Evidence relating cigarette, cigar and pipe smoking to lung cancer and chronic obstructive pulmonary disease: Meta-analysis of recent data from three regions

doi:10.13105/wjma.v11.i5.228

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Meta-Analysis

World J Meta-Anal. Jun 18, 2023; 11(5): 228-252
Published online Jun 18, 2023. doi: 10.13105/wjma.v11.i5.228

Table 1 Details of the 44 studies of lung cancer

Study ID^a	Ref.	Country	Design^b	Study Population	Start year	Year followed	Age^c	Sex^d	Cases	Adjust^e	Excl^f	Latency^g	Endpoint	NRR^h
ACE	[51,52]	US	Cohort	Regional	1995	10	18+	C	111	0, 8	0	0	Died	2
AEROBIC	[53]	US	Cohort	Regional	1974	29	20-84	M	232	0	0	0	Died	1
AGRICAN	[54]	France	Cohort	Regional	2005	6	18+	M, F	664	1	0	0	Diagnosed	2
AHS	[55]	US	Cohort	Pesticide workers	1993	18	NAR	C	789	0, 8	x	0	Diagnosed	2
AMIANT	[56]	Poland	Cohort	Asbestos workers	2000	14	NAR	C	110	0	0	0	Diagnosed	1
ARIC	[57]	US	Cohort	Regional	1987	19	45-64	M, F	470	0, 3	0	0	Diagnosed	4
ATP	[22]	Canada	Cohort	Regional	2001	16	35-69	M, F	210	0, 1, 7	0	0, x	Diagnosed	10
BIOBANK	[58]	UK	Cohort	National	2006	10	40-73	M, F	1493	0	0	0	Diagnosed	2
BWHS	[59]	US	Cohort	National	1995	18	21-69	F	306	0, 1, 7	0	0	Diagnosed	3
CHANCES	[21]	Multiple	Cohort	International	1982	29	46-74	C	14041	0, 7	0	0	Diag, died	4
COAL	[60]	US	Cohort	Coal miners	1969	38	NAR	M	568	7	0	0	Died	1
CPS-I	[26]	US	Cohort	National	1959	6	49+	M, F	1293	0, 1, 3	x	0	Died	6
CPS-II	[26]	US	Cohort	National	1982	6	49+	M, F	4957	0, 1, 3	x	0	Died	6
EPIC	[31]	Multiple	Cohort	International	1991	14	35-70	M	2995	0, 5	x	0	Diagnosed	6
	[32]					8	30-70	M, F	2995	7	0	0	Diagnosed	2
ESTHER	[61]	Germany	Nested CC	Regional	2000	17	50-75	C	143	0	0	0	Diagnosed	1
FRAMING	[62]	US	Cohort	Regional	1954	59	NAR	C	284	0, 1	0	0	Diagnosed	2
HBC	[63]	Finland	Cohort	Regional	2001	5	55-65	C	121	1	0	0	Diagnosed	1
HPFS	[64]	US	Nested CC	Medical workers	1986	14	40-75	M	210	0, 2, 4	0	0	Diagnosed	3
JP8	[23]	Japan	Cohort	National	1984	25	35+	M, F	4478	0, 2, 5	x	0, x	Diagnosed	8
JPHC	[65]	Japan	Cohort	National	1990	21	40-69	M, F	1663	0	x	0	Diagnosed	2
	[66]					3	40-69	M, F	1663	0, 10	x	0	Died	4
KAISER	[67]	US	Cohort	Regional	1978	30	NAR	C	1415	0, 6	0	0	Diagnosed	2
KRIS	[68]	Lithuania	Cohort	Regional	1972	36	40-59	M	343	0, 1, 4	0	x	Diagnosed	3
LSS	[69]	Japan	Cohort	Atomic bomb survivors	1950	59	5+	M, F	1597	0	x	0	Diagnosed	2
MWOMEN	[24]	UK	Cohort	National	1996	15	50-69	F	6331	0, 10	x	0, x	Died	3
NHANES	[70]	US	Cohort	National	1988	18	40+	C	269	0	0	0	Died	1
NHIS	[71]	US	Cohort	National	1987	28	18-84	C	7420	0, 11	0	0	Died	2
	[72]					9	25-79	M, F	7420	0, 4	0	x	Died	4
NHS	[73]	US	Cohort	Medical workers	1980	24	34-59	F	1729	1, 13	0	0	Died	2
	[74]			Medical workers		24	38-63	F	1729	0	0	0	Diagnosed	1
NIHAARP	[75]	US	Cohort	Regional	1995	11	50-71	M, F	17846	0, 5	x	x	Diagnosed	4
	[76]					16	50-71	C	17846	0	0	0	Diagnosed	1
NLCS	[29]	Netherlands	Nested CC	National	1986	17	55-69	C	3355	0	0	0	Diagnosed	3
	[30]					20	55-69	M, F	3355	0	0	0	Diagnosed	2
NLMS	[28]	US	Cohort	National	1985	26	35-80	C	3890	0, 1, 5	x	0	Died	8
NLST	[77]	US	Cohort	Construction workers	1998	18	NAR	M	352	0, 2	0	0	Died	2
NONMET	[78]	US	Nested CC	Non-metal miners	1947	50	NAR	M	198	0, 7	0	0	Died	2
NOWAC	[79]	Norway	Cohort	National	1991	24	31-70	F	1507	0, 1, 3	0	0	Diagnosed	3
PLCO	[80]	US	Cohort	Regional	1993	15	55-74	C	1040	0	0	0	Died	1
	[81]					15	55-74	F	1040	6	0	0	Died	1
QRESEAR	[82]	UK	Cohort	National	1998	15	25-84	M, F	32187	0, 6	0	0	Diagnosed	4
SCCS	[83]	US	Nested CC	Regional	2002	14	40-79	M, F	1334	0	0	0	Diagnosed	2
	[84]					7	40-79	C	1334	10	0	0	Diagnosed	1
SHEETME	[85]	Multiple	Cohort	Sheet metal workers	1986	24	NAR	M	808	0	0	0	Died	1
THIN	[86]	UK	Cohort	National	2000	12	30-99	C	1015	0	0	0	Diagnosed	1
THREEC	[20]	Norway	Cohort	Regional	1974	33	20-49	M	858	0, 10	0, x	0	Died	6
	[87]					35	35-49	M, F	858	0	0	x	Died	2
USA5	[26]	US	Cohort	National	1986	24	45+	M, F	11420	0, 1, 3	0	0	Died	6
VETERAN	[88]	US	Cohort	Regional	1987	28	21-89	M	105	0	0	0	Diagnosed	1
VITAL	[89]	US	Cohort	Regional	2000	7	50-76	C	797	0	0	0	Diagnosed	1
VLAGT	[27]	Netherlands	Cohort	Regional	1965	43	20-65	M, F	275	0, 3, 4	0	0	Died	4
WHI	[90]	US	Cohort	National	1993	16	50-79	F	901	0, 1, 15	0	0	Diagnosed	3

