European Journal of Epidemiology

, Volume 30, Issue 7, pp 553–561 | Cite as

Smoking-attributable mortality in American Indians: findings from the Strong Heart Study

  • Mingzhi Zhang
  • Qiang An
  • Fawn Yeh
  • Ying Zhang
  • Barbara V. Howard
  • Elisa T. Lee
  • Jinying ZhaoEmail author


Cigarette smoking is the leading preventable cause of death worldwide. American Indians have the highest proportion of smoking in the United States. However, few studies have examined the impact of cigarette smoking on disease mortality in this ethnically important but traditionally understudied minority population. Here we estimated the association of cigarette smoking with cardiovascular disease (CVD), cancer and all-cause mortality in American Indians participating in the Strong Heart Study, a large community-based prospective cohort study comprising of 4549 American Indians (aged 45–74 years) followed for about 20 years (1989–2008). Hazard ratio and population attributable risk (PAR) associated with cigarette smoking were estimated by Cox proportional hazard model, adjusting for sex, study site, age, educational level, alcohol consumption, physical activity, BMI, lipids, renal function, hypertension or diabetes status at baseline, and interaction between current smoker and study site. We found that current smoking was significantly associated with cancer mortality (HR 5.0, [1.9–13.4]) in men, (HR 3.9 [1.6–9.7] in women) and all-cause mortality (HR 1.8, [1.2–2.6] in men, HR 1.6, [1.1–2.4] in women). PAR for cancer and all-cause mortality in men were 41.0 and 18.4 %, respectively, whereas the corresponding numbers in women were 24.9 and 10.9 %, respectively. Current smoking also significantly increases the risk of CVD deaths in women (HR 2.2 [1.1, 4.4]), but not men (HR 1.2 [0.6–2.4]). PAR for CVD mortality in women was 14.9 %. In summary, current smoking significantly increases the risk of CVD (in women), cancer and all-cause mortality in American Indians, independent of known risk factors. Culturally specific smoking cessation programs are urgently needed to reduce smoking-related premature deaths.


Cigarette smoking Mortality CVD Cancer All-cause American Indians Strong Heart Study 



The authors would also like to thank the Strong Heart Study participants, Indian Health Service facilities, and participating tribal communities for their extraordinary cooperation and involvement, which has contributed to the success of the Strong Heart Study. The views expressed in this article are those of the authors and do not necessarily reflect those of the Indian Health Service. This study was supported by NIH Grants R01DK091369, R01MH097018, K01AG034259, R21HL092363 and cooperative agreement Grants U01HL65520, U01HL41642, U01HL41652, U01HL41654, and U01HL65521.

Conflict of interest



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Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  • Mingzhi Zhang
    • 1
    • 2
  • Qiang An
    • 1
  • Fawn Yeh
    • 3
  • Ying Zhang
    • 3
    • 4
  • Barbara V. Howard
    • 4
    • 5
  • Elisa T. Lee
    • 3
    • 4
  • Jinying Zhao
    • 1
    Email author
  1. 1.Department of Epidemiology, School of Public Health and Tropical MedicineTulane UniversityNew OrleansUSA
  2. 2.Department of Epidemiology, School of Public HealthMedical College of Soochow UniversitySuzhouChina
  3. 3.Center for American Indian Health ResearchUniversity of Oklahoma Health Science CenterOklahoma CityUSA
  4. 4.Department of Biostatistics and EpidemiologyUniversity of Oklahoma Health Sciences CenterOklahoma CityUSA
  5. 5.MedStar Health Research InstituteHyattsvilleUSA

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