Table 17. Continued

Reg;ion

Survey

akl Country   Year
Central America'

1986

Sample area   Number

Belize

National Drug
Use Survey

12,595

Costa Rica

Honduras

1984

1986

Nicaragua   1988

Panama

1984
1989

Mexico      1989

1988

1980

San Jose
Preuniversity
students

487   15-20 Calderon et al.           17    10 13

694  15-30 National University       29     4 17

High school students 468
in Managua

Nationwide     11,383
Private college      464

Secondary students 9,967

First year      88,735
university
students
Mexico City sec-   3,408
ondary students

Latin Caribbean++
Cuba      1988   Nationwide     1,067

Selected Caribbean countries
Bahamas    1987   Areawide      4,838
               Out-of-school     74
            youths
            In-school youths 4,767
Cayman    1985   Areawide      2,077
  Islands

French
Guiana

1986   Areawide

Jamaica     1987  Secondary students

Suriname

1988   Seven cities and
      rural areas

Aruba and   1988   Aruba
Netherlands
Antilles

Trinidad and 1985  All secondary
Tobago         students

U.S. Virgin 1988   Household
Islands         Behavioral Risk
          Factor Survey

`Given for current daily smokers.
`Smoked during the previous year.
*Ever smoked.
"Smoked during the previous month.

2,192

Age      Sponsor

lo-20 Pride Belize

15-18  University of Nicaragua

1 l-l 8  National Cancer Association
15-19  Department of Health

National University

Mexican Insitute of
Psychiatry

473

13-17 Consumer Institute        8     3 6

United Nations Fund
for Drug Abuse

20$

103  32$

10-l 7  Drug Advisory
      Committee

11-13

1 l-21  National Council on
    Drug Abuse

13-21                     24    12

Prevalence* (%)

Men  Women Total

12$

40    52 46

10    4 7**
3     3 6

6
42$
9+

15$
23$

2%

40   19 29$
7     3   5"

36    12

23

12 17+

1 l-19  Trinidad and Tobago
    Government Drug
    Survey

12-17 U.S. Virgin Islands

Government

_Excludes El Salvador and Guatemala.
**Smoked during the previous week.
`+Excludes Dominican Republic, Haiti, and Puerto Rico.
"SOccasional smoker.


Table 18.  Prevalence of smoking among women of childbearing age, selected Latin American
     and Caribbean countries, 1979-1987                               -

                                    Survev

1
Number    Sponsor   Prevalence (%)

Country

Argentina

Brazil

Chile

Colombia

Costa Rica

Ecuador

Guatemala

Mexico

Panama

Paraguay

Puerto Rico

Suriname

Uruguay

Venezuela

Year      Sample area

1987       Nationwide

1981        Southern Brazil          CDCS
1982        Piaui State                CDC
1982        Amazonas State             CDC
1987        Nationwide               CLAP

1983      Santiago

1987        Nationwide

1986        Nationwide

1987        Nationwide

1983        Nationwide
1987        Nationwide

1979        U.S. border

1987        Nationwide        986

1987        Nationwide      1,935

1982      Entire territory

1985        Urban areas

1987        Nationwide

1987        Nationwide        980       CLAP

4,605       CLAP*

1,480       CLAP

2,009

4,187

CLAP
EP

CDC

CLAP

CLAP

5,169

CLAP

Source:  Pan American Health Organization (1992).
`Centro Latinoamericano de Perinatologia y Desarrollo Human0 de la Organizacibn Panamericana de Salud.
%ix months before pregnancy.
*enters for Disease Control.
BBefore pregnancy/during pregnancy.

Table 19.  Public knowledge and attitudes on smoking and health in Latin America
     and the Caribbean, 1982-1990

38+

25
27
22
36
58/26_

21

12

8

7
3

19

4

7

16

26
44+

34

Country

Bolivia

Year   Sample

1983   344 daily smokers
1983   120 adolescents

1987   72 physicians

Question                Response (%I
Is smoking dangerous? (yes)             83
Is smoking harmful to health? (somewhat     96
or very)
Is smoking harmful to health? (somewhat     94
or very)

Brazil

1988   P&-to Alegre

1988   PBrto Alegre

Is the life expectancy of smokers
decreased by smoking? (yes)
Is environmental tobacco smoke harmful
to children? (yes)

48

100

78  Prevalence and Mortality


Table 19. Continued

Country

Costa Rica

Year

1984

Sample

Urban students

Cuba         1988   Nationwide

Guatemala      1989   Treasury employees

Honduras

1986

1987

Preuniversity students
aged 15-30
Ministry of Health
employees in
Tegucigalpa

Mexico

Panama        1989   Students

Paraguay

Peru

1990   Physicians

1982    Adolescents
1989    Adult smokers

Puerto Rico     1989   San Juan

Uruguay       1984    Montevideo

Venezuela

1984    Nationwide
1984    Caracas

1988    Nationwide
1988    Nationwide

1984    Nationwide

1986   Caracas
1986   Caracas

1986   Caracas

1989   Caracas

Question                  Response (X)

Are health risks associated with smoking?
(adequate knowledge of such risks)

Do you approve of a ban on indoor
smoking? (yes)

Are health risks associated with smoking?
(low level of knowledge)

Does smoking cause lung cancer and
other diseases? (yes)
Do you favor a worksite smoking
regulation? (yes)

Are you bothered by smoking at your
worksite? (yes)

Is smoking harmful to health? (yes)
Is smoking less harmful than use of other
drugs? (yes)

