33 Omission of this study reduced the heterogeneity and had minimal effects on the summary risk estimates attained, reinforcing the conclusions drawn. It is not Roxadustat known why the associations between smoking and Barrett’s esophagus were lower in the Irish study population; the proportion of population-based controls that reported ever smoking was higher (55%) than the other studies (45–47%), but this slightly higher rate is insufficient to mask the association evidenced in the other studies. In addition, the distribution of pack-years of cigarette smoking was similar across control groups and studies,

and provision of individual patient data enabled similar confounding structures to be constructed for study-specific models. FINBAR’s inclusion criteria did restrict recruitment of patients to those with long-segment Barrett’s esophagus (≥3 cm; Table 1); a criterion not used by the other 4 studies included in this analysis. However, this is unlikely to have led to lower estimates of association, given that a previous analysis of Kaiser Permanente Northern California data evidenced a stronger association of cigarette smoking with long-segment Barrett’s esophagus (OR = 1.72; 95% CI: 1.12–2.63) Selleck PI3K inhibitor compared with that for short-segment Barrett’s esophagus (<3 cm; OR = 1.19; 95% CI: 0.76–1.85).31 It remains unexplained why the FINBAR estimates

of association were lower relative to the other studies oxyclozanide included in this pooled analysis. Analyses stratified by sex suggested that cigarette smoking might be a stronger risk factor for Barrett’s esophagus among men than among women. However, this relationship was only observed when assessing ever cigarette smoking in Barrett’s esophagus cases compared with GERD controls; analyses of pack-years of cigarette smoking and comparisons with population-based controls were null. Given the known genotoxic effects of tobacco smoke, evidence that effects of cigarette smoking are similar in men and women,57 and the number of tests conducted, we believe this result

represents a chance finding. Interaction analyses indicated that heartburn/regurgitation symptoms and ever smoking biologically interact in the risk of Barrett’s esophagus—the attributable proportion of disease among individuals exposed to these 2 factors was estimated to be 0.39 (95% CI: 0.25–0.52). Biological interaction of these variables in this setting is plausible, given evidence that tobacco smoke might not only have direct genotoxic effects,58 but might also induce transient lower esophageal sphincter relaxations,59, 60 and 61 increasing the likelihood, length, and severity of gastroesophageal reflux, a major risk factor for Barrett’s18 and the sequela, esophageal adenocarcinoma.17 Interaction between gastroesophageal reflux symptoms and smoking has been reported previously for Barrett’s esophagus with dysplasia26 and for esophageal adenocarcinoma.62 There were several strengths of this analysis.