Abstract
Background:
Previous studies show an association between smoking and anal cancer. The objective of this study was to assess the association between smoking and anal HPV prevalence, incidence and persistence in men.
Methods:
The HPV infection in Men (HIM) Study is a multinational study that enrolled HIV-negative men. At baseline and follow-up visits, anal specimens were collected. HPV genotyping was assessed by Linear Array. Prevalence ratios (PR) were used to assess the association between smoking and anal HPV prevalence. Odds ratios (OR) were used to assess the association between smoking and anal HPV incidence and ≥12-months persistence.
Results:
Current smokers have a higher prevalence (adjusted PR (aPR)=1.36, 95%CI: 1.06–1.73) and incidence (adjusted OR (aOR)=1.74, 95%CI: 1.26–2.39) and ≥12-months persistence (aOR= 1.67, 95%CI: 1.19–2.33) of any anal HPV compared to never smokers. There were no differences in the prevalence, incidence, or persistence of anal HPV between former and never smokers. Smoking status was not associated with the prevalence or persistence of anal HPV among MSM but was associated with higher incidence of HR-HPV. Among men that have sex with women (MSW), current smokers had an increased prevalence and incidence of LR-HPV compared to never smokers.
Conclusions:
Current smokers had a higher prevalence, persistence, and incidence of HPV compared to never smokers. Further research is needed to assess the role smoking in anal HPV persistence and progression to disease.
Impact:
Prevention initiatives should raise awareness about smoking and the risk factor of anal HPV infection and anal cancer.
Keywords: Anal HPV, Smoking, HIM study, Men
Introduction
Anal cancer incidence has been shown to be increasing over time in both men and women from high resource countries.(1) People living with HIV, men that have sex with men (MSM), women with prior vulvar cancer, and solid organ transplant recipients are at higher risk for anal cancer compared to the general population.(2) In the US, anal cancer incidence has increased 2.7% per year between 2001 to 2015 with increases in both men (2.2%) and women (3.1%).(3) The Center for Disease Control reports there are 4700 new cases of HPV-associated anal cancers in women and 2300 in men each year in the US.(4)
Risk factors for anal cancer includes human papillomavirus (HPV) infection, tobacco smoking, HIV infection, and a high number of sexual partners.(5) Worldwide, 88% of anal carcinoma are caused by high-risk HPV (6) and 79% of those are attributable to HPV16 and HPV 18.(1,7) The attributable fraction of HPV16 to anal cancer is greater in persons without HIV than persons with HIV. (1)
Previous studies have shown an association between smoking and cervical and penile HPV infection. (8–12) Smoking suppresses the local immune response, increases cellular turnover and proliferation, upregulates proinflammatory cytokines, and can damage host DNA which could increase the likelihood of HPV persisting.(13) Studies among women have shown HPV infection is associated with cigarette smoking and a higher HPV16 and HPV18 viral load in current smokers compared to never smokers.(8) Smoking at least one pack year of cigarettes was associated with prevalence of anal HPV DNA.(14) We have previously shown an increased prevalence of genial HPV among men that smoke.(9) The objective of this study was to assess the association between tobacco smoking and the prevalence, incidence, and persistence of anal HPV among men residing in Tampa, Florida, US; Sao Paulo, Brazil; and Cuernavaca, Mexico;. Analyses were stratified by sexual orientation given that anal HPV prevalence differs by sexual orientation.
Methods.
Study Population
The HPV infection in men (HIM) study recruited 4123 HIV-negative men between 18–70 years old and residing in Tampa, Florida, US; Cuernavaca, Mexico; and Sao Paulo, Brazil from July 2005 to June 2009. We provided a complete report of study methods in previous publications.(15) Men returned to clinic every 6 months for up to 10 years. From the initial and subsequent visits participants were given a physical exam where multiple samples were obtained for laboratory examination and a self-administered questionnaire looking at sociodemographic characteristics, sexual history, tobacco, and alcohol use.
The study team obtained written informed consent from all subjects. Study procedures were authorized by the Institutional Review Boards at the University of South Florida (Tampa, FL, US), the Ludwig Institute for Cancer Research, the Centro de Referencia e Treinamento em Doencas Sexualmente Transmissiveis e AIDS (São Paulo, Brazil), and the Instituto Nacional de Salud Pública (Cuernavaca, Mexico).
Anal Specimen collection for HPV detection
At each visit, participants were screened for anal HPV infections. A pre-wetted Dacron swab was used to swab 360 degrees of the anal canal epithelium between the anal opening and the anal canal dentate line. The sample was then placed into a standard transport medium and preserved at −80°C.(16) DNA extraction (Qiagen Media Kit), PCR analysis, and HPV genotyping (Roche Linear Array) were conducted on all samples.(17) Only samples that tested positive for beta-globin or an HPV genotype were included in the analysis. The Linear Array assay tests for 37 HPV types, classified as high-risk (HR-HPV; types 16, 18, 31, 33, 35, 39, 45,51, 52, 56, 58, 59, and 68) or low-risk (LR-HPV; types 6, 11, 26, 40, 42, 53, 54, 55, 61, 62, 64, 66, 67, 69, 70, 71, 72, 73,81, 82, 82 subtype IS39, 83, 84, and 89).(18)
Statistical analysis
Participants with missing smoking data (n=39) were excluded. At baseline., participants self-reported the lifetime number of sexual partners and sex was defined as oral, anal, or vaginal sex. Based on the participant’s responses, sexual orientation was categorized into men who have sex with women (MSW) only and men who have sex with men regardless of having sex with women (MSM). Men that did not report any sexual partners at baseline were classified as unknown for sexual orientation. Tobacco smoking status was categorized as: current smoker, former smoker and never smoker. Smoking pack-years was calculated by taking number of packs smoked per year (number of cigarettes per day divided by 20 cigarettes per pack) multiplied by the number of years smoked. The median pack-years smoked was assessed. For current and former smokers separately, tertiles for “number of cigarettes smoked per day,” “number of years smoked,” and “smoking pack-years” were calculated.
