Download NEJM-2013-Smoking-Hazards - Centre for Global Health

st
21
century hazards of
smoking and benefits of
cessation in the United States
Jha P, Ramasundarahettige C, Landsman V, Thun M, Rostron B, Mcgaffey T,
Anderson RA, Peto R
Centre for Global Health Research (CGHR)
St. Michael’s Hospital and Dalla Lana School of Public Health, University of Toronto
[email protected]
NEJM, January 24, 2013 (NOTE STRICT EMBARGO)
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Conclusions
• 21st century smoking risks for American women
and men are comparable (death risks for smokers
are ~3 fold higher than for never smokers)
• Death risks for women who smoke are 50%
greater than estimated from the 1980s studies
• At least a decade of life lost by current smokers
• Never smokers are about twice as likely to reach
age 80 than are current smokers
• Cessation before age 30 yields 10 years of life
versus current smokers
• Cessation by age 40, 50 and 60 yields 9, 6 and 4
years of life versus current smokers
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How was the study done?
• 1997-2004 annual representative surveys (“NHIS”)
that include 93% of Americans (excluding only
those in institutions or on military duty)
• Studies those 25-79 years of age (“middle age”)
• 1.3 million person-years (over 7 years of follow up)
– 220,000 adults; 90,000 men,130,000 women
– 17,000 deaths, of which ~10,000 at 25-79 years
• Link survey participants to National Death Index to
31.12.2006 (>95% match)
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Study team
• Epidemiological experts from St. Michael’s
Hospital, University of Toronto, University of
Oxford, US Centres for Disease Control and
Prevention, and American Cancer Society
• Funded by NIH, CIHR and Bill and Melinda Gates
Foundation (but funders had no role in data
analyses or writing the paper)
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What is new about this study?
• Nationally representative, meaning the
results reflect the whole of the United
States (earlier studies were in specific
groups like nurses or volunteers)
• Women’s risks represent those who
began smoking early in life and
continued smoking through middle age
(and those who quit seriously)
• Examines the health benefits of the
recent increase in cessation
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Differences between smokers and
never smokers
• Smokers were thinner, drank alcohol
more often and were less educated than
never smokers
• The smoker versus never smoker
analyses adjusts for these differences
(and other differences)
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Cessation more common in men
than in women
• At ages 65 to 69, ratio of former to current
smokers is 2:1 for women but 4:1 for men
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Hazard ratios* by disease for current
vs. never smokers, United States
1997-2006, ages 25-79, by gender
Women
Disease
Never/
current
smoker
RR (99%CI)
Men
Never/
current
smoker
Lung cancer
61/267
All cancer
605/525
3.2 (2.6-3.9)
324/665
3.8 (3.1-4.8)
Vascular
784/476
3.2 (2.7-3.9)
500/643
2.6 (2.1-3.2)
Respiratory
119/206
8.5 (6.1-11.8)
45/188
9.0 (5.6-14.4)
3.0 (2.7-3.3)
1283/2030 2.8 (2.4-3.1)
All diseases 2190/1579
17.8 (11.4-27.8) 44/348
RR (99%CI)
14.6 (9.1-23.4)
* Cox- proportional HR adjusted for age, education, alcohol, and adiposity (BMI)
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Source: Jha et al, NEJM , Jan 24, 2013
FEMALES: Survival probabilities between ages 25 and
80 years, among current and never smokers in the US
Source: Jha et al, NEJM , Jan 24, 2013
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HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual
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cohort used
MALES: Survival probabilities between ages 25 and 80
years, among current and never smokers in the US
Source: Jha et al, NEJM, Jan 24, 2013
CGHR.ORG
HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual
Twitter:
CGHR_org
cohort used
HRs for continuing smoking versus cessation
at various ages, adults aged 25 to 79 years
HR
adjusted for age, education, alcohol, and adiposity (BMI)
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Source: Jha et al, NEJM , Jan 24, 2013
Effect of quitting on survival: men/women combined
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Source: Jha et al, NEJM Jan 24, 2013
Global implications
• US has about 40 million smokers, out of a
worldwide total of 1.3 billion smokers
• Unlike in the US, quitting in low or middle income
countries is uncommon (usually as a result of
disease, rather than to avoid disease)
• These “mature” risks suggest that the worldwide
estimates of 21st century smoking deaths are BIG
(perhaps bigger than thought just a few years ago)
 Without widespread cessation, smoking will kill
1 Billion people in the 21st century (mostly in
low/middle income countries) versus “only” 100
Million deaths in the 20th century
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What can be done?
• Higher tobacco taxes are the single most effective
intervention to reduce smoking and smoking
deaths worldwide
• US: 53 cent federal excise tax increase per pack
•
of cigarettes adopted in 2009 will save lives
Other countries need to adopt large increases in
tobacco excise taxes
• Prominent warning labels, advertising restrictions
and cessation support also raise cessation rates
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Conclusions
• 21st century smoking risks for American women
and men are comparable (death risks for smokers
are ~3 fold higher than for never smokers)
• Death risks for women who smoke are 50%
greater than estimated from the 1980s studies
• At least a decade of life lost by current smokers
• Never smokers are about twice as likely to reach
age 80 than are current smokers
• Cessation before age 30 yields 10 years of life
versus current smokers
• Cessation by age 40, 50 and 60 yields 9, 6 and 4
years of life versus current smokers
CGHR.ORG
Twitter: CGHR_org
More material
www.cghr.org/tobacco
1. NEJM Paper and Webappendix
2. PowerPoint slides
3. Frequently asked questions
4. Press release and video interviews
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Source: Jha et al, NEJM , Jan 24, 2013