Are you bothered when other people
smoke? (yes)

Is smoking undesirable? (yes)

Is smoking harmful? (yes)
What is the most important reason to stop
smoking? (health)

Do you believe that smoking is harmful
to the health of smokers? (yes)

Does smoking affect health negatively?
(yes)

Is smoking harmful to health? (yes)
Should smoking be restricted in public
places? (yes)

Should all forms of tobacco advertising be
banned? (yes)

Is smoking harmful to others? (yes)
Are some cigarettes less harmful than
others? (yes)

Should smoking be restricted in public
places? (yes)

Should radio and television advertising of
tobacco be banned-including indirect
advertising? (yes)

81

98

64/56*

50

70

77

90
55

60

30

95
66

89

81

94
83

72

75/81'
53

89

60

so urce:  Pan American Health Organization (1992).
`Smokers/nonsmokers.


Table 20. Modified stem-and-leaf display of prevalence of smoking (%) among adults,
     selected countries of Latin America and the Caribbean, 1980s and 1990~~
                                                     -

Men

o-9
10-19
20-29
30-39
40-49
50-59
60-69

Women

o-9   2 3 4 4 5 6 6 8 8 9
10-19  11 11 11 11 12 13 13 13 14 14 14 14 15 16 17 17 18 18 18 18
20-29  20 20 22 23 23 23 23 24 24 25 26 26 27 27 27 28 29
30-39  30 31 31 32 32 33 33 34 36 36 38
40-49  40 40 45 49

6
10 10 15 18 19

20 23 25 25 25 26 27 27 28 28
32 32 32 33 34 34 35 35 35 35 35 36 36 36 37 37 38 38 38 39 39
40 41 41 42 42 43 43 44 45 45 45 46 48 48 48 48 49 49
51 52 52 53 56
66 68

Median = 37

Median = 20

*Prevalence data from Table 16 are grouped by decile (stem) and listed in ascending order (leaf). The data are from different
sources and derive from various methodologies. This display provides a visual overview of the range of measured values.

Table 21.  Prevalence of smoking (%) among
     Hispanic persons in the United States,
     aged 20-74, by ethnic group and sex,
     selected years

Ethnic group and sex    1982-1984*   1987+

Mexican origin
(southwest United States)
Men                 43.6      31.8
Women               24.5      17.4

Cuban origin (Miami area)
Men                 41.8      23.3
Women              23.1      20.4

Puerto Rican origin
(New York City area)
Men                41.3      38.6
Women               32.6      24.1
*Hispanic Health and Nutrition Examination Survey, 1982-
1984 (Escobedo, Remington, Anda 119891).
`Schoenborn (1989).

80  Prevalence and Mortality


Smoking-Attributable Mortality in Latin America and the Caribbean

Introduction

  Births and deaths are the most widely collected
and reported health events, and mortality is a stan-
dard measure of the health status of a population.
Mortality has traditionally been used as an indicator
of socioeconomic status and standard of living, espe-
cially in countries for which measures of economic
productivity are inappropriate.

  Mortality is a useful measure when setting
health priorities, communicating health-related infor-
mation, and marshalling political support for a health
initiative. It is a measure easily understood by the
public, and it can affect the public's perception of risk.
For example, the following statement about the
United States has a po\sJerful simplicity: "cigarette
smoking, alone, causes more premature deaths than
do all the following together: acquired immunodefi-
ciency syndrome, cocaine, heroin, alcohol, fire, auto-
mobile accidents, homicide, and suicide" (Warner
1987, p. 2081). Yet the data that allow such a statement
are difficult to assemble, and the methodologies used
to determine the number of deaths attributable to
smoking are complex (USDHHS 19891.

  Although useful, mortality data do not indicate
the full effect of a disease or set of diseases on a
community. They do not describe the pain, morbidity,
disability, economic costs, and decreased quality of
life of persons who live with an illness, nor do they
describe the secondary effects on family members who
lose a close relative.

  However, other measures of the effect of a dis-
ease have limitations as well. For example, life expec-
tancy, which can express the health status of a
population, may be misleading. For developing coun-
tries, life expectancy is strongly inff uenced by infant
and childhood mortality and much less so by disease
prevention or therapeutic advances that affect adult
health. People who have died from a smoking-related
disease would have lived approximately 15 years
longer if they had not been smokers (Warner 1987).
This powerful effect is diluted if the improvement in
smokers' life expectancy is averaged over the whole
population.

  In the following discussion, an attempt is made
to specify the number of deaths in Latin America and
the Caribbean attributable to smoking, while keeping
in mind the limitations of common disease measures.
The result is an approximation, an early step in an
iterative process for determining the health impact of

tobacco use in the Americas. The methodology, which
applies the concept of attributable mortality, is com-
plicated by the need to estimate and adjust data to
compensate for missing or insufficient data. A step-
by-step description of the methodology is provided in
Table 22. The effects of the empirical decisions made
are discussed at the end of the chapter (see "A Com-
ment on the Methodology").

Mortality Data

   The data in this section are from the PAHO
Technical Information System, a data base that in-
cludes mortality information. PAHO collects mortal-
ity data (by age, sex, and cause of death) from source
jurisdictions by using questionnaires, national publi-
cations, and other methods. Most of the data are from
civil registries, which rely on death certificates com-
pleted by health personnel in the field. These mortal-
ity data have several problems: the coverage of the
population is incomplete, the quality of some data is
questionable, and the cause-of-death groupings of the
World Health Organization (WHO)/PAHO data col-
lection questionnaire limit comparability with other
data.