Prevalence
For this analysis, participants who had an anal specimen (n=1994) at baseline were included. The outcome of interest was prevalence of: any HPV, LR-HPV, HR-HPV, and multiple infections. In this analysis, any HPV refers to the presence of any of the 37 HPV genotypes. Prevalence of any HPV, HR-HPV, and LR-HPV represented having at least one of those HPV types present at the anal canal. Infection with multiple types, defined as two or more HPV genotypes was also assessed compared to persons with one or no HPV infections at baseline. Multiple anal HPV infections have been previously shown to be a risk factor anal pre-cancer among MSM with HIV.(19,20)
To assess the association between HPV prevalence and smoking status, prevalence ratios (PR) and 95% confidence intervals (CI) using Poisson regression with robust variance estimation were calculated. Outcome variables for the models were: 1) Any HPV vs. No HPV, 2) HR-HPV vs. no HR-HPV, 3) LR-HPV vs. no LR-HPV, 4) multiple HPV infections vs no HPV/only one HPV infection.
Known potential confounders were selected a priori to be used for adjustment in multivariable models. In the overall cohort, prevalence ratios were adjusted for age, country, sexual orientation (MSM or MSW) and lifetime female sexual partners. The MSW only model was adjusted for age, country, and lifetime female sexual partners. The MSM only model was adjusted for country, age, lifetime female and male sexual partners.
Incidence and Duration
Participants could elect to have anal specimens collected at each visit. Men with anal HPV specimens collected at follow-up visits were included (n= 1427). The reduction in sample size resulted in the sexual orientation proportions significantly differing between those with baseline specimens (20.3% MSMW and 68.1% MSW) and those with follow-up specimens (27.1% MSMW and 61.6%). Incident infections were defined as new type specific infection that was not present at baseline and was detected at follow up visits. Incidence of any HPV, HR-HPV, and LR-HPV represented having at least one of those HPV types newly detected at the anal canal. For example, a participant could have HPV16 at baseline and an incident HPV18 detected 6-months later, this participant would have an incident any HPV and HR-HPV. Odds ratios (OR) and 95% confidence intervals were calculated using a multivariable logistic regressions to assess the association between HPV incidence and smoking status. Models were adjusted for baseline known potential confounders that were previously described.
Type-specific HPV infection duration was calculated as the time from prevalent or incident infection detection with observations right-censored at the last positive visit for that infection. HPV clearance is defined as two consecutive negative visits after detection (or a single negative result at the participant’s last visit). Persistent infections were defined as having a type specific infection, prevalent or incident infection, for ≥12 months. Any persistent infections were defined as a participant with ≥ 1 of 37 HPV types persisting for ≥12 months. Men with no persistent infections for ≥ 1 of 37 HPV types were defined as non-cases for any HPV. Similar groupings were done for HR-HPV and LR-HPV. We assessed the difference in duration of anal HPV infections between smoking groups using odds ratios (OR) and 95% confidence intervals were calculated using a multivariable logistic regressions. Models were adjusted for baseline known potential confounders that were previously described.
All statistical analyses were conducted using STATA software, version 15.1 (StataCorp LLC, College Station, Texas).
Data Availability
Data that supports this study are only available upon requests. They are not publicly accessible due to the delicate nature of the data presented in this study. All data pertinent to this study are incorporated in the article or uploaded as supplementary material. Study dataset with deidentified participant data and protocol can be requested from Anna.Giuliano@moffitt.org. Data requests can also be directed to the Center for Immunization and Infection Research, which is the institutional organization that handles data requests. Their email is: CIIRC@moffitt.org.
Results
Among the men with baseline anal HPV samples (n=1994), 23% (n= 454) were current smokers, 19% (n=379) were former smokers and 58% (n=1161) had never smoked. The median pack-years smoked among current and former smokers was 3 years. Table 1 shows the demographic characteristics of study participants stratified by smoking status. In this study population, 45% of participants were between 18–30 years old, 39% were between 31–44 years old and 15% were between 45–70 years old. Mexico had the highest proportion of participants that are current and former smokers (45% and 37% respectively). About 42% of MSW and 44% of MSM were ever smokers. Lifetime number of female sexual partners differed by smoking status, but lifetime male sexual partners did not differ. Former smokers had been smoking for an average of 11 years and 10 cigarettes per day while current smokers, had been smoking for an average of 14 years with 9 cigarettes per day.
Table 1.
