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Hazards of cigarettes, smokeless tobacco and waterpipe in a Middle Eastern Population: a Cohort Study of 50 000 individuals from Iran
  1. Arash Etemadi1,2,
  2. Hooman Khademi2,3,
  3. Farin Kamangar2,4,
  4. Neal D Freedman1,
  5. Christian C Abnet1,
  6. Paul Brennan3,
  7. Reza Malekzadeh2,5
  8. Golestan Cohort Study Team
    1. 1Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, USA
    2. 2Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
    3. 3International Agency for Research on Cancer, Lyon, France
    4. 4Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, Maryland, USA
    5. 5Liver and Pancreaticobilliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
    1. Correspondence to Dr Arash Etemadi, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Rockville, MD 20850, USA; arash.etemadi{at}nih.gov

    Abstract

    Background There is limited information about the hazards of cigarettes, smokeless tobacco and waterpipe in the Middle East. The aim of this study was to determine the association between different types of tobacco use and earlier death in the Golestan Cohort Study.

    Methods The Study includes 50 045 adults (aged 40–75 years) from north eastern Iran. The baseline questionnaire (2004–2008) assessed information about use of cigarettes, chewing tobacco (nass) and waterpipe. To assess the use of each type of tobacco compared with never tobacco users, we used Cox regression models adjusted for age, socioeconomic status, area of residence, education and other tobacco used, and stratified by sex, ethnicity and opium use.

    Results 17% of participants reported a history of cigarette smoking, 7.5% chewing tobacco (nass) and 1.1% smoking waterpipe, and these figures declined in the later birth cohorts. During a median follow-up of 8 years, 4524 deaths occurred (mean age 64.8+9.9 years). Current (HR=1.44; 95% CI 1.28 to 1.61) and former (HR=1.35; 95% CI 1.16 to 1.56) cigarette smokers had higher overall mortality relative to never tobacco users. The highest cigarette-associated risk was for cancer death among current heavy smokers (HR=2.32; 95% CI 1.66 to 3.24). Current nass chewing was associated with overall mortality (HR=1.16; 95% CI 1.01 to 1.34), and there was a 61% higher risk of cancer death in people chewing nass more than five times a day. We observed an association between the cumulative lifetime waterpipe use (waterpipe-years≥28) and both overall (HR=1.66; 95% CI 1.11 to 2.47), and cancer mortality (HR=2.82; 95% CI 1.30 to 6.11).

    Conclusions Regular use of cigarettes, smokeless tobacco and waterpipe were associated with the risk of earlier death (particularly from cancer) in our cohort.

    • Non-cigarette tobacco products
    • Global health
    • Low/Middle income country
    • Smoking Caused Disease

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    Footnotes

    • AE, HK authors have made equal contributions. PB, RM authors have made equal contributions.

    • Collaborators Golestan Cohort Study Team: Hossein Poustchi, (Liver and Pancreaticobilliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran), Akram Pourshams, (Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran), (Liver and Pancreaticobilliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran), Masoud Khoshnia, (Golestan Research Center of Gastroenterology and Hepatology (GRCGH), Golestan University of Medical Sciences, Gorgan, Iran), Samad Gharavi, (Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran), Alireza Norouzi, (Golestan Research Center of Gastroenterology and Hepatology (GRCGH), Golestan University of Medical Sciences, Gorgan, Iran), Shahin Merat, (Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran), (Liver and Pancreaticobilliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran), Elham Jafari, (Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran), (Liver and Pancreaticobilliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran), Farhad Islami, (Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran), (Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia, USA), Shahryar Semnani, (Golestan Research Center of Gastroenterology and Hepatology (GRCGH), Golestan University of Medical Sciences, Gorgan, Iran), Paul DP Pharoah, (Departments of Oncology and Public Health and Primary Care, University of Cambridge, Cambridge, UK), Paolo Boffetta, (The Tisch Cancer Institute and Institute for Translational Epidemiology, Ichan School of Medicine at Mount Sinai, New York, New York, USA), Sanford M. Dawsey, (Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, USA).

    • Contributors AE, HK and FK were involved in writing the manuscript, data analysis and approving the final draft. AE, FK, NDF, CA, PB and RM took part in study design, editing and approving the final draft. The authors worked on the manuscript independently from the funders. They 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. RM is the guarantor.

    • Funding The Golestan Cohort Study was supported by Tehran University of Medical Sciences (grant number: 81/15), Cancer Research UK (grant number: C20/A5860), the Intramural Research Program of the NCI, National Institutes of Health, and various collaborative research agreements with the IARC. The study has also received special support from the Social Security Organisation of Iran Golestan Branch. The funders had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; or the decision to submit the manuscript for publication.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval All cohort participants signed a written informed consent at enrolment, and the study methods were approved by appropriate ethics committees at Tehran University of Medical Sciences, the US National Cancer Institute (NCI), and the International Agency for Research on Cancer (IARC).

    • Provenance and peer review Not commissioned; externally peer reviewed.

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