Coverage

  PAHO has estimated that the underregistration
of mortality is more than 20 percent in Brazil, Colom-
bia, Dominican Republic, Ecuador, EI Salvador, Hon-
duras, Panama, and Peru (PAHO 1990b). The diverse
reporting standards from various countries necessi-
tated several country-specific decisions. In Brazil, for
example, the most populous country in Latin America
and the Caribbean, the estimated underregistration is
approximately 25 percent. The level of underreport-
ing differs between areas, although it tends to be
worse in the poorer, northern part of the country. The
number of reported deaths was used for the whole
country, although it is an underestimate. In Paraguay,
mortality information is published for only a portion
of the country, and the information may not be repre-
sentative of the remainder of the country. However,
the areas not covered by the mortality registry are
geographically defined and include about 40 percent
of the population. Thus, reasonably reliable disease
rates can be determined for a portion of Paraguay but
not for the country as a whole. For this country, data
from the well-defined reporting areas only were used;
for other countries, similar decision rules were used.

Prez~alrircc mrd Mortality   81


Estimate overall mortality
For each country, evaluate vital registration and use the
portion of the data that provides an accurate
population-based mortality estimate.
For the 10 jurisdictions without mortality data, use
United Nations population schedules and apply
mortality rates from countries with similar socio-
demographic configurations.
Do not correct for underreporting.
Exclude and do not correct for ill-defined causes.

(Resultant population and mortality estimates are
reported in Table 25.)

Estimate cause-specific mortality
Identify the major smoking-associated disease groups
(coronary heart disease; cerebrovascular disease;
lung cancer; oral, laryngeal, and esophageal cancer;
bladder cancer; and chronic obstructive pulmonary
disease [COPDI).

Use cause-specific mortality data for countries for
which such data are available.

For the 10 jurisdictions without such data, use data
from four countries representative of the de-
mographic and socioeconomic spectrum of the
Americas (Guatemala, Colombia, Argentina, and
the United States).

(Resultant cause-specific mortality estimates are in
Table 26.)

Estimate relative risk and attributable risk

Use U.S. estimates for relative risk since country-
specific relative risk is generally not available.
Determine the smoking-attributable fraction (SAF) for the
United States by using the attributable-risk calculation.

Data Quality

  One measure of the quality of mortality information
is the proportion of deaths assigned to the rubric "symp-
toms, signs, and illdefined conditions" (Manual oflnter-
national Statistical Classification of Diseases, Injuries, and
Causes of Death, Ninth Revision [ZCD-91). Currently,
the percentage of mortality ascribed to ill-defined

Table 22. Method used for calculating smoking-attributable mortality in the Americas

Adjust estimates by using an index related to lung
cancer

Use an index of the maturity of the epidemic that
relates the lung cancer rate for each country to that
of the United States.

For each country, determine an adjusted SAF for each
disease by multiplying the index by the U.S. SAF for
each disease (Table 32).

For each country, multiply the adjusted SAF for each
disease by the number of deaths from the disease to
obtain smoking-attributable mortality (SAM)
(approximately 375,000).

Adjust the estimate further

Calculate SAM for the United States alone by using
this method and compare the result with the official
value reported for 1985 (U.S. Department of Health
and Human Services 1989).

For each cause, calculate the difference between the
result from this method and from the official
method.

Apply these upward adjustments to the cause-specific
SAMs: increase COPD by 230R, increase cancers by
10.4% (using the difference in lung cancer esti-
mates), and increase other diseases and causes by
16.4% (see footnotes to Table 33).

Calculate the adjusted estimate of SAM in the
Americas (526,000).

causes is greater than 10 percent for 16 of the 39
jurisdictions submitting mortality information
(PAHO 1990a). In this analysis, ill-defined causes were
excluded from calculations of proportions or rates.

  Because a decedent may not have received
health care or the certifying physician may not have
been the physician who treated the decedent, diagnostic

82  Prevalence and MortaZity


imprecision may occur. More serious distortion may
result because the certifying physician did not have
the diagnostic tools necessary for accurately determin-
ing the cause of death.* Furthermore, managers of
health services may not be willing or able to ensure
accurate recording or conduct the diagnostic tests that
would yield an accurate diagnosis, especially for the
elderly. As a result, assessments of mortality levels
and trends are often made by considering disease-
specific rates for middle-aged rather than elderly pop-
ulations (Doll and Peto 1981).

Coding

  Since 1979, PAHO's participating member states
have classified cause of death by using the ICD-9
coding scheme. To store these data, PAHO developed
a grouping of causes of death based on, but not iden-
tical to, the Basic Tabulation List of the ICD-9. The
PAHO grouping is also similar, but not identical, to
the groupings used by WHO and CDC. The difference
in grouping, which has a variable effect on disease
classification, does not affect deaths categorized as
due to the following conditions:

Com~ition                     ICD-9 code
Coronary heart disease              410414
Cerebrovascular disease             430-438
Lung cancer                       162
Cancers of the lip, oral cavity, or pharynx   140-149
Cancer of the esophagus                 150
Cancer of the larynx                   161
Cancer of the bladder                  188

  However, PAHO grouped cancers of the pan-
creas (ICD-9 157) and kidney (ICD-9 189) with other
cancers. Chronic obstructive pulmonary disease
(COPD), when coded as ICD-9 490-492 and 496, can-
not be isolated in the PAHO grouping. The relevant
PAHO categories are "bronchitis (chronic and unspec-
ified), emphysema, and asthma" fICD-9 490-493).
Thus, unlike the grouping for COPD used in the cal-
culation of smoking-attributable mortality (SAM) in
the United States (CDC 19911, the PAHO grouping
includes ICD-9 493 (asthma) and excludes ICD-9 496.

