Smoking-Attributable Mortality and Years of Potential Life Lost -- United States, 1988

Smoking is a leading cause of diseases associated with premature mortality in the United States; in 1985, these diseases accounted for an estimated 390,000 premature deaths (1). In this report, mortality data and estimates of smoking prevalence for 1988 are used to calculate smoking-attributable mortality (SAM), years of potential life lost (YPLL), and age-adjusted SAM and YPLL rates for the United States (2).

Calculations were performed using Smoking-Attributable Mortality, Morbidity, and Economic Cost (SAMMEC II) software (2), which includes relative risk estimates for 22 adult (i.e., greater than or equal to 35 years of age) smoking-related diseases and relative risk estimates for four perinatal (i.e., less than 1 year of age) conditions (Table 1). Age-, sex-, and race-specific mortality data for 1988 were obtained from CDC's National Center for Health Statistics. Data on burn deaths caused by cigarettes were obtained from the Federal Emergency Management Agency (3). The estimated number of deaths among nonsmokers from lung cancer attributable to passive smoking was obtained from a report of the National Academy of Sciences (4). Age-, sex-, and race-specific current and former smoking prevalence rates in 1988 for adults aged greater than or equal to 35 years and for women aged 18-44 years were estimated by linear extrapolation using National Health Interview Survey data for 1974-1987 (1,5).

YPLL before age 65 and before age 85 were calculated according to standard methods (2). Age-adjusted SAM and YPLL rates were calculated by the direct method and standardized to the 1980 U.S. population. YPLL estimates do not include deaths related to passive smoking.

Based on these calculations, in 1988, approximately 434,000 deaths and 1,199,000 YPLL before age 65 (6,028,000 before age 85) were attributable to cigarette smoking (Tables 1 and 2). Although SAM for blacks represented 11% of total SAM, the SAM rate for blacks was 12% higher than for whites. The SAM for men was 66% of total SAM, and the SAM rate for men was more than twice the rate for women (Tables 2 and 3). In addition, the rate of smoking-attributable YPLL before age 65 for blacks was twice that for whites, and the smoking-attributable YPLL rate for men was almost three times that for women. For YPLL before age 85, the rate for blacks was 52% higher than for whites, and for men, more than twice that for women (Table 3). Reported by: JM Shultz, PhD, Univ of Miami School of Medicine, Miami, Florida. Program Svcs Activity, Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: For 1988, total estimated smoking-attributable deaths (434,000) were substantially higher than for 1985 (390,000) (1). Although SAM from ischemic heart disease declined between 1985 and 1988, SAM from lung cancer and chronic obstructive pulmonary disease was higher. Several heart disease categories (International Classification of Diseases, Ninth Revision (ICD-9) rubrics 390-398, 415-417, 420-429) were included in the calculations for 1988 but not for 1985, contributing to the higher SAM estimate for 1988.

The higher SAM rates for blacks underscore concerns about the higher burden of smoking-related diseases among blacks than among whites. For example, the average lung cancer death rate from 1980 through 1987 for blacks was 2.3 times higher than for whites (6). In addition, the larger racial disparity in smoking-attributable YPLL suggests that onset of smoking-attributable disease occurs at younger ages among blacks than among whites.

In this report, the SAM estimate for the United States represents a conservative estimate because it is based on 1988 prevalence data, whereas smoking-attributable diseases in 1988 actually are caused by higher rates of smoking in the 1950s, 1960s, and 1970s. For persons aged greater than or equal to 55 years who smoked during those decades, lung cancer incidence and death rates and the chronic obstructive pulmonary disease death rate are increasing (6,7).

The SAM described in this report also represents a conservative estimate because the calculations did not include deaths from cardiovascular disease that may have been attributable to passive smoking and deaths from cancers at unspecified sites (1), leukemia (8), and ulcers (9)--all of which may also be associated with cigarette smoking. A recent analysis estimated that each year passive smoking is associated with 37,000 deaths from heart disease (10).

Despite declines in the prevalence of smoking in the United States, the absolute numbers of deaths caused by smoking-related diseases may increase for several years. This trend is due partly to the increase in absolute numbers of smokers among the post-World War II generation (i.e., persons aged 25-44 years), who will soon attain the ages at which smoking-related diseases occur (5). Persons in this age group and in older age groups will continue to develop chronic diseases associated with smoking unless widespread cessation efforts are successful. However, because of the declining prevalence of smoking in the United States, death rates of lung cancer (11) and of coronary heart disease (12) among younger men and women have already begun to decline. Because smoking cessation is associated with a decreased risk for premature death at any age (9), efforts to support cessation must be further encouraged in the elderly and other groups (e.g., women and minorities) characterized by higher smoking prevalences or slower rates of decline in smoking.

References

1. CDC. Reducing the health consequences of smoking: 25 years of

progress--a report of the Surgeon General, 1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-8411.

2. Shultz JM, Novotny TE, Rice DP. SAMMEC II: computer software and documentation. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, April 1990.

3. Federal Emergency Management Agency. Fire in the United States: 1983-1987 and highlights for 1988. 7th ed. Emmitsburg, Maryland: US Fire Administration, Federal Emergency Management Agency, August 1990. (FA-94).

4. National Research Council. Environmental tobacco smoke: measuring exposures and assessing health effects. Washington, DC: National Academy Press, 1986.

5. Novotny TE, Fiore MC, Hatziandreu EJ, Giovino GA, Mills SL, Pierce JP. Trends in smoking by age and sex, United States, 1974-1987: the implications for disease impact. Prev Med 1990;19:552-61.

6. CDC. Trends in lung cancer incidence and mortality--United States, 1980-1987. MMWR 1990;39:875,881-3.

7. CDC. Chronic disease reports: chronic obstructive pulmonary disease mortality--United States, 1986. MMWR 1989;38:549-52.

8. Garfinkel L, Boffetta P. Association between smoking and leukemia in two American Cancer Society prospective studies. Cancer 1990;65:2356-60.

9. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416. 10. Glantz SA, Parmley WW. Passive smoking and heart disease: epidemiology, physiology, and biochemistry. Circulation 1991;83:1-12. 11. Devesa SS, Blot WJ, Fraumeni JF. Declining lung cancer rates among young men and women in the United States: a cohort analysis. J Natl Cancer Inst 1989;81:1568-71. 12. Ragland KE, Selvin S, Merrill DW. The onset of decline in ischemic heart disease mortality in the United States. Am J Epidemiol 1989;127:516-31.

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