Association of cigarette use with risk of prostate cancer among US males: a cross-sectional study from NHANES 1999-2020

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We performed this study to examine whether cigarette use is associated with increased risk of prostate cancer. Methods This cross-sectional study used data from the 1999 to 2020 National Health and Nutrition Examination Survey (NHANES), a population-based nationally representative survey designed to assess the health and nutritional status of US adults and children. Males were eligible if they were aged ≥ 20 years at the time of participation. Cigarette use (ever use, categorized into former use and current use) was defined as having smoked at least 100 cigarettes in life. Smoking duration was calculated in former smokers and current smokers. Primary outcome was self-reported diagnosis of prostate cancer by participants. Logistic regression was used to calculate the adjusted odd ratios (aOR) and 95% CI for the associations of cigarette use with risk of prostate cancer, adjusting for demographic characteristics. Subgroup analyses by age group were conducted. Data were analyzed from June 4 to November 30, 2023. Results Of the 107 622 participants in 1999–2020 NHANES, 28 170 were included in the analysis. The mean (SD) age of the 28 170 participants was 46.4 (16.4) years, 68.0% were non-Hispanic White. Compared with never smokers, ever (aOR, 2.23 [95% CI, 1.06–4.68]) and former smokers (aOR, 3.54 [95% CI, 1.60–7.79]), but not current smokers (aOR, 1.04 [95% CI, 0.38–2.85]) had a higher risk of prostate cancer. This higher risk in former (aOR, 3.81 [95% CI, 1.69–8.59) and ever smokers (aOR, 2.77 [95% CI, 1.25–6.13) was also found in participants aged 20–59 years. But a lower risk was observed in current smokers aged ≥ 60 years (aOR, 0.52 [95% CI, 0.32–0.84). Dose-response analysis showed a positive association between smoking duration and risk of prostate cancer in current smokers (aOR, 1.07 [95% CI, 1.03–1.11]) but not in former smokers (aOR, 1.00 [95% CI, 0.99–1.02]). Conclusions This study suggests that cigarette use was associated with an increased risk of prostate cancer in US males, especially among those aged 20–59 years. This modifiable risk factor represents a target for further research into preventing prostate cancer in males. Cigarette use Prostate cancer Risk Cross-sectional NHANES Figures Figure 1 Background Prostate cancer (PCa) is the second most common cancer and the fifth leading cause of cancer death in men, with an estimated 1.4 million new cases and 375 000 deaths in 2020 worldwide [ 1 ]. Age, race, family history, and germline mutations (e.g., BRCA2, HOXB13, and CHEK2) are well-established nonmodifiable risk factors for PCa [ 2 , 3 ]. Modifiable risk factors of PCa, such as environmental exposure, infection, lifestyle, and dietary intake, have also been widely discussed [ 2 , 3 ]. Smoking is a well-known modifiable cause for cancers of 18 sites, the most common of which are the lung, head and neck, bladder, and esophagus [ 4 ]. Several studies have revealed potential biological mechanisms between smoking and PCa carcinogenesis [ 5 , 6 ]. Smoking can result in increased prostatic inflammation [ 7 ], which was reported to be associated with the development of PCa [ 8 , 9 ]. Smoking can also increase testosterone concentrations [ 5 , 6 ] and a higher level of testosterone was associated with an increased risk of PCa [ 10 ]. However, the epidemiological association between smoking and risk of PCa is still a matter of debate, with inconsistent results across different studies [ 11 – 14 ]. A meta-analysis of 24 cohort studies demonstrated that former smokers had a higher risk of PCa compared to never smokers, and current smokers showed a statistically significant elevated risk of PCa in data stratified by the amount smoked [ 11 ]. Results from another study (REDUCE) among men with negative pre-study biopsy found that former and current smoking were not associated with total or low-grade PCa risk but current smoking was associated with an increased risk of high-grade PCa [ 12 ]. Islami et al. found that ever smoking was positively associated with PCa risk in studies completed before the prostate-specific antigen (PSA) screening era; in overall analyses, current smoking was negatively associated with the occurrence of incident PCa [ 13 ]. A recent pooled study involving 5 Swedish cohorts showed that current smoking as associated with a lower risk of PCa, which was most pronounced for low-risk PCa [ 14 ]. In this cross-sectional study, we investigate the association of cigarette use with the risk of PCa using the nationally representative data from the National Health and Nutrition Examination Survey (NHANES), and we specifically focused on the PCa risks across different age groups, which were not explored in previous studies. The findings could contribute to the literature by updating earlier research about cigarette use and PCa risk and help policymakers and healthcare professionals make decisions on smoking management. Methods Study population The NHANES is a population-based repeated survey conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention and designed to assess the health and nutritional status of adults and children in the United States (US). The survey combines both in-home interviews and physical examinations. The in-home interviews include demographic, socioeconomic, dietary, and health-related questions. The physical examinations are performed in a mobile exam center, consisting of medical, dental, and physiological measurements, as well as laboratory tests administered by trained medical personnel. The NHANES uses a complex 4-stage survey design to obtain a nationally representative sample and certain groups (racial and ethnic minority groups, individuals with lower income, etc.) are intentionally oversampled to increase precision for subgroup estimates. Data collection for this program was conducted continuously in 2-year cycles since 1999, with a sample of approximately 5000 persons each year. More details regarding NHANES study procedures can be found on the official website ( www.cdc.gov/nchs/nhanes/index.htm ). In this study, we used data of NHANES from 1999 through 2020. Participants were included in the analysis if they were males and aged 20 years or older at the time of participation. This age range was appropriate because target NHANES questions on cancer history provided an age limit of 20–150 years old. The NHANES study has been continuously approved by the National Center for Health Statistics Research Ethics Review Board since 1999. All participants provided written informed consent at enrollment. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines for cross-sectional studies [ 15 ]. Assessment of cigarette use Questions on cigarette use were asked by trained interviewers using the computer-assisted personal interview (CAPI) system. The CAPI system was programmed with built-in consistency checks to reduce data entry errors, and the collected data were reviewed by the NHANES field office staff for accuracy and completeness. Smoking status was assessed by the question “Have you ever smoked at least 100 cigarettes in your lifetime?”. Participants who reported having smoked at least 100 cigarettes in their lifetime were defined as ever smokers; otherwise, they were defined as never smokers. Ever smokers were further asked “If yes, are you still smoking cigarettes currently?”, those who still smoked cigarettes at the time of investigation were defined as current smokers, and those who had quitted were defined as former smokers. We calculated smoking duration (years) based on participants’ age at the time of investigation and questions including “How old were you when you first started to smoke cigarettes fairly regularly?” for current and former smokers and “How long has it been since you quit smoking cigarettes?” for former smokers. Ascertainment of prostate cancer The primary outcome was self-reported diagnosis of PCa, which was based on the participant’s response to the following questions: “Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?” and “What kind of cancer?”. Assessment of covariates This study adjusted for several demographic covariates. Age was stratified as 20 to 59 and 60 or more years old. Race was recoded as Hispanic (Mexican American and other Hispanic), non-Hispanic White, non-Hispanic Black, and other races (including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, or unknown). Education level was categorized as less than high school, high school or equivalent, some college, and college graduate or above. Marital status was grouped as married/living with partner, widowed/divorced/separated, and never married. Family income was evaluated using the poverty-to-income ratio (PIR, a ratio of family income to poverty level) and categorized into low income (PIR ≤ 1), middle income (PIR 1–4), and high income (PIR ≥ 4) [ 16 ]. Body mass index (BMI), calculated as weight in kilograms divided by height in meters squared, was categorized as underweight (< 18.5), normal (≥ 18.5 & <25), overweight (≥ 25 & <30), and obesity (≥ 30). Statistical analysis Statistical analyses were performed from June 4 to November 30, 2023. Participants’ characteristics were described by mean (standard deviation, SD) and frequencies (weighted percentages) and compared by cigarette use using Chi-square test, t test, and one-way analysis of variance as appropriate. Multivariable logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) for the associations of cigarette use with risk of PCa, adjusting for age, race, education level, marital status, family income, and BMI. Interaction of age and cigarette use was explored based on evidence that the risk of PCa varies by age [ 2 , 3 ]. In addition, we conducted dose-response analyses for the associations of smoking duration (years) with risk of PCa among former and current smokers respectively. Finally, subgroup analyses were conducted across different groups of age, race, education level, and family income. All analyses were conducted in Stata version 16 (StataCorp). Appropriate sample weights