Estimating smoking-attributable mortality in the United States

Trends in atherosclerotic heart disease-related mortality among U.S. adults aged 35 and older: A 22-year analysis

Background

Atherosclerotic heart disease (ASHD) remains a leading cause of mortality worldwide, especially among older adults. Understanding the long-term mortality trends in ASHD can guide public health strategies and address demographic disparities.

Methods

Mortality data for individuals aged 35 years and older were extracted from the CDC WONDER database. Age-adjusted mortality rates (AAMR) per 100,000 persons were calculated and stratified by year, gender, race, urbanization, and place of death. The trends were assessed using the annual percent change (APC) and average annual percent change (AAPC) with 95 % confidence intervals (CI) calculated through Joinpoint regression analysis.

Results

From 1999 to 2020, 7,638,608 ASHD-related deaths were recorded. The overall AAMR declined from 291.08 in 1999 to 170.07 in 2020, with an AAPC of -2.70 % (95 % CI: 2.96 to -2.54). However, an abrupt rise was observed from 2018 to 2020 (APC: 4.55; 95 % CI: 0.77 to 6.75). Males reported higher AAMR than females (Males: 271.9 vs. Females: 151.9). Non-Hispanic (NH) White individuals had the highest AAMR (209.38), followed by NH Black (202.47), NH American Indian (176.12), Hispanic (158.1), and NH Asian (113.7) populations. Nonmetropolitan areas reported the highest AAMR (214.77), while medium metropolitan areas reported the lowest (195.41). The majority of deaths occurred in medical facilities (42.81 %), followed by decedent's homes (25.67 %), and nursing homes (24.79 %).

Conclusion

Despite a long-term decline in ASHD-related mortality, the recent increase from 2018 to 2020 requires further study. Gender and racial disparities persist, highlighting the need for targeted public health efforts to reduce these inequities.

Smoke's Enduring Legacy: Bridging Early-Life Smoking Exposures and Later-Life Epigenetic Age Acceleration

Current literature states that early-life exposure to smoking produces adverse health outcomes in later life, primarily as a result of subsequent engagements with firsthand smoking. The implications of prior research are that smoking cessation can reduce health risk in later life to levels comparable to the risk of those who have never smoked. However, recent evidence suggests that smoking exposure during childhood can have independent and permanent negative effects on health-in particular, on epigenetic aging. This investigation examines whether the effect of early-life firsthand smoking on epigenetic aging is more consistent with (1) a sensitive periods model, which is characterized by independent effects due to early firsthand exposures; or (2) a cumulative risks model, which is typified by persistent smoking. The findings support both models. Smoking during childhood can have long-lasting effects on epigenetic aging, regardless of subsequent engagements. Our evidence suggests that adult cessation can be effective but that the epigenetic age acceleration in later life is largely due to early firsthand smoking itself.

Estimating mortality attributable to alcohol or tobacco - a cohort study from Germany

BACKGROUND

Little is known about mortality from four disorder combinations: fully attributable to alcohol or tobacco, partly attributable to both alcohol and tobacco, to tobacco only, to alcohol only.

AIM

To analyze whether residents who had disclosed risky alcohol drinking or daily tobacco smoking had a shorter time to death than non-risky drinkers and never daily smokers twenty years later according to the disorder combinations.

METHODS

A random adult general population sample (4,075 study participants) of a northern German area had been interviewed in the years 1996-1997. Vital status and death certificate data were gathered 2017-2018. The data analysis included estimates of alcohol- or tobacco-attributable mortality using all conditions given in the death certificate and alternatively the underlying cause of death only.

RESULTS

Among 573 deaths, 71.9-94.1% had any alcohol- or tobacco-attributable disorder depending on the estimate. Risky alcohol consumption and daily tobacco smoking at baseline were related to disorders in the death certificate according to the combinations. Deaths with an alcohol- and tobacco-attributable disorder were related to risky alcohol consumption (subhazard ratio 1.57; 95% confidence interval 1.25-1.98) and to daily tobacco smoking at baseline (subhazard ratio 1.85; 95% confidence interval 1.42-2.41).

CONCLUSION

First, more than 70% of the deceased persons had one or more alcohol- or tobacco-attributable disorders. This finding suggests that total mortality seems to be the suitable outcome if potential effects of alcohol or tobacco consumption in a general population are to be estimated. Second, the relations of risky alcohol consumption and tobacco smoking with time to death speak in favor of the validity of alcohol- and of tobacco-attributable disorders in death certificates and of considering both alcohol consumption and tobacco smoking if attributable deaths are to be estimated.

State cigarette taxes, smoking cessation, and implications for the educational gradient in mortality

BACKGROUND

Recent studies suggest that state policy, such as cigarette tax policy, is associated with variation in the educational gradient in mortality. However, it is unknown whether state cigarette taxes moderate the educational gradient in mortality directly by incentivizing smoking cessation.

METHODS

This study uses 20 years of survey data from the Panel Study of Income Dynamics (N = 89,127 person-years; 751 deaths) merged with administrative data to examine the potential for a single state policy, cigarette taxes, to moderate the education-mortality association through influence on smoking cessation.

RESULTS

In mortality analyses, higher cigarette taxes are associated with a weaker educational gradient in mortality among smokers and overall. Smoking cessation analyses show higher state cigarette taxes increase the odds of quitting only for low-educated smokers, such that each $1 increase in taxes results in an additional 0.4 to 1 life years for low-educated smokers. For more educated subgroups, the association between state cigarette taxes and smoking cessation is confounded by broader temporal trends.

DISCUSSION

State cigarette taxes have potential to weaken the educational gradient in mortality by attenuating educational disparities in smoking cessation, however their direct effect is only on low-educated smokers. The findings help demonstrate how fundamental cause associations are contingent on state policy and vary over time.

Epigenetic Aging Helps Explain Differential Resilience in Older Adults

Past research suggests that resilience to health hazards increases with age, potentially because less resilient individuals die at earlier ages, leaving behind their more resilient peers. Using lifetime cigarette smoking as a model health hazard, we examined whether accelerated epigenetic aging (indicating differences in the speed of individuals' underlying aging process) helps explain age-related resilience in a nationally representative sample of 3,783 older U.S. adults from the Health and Retirement Study. Results of mediation moderation analyses indicated that participants aged 86 or older showed a weaker association between lifetime cigarette smoking and mortality relative to participants aged 76-85 and a weaker association between smoking and multimorbidity relative to all younger cohorts. This moderation effect was mediated by a reduced association between smoking pack-years and epigenetic aging. This research helps identify subpopulations of particularly resilient individuals and identifies epigenetic aging as a potential mechanism explaining this process. Interventions in younger adults could utilize epigenetic aging estimates to identify the most vulnerable individuals and intervene before adverse health outcomes, such as chronic disease morbidity or mortality, manifest.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education

INTRODUCTION

The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking.

METHODS

Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022.

RESULTS

All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender.

CONCLUSIONS

Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

The Link between Democratic Institutions and Population Health in the American States

CONTEXT

This project investigates the role of state-level institutions in explaining variation in population health in the American states. Although cross-national research has established the positive effects of democracy on population health, little attention has been given to subnational units. The authors leverage a new data set to understand how political accountability and a system of checks and balances are associated with state population health.

METHODS

The authors estimate error correction models and two-way fixed effects models to estimate how the strength of state-level democratic institutions is associated with infant mortality rates, life expectancy, and midlife mortality.

