and external causes (in the age group 15-34 years) were the main contributors to the fluctuations in Russian mortality rates observed in 1991-2006. The largest relative changes were for conditions directly related to alcohol intake. Among cardiovascular diseases, fluctuations were due to 'other forms' of acute and chronic ischaemia, and to atherosclerotic heart disease, while rates of myocardial infarction were low and relatively constant. In the autopsy series a very high proportion of decedents whose death was attributed to 'other' or 'not classified' cardiovascular diseases had lethal or potentially lethal concentrations of ethanol in blood. CONCLUSIONS: The increases in mortality in 1991-94 and in 1998-2003 coincided with economic and societal crisis, while decreases in 1994-98 and 2003-06 correlate with improvement in the economic situation. Excessive alcohol intake is a major cause of premature male Russian mortality, although many alcohol-related deaths are wrongly attributed to diseases of the circulatory system.

A nationally representative case-control study of smoking and death in India.

BACKGROUND: The nationwide effects of smoking on mortality in India have not been assessed reliably. METHODS: In a nationally representative sample of 1.1 million homes, we compared the prevalence of smoking among 33,000 deceased women and 41,000 deceased men (case subjects) with the prevalence of smoking among 35,000 living women and 43,000 living men (unmatched control subjects). Mortality risk ratios comparing smokers with nonsmokers were adjusted for age, educational level, and use of alcohol. RESULTS: About 5% of female control subjects and 37% of male control subjects between the ages of 30 and 69 years were smokers. In this age group, smoking was associated with an increased risk of death from any medical cause among both women (risk ratio, 2.0; 99% confidence interval [CI], 1.8 to 2.3) and men (risk ratio, 1.7; 99% CI, 1.6 to 1.8). Daily smoking of even a small amount of tobacco was associated with increased mortality. Excess deaths among smokers, as compared with nonsmokers, were chiefly from tuberculosis among both women (risk ratio, 3.0; 99% CI, 2.4 to 3.9) and men (risk ratio, 2.3; 99% CI, 2.1 to 2.6) and from respiratory, vascular, or neoplastic disease. Smoking was associated with a reduction in median survival of 8 years for women (99% CI, 5 to 11) and 6 years for men (99% CI, 5 to 7). If these associations are mainly causal, smoking in persons between the ages of 30 and 69 years is responsible for about 1 in 20 deaths of women and 1 in 5 deaths of men. In 2010, smoking will cause about 930,000 adult deaths in India; of the dead, about 70% (90,000 women and 580,000 men) will be between the ages of 30 and 69 years. Because of population growth, the absolute number of deaths in this age group is rising by about 3% per year. CONCLUSIONS: Smoking causes a large and growing number of premature deaths in India.

Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America.

BACKGROUND: There are substantial social inequalities in adult male mortality in many countries. Smoking is often more prevalent among men of lower social class, education, or income. The contribution of smoking to these social inequalities in mortality remains uncertain. METHODS: The contribution of smoking to adult mortality in a population can be estimated indirectly from disease-specific death rates in that population (using absolute lung cancer rates to indicate proportions due to smoking of mortality from certain other diseases). We applied these methods to 1996 death rates at ages 35-69 years in men in three different social strata in four countries, based on a total of 0.6 million deaths. The highest and lowest social strata were based on social class (professional vs unskilled manual) in England and Wales, neighbourhood income (top vs bottom quintile) in urban Canada, and completed years of education (more than vs less than 12 years) in the USA and Poland. RESULTS: In each country, there was about a two-fold difference between the highest and the lowest social strata in overall risks of dying among men aged 35-69 years (England and Wales 21%vs 43%, USA 20%vs 37%, Canada 21%vs 34%, Poland 26%vs 50%: four-country mean 22%vs 41%, four-country mean absolute difference 19%). More than half of this difference in mortality between the top and bottom social strata involved differences in risks of being killed at age 35-69 years by smoking (England and Wales 4%vs 19%, USA 4%vs 15%, Canada 6%vs 13%, Poland 5%vs 22%: four-country mean 5%vs 17%, four-country mean absolute difference 12%). Smoking-attributed mortality accounted for nearly half of total male mortality in the lowest social stratum of each country. CONCLUSION: In these populations, most, but not all, of the substantial social inequalities in adult male mortality during the 1990s were due to the effects of smoking. Widespread cessation of smoking could eventually halve the absolute differences between these social strata in the risk of premature death.

[Relationship between smoking and risk of esophageal cancer in 103 areas in China: a large-scale case-control study incorporated into a nationwide survey of mortality].