Life Expectancy and Mortality

Trends in Life Expectancy and Overall Mortality

  For all countries and subregions of the Americas,
the overall trend is an increase in life expectancy at
birth (Table 23). Over the last 35 years in Latin Amer-
ica and the Caribbean, the average life expectancy at

Table 23.  Life expectancy* at birth for persons
     born during selected periods, by region

and count6

Region
and country

Year of birth

1950-55  1970-75  1985-90

51.8     61.2     66.6
40.4     46.7     53.1
37.6     48.5     54.7
43.9     55.5     61.4
42.1     54.0     62.0
45.3     58.8     62.2
42.3     54.7     63.3
42.3     54.0     64.0
51.0     59.8     64.9
48.4     58.9     65.4

2000

Latin America
Bolivia
Haiti
Peru
Guatemala
El Salvador
Nicaragua
Honduras
Brazil
Ecuador
Dominican
Republic
Paraguay
Colombia
Mexico
Venezuela
Argentina
Chile
Uruguay
Costa Rica
Cuba

69.7
60.5
59.4
67.9
68.1
68.8
69.3
68.2
68.0
68.2

            46.0     59.9     65.9   69.7
            62.6     65.6     66.9   67.9
            50.6     61.6     68.2   70.7
             50.8     62.6     68.9   72.1
            55.2     66.2     69.7   71.3
             62.7     67.3     70.6   72.3
            53.8     63.6     71.5   72.7
            66.3     68.8     72.0   73.0
            57.3     68.1     74.7   75.8
            59.5     71.0     75.2   76.3

Caribbean       56.4     67.1     72.4   74.7

North America   69.1     72.2     76.1   78.1
United States   69.0     71.3     75.4   77.6
Canada       69.1     73.1     76.7   78.5

Source: Centro Latinoamericano de Demografia (1990); Pan
American Health Organization (1990a).
*Estimates through 1985 are based on actual data. After
1985, estimates are projections based on trends and on
comparisons with data from similar countries.

birth has increased by about 15 years-from 51.8 to
66.6 years. In North America, the increase was seven
years-from 69.1 to 76.1 years, reflecting a slower
increase as life expectancy at birth reaches age 75 to 80.

  Among Latin American and Caribbean coun-
tries, the current differences in life expectancy at birth
are great-ranging from 53.1 and 54.7 years in Bolivia
and Haiti, respectively, to 75.2 years in Cuba. Over the
last 35 years, the range has diminished somewhat.

2 Historically, the lack of appropriate diagnostic tools had
a major impact on the number of deaths assigned to lung
cancer. When diagnostic radiology was introduced in
England in the 192Os, the rate of certified lung cancer
deaths increased threefold (Pet0 7986).

Prmahce mzd Mortality   83


During 1950 to 1955, the range was 28.7 years; today
it is 22.1 years, and by the year 2000, it is expected to
decrease to 16.9 years. Few Latin American and Ca-
ribbean countries are at the low end of the range. Cur-
rently, only about 3 percent of the population of Latin
America and the Caribbean lives in countries with a
life expectancy at birth lower than 55 years, while 86
percent lives incountries with a life expectancy at birth
of 65 years or more. All countries except Bolivia and
Haiti are expected to achieve a life expectancy at birth
of 65 years or more by the year 2000 (PAHO 1990a).

   Differences in the rate of increase are also evident
among countries. For example, although life expec-
tancy at birth in Chile and Uruguay is now similar, it
increased three times more in Chile than in Uruguay
over the last 35 years. In general, the increase in life
expectancy at birth was slower in the 1970s and 1980s
than in the 1950s.

  The current life expectancy at birth in Latin
America and the Caribbean is equivalent to that in the
United States around 1945 to 1950-before many
major advances in chronic disease prevention and
treatment occurred (PAHO 1990a). Based on the cur-
rent rate of improvement, the life expectancy at birth
in Latin America and the Caribbean should reach that
currently found in the United States by about the first
quarter of the next century (Centro Latinoamericano
de Demografia 1990).

  The range of population and mortality parame-
ters is illustrated by data for four countries (Guate-
mala, Colombia, Argentina, and the United States)
that represent the broad spectrum of variation within
the Americas (Table 24). This variation highlights the

diverse potential effects of smoking on a population.
For example, for all deaths in women (excluding
deaths from ill-defined causes), the fraction of deaths
in women aged 35 or older ranges from 34 percent in
Guatemala to 95 percent in the United States. Since
most SAM occurs among persons 35 years old or older,
it is this group whose health is most affected by a
tobacco habit.

Estimates of Mortality

  The PAHO Technical Information System con-
tains national mortality data suitable for this analysis
for all but 10 jurisdictions in the Americas: Antigua
and Barbuda, Bermuda, Bolivia, Guadaloupe, Gre-
nada, Haiti, Montserrat, Netherlands Antilles, Nicara-
gua, and Saint Pierre and Miquelon.

   To determine the number of deaths in the Amer-
icas attributable to smoking, the number of deaths for
these 10 jurisdictions had to be estimated. The United
Nations (1989) population estimates for these jurisdic-
tions were used for this calculation. Crude population
mortality rates and other major mortality parameters
were applied by using data for countries in the PAHO
Technical Information System believed to be similar
with respect to life expectancy, geographic region,
per capita gross national product, tobacco consump-
tion rates, and other factors. These estimates were
used along with others obtained by standard means
(Table 25).

