Association of Solid Fuel Use With Risk of Cardiovascular and All-Cause Mortality in Rural China | Cardiology | JAMA | JAMA Network
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International Energy Agency.  World Energy Outlook 2016. Paris, France: International Energy Agency; 2016.
Clark  ML, Peel  JL, Balakrishnan  K,  et al.  Health and household air pollution from solid fuel use: the need for improved exposure assessment.  Environ Health Perspect. 2013;121(10):1120-1128.PubMedGoogle Scholar
Gordon  SB, Bruce  NG, Grigg  J,  et al.  Respiratory risks from household air pollution in low and middle income countries.  Lancet Respir Med. 2014;2(10):823-860.PubMedGoogle ScholarCrossref
GBD 2016 Risk Factors Collaborators.  Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.  Lancet. 2017;390(10100):1345-1422.PubMedGoogle ScholarCrossref
Fatmi  Z, Coggon  D.  Coronary heart disease and household air pollution from use of solid fuel: a systematic review.  Br Med Bull. 2016;118(1):91-109.PubMedGoogle ScholarCrossref
Kim  C, Seow  WJ, Shu  XO,  et al.  Cooking coal use and all-cause and cause-specific mortality in a prospective cohort study of women in Shanghai, China.  Environ Health Perspect. 2016;124(9):1384-1389.PubMedGoogle ScholarCrossref
Mitter  SS, Vedanthan  R, Islami  F,  et al.  Household fuel use and cardiovascular disease mortality: Golestan Cohort Study.  Circulation. 2016;133(24):2360-2369.PubMedGoogle ScholarCrossref
Chan  KH, Lam  KBH, Kurmi  OP,  et al; China Kadoorie Biobank Collaborative Group.  Trans-generational changes and rural-urban inequality in household fuel use and cookstove ventilation in China: a multi-region study of 0.5 million adults.  Int J Hyg Environ Health. 2017;220(8):1370-1381.PubMedGoogle ScholarCrossref
Chen  Y, Shen  G, Liu  W,  et al.  Field measurement and estimate of gaseous and particle pollutant emissions from cooking and space heating processes in rural households, northern China.  Atmos Environ. 2016;125:265-271. doi:10.1016/j.atmosenv.2015.11.032Google ScholarCrossref
Chen  Z, Lee  L, Chen  J,  et al.  Cohort profile: the Kadoorie Study of Chronic Disease in China (KSCDC).  Int J Epidemiol. 2005;34(6):1243-1249.PubMedGoogle ScholarCrossref
Chen  Z, Chen  J, Collins  R,  et al; China Kadoorie Biobank (CKB) Collaborative Group.  China Kadoorie Biobank of 0.5 million people: survey methods, baseline characteristics and long-term follow-up.  Int J Epidemiol. 2011;40(6):1652-1666.PubMedGoogle ScholarCrossref
Lewington  S, Lacey  B, Clarke  R,  et al; China Kadoorie Biobank Consortium.  The burden of hypertension and associated risk for cardiovascular mortality in China.  JAMA Intern Med. 2016;176(4):524-532.PubMedGoogle ScholarCrossref
Bragg  F, Holmes  MV, Iona  A,  et al; China Kadoorie Biobank Collaborative Group.  Association between diabetes and cause-specific mortality in rural and urban areas of China.  JAMA. 2017;317(3):280-289.PubMedGoogle ScholarCrossref
Wang  S, Luo  K.  Life expectancy impacts due to heating energy utilization in China: distribution, relations, and policy implications.  Sci Total Environ. 2018;610-611:1047-1056.PubMedGoogle ScholarCrossref
National Bureau of Statistics of the People’s Republic of China. China Yearbook of Rural Household Survey. Accessed March 2, 2018.