FINDINGS

The authors find institutions that promote political accountability are associated with lower infant mortality across the states, while those that promote checks and balances are associated with longer life expectancy. They also find that policy liberalism is associated with better health outcomes.

CONCLUSIONS

Subnational institutions play an important role in population health outcomes, and more research is needed to understand the link between democracy and health. The authors are the first to explore the link between democratic institutions and population health within the United States, contributing to both the social science literature on the positive effects of democracy and the epidemiological literature on subnational health outcomes.

Quantifying the contribution of smoking to regional mortality disparities in Germany: a cross-sectional study

OBJECTIVES

Substantial regional variation in smoking behaviour in Germany has been well documented. However, little is known about how these regional differences in smoking affect regional mortality disparities. We aim to assess the contribution of smoking to regional mortality differentials in Germany over the last four decades.

DESIGN

A cross-sectional study using official cause-specific mortality data by German Federal State aggregated into five macro-regions: East, North, South, West-I and West-II.

PARTICIPANTS

The entire population of Germany stratified by sex, age and region during 1980-2019.

MAIN OUTCOME MEASURES

Smoking-attributable fraction estimated using the Preston-Glei-Wilmoth method; life expectancy at birth before and after the elimination of smoking-attributable deaths.

RESULTS

In all macro-regions, the burden of past smoking has been declining among men but growing rapidly among women. The hypothetical removal of smoking-attributable deaths would eliminate roughly half of the contemporary advantage in life expectancy of the vanguard region South over the other macro-regions, apart from the East. In the latter, smoking only explains around a quarter (0.5 years) of the 2-year difference in male life expectancy compared with the South observed in 2019. Among women, eliminating smoking-attributable deaths would put the East in a more disadvantageous position compared with the South as well as the other macro-regions.

CONCLUSION

While regional differences in smoking histories explain large parts of the regional disparities in male mortality, they are playing an increasingly important role for female mortality trends and differentials. Health policies aiming at reducing regional inequalities should account for regional differences in past smoking behaviour.

Smoking and the widening inequality in life expectancy between metropolitan and nonmetropolitan areas of the United States

Background

Geographic inequality in US mortality has increased rapidly over the last 25 years, particularly between metropolitan and nonmetropolitan areas. These gaps are sizeable and rival life expectancy differences between the US and other high-income countries. This study determines the contribution of smoking, a key contributor to premature mortality in the US, to geographic inequality in mortality over the past quarter century.

Methods

We used death certificate and census data covering the entire US population aged 50+ between Jan 1, 1990 and Dec 31, 2019. We categorized counties into 40 geographic areas cross-classified by region and metropolitan category. We estimated life expectancy at age 50 and the index of dissimilarity for mortality, a measure of inequality in mortality, with and without smoking for these areas in 1990-1992 and 2017-2019. We estimated the changes in life expectancy levels and percent change in inequality in mortality due to smoking between these periods.

Results

We find that the gap in life expectany between metros and nonmetros increased by 2.17 years for men and 2.77 years for women. Changes in smoking-related deaths are responsible for 19% and 22% of those increases, respectively. Among the 40 geographic areas, increases in life expectancy driven by changes in smoking ranged from 0.91 to 2.34 years for men while, for women, smoking-related changes ranged from a 0.61-year decline to a 0.45-year improvement. The most favorable trends in years of life lost to smoking tended to be concentrated in large central metros in the South and Midwest, while the least favorable trends occurred in nonmetros in these same regions. Smoking contributed to increases in mortality inequality for men aged 70+, with the contribution ranging from 8 to 24%, and for women aged 50-84, ranging from 14 to 44%.

Conclusions

Mortality attributable to smoking is declining fastest in large cities and coastal areas and more slowly in nonmetropolitan areas of the US. Increasing geographic inequalities in mortality are partly due to these geographic divergences in smoking patterns over the past several decades. Policies addressing smoking in non-metropolitan areas may reduce geographic inequality in mortality and contribute to future gains in life expectancy.

Trends in lifespan variation across the spectrum of rural and urban places in the United States, 1990-2017

Mortality disparities between urban and rural areas in the United States widened in recent decades as mortality improvements in rural areas slowed. Although the existence of a rural mortality penalty is well-documented, previous research in this area has focused almost exclusively on differences in average levels of mortality between rural and urban areas rather than differences in levels of lifespan variation within rural and urban areas. This oversight is important because monitoring trends in lifespan variation provides unique insights into levels of inequality in the age-at-death distribution within a population. Does the rural mortality penalty in life expectancy extend to lifespan variation? We used U.S. Multiple Cause of Death data files to measure life disparity at birth (e 0 † ) from 1990 to 2017. We found that the rural mortality penalty extends to lifespan variation as large metropolitan areas had greater improvements in life disparity than nonmetropolitan areas. Beginning around 2011, all areas began to show increased life disparity with the largest increases occurring in nonmetropolitan areas. Age decomposition results showed that the nonmetropolitan increases were due to rising working-age mortality. Greater variability in the age-at-death distribution represents an additional dimension of inequality for Americans living in rural places.

The Economics of Tobacco Regulation: A Comprehensive Review

Tobacco regulation has been a major component of health policy in the developed world since the UK Royal College of Physicians' and the US Surgeon General's reports in the 1960s. Such regulation, which has intensified in the past two decades, includes cigarette taxation, place-based smoking bans in areas ranging from bars and restaurants to workplaces, and regulations designed to make tobacco products less desirable. More recently, the availability of alternative products, most notably e-cigarettes, has increased dramatically, and these products are just starting to be regulated. Despite an extensive body of research on tobacco regulations, there remains substantial debate regarding their effectiveness, and ultimately, their impact on economic welfare. We provide the first comprehensive review of the state of research in the economics of tobacco regulation in two decades.

The contribution of smoking-attributable mortality to differences in mortality and life expectancy among US African-American and white adults, 2000–2019

BACKGROUND

The role of smoking in racial disparities in mortality and life expectancy in the United States has been examined previously, but up-to-date estimates are generally unavailable, even though smoking prevalence has declined in recent decades.

OBJECTIVE

We estimate the contribution of smoking-attributable mortality to observed differences in mortality and life expectancy for US African-American and white adults from 2000–2019.

METHODS

The indirect Preston–Glei–Wilmoth method was used with national vital statistics and population data and nationally representative never-smoker lung cancer death rates to estimate the smoking-attributable fraction (SAF) of deaths in the United States by sex-race group from 2000–2019. Mortality rates without smoking-attributable mortality were used to estimate life expectancy at age 50 (e₅₀) by group during the period.

RESULTS

African-American men had the highest estimated SAF during the period, beginning at 26.4% (95% CI:25.0%–27.8%) in 2000 and ending at 12.1% (95% CI:11.4%–12.8%) in 2019. The proportion of the difference in e₅₀ for white and African-American men that was due to smoking decreased from 27.7% to 14.8%. For African-American and white women, the estimated differences in e₅₀ without smoking-attributable mortality were similar to observed differences.

CONCLUSIONS

Smoking continues to contribute to racial disparities in mortality and life expectancy among men in the United States.

CONTRIBUTION

We present updated estimates of the contribution of smoking to mortality differences in the United States using nationally representative data sources.