^aStudy IDs are ACE: The Adverse Childhood Experiences Study; AEROBIC: Aerobics Center Longitudinal Study; AGRICAN: Agriculture and Cancer Study; AHS: Agricultural Health Study; AMIANT: Amiantus; ARIC: Atherosclerosis Risk in Communities study; ATP: Alberta’s Tomorrow Project; BIOBANK: The UK Biobank Study, BWHS: The Black Women's Health Study; CHANCES: Consortium on Health and Ageing: Network of Cohorts in Europe and the United States; COAL: Underground coal miners from 31 US mines; CPS-I: Cancer Prevention Study 1; CPS-II: Cancer Prevention Study 2; EPIC: European Prospective Investigation into Cancer and Nutrition; ESTHER: Epidemiologische Studie zu Chancen der Verhütung, Früherkennung und optimierten Therapie chronischer Erkrankungen in der älteren Bevölkerung; FRAMING: Framingham Heart Study; HBC: Helsinki Birth Cohorts; HPFS: Health Professionals Follow-up Study; JP8: Pooled analysis of eight prospective studies in Japan; JPHC: Japan Public Health Center-based Prospective Study; KAISER: Kaiser Permanente Medical Care Program Study; KRIS: Kaunas–Rotterdam Intervention Study; LSS: Life Span Study; MWOMEN: Million Women Study; NHANES: National Health and Nutrition Examination Survey; NHIS: National Health Interview Survey; NHS: Nurses' Health Study; NIHAARP: National Institutes of Health-American Association of Retired Persons Diet and Health Study; NLCS: Netherlands Cohort Study on Diet and Cancer; NLMS: National Longitudinal Mortality Study; NLST: National Lung Screening Trial; NONMET: Non-metal Mining; NOWAC: Norwegian Women and Cancer study; PLCO: Prostate, Lung, Colorectal, and Ovarian Cancer study; QRESEAR: QResearch database; SCCS: Southern Community Cohort Study; SHEETME: Sheet Metal Workers; THIN: The Health Improvement Network; THREEC: Three counties in Norway; USA5: Pooled analysis of five US cohort studies, VETERAN: Veterans Exercise Testing Study; VITAL: Vitamins and Lifestyle; VLAGT: Vlagtwedde-Vlaardingen Study; WHI: Women’s Health Initiative Observational Study; US: United States; UK: United Kingdom.

