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June 5, 1996, Vol 275, No. 21 >
ARTICLE | June 5, 1996

Morbidity and Mortality in Relation to Cigarette Smoking in Shanghai, China: Title and subTitle BreakA Prospective Male Cohort Study FREE

Jian-Min Yuan, MD; Ronald K. Ross, MD; Xue-Li Wang, RN; Yu-Tang Gao, MD; Brian E. Henderson, MD; Mimi C. Yu, PhD
[+] Author Affiliations

Reprints: Jian-Min Yuan, MD, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave, Los Angeles, CA 90033-0800.


JAMA. 1996;275(21):1646-1650. doi:10.1001/jama.1996.03530450036029
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References

Objective.  —To evaluate prospectively the health risk of cigarette smoking in middle-aged men in Shanghai, China.

Design.  —Prospective cohort study with annual follow-up.

Participants.  —A total of 18244 male residents of Shanghai, China, enrolled in the study during January 1, 1986, through September 30, 1989, and actively followed via annual visits.

Results.  —By September 30, 1993, 852 deaths and 554 incident cancer cases were identified during the follow-up period, which averaged 5.4 years per subject. The overall incidence rate for cancer was 568 per 100 000 man-years, with the 3 leading sites being lung (146/100 000), stomach (116/100 000), and liver (81/100 000). Forty-one percent of all deaths were from cancer. Stroke was the most frequent cause of death unrelated to cancer, with an age-adjusted rate 4.2 times higher than that of US white men (201/100 000 vs 48/100 000), followed by ischemic heart disease, with an age-adjusted rate one-fifth that of US white men (69/100 000 vs 366/100 000). Compared with lifelong nonsmokers, the relative risks in heavy smokers (20 or more cigarettes per day) after adjustment for alcohol consumption were 2.2 for any incident cancer, 9.4 for incident lung cancer, 6.7 for head and neck cancer, and 1.8 for liver cancer. In terms of mortality, heavy smokers were at a 60% greater risk of death relative to lifelong nonsmokers; there was a 2.3-fold excess risk of death from cancer and 2-fold to 3-fold excess risk of death from heart disease.

Conclusions.  —Cigarette smoking is an important predictor of risk of cancer and mortality in men in Shanghai. Among the study subjects, 36% of all cases of cancer and 21% of all deaths could be attributed to cigarette smoking.(JAMA. 1996;275:1646-1650)