were constructed after combing survey cycles, and we used the Taylor series linearization method to calculate the variance for subpopulations of interest accounting for the complex survey design. All P values were from 2-sided tests and results were deemed statistically significant at P < 0.05. Results Participant characteristics Of the 107 622 participants in 1999–2020 NHANES, there were 28 250 males aged 20 years or older; 45 and 35 of these males were excluded due to unavailable data on PCa history and cigarette use. A total of 28 170 participants representing 104 893 498 US males were included in this analysis (Fig. 1 ). The mean (SD) age of participants was 46.4 (16.4) years (Table 1 ); 6976 (14.5%) were Hispanic, 12 464 (68.0%) were non-Hispanic White, and 6030 (10.4%) were non-Hispanic Black. Compared to never smokers, more former smokers but fewer current smokers were aged 60 years or older, married/living with partner, overweight and obesity (all P < 0.05). More former and current smokers had high school or lower education level and low-middle family income than never smokers (all P < 0.05). Fewer former smokers but more current smokers than never smokers were non-Hispanic Black (6.2% vs 13.6% vs 11.4%, P < 0.001). Comparisons of participants’ characteristics between ever smokers and never smokers are shown in Additional file 1. Table 1 Baseline characteristics of study participants a Characteristic Cigarette use, No. (weighted %) P value b Total (n = 28170) Never (n = 12593) Current (n = 6931) Former (n = 8646) Age, mean (SD), years 46.4 (16.4) 43.7 (13.4) 41.9 (12.5) 54.2 (14.5) < 0.001 20–39 9294 (38.7) 5114 (44.5) 2836 (47.7) 1344 (21.9) < 0.001 40–59 8924 (37.8) 4047 (37.7) 2537 (39.1) 2340 (36.8) ≥60 9952 (23.5) 3432 (17.8) 1558 (13.2) 4962 (41.2) Race < 0.001 Hispanic 6976 (14.5) 3282 (15.9) 1572 (14.2) 2122 (12.5) Non-Hispanic White 12464 (68.0) 4991 (64.9) 2952 (65.2) 4521 (75.4) Non-Hispanic Black 6030 (10.4) 2847 (11.4) 1841 (13.6) 1342 (6.2) Other c 2700 (7.1) 1473 (7.8) 566 (7.0) 661 (5.9) Education level < 0.001 Less than high school 7848 (17.7) 2800 (12.8) 2477 (26.6) 2571 (18.1) High school or equivalent 6727 (25.0) 2642 (21.2) 2016 (32.0) 2069 (25.5) Some college 7377 (28.9) 3371 (28.2) 1790 (30.0) 2216 (29.0) College graduate or above 6180 (28.4) 3762 (37.8) 639 (11.3) 1779 (27.3) Marital status < 0.001 Married/living with partner 18137 (67.1) 8157 (68.0) 3762 (56.4) 6218 (74.6) Widowed/divorced/separated 4512 (12.8) 1506 (9.3) 1427 (17.6) 1579 (14.5) Never married 5267 (20.1) 2831 (22.7) 1664 (26.0) 772 (10.9) Family income < 0.001 Low income 4831 (12.7) 1819 (10.6) 1830 (21.3) 1135 (8.5) Middle income 13565 (48.4) 5776 (44.5) 3398 (54.6) 4435 (50.1) High income 7017 (38.9) 3738 (44.9) 1006 (24.1) 2273 (41.4) BMI category < 0.001 Normal 7072 (26.2) 3038 (25.0) 2358 (36.0) 1676 (20.0) Overweight 10117 (38.6) 4548 (39.1) 2239 (34.7) 3330 (41.1) Obesity 8645 (34.1) 4025 (35.0) 1695 (27.1) 2925 (39.4) Underweight 334 (1.1) 105 (0.9) 179 (2.2) 50 (0.5) SD, standard deviation; BMI, body mass index. a Accounting for sampling weights. b Calculated by Chi-square test or one-way analysis of variance. c Other race/ethnicity includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, or unknown. Associations between cigarette use and risk of prostate cancer Table 2 shows that compared to never smokers, an increased risk of PCa was found in former smokers (aOR, 3.54 [95% CI, 1.60–7.79]) and ever smokers (aOR, 2.23 [95% CI, 1.06–4.68]) but not in current smokers (aOR, 1.04 [95% CI, 0.38–2.85]), adjusting for age, race, education level, marital status, family income, BMI, and interaction of age and cigarette use. Dose-response analyses showed that longer smoking duration was associated with an increased risk of PCa in current smokers (aOR, 1.07 [95% CI, 1.03–1.11]) but not in former smokers (aOR, 1.00 [95% CI, 0.99–1.02]), adjusting for age, race, education level, marital status, family income, and BMI. Table 2 Association of cigarette use with prostate cancer Exposures Diagnosed with prostate cancer Crude OR (95% CI) Adjusted OR (95% CI) b P for interaction Cigarette use a Former smokers 2.18 (1.78–2.67) *** 3.54 (1.60–7.79) ** 0.001 Current smokers 0.47 (0.33–0.66) *** 1.04 (0.38–2.85) 0.26 Ever smokers 1.40 (1.15–1.69) ** 2.23 (1.06–4.68) * 0.01 Smoking duration, years Former smokers 1.04 (1.03–1.05) *** 1.00 (0.99–1.02) NA Current smokers 1.11 (1.09–1.13) *** 1.07 (1.03–1.11) *** NA OR, odds ratio; CI, confidence interval; NA, not available *** P < 0.001, ** P < 0.01, * P < 0.05 a Reference group = never smokers b Adjusted for age, race, education level, marital status, family income, and body mass index for “Smoking duration”; additionally adjusted for interaction of age and cigarette use for “Cigarette use”. Table 3 shows that in participants aged 20–59 years, an increased risk of PCa was found in former (aOR, 3.81 [95% CI, 1.69–8.59]) and ever smokers (aOR, 2.77 [95% CI, 1.25–6.13]) but not in current smoker (aOR, 1.43 [95% CI, 0.53–3.87]). In participants aged 60 years or older, current smokers had decreased risks of PCa (aOR, 0.52 [95% CI, 0.32–0.84]) while former smokers (aOR, 0.94 [95% CI, 0.75–1.18]) and ever smokers (aOR, 0.86 [95% CI, 0.69–1.07]) showed neither increased nor decreased PCa risks. Subgroup analyses across varying races, education levels, and family income showed that the increased risk of PCa among ever smokers was only evident in participants of non-Hispanic White race (aOR, 4.10 [95% CI, 1.13–14.88]), in participants with education level of some college or above (aOR, 3.34 [95% CI, 1.52–7.35]), and in participants with high family income (aOR, 2.94 [95% CI, 1.13–7.62]) (Additional file 2). Table 3 Association of cigarette use with prostate cancer by age groups Exposures a Diagnosed with prostate cancer Crude, OR (95% CI) P Adjusted OR (95% CI) b P For participants aged 20–59 years Former smokers 3.35 (1.57–7.18) 0.002 3.81 (1.69–8.59) 0.001 Current smokers 1.14 (0.47–2.78) 0.78 1.43 (0.53–3.87) 0.48 Ever smokers 2.14 (1.07–4.27) 0.03 2.77 (1.25–6.13) 0.01 For participants aged 60 years or older Former smokers 0.91 (0.74–1.12) 0.36 0.94 (0.75–1.18) 0.61 Current smokers 0.54 (0.35–0.81) 0.004 0.52 (0.32–0.84) 0.008 Ever smokers 0.83 (0.68–1.01) 0.07 0.86 (0.69–1.07) 0.17 OR, odds ratio; CI, confidence interval a Reference group = never smokers; b Adjusted for race, education level, marital status, family income, and body mass index. Discussion In this study, we firstly explored the associations between cigarette use and PCa risk by including the interaction effect between cigarette use and age, and found a positive association between former and ever cigarette use and PCa risk that persisted after adjustment for age, race, education level, marital status, family income, BMI, and interaction of age and cigarette use. Smoking duration was positively associated with PCa risk in current smokers. Interestingly, we firstly found the association varies by age groups, with ever and former smokers at an increased PCa risk in men aged 20–59 years but not in men aged ≥ 60 years while current smokers at a decreased PCa risk in men aged ≥ 60 years but not in men aged 20–59 years. Subgroup analyses across different socioeconomic statuses found that ever smokers with high education levels and family income were especially susceptible to increased PCa risk. Ever smokers of non-Hispanic White race also showed an increased PCa risk compared to never smokers. There are several explanations for these results. Burning cigarettes can produce at least 70 carcinogens, many of which play an important role in PCa carcinogenesis via various biological mechanisms [ 5 , 6 ]. Our study provided epidemiological evidence on the positive association between cigarette use and risk of PCa, which was consistent with several prospective cohort studies [ 17 – 19 ] and high-quality meta-analyses [ 11 , 13 ]. The REDUCE study found no association between former or current smoking and total PCa risk could probably be due to the short follow-up time of only 4 years as reported, which is not long enough to see the occurrence of PCa [ 12 ]. The lower risk of PCa in current smokers can probably be attributed to a lower likelihood of PSA testing compared to non-smokers [ 6 , 13 , 14 , 20 ]. Investigational studies have proved that smokers were at risk of PCa but less willing to undergo PSA screen [ 21 , 22 ] and prostate biopsy [ 12 , 23 ]. In addition, smokers were reported to have an 8–12% decrease in PSA level compared to never smokers, which may further reduce the possibility of the next-step prostate biopsy [ 24 ]. As a result, the detection bias could have attenuated the true association of cigarette use with PCa risk, especially for the low-grade or low-risk PCa that is often asymptomatic [ 25 ]. Better socioeconomic status was associated with an increased risk of PCa [ 26 ]. Men with higher education level and family income were more likely to have higher health literacy, better health-related behaviors, and access to healthcare resources [ 27 ], therefore were more likely to do PSA testing [ 22 , 28 , 29 ] and prostate biopsy [ 23 ]. Current smokers in our study had lower percentages of having a college or above education level and high family income, which may lead to a decreased risk of being diagnosed with PCa. Black men in the US have a nearly 1.8 times higher population-level incidence rate than White men [ 30 ]. Determinants of this racial disparity are multifactorial, including socioeconomic and biological factors [ 31 , 32 ]. Black men were more likely to undergo PSA testing and be referred to urology for PCa compared to White men [ 33 ]. We did not find an increased PCa risk in ever smokers of the Black race or any race other than White, which could probably be due to the small sample size of these races. Several other reasons are responsible for the lower risk of PCa in elderly current smokers. The US Preventative Services Task Force recommends against PSA-based screening for PCa in men 70 years and older, and for men aged 55–69 years, the decision to undergo periodic PSA-based screening for PCa should be individualized [ 34 ]. Furthermore, clinicians may stop testing PSA in individuals with short life expectancy or poor performance status to avoid overdiagnosis and overtreatment due to a high proportion of being indolent PCa in a screening setting [ 35 – 37 ], and the older men are less likely to test PSA and undergo a biopsy on their own initiative [ 23 , 28 ]. Besides, elderly smokers may die from more aggressive smoking attributable cancers before the diagnosis of PCa. According to the 2022 data from the American Cancer Society [ 38 ], lung cancer was the leading cause of cancer death in the US. Approximately 81.7% lung cancer deaths were caused by cigarette smoking directly [ 39 ], followed by cancer deaths of larynx (73.8%), esophagus (50.0%), and bladder (46.9%). Heart diseases, chronic lower respiratory diseases, and cerebrovascular diseases were also the most common causes of death in the US [ 38 ], and the majority of deaths from these diseases might be attributed to smoking [ 40 ]. Recent US cancer statistics [ 38 ] indicated that the probability of PCa increases from 1.8% in men aged 50–59 years to 5.1% in men aged 60–69 years, and to 9.0% in men aged 70 years and older, but the prevalence of PCa among the elderly is still vastly underestimated. More than 40% of men > 60 years were identified asymptomatic PCa according to an autopsy series of individuals not screened for PCa and died for causes other than PCa [ 41 ], and the proportion increased to 60% in men > 80 years. The worldwide PCa burden is predicted to grow to almost 2.3 million new cases and 740 000 deaths by 2040 [ 42 ]. Although evidence show that PCa incidence and mortality have been on the decline or have stabilized recently in many high-income countries [ 42 ], the national economic burden associated with cancer care is still substantial, approximately 3.3 billion dollars in the US according to the 2019 annual report [ 43 ]. Cigarette use at PCa diagnosis has showed close associations with aggressive tumor features [ 5 ] and higher risks of tumor recurrence, metastasis, and mortality [ 44 , 45 ], suggesting that it is essential to promote smoking cessation for the benefit of improving prognosis of PCa patients. Our study demonstrated a positive association between cigarette use and PCa risk, and the findings could further emphasize the importance of smoking cessation to prevent the development of PCa. Improving PCa screen in current smokers especially in those with old age and low socioeconomic status is needed, therefore promoting early diagnosis and treatment of PCa in this population. Strengths and Limitations Major strengths of this study include the use of nationally representative survey, implement of a series of subgroup analyses, inclusion of interaction between age and cigarette use, and adjustment for potential confounding factors, implying that our findings have great robustness and generalization. This study also has several limitations. First, we cannot avoid the risk of residual confounding by unmeasured covariates as this is a secondary analysis. Specifically, we did not adjust for the family history of PCa, because these data were only available from 2003 to 2008, and the inclusion of this covariate will reduce sample size. Second, covariates collected at baseline may change over time, and the use of self-reported questionnaires is subject to recall bias and misreporting. Third, owing to the nature of the observational study design, our findings should be interpreted with caution for inference of causality between cigarette use and PCa. Conclusions Our findings suggest that cigarette use was associated with a higher risk of PCa in US males, especially among those who were aged 20–59 years old, and this association was persistent after adjustment for potential confounders. Cigarette use is a modifiable risk factor representing a target for further research into preventing PCa in males. Abbreviations PCa Prostate cancer PSA Prostate-specific antigen NHANES National Health and Nutrition Examination Survey US United States CAPI Computer-assisted personal interview PIR Poverty-to-income ratio BMI Body mass index SD Standard deviation OR Odds ratio CI Confidence interval NA Not available. Declarations Ethics approval and consent to participate This study used data from the National Health and Nutrition Examination Survey (NHANES), which was approved by the National Center for Health Statistics Research Ethics Review Board. All participants provided written informed consent at enrollment. Consent for publication Not applicable. Availability of data and materials Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2020 are publicly available online (https://wwwn.cdc.gov/nchs/nhanes/). Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Sanming Project of Medicine in Shenzhen (grant number: SZSM202011011). The funder had no role in the study design, data collection, analysis and interpretation, or writing of the report. Authors’ contributions XWY, HC, YSW, and JP conceived the study design and are responsible for the overall content. XWY and HC conducted the data analysis and interpretation. JFZ and SQZ assessed and verified the data. XWY and HC drafted the manuscript, and YSW and JP revised the final article. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. 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Jr. Biases in Recommendations for and Acceptance of Prostate Biopsy Significantly Affect Assessment of Prostate Cancer Risk Factors: Results From Two Large Randomized Clinical Trials. J Clin Oncol. 2016;34(36):4338–44. Li J, Thompson T, Joseph DA, Master VA. Association between smoking status, and free, total and percent free prostate specific antigen. J Urol. 2012;187(4):1228–33. Moschini M, Carroll PR, Eggener SE, Epstein JI, Graefen M, Montironi R, et al. Low-risk Prostate Cancer: Identification, Management, and Outcomes. Eur Urol. 2017;72(2):238–49. Coughlin SS. A review of social determinants of prostate cancer risk, stage, and survival. Prostate Int. 2020;8(2):49–54. McMaughan DJ, Oloruntoba O, Smith ML. Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. Front Public Health. 2020;8:231. Johnson JA, Moser RP, Ellison GL, Martin DN. Associations of Prostate-Specific Antigen (PSA) Testing in the US Population: Results from a National Cross-Sectional Survey. J Community Health. 2021;46(2):389–98. Moses KA, Zhao Z, Bi Y, Acquaye J, Holmes A, Blot WJ, et al. The impact of sociodemographic factors and PSA screening among low-income Black and White men: data from the Southern Community Cohort Study. Prostate Cancer Prostatic Dis. 2017;20(4):424–9. Mahal BA, Gerke T, Awasthi S, Soule HR, Simons JW, Miyahira A, et al. Prostate Cancer Racial Disparities: A Systematic Review by the Prostate Cancer Foundation Panel. Eur Urol Oncol. 2022;5(1):18–29. Hinata N, Fujisawa M. Racial Differences in Prostate Cancer Characteristics and Cancer-Specific Mortality: An Overview. World J Mens Health. 2022;40(2):217–27. Chowdhury-Paulino IM, Ericsson C, Vince R, Spratt DE, George DJ, Mucci LA. Racial disparities in prostate cancer among black men: epidemiology and outcomes. Prostate Cancer Prostatic Dis. 2022;25(3):397–402. Lu CD, Adeyemi O, Anderson WE, Hetherington TC, Slawson DC, Tapp H, et al. Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study. J Urol. 2021;206(2):270–8. Grossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, Davidson KW, et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(18):1901–13. Mottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2021;79(2):243–62. Ploussard G, Epstein JI, Montironi R, Carroll PR, Wirth M, Grimm M-O, et al. The contemporary concept of significant versus insignificant prostate cancer. Eur Urol. 2011;60(2):291–303. Ilic D, Djulbegovic M, Jung JH, Hwang EC, Zhou Q, Cleves A, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1). Islami F, Goding Sauer A, Miller KD, Siegel RL, Fedewa SA, Jacobs EJ, et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018;68(1):31–54. Thun MJ, Carter BD, Feskanich D, Freedman ND, Prentice R, Lopez AD, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351–64. Zlotta AR, Egawa S, Pushkar D, Govorov A, Kimura T, Kido M, et al. Prevalence of prostate cancer on autopsy: cross-sectional study on unscreened Caucasian and Asian men. J Natl Cancer Inst. 2013;105(14):1050–8. Culp MB, Soerjomataram I, Efstathiou JA, Bray F, Jemal A. Recent Global Patterns in Prostate Cancer Incidence and Mortality Rates. Eur Urol. 2020;77(1):38–52. Yabroff KR, Mariotto A, Tangka F, Zhao J, Islami F, Sung H et al. Annual Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden Associated With Cancer Care. J Natl Cancer Inst. 2021;113(12):1670-82. Foerster B, Pozo C, Abufaraj M, Mari A, Kimura S, D'Andrea D, et al. Association of Smoking Status With Recurrence, Metastasis, and Mortality Among Patients With Localized Prostate Cancer Undergoing Prostatectomy or Radiotherapy: A Systematic Review and Meta-analysis. JAMA Oncol. 2018;4(7):953–61. Darcey E, Boyle T. Tobacco smoking and survival after a prostate cancer diagnosis: A systematic review and meta-analysis. Cancer Treat Rev. 2018;70:30–40. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3959116","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274782436,"identity":"66f3a97b-3d94-46b3-8671-a8abfef43d4e","order_by":0,"name":"Xiangwei Yang","email":"","orcid":"","institution":"The Seventh Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Xiangwei","middleName":"","lastName":"Yang","suffix":""},{"id":274782437,"identity":"d84ca763-92a3-4c6c-8192-573e48b730ec","order_by":1,"name":"Hong Chen","email":"","orcid":"","institution":"University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Chen","suffix":""},{"id":274782438,"identity":"566bf086-380f-4586-9646-b59c4cc1e3e2","order_by":2,"name":"Junfu Zhang","email":"","orcid":"","institution":"The Seventh Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Junfu","middleName":"","lastName":"Zhang","suffix":""},{"id":274782439,"identity":"2b455960-6adf-4d75-900c-b7b552ad3dc8","order_by":3,"name":"Shiqiang Zhang","email":"","orcid":"","institution":"The Seventh Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Shiqiang","middleName":"","lastName":"Zhang","suffix":""},{"id":274782440,"identity":"7c7ad07e-c62e-4571-b8b6-e20b46c729d9","order_by":4,"name":"Yongda Socrates Wu","email":"","orcid":"","institution":"Children's Hospital of Eastern Ontario Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Yongda","middleName":"Socrates","lastName":"Wu","suffix":""},{"id":274782441,"identity":"6fd8b787-0292-4db7-b5be-323adbc65be3","order_by":5,"name":"Jun Pang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYLACCQYGOX4gfeABTISHCC3Gkg1ALQlEawGCxA0HgCRRWszZzx5+Ydl2h3HztcMPgbbUJc6fkcD44G0bg7w5Di2WPXlpFpJtz5jNbqcZALUcTtxwI4HZcG4bg+HOBuxaDA7kmBlIth1mM7udANJyIHGDRAKbNG8bA5CLQ8v5N2AtPMaz0z/AHMb+G6+WGznGD4BaJAykc0C2MCc23EhgY8anxXLGGzMGiXOHDSRu5xQcSDA4bLzhzMNmyTnnJAw34NBizp9j/Fmi7HB9/+z0zR8+VNTJzm9PPvjhTZmNPE6HMTCwSUsgcR0bGBgbGMDRiwMAtTB//IAkYI9T6SgYBaNgFIxYAADurmGbFEsGiAAAAABJRU5ErkJggg==","orcid":"","institution":"The Seventh Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Jun","middleName":"","lastName":"Pang","suffix":""}],"badges":[],"createdAt":"2024-02-15 16:02:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3959116/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3959116/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-21863-9","type":"published","date":"2025-02-13T15:57:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51719840,"identity":"509ce36c-d40b-4daa-9ad5-2f942055af4e","added_by":"auto","created_at":"2024-02-27 21:40:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25080,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart. NHANES, National Health and Nutrition Examination Survey; PCa, prostate cancer.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3959116/v1/de09ad9d5dc199e508f2e704.png"},{"id":76487529,"identity":"130be184-abe3-4e04-b882-ae552b548202","added_by":"auto","created_at":"2025-02-17 16:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1046430,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3959116/v1/6dd52659-c24a-463b-a9ef-d6dcb86fa101.pdf"},{"id":51719837,"identity":"656e3f51-dec9-4e36-8cf9-2c287f3dfdb2","added_by":"auto","created_at":"2024-02-27 21:40:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":29792,"visible":true,"origin":"","legend":"","description":"","filename":"Additonalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3959116/v1/a80481c8e4e8d573071c5765.docx"},{"id":51719839,"identity":"933de1d1-c057-4591-bdd7-07747e9d1458","added_by":"auto","created_at":"2024-02-27 21:40:55","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":28269,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3959116/v1/9a2db70f73bfef0de63eea21.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of cigarette use with risk of prostate cancer among US males: a cross-sectional study from NHANES 1999-2020","fulltext":[{"header":"Background","content":"\u003cp\u003eProstate cancer (PCa) is the second most common cancer and the fifth leading cause of cancer death in men, with an estimated 1.4\u0026nbsp;million new cases and 375 000 deaths in 2020 worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Age, race, family history, and germline mutations (e.g., BRCA2, HOXB13, and CHEK2) are well-established nonmodifiable risk factors for PCa [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Modifiable risk factors of PCa, such as environmental exposure, infection, lifestyle, and dietary intake, have also been widely discussed [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Smoking is a well-known modifiable cause for cancers of 18 sites, the most common of which are the lung, head and neck, bladder, and esophagus [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Several studies have revealed potential biological mechanisms between smoking and PCa carcinogenesis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Smoking can result in increased prostatic inflammation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which was reported to be associated with the development of PCa [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Smoking can also increase testosterone concentrations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and a higher level of testosterone was associated with an increased risk of PCa [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the epidemiological association between smoking and risk of PCa is still a matter of debate, with inconsistent results across different studies [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A meta-analysis of 24 cohort studies demonstrated that former smokers had a higher risk of PCa compared to never smokers, and current smokers showed a statistically significant elevated risk of PCa in data stratified by the amount smoked [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Results from another study (REDUCE) among men with negative pre-study biopsy found that former and current smoking were not associated with total or low-grade PCa risk but current smoking was associated with an increased risk of high-grade PCa [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Islami et al. found that ever smoking was positively associated with PCa risk in studies completed before the prostate-specific antigen (PSA) screening era; in overall analyses, current smoking was negatively associated with the occurrence of incident PCa [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A recent pooled study involving 5 Swedish cohorts showed that current smoking as associated with a lower risk of PCa, which was most pronounced for low-risk PCa [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this cross-sectional study, we investigate the association of cigarette use with the risk of PCa using the nationally representative data from the National Health and Nutrition Examination Survey (NHANES), and we specifically focused on the PCa risks across different age groups, which were not explored in previous studies. The findings could contribute to the literature by updating earlier research about cigarette use and PCa risk and help policymakers and healthcare professionals make decisions on smoking management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe NHANES is a population-based repeated survey conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention and designed to assess the health and nutritional status of adults and children in the United States (US). The survey combines both in-home interviews and physical examinations. The in-home interviews include demographic, socioeconomic, dietary, and health-related questions. The physical examinations are performed in a mobile exam center, consisting of medical, dental, and physiological measurements, as well as laboratory tests administered by trained medical personnel. The NHANES uses a complex 4-stage survey design to obtain a nationally representative sample and certain groups (racial and ethnic minority groups, individuals with lower income, etc.) are intentionally oversampled to increase precision for subgroup estimates. Data collection for this program was conducted continuously in 2-year cycles since 1999, with a sample of approximately 5000 persons each year. More details regarding NHANES study procedures can be found on the official website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.cdc.gov/nchs/nhanes/index.htm\u003c/span\u003e\u003cspan address=\"http://www.cdc.gov/nchs/nhanes/index.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, we used data of NHANES from 1999 through 2020. Participants were included in the analysis if they were males and aged 20 years or older at the time of participation. This age range was appropriate because target NHANES questions on cancer history provided an age limit of 20\u0026ndash;150 years old. The NHANES study has been continuously approved by the National Center for Health Statistics Research Ethics Review Board since 1999. All participants provided written informed consent at enrollment. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines for cross-sectional studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of cigarette use\u003c/h2\u003e \u003cp\u003eQuestions on cigarette use were asked by trained interviewers using the computer-assisted personal interview (CAPI) system. The CAPI system was programmed with built-in consistency checks to reduce data entry errors, and the collected data were reviewed by the NHANES field office staff for accuracy and completeness. Smoking status was assessed by the question \u0026ldquo;Have you ever smoked at least 100 cigarettes in your lifetime?\u0026rdquo;. Participants who reported having smoked at least 100 cigarettes in their lifetime were defined as ever smokers; otherwise, they were defined as never smokers. Ever smokers were further asked \u0026ldquo;If yes, are you still smoking cigarettes currently?\u0026rdquo;, those who still smoked cigarettes at the time of investigation were defined as current smokers, and those who had quitted were defined as former smokers. We calculated smoking duration (years) based on participants\u0026rsquo; age at the time of investigation and questions including \u0026ldquo;How old were you when you first started to smoke cigarettes fairly regularly?\u0026rdquo; for current and former smokers and \u0026ldquo;How long has it been since you quit smoking cigarettes?\u0026rdquo; for former smokers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAscertainment of prostate cancer\u003c/h2\u003e \u003cp\u003eThe primary outcome was self-reported diagnosis of PCa, which was based on the participant\u0026rsquo;s response to the following questions: \u0026ldquo;Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?\u0026rdquo; and \u0026ldquo;What kind of cancer?