Household Fuel Use and Cardiovascular Disease Mortality: Golestan Cohort Study.
Household air pollution is the third largest risk factor for global disease burden, but direct links with cardiovascular disease mortality are limited. This study aimed to evaluate the relationship between household fuel use and cardiovascular disease mortality.



The Golestan Cohort Study in northeastern Iran enrolled 50 045 individuals 40 to 75 years of age between 2004 and 2008 and collected data on lifetime household fuel use and other baseline exposures. Participants were followed up through 2012 with a 99% successful follow-up rate. Cox proportional hazards models were fitted to calculate hazard ratios for associations between pehen (local dung), wood, kerosene/diesel, or natural gas burning for cooking and heating and all-cause and cause-specific mortality, with adjustment for lifetime exposure to each of these fuels and potential confounders. A total of 3073 participants (6%) died during follow-up; 78% of these deaths were attributable to noncommunicable diseases, including cardiovascular, oncological, and respiratory illnesses. Adjusted 10-year hazard ratios from kerosene/diesel burning were 1.06 (95% confidence interval, 1.02-1.10) and 1.11 (95% confidence interval, 1.06-1.17) for all-cause and cardiovascular mortality, respectively. Subtype-specific analyses revealed a significant increase in ischemic heart disease (10-year hazard ratio, 1.14; 95% confidence interval, 1.06-1.21) and a trend toward cerebrovascular accident (10-year hazard ratio, 1.08; 95% confidence interval, 0.99-1.17) mortality. Stratification by sex revealed a potential signal for increased risk for all-cause and cardiovascular disease mortality among women compared with men, with similar risk for ischemic heart disease mortality.



Household exposure to high-pollution fuels was associated with increased risk for all-cause and cardiovascular disease mortality. Replicating these results worldwide would support efforts to reduce such exposures.
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.). sumeet.mitter@northwestern.edu.
Sumeet S
SS
Mitter
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Rajesh
R
Vedanthan
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Farhad
F
Islami
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Akram
A
Pourshams
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Hooman
H
Khademi
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Farin
F
Kamangar
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Christian C
CC
Abnet
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Sanford M
SM
Dawsey
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Paul D
PD
Pharoah
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Paul
P
Brennan
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Valentin
V
Fuster
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Paolo
P
Boffetta
From Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.M.); Zena and Michael A. Wiener Cardiovascular Institute (R.V., V.F.) and Tisch Cancer Institute and Institute for Translational Epidemiology (F.I., P.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (F.I., A.P., R.M.); Surveillance and Health Services Research, American Cancer Society, Atlanta, GA (F.I.); International Agency for Research on Cancer, Lyon, France (H.K., P.B.); Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD (F.K.); Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD (C.C.A.); Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK (P.D.P.); Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.); and International Prevention Research Institute, Lyon, France (P.B.).
Reza
R
Malekzadeh
D000328:Adult; D000368:Aged; D000393:Air Pollutants / Q000009:adverse effects / Q000032:analysis*; D002318:Cardiovascular Diseases / Q000209:etiology* / Q000401:mortality; D015331:Cohort Studies; D004781:Environmental Exposure / Q000032:analysis*; D005260:Female; D005648:Fuel Oils / Q000009:adverse effects / Q000032:analysis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors
D000393:Air Pollutants; D005648:Fuel Oils
air pollution; epidemiology; heart diseases; mortality; stroke