Assessing quality-adjusted years of life lost associated with exclusive cigarette smoking and smokeless tobacco use

The main purpose of this analysis is to quantify quality adjusted life years (QALYs) lost associated with lifetime exclusive cigarette or smokeless tobacco use among U.S. adults. Multiple waves of National Health Interview Survey (NHIS) data linked to death certificate records were used to define current exclusive cigarette and smokeless tobacco use and associated mortality risks. NHIS data were used to assess health-related quality of life (HRQOL). Regression and Cox proportional hazard modeling were used to adjust HRQOL and mortality risk associated with tobacco use for age, sex, race/ethnicity, body mass index, education, and household poverty level. QALYs were estimated based on adjusted HRQOL and mortality risks. All analyses were initiated in 2019 and completed in 2020. Male current exclusive cigarette smokers, aged 25 to 29 years would lose 8.1 QALYs (SE = 0.09), and male current exclusive smokeless tobacco users aged 25 to 34 would lose 4.1 QALYs (SE = 0.22), compared to never users of tobacco. Current exclusive cigarette or smokeless tobacco use is associated with QALY loss. QALYs lost can be lessened through preventing the initiation of tobacco product use or helping tobacco product users quit as early in life as possible.

Whither weathering? The variable significance of age in Black-White low birth weight disparities

This paper uses birth certificate data to provide novel estimates of the age-specific risk of a low birth weight birth (LBW, an infant born weighting <2500 g) for U.S.-born non-Hispanic Black and White mothers, and finds that patterns vary markedly over space and time. Notably, risk of an LBW birth for Black mothers increased much more steeply with age in 1991-94 than in 2014-17. This decline in LBW risks among older Black mothers led to a decline in the Black-White LBW gap of more than half a percentage point. Both patterns and changes were regional; while age gradients on the Black-White LBW gap were lowest in the South in 1991-94, by 2014-17 they had increased in the South and declined in the rest of the country. These descriptive data allow a new examination of hypotheses regarding the causes of age-specific racial LBW gaps. Research has found that racial disparities in a number of health outcomes, including LBW, increase with age, leading some to speculate that this increase is due to the cumulative effects of exposure to disadvantage. The large degree of variability in Black-White LBW disparities suggests that age-specific causes may also play a role. A series of counterfactual trend analyses explore the roles of two specific mechanisms, smoking and hypertension, and compares these to a more fundamental indicator of socioeconomic status: education.

Rising Geographic Disparities in US Mortality

The 21st century has been a period of rising inequality in both income and health. In this paper, we find that geographic inequality in mortality for midlife Americans increased by about 70 percent between 1992 and 2016. This was not simply because states like New York or California benefited from having a high fraction of college-educated residents who enjoyed the largest health gains during the last several decades. Nor was higher dispersion in mortality caused entirely by the increasing importance of "deaths of despair," or by rising spatial income inequality during the same period. Instead, over time, state-level mortality has become increasingly correlated with state-level income; in 1992 income explained only 3 percent of mortality inequality, but by 2016 state-level income explained 58 percent. These mortality patterns are consistent with the view that high-income states in 1992 were better able to enact public health strategies and adopt behaviors that, over the next quarter-century, resulted in pronounced relative declines in mortality. The substantial longevity gains in high-income states led to greater cross-state inequality in mortality.

Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000-18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database

BACKGROUND

Pulmonary embolism (PE)-related mortality is decreasing in Europe. However, time trends in the USA and Canada remain uncertain because the most recent analyses of PE-related mortality were published in the early 2000s.

METHODS

For this retrospective epidemiological study, we accessed medically certified vital registration data from the WHO Mortality Database (USA and Canada, 2000-17) and the Multiple Cause of Death database produced by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2000-18). We investigated contemporary time trends in PE-related mortality in the USA and Canada and the prevalence of conditions contributing to PE-related mortality reported on the death certificates. We also estimated PE-related mortality by age group and sex. A subgroup analysis by race was performed for the USA.

FINDINGS

In the USA, the age-standardised annual mortality rate (PE as the underlying cause) decreased from 6·0 deaths per 100 000 population (95% CI 5·9-6·1) in 2000 to 4·4 deaths per 100 000 population (4·3-4·5) in 2006. Thereafter, it continued to decrease to 4·1 deaths per 100 000 population (4·0-4·2) in women in 2017 and plateaued at 4·5 deaths per 100 000 population (4·4-4·7) in men in 2017. Among adults aged 25-64 years, it increased after 2006. The median age at death from PE decreased from 73 years to 68 years (2000-18). The prevalence of cancer, respiratory diseases, and infections as a contributing cause of PE-related death increased in all age categories from 2000 to 2018. The annual age-standardised PE-related mortality was consistently higher by up to 50% in Black individuals than in White individuals; these rates were approximately 50% higher in White individuals than in those of other races. In Canada, the annual age-standardised mortality rate from PE as the underlying cause of death decreased from 4·7 deaths per 100 000 population (4·4-5·0) in 2000 to 2·6 deaths per 100 000 population (2·4-2·8) in 2017; this decline slowed after 2006 across age groups and sexes.

INTERPRETATION

After 2006, the initially decreasing PE-related mortality rates in North America progressively reached a plateau in Canada, while a rebound increase was observed among young and middle-aged adults in the USA. These findings parallel recent upward trends in mortality from other cardiovascular diseases and might reflect increasing inequalities in the exposure to risk factors and access to health care.

FUNDING

None.

Association of smoking with incident CKD risk in the general population: A community-based cohort study

BACKGROUND

Chronic kidney disease (CKD) is a public health problem, and an unfavorable lifestyle has been suggested as a modifiable risk factor for CKD. Cigarette smoking is closely associated with cardiovascular disease and cancers; however, there is a lack of evidence to prove that smoking is harmful for kidney health. Therefore, we aimed to determine the relationship between cigarette smoking and CKD among healthy middle-aged adults.

METHODS

Using the database from the Korean Genome and Epidemiology Study, we analyzed 8,661 participants after excluding those with baseline estimated glomerular filtration rate (eGFR)<60 ml/min/1.72 m2 or proteinuria. Exposure of interest was smoking status: never-, former-, and current-smokers. Primary outcome was incident CKD defined as eGFR <60 ml/min/1.73 m2 or newly developed proteinuria.

RESULTS

The mean age of the subjects was 52 years, and 47.6% of them were males. There were 551 (6.4%) and 1,255 (14.5%) subjects with diabetes and hypertension, respectively. The mean eGFR was 93.0 ml/min/1.73 m2. Among the participants, 5,140 (59.3%), 1,336 (15.4%), and 2,185 (25.2%) were never-smokers, former-smokers, and current-smokers, respectively. During a median follow-up of 11.6 years, incident CKD developed in 1,941 (22.4%) subjects with a crude incidence rate of 25.1 (24.0-26.2) per 1,000 person-years. The multivariable Cox regression analysis after adjustment of confounding factors showed hazard ratios (95% confidence interval) of 1.13 (0.95-1.35) and 1.26 (1.07-1.48) for CKD development in the former- and current-smokers, compared with never-smokers.

CONCLUSION

This study showed that smoking was associated with a higher risk of incident CKD among healthy middle-aged adults.

Lung cancer mortality among never-smokers in the United States: estimating smoking-attributable mortality with nationally representative data

PURPOSE

Lung cancer mortality among never-smokers is an often overlooked yet important cause of adult mortality. Moreover, indirect approaches for estimating smoking-attributable mortality use never-smoker lung cancer death rates to approximate smoking burden. To date, though, most studies using indirect approaches import rates from the Cancer Prevention Study II (CPS-II), which is not representative of the U.S.

