Association of Solid Fuel Use With Risk of Cardiovascular and All-Cause Mortality in Rural China | Cardiology | JAMA | JAMA Network
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Original Investigation
April 3, 2018

Association of Solid Fuel Use With Risk of Cardiovascular and All-Cause Mortality in Rural China

Author Affiliations
  • 1Key Laboratory of Environment and Health, Ministry of Education, and State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 2Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
  • 3Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
  • 4The Chinese Academy of Medical Sciences, Beijing, China
  • 5Department of Nutrition and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
JAMA. 2018;319(13):1351-1361. doi:10.1001/jama.2018.2151
Key Points

Question  What is the association of long-term solid fuel use for cooking and heating with risk of cardiovascular and all-cause mortality in China, and the relevance of switching from solid to clean fuels and use of ventilation to this association?

Findings  In this prospective cohort study of 271 217 adults, self-reported solid fuel use was associated with significantly higher risks of cardiovascular mortality (hazard ratio, 1.20 for cooking; 1.29 for heating) and all-cause mortality (hazard ratio, 1.11 for cooking; 1.14 for heating). Lower risks were observed among solid fuel users who reported having switched to clean fuels before the study baseline or using ventilation.

Meaning  Solid fuel use was significantly associated with increased risks of cardiovascular and all-cause mortality; these risks may be lower among those switching from solid to clean fuels or using ventilation.

Abstract

Importance  When combusted indoors, solid fuels generate a large amount of pollutants such as fine particulate matter.

Objective  To assess the associations of solid fuel use for cooking and heating with cardiovascular and all-cause mortality.

Design, Setting, and Participants  This nationwide prospective cohort study recruited participants from 5 rural areas across China between June 2004 and July 2008; mortality follow-up was until January 1, 2014. A total of 271 217 adults without a self-reported history of physician-diagnosed cardiovascular disease at baseline were included, with a random subset (n = 10 892) participating in a resurvey after a mean interval of 2.7 years.

Exposures  Self-reported primary cooking and heating fuels (solid: coal, wood, or charcoal; clean: gas, electricity, or central heating), switching of fuel type before baseline, and use of ventilated cookstoves.

Main Outcomes and Measures  Death from cardiovascular and all causes, collected through established death registries.

Results  Among the 271 217 participants, the mean (SD) age was 51.0 (10.2) years, and 59% (n = 158 914) were women. A total of 66% (n = 179 952) of the participants reported regular cooking (at least weekly) and 60% (n = 163 882) reported winter heating, of whom 84% (n = 150 992) and 90% (n = 147 272) used solid fuels, respectively. There were 15 468 deaths, including 5519 from cardiovascular causes, documented during a mean (SD) of 7.2 (1.4) years of follow-up. Use of solid fuels for cooking was associated with greater risk of cardiovascular mortality (absolute rate difference [ARD] per 100 000 person-years, 135 [95% CI, 77-193]; hazard ratio [HR], 1.20 [95% CI, 1.02-1.41]) and all-cause mortality (ARD, 338 [95% CI, 249-427]; HR, 1.11 [95% CI, 1.03-1.20]). Use of solid fuels for heating was also associated with greater risk of cardiovascular mortality (ARD, 175 [95% CI, 118-231]; HR, 1.29 [95% CI, 1.06-1.55]) and all-cause mortality (ARD, 392 [95% CI, 297-487]; HR, 1.14 [95% CI, 1.03-1.26]). Compared with persistent solid fuel users, participants who reported having previously switched from solid to clean fuels for cooking had a lower risk of cardiovascular mortality (ARD, 138 [95% CI, 71-205]; HR, 0.83 [95% CI, 0.69-0.99]) and all-cause mortality (ARD, 407 [95% CI, 317-497]; HR, 0.87 [95% CI, 0.79-0.95]), while for heating, the ARDs were 193 (95% CI, 128-258) and 492 (95% CI, 383-601), and the HRs were 0.57 (95% CI, 0.42-0.77) and 0.67 (95% CI, 0.57-0.79), respectively. Among solid fuel users, use of ventilated cookstoves was also associated with lower risk of cardiovascular mortality (ARD, 33 [95% CI, −9 to 75]; HR, 0.89 [95% CI, 0.80-0.99]) and all-cause mortality (ARD, 87 [95% CI, 20-153]; HR, 0.91 [95% CI, 0.85-0.96]).

Conclusions and Relevance  In rural China, solid fuel use for cooking and heating was associated with higher risks of cardiovascular and all-cause mortality. These risks may be lower among those who had previously switched to clean fuels and those who used ventilation.

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