European Journal of Epidemiology

, Volume 28, Issue 8, pp 649–658 | Cite as

Impact of smoking and quitting on cardiovascular outcomes and risk advancement periods among older adults

  • Carolin Gellert
  • Ben Schöttker
  • Heiko Müller
  • Bernd Holleczek
  • Hermann Brenner


Smoking is an established risk factor for cardiovascular events, such as myocardial infarction, stroke and cardiovascular death. However, most pertinent studies primarily relied on middle aged adults. We aimed to provide empirical evidence on the association of smoking with cardiovascular events and the benefits of smoking cessation in people aged 50 years or older. In a German population-based cohort study detailed information on lifetime smoking history was obtained from 8,807 individuals aged 50–74 years, without previous myocardial infarction (MI) or stroke. Cox proportional hazards regression was applied to estimate the impact of smoking on MI, stroke and cardiovascular death (CVD) as well as on the combined outcome of major cardiovascular events (MI, stroke or CVD). In addition, the impact of smoking and the benefits of smoking cessation were quantified by risk advancement periods (RAP). The cohort included 17.2 % current smokers, 31.7 % former smokers and 51.1 % never smokers. During a mean follow-up of 9.1 years, 261 participants experienced a first MI, 456 had a primary stroke and 274 died of cardiovascular reasons. Compared to never smokers, adjusted hazard ratios (95 % confidence intervals) of current smokers were 2.25 (1.62–3.12), 2.12 (1.65–2.73) and 2.45 (1.76–3.42) and RAPs were 19.3, 9.8 and 8.4 years for MI, stroke and CVD, respectively. Strong dose–response relationships were seen with both current and life-time amount of smoking. Most of the excess risk and risk advancement disappeared within 5 years after smoking cessation. Smoking is a strong risk factor for cardiovascular events even at older age. Smoking cessation is highly and rapidly beneficial also at advanced age.


Smoking Myocardial infarction Stroke Aged Cohort studies 



The ESTHER study was funded by the Baden-Württemberg state Ministry of Science, Research and Arts (Stuttgart, Germany), the Federal Ministry of Education and Research (Berlin, Germany) and the Federal Ministry of Family Affairs, Senior Citizens, Women and Youth (Berlin, Germany). This analysis was conducted in the context of the CHANCES project funded in the FP7 framework programme of DG-RESEARCH in the European Commission. The project is coordinated by the Hellenic Health Foundation, Greece.

Conflict of interest

None declared.

