Current Trends State-Specific Estimates of Smoking-Attributable Mortality and Years of Potential Life Lost -- United States, 1985

Cigarette smoking is the chief avoidable cause of death in the United States (1). Although annual estimates of smoking-attributable mortality in the United States vary by method and data source, the estimates are uniformly large and range from a low of 270,000 (2) to a high of 485,000 (3). An estimated 320,515 deaths were attributable to smoking in 1984 (4), representing approximately 16% of the total deaths in the United States for that year. Years of potential life lost (YPLL) have also been used to measure the impact of smoking-attributable disease (4,5).

In 1987, a computer software program (Smoking-Attributable Mortality, Morbidity, and Economic Cost (SAMMEC)) developed by the Center for Nonsmoking and Health, Minnesota Department of Health, was distributed by CDC to the other states (6). This software facilitates calculations of smoking-attributable mortality, YPLL, and economic costs. Using the software, all 50 states and the District of Columbia completed these calculations for 1985.

For smoking-attributable deaths and YPLL, the smoking-attributable fractions (SAFs) for 21 smoking-related diseases among adults were calculated using weighted relative risks estimated from four prospective studies on the health effects of smoking (2,4). In addition, risks for four pediatric diseases related to maternal smoking were included in the SAMMEC calculations (7). Age- and sex-specific mortality data for 1985 were obtained from each state's vital records system. Age- and sex-specific weighted smoking prevalence rates (CDC, unpublished data) were obtained from the 1985 Current Population Survey (supplement) of the U.S. Bureau of the Census. The smoking-attributable YPLL were calculated by two methods: 1) to age 65 years and 2) to average life expectancy (5). State-specific rates per 100,000 persons for smoking-attributable mortality and YPLL were calculated using state-specific population data provided by the U.S. Bureau of the Census for 1985 (U.S. Bureau of the Census, unpublished data). These rates were not age-adjusted because insufficient age-specific population data were available to permit age adjustment for all states.

According to state-specific estimates, more than 314,000 U.S. deaths were caused by smoking in 1985. The average number of smoking-attributable deaths per state was 6168 (ranging from 271 in Alaska to 28,533 in California) (Table 1). Of all smoking-attributable deaths in the United States, 67% were among men, 32% among women, and less than 1% among children less than 5 years of age. These deaths in young children resulted from low birthweight/short gestation, respiratory distress syndrome, other respiratory diseases of the newborn, and other diseases of children associated with maternal smoking (4). Smoking-attributable deaths accounted for approximately 936,000 YPLL before age 65 years in 1985. When average life expectancy was used as a cut-off point, approximately 3.6 million YPLL resulted from the smoking-attributable deaths.

The average state smoking-attributable mortality rate was 130.0 per 100,000 persons (ranging from 45.3 in Utah to 175.9 in Kentucky) (Table 2). The average rate of smoking-attributable YPLL before age 65 years was 447.8 per 100,000 persons less than 65 years of age (ranging from 223.5 in Utah to 773.6 in the District of Columbia). The average rate of smoking-attributable YPLL before actual life expectancy was 1503.8 per 100,000 persons (ranging from 643.2 in North Dakota to 2167.3 in Kentucky). Reported by: CH Woernle, MD, State Epidemiologist, Alabama Dept of Public Health. J Wohlleb, MS, Div of Health Statistics, Arkansas Dept of Health. L Parker, PhD, Chronic Disease Br, California Dept of Health Svcs. W Todd, MS, Div of Prevention Programs, Colorado Dept of Health. M Adams, MPH, Office of Health Education, Connecticut State Dept of Health Svcs. F Breukelman, Div of Public Health Education, Delaware Dept of Health and Social Svcs. V Kofie, PhD, Bur of Cancer Control, District of Columbia Dept of Health and Human Svcs. K Rigney, MD, Chronic Disease Br, Hawaii Dept of Health. J Mitten, Health Promotion and Disease Prevention Section, Idaho Dept of Health and Welfare. L Hathcock, PhD, Public Health Statistics Div, Indiana Board of Health. M Eischen, Health Education and Risk Reduction Br, Iowa Dept of Public Health. R Schwartz MSPH, Div of Health Promotion and Education, Maine Sureau of Health. N Fox, PhD, Chronic Disease Prevention Svcs, Maryland Dept of Health and Mental Hygiene. G Connolly, DDS, Office for Nonsmoking and Health, Massachusetts Dept of Public Health. C Daly, MPH, Center for Nonsmoking and Health, Minnesota Dept of Heahh N Gunther, MS, Public Health Statistics Br, Mississippi State Dept of Health. N Miller, MS, Office of Health Promotion, Missouri Dept of Health. R Moon, MPH, Health Svcs Div, Montana Dept of Health and Environmental Sciences. E Wieber, Health Promotion and Education Div, Nebraska Dept of Health. W Morell, Vital Statistics Bur, Nevada Dept of Human Resources. E Schwartz, PhD, Div of Public Health Svcs, New Hampshire Dept of Health and Human Svcs. B Lee, Div of Health Promotion and Education, North Dakota State Dept of Health and Consolidated Laboratories. J Cataldo, Office of Health Promotion, Rhode island Dept of Health. P Lee, MPH, Dept of Health Education, South Carolina Dept of Health and Environmental Control. L Post, MPH, Center for Health Policy and Statistics, South Dakota Dept of Health. C Pearson, MN, Div of Health Promotion, Tennessee -Dept of Health and Environment. R Todd, MSEd, Office of Smoking and Health, Texas Dept of Health. C Chalkley, MHEd, Bur of Health Promotion and Risk Reduction, Utah Dept of Health. C Dickson, MS, Div of Health Promotion, West Virginia Dept of Health. M Futa, MA, Healtn Risk Reduction Program, Wyoming Dept of Health and Social Svcs. Div of Field Svcs, Epidemiology Program Ofice; Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion, CDC. Edrtodol Nete; Smoking causes more premature deaths than all other health-risk behaviors in the United States (8). The state-specific calculations of smoking-attributable mortality permit comparison of the impact of smoking with that of other health risks in states. Even as smoking prevalence declines in this country (9), smoking-attributable illness will continue to produce an enormous disease burden well into the 21st century (10). Thus, efforts to reduce tobacco use in each state must continue to be a high public health priority.

