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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. Surveillance for Smoking-Attributable Mortality and Years of Potential Life Lost, by State -- United States, 1990David E. Nelson, M.D., M.P.H. Randahl S. Kirkendall, M.P.H. Richard L. Lawton, Ph.D. Jeffrey H. Chrismon Robert K. Merritt, M.S. David A. Arday, M.D., M.P.H. Gary A. Giovino, Ph.D., M.S. Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion Abstract Problem/Condition: Mortality and years of potential life lost attributable to cigarette smoking. Reporting Period Covered: 1990. Description of System: Mortality and years of potential life lost were estimated for each state by using the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) software. These estimates were based on attributable risk formulas for smoking-related causes of death. Estimates of smoking prevalence were obtained from the Behavioral Risk Factor Surveillance System and the U.S. Bureau of the Census, and mortality data were obtained from CDC. Results: The median estimate for the number of smoking-attributable deaths among states was 5,619 (range: 402 {Alaska} to 42,574 {California}). Within each state, the number of smoking-attributable deaths among males was approximately twice as high as among females. Utah had the lowest mortality rate (218.0 per 100,000 population) and the lowest percentage of all deaths attributable to cigarette smoking (13.4%). Nevada had the highest mortality rate (478.1 per 100,000 population) and the highest percentage of deaths from smoking (24.0%). The number of years of potential life lost ranged from 6,720 (Alaska) to 498,297 (California). Interpretation: The number of deaths attributable to cigarette smoking in 1990 remained high. Efforts are needed to control tobacco use in all states. Actions Taken: SAMMEC data are used in many states to assist policymakers in strengthening tobacco control efforts. INTRODUCTION Cigarette smoking is the single most preventable cause of premature death in the United States (1). In 1990, smoking accounted for more than 400,000 deaths nationwide (2). Although national estimates of smoking- attributable mortality (SAM) and years of potential life lost (YPLL) have been made periodically (1-11), state-specific SAM and YPLL estimates for all states have been published only for 1985 (12,13). SAM and YPLL data can be used by states to document the toll of smoking-related health problems and to encourage tobacco control efforts in a variety of settings (14-18). METHODS For this report, state-specific cigarette smoking prevalence, SAM, and YPLL from smoking were estimated by using the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) software package (version 2.1) (19) developed by CDC's Office on Smoking and Health. SAMMEC estimates the number of smoking-related deaths from neoplastic, cardiovascular, and respiratory conditions and diseases of infants by using attributable risk formulas based on smoking prevalence and relative risks for certain conditions among current and former smokers (compared with risks for nonsmokers) (Table_1). Injury surveillance studies are used to estimate burn deaths associated with cigarette smoking (19) (Table_1). State estimates of cigarette smoking prevalence in 1990 were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) for 44 states and the District of Columbia. For the six states not participating in BRFSS in 1990 (Alaska, Arkansas, Kansas, Nevada, New Jersey, and Wyoming), prevalence estimates were obtained from the 1989 Current Population Survey conducted by the U.S. Bureau of the Census (U.S. Bureau of the Census, unpublished data, 1990). Mortality data for 1990 were