Smoking is the most preventable cause of death in our society. During 1995, approximately 2.1 million people in developed countries died as a result of smoking. Tobacco use is responsible for nearly one in five deaths in the United States. Based on data from the American Cancer Society's Cancer Prevention Study II, it is estimated that 430,700 US deaths per year were attributable to smoking during 1990-1994. Although
the number of cardiovascular deaths is declining,
smoking-related cancer deaths continue to rise. Since 1987, more women have died each year from lung cancer than breast cancer, which was the major cause of cancer death in women for over 40 years. Approximately half of all continuing smokers die prematurely from smoking. Of these, approximately half die in middle age (35-69), losing an average of 20 to 25 years of life expectancy.
Lung cancer mortality rates are about 23 times higher for current male smokers and 13 times higher for current female smokers compared to lifelong never-smokers. In addition to being responsible
for 87% of lung cancers, smoking is also associated with cancers of the mouth, pharynx, larynx, esophagus, pancreas, uterine cervix, kidney, and bladder. Smoking accounts for at least 30% of all cancer deaths, is a major cause of heart disease, and is associated with conditions ranging from colds and gastric ulcers to chronic bronchitis, emphysema, and cerebrovascular disease.
Trends in Smoking
The National Health Interview Survey (NHIS) data show that cigarette smoking among adults aged 18 and over declined 40% between 1965 and 1990-from 42% to 25%. However, between 1990 and
1995, overall smoking prevalence was virtually unchanged. Between 1983 and 1995:
From 1991 to 1997, the prevalence of current cigarette smoking among high school students increased 32%; current cigarette smoking increased 80% among African-American students, 34% among Hispanic students, and 28% among white students.
- Smoking prevalence among men 18 and older declined from 34% to 26% for white men, and from 41% to 29% for African-American men.
- Smoking prevalence among white women declined from 30% to 24%; from 32% to 23% among African-American women.
- Smoking prevalence among college graduates decreased by one-third from 21% to 14% and among adults without a high school education decreased only 12% from 41% to 36%.
- Per capita consumption of cigarettes continues to decline. After peaking at 4,345 in 1963, consumption among Americans 18 years and older has decreased 43% to an estimated 2,423 in 1997.
Past-month smoking rates among high school students in the US are on the rise-increasing by nearly a third from 27.5% in 1991 to 36.4% in 1997. Nearly half (48.2%) of male students and more than a third (36.0%) of female students reported using some form of tobacco-cigarettes, cigars, or smokeless tobacco-in the past month.
Profile of Smokers
In 1995, an estimated 47 million adults (24.5 million men and 22.5 million women) were current smokers in the US: 20.1% of adults smoked every day and 4.6% smoked on some days.
The 1997 Youth Risk Behavior Survey (YRBS) data show that:
- Smoking prevalence was higher for men (27.0%) than for women (22.6%), and highest among American Indians/Alaskan Natives (36.2%) compared with other racial and ethnic groups.
- Smoking prevalence was highest among men who had dropped out of school (41.9%).
- For the more than 80% of adults who ever smoked, cigarette smoking was initiated by age 18 and more than half were already smoking regularly by that age.
- Nationwide, 70.2% of high school students have tried cigarette smoking.
- More than one-third (36.4%) of high school students were current cigarette smokers, i.e., smoked at least one cigarette in the past 30 days.
percent of high school students smoked cigarettes on at least 20 of the 30 days preceding the survey.
- White students (19.9%) were more likely than African-American (7.2%) or Hispanic (10.9%) students to smoke frequently.
From 1993 to 1997, consumption of large cigars and cigarillos increased by 68% to reach the highest level since the mid-1980s. Overall, cigar use (including small cigars) should exceed
5.1 billion in 1997 and the trend of increasing cigar use is predicted to continue.
Cigar smoking has been publicized by celebrities, and some nightclubs and restaurants are promoting new cigar smoking sections. Congress did not explicitly include cigars in the 1984 law requiring health warnings on cigarettes, so cigar packages bear no warning from the US Surgeon General. The following health consequences of cigar smoking are presented in the 1998 National Cancer Institute Monograph:
- Data from the California Adult Tobacco Use Surveys show that the rates of cigar smoking increased from 1990 to 1996 among adult males, with the greatest increase in occasional cigar smoking among younger men (aged 18 to 24) and men with at least a college degree.
- A substantial number of adolescents are also smoking cigars. In 1997, overall prevalence of smoking at least one cigar in the past 30 days was 22.0% among high school students; males (31.2%) were more likely to have smoked cigars than females (10.8%).
- US students in Grades 9-12 who used other tobacco products (cigarettes, smokeless tobacco) were more likely to report smoking cigars. Nearly three-fourths of male and one-third of female cigarette smokers reported smoking at least one cigar in the past year. Twenty percent of males and 7.8% of females in Grades 9-12 who were not cigarette smokers have smoked a cigar in the past year.
- Most of the same carcinogens and cancer-producing chemicals found in cigarettes are found in cigars.
