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State-Specific Smoking-Attributable Mortality and Years of Potential Life Lost --- United States, 2000--2004

Please note: An erratum has been published for this article. To view the erratum, please click here.

Smoking can cause lung and other cancers, coronary heart disease, stroke, chronic respiratory disease, and other diseases (1). In 2008, CDC reported that cigarette smoking and exposure to secondhand smoke resulted in an estimated 443,000 deaths and 5.1 million years of potential life lost (YPLL) annually in the United States during 2000--2004 (2). This report presents state-specific average annual smoking-attributable mortality (SAM) and YPLL estimates for the same period among adults aged >35 years. The report also compares 2000--2004 average annual SAM rates per 100,000 population with rates for 1996--1999. The analysis was based on data from CDC's Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) system.* Substantial variation in average annual number of deaths attributed to smoking during 2000--2004 occurred among the states (range: 492 [Alaska] to 36,687 [California]). From 1996--1999 to 2000--2004, declines in SAM rates occurred in 49 states and the District of Columbia (DC), reflecting progress made in lowering smoking prevalence in the United States during the past 40 years. Rates declined in men in 49 states and DC, but declined in women in only 32 states. To reduce SAM rates further, comprehensive evidence-based approaches for preventing smoking initiation and increasing cessation need to be implemented fully, and states should fund tobacco control activities at the level recommended by CDC (3,4).

State-specific SAM and YPLL from smoking were estimated by using SAMMEC. Sex- and age-specific SAMs were calculated by multiplying the total number of deaths among adults aged >35 years from 19 diseases caused by cigarette smoking (1) by estimates of the smoking-attributable fraction (SAF)† of preventable deaths for each disease. The attributable fractions provide estimates of the public health burden of each risk factor and the relative importance of risk factors for multifactorial diseases (2). SAFs were derived using sex-specific relative risk (RR) estimates for current and former smokers for each cause of death from the American Cancer Society's Cancer Prevention Study-II (CPS-II) for the period 1982--1988. For ischemic heart disease and cerebrovascular disease mortality, RR estimates were stratified by age (35--64 years and >65 years). Sex- and age-specific (35--64 years and >65 years) current and former cigarette smoking prevalence estimates from the Behavioral Risk Factor Surveillance System (BRFSS) were used to calculate the SAFs. Smoking-attributable YPLL were estimated by multiplying sex- and age-specific SAM by remaining life expectancy at the time of death. State-specific SAM rates per 100,000 population by sex for a given year were calculated using state SAM estimates for the year and population estimates from the U.S. Census Bureau. International Classification of Diseases, Ninth Revision (ICD-9) codes were used for cause of death in 1996--1998, whereas International Classification of Diseases, Tenth Revision (ICD-10) codes were used for 1999--2004 data. Comparability ratios (5) from ICD-9 to ICD-10 were applied to 1996--1998 data to enable comparisons with 2000--2004 data. Data for the years 2000--2004 were used in this report because they correspond to the years available to states in the SAMMEC system to calculate their state-specific SAM estimates. Infant deaths caused by smoking during pregnancy, deaths from exposure to secondhand smoke, and smoking-related fire deaths (2) were not included in the state-specific estimates.

During 2000--2004, the state-specific median estimate of the average annual number of smoking-attributable deaths among adults aged >35 years was 5,534 (range: 492 [Alaska] to 36,687 [California]). SAM estimates for males ranged from 314 (Alaska) to 21,407 (California) and the SAM estimates for females ranged from 178 (Alaska) to 15,280 (California). For every state, the annual number of smoking-related deaths was higher among males than females (Table 1).

The average annual YPLL estimates ranged from 7,762 (Alaska) to 481,529 (California). The YPLL estimates ranged from 4,586 (Alaska) to 288,823 (California) for males and from 3,176 (Alaska) to 192,706 (California) for females (Table 1).

