Jha P, Ramasundarahettige C, Landsman V, Thun M, Rostron B, Mcgaffey T, Anderson RA, Peto R

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21st 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. Michaels Hospital and Dalla Lana School of
  Public Health, University of Toronto
• jhap_at_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 (gt95 match)

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Study team

• Epidemiological experts from St. Michaels
  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)
• Womens 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 21 for women but 41 for men

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Hazard ratios by disease for current vs. never
smokers, United States 1997-2006, ages 25-79, by
gender
Disease Women Women Men Men
Disease Never/ current smoker RR (99CI) Never/ current smoker RR (99CI)
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)
Cox- proportional HR adjusted for age,
education, alcohol, and adiposity (BMI)
Source Jha et al, NEJM , Jan 24, 2013
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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
HR adjusted for age, education, alcohol,
adiposity (BMI), scaled to 2004 national rates,
but comparable results if only actual cohort used
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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
HR adjusted for age, education, alcohol,
adiposity (BMI), scaled to 2004 national rates,
but comparable results if only actual cohort used
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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
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Effect of quitting on survival men/women combined
Source Jha et al, NEJM Jan 24, 2013
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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

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More materialwww.cghr.org/tobacco 1. NEJM
Paper and Webappendix2. PowerPoint slides3.
Frequently asked questions4. Press release and
video interviews
Source Jha et al, NEJM , Jan 24, 2013