Perspectives in Disease Prevention and Health Promotion Smoking- Attributable Mortality and Years of Potential Life Lost -- United States, 1984

Cigarette smoking has been identified as the chief avoidable cause of death in the United States (1). Several estimates of mortality attributable to cigarette smoking have been reported, including 270,000 deaths for 1980 (2) and 314,000 deaths for 1982 (3). Published estimates vary considerably because of changing mortality rates, decreasing smoking rates, and differences in methods used. Smoking-attributable mortality and years of potential life lost (YPLL) for 1984 are analyzed in this report.

Relative risk (RR) estimates for smoking-related diseases and prevalence estimates of current, former, and never smokers among adults greater than or equal to20 years of age were used to calculate the smoking-attributable fraction (SAF) and smoking-attributable mortality for 19 underlying causes of death (2) (Table 1).* Age-, sex-, and race-specific mortality data for 1984 were obtained from National Center for Health Statistics reports. Age-, sex-, and race-specific smoking prevalence rates were obtained from the 1985 Current Population Survey (Supplement) of the Bureau of the Census (Office on Smoking and Health, CDC, unpublished data). Years of potential life lost were calculated to age 65 according to previously described methods (6). Age-adjusted smoking-attributable mortality and YPLL rates were calculated by the direct method, with the 1984 U.S. population used as the standard.

For deaths among adults, the disease-specific SAFs are derived from RR estimates for current and former smokers that are weighted averages from four prospective studies (7-10). RR estimates for women based on these studies may be lower than the current RRs for many of the specific smoking-related diseases among women. However, the SAF for lung cancer among women (0.75) has been updated based on RR estimates from more recent mortality data (11). Race-specific RR estimates for smoking-attributable diseases were not available.

For four pediatric diagnoses, the mortality attributed to maternal smoking during pregnancy for childrenless than 1 year of age was determined. These calculations used RR estimates from McIntosh (12) and current smoking prevalence among women 20-64 years of age as a proxy for the percentage of pregnant women who smoke. The RR (1.50) for sudden infant death syndrome from McIntosh (12) was used, but the RR (1.76) for total infant mortality reported by McIntosh was used to calculate the SAF for only three specific infant death categories (short gestation/low birthweight, respiratory distress syndrome, and other respiratory conditions).

An estimated 315,120 deaths and 949,924 YPLL before age 65 years resulted from cigarette smoking in 1984 (Table 2). The smoking-attributable mortality rate among men is more than twice the rate among women, and the rate among blacks is 20% higher than the rate among whites (Table 3). The smoking-attributable YPLL rate among men is more than twice the rate among women, and the rate among blacks is more than twice the rate among whites (Table 3). Reported by: Office on Smoking and Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The total smoking-attributable mortality and YPLL reported here is similar to that cited in previous reports (2,3), showing that the disease impact of smoking in the United States continues to be enormous despite recent declines in the prevalence of smoking. These figures do not include mortality and YPLL due to peripheral vascular disease (for which specific RR estimates are generally lacking), cancer at unspecified sites, cigarette-caused fires, or involuntary (passive) smoking. In 1984, an estimated 1,570 deaths were attributed to cigarette-initiated fires (13); an estimated 3,825 nonsmokers per year die from lung cancer attributed to involuntary smoking (14). When the figures for fires and involuntary smoking are included, the estimated total of smoking-attributable deaths in the United States in 1984 is 320,515, or 15.7% of all (2,039,369) U.S. deaths. Total smoking-attributable YPLL (949,924) represents 8.1% of all (11,761,000) U.S. YPLL before age 65 (excluding YPLL due to cigarette-caused fires or involuntary smoking).