POPULATION

METHODS

We use the nationally representative 1985-2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) to calculate lung cancer death rates among never-smokers aged 50 years or older. We then import rates from NHIS-LMF and CPS-II into the Preston-Glei-Wilmoth indirect method to determine whether smoking-attributable fractions differ.

RESULTS

Never-smokers account for 16% of U.S. lung cancer deaths among women and 11% among men. Lung cancer death rates among never-smokers are higher in NHIS-LMF than CPS-II for several age groups. Smoking-attributable fractions of mortality are slightly lower with NHIS-LMF rates (19% of male deaths and 16% of female deaths) than with CPS-II rates (21% of male deaths and 17% of female deaths).

CONCLUSIONS

Fractions based on nonrepresentative CPS-II data may modestly overestimate smoking-attributable mortality. Thus, indirect methods should use never-smoker lung cancer death rates from such nationally representative datasets as NHIS-LMF.

ESTIMATING AND FORECASTING THE SMOKING-ATTRIBUTABLE MORTALITY FRACTION FOR BOTH GENDERS JOINTLY IN OVER 60 COUNTRIES

Smoking is one of the leading preventable threats to human health and a major risk factor for lung cancer, upper aero-digestive cancer, and chronic obstructive pulmonary disease. Estimating and forecasting the smoking attributable fraction (SAF) of mortality can yield insights into smoking epidemics and also provide a basis for more accurate mortality and life expectancy projection. Peto et al. (1992) proposed a method to estimate the SAF using the lung cancer mortality rate as an indicator of exposure to smoking in the population of interest. Here we use the same method to estimate the all-age SAF (ASAF) for both genders for over 60 countries. We document a strong and cross-nationally consistent pattern of the evolution of the SAF over time. We use this as the basis for a new Bayesian hierarchical model to project future male and female ASAF from over 60 countries simultaneously. This gives forecasts as well as predictive distributions that can be used to find uncertainty intervals for any quantity of interest. We assess the model using out-of-sample predictive validation, and find that it provides good forecasts and well calibrated forecast intervals, comparing favorably with other methods.

Estimating the impact of drug use on US mortality, 1999-2016

The impact of rising drug use on US mortality may extend beyond deaths coded as drug-related to include excess mortality from other causes affected by drug use. Here, we estimate the full extent of drug-associated mortality. We use annual death rates for 1999–2016 by state, sex, five-year age group, and cause of death to model the relationship between drug-coded mortality—which serves as an indicator of the population-level prevalence of drug use—and mortality from other causes. Among residents aged 15–64 living in the 50 US states, the estimated number of drug-associated deaths in 2016 (141,695) was 2.2 times the number of drug-coded deaths (63,000). Adverse trends since 2010 in midlife mortality are largely attributable to drug-associated mortality. In the absence of drug use, we estimate that the probability of dying between ages 15 and 65 would have continued to decline after 2010 among men (to 15% in 2016) and would have remained at a low level (10%) among women. Our results suggest that an additional 3.9% of men and 1.8% of women died between ages 15 and 65 in 2016 because of drug use. In terms of life expectancy beyond age 15, we estimate that drug use cost men 1.4 years and women 0.7 years, on average. In the hardest-hit state (West Virginia), drug use cost men 3.6 and women 1.9 life years. Recent declines in US life expectancy have been blamed largely on the drug epidemic. Consistent with that inference, our results imply that, in the absence of drug use, life expectancy at age 15 would have increased slightly between 2014 and 2016. Drug-associated mortality in the US is roughly double that implied by drug-coded deaths alone. The drug epidemic is exacting a heavy cost to American lives, not only from overdoses but from a variety of causes.

Progression of the smoking epidemic in high-income regions and its effects on male-female survival differences: a cohort-by-age analysis of 17 countries

BACKGROUND

Of all lifestyle behaviours, smoking caused the most deaths in the last century. Because of the time lag between the act of smoking and dying from smoking, and because males generally take up smoking before females do, male and female smoking epidemiology often follows a typical double wave pattern dubbed the 'smoking epidemic'. How are male and female deaths from this epidemic differentially progressing in high-income regions on a cohort-by-age basis? How have they affected male-female survival differences?

METHODS

We used data for the period 1950-2015 from the WHO Mortality Database and the Human Mortality Database on three geographic regions that have progressed most into the smoking epidemic: high-income North America, high-income Europe and high-income Oceania. We examined changes in smoking-attributable mortality fractions as estimated by the Preston-Glei-Wilmoth method by age (ages 50-85) across birth cohorts 1870-1965. We used these to trace sex differences with and without smoking-attributable mortality in period life expectancy between ages 50 and 85.

RESULTS

In all three high-income regions, smoking explained up to 50% of sex differences in period life expectancy between ages 50 and 85 over the study period. These sex differences have declined since at least 1980, driven by smoking-attributable mortality, which tended to decline in males and increase in females overall. Thus, there was a convergence between sexes across recent cohorts. While smoking-attributable mortality was still increasing for older female cohorts, it was declining for females in the more recent cohorts in the US and Europe, as well as for males in all three regions.

CONCLUSIONS

The smoking epidemic contributed substantially to the male-female survival gap and to the recent narrowing of that gap in high-income North America, high-income Europe and high-income Oceania. The precipitous decline in smoking-attributable mortality in recent cohorts bodes somewhat hopeful. Yet, smoking-attributable mortality remains high, and therefore cause for concern.

Living race together: the role of partner's race in racial/ethnic differences in smoking

Objective: Crossing racial lines provides a unique context for understanding racial patterns in smoking. This research explores whether adults whose unions cross racial lines behave more similarly to their own group or their partner'sDesign: Using a sample of respondents from the National Health Interview Survey (2001-2011), we compare the likelihood of current smoking and quitting smoking among adults in mixed-race unions to adults in same-race unions.Results: Adults with different-race partners generally mirror their partner's group; people of color with White partners have a higher likelihood of being current smokers, similar to Whites, while Whites partnered with Asians and Latina/os are, like other Asians and Latino/as, less likely to smoke. There are fewer differences in the likelihood of quitting smoking.

Changes in urban and rural cigarette smoking and cannabis use from 2007 to 2017 in adults in the United States

INTRODUCTION

Rural-urban differences in cigarette and cannabis use have traditionally shown higher levels of cigarette smoking in rural areas and of cannabis use in urban areas. To assess for changes in this pattern of use, we examined trends and prevalence of cigarette, cannabis, and co-use across urban-rural localities.

METHODS

Urban-rural trends in current cigarette and/or cannabis use was evaluated using 11 cohorts (2007-2017) of the National Survey on Drug Use and Health (NSDUH; N = 397,542). We used logistic regressions to model cigarette and cannabis use over time, adjusting for demographics (age, gender, race/ethnicity, income, education), in addition to assessing patterns of cannabis use among cigarette smokers and nonsmokers.

RESULTS

Despite decreases in cigarette smoking overall, between 2007 and 2017, the urban-rural disparity in cigarette smoking increased (AOR = 1.17), with less reduction in rural as compared to urban cigarette smokers. Cannabis use increased in general (AOR = 1.88 by 2017), with greater odds in urban than rural regions. Cannabis use increased more rapidly in non-cigarette smokers than smokers (AOR = 1.37 by 2017), with 219% greater odds of cannabis use in rural non-cigarette smokers in 2017 versus 2007.