\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of covariates\u003c/h2\u003e \u003cp\u003eThis study adjusted for several demographic covariates. Age was stratified as 20 to 59 and 60 or more years old. Race was recoded as Hispanic (Mexican American and other Hispanic), non-Hispanic White, non-Hispanic Black, and other races (including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, or unknown). Education level was categorized as less than high school, high school or equivalent, some college, and college graduate or above. Marital status was grouped as married/living with partner, widowed/divorced/separated, and never married. Family income was evaluated using the poverty-to-income ratio (PIR, a ratio of family income to poverty level) and categorized into low income (PIR\u0026thinsp;\u0026le;\u0026thinsp;1), middle income (PIR 1\u0026ndash;4), and high income (PIR\u0026thinsp;\u0026ge;\u0026thinsp;4) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Body mass index (BMI), calculated as weight in kilograms divided by height in meters squared, was categorized as underweight (\u0026lt;\u0026thinsp;18.5), normal (\u0026ge;\u0026thinsp;18.5 \u0026amp; \u0026lt;25), overweight (\u0026ge;\u0026thinsp;25 \u0026amp; \u0026lt;30), and obesity (\u0026ge;\u0026thinsp;30).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed from June 4 to November 30, 2023. Participants\u0026rsquo; characteristics were described by mean (standard deviation, SD) and frequencies (weighted percentages) and compared by cigarette use using Chi-square test, t test, and one-way analysis of variance as appropriate. Multivariable logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) for the associations of cigarette use with risk of PCa, adjusting for age, race, education level, marital status, family income, and BMI. Interaction of age and cigarette use was explored based on evidence that the risk of PCa varies by age [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In addition, we conducted dose-response analyses for the associations of smoking duration (years) with risk of PCa among former and current smokers respectively. Finally, subgroup analyses were conducted across different groups of age, race, education level, and family income.\u003c/p\u003e \u003cp\u003eAll analyses were conducted in Stata version 16 (StataCorp). Appropriate sample weights were constructed after combing survey cycles, and we used the Taylor series linearization method to calculate the variance for subpopulations of interest accounting for the complex survey design. All P values were from 2-sided tests and results were deemed statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eOf the 107 622 participants in 1999\u0026ndash;2020 NHANES, there were 28 250 males aged 20 years or older; 45 and 35 of these males were excluded due to unavailable data on PCa history and cigarette use. A total of 28 170 participants representing 104 893 498 US males were included in this analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean (SD) age of participants was 46.4 (16.4) years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e); 6976 (14.5%) were Hispanic, 12 464 (68.0%) were non-Hispanic White, and 6030 (10.4%) were non-Hispanic Black. Compared to never smokers, more former smokers but fewer current smokers were aged 60 years or older, married/living with partner, overweight and obesity (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). More former and current smokers had high school or lower education level and low-middle family income than never smokers (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Fewer former smokers but more current smokers than never smokers were non-Hispanic Black (6.2% vs 13.6% vs 11.4%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Comparisons of participants\u0026rsquo; characteristics between ever smokers and never smokers are shown in Additional file 1.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of study participants\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eCigarette use, No. (weighted %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;28170)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNever (n\u0026thinsp;=\u0026thinsp;12593)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCurrent (n\u0026thinsp;=\u0026thinsp;6931)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFormer (n\u0026thinsp;=\u0026thinsp;8646)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, mean (SD), years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.4 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.7 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.9 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54.2 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9294 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5114 (44.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2836 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1344 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8924 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4047 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2537 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2340 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9952 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3432 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1558 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4962 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6976 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3282 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1572 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2122 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12464 (68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4991 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2952 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4521 (75.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic Black\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6030 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2847 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1841 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1342 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2700 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1473 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e566 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e661 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7848 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2800 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2477 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2571 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or equivalent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6727 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2642 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2016 (32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2069 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome college\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7377 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3371 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1790 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2216 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege graduate or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6180 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3762 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e639 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1779 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/living with partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18137 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8157 (68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3762 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6218 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed/divorced/separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4512 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1506 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1427 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1579 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5267 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2831 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1664 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e772 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4831 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1819 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1830 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1135 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13565 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5776 (44.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3398 (54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4435 (50.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7017 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3738 (44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1006 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2273 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7072 (26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3038 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2358 (36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1676 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10117 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4548 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2239 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3330 (41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObesity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8645 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4025 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1695 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2925 (39.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e334 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e179 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD, standard deviation; BMI, body mass index.\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e Accounting for sampling weights.\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Calculated by Chi-square test or one-way analysis of variance.\u003c/p\u003e \u003cp\u003e \u003csup\u003ec\u003c/sup\u003e Other race/ethnicity includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, or unknown.