   These nonstandard estimates are sensitive to the
choice of country used to model the mortality struc-
ture. In general, these are underestimates of actual
mortality because of underreporting and because

Table 24.  Mortality from defined causes,* selected countries, c. 1985
                                  Persons aged 235 years

Country

Sex

Population+

Total
Mortality+

Mortality+

Percentage of
total mortality

Guatemala         M         3,914
               F         3,826

Colombia         M         14,103
               F         14,007

Argentina         M         15,049
              F         15,283

United States       M        116,160
              F        122,571

Source:  Pan American Health Organization (1990b).
*Excludes ill-defined causes; see text.
+Number, in thousands.

32            11           34
27             9           34

74           45            61
55           39           70

129           110           85
103           89           86

1,080           987           91
975           930           95

84  Prevalence and Mortality


Table 25.  Mortality from defined causes,* regions of the Americas, c. 1985

Region

Latin America

Sex

M
F

Andean Area

Southern ConeS

Brazil                M

Central Americas

Mexico

M     39,744         224
F     39,631          171

Latin Caribbean

M     12,934         101
F      12,801          87

32           41
26           42

134           60
112           66

63           62
52           60

Caribbean

M      3,510          21           17           78
F      3,571          18           15           82

North America"

M     128,768       1,179
F     135,410       1,055

1,078           92
1,006           95

1,831           77
1,614           82
3,444           80

All regions of the Americas    M     329,301       2,368
                    F     335,868       1,965
   Total                  665,169       4,333

Population+

Total
Mortality+

197,023       1,168
196,887         892

40,177          207
39,705          166

24,377         190
24,785         153

Mortality+

  736
  592

  109
   95

  159
  131

Percentage of
total mortality

    63
    66

    53
    57

    84
    86

67,601         367          239           65
67,963         254          177           70

12,190          78
12,002          62

Source:  Pan American Health Organization (1990b)
*Excludes ill-defined causes; see text.
+Number, in thousands.
SIncludes Falkland Islands.
SExcludes Belize.
IlIncludes Bermuda and St. Pierre and Miquelon.

mortality from ill-defined causes has been excluded   to a high of 92 to 95 percent in North America. Most
(as discussed earlier). The resultant estimates of   of the population of Latin America lives in countries
smoking-related mortality are conservative.       where this fraction is between 60 and 70 percent.

Total, Cause-Specific, and Age-Specific Mortality

  The composite of reported and estimated mor-
tality indicates that approximately 4,300,OOO deaths
occur in the Americas each year; about half of these
deaths (2,060,OOO) occur in Latin America (Table 25).
In the Americas overall, about 80 percent of deaths
occur among persons aged 35 or older; in Latin Amer-
ica, the fraction is about 64 percent. The fraction of
deaths occurring among persons aged 35 or older
varies from a low of about 41 percent in Central America

  The greatest absolute increase in life expectancy
at birth is generally associated with improvements in
mortality rates for children. In Latin America, a gra-
dient of economic development is associated with
increased life expectancy. In general, the death rate
for children is lower in more highly developed coun-
tries, but the death rate for older persons is similar in
various economic settings. For example, in Argentina,
the mortality rate per 1,000 persons under five years
of age is 7.9, and for persons aged 65 or older, it is 65.8.
In Guatemala, the rate for persons under five years of

Persons aged 235 years

Prevalence and Mortality   85


age is 21.4, but for persons aged 65 or older, it is 67.5
(PAHO 1990a).

  The gradient of economic development is also
reflected in the cause-of-death mortality structure.
Among men aged 45 to 64, mortality from heart dis-
ease, expressed as a percentage of total mortality, is 11
percent in Guatemala, 27 percent in Colombia, and 37
percent in the United States. But some similarities are
emerging. For both the 45 to 64 and the 65 or older age
groups, the three leading causes of death for each sex
are the same in both Colombia and the United States.
For the oldest age group, the leading cause of death-
diseases of the heart-is also the same in Guatemala
(PAHO 1990a).

  This pattern-increasing similarity of causes of
death-is likely to intensify. As life expectancy im-
proves, the epidemiologic profile of a country
changes. Countries with a lower life expectancy tend
to have a younger population, and the greatest mor-
tality is in the younger age groups. In these countries,
deaths are primarily due to infections (such as acute
respiratory infections and diarrhea), malnutrition,
and conditions originating in the perinatal period. As
these diseases are controlled and life expectancy in-
creases, deaths from chronic diseases-in particular,

cardiovascular diseases and cancer-become the
dominant health problem (PAHO 1990a).

Mortality from Smoking-Related Diseases

Estimates of Cause-Specific Mortality

  The major diseases associated with tobacco
smoking include coronary heart disease, cerebrovas-
cular disease, COPD, and cancers of the lung, lip, oral
cavity, pharynx, larynx, esophagus, pancreas, blad-
der, and kidney. In the United States, each of these
causes (considering cancers of the lip, oral cavity, and
pharynx as a single group) contributes at least 2,000
deaths to the total number of deaths attributable to
smoking (USDHHS 1989).