Demographic characteristic stratified by smoking status
| Characteristic | Current (n=454) | Former (n=379) | Never (n=1161) |
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| Age categories | |||
| 18–30 | 202 (44.5) | 105 (27.7) | 602 (51.8) |
| 31–44 | 193 (42.5) | 163 (43.0) | 431 (37.1) |
| 45–70 | 59 (13.0) | 111 (29.3) | 128 (11.0) |
| Country of Residence | |||
| USA | 110 (24.2) | 120 (31.7) | 396 (34.1) |
| Mexico | 205 (45.1) | 142 (37.5) | 304 (26.2) |
| Brazil | 139 (30.6) | 117 (30.9) | 461 (39.7) |
| Race | |||
| White | 170 (37.4) | 182 (48) | 562 (48.4) |
| Black | 63 (13.9) | 39 (10.3) | 204 (17.6) |
| Asian/PI | 6 (1.3) | 3 (0.8) | 32 (2.8) |
| Other | 205 (44.1) | 149 (39.3) | 328 (28.2) |
| Refused | 10 (2.2) | 6 (1.6) | 35 (3) |
| Ethnicity | |||
| Non-Hispanic | 198 (43.6) | 186 (49.5) | 667 (58.4) |
| Hispanic | 256 (56.4) | 190 (50.5) | 476 (41.6) |
| Marital status | |||
| Divorced/separated | 52 (11.5) | 44 (11.6) | 88 (7.6) |
| Married/cohabitating | 205 (45.4) | 228 (60.2) | 497 (43.0) |
| Single | 195 (43.1) | 107 (28.2) | 572 (49.4) |
| Sexual Orientation | |||
| MSM | 97 (21.4) | 84 (22.2) | 224 (19.3) |
| MSW | 303 (66.7) | 267 (70.5) | 787 (67.8) |
| Unknown | 54 (11.9) | 28 (7.4) | 150 (12.9) |
| Lifetime Male Sexual Partners | |||
| 0–1 | 370(81.5) | 316(83.38) | 982(84.58) |
| 2–9 | 37(8.15) | 35(9.23) | 91(7.84) |
| 10 to 49 | 28(6.17) | 15(3.96) | 49(4.22) |
| 50+ | 11(2.42) | 9(2.37) | 28(2.41) |
| Missing | 8 (1.8) | 4 (1.1) | 11 (0.9) |
| Lifetime Female Sexual Partners | |||
| 0–1 | 62 (13.7) | 33 (8.7) | 292 (25.1) |
| 2–9 | 163 (36.0) | 141 (37.2) | 477 (41.1) |
| 10–49 | 159 (35.0) | 161 (42.5) | 297 (25.6) |
| 50+ | 37 (8.1) | 25 (6.6) | 50 (4.3) |
| Missing | 33 (7.3) | 19 (5.0) | 45 (3.9) |
| Years smoked | |||
| Mean (std) | 14.7 (11.3) | 10.8 (9.2) | n/a |
| Median (IQR) | 12 (7–20) | 9 (3–15) | n/a |
| Average cigarettes per day | |||
| Mean (std) | 8.5 (7.7) | 10.4 (11.7) | n/a |
| Median (IQR) | 6 (3–12) | 5 (2–15) | n/a |
| Pack years | |||
| Mean (std) | 7.5 (10.4) | 8.1 (15.7) | n/a |
| Median (IQR) | 3.6 (1.0–9.8) | 2.4 (0.5–10) |
Abbreviations: std= standard deviation; IQR= interquartile range
Anal HPV genotype prevalence by smoking status is described in Table 2. Overall, the prevalence of any anal HPV was 23.6% (95% CI 19.9–27.2) among current smoker, 15.8% (95% CI 12.5–19.9) among former smoker and 17.4% (95% CI 15.3–19.7) among never smoker. Any LR-HPV prevalence was highest in current smoker (18.1%, 95% CI 14.8–21.9) followed by former smoker (12.7%, 95% CI 9.6–16.4) and never smoker (11.5%, 95% CI 9.8–13.5). When stratified by sexual orientation, there were no statistically significant differences in the prevalence of anal HPV groupings among MSM by smoking status. However, among MSW the prevalence of any anal HPV was 16.8% (95% CI 13.0–21.5) in current smoker, 9.7% (95% CI 6.7–13.9) among former smoker and 10.3% (95% CI 8.3–12.6) among never smoker. Anal LR- and HR-HPV prevalence were also higher among current MSW smokers compared to never smokers. The prevalence of multiple infections was highest among current smokers in all three groups: overall, MSM, and MSW. Prevalence of individual HPV genotypes by smoking status is shown in Supplemental Table 1. There were no differences in anal HPV prevalence by smoking intensity among current or former smokers (Supplemental Table 2).
Table 2.
Prevalence and 95% confidence intervals of HPV genotypes by smoking status overall and stratified by sexual orientation
| Overall (n=1994) | MSM (n=405) | MSW (n=1357) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Current (n=454) | Former (n=379) | Never (n=1161) | Current (n=97) | Former (n=84) | Never (n=224) | Current (n=303) | Former (n=267) | Never (n=787) | |
| HPV Status | |||||||||
| Negative | 76.4(72.3–80.1) | 84.2(80.1–87.5) | 82.6(80.3–84.7) | 54.6(44.6–64.3) | 66.7(55.9–75.9) | 54.5(47.9–60.9) | 83.2(78.5–86.9) | 90.3(86.1–93.3) | 89.7(87.3–91.6) |
| Any a | 23.6(19.9–27.7) | 15.8(12.5–19.9) | 17.4(15.3–19.7) | 45.4(35.7–55.3) | 33.3(24.1–44.1) | 45.5(39.1–52.1) | 16.8(13.0–21.5) | 9.7(6.7–13.9) | 10.3(8.3–12.6) |
| Low Risk a | 18.1(14.8–21.9) | 12.7(9.6–16.4) | 11.5(9.8–13.5) | 37.1(28.1–47.1) | 27.4(18.9–37.8) | 31.7(25.9–38.1) | 12.2(8.9–16.4) | 7.1(4.6–10.9) | 6.3(4.8–8.3) |
| High Risk a | 13.6(10.8–17.1) | 7.6(5.4–10.8) | 11(9.3–12.9) | 27.8(19.8–37.6) | 20.2(12.9–30.2) | 31.7(25.9–38.1) | 8.91(6.2–12.7) | 4.1(2.29–7.3) | 5.7(4.3–7.6) |
| Multiple Infections b | 13.2(10.4–16.6) | 5.5(3.6–8.3) | 8.3(6.8–9.9) | 36.1(27.1–46.1) | 19(11.9–28.9) | 27.2(21.8–33.4) | 6.3(4.0–9.6) | 1.5(0.6–3.9) | 3.2(2.1–4.6) |
Any, High Risk, Low Risk = prevalence of one or more anal HPV infections for that grouping
Multiple infections= having two or more prevalent any anal HPV infections
The association between anal HPV prevalence and smoking status is presented in Table 3. The unadjusted PRs for HPV prevalence and smoking are shown in Supplemental Table 3. Current smokers had a higher prevalence of any anal HPV (adjusted PR (aPR)=1.36, 95%CI: 1.06–1.73) and LR-HPV (aPR=1.59, 95%CI: 1.20–2.12) compared to never smokers after adjusting for age, country, lifetime female sexual partners, and sexual orientation. Current smokers had a significantly higher prevalence of multiple infections (aPR= 1.57, 95%CI: 1.12–2.18) compared to never smokers. There was no significant difference between former smoker and never smokers in the prevalence of anal HPV. The association between smoking intensity, defined as ≥3 pack-years or <3 pack-years among current and former smokers and the prevalence of anal HPV was assessed (Supplemental Table 4). Current smokers with ≥3 pack-years had a significantly higher prevalence of LR-HPV (aPR=1.66, 95%CI: 1.18–2.34) and multiple infections (aPR= 1.63, 95%CI: 1.09–2.45) compared to never smokers. Current smokers with <3 pack-years had a significantly higher prevalence of any HPV and LR-HPV. In a post hoc analysis, we stratified by country and found that current smokers in the US had a significantly higher prevalence of any (aPR=2.04, 95% CI: 1.24–3.36), LR-HPV (aPR=3.25, 95% CI: 1.67–6.29), and multiple infections (aPR= 2.63, 95%CI: 1.11–6.27) compared to never smokers (Supplemental Table 5). There were no significant differences in Brazil or Mexico comparing the prevalence of anal HPV by smoking status (Supplemental Table 5).
