Article Text

Smoking and the risk of amyotrophic lateral sclerosis: a systematic review and meta-analysis
  1. Alvaro Alonso1,2,
  2. Giancarlo Logroscino3,
  3. Miguel A Hernán4,5
  1. 1Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
  2. 2Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Spain
  3. 3Department of Neurological Sciences, University of Bari, Bari, Italy
  4. 4Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
  5. 5Harvard-MIT Division of Health Sciences, Boston, Massachusetts, USA
  1. Correspondence to Dr A Alonso, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S, Suite 300, MN 55416, USA; aalogut{at}


Background Epidemiologic studies have provided inconsistent results on the association of cigarette smoking with the incidence of amyotrophic lateral sclerosis (ALS). To summarise published evidence and explore sources of heterogeneity, we conducted a systematic review and meta-analysis of studies that evaluated this association.

Methods Published studies evaluating the association of smoking with incidence of ALS were searched in bibliographic databases, with relevant information collected from each article. A random effects approach was used to pool the relative rate (RR) estimates from different studies. Between study heterogeneity was explored with a meta-regression approach.

Results 18 publications reported associations between smoking and ALS risk in 15 case control studies and five cohort studies. The pooled RR (95% CI) of ALS was 1.28 (0.97 to 1.68) for current versus never smokers and 1.12 (0.98 to 1.27) for ever versus never smokers. The study specifics RRs were heterogeneous (p<0.01). The proportion of women in the study population explained 46% of between study variability. The estimated RR (95% CI) of ALS for ever versus never smokers was 0.86 (0.71 to 1.03) in men and 1.66 (1.31 to 2.10) in women.

Interpretation This meta-analysis does not support an overall strong association of smoking with ALS risk but suggests that smoking might be associated with a higher risk of ALS in women.


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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.