Smoking as a risk factor for accident death: a meta-analysis of cohort studies

doi:10.1016/S0001-4575(99)00034-2

Accident Analysis & Prevention

Volume 32, Issue 3, May 2000, Pages 397-405

https://doi.org/10.1016/S0001-4575(99)00034-2 Get rights and content

Abstract

This meta-analysis discusses the consistency, strength, dose-response, independence, and generalizability of published cohort data on accident death relative risks in smokers. To locate data, three authors independently searched MEDLINE, and bibliographies of the pertinent studies found, for data which allowed estimation of an appropriate cigarette smoker accident death relative risk (and 95% confidence interval). Relative risks and dose-response were summarized by fixed effects and Poisson modeling, respectively. Four pertinent cohort studies including eight populations were located. Cigarette smoking predicted summary accident death relative risks of 1.51 (95% confidence interval 1.27–1.78) versus never smokers and 1.35 (1.17–1.57) versus ex-smokers. Summary dose-response trends were significant (P=0.0000) versus never or least smoking referents. In individual studies, the smoking/accident death association persisted after adjustment or, in effect stratification, for age, race, sex, and occupation: occupation and time period; or numerous cardiac risk factors. This meta-analysis found significant, consistent, dose-response, often strong and independent (of age, race, and sex), prospective associations of smoking with accident death, internationally. Further studies and warnings of the smoking/accident death associations seem merited

Introduction

Accidents cause over 90 000 US (Rivara et al., 1997) and three million worldwide deaths annually (World Health Organisation, 1996a, World Health Organisation, 1996b, World Health Organisation and the World Bank, 1996). Accidents rank fifth among the leading causes of death in the world and probably account for over half (World Health Organisation, 1996a, World Health Organisation, 1996b, World Health Organisation and the World Bank, 1996) of the 10–30% of all hospital admissions that are due to injury (Berger and Mohan, 1996) and about a third of all deaths ages 10–24 are accidents (World Health Organisation, 1996a, World Health Organisation, 1996b, World Health Organisation and the World Bank, 1996, Berger and Mohan, 1996). Accidents represent 12% of the global burden of disease (World Health Organisation, 1996a, World Health Organisation, 1996b, World Health Organisation and the World Bank, 1996).

The World Health Organisation recently recommended that ‘Possible links between… each type of injury and a range of modifiable risk factors… should be quantified’ (World Health Organisation, 1996a, World Health Organisation, 1996b, World Health Organisation and the World Bank, 1996). In a meta-analysis of smoking and injury, we have shown numerous consistent, dose-response, independent, prospective smoking/injury associations, internationally (Leistikow et al., 1998). We also showed suggestive, P=0.1 smoking/injury death associations in secondary analyses of randomized controlled trial data (Leistikow and Shipley, 1999).

Smoking directly causes fire, explosion, (Sacks and Nelson, 1994, Leistikow and Martin, 1999) and poisoning accidents (MMWR, 1993, MMWR, 1997, Hayes and Laws, 1991, Woolf et al., 1996). Smoking may be the leading cause of fire deaths in the West (Whidden and Whidden, 1996).

It has long been recognized that impaired fitness, e.g. intoxication or debility, may both increase accidents and increase the severity of injuries from accidents that do occur (Haddon, 1980). Smoking is an acknowledged, immense, globally generally increasing, modifiable cause of impaired fitness, including general clinical accident precursors such as debilities, distractions (Sacks and Nelson, 1994), impaired reflexes (Domino and Von Baumgarten, 1969, Wakeham, 1969, Furberg and Ringqvist, 1973), and decrements in physiologic performance (Hirsch et al., 1985, Morton and Holmik, 1985, Perkins et al., 1989, Sandvik et al., 1995), and healing (Kurz et al., 1996, Kwiatkowski et al., 1996). Tobacco industry researchers privately reported nearly 30 years ago that smokers have accident excesses (Wakeham, 1969) and that a dose-response relationship exists between smoking and injury (Dunn, 1969).

The consistency, dose-response, strength, independence, generalizability, and possible importance of associations between smoking and accidents other than motor vehicle accidents have been publicly largely unquantified (Sacks and Nelson, 1994) or unaddressed (Smith et al., 1992, Doll et al., 1994). To quantify the magnitude, dose-response, and characteristics of smoking/accident associations, we will provide a first meta-analysis of smoking and accident death risk in cohort studies.

Section snippets

Methods

The search, data extraction, and analysis have previously been described in a parallel analysis of smoking/injury (not specifically accident) associations (Leistikow et al., 1998). In brief, MEDLINE and the bibliographies of pertinent retrieved articles were independently searched by three authors using accident or injury, mortality, and cohort or review study type keywords. Two authors independently abstracted the data. Relative risks (RR) were calculated and summarized using RevMan software

Results

Four studies covering eight age–sex specific cohorts met these criteria and are described in Table 1 (Friberg et al., 1973, Hemenway et al., 1993, Kawachi et al., 1993, Tverdal et al., 1993, Doll et al., 1994). (Smoking/injury associations in these and additional cohorts are described elsewhere) (Leistikow et al., 1998). Two papers from the US Nurses Health Study are described as one study as we computed the estimated accident death numbers by subtracting the nurses suicides (Hemenway et al.,

Discussion

We found published, international, prospective associations between cigarette smoking and accident death in the US, UK, Norway, and Sweden (Table 1 and Fig. 1). The included associations are strongly positive in the heaviest smokers (RRs of 2.2–4 in four (Friberg et al., 1973, Tverdal et al., 1993, Doll et al., 1994) of the five populations with nine or more heaviest smoker deaths. The populations with heaviest smoker RR over 2 included 121 of 141 total heaviest smoker accident deaths (Table 1

Acknowledgements

We wish to acknowledge the helpful comments of Ellen Gold and Steven Samuels and financial support from the Departments of Epidemiology and Preventive Medicine, Internal Medicine, and Employee Health, University of California, Davis.

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Smoking as a risk factor for accident death: a meta-analysis of cohort studies

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

J. Thorac. Cardiovasc. Surg.

Prev. Med.

J. Allergy. Clin. Immunol.

Lancet

Addict. Behav.

Lancet

Accid. Anal. Prev.

Prev. Med.

Prev. Med.

J. Clin. Epidemiol.

Mayo Clin. Proc.

Tobacco and children. An economic evaluation of the medical effects of parental smoking

Arch. Pediatr. Adolesc. Med.

Tobacco and injury: an annotated bibliography

Injury Control: A Global View

Meta-analysis. Beyond the grand mean?

Br. Med. J.

Mortality in relation to smoking: 40 years’ observations on male British doctors

Br. Med. J.

Prediction of rib fracture injury outcome by an artificial neural network

J. Trauma

Tobacco cigarette smoking and patellar reflex depression

Clin. Pharmacol. Ther.

Bias in meta-analysis detected by a simple, graphical test

Br. Med. J.

Multicenter study of general anesthesia. III. Predictors of severe perioperative adverse outcomes [published erratum appears in Anesthesiology 1992 July 77 (1), 222] [see comments]

Anesthesiology

Mortality in twins in relation to smoking habits and alcohol problems

Arch. Environ. Health

Achilles reflex time and sympathetic tone

Ups. J. Med. Sci.

Advances in the epidemiology of injuries as a basis for public policy

Public. Health. Rep.

The US smoking material fire problem through 1995

Smoking and suicide among nurses

Am. J. Public. Health.

Immediate effects of cigarette smoking on cardiorespiratory responses to exercise

J. Appl. Physiol.

Cigarette smoking decreases tissue oxygen

Arch. Surg.