During 2000--2004, overall average annual SAM rates per 100,000 population were lowest in Utah (138.3), Hawaii (167.6), and Minnesota (215.1), and highest in Kentucky (370.6), West Virginia (344.3), and Nevada (343.7) (Table 2). Median SAM rates per 100,000 population overall were 288.1 for 1996--1999 and 263.3 for 2000--2004 (Table 2). Changes in smoking-attributable deaths per 100,000 population during these two periods varied among states; SAM rates among adults declined the most in Nevada (-44.4 deaths per 100,000 population), California (-37.8), and Virginia (-33.4). Average annual overall SAM rates decreased from 1996--1999 to 2000--2004 in all states except Oklahoma, which experienced an increase of 26.9 deaths per 100,000. Compared with 1996--1999, average annual SAM rates declined in 2000--2004 among men in all states except Oklahoma, but increased among women in several states (Alabama, Arizona, Arkansas, Georgia,

Indiana, Kansas, Kentucky, Louisiana, Mississippi, Michigan, North Carolina, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas) and DC (Table 2).

Reported by: B Adhikari, PhD, J Kahende, PhD, A Malarcher, PhD, C Husten, MD, K Asman, MSPH, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

During 2000--2004, substantial variation occurred in the estimated absolute number of deaths caused by cigarette smoking across the 50 states and DC. Such variations have been observed previously and are the result of differences across states in total population size, demographic characteristics of state populations, and in smoking prevalence (6,7). Estimates of absolute SAM within states do not appear to have decreased from 1990 to 2004 (7) despite declines in smoking prevalence in the majority of states.§ The lack of change in absolute SAM over time is likely attributable to long-term population increases and the inclusion of additional smoking-related diseases in the SAM calculation as recent scientific studies have identified additional diseases caused by smoking (1).

The analysis in this report used the latest SAMMEC methodology to retrospectively calculate SAM rates in 1996--1999 and compare those with SAM rates in 2000--2004. The results showed that SAM rates decreased in 49 states and DC, but declined in women in only 32 states. This overall progress in decreasing SAM rates in the United States reflects the growth and effectiveness of tobacco control programs and progress in decreasing SAM rates. However, the results also indicate that more progress was made in reducing SAM rates in men than in women and that further efforts are needed to reduce SAM rates among both sexes.

The findings in this report are subject to at least five limitations. First, the estimates understate deaths attributable to all tobacco use because estimates of deaths attributable to cigar smoking, pipe smoking, and smokeless tobacco use were not included. Second, RRs were based on deaths during 1982--1988 among birth cohorts who might have had different smoking histories than current or former smokers in 2000--2004 (e.g., age of initiation and duration of smoking before quitting). CDC is continuing to monitor whether the RRs for smoking are changing over time. CDC is considering whether to use updated RRs for future SAMMEC estimates, particularly for females, because more recent cohorts of female smokers took up smoking at younger ages than did earlier cohorts (8). Third, RRs from CPS-II were adjusted for the effects of age but not for other possible confounders (e.g., alcohol use and education level). However, research suggests that alcohol and other confounders had little effect on SAM estimates for lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, and cerebrovascular disease (2). Fourth, BRFSS does not survey persons in households without landline telephones, raising concerns about the representativeness of landline telephone surveys. However, persons without landlines are more likely to be younger than age 35 years (9) and therefore less likely to be included in these estimates. Finally, some states have low response rates for BRFSS. Lower response rates indicate a potential for response bias; however, BRFSS estimates for current cigarette smoking are comparable to smoking estimates from other surveys with higher response rates (10).

SAM is one measure that is used to monitor the public health burden of cigarette smoking in the United States (2) and in each state. These most recent SAM estimates indicate that in recent years cigarette smoking continued to impose a substantial health burden on U.S. adults in all states. Changes in SAM rates across time quantify the potential gain that can be realized from effective tobacco control programs that decrease smoking initiation and increase smoking cessation (3).** The Institute of Medicine has called for aggressive action to end the tobacco epidemic (4). Fully implementing effective state comprehensive tobacco control programs, as recommended by CDC (3), can further reduce smoking prevalence and deaths caused by cigarette smoking in all states and increase life expectancy.