Yang  GH, Stroup  DF, Thacker  SB.  National public health surveillance in China: implications for public health in China and the United States.  Biomed Environ Sci. 1997;10(1):1-13.PubMedGoogle Scholar
Landis  JR, Koch  GG.  The measurement of observer agreement for categorical data.  Biometrics. 1977;33(1):159-174.PubMedGoogle ScholarCrossref
Li  R, Chambless  L.  Test for additive interaction in proportional hazards models.  Ann Epidemiol. 2007;17(3):227-236.PubMedGoogle ScholarCrossref
Plummer  M.  Improved estimates of floating absolute risk.  Stat Med. 2004;2(1):93-104Google ScholarCrossref
McCracken  JP, Smith  KR, Díaz  A, Mittleman  MA, Schwartz  J.  Chimney stove intervention to reduce long-term wood smoke exposure lowers blood pressure among Guatemalan women.  Environ Health Perspect. 2007;115(7):996-1001.PubMedGoogle ScholarCrossref
Quansah  R, Semple  S, Ochieng  CA,  et al.  Effectiveness of interventions to reduce household air pollution and/or improve health in homes using solid fuel in low-and-middle income countries: a systematic review and meta-analysis.  Environ Int. 2017;103:73-90.PubMedGoogle ScholarCrossref
Clark  ML, Bachand  AM, Heiderscheidt  JM,  et al.  Impact of a cleaner-burning cookstove intervention on blood pressure in Nicaraguan women.  Indoor Air. 2013;23(2):105-114.PubMedGoogle ScholarCrossref
Alexander  D, Larson  T, Bolton  S, Vedal  S.  Systolic blood pressure changes in indigenous Bolivian women associated with an improved cookstove intervention.  Air Qual Atmos Health. 2015;8(1):47-53. doi:10.1007/s11869-014-0267-6Google ScholarCrossref
Ni  K, Carter  E, Schauer  JJ,  et al.  Seasonal variation in outdoor, indoor, and personal air pollution exposures of women using wood stoves in the Tibetan Plateau: baseline assessment for an energy intervention study.  Environ Int. 2016;94:449-457.PubMedGoogle ScholarCrossref
Newby  DE, Mannucci  PM, Tell  GS,  et al; ESC Working Group on Thrombosis, European Association for Cardiovascular Prevention and Rehabilitation; ESC Heart Failure Association.  Expert position paper on air pollution and cardiovascular disease.  Eur Heart J. 2015;36(2):83-93b.PubMedGoogle ScholarCrossref
Dutta  A, Mukherjee  B, Das  D, Banerjee  A, Ray  MR.  Hypertension with elevated levels of oxidized low-density lipoprotein and anticardiolipin antibody in the circulation of premenopausal Indian women chronically exposed to biomass smoke during cooking.  Indoor Air. 2011;21(2):165-176.PubMedGoogle ScholarCrossref
Painschab  MS, Davila-Roman  VG, Gilman  RH,  et al; CRONICAS Cohort Study Group.  Chronic exposure to biomass fuel is associated with increased carotid artery intima-media thickness and a higher prevalence of atherosclerotic plaque.  Heart. 2013;99(14):984-991.PubMedGoogle ScholarCrossref
Baumgartner  J, Schauer  JJ, Ezzati  M,  et al.  Indoor air pollution and blood pressure in adult women living in rural China.  Environ Health Perspect. 2011;119(10):1390-1395.PubMedGoogle ScholarCrossref
Hutcheon  JA, Chiolero  A, Hanley  JA.  Random measurement error and regression dilution bias.  BMJ. 2010;340:c2289.PubMedGoogle ScholarCrossref
Clark  AM, DesMeules  M, Luo  W, Duncan  AS, Wielgosz  A.  Socioeconomic status and cardiovascular disease: risks and implications for care.  Nat Rev Cardiol. 2009;6(11):712-722.PubMedGoogle ScholarCrossref
Wu  Y, Benjamin  EJ, MacMahon  S.  Prevention and control of cardiovascular disease in the rapidly changing economy of China.  Circulation. 2016;133(24):2545-2560.PubMedGoogle ScholarCrossref
Stringhini  S, Sabia  S, Shipley  M,  et al.  Association of socioeconomic position with health behaviors and mortality.  JAMA. 2010;303(12):1159-1166.PubMedGoogle ScholarCrossref
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.


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.