obtained from CDC's National Center for Health Statistics (NCHS). To estimate deaths among infants (i.e., deaths among children less than 1 year of age), the 1989 national estimate of cigarette smoking prevalence of 20% among pregnant women was used for all states (20). SAM rates per 100,000 were calculated for persons greater than or equal to 35 years of age * and were age- adjusted to the 1990 U.S. population to provide comparable estimates across states. YPLL that accounts for life expectancy at age of death was calculated by using standard methodology (19). RESULTS State-specific estimates of cigarette smoking prevalence among persons ages 35-64 years ranged from 21.8% to 39.7% for men and from 14.6% to 30.8% for women (Table_2). For persons greater than or equal to 65 years of age, the prevalence ranged from 9.1% to 26.0% for men and from 4.7% to 19.1% for women. The median estimate for the number of smoking-attributable deaths was 5,619 (range: from 402 {Alaska} to 42,574 {California}) (Table_3). Within each state, males had approximately twice as many smoking- attributable deaths as females. When the data were totaled across all states, 415,226 deaths were attributable to smoking. The median SAM rate was 363.3 per 100,000 population; this rate ranged from 218.0 per 100,000 in Utah to 478.1 per 100,000 in Nevada. The median percentage of all deaths attributable to smoking was 19.2% (range: from 13.4% {Utah} to 24.0% {Nevada}). The median estimate for YPLL was 66,959 (range: from 6,720 {Alaska} to 498,297 {California}) (Table_4). DISCUSSION These findings indicate that, in 1990, cigarette smoking contributed substantially to premature mortality. SAM rates tended to be higher in the southeastern states, but all states continued to report substantial numbers of premature deaths caused by cigarette use. Although different data sources were used for cigarette smoking prevalence and state-specific estimates of deaths from environmental tobacco smoke were lacking, the total of 415,226 deaths totaled across the states is similar to the recent 1990 national estimate of 418,690 deaths from smoking (2). If the state- based estimate were augmented by the 3,000 deaths from environmental tobacco smoke that were included in the national estimate, the two estimates would differ by less than 1%. State SAMMEC estimates have been published in health journals and state reports to notify scientists, policymakers, and the public of the magnitude of mortality associated with smoking (14-18,21). For example, in Oregon, a report on tobacco use that relied heavily on SAMMEC calculations was used for assisting tobacco control efforts (21), and the state legislature enacted legislation to increase the state excise tax on cigarettes. For at least three reasons, these estimates for SAM and YPLL are underestimated. First, these estimates were based on data for cigarette smoking prevalence from 1990. Most smoking-attributable deaths for that year resulted from smoking during preceding decades, when smoking prevalence was considerably higher (10). Second, the state-specific SAMMEC estimates do not include deaths from other conditions (e.g., such as environmental tobacco smoke {22}, leukemia {23}, and peptic ulcer disease {1 }) that may also be associated with smoking, nor do they include mortality caused by other forms of tobacco use. Third, these data are not comparable with 1985 state-specific estimates because of substantial differences in SAMMEC methodology, in sources of data on state smoking prevalence, and in age adjustment of mortality rates (12,13). To reduce the health impact of cigarette use, continued progress must be made in reducing smoking prevalence. Although smoking