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAssociations between cigarette use and risk of prostate cancer\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that compared to never smokers, an increased risk of PCa was found in former smokers (aOR, 3.54 [95% CI, 1.60\u0026ndash;7.79]) and ever smokers (aOR, 2.23 [95% CI, 1.06\u0026ndash;4.68]) but not in current smokers (aOR, 1.04 [95% CI, 0.38\u0026ndash;2.85]), adjusting for age, race, education level, marital status, family income, BMI, and interaction of age and cigarette use. Dose-response analyses showed that longer smoking duration was associated with an increased risk of PCa in current smokers (aOR, 1.07 [95% CI, 1.03\u0026ndash;1.11]) but not in former smokers (aOR, 1.00 [95% CI, 0.99\u0026ndash;1.02]), adjusting for age, race, education level, marital status, family income, and BMI.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of cigarette use with prostate cancer\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExposures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDiagnosed with prostate cancer\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP for interaction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCigarette use\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.18 (1.78\u0026ndash;2.67)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.54 (1.60\u0026ndash;7.79)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.47 (0.33\u0026ndash;0.66)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.04 (0.38\u0026ndash;2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.40 (1.15\u0026ndash;1.69)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.23 (1.06\u0026ndash;4.68)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking duration, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.04 (1.03\u0026ndash;1.05)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00 (0.99\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.11 (1.09\u0026ndash;1.13)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07 (1.03\u0026ndash;1.11)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOR, odds ratio; CI, confidence interval; NA, not available\u003c/p\u003e \u003cp\u003e \u003csup\u003e***\u003c/sup\u003e P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003csup\u003e**\u003c/sup\u003e P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003csup\u003e*\u003c/sup\u003e P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e Reference group\u0026thinsp;=\u0026thinsp;never smokers\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Adjusted for age, race, education level, marital status, family income, and body mass index for \u0026ldquo;Smoking duration\u0026rdquo;; additionally adjusted for interaction of age and cigarette use for \u0026ldquo;Cigarette use\u0026rdquo;.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that in participants aged 20\u0026ndash;59 years, an increased risk of PCa was found in former (aOR, 3.81 [95% CI, 1.69\u0026ndash;8.59]) and ever smokers (aOR, 2.77 [95% CI, 1.25\u0026ndash;6.13]) but not in current smoker (aOR, 1.43 [95% CI, 0.53\u0026ndash;3.87]). In participants aged 60 years or older, current smokers had decreased risks of PCa (aOR, 0.52 [95% CI, 0.32\u0026ndash;0.84]) while former smokers (aOR, 0.94 [95% CI, 0.75\u0026ndash;1.18]) and ever smokers (aOR, 0.86 [95% CI, 0.69\u0026ndash;1.07]) showed neither increased nor decreased PCa risks. Subgroup analyses across varying races, education levels, and family income showed that the increased risk of PCa among ever smokers was only evident in participants of non-Hispanic White race (aOR, 4.10 [95% CI, 1.13\u0026ndash;14.88]), in participants with education level of some college or above (aOR, 3.34 [95% CI, 1.52\u0026ndash;7.35]), and in participants with high family income (aOR, 2.94 [95% CI, 1.13\u0026ndash;7.62]) (Additional file 2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of cigarette use with prostate cancer by age groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExposures\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDiagnosed with prostate cancer\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude, OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eFor participants aged 20\u0026ndash;59 years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.35 (1.57\u0026ndash;7.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.81 (1.69\u0026ndash;8.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.14 (0.47\u0026ndash;2.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.43 (0.53\u0026ndash;3.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.14 (1.07\u0026ndash;4.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.77 (1.25\u0026ndash;6.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFor participants aged 60 years or older\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.91 (0.74\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94 (0.75\u0026ndash;1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.54 (0.35\u0026ndash;0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52 (0.32\u0026ndash;0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver smokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.83 (0.68\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86 (0.69\u0026ndash;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eOR, odds ratio; CI, confidence interval\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Reference group\u0026thinsp;=\u0026thinsp;never smokers;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Adjusted for race, education level, marital status, family income, and body mass index.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we firstly explored the associations between cigarette use and PCa risk by including the interaction effect between cigarette use and age, and found a positive association between former and ever cigarette use and PCa risk that persisted after adjustment for age, race, education level, marital status, family income, BMI, and interaction of age and cigarette use. Smoking duration was positively associated with PCa risk in current smokers. Interestingly, we firstly found the association varies by age groups, with ever and former smokers at an increased PCa risk in men aged 20\u0026ndash;59 years but not in men aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years while current smokers at a decreased PCa risk in men aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years but not in men aged 20\u0026ndash;59 years. Subgroup analyses across different socioeconomic statuses found that ever smokers with high education levels and family income were especially susceptible to increased PCa risk. Ever smokers of non-Hispanic White race also showed an increased PCa risk compared to never smokers.\u003c/p\u003e \u003cp\u003eThere are several explanations for these results. Burning cigarettes can produce at least 70 carcinogens, many of which play an important role in PCa carcinogenesis via various biological mechanisms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Our study provided epidemiological evidence on the positive association between cigarette use and risk of PCa, which was consistent with several prospective cohort studies [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and high-quality meta-analyses [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The REDUCE study found no association between former or current smoking and total PCa risk could probably be due to the short follow-up time of only 4 years as reported, which is not long enough to see the occurrence of PCa [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The lower risk of PCa in current smokers can probably be attributed to a lower likelihood of PSA testing compared to non-smokers [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Investigational studies have proved that smokers were at risk of PCa but less willing to undergo PSA screen [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and prostate biopsy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In addition, smokers were reported to have an 8\u0026ndash;12% decrease in PSA level compared to never smokers, which may further reduce the possibility of the next-step prostate biopsy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As a result, the detection bias could have attenuated the true association of cigarette use with PCa risk, especially for the low-grade or low-risk PCa that is often asymptomatic [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Better socioeconomic status was associated with an increased risk of PCa [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Men with higher education level and family income were more likely to have higher health literacy, better health-related behaviors, and access to healthcare resources [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], therefore were more likely to do PSA testing [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and prostate biopsy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Current smokers in our study had lower percentages of having a college or above education level and high family income, which may lead to a decreased risk of being diagnosed with PCa. Black men in the US have a nearly 1.8 times higher population-level incidence rate than White men [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Determinants of this racial disparity are multifactorial, including socioeconomic and biological factors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Black men were more likely to undergo PSA testing and be referred to urology for PCa compared to White men [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. We did not find an increased PCa risk in ever smokers of the Black race or any race other than White, which could probably be due to the small sample size of these races.