  The four countries for which population data
were assessed (Table 24) and the six smoking-related
conditions (Table 26) were the focus of this analysis of
the effect of smoking on countries of the Americas.
Cancers of the lip, oral cavity, pharynx, larynx, and
esophagus were grouped because of the similar smoking-
attributable risk for these conditions (USDHHS 1989).
Cancers of the kidney and pancreas were excluded
because they cannot be specifically identified in the
PAHO Technical Information System. The four countries

Table 26.  Deaths from six major causes as a percentage of all deaths from defined causes,* for persons
     aged 35 or older, selected countries, c. 1985

   Corm-;ry Cormr~ry Cerebro- Cerebro-      Oral,+          Chronic
                      vascular  vascular     laryngeal,        obstructive
Country    disease   disease   disease   disease  Lung and esopha- Bladder pulmona-ry   All
and sext  (aged 35-64) (aged 265) (aged 3.564) (aged 265) cancer geal cancer   cancer  diseases categories

Guatemala
Men       2.2      3.6      1.2      2.5     0.1     0.3      0.1      1.2     11.2
Women     1.6      3.2      1.8      3.8     0.4     0.1      0.0      1.1     12.0

Colombia
Men       6.3      10.1      3.4      6.8     2.1      1.6      0.3      1.9     32.5
Women     4.7     10.2      4.7      9.5     1.3     1.0      0.2      1.8     33.4

Argentina
Men       4.8      8.1      3.6      7.0     5.6     2.5      0.9      1.2     33.7
Women     1.6      8.6      2.7      9.9     1.1     0.8      0.2      0.9     25.8

United States
Men       7.6     21.3      1.0      5.0     8.5      1.5      0.7      1.3     46.9
Women     2.8      24.1       1.0      8.9     4.2     0.6      0.3      0.9     42.8

Source:  Pan American Health Organization (1990b).
*Codes from Manual uflntm~ational Stntistical Classification of Diseases, [Injuries, ad Causes of Death, Ninth Revision: coronary
heart disease, 410-414; cerebrovascular disease,430438; lung cancer, 162; cancers of lip, oral cavity, and pharynx, 140-149;
cancer of the esophagus, 150; cancer of the larynx, 161; cancer of the bladder, 188.
`Cancer of the lip, oral cavity, and pharvnx.

SThe denominator for each row is the total number of deaths from defined causes, by country and sex.
%ee text for a description of this rubric.

86  Prevalence and Mortality


chosen represented four different points on the spec-
trum of mortality rates. Guatemala was chosen, even
though its lung cancer rate is low, because it reports
nationwide mortality statistics and has one of the low-
est levels of life expectancy in Latin America.

  For persons aged 35 or older, the distribution of
deaths from the six major causes was expressed as a
percentage of all deaths from defined causes (Table
26). Because SAM from coronary heart disease and
cerebrovascular disease differs significantly between
persons aged 35 to 64 and persons aged 65 or over
(USDHHS 1989), estimates for both these age groups
are presented.

  For all six smoking-related illnesses and age sub-
categories taken together (Table 26, last column), the
proportion of deaths caused in persons aged 35 or
older differed among the countries. In Guatemala,
these diseases accounted for slightly over IO percent
of adult deaths. In Argentina and Colombia, they
accounted for 25 to 33 percent of deaths, while in the
United States, they contributed approximately 45 per-
cent of deaths.

  To estimate the number of deaths from smoking-
related conditions for subregions of the Americas
(Table 27), both the reported mortality data (Table 25)
and synthetic mortality estimates for the 10 jurisdic-
tions without data were used. For these jurisdictions,
the mortality distribution patterns from the four se-
lected countries (Table 24) were applied, as described.

  Substantially more deaths in North America
than in Latin America and the Caribbean were attrib-
uted to coronary heart disease, lung cancer, and blad-
der cancer. The number of deaths was similar in
North America and in Latin America and the Carib-
bean for cerebrovascular disease, COPD, and oral can-
cer. Using these estimates, 81 percent of lung cancer
deaths in the Americas occur in North America. When
accounting for underreporting, the proportion is prob-
ably closer to 75 percent. (Using a different approach,
other researchers have estimated that North America
accounts for 77 percent of lung cancer deaths [Parkin,
Laara, Muir 19881). Because lung cancer is a strong
indicator of all smoking-attributable diseases, a rough
approximation suggests that the number of deaths in
Latin America and the Caribbean attributable to
smoking will be about one-third to one-fourth of the
number in North America.

Estimates of Relative Risk Due to Smoking

  Relative risk is defined as Y = &1)/d(O), where d(l)
and d(O) are the incidence of a particular disease for
exposed and unexposed cohorts, respectively. For
current smokers, the relative risk for a disease estimates

the increase in disease incidence associated with a
history of smoking. This risk varies widely among
population groups due to differences in smoking-
related factors, such as person-years of smoking con-
tributed by heavy smokers, age at initiation, and ciga-
rette product smoked. For example, among current
smokers in a population, the relative risk for lung
cancer would be expected to be relatively low if a
sizable proportion of the population recently began to
smoke heavily. If, however, heavy smoking has been
common since World War II, the risk would be rela-
tively high. The main reason for this effect is that the
exposure category defined by "current smokers" is
based on current rather than past smoking habit, but
lung cancer rates primarily depend on smoking pat-
terns of 20 or more years ago.

  For many of the smoking-related causes of death,
few country-specific estimates of relative risk are
available for Latin American and Caribbean popula-
tions, and most have focused on cancer. For current
cigarette smokers in the United States, aged 35 or
older, the estimated relative risk for lung cancer is 22.4
for men and 11.9 for women (USDHHS 1989). In
Cuba, the relative risk is 14.1 for men and 7.3 for
women. Dark tobacco is the variety of tobacco most
commonly smoked in Cuba and many other areas of
Latin America. In Cuba, dark tobacco is associated
with a higher relative risk for lung cancer than light
tobacco is: for men, 14.3 and 11.3, respectively, and for
women, 8.6 and 4.6, respectively (Joly, Lubin, Car-
aballoso 1983). In Colombia, the relative risk for lung
cancer among current smokers was 10.3 in one case-
control study of 102 persons with lung cancer, 74
percent of whom were men (Restrepo et al. 1989).