Among blacks, the smoking-attributable mortality (32,779) represents 13.9% of total 1984 mortality (235,884), whereas the smoking-attributable mortality for whites (279,636) was 15.7% of total 1984 mortality (1,781,897), excluding deaths due to fires or involuntary smoking. However, the smoking-attributable mortality rate and YPLL rate were higher among blacks than among whites. These differences in rates reflect a higher prevalence of smoking and a higher mortality rate from smoking-related diseases among blacks. Higher YPLL rates among blacks may also reflect more smoking-attributable deaths at earlier ages. Because blacks tend to smoke fewer cigarettes per day than whites (15,16), the difference in smoking-attributable mortality and YPLL rates between blacks and whites may be slightly overestimated. On the other hand, the RR of smoking-related diseases among blacks may be higher than the RR estimates used here because of increased interactions between smoking and other risk factors, different tar and nicotine exposures, or different smoking patterns. Still, these findings support previously cited concerns regarding the increased burden of smoking-related disease among blacks (17).

Smoking prevalence for 1985 was used to calculate the SAFs in this study. However, the 1984 smoking-related mortality is a result of a higher smoking prevalence during the 1950s, '60s, and '70s, the decades during which these diseases were developing. Therefore, the SAFs used here are conservative.

CDC has examined YPLL before age 65 years since 1979 (6). In this study, most smoking-related deaths (218,691, or 69.4%) occurred among persons greater than or equal to65 years of age. Thus, the smoking-attributable YPLL among personsless than 65 reported here (949,924) is substantially lower than the 3.6 million smoking-attributable YPLL calculated when the average life expectancy in the United States is used for calculating YPLL for 1984.

Group-specific calculations such as these are possible for states and other defined populations if mortality and smoking prevalence data for those populations are available. A computer program has recently been developed to aid in calculating mortality and YPLL attributed to cigarette smoking (18). CDC is now collaborating with all 50 state health departments, Puerto Rico, and the District of Columbia to perform similar studies. Results from this project will be reported in 1988.

References

1. Office on Smoking and Health. The health consequences of smoking:cancer--a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1982:xi; DHHS publication no. (PHS)82-50179.

2. Rice DP, Hodgson TA, Sinsheimer P, Browner W, Kopstein AN. The economic costs of the health effects of smoking, 1984. Milbank Mem Fund Q 1986;64:489-547.

3. Office of Technology Assessment. Smoking-related deaths and financial costs. OTA Staff Memorandum. Health Program, U.S. Congress, 1985.

4. Walter SD. The estimation and interpretation of attributable risk in health research. Biometrics 1976;32:829-49.

5. Lilienfeld AM, Lilienfeld DE. Foundations of epidemiology. 2nd ed. New York: Oxford University Press, 1980.

6. CDC. Premature mortality in the United States: public health issues in the use of years of potential life lost. MMWR 1986;35(suppl 2S).

7. Hammond EC. Smoking in relation to the death rates of one million men and women. In: Haenszel WM, ed. Epidemiological approaches to the study of cancer and other chronic diseases. Bethesda: National Cancer Institute, US Department of Health, Education, and Welfare, Public Health Service, 1966:127-204. (NCI Monograph no. 19).

8. Doll R, Peto R. Mortality in relation to smoking: 20 years' observations on male British Doctors. Br Med J 1976;2:1525-36.

9. Doll R, Gray R, Hafner B, Peto R. Mortality in relation to smoking: 22 years' observations on female British doctors. Br Med J 1980;280:967-71.

10. Cederl|$$|Adof R, Friberg L, Lundman T. The interactions of smoking, environment, and heredity and their implications for disease etiology: a report of epidemiological studies on the Swedish twin registries. Acta Med Scand 1977;612(suppl):7-128.

11. American Cancer Society. 1986 cancer facts and figures. New York: American Cancer Society, 1986:p17.

12. McIntosh ID. Smoking and pregnancy: attributable risks and public health implications. Can J Public Health 1984;75:141-8.

13. Hall JR Jr. Expected changes in fire damages from reducing cigarette ignition propensity. Report No. 5, Technical Study Group, Cigarette Safety Act of 1984. Quincy, Massachusetts: National Fire Protection Association, Fire Analysis Division, 1987.

14. National Academy of Sciences. Environmental tobacco smoke: measuring exposures and assessing health effects. Washington, DC: National Academy Press, 1986: Appendix D.

15. CDC. Cigarette smoking in the United States, 1986. MMWR 1987;36:581-5.

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