References

  1. CDC. Health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2004. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
  2. CDC. Smoking-attributable mortality, years of potential life lost, and productivity losses---United States, 2000--2004. MMWR 2008;57:1226--8.
  3. CDC. Best practices for comprehensive tobacco control programs---2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices.
  4. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National Academies Press; 2007.
  5. Anderson RN, Minino AM, Hoyert DL, Rosenberg HM. Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates. Natl Vital Stat Rep 2001;49(2):1--32. 
  6. Ezzati M, Friedman AB, Kulkarni SC, Murray CJL. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Med 2008;5:e66. Available at http://www.plosmedicine.org.
  7. Nelson DE, Kirkendall RS, Lawton RL, et al. Surveillance for smoking-attributable mortality and years of potential life lost, by state---United States, 1990. MMWR 1994;43(No. SS-1).
  8. CDC. Women and smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2001. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001.
  9. Blumberg SJ, Luke JV. Wireless substitution: early release of estimates based on data from the National Health Interview Survey, July--December 2006. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless200705.pdf.
  10. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Social Prev Med 2001;46:S3--42.

* SAMMEC estimates state-specific SAM and YPLL based on data from the Behavioral Risk Factor Surveillance System and death certificate data from the National Center for Health Statistics. The computations also use other data elements; available at http://apps.nccd.cdc.gov/sammec.

† SAFs for each disease are calculated using the following equation: SAF = [(p1(RR1 -- 1) + p2(RR2 -- 1)] / [p1(RR1 -- 1) + p2(RR2 -- 1) + 1], where p1 = percentage of current smokers (persons who have smoked >100 cigarettes and now smoke every day or some days), p2 = percentage of former smokers (persons who have smoked >100 cigarettes and do not currently smoke), RR1 = relative risk for current smokers relative to never smokers, and RR2 = relative risk for former smokers relative to never smokers.

§ State-level data on tobacco use prevention and control are available through the State Tobacco Activities and Evaluation (STATE) System at http://apps.nccd.cdc.gov/statesystem.

Data on cigarette smoking prevalence used to calculate the state-specific SAM estimates are from BRFSS, which uses a multistage sampling design primarily to generate state estimates. When aggregated, these state SAM estimates are comparable to the national estimate (2), which was calculated using cigarette smoking prevalence data from the National Health Interview Survey (after excluding infant deaths caused by smoking during pregnancy, deaths from exposure to secondhand smoke, and smoking-related fire deaths).

** Additional information on effective tobacco-control programs is available from CDC's Guide to Community Preventive Services at http://www.thecommunityguide.org/tobacco.

Table 1