REFERENCES

1 +
Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of Progress; A Report of the Surgeon General, 1989 . Rockville, Md: US Dept of Health and Human Services, Public Health Service; 1989;. US Dept of Health and Human Services publication CDC 89-8411.
2 +
Doll R, Peto R.  Mortality in relation to smoking: 20 years' observations on male British doctors. BMJ . 1976;;2:1525-1536.
3 +
Rogot E, Murray JL.  Smoking and causes of death among U.S. veterans: 16 years of observation. Public Health Rep . 1980;;95:213-222.
4 +
Hammond EC, Seidmen H.  Smoking and cancer in the United States. Prev Med . 1980;;9:169-173.
5 +
Carstensen JM, Pershagen G, Eklund G.  Mortality in relation to cigarette and pipe smoking: 16 years' observation of 25,000 Swedish men. J Epidemiol Commun Health . 1987;;41:166-172.
6 +
Baron AE, Franceschi S, Barra S, Talamini R, Vecchia CL.  A comparison of the joint effects of alcohol and smoking on the risk of cancer across sites in the upper aerodigestive tract. Cancer Epidemiol Biomarkers Prev . 1993;;2:519-523.
7 +
Freund KM, Belanger AJ, D'Agostino RB, Kannel WB.  The health risks of smoking: the Framingham Study: 34 years of follow-up. Ann Epidemiol . 1993;;3:417-424.
8 +
Paganini-Hill A, Hsu G.  Smoking and mortality among residents of a California retirement community. Am J Public Health . 1994;;84:992-995.
9 +
Centers for Disease Control and Prevention.  Cigarette smoking-attributable mortality and years of potential life lost—United States, 1990. MMWR Morb Mortal Wkly Rep . 1993;;42:645-649.
10 +
Collaborative Group for Investigating Prevalence of Smoking.  Results of national sampling survey on prevalence of smoking [in Chinese]. Chin Med J . 1987;;67:229-232.
11 +
Hammond EC, Garfinkel L.  Smoking habits of men and women. J Natl Cancer Inst . 1961;;27:419-442.
12 +
Peto R.  Tobacco: U.K. and China. Lancet . 1986;; 2:1038.
13 +
Novotny TE, Peto R.  Estimates of future adverse health effects of smoking in China. Public Health Rep . 1988;;103:552-553.
14 +
Deng J, Gao YT.  The prevalence of smoking habit among 110,000 adult residents in Shanghai urban area [in Chinese]. Chin J Prev Med . 1985;;5: 271-274.
15 +
Ross RK, Yuan J-M, Yu MC, et al.  Urinary aflatoxin biomarkers and risk of hepatocellular carcinoma. Lancet . 1992;;339:943-946.
16 +
National Center for Health Statistics. Vital Statistics of the United States, 1989: Vol 2, Mortality, Part A . Hyattsville, Md: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 1993;. US Dept of Health and Human Services publication PHS 93-1101.
17 +
Breslow NE, Day NE. Statistical Methods in Cancer Research, Volume II: The Design and Analysis of Cohort Studies . Lyon, France: International Agency for Research on Cancer; 1987;. International Agency for Research on Cancer scientific publications 82.
18 +
Leung HM, Kupper LL.  Comparison of confidence intervals for attributable risk. Biometrics . 1981;;37:293-302.
19 +
Yu JJ, Mattson ME, Boyd GM, et al.  A comparison of smoking patterns in the People's Republic of China with the United States: an impending health catastrophe in the middle kingdom. JAMA . 1990;;264:1575-1579.
20 +
Parkin DM, Muir CS, Whelan SL, Gao Y-T, Farlay J, Powell J, eds. Cancer Incidence in Five Continents, Volume 6 . Lyon, France: International Agency for Research on Cancer; 1992;. International Agency for Research on Cancer scientific publications 120.
21 +
Shopland DR, Eyre HJ, Pechacek TF.  Smoking-attributable cancer mortality in 1991: is lung cancer now the leading cause of death among smokers in the United States? J Natl Cancer Inst . 1991;;83: 1142-1148.
22 +
Lam KC, Yu MC, Leung JWC, Henderson BE.  Hepatitis B virus and cigarette smoking: risk factors for hepatocellular carcinoma in Hong Kong. Cancer Res . 1982;;42:5246-5248.
23 +
Yu MC, Tong MJ, Govindarajan S, Henderson BE.  Nonviral risk factors for hepatocellular carcinoma in a low-risk population, the non-Asians of Los Angeles County, California. J Natl Cancer Inst . 1991;;83:1820-1826.
24 +
Chen D, Roman GC, Wu G-X, et al.  Stroke in China (Sino-MONICA-Beijing Study) 1984-1986. Neuroepidemiology . 1992;;11:15-23.
25 +
Kodama K.  Stroke trends in Japan. Ann Epidemiol . 1993;;3:524-528.
26 +
Thom TJ.  Stroke mortality trends: an international perspective. Ann Epidemiol . 1993;;3:509-518.
27 +