The national estimate for the total number of smoking-attributable deaths reported here is remarkably similar to the 1984 estimate (320.515) (4), despite the following differences in the methods used to calculate the two estimates:

1. the 1985 state-specific mortality data were used in these calculations rather than 1984 national mortality data; 2) different SAFs for lung cancer among women were used in the two calculations; and 3) deaths among nonsmokers caused by passive smoking (1570) and deaths from cigarette-caused fires (3825) were included in the previous estimate (4) but not in the state-specific estimates used here.

The longitudinal studies used to derive relative risk estimates for the SAMMEC calculations involved persons who began somking between 1900 and 1950. The pattern of smoking among U.S. men was well-established by the end of that period; however, women did not begin smoking in large numbers until the 1950's and 1960s (11) Therefore, the results produced by SAMMEC probably underestimate the actal disease impact of smoking among women in 1985.

The smoking-attributable mortality and YPLL rates reported here were not age-adjusted, thus limiting comparisons among states. Despite these limitations, SAMMEC is a useful epidemiologic tool that helps organize and translate surveillance data into an understandable framework. Some states have already reported their use of the data produced by SAMMEC (12-14). The SAMMEC software also demon-strates the effectiveness of public health surveillance data when linked by state epidemiologists, state-based health promotion professionals, state vital records departments, federal public health agencies, and others in addressing smoking and other public health problems.

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. Ravenholt RT. Tobacco's impact on twentieth-century U.S. mortality patterns. Am j Preventive Med 1985;1(4):4-17.

4. CDC. Smoking-attributable mortality and years of potential life lost-United States, 1984. MMWR 1987;36:693-7.

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

6. Shultz JM. SAMMEC: smoking-attributable mortality, morbidity, and economic costs (computer software and documentation). Minneapolis: Minnesota Department of Health, Center for Nonsmoking and Health, 1986.

7. Mclntosh ID. Smoking and pregnancy: attributable risks and public health implications. Can j Public Health 1984;75:141-8.

8. Warner KE. Health and economic implications of a tobacco-free society. JAMA 1987;258:208-6.

9. CDC. Cigarette smoking in the United States, 1986. MMWR 1987;36:581-5. 10.Brown CC, Kessler LG. Projections of lung cancer mortality in the United States: 1985-2025. J Natl Cancer Inst 1988;80:43-51. 11.Warner KE, Murt HA. Impact of the antismoking campaign on smoking prevalence: a cohort analysis. J Public Health Policy 1982;3:374-90. 12.Shultz JM, Moen ME, Pechacek TF, et al. The Minnesota Plan for Nonsmoking and Health: the legislative experience. J Public Health Policy 1986;7:300-13. 13.Vermont Department of Health. The public health impact and economic costs of cigarette smoking, Vermont, 1985. Dis Control Bull, May 1987. 14.Woernle CH. The burden of cigarette smoking in Alabama. Alabama Department of Public Health Epidemiol Rep 19871(5): 1-2.

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