CONCLUSIONS

Rurality remains an important risk factor for cigarette smoking in adults and the fastest-growing group of cannabis users is rural non-cigarette smokers; however, cannabis use is currently still more prevalent in urban areas. Improved reach and access to empirically-supported prevention and treatment, especially in rural areas, along with dissemination and enforcement of policy-level regulations, may mitigate disparities in cigarette use and slow the increase in rural cannabis use.

Life Expectancy and Mortality Rates in the United States, 1959-2017

Importance

US life expectancy has not kept pace with that of other wealthy countries and is now decreasing.

Objective

To examine vital statistics and review the history of changes in US life expectancy and increasing mortality rates; and to identify potential contributing factors, drawing insights from current literature and an analysis of state-level trends.

Evidence

Life expectancy data for 1959-2016 and cause-specific mortality rates for 1999-2017 were obtained from the US Mortality Database and CDC WONDER, respectively. The analysis focused on midlife deaths (ages 25-64 years), stratified by sex, race/ethnicity, socioeconomic status, and geography (including the 50 states). Published research from January 1990 through August 2019 that examined relevant mortality trends and potential contributory factors was examined.

Findings

Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups, caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases. The largest relative increases in midlife mortality rates occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%). The increase in midlife mortality during 2010-2017 was associated with an estimated 33 307 excess US deaths, 32.8% of which occurred in 4 Ohio Valley states.

Conclusions and Relevance

US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.

Moving Upstream: The Effect of Tobacco Clean Air Restrictions on Educational Inequalities in Smoking Among Young Adults

Education affords a range of direct and indirect benefits that promote longer and healthier lives and stratify health lifestyles. We use tobacco clean air policies to examine whether policies that apply universally-interventions that bypass individuals' unequal access and ability to employ flexible resources to avoid health hazards-have an effect on educational inequalities in health behaviors. We test theoretically informed but competing hypotheses that these policies either amplify or attenuate the association between education and smoking behavior. Our results provide evidence that interventions that move upstream to apply universally regardless of individual educational attainment-here, tobacco clean air policies-are particularly effective among young adults with the lowest levels of parental or individual educational attainment. These findings provide important evidence that upstream approaches may disrupt persistent educational inequalities in health behaviors. In doing so, they provide opportunities to intervene on behaviors in early adulthood that contribute to disparities in morbidity and mortality later in the life course. These findings also help assuage concerns that tobacco clean air policies increase educational inequalities in smoking by stigmatizing those with the fewest resources.

Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease

IMPORTANCE

The time course of cardiovascular disease (CVD) risk after smoking cessation is unclear. Risk calculators consider former smokers to be at risk for only 5 years.

OBJECTIVE

To evaluate the association between years since quitting smoking and incident CVD.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of prospectively collected data from Framingham Heart Study participants without baseline CVD (original cohort: attending their fourth examination in 1954-1958; offspring cohort: attending their first examination in 1971-1975) who were followed up through December 2015.

EXPOSURES

Time-updated self-reported smoking status, years since quitting, and cumulative pack-years.

MAIN OUTCOMES AND MEASURES

Incident CVD (myocardial infarction, stroke, heart failure, or cardiovascular death). Primary analyses included both cohorts (pooled) and were restricted to heavy ever smokers (≥20 pack-years).

RESULTS

The study population included 8770 individuals (original cohort: n = 3805; offspring cohort: n = 4965) with a mean age of 42.2 (SD, 11.8) years and 45% male. There were 5308 ever smokers with a median 17.2 (interquartile range, 7-30) baseline pack-years, including 2371 heavy ever smokers (406 [17%] former and 1965 [83%] current). Over 26.4 median follow-up years, 2435 first CVD events occurred (original cohort: n = 1612 [n = 665 among heavy smokers]; offspring cohort: n = 823 [n = 430 among heavy smokers]). In the pooled cohort, compared with current smoking, quitting within 5 years was associated with significantly lower rates of incident CVD (incidence rates per 1000 person-years: current smoking, 11.56 [95% CI, 10.30-12.98]; quitting within 5 years, 6.94 [95% CI, 5.61-8.59]; difference, -4.51 [95% CI, -5.90 to -2.77]) and lower risk of incident CVD (hazard ratio, 0.61; 95% CI, 0.49-0.76). Compared with never smoking, quitting smoking ceased to be significantly associated with greater CVD risk between 10 and 15 years after cessation in the pooled cohort (incidence rates per 1000 person-years: never smoking, 5.09 [95% CI, 4.52-5.74]; quitting within 10 to <15 years, 6.31 [95% CI, 4.93-8.09]; difference, 1.27 [95% CI, -0.10 to 3.05]; hazard ratio, 1.25 [95% CI, 0.98-1.60]).

CONCLUSIONS AND RELEVANCE

Among heavy smokers, smoking cessation was associated with significantly lower risk of CVD within 5 years relative to current smokers. However, relative to never smokers, former smokers' CVD risk remained significantly elevated beyond 5 years after smoking cessation.

Building a tobacco user registry by extracting multiple smoking behaviors from clinical notes

Background

Usage of structured fields in Electronic Health Records (EHRs) to ascertain smoking history is important but fails in capturing the nuances of smoking behaviors. Knowledge of smoking behaviors, such as pack year history and most recent cessation date, allows care providers to select the best care plan for patients at risk of smoking attributable diseases.

Methods

We developed and evaluated a health informatics pipeline for identifying complete smoking history from clinical notes in EHRs. We utilized 758 patient-visit notes (from visits between 03/28/2016 and 04/04/2016) from our local EHR in addition to a public dataset of 502 clinical notes from the 2006 i2b2 Challenge to assess the performance of this pipeline. We used a machine-learning classifier to extract smoking status and a comprehensive set of text processing regular expressions to extract pack years and cessation date information from these clinical notes.

Results

We identified smoking status with an F1 score of 0.90 on both the i2b2 and local data sets. Regular expression identification of pack year history in the local test set was 91.7% sensitive and 95.2% specific, but due to variable context the pack year extraction was incomplete in 25% of cases, extracting packs per day or years smoked only. Regular expression identification of cessation date was 63.2% sensitive and 94.6% specific.

Conclusions

Our work indicates that the development of an EHR-based Smokers’ Registry containing information relating to smoking behaviors, not just status, from free-text clinical notes using an informatics pipeline is feasible. This pipeline is capable of functioning in external EHRs, reducing the amount of time and money needed at the institute-level to create a Smokers’ Registry for improved identification of patient risk and eligibility for preventative and early detection services.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0863-3) contains supplementary material, which is available to authorized users.

Assessing data availability and quality within an electronic health record system through external validation against an external clinical data source

BACKGROUND

Approximately 20% of deaths in the US each year are attributable to smoking, yet current practices in the recording of this health risk in electronic health records (EHRs) have not led to discernable changes in health outcomes. Several groups have developed algorithms for extracting smoking behaviors from clinical notes, but none of these approaches were assessed with external data to report on anticipated clinical performance.

METHODS

Previously, we developed an informatics pipeline that extracts smoking status, pack year history, and cessation date from clinical notes. Here we report on the clinical implementation performance of our pipeline using 1,504 clinical notes matched to an external questionnaire.