Abbott RD, Yin Y, Reed DM, Yano K.  Risk of stroke in male cigarette smokers. N Engl J Med . 1986;;315:717-720.
28 +
Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger AJ.  Cigarette smoking as a risk factor for stroke: the Framingham Study. JAMA . 1988;; 259:1025-1029.
29 +
Colditz GA, Bonita R, Stampfer MJ, et al.  Cigarette smoking and risk of stroke in middle-aged women. N Engl J Med . 1988;;318:937-941.
30 +
Semenciw RM, Morrison HI, Mao Y, Johansen H, Davies JW, Wigle DT.  Major risk factors for cardiovascular disease mortality in adults: results from the nutrition Canada survey cohort. Int J Epidemiol . 1988;;17:317-324.
31 +
Harmsen P, Rosengren A, Tsipogianni A, Wilhelmsen L.  Risk factors for stroke in middle-aged men in Göteborg, Sweden. Stroke . 1990;;21: 223-229.
32 +
Haheim LL, Holme I, Hjermann I, Leren P.  Risk factors of stroke incidence and mortality: a 12-year follow-up of the Oslo study. Stroke . 1993;; 24:1484-1489.
33 +
Robbins AS, Manson JE, Lee I-M, Satterfield S, Hennekens CH.  Cigarette smoking and stroke in a cohort of U.S. male physicians. Ann Intern Med . 1994;;120:458-462.
34 +
Ross RK, Yuan J-M, Henderson BE, Park J, Gao Y-T, Yu MC.  A prospective evaluation of dietary and other predictors of fatal stroke in Shanghai, China. Am J Epidemiol . In press.
35 +
Willett WC, Green A, Stampfer MJ, et al.  Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. N Engl J Med . 1987;;317:1303-1309.
36 +
Ragland DR, Brand RJ.  Coronary heart disease mortality in the Western Collaborative Group Study: follow-up experience of 22 years. Am J Epidemiol . 1988;;127:462-475.
37 +
Dagenais GR, Robitaille N-M, Lupein PJ, et al.  First coronary heart disease event rates in relation to major risk factors: Quebec cardiovascular study. Can J Cardiol . 1990;;6:274-280.
38 +
Dagenais GR, Ahmed Z, Robitaille N-M, et al.  Total and coronary heart disease mortality in relation to major risk factors: Quebec cardiovascular study. Can J Cardiol . 1990;;6:59-65.
39 +
Menotti A, Keys A, Kromhout D, et al.  Twenty-five-year mortality from coronary heart disease and its prediction in five cohorts of middle-aged men in Finland, the Netherlands, and Italy. Prev Med . 1990;;19:270-278.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of Progress; A Report of the Surgeon General, 1989 . Rockville, Md: US Dept of Health and Human Services, Public Health Service; 1989;. US Dept of Health and Human Services publication CDC 89-8411.
2 +
Doll R, Peto R.  Mortality in relation to smoking: 20 years' observations on male British doctors. BMJ . 1976;;2:1525-1536.
3 +
Rogot E, Murray JL.  Smoking and causes of death among U.S. veterans: 16 years of observation. Public Health Rep . 1980;;95:213-222.
4 +
Hammond EC, Seidmen H.  Smoking and cancer in the United States. Prev Med . 1980;;9:169-173.
5 +
Carstensen JM, Pershagen G, Eklund G.  Mortality in relation to cigarette and pipe smoking: 16 years' observation of 25,000 Swedish men. J Epidemiol Commun Health . 1987;;41:166-172.
6 +
Baron AE, Franceschi S, Barra S, Talamini R, Vecchia CL.  A comparison of the joint effects of alcohol and smoking on the risk of cancer across sites in the upper aerodigestive tract. Cancer Epidemiol Biomarkers Prev . 1993;;2:519-523.
7 +
Freund KM, Belanger AJ, D'Agostino RB, Kannel WB.  The health risks of smoking: the Framingham Study: 34 years of follow-up. Ann Epidemiol . 1993;;3:417-424.
8 +
Paganini-Hill A, Hsu G.  Smoking and mortality among residents of a California retirement community. Am J Public Health . 1994;;84:992-995.
9 +
Centers for Disease Control and Prevention.  Cigarette smoking-attributable mortality and years of potential life lost—United States, 1990. MMWR Morb Mortal Wkly Rep . 1993;;42:645-649.
10 +
Collaborative Group for Investigating Prevalence of Smoking.  Results of national sampling survey on prevalence of smoking [in Chinese]. Chin Med J . 1987;;67:229-232.
11 +
Hammond EC, Garfinkel L.  Smoking habits of men and women. J Natl Cancer Inst . 1961;;27:419-442.
12 +
Peto R.  Tobacco: U.K. and China. Lancet . 1986;; 2:1038.
13 +
Novotny TE, Peto R.  Estimates of future adverse health effects of smoking in China. Public Health Rep . 1988;;103:552-553.
14 +
Deng J, Gao YT.  The prevalence of smoking habit among 110,000 adult residents in Shanghai urban area [in Chinese]. Chin J Prev Med . 1985;;5: 271-274.
15 +