prevalence has declined substantially since the 1960s (1), about 20% of deaths in the United States can be attributed to cigarette smoking (2). Vigorous efforts are needed to prevent the initiation of smoking, encourage smoking cessation, and protect nonsmokers from the adverse effects of environmental tobacco smoke. Because many factors influence smoking initiation and smoking cessation, multiple approaches are necessary (1). Examples of these approaches include increasing educational efforts, reducing minors' access to tobacco products, increasing tobacco excise taxes, implementing more extensive and intensive counseling by health-care providers on smoking prevention and cessation, developing and enacting strong policies and laws for clean indoor air, and restricting or eliminating advertising to which persons less than 18 years old are likely to be exposed (2,24). References
In categories other than deaths from burns and deaths among infants, the number of deaths among persons less than 35 years of age was too small to attain statistical significance. 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. Relative risks attributable to smoking and estimated smoking-attributable
mortality (SAM) for current and former smokers compared with nonsmokers, by
disease category and sex -- United States, 1990
=============================================================================================
Relative risk
-------------------------------------
Males Females
---------------- ----------------
Current Former Current Former
Disease category (ICD-9) smokers smokers smokers smokers
-------------------------------------------------------------------------------------------
Diseases among adults (>=35 yrs of age)
Neoplasms
Lip, oral cavity, pharynx (140-149) 27.5 8.8 5.6 2.9
Esophagus (150) 7.6 5.8 10.3 3.2
Pancreas (157) 2.1 1.1 2.3 1.8
Larynx (161) 10.5 5.2 17.8 11.9
Trachea, lung, bronchus (162) 22.4 9.4 11.9 4.7
Cervix uteri (180) NA NA 2.1 1.9
Urinary bladder (188) 2.9 1.9 2.6 1.9
Kidney, other urinary (189) 3.0 2.0 1.4 1.2
Cardiovascular diseases
Hypertensive diseases (401-404) 1.9 1.3 1.7 1.2
Ischemic heart disease (410-414)
Persons ages 35-64 yrs 2.8 1.8 3.0 1.4
Persons ages >=65 yrs 1.6 1.3 1.6 1.3
Other heart diseases (390-398, 415-417, 420-429) 1.9 1.3 1.7 1.2
Cerebrovascular diseases (430-438)
Persons ages 35-64 yrs 3.7 1.4 4.8 1.4
Persons ages >=65 yrs 1.9 1.3 1.5 1.0
Atherosclerosis (440) 4.1 2.3 3.0 1.3
Aortic aneurysm (441) 4.1 2.3 3.0 1.3
Other arterial diseases (442-448) 4.1 2.3 3.0 1.3
Respiratory diseases
Pneumonia and influenza (480-487) 2.0 1.6 2.2 1.4
Bronchitis and emphysema (491-492) 9.7 8.8 10.5 7.0
Chronic airways obstruction (496) 9.7 8.8 10.5 7.0
Other respiratory diseases (010-012, 493) 2.0 1.6 2.2 1.4
Diseases among infants (<1 yr of age)
Short gestation, low birth weight (765) 1.8 1.8
Respiratory distress syndrome (769) 1.8 1.8
Other respiratory conditions of newborn (770) 1.8 1.8
Sudden infant death syndrome (798) 1.5 1.5
Deaths * from burns (E890-E899) NA NA
-------------------------------------------------------------------------------------------
* Estimated to be 50% of deaths on the basis of injury surveillance studies (19).
NA = not applicable.
ICD-9 = International Classification of Diseases, 9th revision.
=============================================================================================
Return to top. Table_2 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 2. State-specific estimates of cigarette smoking prevalence, by age and sex --
United States, 1990
===========================================================================================
Age (yrs)
-----------------------------------------------
