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Combined effects of overweight and smoking in late adolescence on subsequent mortality: nationwide cohort study

BMJ 2009; 338 doi: (Published 25 February 2009) Cite this as: BMJ 2009;338:b496
  1. Martin Neovius, postdoctoral fellow12,
  2. Johan Sundström, associate professor3,
  3. Finn Rasmussen, professor2
  1. 1Clinical Epidemiology Unit, Department of Medicine, Karolinska Institute, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
  2. 2Department of Public Health Sciences, Karolinska Institute, Karolinska University Hospital (Norrbacka)
  3. 3Department of Medical Sciences, Uppsala University Hospital, SE-75185 Uppsala, Sweden
  1. Correspondence to: M Neovius martin.neovius{at}
  • Accepted 17 November 2008


Objective To investigate the combined effects on adult mortality of overweight and smoking in late adolescence.

Design Record linkage study with Cox proportional hazard ratios adjusted for muscle strength, socioeconomic position, and age.

Setting Swedish military service conscription register, cause of death register, and census data.

Participants 45 920 Swedish men (mean age 18.7, SD 0.5) followed for 38 years.

Main outcome measures Body mass index (underweight (BMI <18.5), normal weight (18.5-24.9), overweight (25-29.9), and obesity (≥30)), muscle strength, and self reported smoking (non-smoker, light smoker (1-10 cigarettes/day), heavy smoker (>10/day)) at mandatory military conscription tests in 1969-70. All cause mortality.

Results Over 1.7 million person years, 2897 men died. Compared with normal weight men (incidence rate 17/10 000 person years, 95% confidence interval 16 to 18), risk of mortality was increased in overweight (hazard ratio 1.33, 1.15 to 1.53; incidence rate 23, 20 to 26) and obese men (hazard ratio 2.14, 1.61 to 2.85; incidence rate 38, 27 to 48), with similar relative estimates in separate analyses of smokers and non-smokers. No increased risk was detected in underweight men (hazard ratio 0.97, 0.86 to 1.08; incidence rate 18, 16 to 19), though extreme underweight (BMI <17) was associated with increased mortality (hazard ratio 1.33, 1.07 to 1.64; incidence rate 24, 19 to 29). The relative excess risk due to interaction between BMI and smoking status was not significant in any stratum. Furthermore, all estimates of interaction were of small magnitude, except for the combination of obesity and heavy smoking (relative excess risk 1.5, −0.7 to 3.7). Compared with non-smokers (incidence rate 14, 13 to 15), risk was increased in both light (hazard ratio 1.54, 1.41 to 1.70; incidence rate 15, 14 to 16) and heavy smokers (hazard ratio 2.11, 1.92 to 2.31; incidence rate 26, 24 to 27).

Conclusions Regardless of smoking status, overweight and obesity in late adolescence increases the risk of adult mortality. Obesity and overweight were as hazardous as heavy and light smoking, respectively, but there was no interaction between BMI and smoking status. The global obesity epidemic and smoking among adolescents remain important targets for intensified public health initiatives.


  • Contributors: MN conceived the hypothesis, conducted the statistical analyses, and wrote the first draft of the manuscript. JS and FR provided critical input at all stages and critically reviewed and contributed to the final draft. All authors are guarantors.

  • Funding: MN was funded by Arbetsmarknadens Forsakrings-och Aktiebolag (AFA) and JS by the Swedish Heart-Lung Foundation and the Swedish Research Council (2007-5942). The funding sources did not read or comment on any version of the manuscript, nor influence the analyses in any way.

  • Competing interests: None declared.

  • Ethical approval: The study was approved by the ethics committee at the Karolinska Institute, Stockholm, Sweden.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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