\u003c/p\u003e \u003cp\u003eSeveral other reasons are responsible for the lower risk of PCa in elderly current smokers. The US Preventative Services Task Force recommends against PSA-based screening for PCa in men 70 years and older, and for men aged 55\u0026ndash;69 years, the decision to undergo periodic PSA-based screening for PCa should be individualized [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, clinicians may stop testing PSA in individuals with short life expectancy or poor performance status to avoid overdiagnosis and overtreatment due to a high proportion of being indolent PCa in a screening setting [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and the older men are less likely to test PSA and undergo a biopsy on their own initiative [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Besides, elderly smokers may die from more aggressive smoking attributable cancers before the diagnosis of PCa. According to the 2022 data from the American Cancer Society [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], lung cancer was the leading cause of cancer death in the US. Approximately 81.7% lung cancer deaths were caused by cigarette smoking directly [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], followed by cancer deaths of larynx (73.8%), esophagus (50.0%), and bladder (46.9%). Heart diseases, chronic lower respiratory diseases, and cerebrovascular diseases were also the most common causes of death in the US [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and the majority of deaths from these diseases might be attributed to smoking [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Recent US cancer statistics [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] indicated that the probability of PCa increases from 1.8% in men aged 50\u0026ndash;59 years to 5.1% in men aged 60\u0026ndash;69 years, and to 9.0% in men aged 70 years and older, but the prevalence of PCa among the elderly is still vastly underestimated. More than 40% of men\u0026thinsp;\u0026gt;\u0026thinsp;60 years were identified asymptomatic PCa according to an autopsy series of individuals not screened for PCa and died for causes other than PCa [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and the proportion increased to 60% in men\u0026thinsp;\u0026gt;\u0026thinsp;80 years.\u003c/p\u003e \u003cp\u003eThe worldwide PCa burden is predicted to grow to almost 2.3\u0026nbsp;million new cases and 740 000 deaths by 2040 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Although evidence show that PCa incidence and mortality have been on the decline or have stabilized recently in many high-income countries [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], the national economic burden associated with cancer care is still substantial, approximately 3.3\u0026nbsp;billion dollars in the US according to the 2019 annual report [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Cigarette use at PCa diagnosis has showed close associations with aggressive tumor features [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and higher risks of tumor recurrence, metastasis, and mortality [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], suggesting that it is essential to promote smoking cessation for the benefit of improving prognosis of PCa patients. Our study demonstrated a positive association between cigarette use and PCa risk, and the findings could further emphasize the importance of smoking cessation to prevent the development of PCa. Improving PCa screen in current smokers especially in those with old age and low socioeconomic status is needed, therefore promoting early diagnosis and treatment of PCa in this population.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eMajor strengths of this study include the use of nationally representative survey, implement of a series of subgroup analyses, inclusion of interaction between age and cigarette use, and adjustment for potential confounding factors, implying that our findings have great robustness and generalization. This study also has several limitations. First, we cannot avoid the risk of residual confounding by unmeasured covariates as this is a secondary analysis. Specifically, we did not adjust for the family history of PCa, because these data were only available from 2003 to 2008, and the inclusion of this covariate will reduce sample size. Second, covariates collected at baseline may change over time, and the use of self-reported questionnaires is subject to recall bias and misreporting. Third, owing to the nature of the observational study design, our findings should be interpreted with caution for inference of causality between cigarette use and PCa.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings suggest that cigarette use was associated with a higher risk of PCa in US males, especially among those who were aged 20\u0026ndash;59 years old, and this association was persistent after adjustment for potential confounders. Cigarette use is a modifiable risk factor representing a target for further research into preventing PCa in males.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCa\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProstate cancer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProstate-specific antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHANES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health and Nutrition Examination Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputer-assisted personal interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePoverty-to-income ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNot available.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used data from the National Health and Nutrition Examination Survey (NHANES), which was approved by the National Center for Health Statistics Research Ethics Review Board. All participants provided written informed consent at enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the National Health and Nutrition Examination Survey (NHANES) 1999-2020 are publicly available online (https://wwwn.cdc.gov/nchs/nhanes/).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the\u0026nbsp;Sanming Project of Medicine in Shenzhen (grant number: SZSM202011011).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe funder had no role in the study design, data collection, analysis and interpretation, or writing of the report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXWY, HC, YSW, and JP conceived the study design and are responsible for the overall content. XWY and HC conducted the data analysis and interpretation. JFZ and SQZ assessed and verified the data. XWY and HC drafted the manuscript, and YSW and JP revised the final article. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGandaglia G, Leni R, Bray F, Fleshner N, Freedland SJ, Kibel A, et al. Epidemiology and Prevention of Prostate Cancer. Eur Urol Oncol. 2021;4(6):877\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergengren O, Pekala KR, Matsoukas K, Fainberg J, Mungovan SF, Bratt O, et al. 2022 Update on Prostate Cancer Epidemiology and Risk Factors-A Systematic Review. Eur Urol. 2023;84(2):191\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaram-Hage M, Cinciripini PM, Gritz ER. Tobacco use and cessation for cancer survivors: an overview for clinicians. CA Cancer J Clin. 2014;64(4):272\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrookman-May SD, Campi R, Henr\u0026iacute;quez JDS, Klatte T, Langenhuijsen JF, Brausi M, et al. Latest Evidence on the Impact of Smoking, Sports, and Sexual Activity as Modifiable Lifestyle Risk Factors for Prostate Cancer Incidence, Recurrence, and Progression: A Systematic Review of the Literature by the European Association of Urology Section of Oncological Urology (ESOU). Eur Urol Focus. 2019;5(5):756\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang X, Chen H, Zhang S, Chen X, Sheng Y, Pang J. Association of cigarette smoking habits with the risk of prostate cancer: a systematic review and meta-analysis. BMC Public Health. 2023;23(1):1150.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith K, Byrne, Casta\u0026ntilde;o JM, Chirlaque MD, Lilja H, Agudo A, et al. Vasectomy and Prostate Cancer Risk in the European Prospective Investigation Into Cancer and Nutrition (EPIC). J Clin Oncol. 2017;35(12):1297\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Nunzio C, Kramer G, Marberger M, Montironi R, Nelson W, Schr\u0026ouml;der F, et al. The controversial relationship between benign prostatic hyperplasia and prostate cancer: the role of inflammation. Eur Urol. 2011;60(1):106\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Wang Y, Qin Z, Gao X, Xing Q, Li R, et al. Correlation between Prostatitis, Benign Prostatic Hyperplasia and Prostate Cancer: A systematic review and Meta-analysis. J Cancer. 2020;11(1):177\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatts EL, Appleby PN, Perez-Cornago A, Bueno-de-Mesquita HB, Chan JM, Chen C, et al. Low Free Testosterone and Prostate Cancer Risk: A Collaborative Analysis of 20 Prospective Studies. Eur Urol. 2018;74(5):585\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuncharek M, Haddock KS, Reid R, Kupelnick B. Smoking as a risk factor for prostate cancer: a meta-analysis of 24 prospective cohort studies. Am J Public Health. 2010;100(4):693\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo T, Howard LE, Vidal AC, Gerber L, Moreira D, McKeever M, et al. Smoking and risk of low- and high-grade prostate cancer: results from the REDUCE study. Clin Cancer Res. 2014;20(20):5331\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslami F, Moreira DM, Boffetta P, Freedland SJ. A systematic review and meta-analysis of tobacco use and prostate cancer mortality and incidence in prospective cohort studies. Eur Urol. 2014;66(6):1054\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJochems SHJ, Fritz J, Haggstrom C, Jarvholm B, Stattin P, Stocks T. Smoking and Risk of Prostate Cancer and Prostate Cancer Death: A Pooled Study. Eur Urol. 2023;83(5):422\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y-B, Chen C, Pan X-F, Guo J, Li Y, Franco OH, et al. Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies. BMJ. 2021;373:n604.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarlsen RV, Bidstrup PE, Christensen J, Larsen SB, Tj\u0026oslash;nneland A, Dalton SO, et al. Men with cancer change their health behaviour: a prospective study from the Danish diet, cancer and health study. Br J Cancer. 2012;107(1):201\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeybels MS, Verhage BAJ, van Schooten FJ, van den Brandt PA. Measures of combined antioxidant and pro-oxidant exposures and risk of overall and advanced stage prostate cancer. Ann Epidemiol. 