Case-control studies provide a relatively simple way

to investigate causes of diseases, especially rare

diseases. They include people with disease (or
other outcome variable) of interest and a suitable
control (comparison or reference) group of people
unaffected by the disease or outcome variable. The
study compares the occurrence of the possible
cause in cases and in controls. The investigators
collect data on disease occurrence at one point in
time and exposures at a previous point in time.
 CASE CONTROL is a type of Analytical study.
 It is often called a Retrospective study. In recent years,
this has emerged as a permanent method of
epidemiological investigation.
 By definition, this study involves two populations – Cases
and Control i.e. the unit is the individual rather than the
group. Besides the focus is on a disease or some other
health problem that has already developed.
 These are basically Comparison Studies. Cases and
Controls must be comparable with respect to known
“confounding factors” such as age, sex, occupation, social
status etc.
 The case control has 3 different features:

a) Both exposure and outcome (disease) have occurred

before the start of the study.
b) The study proceeds backwards from effect to cause.
c) It uses a control and comparison group to support or
refute an inference.
 Selection of Cases and Control.
 Matching.
 Measurement of exposure.
 Analysis and interpretation
 ADVANTAGES
 Relatively easy to carry out.
 Rapid and inexpensive.
(compared to cohort study)
 Require few subjects.
 Suitable to investigate rare
diseases.
 Allows the study of several
different etiological
factors( e.g. Smoking, physical
activity, personality
characteristics, M.I etc.)
 Risk factors can be identified.
 Rational prevention and control
programmes can be established.
DISADVANTAGES
 Selection of an appropriate group
may be difficult.
 Problems of Bias relies on memory
or past records i.e. Accuracy and
Validation may be uncertain.
 Does not distinguish between
causes and associated factors.
 Not suited to the evaluation of
therapy or prophylaxis of disease.
 Incidence cannot be measured but
only Relative risk can be estimated.
 Most deaths in the country are from respiratory,
cardiac or neoplastic disorders or from tuberculosis;
the death rates from these diseases can be increased by
smoking.
 Large number of household surveys have shown that in
middle age, more than one third of men and a few
percent of women smoke tobacco.
 Thus, to assess the hazards of smoking in India, a
case-control study was conducted, collecting
information on all adult deaths from 2001 to 2003 in a
nationally representative sample of 1.1 million homes.
 Study design
 The study was conducted in 1.1 million homes in 6671
small areas chosen randomly from all parts of India.
 Each home where a death was recorded between 2001-03
was visited by 1 of 900 non-medical field-workers to
collect information.
 The underlying causes of death were sought by verbal
autopsy i.e a structured investigation of events leading to
death.
 Two trained physicians independently assigned codes to
the cause of death.
 If two physicians did not agree on the assigned three-digit
code, a senior physician adjudicated.
Among the case subjects, data was available for 33,069
women and 41,054 men.

Among the controls, 34,857 women and 43,078 men

were assessed.

Women and men were analyzed separately.

 The field-workers asked respondents

 The cause of death

 Whether the deceased person had been a smoker
within the previous 5 yrs and if yes, the number of
bidis or cigarettes the person smoked per day.
 Questions on tobacco smoking, quid chewing, alcohol
consumption.
 Years of education.
 Similar questions were asked by the respondents
about themselves.
 Controls are not matched to particular cases.
 So the control group remains the same when studying
different underlying causes of death.
 Controls are, on average, younger than cases.
 The major analyses use logistic regression to adjust for :
 age(five-year age groups),
 education (no education

[defined as no formal education or not completing

primary school]; primary or middle; grade 10 or higher;
unknown)
 alcohol use (yes; no; unknown).
This includes
 Characteristics of the Subjects
 Smoking and Mortality
 Underlying Causes of Death
 Graphs
 In the group of control subjects, the prevalence
of smoking among men rose with age (8% to
40%)
 Between the ages of 40 and 59 years, smoking
was more common among men without
primary education (44%) than among other
men (35%). Primary Education plays a vital
role.
 Among men & women between the ages of 30
and 69 years, 55% & 9% respectively of those
who died from any medical cause were
smokers respectively.
 % of smokers among cases
 In Women
tuberculosis 13%
respiratory disease 14%
stroke (6%) and heart disease (10%).
 In male
tuberculosis 66 %
Respiratory disease 60%
 Demographic Characteristics of the Subjects, According to Age

Age
(Women)

Age (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
 Demographic Characteristics of the Subjects, According to residence

Residence
(Women)

Residence (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
 Characteristics of the Subjects, According to Education level

Educational level (Women)

Educational level (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
 Demographic Characteristics of the Subjects, According to Religion

Religion (Women)

Religion (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
 Characteristics of the Subjects, According to behaviour towards chewing
tobacco

Chewing tobacco (Women)

Chewing tobacco (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
 Characteristics of the Subjects, According to alcohol consumption

Alcohol consumption (Women)

Alcohol consumption (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
 Characteristics of the Subjects, According to behaviour towards tobacco
smoking

Smoking tobacco (Women)

Smoking tobacco (Men)

Women : Case Subjects (N = 33,069), Control Subjects(N = 34,857)

Men : Case Subjects(N = 41,054), Control Subjects(N = 43,078)
Prevalence of Smoking in India, According to
Age and Sex.

AGE (years)
Death from Any Medical Cause and Rate of
Smoking among Women
Death from Any Medical Cause and Rate of
Smoking among Men
Cumulative Probability of Death from Any Cause among
smokers and Nonsmokers between the Ages of 30 and 69
Years.

Women

AGE (years)

Men

AGE (years)
 Smoking causes large and growing number of
premature deaths in India.
 Not only relation between smoking and
mortality was calculated but also dose response
relation between smoking and mortality was
calculated.
 Sample size was fair enough.
 Odds ratio for each group can be calculated.
 Matching is clearly defined.
 Operational definitions clearly defined.
 There may be some other variables such as stress,
family history of smoking that were not measured.
 Tobacco use and alcohol use are strongly correlated,
so residual confounding by the use of alcohol could
explain some of the excess mortality among smokers.
 The study did not have information on the smoking
status of people who were homeless or living alone
when they died. Overall, we obtained information on
smoking for only 88% of the enumerated deaths.
 Control subjects were self-selected by the willingness
to be interviewed (selection bias).
 Interviewer and memory recall bias would have been
there.
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