^bNested CC: Nested case-control.

^cNAR: No age restriction.

^dC: Results only for sexes combined.

^eNumber of adjustment factors for which RR available (0 = unadjusted, 1 = age adjusted, N > 1 = adjusted for N factors).

^fx: Results available for exclusive use.

^gx: Results available with deaths excluded in the early period of follow-up.

^hNumber of RRs available.

Table 2 Details of the 18 studies of chronic obstructive pulmonary disease

Study ID^a	Ref.	Country	Study Population	Start year	Year followed	Age^b	Sex^c	Cases	COPD definition^d	Adjust^e	Excl^f	Latency^g	Endpoint	NRR^h
CPRD	[91]	UK	Regional	2003	4	40-89	C	14446	3	0	0	0	Diagnosed	1
CPS-I	[26]	US	National	1959	6	49+	M, F	782	DU	0, 1, 3	0, x	0	Died	6
CPS-II	[26]	US	National	1982	6	49+	M, F	2128	DU	0, 1, 3	0, x	0	Died	6
Finn Twins	[92]	Finland	National	1975	27	17+	C	511	5	0, 2	0	0	Diagnosed	2
JACC	[93]	Japan	National	1988	20	40-79	M, F	285	6	0, 1, 9	0	0	Died	6
KAISER	[94]	US	Regional	1978	28	NAR	C	778	4	0, 6	0	0	Diagnosed	2
MWOMEN	[24]	UK	National	1996	15	50-69	F	1910	2	0, 5	x	0	Died	3
NHS-HPFS	[95]	US	Regional	1976	24	30-75	C	832	1	0	0	0	Diagnosed	1
NIH-AARP	[96]	US	Regional	1995	11	50-70	C	3648	1	0	0	0	Diagnosed	1
NLMS	[28]	US	National	1985	26	35-80	C	2091	2	0, 1, 5	x	0	Died	9
NOWACⁱ	[97]	Norway	National	1991	17	26-71	F	68	2	1, 6	x	0	Died	2
PATH	[98]	US	National	2013	3	18+	C	319	1	0	0	0	Diagnosed	1
SMC	[99]	Sweden	Regional	1997	17	48-83	F	1495	8	0	x	x	Diagnosed	1
THIN	[86]	UK	National	2000	12	30-99	C	3901	9	0	0	0	Diagnosed	1
USA5	[26]	US	Regional	1986	24	50+	M, F	9246	DU	0, 1, 3	0, x	0	Died	6
	[100]				25	50+	M, F	9246	2	0, 5	0, x	0	Died	4
VLAGT	[27]	Netherlands	Regional	1965	43	NAR	M, F	313	7	0, 3	0, x	0	Died	4
WHI	[25]	US	Regional	1993	22	50-79	F	4959	1	0	x	0	Diagnosed	1
WHS	[101]	US	Regional	1993	11	45+	F	1604	1	0	x	0	Diagnosed	1

