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Smoking harms nearly every organ of the body, causing many diseases
and reducing quality of life and life expectancy.1 This report
assesses the health consequences and productivity losses attributable to smoking
in the United States during 1997-2001. CDC calculated national estimates of
annual smoking-attributable mortality (SAM), years of potential life lost
(YPLL) for adults and infants, and productivity losses for adults. The findings
indicated that, during 1997-2001, cigarette smoking and exposure to tobacco
smoke resulted in approximately 438,000 premature deaths in the United States,
5.5 million YPLL, and $92 billion in productivity losses annually. Implementation
of comprehensive tobacco-control programs as recommended by CDC can reduce
smoking prevalence and related mortality and health-care costs.1
The Adult and Maternal and Child Health Smoking-Attributable Mortality,
Morbidity and Economic Cost (SAMMEC) software2 was revised on the
basis of findings from the 2004 Surgeon General’s report on diseases
caused by smoking.1 The list of smoking-attributable diseases now
includes stomach cancer and acute myeloid leukemia and excludes hypertension.
Sex- and age-specific smoking-attributable deaths were calculated by multiplying
the total number of deaths for 19 adult and four infant disease categories
by estimates of the smoking-attributable fraction (SAF) of preventable deaths.
The attributable fractions provide estimates of the public health burden of
each risk factor and the relative importance of risk factors for multifactorial
diseases. Because of the effect of interactions between various risk factors,
attributable fractions for a given disease can add up to more than 100%. For
adults, SAFs were derived by using sex-specific relative risk (RR) estimates2 for current and former smokers for each cause of death from the American
Cancer Society’s Cancer Prevention Study-II (CPS-II) for the period
1982-1988.2 For ischemic heart disease and cerebrovascular disease
deaths, RR estimates were also stratified by age (35-64 years and ≥65 years).
SAFs also used sex- and age-specific (35-64 years and ≥65 years) current
and former cigarette smoking–prevalence estimates from the National
Health Interview Survey.* For infants, SAFs were calculated by using pediatric
RR estimates2 and maternal smoking prevalence estimates from birth
certificates.2 Smoking-attributable YPLL and productivity losses
were estimated by multiplying sex- and age-specific SAM by remaining life
expectancy3 and lifetime earnings data.4 In addition,
smoking-attributable fire-related deaths5 and lung cancer and heart
disease deaths attributable to exposure to secondhand smoke6,7 were
included in the SAM estimates.
During 1997-2001, smoking resulted in an estimated annual average of
259,494 deaths among men and 178,408 deaths among women in the United States.
Among adults, 158,529 (39.8%) of these deaths were attributed to cancer, 137,979
(34.7%) to cardiovascular diseases, and 101,454 (25.5%) to respiratory diseases.
The three leading specific causes of smoking-attributable death were lung
cancer (123,836), chronic obstructive pulmonary disease (COPD)† (90,582),
and ischemic heart disease (86,801). Smoking during pregnancy resulted in
an estimated 910 infant deaths annually during 1997-2001. An estimated 38,112
lung cancer and heart disease deaths annually were attributable to exposure
to secondhand smoke. The average annual SAM estimates also included 918 deaths
from smoking-attributable fires.
During 1997-2001, on average, smoking accounted for an estimated 3.3
million YPLL for men and 2.2 million YPLL for women annually, excluding burn
deaths and adult deaths from secondhand smoke. Estimates for average annual
smoking-attributable productivity losses were approximately $61.9 billion
for men and $30.5 billion for women during this period.
BS Armour, PhD, T Woollery, PhD, A Malarcher, PhD, TF Pechacek, PhD,
C Husten, MD, Office on Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, CDC.
During 1997-2001, an estimated 438,000 persons in the United States
died prematurely each year as a result of smoking or exposure to secondhand
smoke. This figure is lower than the average annual estimate of approximately
440,000 deaths during 1995-19998 because of changes in the list
of smoking-attributable diseases and declines in the prevalence of smoking.
Accelerated reductions in the prevalence of smoking could prevent millions
of premature deaths.1
The findings in this report are subject to at least six limitations.
First, the estimates understate deaths attributable to tobacco use because
estimates of deaths attributable to cigar smoking, pipe smoking, and smokeless
tobacco use were excluded. Second, RRs were based on deaths during 1982-1988
among birth cohorts who might have had different smoking histories than current
or former smokers (e.g., age of initiation and duration of smoking before
quitting). Third, this report used a death certificate–based definition
of COPD, including codes for bronchitis/emphysema and chronic airway obstruction
(ICD-10 J44).1 Therefore, the COPD SAM estimate used for this report
might differ from other estimates that use other definitions of COPD.1 Fourth, RRs were adjusted for the effects
of age but not for other potential confounders. However, research suggests
that education, alcohol, and other confounders had negligible additional impact
on SAM estimates for lung cancer, COPD, ischemic heart disease, and cerebrovascular
disease in CPS-II.2 Fifth, productivity losses understate the total
costs of smoking because costs associated with smoking-attributable health-care
expenditures, smoking-related disability, employee absenteeism, and secondhand
smoke–attributable disease morbidity and mortality were not included.
Finally, the estimates do not account for the sampling variability in smoking
prevalence estimates or in RRs.
Cigarette smoking continues to impose substantial health and financial
costs on society. In 1998, smoking-attributable health-care expenditures were
estimated at $75.5 billion.2 During 1997-2001, these expenditures
plus the productivity losses ($92 billion) exceeded $167 billion per year.
By comparison, investments in comprehensive, state-based tobacco prevention
and control programs in 2002 were approximately 200-fold smaller than those
costs.9 Because investments in evidence-based prevention programs
have produced larger and faster reductions in cigarette consumption,10 increased investments to the levels recommended by CDC are needed
to achieve a greater health impact.
REFERENCES: 10 available
*SAFs for each disease are calculated by using the following equation:
SAF = [(p1(RR1 – (1) + p2(RR2 – 1)] / [ p1(RR1 – (1) + p2(RR2 – (1) + 1] where p1 = percentage of
current smokers (persons who have smoked ≥100 cigarettes and now smoke
every day or some days), p2 = percentage of former smokers (persons
who have smoked ≥100 cigarettes and do not currently smoke), RR1 =
relative risk for current smokers relative to never smokers, and RR2 = relative risk for former smokers relative to never smokers.
†COPD includes bronchitis/emphysema (International
Classification of Diseases, Tenth Revision [ICD-10] codes J40–J42
and J43) and chronic airway obstruction (ICD-10 J44).1
Annual Smoking-Attributable Mortality, Years of Potential Life Lost,
and Productivity Losses—United States, 1997-2001. JAMA. 2005;294(7):788–789. doi:10.1001/jama.294.7.788