Table 3:
Prevalence Ratios for HPV infection by smoking status and sexual orientation
| Any HPV a | High Risk HPV a | Low Risk HPV a | Multiple Infections a | |
|---|---|---|---|---|
| aPR (95% CI) a | aPR (95% CI) a | aPR (95% CI) a | aPR (95% CI) a | |
| Overall | ||||
| Smoking Status | ||||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) | 1.0(ref) |
| Former | 0.97 (0.72–1.31) | 0.77 (0.51–1.17) | 1.21 (0.86–1.71) | 0.78(0.48–1.28) |
| Current | 1.36 (1.06–1.73) | 1.24 (0.91–1.70) | 1.59 (1.20–2.12) | 1.57(1.12–2.18) |
| MSM | ||||
| Smoking Status | ||||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 0.93(0.60–1.45) | 0.81(0.46–1.42) | 1.08(0.66–1.77) | 0.92(0.69–1.24) |
| Current | 0.93(0.65–1.35) | 0.79(0.50–1.25) | 1.10(0.73–1.66) | 0.94(0.75–1.19) |
| MSW | ||||
| Smoking Status | ||||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 0.81 (0.51–1.28) | 0.68 (0.35–1.35) | 0.94 (0.54–1.63) | 0.77(0.52–1.14) |
| Current | 1.39 (0.96–2.02) | 1.41 (0.85–2.33) | 1.60 (1.02–2.50) | 1.79(1.35–2.39) |
Any, High Risk, Low Risk = models assessed the prevalence of one or more anal HPV infections for that grouping
Multiple infections= models assessed having two or more prevalent any anal HPV infections
aPR= multivariable PR adjusted for age, country, sexual orientation and lifetime female sexual partners (overall); age, country, lifetime female sexual partners, and lifetime male sexual partners (MSM); age, country, and lifetime female sexual partners (MSW)
The association between smoking status and anal HPV infection stratified by sexual orientation is presented in Tables 3. Anal HPV prevalence did not statistically differ by smoking status among MSM. Among MSW, current smokers had an increased prevalence of LR-HPV (aPR=1.60 95% CI: 1.02–2.50) compared to never smokers after adjusting for age, country, and lifetime female sexual partners. Current MSW smokers were more likely to have multiple HPV infections (aPR= 1.79, 95%CI: 1.35–2.39) compared to never smokers. Additionally, when smoking intensity (<3 or ≥3 pack-years) was assessed among current smokers, both were not associated with increased prevalence of multiple infections compared to never smokers. There were no significant differences between never and former smokers and anal HPV prevalence among MSW.
Incidence of any HPV was 37% among current smokers, 25% among former, and 28% among never smokers. The association between smoking and the incidence of HPV infections is presented in Table 4. The unadjusted odds ratios for incident infections are shown in Supplemental Table 6. Overall, current smokers were significantly more likely to have an incident any HPV (aOR=1.74, 95% CI: 1.26–2.39), incident HR-HPV (aOR=1.63, 95% CI: 1.15–2.31) and incident LR-HPV (aOR=1.62, 95% CI: 1.16–2.27) infection compared to never smokers. Among MSM, current smokers were significantly more likely to have an incident HR-HPV infection (aOR=1.73, 95% CI: 1.00–2.99). Among MSW, current smokers were significantly more likely to have an incident any HPV (aOR=1.82, 95% CI: 1.17–2.82) and incident LR-HPV (aOR=1.99, 95% CI: 1.23–3.23) infection compared to never smokers. There were no significant differences between never and former smokers and anal HPV incidence.