- Regular cigar smoking causes cancer of the lung, oral cavity, larynx, esophagus, and probably cancer of the pancreas.
to cigarette smokers, cigar smokers have 4 to 10 times greater risk of dying from laryngeal, oral, or esophageal cancers compared with nonsmokers.
In September 1990, the US Surgeon General outlined the benefits of smoking cessation:
In 1995, an estimated 68.2% of current smokers reported that they wanted to quit smoking completely. Quit attempts, abstaining from smoking for at least one day during the preceding 12
months, were made by about 45.8% of current every-day smokers. About 23.3% of US adults (25 million men and 19.3 million women) were former smokers in 1995.
- People who quit, regardless of age, live longer than people who continue to smoke.
- Smokers who quit before age 50 have half the risk of dying in the next 15 years compared with those who continue to smoke.
smoking substantially decreases the risk of lung, laryngeal, esophageal, oral, pancreatic, bladder, and cervical cancers.
- Benefits of cessation include risk reduction for other major diseases including coronary heart disease and cardiovascular disease.
Teenagers find it very difficult to quit smoking-72.9% of teens who had ever smoked daily had tried to quit and only 13.5% had been successful. The 1990-1992 National Comorbidity Survey estimated that 23.6% of persons aged
15-24 years who ever used cigarettes went on to become addicted. This conversion rate (from use to dependence) was similar to rates for use of cocaine (24.5%) and heroin (20.1%). Although approximately 70% of adolescent smokers regret ever starting, cessation programs designed for young people have had very low success rates.
In 1993, the US Environmental Protection Agency declared that secondhand smoke, also called environmental tobacco smoke (ETS), is a human carcinogen. Each year, about 3,000 nonsmoking
adults die of lung cancer as a result of breathing the smoke of others' cigarettes.
Public policies to protect people from secondhand smoke and protect children from tobacco-caused disease and addiction can be enacted at the local, state, or federal levels. Because there are no safe levels of secondhand smoke, it is important that any such policies be as strong as possible and that they do not prevent action at other levels of government.
- ETS causes an estimated 35,000 to 40,000 deaths from heart disease in people who are not current smokers.
- Secondhand smoke causes other respiratory problems in nonsmokers: coughing, phlegm, chest discomfort, and reduced lung function.
- Each year, exposure to secondhand smoke causes 150,000 to 300,000 lower respiratory tract infections (such as pneumonia and bronchitis) in US infants and children younger than 18 months of age. These infections result in 7,500 to 15,000 hospitalizations every year.
- Secondhand smoke increases the number of asthma attacks and the severity of asthma in about 20% of this country's 2 to 5 million
- Secondhand smoke contains over 4,000 chemical compounds, including carbon monoxide, formaldehyde, ammonia, nickel, zinc, acetone, cholesterol, hydrogen cyanide, and formic acid. Four chemicals in secondhand smoke (benzene, 2-naphthylamine, 4-aminobiphenyl, and polonium-210) are known human carcinogens, based on EPA standards. Ten other chemicals in secondhand smoke are classified by the EPA
as probable human carcinogens.
US cigarette exports have increased due to aggressive marketing by tobacco companies and expanding foreign markets. A 1998 tobacco report of the US Department of Agriculture estimates:
- US tobacco net exports have increased from about 2.1 billion in 1986 to 4.9 billion in 1997, down from the peak of $5.9 billion in 1995.
- US cigarette exports for 1997 dropped from last year's 243.9 billion pieces to 217 billion.
cigarette exports to Japan have increased more than ninefold, from 6.5 billion in 1985 to an estimated 67.7 billion in 1997.
- Exports to the countries that formerly comprised the Soviet Union have more than doubled from 4.6 billion in 1991 to an estimated 14.9 billion in 1997.
In 1986, the US Surgeon General concluded that the use of smokeless tobacco is not a safe substitute for smoking cigarettes. It can cause cancer and a number of non-cancerous oral conditions and can lead to nicotine addiction
- Oral cancer occurs several times more frequently among snuff dippers compared with non-tobacco users.
- The excess risk of cancer of the cheek and gum may reach nearly 50-fold among long-term snuff users.
to the US Department of Agriculture, US output of moist snuff has risen 100%, from about 30 million pounds in 1981 to an estimated 60 million pounds in 1997.
- The Centers for Disease Control and Prevention's national Youth Risk Behavior Survey reported that about 15.8% of male high school students currently used chewing tobacco or snuff in 1997.
- Among adults aged 18 and older, 5.9% of men and 0.6% of women were current users of chewing tobacco or snuff according to aggregated 1987 and 1991 National Health Interview Survey data.
American Indian/Alaska Native (7.8%) and white (6.8%) men were more likely than African-American (3.1%), Hispanic (1.5%), and Asian American/Pacific Islander men (1.2%) to use smokeless tobacco.
Costs of Tobacco
Tobacco costs to our society are best measured by the number of people who die or suffer illness because of its use. Tobacco use also drains the US economy of more than $100 billion in health care costs and lost productivity.
