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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail. Projected Smoking-Related Deaths Among Youth -- United StatesOn August 23, 1996, the Food and Drug Administration (FDA) issued a regulation restricting the sale and distribution of cigarettes and smokeless tobacco to children and teenagers to reduce the number of youth who use these products and to reduce the life-threatening consequences associated with tobacco use (1). Despite widespread efforts to educate U.S. youths about the health consequences associated with smoking (2), the prevalence of smoking among this group has been increasing since 1992 (3). To assess the need for continued public health efforts to prevent nicotine addiction, CDC used a model including data from the Behavioral Risk Factor Surveillance System (BRFSS) to project the future impact of smoking on the health of children and teenagers. This report presents the findings of the analysis, which indicate that, if current tobacco-use patterns persist, an estimated 5 million persons who were aged 0-17 years in 1995 will die prematurely from a smoking-related illness. State-specific data on the prevalence of current smoking among adults aged 18-30 years in all 50 states and the District of Columbia were obtained from the BRFSS for 1994 and 1995 (4). Current smokers were respondents who reported having smoked 100 cigarettes during their lifetimes and who reported currently smoking. Because the prevalence of smoking in a birth cohort peaks during early adulthood (2), the average prevalence of smoking among adults aged 18-30 years for each state during 1994-1995 was used to estimate the future prevalence of smoking during early adulthood for the birth cohorts currently aged 0-17 years. The number of persons aged 0-17 years in 1995 in each state was obtained from U.S. census reports (5) and was multiplied by the estimated prevalence of future smoking to calculate the estimated number of youths who may become regular smokers in each state. Overall, the estimated number of future smokers among the cohort of persons who were aged 0-17 years in 1995 was 16,620,878 for the United States (range: 15,398 {District of Columbia} to 1,446,550 {California}) (Table_1). The projected number of smoking-related deaths among youth smokers was based on the combined estimates of young adult smokers who continue to smoke throughout their lifetimes and estimates of premature death attributable to smoking among continuing smokers (6) and among those who quit after age 35 years (7). Based on data from the 1986 National Mortality Followback Survey (NMFS), 55% (95% confidence interval {CI}= plus or minus 1%) of persons who had ever smoked greater than or equal to 100 cigarettes during their lifetimes continued to smoke until 1 year before their deaths, and 45% (95% CI= plus or minus 1%) quit smoking earlier in their adult lives (CDC, unpublished data, 1995). Based on data from long-term cohort studies, an estimated 50% of deaths among continuing smokers will be attributable to smoking (6). Although estimates of the number of smoking-attributable deaths among former smokers range from 10% to 37%, a conservative estimate of 10% was used in this analysis (7; CDC, unpublished data, 1996). The future probability of smoking-attributable mortality (PSAM) among youth was computed to be PSAM={(0.55 X 0.5)+(0.45 X 0.1)}=0.32. Estimates for the variance of the two smoking-attributable fractions (50% and 10%) within the PSAM were computed from the Cancer Prevention Study II (8). These two variances were combined with the variances for the probabilities of continued smoking or quitting using a Taylor Series approximation method, which yielded an estimate of 0.00422 of the relative error of the PSAM. To reflect the uncertainty of the multiple assumptions about future smoking and mortality patterns, this error estimate for the PSAM was increased by a factor of 2.5, yielding an estimated standard error of 0.0106. Based on application of this PSAM to the state-specific estimates of potential smokers, the overall number of potential future smoking-attributable deaths among persons aged 0-17 years during 1995 was 5,318,681 for the United States (range: 4927 {District of Columbia} to 462,896 {California}) (Table_1). Based on the estimated PSAM variance and the state-specific sampling