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21 st century hazards of smoking and benefits of cessation in the United States

Jha P, Ramasundarahettige C, Landsman V, Thun M, Rostron B, Mcgaffey T, Anderson RA, Peto R Centre for Global Health Research (CGHR) St. Michael’s Hospital and Dalla Lana School of Public Health, University of Toronto jhap@smh.ca NEJM, January 24, 2013 (NOTE STRICT EMBARGO).

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21 st century hazards of smoking and benefits of cessation in the United States

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  1. Jha P, Ramasundarahettige C, Landsman V, Thun M, Rostron B, Mcgaffey T, Anderson RA, Peto R Centre for Global Health Research (CGHR) St. Michael’s Hospital and Dalla Lana School of Public Health, University of Toronto jhap@smh.ca NEJM, January 24, 2013 (NOTE STRICT EMBARGO) 21st century hazards of smokingand benefits of cessation in the United States

  2. 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

  3. 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)

  4. 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)

  5. 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

  6. 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)

  7. 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

  8. Hazard ratios* by disease for current vs. never smokers, United States 1997-2006, ages 25-79, by gender * Cox- proportional HR adjusted for age, education, alcohol, and adiposity (BMI) Source: Jha et al, NEJM , Jan 24, 2013

  9. FEMALES: Survival probabilities between ages 25 and 80 years, among current and never smokers in the US Source: Jha et al, NEJM , Jan 24, 2013 HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used

  10. MALES: Survival probabilities between ages 25 and 80 years, among current and never smokers in the US Source: Jha et al, NEJM, Jan 24, 2013 HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used

  11. HRs for continuing smoking versus cessation at various ages, adults aged 25 to 79 years HR adjusted for age, education, alcohol, and adiposity (BMI) Source: Jha et al, NEJM , Jan 24, 2013

  12. Effect of quitting on survival: men/women combined Source: Jha et al, NEJM Jan 24, 2013

  13. 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

  14. 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

  15. 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

  16. More materialwww.cghr.org/tobacco1. NEJM Paper and Webappendix2. PowerPoint slides3. Frequently asked questions4. Press release and video interviews Source: Jha et al, NEJM , Jan 24, 2013

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