OBJECTIVE: To examine the relationship between smoking and risk of esophageal cancer (EC), and present a theoretical framework of control selection in population-based case-control study which was incorporated into a nationwide retrospective survey of mortality in China. METHODS: A large-scale population-based case-control study was incorporated into the nationwide retrospective survey of mortality conducted 1989 - 1991 in 24 urban cities selected by non-random sampling and 79 rural counties selected from 3000 counties included in the 1973 - 1975 cancer distribution survey by random sampling during. A questionnaire survey was conducted by home visit to investigate the death causes and smoking history of 19 734 deceased male adults who died of esophageal cancer during 1986 - 1988 at the age >or= 35. Two control groups were set up to undergo questionnaire survey by home visit to investigate the smoking history of the deceased persons and the informants. Control group I included the surviving spouses or other informants of 31 989 male adults who died of non-malignant digestive diseases during 1986 - 1988 at the age >or= 35, and control group II included 104 846 male spouses of the deceased female adults who died of different causes during 1986 - 1989 at the age >or= 35. The relative risks and population smoking attributable risks for EC were calculated using non-conditional logistic model, and the results were compared for consistency between the analyses using two different control groups. RESULTS: The EC absolute death rates were higher in the smokers than in the non-smokers in all urban and rural area groups. The total EC absolute death rate per 1000 among the non-smokers vs. smokers was 0.37:0.65 in the urban areas, 0.99:1.29 in the inland rural areas, and 1.09:1.62 in the coastal rural areas in the control group I, and there was a similar trend in the control group II. There was a significant dose-response relation between the period of smoking and the death risk of EC and between the daily cigarette consumption and the death risk of EC. The risk ratios, for example, for cigarette per day < 10, 10-, and 20- in the urban men were 1.42, 1.82, 2.22 in the control group I (trend test P < 0.01), and 1.57, 1.95, and 3.18 in the control group II (trend test P < 0.01). CONCLUSION: Smoking is an important risk factor for mortality from EC in China. Investigating the surviving spouses of the deceased patients is a creative, effective, and feasible trial, with the prerequisite of whole population-based survey, in study of the main types of death and the relevant risk factors.

Mortality in relation to alcohol consumption: a prospective study among male British doctors.

BACKGROUND: To relate alcohol consumption patterns to mortality in an elderly population. METHODS: We undertook a 23-year prospective study of 12 000 male British doctors aged 48-78 years in 1978, involving 7000 deaths. Questionnaires about drinking and smoking were completed in 1978 and once again in 1989-91. Mortality analyses are standardized for age, follow-up duration, and smoking, and (during the last decade of the study, 1991-2001) subdivide non-drinkers into never-drinkers and ex-drinkers. RESULTS: In this elderly population, with mean alcohol consumption per drinker of 2 to 3 units per day, the causes of death that are already known to be augmentable by alcohol accounted for only 5% of the deaths (1% liver disease, 2% cancer of the mouth, pharynx, larynx, or oesophagus, and 2% external causes of death) and were significantly elevated only among men consuming >2 units/day. Vascular disease and respiratory disease accounted for more than half of all the deaths and were both significantly less common among current than among non-drinkers; hence, overall mortality was also significantly lower (relative risk, RR 0.81, CI 0.76-0.87, P = 0.001). The non-drinkers, however, include the ex-drinkers, some of whom may have stopped recently because of illness, and during the last decade of the study (1991-2001) overall mortality was significantly higher in the few ex-drinkers who had been current drinkers in 1978 than in the never-drinkers or current drinkers. To avoid bias, these 239 ex-drinkers were considered together with the 6271 current drinkers and compared with the 750 men who had been non-drinkers in both questionnaires. Even so, ischaemic heart disease (RR 0.72, CI 0.58-0.88, P = 0.002), respiratory disease (RR 0.69, CI 0.52-0.92, P = 0.01), and all-cause (RR 0.88, CI 0.79-0.98, P = 0.02) mortality were significantly lower than in the non-drinkers. CONCLUSIONS: Although some of the apparently protective effect of alcohol against disease is artefactual, some of it is real.

Mortality in relation to smoking: 50 years' observations on male British doctors.