Table 4:
Odds Ratios for Incident Infections by smoking status and sexual orientation
| Any HPV a | High Risk HPV a | Low Risk HPV a | |
|---|---|---|---|
| aOR (95% CI) b | aOR (95% CI) b | aOR (95% CI) b | |
| Overall | |||
| Smoking Status | |||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 1.06(0.73–1.54) | 0.87(0.56–1.35) | 1.366(0.923–2.0) |
| Current | 1.74(1.26–2.39) | 1.63(1.15–2.31) | 1.62(1.16–2.27) |
| MSM | |||
| Smoking Status | |||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 0.76(0.4–1.45) | 0.72(0.37–1.4) | 0.96(0.5–1.86) |
| Current | 1.21(0.67–2.18) | 1.73(1.00–2.99) | 0.87(0.49–1.55) |
| MSW | |||
| Smoking Status | |||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 0.99(0.59–1.7) | 0.79(0.39–1.59) | 1.34(0.76–2.36) |
| Current | 1.82(1.17–2.82) | 1.42(0.82–2.47) | 1.99(1.23–3.23) |
Any, High Risk, Low Risk = models assessed the incidence of one or more anal HPV infections for that grouping
aOR= multivariable OR adjusted for age, country, sexual orientation and lifetime female sexual partners (overall); age, country, lifetime female sexual partners, and lifetime male sexual partners (MSM); age, country, and lifetime female sexual partners (MSW)
Persistence of any HPV greater than 12 months among current smokers was 26%, 19% among former smokers and 19% among never smokers. The effect of smoking on HPV infections persisting ≥12 months is presented in Table 5. The unadjusted odds ratios for persistent infections are shown in Supplemental Table 7. Overall, current smokers were significantly more likely to have an HPV infection persist greater than 12 months compared to never smokers (aOR=1.67, 95% CI: 1.19–2.33). This same association was seen among MSW (aOR=1.83, 95% CI: 1.12–2.98). However, smoking was not significantly associated with HPV persistence among MSM.
Table 5:
Odds Ratios for Persistent Infection lasting ≥12 months by smoking status and sexual orientation
| Any HPV a | High Risk HPV a | Low Risk HPV a | |
|---|---|---|---|
| aOR (95% CI) b | aOR (95% CI) b | aOR (95% CI) b | |
| Overall | |||
| Smoking Status | |||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 1.19 (0.80–1.76) | 0.72 (0.42–1.24) | 1.06 (0.69–1.64) |
| Current | 1.67 (1.19–2.33) | 1.40 (0.94–2.12) | 1.32 (0.91–1.91) |
| MSM | |||
| Smoking Status | |||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 1.26 (0.66–2.41) | 0.78 (0.38–1.62) | 1.13 (0.59–2.16) |
| Current | 1.10 (0.63–1.91) | 0.88 (0.49–1.59) | 0.93 (0.53–1.62) |
| MSW | |||
| Smoking Status | |||
| Never | 1.0 (ref) | 1.0 (ref) | 1.0 (ref) |
| Former | 0.9 (0.49–1.64) | 0.52 (0.19–1.44) | 0.96 (0.50–1.87) |
| Current | 1.83 (1.12–2.98) | 1.89 (0.94–3.78) | 1.51 (0.84–2.69) |
Any, High Risk, Low Risk = models assessed the persistence of one or more anal HPV infections lasting ≥12 months for that grouping
aOR= multivariable OR adjusted for age, country, sexual orientation and lifetime female sexual partners (overall); age, country, lifetime female sexual partners, and lifetime male sexual partners (MSM); age, country, and lifetime female sexual partners (MSW)
Discussion
In this multinational cohort of HIV-negative men, the prevalence, incidence, and duration of anal HPV by smoking status and smoking intensity was assessed. Current smokers had a significantly higher prevalence and incidence of any anal HPV and LR-HPV compared to never smokers and were more likely to have prevalent multiple HPV infections than never smokers. Interestingly, there were no differences in prevalence, incidence, or duration of anal HPV between former and never smokers. When models were stratified by sexual orientation, MSW that currently smoke had a significantly higher prevalence and incidence of anal any LR-HPV and prevalent multiple HPV infections compared to never smokers. There was no difference between HPV prevalence and duration among MSM that currently smoke compared to never smokers, but current smokers had a significantly higher HR-HPV incidence compared to never.
Among MSM without HIV, the prevalence of anal HPV is common with 47% being infected with any HPV in a recent meta-analysis.(21) In this study, 43% of MSM were infected with any HPV and HPV prevalence was not associated with smoking status. These results are consistent with two studies among MSM that found that current smoking was not associated with the prevalence of any HPV compared to those not currently smoking.(22,23) and our prior work among MSM in the HIM Study.(24) While Goldstone, et al reported a significant increased prevalence of any HPV among MSM former smokers compared to never smokers but no difference between current and never smokers.(25) Smoking may not be associated with prevalent HPV infection, but there was a significantly higher incidence of HR-HPV among smokers compared to never smokers. The association between anal HPV incidence and persistence and smoking among MSM without HIV has not previously been reported in the literature. Further studies are needed to assess the role of smoking in anal HPV persistence and development of anal disease among MSM without HIV.