errors from the BRFSS estimates of smoking prevalence, the estimated number of smoking-related deaths for the United States overall was predicted to vary by less than or equal to 160,000 deaths. Reported by the following BRFSS coordinators: J Durham, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; S Loyd, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, New Mexico; T Melnik, DrPH, New York; G Lengerich, VMD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; J Ferguson, DrPh, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; J Stones, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. P Mowery, MA, J Shulman, PhD, Battelle Memorial Institute, Baltimore, Maryland. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial NoteEditorial Note: The findings in this report indicate that, if current patterns of smoking behavior persist, an estimated 5 million U.S. persons who were aged 0-17 years in 1995 could die prematurely from smoking-related illnesses. These projected patterns of smoking and smoking-related deaths could result in an estimated $200 billion (in 1993 dollars) in future health-care costs (i.e., $12,000 per smoker) (9) and approximately 64 million years of potential life lost (i.e., 12-21 years per smoking-related death) (6,9,10), underscoring the need for intensifing efforts to prevent smoking initiation among youth. The projection method used in this analysis is subject to at least three limitations. First, although this method has been recommended for estimating future tobacco-related deaths in developed countries (6), alternative methods may be more precise (e.g., life-table procedures used to project future disease-specific outcomes, particularly lung cancer). Second, this method assumes that future smoking patterns and smoking-related disease rates will be similar to those observed in recent generations. However, future patterns may differ: for example, the estimates of future smoking prevalence in this analysis may be underestimated because smoking prevalences among teenagers have been increasing in recent years (3). Third, the estimated risks for smoking-attributable death and the smoking-attributable fractions among quitters (i.e., 10%) and continuing smokers (i.e., 50%) are based on studies of adults who began smoking during the mid 1900s (6,7). More recent data indicate that relative risks of smoking for more recent birth cohorts of both men and women have been increasing rather than decreasing (8). Factors related to changes in the intensity and duration of smoking may account in part for the substantial increase in the relative risks of smoking from the 1960s to the 1980s (e.g., relative risks of lung cancer increased from 11.4 to 22.4 for men and from 2.7 to 11.9 for women) (8). These increases in risk occurred despite changes in the composition of tobacco products commonly smoked, including the widespread adoption of filter-tipped, potentially lower "tar" cigarettes (8). While future changes in tobacco products could reduce health risks associated with smoking, smoking intensity and duration are likely to remain the major predictors of future risk (8). Therefore, unless U.S. persons who were aged 0-17 years during 1995 and who are current or potential smokers alter their future smoking behavior relative to patterns of previous generations (e.g., smoke fewer cigarettes per day or quit earlier in life), the relative risks of smoking probably will remain high. FDA has issued regulations to restrict youth access to tobacco and to reduce the appeal of cigarette advertising among youths and has issued a proposal to require a program to educate youths about the health consequences associated with tobacco use (1). Because smoking-related deaths are preventable (1,9), public health efforts should emphasize both prevention of smoking initiation in the youngest birth cohorts (2) and cessation as early as possible among youth who already have started smoking (6,7). References
