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Smoking and Atherosclerotic Cardiovascular Disease in Men With Low Levels of Serum Cholesterol
The Korea Medical Insurance Corporation Study
Sun Ha Jee, PhD, MHS;
Il Suh, MD, PhD;
Il Soon Kim, MD, PhD;
Lawrence J. Appel, MD, MPH
JAMA. 1999;282:2149-2155.
Context Few studies have examined the interactive effects of smoking and serum cholesterol level on morbidity and mortality from cardiovascular dieseases. In East Asia, where the prevalence of smoking is among the highest in the world, morbidity and mortality from ischemic heart disease (IHD) is rapidly escalating.
Objectives To determine whether cigarette smoking is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD) in the Republic of Korea (South Korea), a population that has relatively low levels of serum cholesterol, and to determine whether serum cholesterol levels modify the risk relationship between smoking and ASCVD.
Design Prospective cohort study with a follow-up period of 6 years (1993-1998).
Setting and Subjects A total of 106,745 Korean men aged 35 to 59 years who received health insurance from the Korea Medical Insurance Corporation and who had biennial medical evaluations in 1990 and 1992.
Main Outcome Measures Hospital admissions and deaths from IHD, cerebrovascular disease (CVD), and total ASCVD.
Results At baseline, 61,389 (58%) were current cigarette smokers and 64,482 (60%) had a total cholesterol level of less than 5.17 mmol/L (200 mg/dL). Between 1993 and 1998, 1006 IHD events (176 per 100,000 person-years), 1364 CVD events (238 per 100,000 person-years), and 716 other ASCVD events (125 per 100,000 person-years) occurred. In multivariate Cox proportional hazard models controlling for age, hypertension, hypercholesterolemia, and diabetes, current smoking increased the risk of IHD (risk ratio [RR], 2.2; 95% confidence interval [CI], 1.8-2.8), CVD (RR, 1.6; 95% CI, 1.4-1.8), and total ASCVD (RR, 1.6; 95% CI, 1.5-1.8). For each outcome, there were significant dose-response relationships with amount and duration of smoking. Throughout the range of serum cholesterol levels, current smoking significantly increased the risk of IHD and CVD. In the lowest quartile of serum cholesterol levels (<4.42 mmol/L [171 mg/dL]), the RR from current smoking was 3.3 (95% CI, 1.7-6.2) for IHD and 1.6 (95% CI, 1.2-2.3) for CVD. There was no evidence of an interaction between smoking and serum cholesterol (P for interaction = .75, .87, and .92 for IHD, CVD, and total ASCVD, respectively).
Conclusions This study demonstrates that in Korea smoking is a major independent risk factor for IHD, CVD, and ASCVD and that a low cholesterol level confers no protective benefit against smoking-related ASCVD.
Author Affiliations: Department of Epidemiology and Disease Control, Graduate School of Health Science and Management, Yonsei University, Seoul, Republic of Korea (Dr Jee); Department of Preventive Medicine and Public Health, Yonsei University College of Medicine, Seoul, Republic of Korea (Drs Suh and Kim); and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Md (Dr Appel).
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