^aStudy IDs are CPRD: Clinical Practice Research Datalink; CPS-I: Cancer Prevention Study 1; CPS-II: Cancer Prevention Study 2; Finn Twins: Finnish Twin Cohort; JACC: Japanese Collaborative Cohort Study; KAISER: Kaiser Permanente Medical Care Program Study; Million: Million Women Study; NHS-HPFS: Nurses’ Health Study and Health Professionals Follow-up Study; NIH-AARP: National Institutes of Health–AARP Diet and Health Study; NLMS: National Longitudinal Mortality Study; NOWAC: Norwegian Women and Cancer Study; PATH: Population Assessment of Tobacco and Health Study; SMC: Swedish Mammography Cohort; THIN: The Health Improvement Network; USA5: Five US Cohort Studies; VLAGT: Vlagtwedde-Vlaardingen Study; WHI: Women’s Health Initiative Observational Study and; WHS: Women’s Health Study; US: United States; UK: United Kingdom.

^bNAR: No age restriction.

^cC: Results only for sexes combined.

^dDisease definition codes: 1 = Self-report; 2 = ICD-10 J40-44; 3 = GP notes and ICD-10 J41-44; 4 = ICD-9 491, 492, 494-496; 5 = Participants entitled to special reimbursement or regularly used anticholinergics; 6 = ICD-10 J41-J44 J47; 7 = ICD-9 490-2, 494, 496 ICD-10 J40-J44, J47; 8 = ICD-10 J44; 9 = GP notes and ICD codes, unstated; DU = definition unstated; COPD: Chronic obstructive pulmonary disease.

^eNumber of adjustment factors for which RR available (0 = unadjusted, 1 = age adjusted, N>1 = adjusted for N factors).

^fx: Results available for exclusive use.

^gx: Results available with deaths excluded in early period of follow-up.

^hNumber of RRs available.

ⁱStudy included despite only 68 COPD cases as results are available for lung cancer.

Table 3 Lung cancer and current vs never cigarette smoking – results from random effects meta-analyses

Full output table	Factor	Level	No. of RRs	No. of studies	RR (95%CI)	Heterogeneity test by level (NS = P ≥ 0.1) and trend if relevant
	All		62	44	12.14 (10.30-14.30)	P < 0.001
4	Sex	Combined	12	12	12.93 (10.55-15.84)
		Males	26	26	12.95 (9.82-17.08)
		Females	24	24	11.32 (8.46-15.15)	NS
5	Region	N. America	34	26	15.15 (12.77-17.96)
		Europe	21	14	12.30 (9.77-15.49)
		Japan	6	3	3.61 (2.87-4.55)
		Multi	1	1	13.10 (9.91-17.32)	P < 0.001
6	Study population	International	3	2	14.45 (6.85-30.50)
		National	25	16	10.26 (8.03-13.12)
		Regional	24	17	16.27 (13.39-19.77)
		Specific	10	9	9.71 (5.41-17.42)	P < 0.05
7	Year of start of baseline	< 1980	14	10	8.65 (5.83-12.83)
		1980-89	19	13	12.92 (9.83-16.98)
		1990-99	16	12	13.45 (9.76-18.53)
		2000+	13	9	14.38 (11.40-18.15)	NS trend P < 0.1
8	Number of cases	< 500	19	16	11.90 (9.55-14.83)
		500-1999	24	17	11.68 (8.65-15.75)
		2000+	19	11	12.76 (9.99-16.31)	NS trend NS
9	Exclusive cigarettes	No	45	35	13.47 (11.55-15.72)
	Exclusive cigarettes	Yes	17	11	9.50 (6.61-13.64)	P < 0.1
10	Latency rule applied	No	51	38	11.93 (9.97-14.28)
	Latency rule applied	Yes	11	7	13.13 (8.69-19.83)	NS
11	Study design	Cohort	55	39	12.35 (10.35-14.73)
	Study design	Nested case control	7	5	10.41 (8.04-13.48)	NS
12, 13	Lowest age considered	< 30	15	10	11.30 (7.37-17.33)
		30-39	11	8	11.41 (7.80-16.70)
		40-48	14	9	13.29 (9.15-19.30)
		49+	14	10	13.62 (10.22-18.16)	NS trend without
		Missing	8	8	10.79 (7.64-15.23)	Missing NS
14	Year of follow-up	< 10	11	7	12.63 (8.49-18.80)
		10- < 15	11	8	16.05 (12.48-20.65)
		15- < 20	14	11	16.05 (12.69-20.30)
		20- < 30	15	11	9.08 (6.26-13.15)
		30+	11	8	9.57 (6.01-15.26)	P < 0.05 trend P < 0.1
15	Endpoint	Died	23	17	14.85 (11.99-18.38)
		Diagnosed	39	27	10.82 (8.61-13.60)	P < 0.05
16	Number of adjustment factors	None	20	15	9.65 (7.13-13.05)
		Age only	4	3	11.80 (5.24-26.56)
		More	38	28	13.68 (11.46-16.34)	NS trend P < 0.1