TABLE 1. Estimated annual smoking-attributable mortality (SAM) and years of potential life lost (YPLL), by state and sex — Smoking-Attributable Mortality, Morbidity, and Economic Costs system, United States, 2000–2004* State SAM YPLL Male Female Total Male Female Total Alabama 4,860 2,725 7,585 70,913 38,113 109,026 Alaska 314 178 492 4,586 3,176 7,762 Arizona 4,090 2,770 6,859 51,137 36,640 87,777 Arkansas 3,109 1,806 4,915 42,682 26,626 69,308 California 21,407 15,280 36,687 288,823 192,706 481,529 Colorado 2,586 1,804 4,390 32,007 22,898 54,905 Connecticut 2,639 2,146 4,785 34,536 28,161 62,697 Delaware 710 488 1,198 9,737 6,661 16,398 District of Colombia 439 283 722 7,198 4,424 11,622 Florida 17,073 11,536 28,609 230,840 151,559 382,399 Georgia 6,642 3,904 10,547 101,839 60,435 162,274 Hawaii 801 359 1,160 10,775 5,305 16,080 Idaho 935 576 1,511 12,379 8,087 20,466 Illinois 9,963 6,638 16,601 139,125 90,498 229,623 Indiana 5,858 3,873 9,731 83,025 55,890 138,915 Iowa 2,845 1,599 4,444 36,696 20,321 57,017 Kansas 2,383 1,501 3,884 31,295 19,246 50,541 Kentucky 4,808 3,040 7,848 68,526 44,234 112,760 Louisiana 4,099 2,401 6,500 59,497 36,273 95,770 Maine 1,310 925 2,235 17,312 12,705 30,017 Maryland 3,931 2,930 6,861 55,680 40,412 96,092 Massachusetts 4,983 4,032 9,016 66,004 53,901 119,905 Michigan 8,602 5,922 14,523 120,649 88,498 209,147 Minnesota 3,404 2,130 5,534 42,072 27,305 69,377 Mississippi 3,122 1,634 4,757 45,536 25,141 70,677 Missouri 5,818 3,767 9,585 80,812 55,515 136,327 Montana 849 572 1,421 10,463 6,608 17,071 Nebraska 1,460 812 2,272 17,631 10,710 28,341 Nevada 1,935 1,376 3,311 25,617 19,907 45,524 New Hampshire 1,001 763 1,763 13,878 10,144 24,022 New Jersey 6,330 4,873 11,203 88,749 64,808 153,557 New Mexico 1,278 828 2,106 16,156 11,130 27,286 New York 14,294 11,139 25,433 190,074 154,036 344,110 North Carolina 7,620 4,645 12,265 112,010 69,556 181,566 North Dakota 593 282 875 7,575 3,558 11,133 Ohio 11,046 7,547 18,593 154,657 109,652 264,309 Oklahoma 3,748 2,461 6,209 50,117 35,091 85,208 Oregon 2,909 2,070 4,979 36,775 27,717 64,492 Pennsylvania 11,888 8,139 20,027 159,521 112,814 272,335 Rhode Island 956 739 1,695 11,780 9,973 21,753 South Carolina 3,901 2,227 6,127 58,830 34,871 93,701 South Dakota 707 361 1,068 8,099 5,059 13,158 Tennessee 6,063 3,649 9,712 90,044 52,257 142,301 Texas 15,089 9,483 24,571 218,133 132,276 350,409 Utah 799 356 1,155 10,275 4,796 15,071 Vermont 482 348 831 6,599 4,833 11,432 Virginia 5,583 3,659 9,242 80,084 52,073 132,157 Washington 4,439 3,180 7,619 59,695 44,366 104,061 West Virginia 2,279 1,542 3,821 33,627 22,529 56,156 Wisconsin 4,402 2,841 7,243 57,576 39,880 97,456 Wyoming 420 282 702 5,181 3,625 8,806 * Estimated smoking-attributable mortality rates among adults aged >35 years. Deaths resulting from secondhand smoke and smoking-related fires, which are included in national estimates, are not included in these estimates.
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Table 2