Table_1 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size. TABLE 1. Prevalence of current smoking among adults aged 18-30 years * and projected number of persons aged 0-17 years who will become smokers + and die prematurely as adults because of a smoking-related illness, by state -- United States, 1995 ============================================================================================================================================================ Prevalence of current smoking Persons aged 0-17 years among persons -------------------------------------------------------------------------- aged 18-30 years Projected smokers Projected no. ------------------------ ----------------------- deaths State % (95% CI &) No. @ No. (95% CI) ------------------------------------------------------------------------------------------------------------------------------------------------------------ Alabama 24.1 (+/-3.4%) 1,080,145 260,639 (+/- 36,465) 83,404 Alaska 29.7 (+/-4.8%) 189,253 56,246 (+/- 9,006) 17,999 Arizona 25.8 (+/-4.6%) 1,193,270 307,864 (+/- 54,337) 98,516 Arkansas 24.0 (+/-3.5%) 649,521 155,690 (+/- 22,994) 49,821 California 16.5 (+/-2.0%) 8,793,616 1,446,550 (+/-176,420) 462,896 Colorado 27.7 (+/-3.6%) 981,200 271,694 (+/- 35,093) 86,942 Connecticut 22.0 (+/-3.5%) 797,733 175,501 (+/- 27,690) 56,160 Delaware 29.0 (+/-3.3%) 178,826 51,806 (+/- 5,968) 16,578 District of 13.4 (+/-4.3%) 114,652 15,398 (+/- 4,887) 4,927 Columbia Florida 27.5 (+/-2.8%) 3,371,328 928,464 (+/- 93,582) 297,108 Georgia 21.3 (+/-3.0%) 1,923,594 409,726 (+/- 57,900) 131,112 Hawaii 20.9 (+/-3.0%) 309,262 64,574 (+/- 9,353) 20,664 Idaho 21.9 (+/-3.0%) 347,924 76,230 (+/- 10,517) 24,394 Illinois 26.0 (+/-3.2%) 3,125,894 813,670 (+/- 99,723) 260,374 Indiana 30.0 (+/-3.1%) 1,487,359 439,515 (+/- 46,329) 140,645 Iowa 23.1 (+/-2.7%) 724,511 167,507 (+/- 19,326) 53,602 Kansas 22.2 (+/-3.5%) 692,761 153,862 (+/- 23,936) 49,236 Kentucky 28.2 (+/-3.3%) 972,708 274,693 (+/- 32,116) 87,902 Louisiana 26.7 (+/-3.5%) 1,239,214 331,366 (+/- 43,742) 106,037 Maine 32.0 (+/-4.9%) 304,895 97,536 (+/- 14,792) 31,211 Maryland 21.1 (+/-2.0%) 1,271,966 267,876 (+/- 25,759) 85,720 Massachusetts 23.1 (+/-3.4%) 1,431,854 330,186 (+/- 48,366) 105,659 Michigan 28.6 (+/-3.1%) 2,519,455 721,572 (+/- 78,357) 230,903 Minnesota 24.3 (+/-2.2%) 1,245,492 303,153 (+/- 27,294) 97,009 Mississippi 20.0 (+/-3.5%) 761,909 152,610 (+/- 26,343) 48,835 Missouri 26.9 (+/-4.3%) 1,381,552 372,052 (+/- 59,197) 119,057 Montana 19.9 (+/-4.3%) 236,134 47,014 (+/- 10,151) 15,045 Nebraska 25.0 (+/-3.6%) 443,297 110,913 (+/- 15,842) 35,492 Nevada 24.8 (+/-3.4%) 398,586 98,770 (+/- 13,716) 31,606 New Hampshire 25.2 (+/-4.0%) 294,969 74,303 (+/- 11,886) 23,777 New Jersey 21.6 (+/-3.8%) 1,963,523 423,728 (+/- 74,663) 135,593 New Mexico 20.9 (+/-4.1%) 500,099 104,271 (+/- 20,422) 33,367 New York 26.0 (+/-3.1%) 4,536,862 1,179,584 (+/-141,545) 377,467 North Carolina 28.8 (+/-3.0%) 1,799,119 517,786 (+/- 53,965) 165,692 North Dakota 22.5 (+/-3.2%) 170,445 38,350 (+/- 5,367) 12,272 Ohio 31.2 (+/-4.6%) 2,859,848 891,129 (+/-131,262) 285,161 Oklahoma 22.7 (+/-5.2%) 878,039 199,490 (+/- 45,586) 63,837 Oregon 24.1 (+/-2.9%) 797,040 191,688 (+/- 23,220) 61,340 Pennsylvania 29.5 (+/-2.9%) 2,909,302 857,371 (+/- 84,342) 274,359 Rhode Island 30.9 (+/-5.9%) 237,611 73,446 (+/- 13,931) 23,503 South Carolina 22.0 (+/-3.0%) 944,384 208,142 (+/- 28,621) 66,606 South Dakota 22.1 (+/-3.3%) 206,436 45,705 (+/- 6,715) 14,626 Tennessee 25.1 (+/-2.9%) 1,310,297 329,147 (+/- 38,256) 105,327 Texas 21.5 (+/-3.6%) 5,400,417 1,158,389 (+/-192,545) 370,685 Utah 16.1 (+/-2.5%) 674,618 108,883 (+/- 16,797) 34,843 Vermont 26.3 (+/-3.4%) 146,760 38,613 (+/- 4,914) 12,356 Virginia 26.3 (+/-3.5%) 1,612,527 423,288 (+/- 56,079) 135,452 Washington 23.8 (+/-2.5%) 1,418,404 336,871 (+/- 34,770) 107,799 West Virginia 28.6 (+/-3.3%) 421,868 120,443 (+/- 13,970) 38,542 Wisconsin 27.0 (+/-3.8%) 1,353,205 365,907 (+/- 51,333) 117,090 Wyoming 23.2 (+/-4.3%) 136,268 31,669 (+/- 5,812) 10,134 Total NA NA 68,739,952 16,620,878 (+/-219,091) 5,318,681 ------------------------------------------------------------------------------------------------------------------------------------------------------------ * Obtained from Behavioral Risk Factor Surveillance System data for 1994 and 1995, except for Rhode Island for 1995 and the District of Columbia for 1994. + Based on 1995 population data and the prevalence of current smoking among adults aged 18-30 years. & Confidence interval. @ Obtained from 1995 census data. ============================================================================================================================================================ Return to top. 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