Smoking as a risk factor for lower extremity peripheral artery disease in women compared to men: A systematic review and meta-analysis

Ying Xu; Anna Louise Pouncey; Zien Zhou; Mark Woodward; Katie Harris

doi:10.1371/journal.pone.0300963

Smoking as a risk factor for lower extremity peripheral artery disease in women compared to men: A systematic review and meta-analysis

PLoS One. 2024 Apr 24;19(4):e0300963. doi: 10.1371/journal.pone.0300963. eCollection 2024.

Authors

Ying Xu^{1

2}, Anna Louise Pouncey³, Zien Zhou¹, Mark Woodward^{1

4}, Katie Harris¹

Affiliations

¹ Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.
² Faculty of Medicine, Australian Institute of Health Innovation, Centre for Health Systems and Safety Research, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia.
³ Faculty of Medicine, Department of Vascular Surgery, Division of Surgery and Cancer, Imperial College London, QEQM, St Mary's Hospital, London, United Kingdom.
⁴ The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom.

Abstract

Background: To investigate whether the relationship between smoking and peripheral artery disease (PAD) differs by sex (PROSPERO CRD42022352318).

Methods: PubMed, EMBASE, and CINAHL were searched (3 March 2024) for studies reporting associations between smoking and PAD in both sexes, at least adjusted for age. Data were pooled using random effects. Between-study heterogeneity was examined using I2 statistic and Cochran's Q test. Newcastle-Ottowa Scale was adopted for quality assessment.

Results: Four cohort studies (n = 2,117,860, 54.4% women) and thirteen cross-sectional studies (n = 230,436, 59.9% women) were included. In cohort studies, former and current smokers had higher risk of PAD than never smokers. Compared to those who never or previously smoked, women current smokers (relative risk (RR) 5.30 (95% confidence interval 3.17, 8.87)) had higher excess risk of PAD than men (RR 3.30 (2.46, 4.42)), women-to-men ratio of RR 1.45 (1.30, 1.62)(I2 = 0%, p = 0.328). In cross-sectional studies, risk of PAD was higher among former and current compared to never smokers, more so in men, women-to-men ratios of odds ratio: 0.64 (0.46, 0.90)(I2 = 30%, p = 0.192), 0.63 (0.50, 0.79)(I2 = 0%, p = 0.594), respectively. For both sexes, risk of PAD was higher among current smokers compared to those who were not currently smoking. Cohort studies and five cross-sectional studies were of good quality, scoring 6 to 8 of a possible maximum 9 points. Eight cross-sectional studies scored 2 to 5.

Discussions: Further research is required to elucidate sex differences in the relationships between smoking and PAD, as the current evidence is limited and mixed. Tobacco-control programs should consider both sexes.

Copyright: © 2024 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication types

Systematic Review
Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Cross-Sectional Studies
Female
Humans
Lower Extremity* / blood supply
Male
Peripheral Arterial Disease* / epidemiology
Peripheral Arterial Disease* / etiology
Risk Factors
Sex Factors
Smoking* / adverse effects

Grants and funding

This work is supported by the GeorgeThink, an institutional seed funding award, from The George Institute for Global Health. ALP is supported by a National Institute for Health and Care Research (NIHR) Doctoral Fellowship (NIHR301767). ZZ is supported by the NSW Cardiovascular Elite Postdoctoral Researcher Grant (H23/15813) from NSW Health, Australia. MW is supported by an Australian NHMRC Investigator Grant, Leadership 2 (APP1174120), and Program Grant (APP1149987). The funders had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.