RESULTS

We found that 73% of available notes contained no smoking behavior information. The weighted Cohen's kappa between the external questionnaire and EHR smoking status was 0.62 (95% CI 0.56-0.69) for the clinical notes we were able to extract information from. The correlation between pack years reported by our pipeline and the external questionnaire was 0.39 on the 81 notes for which this information was present in both. We also assessed for lung cancer screening eligibility using notes from individuals identified as never smokers or smokers with pack year history extracted by our pipeline (n = 196). We found a positive predictive value of 85.4%, a negative predictive value of 83.8%, sensitivity of 63.1%, and specificity of 94.7%.

CONCLUSIONS

We have demonstrated that our pipeline can extract smoking behaviors from unannotated EHR notes when the information is present. This information is reliable enough to identify patients most likely to be eligible for smoking related services. Ensuring capture of smoking information during clinical encounters should continue to be a high priority.

Smoking related outcomes before and after implementation of tobacco-free grounds in residential substance use disorder treatment programs

BACKGROUND

This study examined the impact of a tobacco-free grounds (TFG) policy and the California $2.00/pack tobacco tax increase on tobacco use among individuals in residential substance use disorder (SUD) treatment.

METHODS

We conducted three cross-sectional surveys of clients enrolled in three residential SUD treatment programs. Wave 1 (Pre-TFG) included 190 clients, wave 2 (post-TFG and pre-tax increase) included 200 clients, and wave 3 (post-tax increase) included 201 clients. Demographic and tobacco-use characteristics were first compared between waves using bivariate comparisons. Regression models were used to compare each outcome with survey wave as the predictor, while adjusting for demographic characteristics and nesting of participants within programs.

RESULTS

Odds of clients being current smokers was lower (AOR = 0.43, 95%CI = 0.30,0.60) after implementation of TFG compared to baseline. Adjusted mean ratio (AMR) for cigarettes per day was lower post-TFG compared to baseline (AMR = 0.70, CI = 0.59, 0.83). There were no differences, across waves, in tobacco-related knowledge, attitudes, or services received by program clients, or use of nicotine replacement therapy. Increased cigarette taxation was not associated with reductions in client smoking.

CONCLUSION

Implementation of a TFG policy was associated with a lower prevalence of client smoking among individuals in residential SUD treatment. Increased state cigarette excise taxes were not associated with a further reduction in client smoking in the presence of TFG policies, though this may have been confounded by relaxing of the TFG policy. SUD treatment programs should promote TFG policies and increase tobacco cessation services for clients.

Adolescent tolerance for deviance, cigarette smoking trajectories, and premature mortality: A longitudinal study

Cigarette smoking is a well-established cause of excess morbidity and mortality in the United States and globally. The current study builds on the existing literature by examining how smoking trajectories might be a mechanism through which adolescent tolerance for deviance predicts premature all-cause and tobacco-specific mortality. Participants were from a cohort-sequential study conducted in the Midwestern United States of the natural history of cigarette smoking from adolescence through midlife that collected nine waves of data from 1980 to 2011. For the current study, we selected participants who were measured at least once at age 18 or older and who did not die before age 24 (n = 7575). Participants' tolerance for deviance was assessed in adolescence, smoking trajectory group was based on self-reported smoking status during the first six waves of data collection, and cause of death for deceased participants (n = 222) was obtained from the National Death Index. Mediation analyses using the joint significance test were conducted separately for all-cause mortality and tobacco-specific mortality. Adolescent tolerance for deviance significantly predicted smoking trajectory group over and above the influence of covariates. Adolescents with higher tolerance for deviance were more likely to belong to any smoking trajectory group compared to abstainers, and membership in a smoking trajectory group characterized by early onset and heavy, persistent smoking was related to premature all-cause and tobacco-specific mortality. Finally, smoking trajectory group was a significant mediator of the relation between adolescent tolerance for deviance and all-cause mortality.

Smoking-attributable mortality by cause of death in the United States: An indirect approach

More than 50 years after the U.S. Surgeon General's first report on cigarette smoking and mortality, smoking remains the leading cause of preventable death in the United States. The first report established a causal association between smoking and lung cancer, and subsequent reports expanded the list of smoking-attributable causes of death to include other cancers, cardiovascular diseases, stroke, and respiratory diseases. For a second level of causes of death, the current evidence is suggestive but not sufficient to infer a causal relationship with smoking. This study draws on 1980–2004 U.S. vital statistics data and applies a cause-specific version of the Preston-Glei-Wilmoth indirect method, which uses the association between lung cancer death rates and death rates for other causes of death to estimate the fraction and number of deaths attributable to smoking overall and by cause. Nearly all of the established and additional causes of death are positively associated with lung cancer mortality, suggesting that the additional causes are in fact attributable to smoking. I find 420,284 annual smoking-attributable deaths at ages 50+ for years 2000–2004, 14% of which are due to the additional causes. Results corroborate recent estimates of cause-specific smoking-attributable mortality using prospective cohort data that directly measure smoking status. The U.S. Surgeon General should reevaluate the evidence for the additional causes and consider reclassifying them as causally attributable to smoking.

•

Examines association between mortality from lung cancer and specific causes of death.

•

Evidence for some causes of death is not yet sufficient to infer causal link to smoking.

•

420,284 annual deaths were due to smoking among U.S. adults ages 50+ in 2000–2004.

•

A portion of deaths from breast and prostate cancer may be attributable to smoking.

Comparing Observed and Unobserved Components of Childhood: Evidence From Finnish Register Data on Midlife Mortality From Siblings and Their Parents

In this study, we argue that the long arm of childhood that determines adult mortality should be thought of as comprising an observed part and its unobserved counterpart, reflecting the observed socioeconomic position of individuals and their parents and unobserved factors shared within a family. Our estimates of the observed and unobserved parts of the long arm of childhood are based on family-level variance in a survival analytic regression model, using siblings nested within families as the units of analysis. The study uses a sample of Finnish siblings born between 1936 and 1950 obtained from Finnish census data. Individuals are followed from ages 35 to 72. To explain familial influence on mortality, we use demographic background factors, the socioeconomic position of the parents, and the individuals' own socioeconomic position at age 35 as predictors of all-cause and cause-specific mortality. The observed part-demographic and socioeconomic factors, including region; number of siblings; native language; parents' education and occupation; and individuals' income, occupation, tenancy status, and education-accounts for between 10 % and 25 % of the total familial influence on mortality. The larger part of the influence of the family on mortality is not explained by observed individual and parental socioeconomic position or demographic background and thus remains an unobserved component of the arm of childhood. This component highlights the need to investigate the influence of childhood circumstances on adult mortality in a comprehensive framework, including demographic, social, behavioral, and genetic information from the family of origin.

Evaluating the Evidence on Sitting, Smoking, and Health: Is Sitting Really the New Smoking?