2012;22(11):814\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafique K, McLoone P, Qureshi K, Leung H, Hart C, Morrison DS. Coffee consumption and prostate cancer risk: further evidence for inverse relationship. Nutr J. 2012;11:42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Fayez S, El-Metwally A. Cigarette smoking and prostate cancer: A systematic review and meta-analysis of prospective cohort studies. Tob Induc Dis. 2023;21:19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRolison JJ, Hanoch Y, Miron-Shatz T. Smokers: at risk for prostate cancer but unlikely to screen. Addict Behav. 2012;37(6):736\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLittlejohns TJ, Travis RC, Key TJ, Allen NE. Lifestyle factors and prostate-specific antigen (PSA) testing in UK Biobank: Implications for epidemiological research. Cancer Epidemiol. 2016;45:40\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTangen CM, Goodman PJ, Till C, Schenk JM, Lucia MS, Thompson IM. Jr. Biases in Recommendations for and Acceptance of Prostate Biopsy Significantly Affect Assessment of Prostate Cancer Risk Factors: Results From Two Large Randomized Clinical Trials. J Clin Oncol. 2016;34(36):4338\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Thompson T, Joseph DA, Master VA. Association between smoking status, and free, total and percent free prostate specific antigen. J Urol. 2012;187(4):1228\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoschini M, Carroll PR, Eggener SE, Epstein JI, Graefen M, Montironi R, et al. Low-risk Prostate Cancer: Identification, Management, and Outcomes. Eur Urol. 2017;72(2):238\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoughlin SS. A review of social determinants of prostate cancer risk, stage, and survival. Prostate Int. 2020;8(2):49\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcMaughan DJ, Oloruntoba O, Smith ML. Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. Front Public Health. 2020;8:231.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson JA, Moser RP, Ellison GL, Martin DN. Associations of Prostate-Specific Antigen (PSA) Testing in the US Population: Results from a National Cross-Sectional Survey. J Community Health. 2021;46(2):389\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoses KA, Zhao Z, Bi Y, Acquaye J, Holmes A, Blot WJ, et al. The impact of sociodemographic factors and PSA screening among low-income Black and White men: data from the Southern Community Cohort Study. Prostate Cancer Prostatic Dis. 2017;20(4):424\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahal BA, Gerke T, Awasthi S, Soule HR, Simons JW, Miyahira A, et al. Prostate Cancer Racial Disparities: A Systematic Review by the Prostate Cancer Foundation Panel. Eur Urol Oncol. 2022;5(1):18\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHinata N, Fujisawa M. Racial Differences in Prostate Cancer Characteristics and Cancer-Specific Mortality: An Overview. World J Mens Health. 2022;40(2):217\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChowdhury-Paulino IM, Ericsson C, Vince R, Spratt DE, George DJ, Mucci LA. Racial disparities in prostate cancer among black men: epidemiology and outcomes. Prostate Cancer Prostatic Dis. 2022;25(3):397\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu CD, Adeyemi O, Anderson WE, Hetherington TC, Slawson DC, Tapp H, et al. Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study. J Urol. 2021;206(2):270\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, Davidson KW, et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(18):1901\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2021;79(2):243\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePloussard G, Epstein JI, Montironi R, Carroll PR, Wirth M, Grimm M-O, et al. The contemporary concept of significant versus insignificant prostate cancer. Eur Urol. 2011;60(2):291\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIlic D, Djulbegovic M, Jung JH, Hwang EC, Zhou Q, Cleves A, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslami F, Goding Sauer A, Miller KD, Siegel RL, Fedewa SA, Jacobs EJ, et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018;68(1):31\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThun MJ, Carter BD, Feskanich D, Freedman ND, Prentice R, Lopez AD, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZlotta AR, Egawa S, Pushkar D, Govorov A, Kimura T, Kido M, et al. Prevalence of prostate cancer on autopsy: cross-sectional study on unscreened Caucasian and Asian men. J Natl Cancer Inst. 2013;105(14):1050\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCulp MB, Soerjomataram I, Efstathiou JA, Bray F, Jemal A. Recent Global Patterns in Prostate Cancer Incidence and Mortality Rates. Eur Urol. 2020;77(1):38\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYabroff KR, Mariotto A, Tangka F, Zhao J, Islami F, Sung H et al. Annual Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden Associated With Cancer Care. J Natl Cancer Inst. 2021;113(12):1670-82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoerster B, Pozo C, Abufaraj M, Mari A, Kimura S, D'Andrea D, et al. Association of Smoking Status With Recurrence, Metastasis, and Mortality Among Patients With Localized Prostate Cancer Undergoing Prostatectomy or Radiotherapy: A Systematic Review and Meta-analysis. JAMA Oncol. 2018;4(7):953\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarcey E, Boyle T. Tobacco smoking and survival after a prostate cancer diagnosis: A systematic review and meta-analysis. Cancer Treat Rev. 2018;70:30\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cigarette use, Prostate cancer, Risk, Cross-sectional, NHANES","lastPublishedDoi":"10.21203/rs.3.rs-3959116/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3959116/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAssociation of cigarette use with risk of prostate cancer remains unclear. We performed this study to examine whether cigarette use is associated with increased risk of prostate cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study used data from the 1999 to 2020 National Health and Nutrition Examination Survey (NHANES), a population-based nationally representative survey designed to assess the health and nutritional status of US adults and children. Males were eligible if they were aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years at the time of participation. Cigarette use (ever use, categorized into former use and current use) was defined as having smoked at least 100 cigarettes in life. Smoking duration was calculated in former smokers and current smokers. Primary outcome was self-reported diagnosis of prostate cancer by participants. Logistic regression was used to calculate the adjusted odd ratios (aOR) and 95% CI for the associations of cigarette use with risk of prostate cancer, adjusting for demographic characteristics. Subgroup analyses by age group were conducted. Data were analyzed from June 4 to November 30, 2023.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 107 622 participants in 1999\u0026ndash;2020 NHANES, 28 170 were included in the analysis. The mean (SD) age of the 28 170 participants was 46.4 (16.4) years, 68.0% were non-Hispanic White. Compared with never smokers, ever (aOR, 2.23 [95% CI, 1.06\u0026ndash;4.68]) and former smokers (aOR, 3.54 [95% CI, 1.60\u0026ndash;7.79]), but not current smokers (aOR, 1.04 [95% CI, 0.38\u0026ndash;2.85]) had a higher risk of prostate cancer. This higher risk in former (aOR, 3.81 [95% CI, 1.69\u0026ndash;8.59) and ever smokers (aOR, 2.77 [95% CI, 1.25\u0026ndash;6.13) was also found in participants aged 20\u0026ndash;59 years. But a lower risk was observed in current smokers aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years (aOR, 0.52 [95% CI, 0.32\u0026ndash;0.84). Dose-response analysis showed a positive association between smoking duration and risk of prostate cancer in current smokers (aOR, 1.07 [95% CI, 1.03\u0026ndash;1.11]) but not in former smokers (aOR, 1.00 [95% CI, 0.99\u0026ndash;1.02]).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study suggests that cigarette use was associated with an increased risk of prostate cancer in US males, especially among those aged 20\u0026ndash;59 years. This modifiable risk factor represents a target for further research into preventing prostate cancer in males.\u003c/p\u003e","manuscriptTitle":"Association of cigarette use with risk of prostate cancer among US males: a cross-sectional study from NHANES 1999-2020","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-27 21:40:40","doi":"10.21203/rs.3.rs-3959116/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-06T10:20:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-18T05:13:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-11-09T10:25:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-06T19:12:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143477215919573932155224570409529782726","date":"2024-08-28T23:55:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73438998438718810249053216457023652980","date":"2024-08-28T11:52:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-17T08:44:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T05:22:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-22T12:31:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-22T12:28:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-02-15T15:57:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82b51201-71e1-4422-8bd4-6d1db0133a09","owner":[],"postedDate":"February 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:02:55+00:00","versionOfRecord":{"articleIdentity":"rs-3959116","link":"https://doi.org/10.1186/s12889-025-21863-9","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-02-13 15:57:42","publishedOnDateReadable":"February 13th, 2025"},"versionCreatedAt":"2024-02-27 21:40:40","video":"","vorDoi":"10.1186/s12889-025-21863-9","vorDoiUrl":"https://doi.org/10.1186/s12889-025-21863-9","workflowStages":[]},"version":"v1","identity":"rs-3959116","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3959116","identity":"rs-3959116","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}