Supplementary material

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  1. 1.
    Kenfield SA, Wei EK, Rosner BA, et al. Burden of smoking on cause-specific mortality: application to the Nurses’ Health Study. Tob Control. 2010;19:248–54.PubMedCrossRefGoogle Scholar
  2. 2.
    Shah RS, Cole JW. Smoking and stroke: the more you smoke the more you stroke. Expert Rev Cardiovasc Ther. 2010;8:917–32.PubMedCrossRefGoogle Scholar
  3. 3.
    Ferrie JE, Singh-Manoux A, Kivimaki M, et al. Cardiorespiratory risk factors as predictors of 40-year mortality in women and men. Heart. 2009;95:1250–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:647–58.PubMedCrossRefGoogle Scholar
  5. 5.
    Kelly-Hayes M. Influence of age and health behaviors on stroke risk: lessons from longitudinal studies. J Am Geriatr Soc. 2010;58(Suppl 2):S325–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Kondo T, Osugi S, Shimokata K, et al. Smoking and smoking cessation in relation to all-cause mortality and cardiovascular events in 25,464 healthy male Japanese workers. Circ J. 2011;75:2885–92.PubMedCrossRefGoogle Scholar
  7. 7.
    Mitchell JA, Bornstein DB, Sui X, et al. The impact of combined health factors on cardiovascular disease mortality. Am Heart J. 2010;160:102–8.PubMedCrossRefGoogle Scholar
  8. 8.
    WHO Report on the Global Tobacco Epidemic. The MPOWER package. Geneva: World Health Organization; 2008.Google Scholar
  9. 9.
    Lopez AD, Mathers CD, Ezzati M, et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367:1747–57.PubMedCrossRefGoogle Scholar
  10. 10.
    Gellert C, Schöttker B, Brenner H. Smoking and all-cause mortality in older people: systematic review and meta-analysis. Arch Intern Med. 2012;172:837–44.PubMedCrossRefGoogle Scholar
  11. 11.
    Beer C, Alfonso H, Flicker L, et al. Traditional risk factors for incident cardiovascular events have limited importance in later life compared with the health in men study cardiovascular risk score. Stroke. 2011;42:952–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Myint PK, Sinha S, Luben RN, et al. Risk factors for first-ever stroke in the EPIC-Norfolk prospective population-based study. Eur J Cardiovasc Prev Rehabil. 2008;15:663–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Kelly TN, Gu D, Chen J, et al. Cigarette smoking and risk of stroke in the Chinese adult population. Stroke. 2008;39:1688–93.PubMedCrossRefGoogle Scholar
  14. 14.
    Menotti A, Kromhout D, Blackburn H, et al. Forty-year mortality from cardiovascular diseases and all causes of death in the US Railroad cohort of the Seven Countries Study. Eur J Epidemiol. 2004;19:417–24.PubMedCrossRefGoogle Scholar
  15. 15.
    Brenner H, Gefeller O, Greenland S. Risk and rate advancement periods as measures of exposure impact on the occurrence of chronic diseases. Epidemiology. 1993;4:229–36.PubMedCrossRefGoogle Scholar
  16. 16.
    Löw M, Stegmaier C, Ziegler H, et al. Epidemiologische Studie zu Chancen der Verhütung, Früherkennung und optimierten Therapie chronischer Erkrankungen in der älteren Bevölkerung (ESTHER –Studie). Dtsch Med Wochenschr. 2004;129:2643–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Ezzati M, Lopez AD, Rodgers A, et al. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors, chap. 12: alcohol use. Geneva, Switzerland: World Health Organization; 2004.Google Scholar
  18. 18.
    Zhang QL, Baumert J, Ladwig KH, et al. Association of daily tar and nicotine intake with incident myocardial infarction: results from the population-based MONICA/KORA Augsburg Cohort Study 1984–2002. BMC Public Health. 2011;11:273.PubMedCrossRefGoogle Scholar
  19. 19.
    Asplund K, Karvanen J, Giampaoli S, et al. Relative risks for stroke by age, sex, and population based on follow-up of 18 European populations in the MORGAM Project. Stroke. 2009;40:2319–26.PubMedCrossRefGoogle Scholar
  20. 20.
    Huxley RR, Yatsuya H, Lutsey PL, et al. Impact of age at smoking initiation, dosage, and time since quitting on cardiovascular disease in African Americans and whites: the atherosclerosis risk in communities study. Am J Epidemiol. 2012;175:816–26.PubMedCrossRefGoogle Scholar
  21. 21.
    Schwartz SW, Carlucci C, Chambless LE, et al. Synergism between smoking and vital exhaustion in the risk of ischemic stroke: evidence from the ARIC study. Ann Epidemiol. 2004;14:416–24.PubMedCrossRefGoogle Scholar
  22. 22.
    Woodward M, Lam TH, Barzi F, et al. Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region. Int J Epidemiol. 2005;34:1036–45.PubMedCrossRefGoogle Scholar
  23. 23.
    Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet. 2011;378:1297–305.PubMedCrossRefGoogle Scholar
  24. 24.
    Grundtvig M, Hagen TP, German M, et al. Sex-based differences in premature first myocardial infarction caused by smoking: twice as many years lost by women as by men. Eur J Cardiovasc Prev Rehabil. 2009;16:174–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Mueck AO, Seeger H. Smoking, estradiol metabolism and hormone replacement therapy. Curr Med Chem Cardiovasc Hematol Agents. 2005;3:45–54.PubMedCrossRefGoogle Scholar
  26. 26.
    McVay MA, Copeland AL. Smoking cessation in peri- and postmenopausal women: a review. Exp Clin Psychopharmacol. 2011;19:192–202.PubMedCrossRefGoogle Scholar
  27. 27.
    Mueck AO. Postmenopausal hormone replacement therapy and cardiovascular disease: the value of transdermal estradiol and micronized progesterone. Climacteric. 2012;15(Suppl 1):11–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Nelson HD, Walker M, Zakher B, et al. Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force recommendations. Ann Intern Med. 2012;157:104–13.PubMedGoogle Scholar
  29. 29.
    Schierbeck LL, Rejnmark L, Tofteng CL, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ. 2012;345:e6409.PubMedCrossRefGoogle Scholar
  30. 30.
    Su IH, Chen YC, Hwang WT, et al. Risks and benefits of menopausal hormone therapy in postmenopausal Chinese women. Menopause. 2012;19:931–41.PubMedCrossRefGoogle Scholar
  31. 31.
    Diez Roux AV, Borrell LN, Haan M, et al. Neighbourhood environments and mortality in an elderly cohort: results from the cardiovascular health study. J Epidemiol Community Health. 2004;58:917–23.PubMedCrossRefGoogle Scholar
  32. 32.
    Liese AD, Hense HW, Brenner H, et al. Assessing the impact of classical risk factors on myocardial infarction by rate advancement periods. Am J Epidemiol. 2000;152:884–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Finkelstein MM, Jerrett M, Sears MR. Traffic air pollution and mortality rate advancement periods. Am J Epidemiol. 2004;160:173–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Keil U, Liese AD, Hense HW, et al. Classical risk factors and their impact on incident non-fatal and fatal myocardial infarction and all-cause mortality in southern Germany—results from the MONICA Augsburg cohort study 1984–1992. Eur Heart J. 1998;19:1197–207.PubMedCrossRefGoogle Scholar
  35. 35.
    Moride Y, Abenhaim L. Evidence of the depletion of susceptibles effect in non-experimental pharmacoepidemiologic research. J Clin Epidemiol. 1994;47:731–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Tournier M, Moride Y, Lesk M, et al. The depletion of susceptibles effect in the assessment of burden-of-illness: the example of age-related macular degeneration in the community-dwelling elderly population of Quebec. Can J Clin Pharmacol. 2008;15:e22–35.PubMedGoogle Scholar
  37. 37.
    Arrighi HM, Hertz-Picciotto I. The evolving concept of the healthy worker survivor effect. Epidemiology. 1994;5:189–96.PubMedCrossRefGoogle Scholar
  38. 38.
    Sturgeon SR, Schairer C, Brinton LA, et al. Evidence of a healthy estrogen user survivor effect. Epidemiology. 1995;6:227–31.PubMedCrossRefGoogle Scholar
  39. 39.
    Breitling LP, Müller H, Raum E, et al. Low-to-moderate alcohol consumption and smoking cessation rates: retrospective analysis of 4576 elderly ever-smokers. Drug Alcohol Depend. 2010;108:122–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Carolin Gellert
    • 1
  • Ben Schöttker
    • 1
  • Heiko Müller
    • 1
  • Bernd Holleczek
    • 2
  • Hermann Brenner
    • 1
    • 3
  1. 1.Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research Center (DKFZ)HeidelbergGermany
  2. 2.Saarland Cancer RegistrySaarbrückenGermany
  3. 3.Division of Clinical Epidemiology and Aging Research (C070)German Cancer Research Center (DKFZ)HeidelbergGermany

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