Association of Smoking with Lower Urinary Tract Symptoms
ABSTRACT & COMMENTARY
Synopsis: It appears clear that current or former smoking increases the risk of lower urinary tract symptoms in middle-aged and elderly men.
Source: Koskimaki J, et al. J Urol 1998;159:1580-1582.
Smoking is the most important cause of bladder cancer. The association of smoking and benign prostatic hyperplasia, which is responsible for most lower urinary tract symptoms in older men, is less clear. A recent study from Koskimaki and colleagues was undertaken to evaluate the association of smoking with lower urinary tract symptoms.
Using a mail questionnaire, the authors conducted a population-based study out of Tampere, Finland, and 11 rural or semirural areas in a single county. There were 3143 men born in 1924, 1934, or 1944 in that county who were 50, 60, or 70 years old in 1994, when the study was conducted. Sixty-eight percent of the men comprised the study group after exclusions for missing smoking questions, renal failure, and several other criteria. A modified Danish Prostate Symptom Score-1 was used to assess urinary symptoms and associated bothersomeness.
The symptom index was obtained by: 1) multiplying the symptoms and bothersomeness scores of hesitancy, incomplete emptying, urge, incontinence, nocturia, and daytime frequency, and 2) adding all the scores together. Symptoms and bothersomeness were assessed on a scale of 0 to 3, with 3 being the most severe. The symptom index for lower urinary tract symptoms was considered positive when it totaled seven points. Smoking was defined as current, former, or never if the individual had been currently smoking for at least one year, at least a one-year history of smoking at sometime in the past but not currently, and no history or less than one-year history of smoking in the past, respectively.
Overall, 20% were non-smokers. The prevalence of lower urinary tract symptoms (symptom score 7 or higher) was significantly higher in men who smoked currently or formerly than in those who never smoked. Overall, 59% men ranked between 1 and 6 on the symptom index, and only 24% had a score of seven points or more. The proportion of men with a score of 7 or greater increased with age. Only 13% of 50-year-olds scored 7 or greater, compared with 28% of 60-year-olds and 32% of 70-year-olds.
The age-adjusted odds ratios for lower urinary tract symptoms for current and former smokers were 1.47 and 1.38, respectively, compared with non-smokers. After adjustment for alcohol consumption, body mass index, previous prostate surgery, pelvic area surgery, prostate cancer, and bladder cancer, the odds ratios for a high symptom index were still statistically significant for current and former smokers at 1.39 and 1.34, respectively, compared with non-smokers. Generally, the risk of symptoms increased with years of smoking, The risk clearly declined in former smokers by years after cessation of smoking, and 40 years after cessation of smoking, the risk of lower urinary tract symptoms was the same as in the non-smokers.
COMMENT BY KAMALJIT SETHI, MD
Smoking causes much more then lung cancer. In a 40-year follow-up study of British physicians, a strong association was reported between smoking and increased mortality from as many as 24 causes.1
While the precise mechanism is not known, it appears clear that current or former smoking increases the risk of lower urinary tract symptoms in middle-aged and elderly men. The changes caused by smoking start early. They may be reversible after cessation of smoking, but recovery takes a long time (40 years according to this study). A simple mathematical example to ponder upon--a couple of years of teenage smoking in a young man buys at least 40 years of additional risk for all smoking-related problems, including lower urinary tract symptoms. It is time to call the question, the current cigar fad notwithstanding, to smoke or not to smoke? Perhaps even Hamlet would not have had a question.
Reference
1. Doll, et al. BMJ 1994;309:901.
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