Associations of Cigarette Smoking With Subclinical Inflammation and Atherosclerosis: ELSA-Brasil (The Brazilian Longitudinal Study of Adult Health)

J Am Heart Assoc. 2017 Jun 24;6(6):e005088. doi: 10.1161/JAHA.116.005088.


Background: There is a need to identify sensitive biomarkers of early tobacco-related cardiovascular disease. We examined the association of smoking status, burden, time since quitting, and intensity, with markers of inflammation and subclinical atherosclerosis.

Methods and results: We studied 14 103 participants without clinical cardiovascular disease in ELSA-Brasil (Brazilian Longitudinal Study of Adult Health). We evaluated baseline cross-sectional associations between smoking parameters and inflammation (high-sensitivity C-reactive protein [hsCRP]) and measures of subclinical atherosclerosis (carotid intima-media thickness, ankle-brachial index, and coronary artery calcium [CAC]). The cohort included 1844 current smokers, 4121 former smokers, and 8138 never smokers. Mean age was 51.7±8.9 years; 44.8% were male. After multivariable adjustment, compared with never smokers, current smokers had significantly higher levels of hsCRP (β=0.24, 0.19-0.29 mg/L; P<0.001) and carotid intima-media thickness (β=0.03, 0.02-0.04 mm; P<0.001) and odds of ankle-brachial index ≤1.0 (odds ratio: 2.52; 95% confidence interval, 2.06-3.08; P<0.001) and CAC >0 (odds ratio: 1.83; 95% confidence interval, 1.46-2.30; P<0.001). Among former and current smokers, pack-years of smoking (burden) were significantly associated with hsCRP (P<0.001 and P=0.006, respectively) and CAC (P<0.001 and P=0.002, respectively). Among former smokers, hsCRP and carotid intima-media thickness levels and odds of ankle-brachial index ≤1.0 and CAC >0 were lower with increasing time since quitting (P<0.01). Among current smokers, number of cigarettes per day (intensity) was positively associated with hsCRP (P<0.001) and CAC >0 (P=0.03) after adjusting for duration of smoking.

Conclusions: Strong associations were observed between smoking status, burden, and intensity with inflammation (hsCRP) and subclinical atherosclerosis (carotid intima-media thickness, ankle-brachial index, CAC). These markers of early cardiovascular disease injury may be used for the further study and regulation of traditional and novel tobacco products.

Keywords: atherosclerosis; inflammation; smoking; subclinical atherosclerosis risk factor; tobacco products.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Ankle Brachial Index
  • Asymptomatic Diseases
  • Atherosclerosis / blood
  • Atherosclerosis / diagnostic imaging
  • Atherosclerosis / epidemiology*
  • Biomarkers / blood
  • Brazil / epidemiology
  • C-Reactive Protein / analysis
  • Carotid Artery Diseases / blood
  • Carotid Artery Diseases / diagnostic imaging
  • Carotid Artery Diseases / epidemiology*
  • Carotid Intima-Media Thickness
  • Chi-Square Distribution
  • Coronary Angiography
  • Coronary Artery Disease / blood
  • Coronary Artery Disease / diagnosis
  • Coronary Artery Disease / epidemiology*
  • Cross-Sectional Studies
  • Female
  • Humans
  • Inflammation / blood
  • Inflammation / diagnosis
  • Inflammation / epidemiology*
  • Inflammation Mediators / blood
  • Linear Models
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Prognosis
  • Prospective Studies
  • Risk Assessment
  • Risk Factors
  • Risk Reduction Behavior
  • Smoking / adverse effects*
  • Smoking / epidemiology*
  • Smoking Cessation
  • Time Factors


  • Biomarkers
  • Inflammation Mediators
  • C-Reactive Protein