Sitting has frequently been equated with smoking, with some sources even suggesting that smoking is safer than sitting. This commentary highlights how sitting and smoking are not comparable. The most recent meta-analysis of sedentary behavior and health outcomes reported a hazard ratio of 1.22 (95% confidence interval [CI] = 1.09, 1.41) for all-cause mortality. The relative risk (RR) of death from all causes among current smokers, compared with those who have never smoked, is 2.80 (95% CI = 2.72, 2.88) for men and 2.76 for women (95% CI = 2.69, 2.84). The risk is substantially higher for heavy smokers (> 40 cigarettes per day: RR = 4.08 [95% CI = 3.68, 4.52] for men, and 4.41 [95% CI = 3.70, 5.25] for women). These estimates correspond to absolute risk differences of more than 2000 excess deaths from any cause per 100 000 persons per year among the heaviest smokers compared with never smokers, versus 190 excess deaths per 100 000 persons per year when comparing people with the highest volume of sitting with the lowest. Conflicting or distorted information about health risks related to behavioral choices and environmental exposures can lead to confusion and public doubt with respect to health recommendations.

Smoking and Variation in the Hispanic Paradox: A Comparison of Low Birthweight Across 33 US States

The Hispanic Paradox in birth outcomes is well documented for the US as a whole, but little work has considered geographic variation underlying the national pattern. This inquiry is important given the rapid growth of the Hispanic population and its geographic dispersion. Using birth records data from 2014 through 2016, we document state variation in birthweight differentials between US-born white women and the three Hispanic populations with the largest numbers of births: US-born Mexican women, foreign-born Mexican women, and foreign-born Central and South American women. Our analyses reveal substantial geographic variation in Hispanic immigrant-white low birthweight disparities. For example, Hispanic immigrants in Southeastern states and in some states from other regions have reduced risk of low birthweight relative to whites, consistent with a "Hispanic Paradox." A significant portion of Hispanic immigrants' birthweight advantage in these states is explained by lower rates of smoking relative to whites. However, Hispanic immigrants have higher rates of low birthweight in California and several other Western states. The different state patterns are largely driven by geographic variation in smoking among whites, rather than geographic differences in Hispanic immigrants' birthweights. In contrast, US-born Mexicans generally have similar or slightly higher odds of low birthweight than whites across the US. Overall, we show that the Hispanic Paradox in birthweight varies quite dramatically by state, driven by geographic variation in low birthweight among whites associated with white smoking disparities across states.

Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990-2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.

Smoking-attributable Mortality by State in 2014, U.S

INTRODUCTION

Contemporary state-specific estimates of mortality caused by cigarette smoking are important for tobacco control advocacy and healthcare planning in the U.S., but are currently lacking.

METHODS

The population-attributable fraction (i.e., proportion of deaths in the population caused by smoking), number of deaths, and number of years of potential life lost because of active cigarette smoking were estimated for each state based on state-specific smoking prevalence data from the 2014 Behavioral Risk Factor Surveillance System, recently updated relative risks of smoking, and numbers of deaths from smoking-attributable diseases. Analyses were performed in 2017.

RESULTS

In 2014, active cigarette smoking caused an estimated 448,865 deaths (258,456 men and 190,409 women), representing 17.8% (95% CI=17.7%, 17.9%) of all deaths at age >35 years in the U.S. These deaths resulted in the premature loss of 6,387,021 years of life in 2014. Across states, population-attributable fractions ranged from 12.4% in Utah to 25.2% in Arkansas in men, and from 7.0% in Utah to 20.0% in Nevada in women. Cigarette smoking caused >20% of all deaths in seven states (Kentucky, Arkansas, Nevada, Tennessee, West Virginia, Oklahoma, and Missouri). California had the highest number of smoking-attributable deaths (n=38,182) and years of potential life lost (508,370 years), despite a relatively low population-attributable fraction (16.2%).

CONCLUSIONS

Cigarette smoking continues to cause a substantial proportion of deaths in every state, with the highest population-attributable fractions in Nevada and the South. The continuing high burden in states with longstanding tobacco control, like California, highlights the need for enhanced tobacco control in all states.

The German East-West Mortality Difference: Two Crossovers Driven by Smoking

Before the fall of the Berlin Wall, mortality was considerably higher in the former East Germany than in West Germany. The gap narrowed rapidly after German reunification. The convergence was particularly strong for women, to the point that Eastern women aged 50-69 now have lower mortality despite lower incomes and worse overall living conditions. Prior research has shown that lower smoking rates among East German female cohorts born in the 1940s and 1950s were a major contributor to this crossover. However, after 1990, smoking behavior changed dramatically, with higher smoking intensity observed among women in the eastern part of Germany. We forecast the impact of this changing smoking behavior on East-West mortality differences and find that the higher smoking rates among younger East German cohorts will reverse their contemporary mortality advantage. Mortality forecasting methods that do not account for smoking would, perhaps misleadingly, forecast a growing mortality advantage for East German women. Experience from other countries shows that smoking can be effectively reduced by strict anti-smoking policies. Instead, East Germany is becoming an example warning of the consequences of weakening anti-smoking policies and changing behavioral norms.

Smoking Behaviors in Kosova: Results of Steps Survey

Introduction

Tobacco use continues to be the leading global cause of preventable death. Most of these deaths occur in low and middle-income countries, and this trend is expected to widen further over the next several decades. The overall objective of the study is to describe and analyse the smoking behaviours of adults in Kosova.

Methods

According to the STEPs methodology, 6,400 respondents, aged 15 - 64 years, are selected randomly within each sex and 10-year age-group. Out of 6,400 participants, 6,117 were selected, which is approximately 95.6%.

Results

The prevalence of smoking was higher among males (37.4%) compared with females (19.7%). In all age groups, the prevalence of smoking was higher among males compared with females. Regarding the age group of 15 - 24 years, the prevalence of smoking was 16.0%, but in the age group of 25 - 34 years, it nearly doubled to the rate of 31.9%. We have a smaller increase in the age group of 35 - 44 years, and after the age of 45, it falls gradually.

Conclusions

The prevalence of smoking in Kosova is high compared with other countries in Eastern Europe. In future decades, Kosova will face a high probability of an increased burden of smoking-related diseases.

Inequality in mortality decreased among the young while increasing for older adults, 1990-2010

Many recent studies point to increasing inequality in mortality in the United States over the past 20 years. These studies often use mortality rates in middle and old age. We used poverty level rankings of groups of U.S. counties as a basis for analyzing inequality in mortality for all age groups in 1990, 2000, and 2010. Consistent with previous studies, we found increasing inequality in mortality at older ages. For children and young adults below age 20, however, we found strong mortality improvements that were most pronounced in poorer counties, implying a strong decrease in mortality inequality. These younger cohorts will form the future adult U.S. population, so this research suggests that inequality in old-age mortality is likely to decline.

The impact of tobacco taxes on mortality in the USA, 1970-2005

OBJECTIVES

This paper aimed to estimate the effect of tobacco taxes on total mortality and cause-specific mortality in the 50 States plus the District of Columbia, USA, over the period 1970-2005 as well as the net effect on deaths averted in 2010.

METHODS

We used a fixed effects panel regression to measure the impact of changes in total tobacco taxes on total and cause-specific mortality rates over the period 1970-2005, using a 5-year lag structure between changes in tobacco taxes and mortality rates. The estimates were used to determine the number of deaths averted in the year 2010 by tobacco tax increases over the period 1970-2005.

RESULTS

Descriptive results showed that nominal total tobacco tax increased from US$0.18 in 1970 to US$1.24 in 2005, which after adjusting to 2005 US$, corresponds to an increase in real total tobacco tax from US$ 0.89 in 1970 to US$ 1.24 in 2005. We found that increases in total tobacco tax were beneficial, with a $1 increase in total tobacco tax decreasing overall mortality rate by 8.0%. Based on these results, we estimated a net saving of 53 300 lives in 2010 due to the tobacco tax changes over the period 1970-2005.