35-64 >=65
--------------------- ---------------------
State Men (%) Women (%) Men (%) Women (%)
----------------------------------------------------------------------
Alabama 31.1 22.9 15.0 6.2
Alaska 33.3 24.5 17.8 13.2
Arizona 24.0 21.0 11.0 10.1
Arkansas 35.9 29.8 16.4 6.7
California 21.8 21.7 16.8 16.6
Colorado 24.2 26.4 12.5 11.4
Connecticut 27.4 22.9 11.8 12.0
Delaware 23.7 28.0 11.3 8.4
District of Columbia 30.4 21.0 21.2 6.8
Florida 33.7 21.6 17.4 13.1
Georgia 34.8 25.9 19.4 13.0
Hawaii 26.5 20.4 12.1 7.5
Idaho 23.7 20.8 12.5 11.8
Illinois 34.0 23.9 17.0 17.7
Indiana 33.1 26.4 16.8 11.7
Iowa 28.2 22.0 12.1 8.4
Kansas 30.7 18.7 14.2 6.7
Kentucky 39.7 29.0 19.1 11.3
Louisiana 32.7 24.7 14.9 8.6
Maine 33.2 24.3 17.0 12.7
Maryland 27.5 20.6 15.2 13.5
Massachusetts 28.2 20.1 16.5 15.3
Michigan 34.1 28.2 17.2 11.7
Minnesota 24.6 23.1 12.3 7.9
Mississippi 33.3 21.3 20.8 11.3
Missouri 31.9 23.6 14.9 11.2
Montana 25.2 25.1 12.2 15.6
Nebraska 33.3 25.5 20.9 7.9
Nevada 38.4 30.1 15.0 12.1
New Hampshire 25.2 21.5 16.3 14.5
New Jersey 28.8 25.1 13.0 15.1
New Mexico 22.8 25.1 15.7 11.7
New York 23.1 30.2 10.6 12.6
North Carolina 31.2 29.3 20.6 9.5
North Dakota 26.5 26.5 11.8 4.7
Ohio 30.3 27.7 9.1 12.9
Oklahoma 30.5 30.8 19.5 12.2
Oregon 27.7 22.1 11.3 13.7
Pennsylvania 27.7 25.1 10.8 13.3
Rhode Island 28.5 26.4 18.5 10.3
South Carolina 39.4 24.8 26.0 13.6
South Dakota 25.8 21.8 18.3 9.9
Tennessee 33.0 28.4 25.1 12.1
Texas 27.0 25.9 18.3 14.9
Utah 25.2 14.6 10.8 7.3
Vermont 26.1 20.9 11.3 10.0
Virginia 28.7 24.7 16.3 14.4
Washington 26.7 19.9 15.7 15.5
West Virginia 32.7 26.2 18.3 16.4
Wisconsin 28.1 26.4 10.0 9.7
Wyoming 28.2 27.6 20.1 19.1
Highest value 39.7 30.8 26.0 19.1
Lowest value 21.8 14.6 9.1 4.7
Median 28.5 24.7 15.7 11.8
----------------------------------------------------------------------
Source: 1990 Behavioral Risk Factor Surveillance System for 44 states and the District of
Columbia; 1989 Current Population Survey of the U.S. Bureau of the Census for Alaska,
Arkansas, Kansas, Nevada, New Jersey, and Wyoming.
===========================================================================================
Return to top. Table_3 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 3. State-specific estimates of smoking-attributable mortality, by sex -- United
States, 1990
==================================================================================================
Percentage of all
State Male Female Total Rate * Rank + deaths
---------------------------------------------------------------------------------------
Alabama 4,960 1,841 6,801 350.4 22 17.3
Alaska 290 112 402 398.2 46 18.4
Arizona 3,839 1,858 5,697 339.6 16 19.8
Arkansas 3,410 1,296 4,706 376.3 35 19.1
California 25,821 16,753 42,574 366.3 27 19.9
Colorado 2,658 1,513 4,171 331.4 13 19.3
Connecticut 3,337 2,025 5,362 325.7 12 19.4
Delaware 745 433 1,178 393.1 44 20.4
District of Columbia 874 413 1,287 444.7 50 17.6
Florida 18,865 9,731 28,596 357.5 24 21.3
Georgia 6,692 3,002 9,694 383.5 38 18.7
Hawaii 849 325 1,174 257.2 2 17.3
Idaho 865 439 1,304 293.2 4 17.5
Illinois 12,028 7,241 19,269 360.0 25 18.7
Indiana 6,924 3,326 10,250 394.3 45 20.7
Iowa 3,410 1,406 4,816 304.2 7 17.9
Kansas 2,728 1,100 3,828 300.8 6 17.2
Kentucky 5,127 2,322 7,449 428.7 47 21.2
Louisiana 4,829 2,058 6,887 388.2 40 18.3
Maine 1,508 868 2,376 389.4 42 21.4
Maryland 4,593 2,777 7,370 378.1 36 19.2
Massachusetts 6,132 4,298 10,430 345.3 17 19.6
Michigan 10,386 5,068 15,454 372.5 33 19.6
Minnesota 4,237 1,890 6,127 295.2 5 17.6
Mississippi 3,188 1,270 4,458 375.1 34 17.7
Missouri 6,907 3,270 10,177 383.8 39 20.2
Montana 856 457 1,313 334.2 15 19.1
Nebraska 1,965 710 2,675 321.0 11 18.1
Nevada 1,517 717 2,234 478.1 51 24.0