Health care expenditures caused directly by smoking totaled $50 billion in 1993, according to the Centers for Disease Control and Prevention. Forty-three percent of these costs were paid by government funds, including Medicaid and Medicare. Tobacco costs Medicare more than $10 billion per year. Smoking costs Medicaid alone $12.9 billion per
year-about one-seventh of the total Medicaid budget. The impact of cigarette smoking on state Medicaid budgets varies among states, ranging from $1.9 billion in New York to $11.4 million in Wyoming. Lost economic productivity caused by smoking cost the US economy $47.2 billion in 1990, according to the Office of Technology Assessment. Adjusted for inflation, the total economic cost of smoking
is more than $100 billion per year. This does not include costs associated with diseases caused by environmental tobacco smoke, burn care resulting from cigarette smoking-related fires, or perinatal care for low-birthweight infants of mothers who smoke. Even though smokers die younger than the
average American, over the course of their lives, current and former smokers generate an estimated $501 billion in excess health care costs. On average, each cigarette pack sold costs Americans more than $3.90 in smoking-related expenses.
Peto R, Lopez AD, Boreham J, Thun M, Heath C, Jr. Mortality from Smoking in Developed Countries 1950-2000. New York: Oxford University Press, 1994.
Centers for Disease Control and Prevention. Cigarette smoking-attributable mortality and years of potential life lost-United States, 1984. MMWR. 1997; 46:444-450.
- US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411, 1989.
- National Center for Health Statistics. Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Hyattsville, MD: 1998.
- Tobacco Situation and Outlook Report. Market and Trade Economics Division, Economic Research Service, U.S. Department of Agriculture, April 1998,
- Office on Smoking and Health and Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Tobacco use among high school students-United States, 1997. MMWR. 1998;47(12):229-233.
- Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Cigarette smoking among adults-United States, 1995. MMWR. 1997; 46:1217-1220.
- Gerlach KK, Cummings KM, Hyland A, Gilpin EA, Johnson MD, Pierce JP. Trends in Cigar Consumption and Smoking Prevalence (Chapter 2). In: Cigars: Health Effects and Trends,
Monograph No. 9. Burns D, Cummings KM, Hoffman D, Editors, Bethesda, MD, US Department of Health and Human Services, National Institutes of Health, NIH Pub. No. 98-4302, 1998.
- Centers for Disease Control and Prevention. Cigar smoking among teenagers-United States, Massachusetts, and New York, 1996. MMWR. 46(20)433-440.
- Letter from John Slade, MD, Chair, Committee on Nicotine Dependence, American Society of Addiction Medicine, to Jerold Mande, Senior Advisor to the Director, White House Office of Science and Technology Policy, August 11, 1997.
- Shanks TG, Burns DM. Disease Consequences
of Cigar Smoking (Chapter 4). In: Cigars: Health Effects and Trends, Monograph No. 9. Burns D, Cummings KM, Hoffman D, Editors, Bethesda, MD, US Department of Health and Human Services, National Institutes of Health, NIH Pub. No. 98-4302, 1998.
- US Department of Health and Human Services. The Health Benefits of Smoking Cessation. US Department of
Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 90-8416, 1990.
- Centers for Disease Control and Prevention. Selected cigarette smoking initiation and quitting behaviors among high school students-United
States, 1997. MMWR. 47(19)386-389.
- Anthony J.C., Warner, L.A., Kessler, R.C. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances and inhalants: basic findings from the National Comorbidity Survey, Experimental and Clinical Psychopharmacology. 1994;2:
- US Department of Health and Human Services, Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Smoking and Tobacco Control, Monograph 4. NIH Pub. No. 93-3605, 1993.
- US Department of Health and Human Services. The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General. US Department of Health and Human Services, Public Health Services, National Institutes of Health, National Cancer Institute. DHHS Publication No. (NIH) 86-2874, 1986.
- US Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups-African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998.
- Centers for Disease Control and Prevention. Medical-care expenditures attributable to cigarette smoking-United States, 1993. MMWR. 1994;44 (26): 469-472.
- Miller LS, Zhang X, Novotny T, Rice DP, Max W. State estimates of Medicaid expenditures attributable to cigarette smoking-Fiscal year 1993, Public Health Reports. 1998. 113:140-151.
- Office of Technology Assessment. Statement
on Smoking-Related Deaths and Financial Costs: Office of Technology Assessment Estimates for 1990 Before the Senate Special Committee on Aging Hearing on Preventive Health. An Office of Prevention Saves a Pound of Care. May 6, 1993, p. 7.
- Hodgson TA. Cigarette smoking and lifetime medical expenditures. The Milbank Quarterly.
- The average economic cost of a pack
of cigarettes is calculated by dividing the direct and indirect costs of smoking, as provided by the Centers for Disease Control and Prevention and the Office of Technology Assessment, respectively, by the total number of cigarette packs sold in the US, as reported by the Tobacco Institute in The Tax Budget on Tobacco. 1994;29:6.