OBJECTIVE: To compare the hazards of cigarette smoking in men who formed their habits at different periods, and the extent of the reduction in risk when cigarette smoking is stopped at different ages. DESIGN: Prospective study that has continued from 1951 to 2001. SETTING: United Kingdom. PARTICIPANTS: 34 439 male British doctors. Information about their smoking habits was obtained in 1951, and periodically thereafter; cause specific mortality was monitored for 50 years. MAIN OUTCOME MEASURES: Overall mortality by smoking habit, considering separately men born in different periods. RESULTS: The excess mortality associated with smoking chiefly involved vascular, neoplastic, and respiratory diseases that can be caused by smoking. Men born in 1900-1930 who smoked only cigarettes and continued smoking died on average about 10 years younger than lifelong non-smokers. Cessation at age 60, 50, 40, or 30 years gained, respectively, about 3, 6, 9, or 10 years of life expectancy. The excess mortality associated with cigarette smoking was less for men born in the 19th century and was greatest for men born in the 1920s. The cigarette smoker versus non-smoker probabilities of dying in middle age (35-69) were 42% nu 24% (a twofold death rate ratio) for those born in 1900-1909, but were 43% nu 15% (a threefold death rate ratio) for those born in the 1920s. At older ages, the cigarette smoker versus non-smoker probabilities of surviving from age 70 to 90 were 10% nu 12% at the death rates of the 1950s (that is, among men born around the 1870s) but were 7% nu 33% (again a threefold death rate ratio) at the death rates of the 1990s (that is, among men born around the 1910s). CONCLUSION: A substantial progressive decrease in the mortality rates among non-smokers over the past half century (due to prevention and improved treatment of disease) has been wholly outweighed, among cigarette smokers, by a progressive increase in the smoker nu non-smoker death rate ratio due to earlier and more intensive use of cigarettes. Among the men born around 1920, prolonged cigarette smoking from early adult life tripled age specific mortality rates, but cessation at age 50 halved the hazard, and cessation at age 30 avoided almost all of it.

Smoking and liver cancer in China: case-control comparison of 36,000 liver cancer deaths vs. 17,000 cirrhosis deaths.

Liver cancer and liver cirrhosis are common causes of death in China, where chronic lifelong hepatitis B infection is a major cause of both diseases. To help determine whether smoking is a cofactor for the development of liver cancer, we ascertained retrospectively the smoking habits of 36,000 adults who had died from liver cancer (cases) and 17,000 who had died from cirrhosis (controls) in 24 Chinese cities and 74 rural counties. Calculations of the smoker vs. nonsmoker risk ratios (RR) for liver cancer mortality were standardised for age and locality. Among adult men (aged 35+) there was a 36% excess risk of death from liver cancer among smokers (smoker vs. nonsmoker standardised risk ratio [RR] =1.36, with 95% confidence interval [CI] 1.29-1.43, 2p<0.00001; attributable fraction 18%). In the general male population this indicates absolute risks of death from liver cancer before age 70 of about 4% in smokers and 3% in nonsmokers (in the absence of other causes). Most liver cancer, however, occurs among the 10-12% of men with haematological evidence of chronic hepatitis B infection, so among them the corresponding risks would be about 33% in smokers and 25% in nonsmokers. The RR was approximately independent of age, was similar in urban and rural areas, was not significantly related to the age when smoking started but was significantly (p<0.001) greater for cigarette smokers than for smokers of other forms of tobacco. Among men who smoked only cigarettes, the RR was significantly (p<0.001 for trend) related to daily consumption, with a greater hazard among those who smoked 20/day (RR 1.50, 95% CI 1.39-1.62) than among those who smoked fewer (mean 10/day: RR=1.32, 95% CI 1.23-1.41). Smoking was also associated with a significant excess of liver cancer death in women (RR 1.17, 95% CI 1.06-1.29, 2p=0.003; attributable fraction 3%), but fewer women (17%) than men (62%) were smokers, and their cigarette consumption per smoker was lower. Among women who smoked only cigarettes, there was a significantly greater hazard among those who smoked at least 20/day (mean 22/day: RR=1.45, 95% CI 1.18-1.79) than among those who smoked fewer (mean 8/day: RR=1.09, 95% CI 0.94-1.25). These associations indicate that tobacco is currently responsible for about 50,000 liver cancer deaths each year in China, chiefly among men with chronic HBV infection.

Smoking and cardiovascular disease.

Tobacco, especially cigarette, smoking is a major cause of cardiovascular disease (CVD), responsible for about one third of all CVD deaths in most Western populations. The risk of CVD death increases with increasing exposure to cigarette smoke, as measured by the number of cigarettes smoked daily, the duration of smoking, the degree of inhalation and the age of initiation. The relative risk for CVD is substantially greater in early adult life than in old age, and is associated more strongly with cigarettes than with other types of tobacco. Exposure to environmental tobacco smoke in never-smokers is also associated with 20-30% excess risk of coronary heart disease. There is convincing evidence that stopping smoking works, even after a heart attack, and that the excess risk declines fairly rapidly, with the risk approaching the level of never-smokers within about 10 years of quitting. Although the smoking prevalence has declined dramatically over the last few decades in many Western populations, it is increasing rapidly in most developing countries, with an emerging epidemic of tobacco related death.