Based on our knowledge, we are the first to report here the role of smoking in anal HPV prevalence, incidence, and persistence among MSW without HIV. As expected, the prevalence of anal HPV among MSW (12%) was significantly lower compared to MSM (47%). Current smokers had a significantly higher prevalence of LR-HPV and multiple HPV infections compared to never smokers. We previously reported risk factors associated with anal HPV prevalence among a smaller subset of MSW in the HIM Study, and in adjusted models found that formers smokers were significantly less likely to have a prevalent HPV infection than never smokers.(26) While there are no other published studies among MSW without HIV, among MSW with HIV, current smokers were significantly more likely to have prevalent HPV infection compared to nonsmokers.(27)
We also found that MSW that are current smokers were more likely to have an incident LR-HPV infection compared to never smokers and any HPV infections were more likely to persist >12 months in current smokers compared to never. LR-HPV infections are common and are associated with condylomas within the anal canal and genitals.(28) While the majority of anal cancers are caused by HPV16, low-risk HPV genotypes like HPV6 have been shown to cause anal cancer and anal warts.(1) MSW are likely not having anal intercourse, yet we are detecting HPV within the anal canal. It is possible that these infections are occurring through autoinoculation or partner inoculation. It is interesting that the LR-HPV prevalence and incidence were strongly associated with smoking status among MSW, but we did not see a significant association with HR-HPV. Within the HIM Study, we have reported MSW with genital HPV infections are more likely to acquire anal HPV compared to men without genital infections.(29) Current smokers are also more likely to have prevalent genital HPV infection compared to never smokers (9) and current smokers had a higher incidence of LR-HPV at the genitals compared to never smokers.(30)
Tobacco smoking has been shown to be associated with anal cancer development in several studies.(31–35) Several case-controls studies in both men and women have reported a two-fold increased odds of anal cancer among smokers compared to non-smokers.(31–34) Recent data from the Surveillance, Epidemiology, and End Results (SEER) showed counties with high smoking prevalence have higher anal cancer incidence in both males (4% per year) and females (5% per year) compared to counties with low smoking prevalence.(35) Similarly, studies among people living with HIV also found an association between smoking and anal cancer.(36) Smoking has also been shown to increase the risk for other HPV-associated cancers.(37–41) The tobacco use could be affecting HPV persistence or progression of HPV-related lesions to cancer by reducing the immune response to HPV infections.(13,39)
Strengths of this study include large sample size, data from three international sites and ability to assess the association among both MSW and MSM. Very few studies have assessed the prevalence of anal HPV among MSW populations or MSM without HIV. The three sites had standard protocols for specimen processing and data collection. In order to interpret our results, it is important to keep in mind some of the limitations of this study. The results may not be generalizable to the broader male population within these communities given that the HIM Study is not a population-based cohort study. The demographics such as age, ethnicity and education of the participants included at each site are similar to communities that they were enrolled from. Lifetime number of sexual partners were adjusted for the models, but this does not capture the different types of sexual intercourse. While these data are unique, there were only 405 MSM included in these analyses, and we may have been limited in the power to detect significant differences. There are differences in anal HPV prevalence among MSM by type of anal intercourse, i.e., either receptive or insertive. Detection of HPV infections does not mean that the infection is active and could cause disease. Further research is needed to understand fully the role of smoking in progression of HPV infections to disease in both MSM and MSW.
In conclusion, our study found currently smoking was associated with a higher prevalence and incidence of anal HPV. While we did not see a difference in the prevalence and duration of anal HPV among MSM that currently smoke, currently smoking was associated with incident HR-HPV infections. MSW that currently smoked had a higher prevalence and incidence of LR-HPV. There were no differences in the prevalence, incidence, or duration of anal HPV between former and never smokers. Smoking may alter the immune response to HPV infection and smoking cessation could be an important step in preventing anal cancer. Therefore, it is important to conduct more studies on the effects of smoking on anal HPV persistence and progression to anal disease and to educate the public about the increased risk for anal HPV infection and anal cancer among smokers.
Supplementary Material
Acknowledgements
This research was supported in part by research funding from Merck Sharp & Dohme Corp. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp.
We thank the HIM Study teams and participants in the United States (Moffitt Cancer Center, Tampa), Brazil (Centro de Referência e Treinamento em DST/AIDS, Fundação Faculdade de Medicina Instituto do Câncer do Estado de São Paulo, Ludwig Institute for Cancer Research, São Paulo), and Mexico (Instituto Mexicano del Seguro Social, Instituto Nacional de Salud Pública, Cuernavaca).
Funding:
The HIM Study was supported by the National Cancer Institute [R01 CA098803 to A.R. Giuliano] and National Institute of Allergy and Infectious Disease (R03 AI127205 to S.L. Sudenga and R21 AI101417 to A.G. Nyitray), National Institutes of Health; and the Merck Investigator Initiated Studies Program (IISP33707 to A.G. Nyitray). S.L. Sudenga (K07 CA225404) is supported by the National Cancer Institute.
Footnotes
Conflicts of Interest: A.R. Giuliano and E. Lazcano Ponce are members of the Merck Advisory Board. L.L. Villa is an occasional speaker and consultant of MSD for HPV prophylactic vaccines and received funding from Merck for IISP. A.R. Giuliano’s institution received funding from Merck for IISP studies and a Merck Sponsored Clinical Trial. S.L. Sudenga (IISP53280) and A.G. Nyitray (IISP33707) received grants from Merck Investigator Initiated Studies Program. No conflicts of interest were disclosed for any of the remaining authors.
Presentation in part: 34th International Papillomavirus Conference, Toronto, Canada November 2021.
References
- 1.Lin C, Franceschi S, Clifford GM. Human papillomavirus types from infection to cancer in the anus, according to sex and HIV status: a systematic review and meta-analysis. The Lancet Infectious diseases 2018;18(2):198–206 doi 10.1016/s1473-3099(17)30653-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Clifford GM, Georges D, Shiels MS, Engels EA, Albuquerque A, Poynten IM, et al. A meta-analysis of anal cancer incidence by risk group: Toward a unified anal cancer risk scale. International Journal of Cancer 2021;148(1):38–47 doi 10.1002/ijc.33185. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Deshmukh AA, Suk R, Shiels MS, Sonawane K, Nyitray AG, Liu Y, et al. Recent Trends in Squamous Cell Carcinoma of the Anus Incidence and Mortality in the United States, 2001–2015. J Natl Cancer Inst 2020;112(8):829–38 doi 10.1093/jnci/djz219. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Centers for Disease Control and Prevention. 2021. 5/21/2021. Cancers Associated with Human Papillomavirus, United States—2014–2018, USCS Data Brief, no. 26. <https://www.cdc.gov/cancer/uscs/about/data-briefs/no26-hpv-assoc-cancers-UnitedStates-2014-2018.htm>. Accessed 2021 5/21/2021.