  The study in Colombia also reported relative risk
for cancer of the bladder, larynx, and oral cavity/ hy-
popharynx of 3.7, 37.9, and 11.2, respectively. In La
Plata, Argentina, where the rate of bladder cancer is
high, a relative risk of 7.2 for bladder cancer was found
for men who were current smokers (Iscovich et ~31.
1987). In a study of 232 cases of cancer in Brazil (87
percent of patients were men), the relative risk for
cancer of the tongue, gum, floor of the mouth ~1~1
other parts of the oral cavity was 9.3 for current snlok-
ers of manufactured cigarettes (Franc0 et al. 1989). 11~
a 1966 case-control study of male cigarette smokers
and nonsmokers in Puerto Rico, the relati\,e risk \VII~
1.5 for esophageal cancer, 1.1 for cancer of the scroll
cavity, and 2.7 for cancer of the pharynx (Martine'
1969). In Montevideo, Uruguay, the relati\,e risk for
laryngeal cancer was 35.4 for male smoker5 Of d&irk
tobacco and 14.7 for male smokers of light tobacco (IX
Stefani et al, 1987). For comparison, for U.S. mc'il \\`llo


Table 27.  Deaths (in thousands) from six major causes, * for persons aged 35 or older, selected regions

                                                           -
     of the Americas, c. 1985
                  _.~. ~~__~
       Coronary Coronary Cerebro- Cerebro-
           heart    heart    vascular   vascular
Re ion
Fi         disease   disease   disease   disease   Lung
an sex     (aged 35-W (aged 265) (aged 3S64) (aged 265)   cancer

Oral,+
laryngeal,
and esopha-
geal cancer

Bladder
cancer

Chronic
obstructive
p;;ye;;;q

"

Latin America
Men         38.1
Women       16.7

Andean Area
  Men        5.5
  Women      3.1
Southern Cones
  Men        7.3
   Women      2.2

Brazil
  Men        16.6
   Women       7.2
Central America"
   Men         1.0
   Women      0.5

Mexico
  Men         4.2
   Women       1.9

Latin Caribbean
  Men        3.5
  Women       1.8

Caribbean
Men          0.8
Women        0.4
North America'
Men         82.2
Women       27.8

All regions of
the Americas
Men         121.0
Women       44.9
   Total      165.9

59.7     28.5     49.8     22.4      14.1      3.0     15.6
53.2      22.6      55.5      6.8      4.0      1.0     11.3

8.7      3.2      6.1      2.1      1.3      0.3      2.0
7.6      3.3      7.2      1.0      0.6      0.1      1.8

13.8      5.5      11.9      8.2      3.9      1.2      2.9
12.6      3.7      14.4      1.4       1.1      0.3      1.7

19.3      15.7      21.0      6.1       6.2      0.9      4.8
17.5      11.5      21.7      1.9       1.4      0.3      2.7

2.0      0.5      1.3      0.3      0.2      0.05     0.6
1.6      0.6       1.5      0.2      0.01      0.02     0.5

7.1      2.3      5.6      2.8       1.1       0.3      4.5
6.3       2.2      6.8      1.3       0.4      0.1      3.8

8.9      1.4      3.9      2.5       1.4      0.3      0.9
7.5      1.3      3.9      0.9      0.4      0.1      0.7

1.2      0.7      1.9      0.4      0.3      0.1      0.3
1.1      0.6      2.2      0.1       0.1       0.03     0.2

230.3      11.2      54.7     92.0      16.4      7.5      14.2
242.2       9.6      89.8     41.7      6.1       3.4      9.2

291.2      40.4     106.3     114.4      30.8      10.6     30.1
296.5      32.8     147.5     48.5      10.1       4.4     20.6
587.7      73.2     253.8     162.9     40.9      15.0     50.7

Source:  Pan American Health Organization (1990b).
*Codes from Manual of Intertrational Statistical CIassificatim of Diseases, I?rjuries, fl?~d Cawes (?f Dmth, Ninth Revision: coronary
heart disease, 410414; cerebrovascular disease, 43&438; lung cancer, 162; cancers of lip, oral cavity, and pharynx, 14G149;
cancer of the esophagus, 150; cancer of the larynx, 161; cancer of the bladder, 188.
`Cancer of the lip, oral cavity, and pharynx.
% ee text for a description of this rubric.
_Includes Falkland Islands.
"Excludes Belize.
`Includes Bermuda and St. Pierre and Miquelon.

88  Prevalence and Mortality


are current smokers, the relative risk for cancer of the
bladder is 2.9, cancer of the esophagus 7.6, cancer of
the larynx 10.5, and cancer of the lip, oral cavity, and
pharynx 27.5 (USDHHS 1989).

  Two case-control studies were conducted to in-
vestigate the factors associated with esophageal can-
cer in Uruguay, which has one of the highest rates of
esophageal cancer in the world. In one study of 226
cases, the relative risk was 6.5 for ever smokers (82
percent were men) (Vassallo et al. 1985). In the other
study of 199 cases, the relative risk was 5.7 for current
male smokers (De Stefani et al. 1990). In bordering
southern Brazil, which also has a high rate of esopha-
geal cancer, the relative risk was 8.4 for male smokers
(Victora et al. 1987).