TABLE 2. Estimates of average annual smoking-attributable mortality (SAM) rates per 100,000 population, by state, year, and sex — Smoking-Attributable Mortality, Morbidity, and Economic Costs system, United States, 1996–2004* SAM rates Percentage-point change 1996–1999 2000–2004 1996–1999 to 2000–2004 State Male Female Overall Male Female Overall Male Female Overall Alabama 536.9 184.3 323.5 504.3 192.5 317.5 -32.6 8.2 -5.9 Alaska 396.7 218.9 300.4 374.0 188.2 270.4 -22.7 -30.7 -30.0 Arizona 376.5 165.9 256.3 337.6 176.7 247.4 -38.9 10.9 -8.9 Arkansas 525.1 200.0 333.5 492.1 203.9 323.7 -33.0 3.9 -9.8 California 391.5 189.3 272.8 327.4 167.6 235.0 -64.1 -21.7 -37.8 Colorado 394.0 174.0 261.9 337.0 168.6 237.6 -57.0 -5.3 -24.3 Connecticut 369.4 183.0 256.7 330.4 174.8 238.3 -39.0 -8.1 -18.4 Delaware 455.7 207.7 307.6 397.7 196.8 280.9 -58.0 -10.9 -26.7 District of Colombia 419.7 159.6 261.8 379.9 160.5 249.9 -39.8 0.9 -11.9 Florida 404.8 191.3 283.8 359.4 180.3 258.8 -45.4 -11.0 -25.0 Georgia 513.3 179.1 308.5 469.6 188.0 299.4 -43.7 8.9 -9.1 Hawaii 296.7 110.2 195.6 261.7 93.4 167.6 -35.0 -16.8 -28.0 Idaho 391.4 160.9 258.9 337.8 159.6 237.4 -53.6 -1.3 -21.5 Illinois 445.6 188.0 290.7 390.9 175.4 263.1 -54.7 -12.6 -27.6 Indiana 500.9 206.0 323.3 457.2 207.7 308.9 -43.7 1.7 -14.4 Iowa 431.6 152.0 263.3 392.7 149.1 248.0 -38.9 -2.9 -15.3 Kansas 430.0 157.4 267.1 395.1 170.9 262.7 -34.9 13.5 -4.4 Kentucky 604.0 238.2 383.9 555.8 244.4 370.6 -48.2 6.3 -13.3 Louisiana 510.2 187.5 316.6 459.8 189.1 299.8 -50.4 1.6 -16.8 Maine 447.0 215.4 308.2 412.1 203.5 289.8 -34.9 -11.9 -18.4 Maryland 422.5 199.1 288.1 366.1 189.1 261.9 -56.4 -10.0 -26.2 Massachusetts 397.7 189.0 269.7 350.1 182.3 249.4 -47.6 -6.7 -20.3 Michigan 466.3 194.2 303.0 403.8 196.4 281.9 -62.5 2.2 -21.1 Minnesota 357.8 143.8 229.5 323.0 140.3 215.1 -34.8 -3.5 -14.4 Mississippi 592.1 179.4 343.0 542.1 193.8 333.6 -49.9 14.4 -9.4 Missouri 508.1 220.1 335.1 458.9 204.0 307.8 -49.2 -16.1 -27.3 Montana 439.5 200.3 300.3 383.8 195.9 276.0 -55.7 -4.3 -24.3 Nebraska 429.5 150.2 261.7 373.5 142.0 235.8 -56.0 -8.2 -25.9 Nevada 496.7 299.0 388.1 437.0 266.4 343.7 -59.7 -32.6 -44.4 New Hampshire 432.4 212.5 300.1 373.1 200.3 272.4 -59.3 -12.2 -27.7 New Jersey 391.9 173.6 259.7 339.2 171.7 239.5 -52.7 -1.9 -20.2 New Mexico 374.5 169.1 255.1 331.0 161.5 234.0 -43.5 -7.6 -21.1 New York 385.7 187.7 266.4 349.4 176.5 246.1 -36.3 -11.2 -20.3 North Carolina 512.8 180.2 310.6 458.7 190.7 298.4 -54.1 10.6 -12.2 North Dakota 389.3 127.3 236.5 365.9 125.5 225.6 -23.4 -1.8 -10.9 Ohio 482.4 200.5 311.7 438.5 203.9 299.1 -43.9 3.4 -12.6 Oklahoma 465.9 193.8 305.2 481.5 225.8 332.1 15.6 32.0 26.9 Oregon 412.8 197.2 286.7 362.8 191.3 263.3 -50.0 -5.9 -23.4 Pennsylvania 425.4 178.0 275.9 384.2 173.7 259.0 -41.2 -4.3 -16.9 Rhode Island 431.9 191.6 284.5 383.9 188.2 266.8 -48.0 -3.4 -17.7 South Carolina 506.0 172.9 305.6 453.1 183.3 293.4 -52.9 10.4 -12.2 South Dakota 450.3 126.8 259.6 378.9 138.4 239.2 -71.4 11.6 -20.4 Tennessee 545.7 199.6 337.4 497.1 207.7 325.0 -48.6 8.1 -12.4 Texas 463.6 176.5 292.3 401.7 181.6 273.1 -61.9 5.1 -19.2 Utah 246.4 79.0 149.3 221.3 75.6 138.3 -25.1 -3.4 -11.0 Vermont 415.5 178.2 274.0 349.3 176.0 247.5 -66.2 -2.2 -26.5 Virginia 467.9 192.6 300.4 395.5 180.0 267.0 -72.4 -12.6 -33.4 Washington 402.8 199.7 284.0 359.2 189.4 261.0 -43.6 -10.3 -23.0 West Virginia 563.3 236.2 365.8 501.7 235.8 344.3 -61.6 -0.4 -21.5 Wisconsin 404.5 162.2 260.3 362.7 162.2 244.2 -41.8 0.0 -16.1 Wyoming 439.6 207.9 302.5 395.0 201.4 283.1 -44.6 -6.5 -19.4 Median 431.9 187.7 288.1 383.9 183.3 263.3 -48.0 -4.4 -24.8 * Estimated smoking-attributable mortality rates among adults aged >35 years. Deaths resulting from secondhand smoke and smoking-related fires, which are included in national estimates, are not included in these estimates. Comparability ratios were applied so that 1996–1998 estimates using International Classification of Diseases, Ninth Revision (ICD-9) codes are comparable to estimates for 2000–2004 using International Classification of Diseases, Tenth Revision (ICD-10) codes.
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