- 5.Nelson VM, Benson AB 3rd. Epidemiology of Anal Canal Cancer. Surgical oncology clinics of North America 2017;26(1):9–15 doi 10.1016/j.soc.2016.07.001. [DOI] [PubMed] [Google Scholar]
- 6.de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV by site, country and HPV type. International journal of cancer 2017;141(4):664–70 doi 10.1002/ijc.30716. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Viens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, et al. Human Papillomavirus-Associated Cancers - United States, 2008–2012. MMWR Morb Mortal Wkly Rep 2016;65(26):661–6 doi 10.15585/mmwr.mm6526a1. [DOI] [PubMed] [Google Scholar]
- 8.Xi LF, Koutsky LA, Castle PE, Edelstein ZR, Meyers C, Ho J, et al. Relationship between cigarette smoking and human papilloma virus types 16 and 18 DNA load. Cancer Epidemiology, Biomarkers & Prevention 2009;18(12):3490–6 doi 10.1158/1055-9965.epi-09-0763. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Schabath MB, Villa LL, Lazcano-Ponce E, Salmerón J, Quiterio M, Giuliano AR. Smoking and human papillomavirus (HPV) infection in the HPV in Men (HIM) study. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 2012;21(1):102–10 doi 10.1158/1055-9965.epi-11-0591. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sadate-Ngatchou P, Carter JJ, Hawes SE, Feng Q, Lasof T, Stern JE, et al. Determinants of High-Risk Human Papillomavirus Seroprevalence and DNA Prevalence in Mid-Adult Women. Sexually Transmitted Diseases 2016;43(3):192–8 doi 10.1097/olq.0000000000000409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kelsey KT, Nelson HH, Kim S, Pawlita M, Langevin SM, Eliot M, et al. Human papillomavirus serology and tobacco smoking in a community control group. BMC Infectious Diseases 2015;15(1):8 doi 10.1186/s12879-014-0737-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Winer RL, Hughes JP, Feng Q, Xi LF, Lee S-K, O’Reilly SF, et al. Prevalence and Risk Factors for Oncogenic Human Papillomavirus Infections in High-Risk Mid-Adult Women. Sexually Transmitted Diseases 2012;39(11):848–56 doi 10.1097/OLQ.0b013e3182641f1c. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Sopori M Effects of cigarette smoke on the immune system. Nature reviews Immunology 2002;2(5):372–7 doi 10.1038/nri803. [DOI] [PubMed] [Google Scholar]
- 14.Palefsky JM. Anal human papillomavirus infection and anal cancer in HIV-positive individuals: an emerging problem. AIDS (London, England) 1994;8(3):283–95 doi 10.1097/00002030-199403000-00001. [DOI] [PubMed] [Google Scholar]
- 15.Giuliano AR, Lazcano-Ponce E, Villa LL, Flores R, Salmeron J, Lee JH, et al. The human papillomavirus infection in men study: human papillomavirus prevalence and type distribution among men residing in Brazil, Mexico, and the United States. Cancer Epidemiology, Biomarkers & Prevention 2008;17(8):2036–43 doi 10.1158/1055-9965.epi-08-0151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Nyitray AG, Carvalho da Silva RJ, Baggio ML, Smith D, Abrahamsen M, Papenfuss M, et al. Six-month incidence, persistence, and factors associated with persistence of anal human papillomavirus in men: the HPV in men study. Journal of Infectious Diseases 2011;204(11):1711–22 doi 10.1093/infdis/jir637. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Gravitt PE, Peyton CL, Apple RJ, Wheeler CM. Genotyping of 27 human papillomavirus types by using L1 consensus PCR products by a single-hybridization, reverse line blot detection method. Journal of clinical microbiology 1998;36(10):3020–7 doi 10.1128/jcm.36.10.3020-3027.1998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Bouvard V, Baan R, Straif K, Grosse Y, Secretan B, El Ghissassi F, et al. A review of human carcinogens--Part B: biological agents. Lancet Oncol 2009;10(4):321–2 doi 10.1016/s1470-2045(09)70096-8. [DOI] [PubMed] [Google Scholar]
- 19.Cheng SH, Liao KS, Wang CC, Cheng CY, Chu FY. Multiple types of human papillomavirus infection and anal precancerous lesions in HIV-infected men in Taiwan: a cross-sectional study. BMJ open 2018;8(1):e019894 doi 10.1136/bmjopen-2017-019894. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sahasrabuddhe VV, Castle PE, Follansbee S, Borgonovo S, Tokugawa D, Schwartz LM, et al. Human papillomavirus genotype attribution and estimation of preventable fraction of anal intraepithelial neoplasia cases among HIV-infected men who have sex with men. The Journal of infectious diseases 2013;207(3):392–401 doi 10.1093/infdis/jis694. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Marra E, Lin C, Clifford GM. Type-Specific Anal Human Papillomavirus Prevalence Among Men, According to Sexual Preference and HIV Status: A Systematic Literature Review and Meta-Analysis. The Journal of infectious diseases 2019;219(4):590–8 doi 10.1093/infdis/jiy556. [DOI] [PubMed] [Google Scholar]
- 22.Choi Y, Loutfy M, Remis RS, Liu J, Rebbapragada A, Huibner S, et al. HPV genotyping and risk factors for anal high-risk HPV infection in men who have sex with men from Toronto, Canada. Sci Rep 2021;11(1):4779 doi 10.1038/s41598-021-84079-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Chin-Hong PV, Vittinghoff E, Cranston RD, Buchbinder S, Cohen D, Colfax G, et al. Age-Specific prevalence of anal human papillomavirus infection in HIV-negative sexually active men who have sex with men: the EXPLORE study. The Journal of infectious diseases 2004;190(12):2070–6 doi 10.1086/425906. [DOI] [PubMed] [Google Scholar]