CONCLUSIONS

Our results demonstrate that higher tobacco taxes lead to lower total mortality rates and avoided deaths. Strong tobacco tax policies are essential to improving overall population health.

Mortality Inequality: The Good News from a County-Level Approach

In this essay, we ask whether the distributions of life expectancy and mortality have become generally more unequal, as many seem to believe, and we report some good news. Focusing on groups of counties ranked by their poverty rates, we show that gains in life expectancy at birth have actually been relatively equally distributed between rich and poor areas. Analysts who have concluded that inequality in life expectancy is increasing have generally focused on life expectancy at age 40 to 50. This observation suggests that it is important to examine trends in mortality for younger and older ages separately. Turning to an analysis of age-specific mortality rates, we show that among adults age 50 and over, mortality has declined more quickly in richer areas than in poorer ones, resulting in increased inequality in mortality. This finding is consistent with previous research on the subject. However, among children, mortality has been falling more quickly in poorer areas with the result that inequality in mortality has fallen substantially over time. We also show that there have been stunning declines in mortality rates for African Americans between 1990 and 2010, especially for black men. Finally we offer some hypotheses about causes for the results we see, including a discussion of differential smoking patterns by age and socioeconomic status.

The influence of perceived neighborhood disorder on smoking cessation among urban safety net hospital patients

BACKGROUND

Although research has shown that objective neighborhood characteristics are associated with health behaviors including smoking, little is known about the influence of perceived neighborhood characteristics on a smoking cessation attempt.

METHODS

Participants (N=139) enrolled in a Dallas safety-net hospital smoking cessation program were followed from 1 week pre-quit through 4 weeks post-quit. Logistic regression analyses were conducted to evaluate the impact of perceived neighborhood order and disorder on the likelihood of achieving biochemically verified point prevalence and continuous smoking abstinence 4 weeks following a scheduled quit attempt. Analyses were adjusted for demographic characteristics, cigarettes per day, intervention group, and pharmacological treatment.

RESULTS

Participants were primarily non-White (72.7%) and female (56.8%) with a mean age of 52.5 (SD=3.7) years. Most reported an annual household income of ≤$25,000 (86.3%). Logistic regression analyses indicated that greater neighborhood physical (p=.048) and social order (p=.039) were associated with a greater likelihood of achieving point prevalence smoking abstinence at 4 weeks post-quit. Greater perceived physical (p=.035) and social disorder (p=.039) and total neighborhood disorder (p=.014), were associated with a reduced likelihood of achieving point prevalence abstinence. Social disorder (p=.040) was associated with a reduced likelihood of achieving continuous abstinence at 4 weeks post-quit, while social order (p=.020) was associated with an increased likelihood of continuous abstinence.

CONCLUSIONS

Perceptions of neighborhood order and disorder were associated with the likelihood of smoking cessation among socioeconomically disadvantaged smokers making a quit attempt. Findings highlight the need to address perceptions of the neighborhood environment among disadvantaged smokers seeking treatment.

Intergenerational transmission of the healthy immigrant effect (HIE) through birth weight: A systematic review and meta-analysis

This review examines intergenerational differences in birth weight among children born to first-generation and second-generation immigrant mothers and the extent to which they vary by country of origin and receiving country. We searched MEDLINE, EMBASE, Web of Science, PubMed, and ProQuest from inception to October 2014 for articles that recorded the mean birth weight (in grams) or odds of low birth weight (LBW) of children born to immigrant mothers and one subsequent generation. Studies were analyzed descriptively and meta-analyzed using Review Manager 5.3 software. We identified 10 studies (8 retrospective cohort and 2 cross-sectional studies) including 158,843 first and second-generation immigrant women. The United States and the United Kingdom represented the receiving countries with the majority of immigrants originating from Mexico and South Asia. Six studies were meta-analyzed for mean birth weight and seven for low birth weight. Across all studies, there was found to be no statistically significant difference in mean birth weight between first and second-generation children. However, the odds of being LBW were 1.21 [95% CI, 1.15, 1.27] times greater among second-generation children. Second-generation children of Mexican descent in particular were at increased odds of LBW (OR = 1.47 [95% CI, 1.28, 1.69]). In the United States, second-generation children were at 34% higher odds of being LBW (OR = 1.34 [95% CI, 1.13, 1.58]) when compared to their first-generation counterparts. This effect was slightly smaller in the United Kingdom (OR = 1.18 [95% CI, 1.13, 1.23]). In conclusion, immigration to a new country may differentially influence low birth weight over generations, depending on the mother's nativity and the country she immigrates to.

The Contribution of Smoking to Educational Gradients in U.S. Life Expectancy

Researchers have documented widening educational gradients in mortality in the United States since the 1970s. While smoking has been proposed as a key explanation for this trend, no prior study has quantified the contribution of smoking to increasing education gaps in longevity. We estimate the contribution of smoking to educational gradients in life expectancy using data on white men and women ages 50 and older from the National Longitudinal Mortality Study (N = 283,430; 68,644 deaths) and the National Health Interview Survey (N = 584,811; 127,226 deaths) in five periods covering the 1980s to 2006. In each period, smoking makes an important contribution to education gaps in longevity for white men and women. Smoking accounts for half the increase in the gap for white women but does not explain the widening gap for white men in the most recent period. Addressing greater initiation and continued smoking among the less educated may reduce mortality inequalities.

Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data

BACKGROUND

Impressive decreases in cardiovascular mortality have been achieved through risk factor reduction and clinical intervention, yet cardiovascular disease remains a leading cause of death nationally.

OBJECTIVE

To estimate up-to-date preventable fractions of cardiovascular mortality associated with elimination and reduction of 5 leading risk factors nationally and by state in the United States.

DESIGN

Cross-sectional and cohort studies.

SETTING

Nationally representative and state-representative samples of the U.S. population.

PARTICIPANTS

Adults aged 45 to 79 years.

MEASUREMENTS

Self-reported risk factor status in the BRFSS (Behavioral Risk Factor Surveillance System) 2009-2010 was corrected to approximate clinical definitions. The relative hazards of cardiovascular death (International Classification of Diseases, 10th Revision, codes I00 to I99) associated with risk factors were estimated using data from NHANES (National Health and Nutrition Examination Survey) (1988-1994 and 1999-2004, followed through 2006).

RESULTS

The preventable fraction of cardiovascular mortality associated with complete elimination of elevated cholesterol levels, diabetes, hypertension, obesity, and smoking was 54.0% for men and 49.6% for women in 2009 to 2010. When the more feasible target of reducing risk factors to the best achieved levels in the states was considered, diabetes (1.7% and 4.1%), hypertension (3.8% and 7.3%), and smoking (5.1% and 4.4%) were independently associated with the largest preventable fractions among men and women, respectively. With both targets, southern states had the largest preventable fractions, and western states had the smallest.

LIMITATION

Self-reported state data; mortality hazards relied on baseline risk factor status.

CONCLUSION

Major modifiable cardiovascular risk factors collectively accounted for half of cardiovascular deaths in U.S. adults aged 45 to 79 years in 2009 to 2010. Fewer than 10% of cardiovascular deaths nationally could be prevented if all states were to achieve risk factor levels observed in the best-performing states.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.