st
21
century hazards of
smoking and benefits of
cessation in the United States
Jha 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
jhap@smh.ca
NEJM, January 24, 2013 (NOTE STRICT EMBARGO)
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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
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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)
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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)
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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
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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)
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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
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Hazard ratios* by disease for current
vs. never smokers, United States
1997-2006, ages 25-79, by gender
Women
Disease
Never/
current
smoker
RR (99%CI)
Men
Never/
current
smoker
Lung cancer
61/267
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)
3.0 (2.7-3.3)
1283/2030 2.8 (2.4-3.1)
All diseases 2190/1579
17.8 (11.4-27.8) 44/348
RR (99%CI)
14.6 (9.1-23.4)
* Cox- proportional HR adjusted for age, education, alcohol, and adiposity (BMI)
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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
Source: Jha et al, NEJM , Jan 24, 2013
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HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual
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cohort used
MALES: Survival probabilities between ages 25 and 80
years, among current and never smokers in the US
Source: Jha et al, NEJM, Jan 24, 2013
CGHR.ORG
HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual
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CGHR_org
cohort used
HRs for continuing smoking versus cessation
at various ages, adults aged 25 to 79 years
HR
adjusted for age, education, alcohol, and adiposity (BMI)
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Source: Jha et al, NEJM , Jan 24, 2013
Effect of quitting on survival: men/women combined
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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
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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
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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
CGHR.ORG
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More material
www.cghr.org/tobacco
1. NEJM Paper and Webappendix
2. PowerPoint slides
3. Frequently asked questions
4. Press release and video interviews
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Source: Jha et al, NEJM , Jan 24, 2013