- 24.Nyitray AG, Smith D, Villa L, Lazcano-Ponce E, Abrahamsen M, Papenfuss M, et al. Prevalence of and risk factors for anal human papillomavirus infection in men who have sex with women: a cross-national study. The Journal of infectious diseases 2010;201(10):1498–508 doi 10.1086/652187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Goldstone S, Palefsky JM, Giuliano AR, Moreira ED Jr., Aranda C, Jessen H, et al. Prevalence of and risk factors for human papillomavirus (HPV) infection among HIV-seronegative men who have sex with men. The Journal of infectious diseases 2011;203(1):66–74 doi 10.1093/infdis/jiq016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Nyitray AG, Smith D, Villa L, Lazcano-Ponce E, Abrahamsen M, Papenfuss M, et al. Prevalence of and risk factors for anal human papillomavirus infection in men who have sex with women: a cross-national study. Journal of Infectious Diseases 2010;201(10):1498–508 doi 10.1086/652187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Patel P, Bush T, Kojic EM, Conley L, Unger ER, Darragh TM, et al. Prevalence, Incidence, and Clearance of Anal High-Risk Human Papillomavirus Infection Among HIV-Infected Men in the SUN Study. The Journal of infectious diseases 2018;217(6):953–63 doi 10.1093/infdis/jix607. [DOI] [PubMed] [Google Scholar]
- 28.Sudenga SL, Ingles DJ, Pierce Campbell CM, Lin HY, Fulp WJ, Messina JL, et al. Genital Human Papillomavirus Infection Progression to External Genital Lesions: The HIM Study. European urology 2016;69(1):166–73 doi 10.1016/j.eururo.2015.05.032. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Pamnani SJ, Nyitray AG, Abrahamsen M, Rollison DE, Villa LL, Lazcano-Ponce E, et al. Sequential Acquisition of Anal Human Papillomavirus (HPV) Infection Following Genital Infection Among Men Who Have Sex With Women: The HPV Infection in Men (HIM) Study. The Journal of infectious diseases 2016;214(8):1180–7 doi 10.1093/infdis/jiw334. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Schabath MB, Villa LL, Lin HY, Fulp WJ, Lazcano-Ponce E, Salmerón J, et al. A prospective analysis of smoking and human papillomavirus infection among men in the HPV in Men Study. International journal of cancer 2014;134(10):2448–57 doi 10.1002/ijc.28567. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Bertisch B, Franceschi S, Lise M, Vernazza P, Keiser O, Schöni-Affolter F, et al. Risk factors for anal cancer in persons infected with HIV: a nested case-control study in the Swiss HIV Cohort Study. Am J Epidemiol 2013;178(6):877–84 doi 10.1093/aje/kwt153. [DOI] [PubMed] [Google Scholar]
- 32.Coffey K, Beral V, Green J, Reeves G, Barnes I. Lifestyle and reproductive risk factors associated with anal cancer in women aged over 50 years. British journal of cancer 2015;112(9):1568–74 doi 10.1038/bjc.2015.89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Frisch M, Glimelius B, Wohlfahrt J, Adami HO, Melbye M. Tobacco smoking as a risk factor in anal carcinoma: an antiestrogenic mechanism? Journal of the National Cancer Institute 1999;91(8):708–15 doi 10.1093/jnci/91.8.708. [DOI] [PubMed] [Google Scholar]
- 34.Moura MA, Bergmann A, Aguiar SS, Thuler LC. The magnitude of the association between smoking and the risk of developing cancer in Brazil: a multicenter study. BMJ open 2014;4(2):e003736 doi 10.1136/bmjopen-2013-003736. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Lin Y-Y, Damgacioglu H, Suk R, Wu C-F, Zhu Y, Ortiz AP, et al. Trends in the Incidence of Human Papillomavirus-Associated Cancers by County-Level Income and Smoking Prevalence in the United States, 2000–2018. JNCI Cancer Spectrum 2022;6(2):pkac004 doi 10.1093/jncics/pkac004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.D’Souza G, Wiley DJ, Li X, Chmiel JS, Margolick JB, Cranston RD, et al. Incidence and epidemiology of anal cancer in the multicenter AIDS cohort study. Journal of acquired immune deficiency syndromes (1999) 2008;48(4):491–9 doi 10.1097/QAI.0b013e31817aebfe. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Vaccarella S, Plummer M, Franceschi S, Gravitt P, Papenfuss M, Smith D, et al. Clustering of human papillomavirus (HPV) types in the male genital tract: the HPV in men (HIM) study. Journal of Infectious Diseases 2011;204(10):1500–4 doi 10.1093/infdis/jir595. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Jensen KE, Schmiedel S, Frederiksen K, Norrild B, Iftner T, Kjær SK. Risk for cervical intraepithelial neoplasia grade 3 or worse in relation to smoking among women with persistent human papillomavirus infection. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 2012;21(11):1949–55 doi 10.1158/1055-9965.epi-12-0663. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Fonseca-Moutinho JA. Smoking and cervical cancer. ISRN Obstet Gynecol 2011;2011:847684- doi 10.5402/2011/847684. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Anantharaman D, Muller DC, Lagiou P, Ahrens W, Holcátová I, Merletti F, et al. Combined effects of smoking and HPV16 in oropharyngeal cancer. International Journal of Epidemiology 2016;45(3):752–61 doi 10.1093/ije/dyw069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Daling JR, Madeleine MM, Johnson LG, Schwartz SM, Shera KA, Wurscher MA, et al. Penile cancer: Importance of circumcision, human papillomavirus and smoking in in situ and invasive disease. International journal of cancer 2005;116(4):606–16 doi 10.1002/ijc.21009. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data that supports this study are only available upon requests. They are not publicly accessible due to the delicate nature of the data presented in this study. All data pertinent to this study are incorporated in the article or uploaded as supplementary material. Study dataset with deidentified participant data and protocol can be requested from Anna.Giuliano@moffitt.org. Data requests can also be directed to the Center for Immunization and Infection Research, which is the institutional organization that handles data requests. Their email is: CIIRC@moffitt.org.