21 st century hazards of smoking and benefits of cessation in the united states

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21st century hazards of smoking and benefits of

cessation in the United StatesJha P, Ramasundarahettige C, Landsman V, Thun M, Rostron B, Mcgaffey T,

Anderson RA, Peto R

Centre for Global Health Research (CGHR)St. Michael’s Hospital and Dalla Lana School of Public Health, University of Toronto

[email protected]

NEJM, January 24, 2013 (NOTE STRICT EMBARGO)


Conclusions• 21st century smoking risks for American women and

men are comparable (death risks for smokers are ~3 fold higher than for never smokers)

• Death risks for women who smoke are 50% greater than estimated from the 1980s studies

• At least a decade of life lost by current smokers• Never smokers are about twice as likely to reach age 80

than are current smokers • Cessation before age 30 yields 10 years of life versus

current smokers• Cessation by age 40, 50 and 60 yields 9, 6 and 4 years

of life versus current smokers


How was the study done?• 1997-2004 annual representative surveys

(“NHIS”) that include 93% of Americans (excluding only those in institutions or on military duty)

• Studies those 25-79 years of age (“middle age”)

• 1.3 million person-years (over 7 years of follow up) – 220,000 adults; 90,000 men,130,000 women – 17,000 deaths, of which ~10,000 at 25-79

years• Link survey participants to National Death

Index to 31.12.2006 (>95% match)


Study team• Epidemiological experts from St.

Michael’s Hospital, University of Toronto, University of Oxford, US Centres for Disease Control and Prevention, and American Cancer Society

• Funded by NIH, CIHR and Bill and Melinda Gates Foundation (but funders had no role in data analyses or writing the paper)


What is new about this study?

• Nationally representative, meaning the results reflect the whole of the United States (earlier studies were in specific groups like nurses or volunteers)

• Women’s risks represent those who began smoking early in life and continued smoking through middle age (and those who quit seriously)

• Examines the health benefits of the recent increase in cessation


Differences between smokers and never smokers

• Smokers were thinner, drank alcohol more often and were less educated than never smokers

• The smoker versus never smoker analyses adjusts for these differences (and other differences)


Cessation more common in men than in women

• At ages 65 to 69, ratio of former to current smokers is 2:1 for women but 4:1 for men


Disease

Women MenNever/

current smoker

RR (99%CI)

Never/

current

smoker

RR (99%CI)

Lung cancer 61/267 17.8 (11.4-27.8) 44/348 14.6 (9.1-23.4)

All cancer 605/525 3.2 (2.6-3.9) 324/665 3.8 (3.1-4.8)

Vascular 784/476 3.2 (2.7-3.9) 500/643 2.6 (2.1-3.2)

Respiratory 119/206 8.5 (6.1-11.8) 45/188 9.0 (5.6-14.4)

All diseases 2190/1579 3.0 (2.7-3.3) 1283/2030 2.8 (2.4-3.1)

Hazard ratios* by disease for current vs. never smokers, United States 1997-2006, ages 25-79, by gender

* Cox- proportional HR adjusted for age, education, alcohol, and adiposity (BMI)

Source: Jha et al, NEJM , Jan 24, 2013


FEMALES: Survival probabilities between ages 25 and 80 years, among current and never smokers in the US

HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used



MALES: Survival probabilities between ages 25 and 80 years, among current and never smokers in the US

HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used

Source: Jha et al, NEJM, Jan 24, 2013


HRs for continuing smoking versus cessation at various ages, adults aged 25 to 79 years

HR adjusted for age, education, alcohol, and adiposity (BMI)Source: Jha et al, NEJM , Jan 24, 2013


Effect of quitting on survival: men/women combined

Source: Jha et al, NEJM Jan 24, 2013


Global implications• US has about 40 million smokers, out of a

worldwide total of 1.3 billion smokers• Unlike in the US, quitting in low or middle income

countries is uncommon (usually as a result of disease, rather than to avoid disease)

• These “mature” risks suggest that the worldwide estimates of 21st century smoking deaths are BIG (perhaps bigger than thought just a few years ago) Without widespread cessation, smoking will kill

1 Billion people in the 21st century (mostly in low/middle income countries) versus “only” 100 Million deaths in the 20th century


What can be done?• Higher tobacco taxes are the single most

effective intervention to reduce smoking and smoking deaths worldwide

• US: 53 cent federal excise tax increase per pack of cigarettes adopted in 2009 will save lives

• Other countries need to adopt large increases in tobacco excise taxes

• Prominent warning labels, advertising restrictions and cessation support also raise cessation rates


Conclusions• 21st century smoking risks for American women and

men are comparable (death risks for smokers are ~3 fold higher than for never smokers)

• Death risks for women who smoke are 50% greater than estimated from the 1980s studies

• At least a decade of life lost by current smokers• Never smokers are about twice as likely to reach age 80

than are current smokers • Cessation before age 30 yields 10 years of life versus

current smokers• Cessation by age 40, 50 and 60 yields 9, 6 and 4 years

of life versus current smokers


More materialwww.cghr.org/tobacco

1. NEJM Paper and Webappendix

2. PowerPoint slides

3. Frequently asked questions

4. Press release and video interviews


21 st century hazards of smoking and benefits of cessation in the united states

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