RR: Relative risk; NS: Not significant.

Table 4 Chronic obstructive pulmonary disease and current vs never cigarette smoking – results from random effects meta-analyses

Full output table	Factor	Level	No. of RRs	No. of Studies	RR (95%CI)	Heterogeneity test by level (NS = P ≥ 0.1) and trend if relevant
	All		23	18	9.19 (6.97-12.13)	P < 0.001
4	Sex	Combined	8	8	8.91 (7.05-11.26)
		Males	5	5	9.56 (4.22-21.64)
		Females	10	10	9.33 (4.91-17.71)	NS
5	Region	N. America	13	10	8.91 (5.73-13.84)
		Europe	8	7	10.63 (6.93-16.29)
		Japan	2	1	6.00 (2.97-12.12)	NS
6	Study population	National	12	9	8.90 (6.47-12.24)
	Study population	Regional	11	9	9.51 (6.16-14.66)	NS
7	Year of start	< 1988	12	8	10.24 (7.26-14.45)
	of baseline	1988+	11	10	8.14 (5.78-11.47)	NS
8	Number of cases	< 1000	11	8	7.42 (5.65-9.74)
	Number of cases	1000+	12	10	10.67 (7.26-15.68)	NS
9	Exclusive cigarettes	No	13	12	9.02 (6.78-12.00)
	Exclusive cigarettes	Yes	10	10	9.48 (5.25-17.14)	NS
10	Latency rule applied	No	21	16	8.41 (6.38-11.09)
	Latency rule applied	Yes	2	2	21.67 (7.74-60.66)	P < 0.1
11, 12	Lowest age considered	< 34	5	5	8.36 (7.13-9.80)
		35-45	5	4	6.26 (4.31-9.08)
		46-49	5	3	7.92 (5.41-11.58)
		50+	5	4	15.36 (5.95-39.66)	NS trend without
		Missing	3	2	9.33 (5.00-17.40)	Missing NS
13	Year of follow-up	< 10	6	4	6.85 (5.24-8.94)
		10- < 20	6	6	11.32 (6.67-19.20)
		20- < 30	9	7	10.11 (5.21-19.60)
		30+	2	1	6.29 (3.73-10.59)	NS trend NS
14	COPD definition^a	Excl. Bronch	6	5	17.45 (8.35-36.44)
		Incl. Bronch	5	3	7.83 (4.60-13.35)
		Other	12	10	7.15 (5.19-9.84)	P < 0.1
15	Endpoint	Died	13	8	10.95 (7.42-16.15)
	Endpoint	Diagnosed	10	10	7.49 (5.63-9.95)	NS
16	Number of adjustment factors	None	8	8	6.96 (5.09-9.53)
	Number of adjustment factors	More	15	10	10.83 (7.67-15.29)	P < 0.1

^aExcl. Bronch: Excluding bronchiectasis (codes 2 and 3 in Table 2); Incl. Bronch: Including bronchiectasis (codes 4, 6 and 7). COPD: Chronic obstructive pulmonary disease; RR: Relative risk; NS: Not significant.

Citation: Lee PN, Coombs KJ, Hamling JS. Evidence relating cigarette, cigar and pipe smoking to lung cancer and chronic obstructive pulmonary disease: Meta-analysis of recent data from three regions. World J Meta-Anal 2023; 11(5): 228-252
URL: https://www.wjgnet.com/2308-3840/full/v11/i5/228.htm
DOI: https://dx.doi.org/10.13105/wjma.v11.i5.228