Ross RK, Yuan J-M, Yu MC, et al.  Urinary aflatoxin biomarkers and risk of hepatocellular carcinoma. Lancet . 1992;;339:943-946.
16 +
National Center for Health Statistics. Vital Statistics of the United States, 1989: Vol 2, Mortality, Part A . Hyattsville, Md: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 1993;. US Dept of Health and Human Services publication PHS 93-1101.
17 +
Breslow NE, Day NE. Statistical Methods in Cancer Research, Volume II: The Design and Analysis of Cohort Studies . Lyon, France: International Agency for Research on Cancer; 1987;. International Agency for Research on Cancer scientific publications 82.
18 +
Leung HM, Kupper LL.  Comparison of confidence intervals for attributable risk. Biometrics . 1981;;37:293-302.
19 +
Yu JJ, Mattson ME, Boyd GM, et al.  A comparison of smoking patterns in the People's Republic of China with the United States: an impending health catastrophe in the middle kingdom. JAMA . 1990;;264:1575-1579.
20 +
Parkin DM, Muir CS, Whelan SL, Gao Y-T, Farlay J, Powell J, eds. Cancer Incidence in Five Continents, Volume 6 . Lyon, France: International Agency for Research on Cancer; 1992;. International Agency for Research on Cancer scientific publications 120.
21 +
Shopland DR, Eyre HJ, Pechacek TF.  Smoking-attributable cancer mortality in 1991: is lung cancer now the leading cause of death among smokers in the United States? J Natl Cancer Inst . 1991;;83: 1142-1148.
22 +
Lam KC, Yu MC, Leung JWC, Henderson BE.  Hepatitis B virus and cigarette smoking: risk factors for hepatocellular carcinoma in Hong Kong. Cancer Res . 1982;;42:5246-5248.
23 +
Yu MC, Tong MJ, Govindarajan S, Henderson BE.  Nonviral risk factors for hepatocellular carcinoma in a low-risk population, the non-Asians of Los Angeles County, California. J Natl Cancer Inst . 1991;;83:1820-1826.
24 +
Chen D, Roman GC, Wu G-X, et al.  Stroke in China (Sino-MONICA-Beijing Study) 1984-1986. Neuroepidemiology . 1992;;11:15-23.
25 +
Kodama K.  Stroke trends in Japan. Ann Epidemiol . 1993;;3:524-528.
26 +
Thom TJ.  Stroke mortality trends: an international perspective. Ann Epidemiol . 1993;;3:509-518.
27 +
Abbott RD, Yin Y, Reed DM, Yano K.  Risk of stroke in male cigarette smokers. N Engl J Med . 1986;;315:717-720.
28 +
Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger AJ.  Cigarette smoking as a risk factor for stroke: the Framingham Study. JAMA . 1988;; 259:1025-1029.
29 +
Colditz GA, Bonita R, Stampfer MJ, et al.  Cigarette smoking and risk of stroke in middle-aged women. N Engl J Med . 1988;;318:937-941.
30 +
Semenciw RM, Morrison HI, Mao Y, Johansen H, Davies JW, Wigle DT.  Major risk factors for cardiovascular disease mortality in adults: results from the nutrition Canada survey cohort. Int J Epidemiol . 1988;;17:317-324.
31 +
Harmsen P, Rosengren A, Tsipogianni A, Wilhelmsen L.  Risk factors for stroke in middle-aged men in Göteborg, Sweden. Stroke . 1990;;21: 223-229.
32 +
Haheim LL, Holme I, Hjermann I, Leren P.  Risk factors of stroke incidence and mortality: a 12-year follow-up of the Oslo study. Stroke . 1993;; 24:1484-1489.
33 +
Robbins AS, Manson JE, Lee I-M, Satterfield S, Hennekens CH.  Cigarette smoking and stroke in a cohort of U.S. male physicians. Ann Intern Med . 1994;;120:458-462.
34 +
Ross RK, Yuan J-M, Henderson BE, Park J, Gao Y-T, Yu MC.  A prospective evaluation of dietary and other predictors of fatal stroke in Shanghai, China. Am J Epidemiol . In press.
35 +
Willett WC, Green A, Stampfer MJ, et al.  Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. N Engl J Med . 1987;;317:1303-1309.
36 +
Ragland DR, Brand RJ.  Coronary heart disease mortality in the Western Collaborative Group Study: follow-up experience of 22 years. Am J Epidemiol . 1988;;127:462-475.
37 +
Dagenais GR, Robitaille N-M, Lupein PJ, et al.  First coronary heart disease event rates in relation to major risk factors: Quebec cardiovascular study. Can J Cardiol . 1990;;6:274-280.
38 +
Dagenais GR, Ahmed Z, Robitaille N-M, et al.  Total and coronary heart disease mortality in relation to major risk factors: Quebec cardiovascular study. Can J Cardiol . 1990;;6:59-65.
39 +
Menotti A, Keys A, Kromhout D, et al.  Twenty-five-year mortality from coronary heart disease and its prediction in five cohorts of middle-aged men in Finland, the Netherlands, and Italy. Prev Med . 1990;;19:270-278.

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