New Hampshire 1,036 619 1,655 349.3 20 19.5
New Jersey 7,734 4,871 12,605 334.1 14 17.9
New Mexico 1,097 644 1,741 287.7 3 16.4
New York 18,612 12,380 30,992 352.8 23 18.3
North Carolina 7,922 3,110 11,032 367.6 30 19.2
North Dakota 790 241 1,031 308.2 9 18.2
Ohio 11,421 6,693 18,114 347.7 19 18.3
Oklahoma 4,132 2,006 6,138 390.4 43 20.2
Oregon 3,393 1,833 5,226 369.3 31 20.8
Pennsylvania 14,576 8,048 22,624 346.8 18 18.6
Rhode Island 1,250 631 1,881 350.3 21 19.6
South Carolina 3,928 1,691 5,619 380.1 37 18.9
South Dakota 877 298 1,175 307.9 8 18.6
Tennessee 7,146 3,068 10,214 442.1 49 22.1
Texas 16,705 8,747 25,452 389.1 41 20.3
Utah 940 288 1,228 218.0 1 13.4
Vermont 617 296 913 363.3 26 19.9
Virginia 5,926 3,311 9,237 366.6 28 19.2
Washington 4,892 2,898 7,790 367.4 29 21.0
West Virginia 2,831 1,390 4,221 433.6 48 21.8
Wisconsin 4,995 2,625 7,620 313.3 10 17.8
Wyoming 419 240 659 371.0 32 20.6
Highest value 25,821 16,753 42,574 478.1 24.0
Lowest value 290 112 402 218.0 13.4
Median 3,839 1,841 5,619 363.3 19.2
---------------------------------------------------------------------------------------
* Per 100,000 population among adults ages >=35 years, age-adjusted to the 1990 U.S. population;
rates exclude deaths among infants and burn deaths among persons ages 1-34 years.
+ Based on mortality rate.
==================================================================================================
Return to top. Table_4 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 4. Estimated smoking-attributable years of potential life lost, *
by sex -- United States, 1990
=========================================================================
Years of potential life lost
-------------------------------
State Male Female Total
--------------------------------------------------------
Alabama 62,287 28,073 90,360
Alaska 4,711 2,009 6,720
Arizona 42,421 24,538 66,959
Arkansas 39,425 19,317 58,742
California 290,416 207,881 498,297
Colorado 29,800 19,200 49,000
Connecticut 35,943 24,592 60,535
Delaware 9,102 6,146 15,248
District of Columbia 13,512 7,660 21,172
Florida 206,881 121,310 328,191
Georgia 88,396 45,772 134,168
Hawaii 10,135 5,087 15,222
Idaho 9,052 5,656 14,708
Illinois 143,258 92,675 235,933
Indiana 79,155 44,429 123,584
Iowa 34,121 16,400 50,521
Kansas 28,713 13,827 42,540
Kentucky 61,404 33,198 94,602
Louisiana 62,828 32,058 94,886
Maine 16,879 10,540 27,419
Maryland 55,786 36,411 92,197
Massachusetts 68,822 48,818 117,640
Michigan 123,337 72,263 195,600
Minnesota 44,365 23,470 67,835
Mississippi 39,230 18,609 57,839
Missouri 79,112 43,024 122,136
Montana 8,741 5,750 14,491
Nebraska 20,060 9,015 29,075
Nevada 19,291 10,963 30,254
New Hampshire 11,675 7,318 18,993
New Jersey 90,653 61,120 151,773
New Mexico 12,710 8,446 21,156
New York 219,751 157,779 377,530
North Carolina 99,223 48,587 147,810
North Dakota 8,028 3,689 11,717
Ohio 140,831 90,666 231,497
Oklahoma 46,252 26,805 73,057
Oregon 36,425 22,792 59,217
Pennsylvania 168,532 103,307 271,839
Rhode Island 14,006 7,535 21,541
South Carolina 52,910 26,159 79,069
South Dakota 9,033 3,651 12,684
Tennessee 87,627 45,008 132,635
Texas 201,112 116,519 317,631
Utah 10,552 4,020 14,572
Vermont 7,042 3,589 10,631
Virginia 74,535 45,181 119,716
Washington 53,757 35,465 89,222
West Virginia 32,784 18,223 51,007
Wisconsin 54,529 31,816 86,345
Wyoming 4,509 2,789 7,298
Highest value 290,416 207,881 498,297
Lowest value 4,509 2,009 6,720
Median 42,421 24,538 66,959
--------------------------------------------------------
* Calculated by using life expectancy at age of death.
=========================================================================
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