  For countries for which relative risk estimates
were lacking, relative risks were derived from U.S.
data and used in the following computations of SAM
(USDHHS 1989, 1990). Small differences in relative
risk estimates are unlikely to have a large overall effect
on SAM because of the structure of the formula for
calculating attributable risk (see below).

Smoking-Attributable Mortality

Estimates of Smoking-Attributable Mortality
Worldwide

  Interest in attempting to quantify the extent of
the health hazard caused by tobacco led to develop-
ment of smoking-attributable fractions (SAFs). These
values estimate the proportion of cases of a specific
disease in a population that can beattributed to smoking.

SAF = P(u-ll---
  1 +p (r-l)

in which p is the proportion of the population that has
ever smoked and Y is the risk for ever smokers relative
to never smokers. The SAF calculated for each disease
of interest is multiplied by the number of deaths for
that disease, and the result is the SAM for that disease.
The sum of SAM values for all diseases associated
with tobacco use gives the total number of deaths
attributable to smoking.

  The SAF can be refined to account for differences
in smoking status (never, current, or former smoker)
and for age and sex subgroups. Smoking prevalence
and relative risk can be estimated for each of these
subgroups. SAFs have been calculated for 10 selected
causes of death in the United States (Table 28).

  Recent studies have estimated the number of
deaths attributable to smoking in the United States
(Table 29). The estimates by Rice and colleagues,

Table 28. Smoking-attributable fraction for 10
     selected causes of death, United States,
       1985

Men   Women
~~~ ~~~ L?) ~
(7c'c)

45      41

21      12

51      55

24       6
90      79

92      61
81      87
78      75
29      34
47     37
48      12

84      79
-.

Cause of death

Coronary heart disease
(aged 35-64)
Coronary heart disease
(aged 565)
Cerebrovascular disease
(aged 35-64)
Cerebrovascular disease
(aged 265)
Cancer of the lung
Cancer of the lip, oral cavity,
and pharynx
Cancer of the larynx
Cancer of the esophagus
Cancer of the pancreas
Cancer of the bladder
Cancer of the kidney
Chronic obstructive pulmonary
disease

Source:  U.S. Department of Health and
(1989).

Human Services

CDC, and USDHHS all considered smoking status,

age, and sex. The estimates vary for several reasons:
the diseases included, the specific methodology used,
the target year, and the source of the smoking preva-
lence data and the relative risk estimates. The most
recent (1988) estimate for the United States (434,000
smoking-attributable deaths) is discussed in Chapter
4, "Economic Costs of the Health Effects of Smoking."
The 1985 estimate is used here to maintain consistency
with data available for Latin America and the Caribbean.
  SAM has been estimated for many European
countries (Table 30), and the current worldwide esti-
mate is 3 million smoking-attributable deaths per year.
  The methodology described earlier for calculat-
ing SAM can be used for countries for which reliable
information is available on smoking prevalence and
on the risk for major tobacco-associated diseases
among ever smokers relative to never smokers. Un-
fortunately, few countries in Latin America have such
data; an alternative methodology for calculating SAM
is described below.

Lung Cancer Mortality as an Index of Prior
Smoking in a Population
  Numerous attempts have been made to describe
the relationship between smoking habits and mortality

Prezahce nud Mortality   89


Table 29. Smoking-attributable mortality       smoking habits of the population, as expressed by the
      in the United States            risk of dying from lung cancer.

Reference

Rice et al., 1986

U.S. Office of Technology
Assessment, 1985

Centers for Disease Control,
1987b

Year   Estimate

1980   270,000

1982   314,000

1985   320,000

for R(US,N-Sj < R(C) < RKIS)

U.S. Department of Health
and Human Services, 1989

1985*  390,000

in which R(C) is the lung cancer mortality rate for a
country in the Americas, R(US) is the lung cancer rate
for the United States (Table 31), and RtUS,N-S) is the
lung cancer rate for never smokers in the United States
(12.7 for men and 11.1 for women). When R(C) is
greater than RfUS), the index is arbitrarily set to 1.
  The index has the following properties:
o It equals 0 for the few countries in Latin America
and the Caribbean with a lung cancer rate below
that of never smokers in the United States.
o It equals 1 for countries that have a lung cancer rate
higher than that of the United States (although there
were none).

*The 1985 estimate (rather than the 1988 estimate of 434,000
reported in Chapter 4, Table 1) is used here to maintain
consistency with the demographic and vital data available
for Latin America and the Caribbean.

from lung cancer in a population. Many of these
attempts have not been entirely successful, primarily
due to the lack of key information. Current lung cancer
mortality rates reflect smoking habits of 20 to 40 years
ago. Reliable data on lung cancer incidence and mor-
tality are available for many industrialized countries,
but only limited information is available on previous
smoking habits. Furthermore, the relationship between
smoking and lung cancer is affected by many factors.
Duration of smoking is the factor most strongly corre-
lated with risk for lung cancer. For example, when
duration of regular tobacco use is doubled from 15 to
30 years, lung cancer incidence increases about 20-fold
Pete 1986). Other factors that affect lung cancer risk
include number of cigarettes smoked per day, age at
initiation, tar yield of tobacco products, use of filters,
blend of tobaccos, and depth of inhalation. Many of
these factors vary over time, not only for a national
population but for individuals within a population.
Only in recent years have surveys in a few industrial-
ized countries collected data on these factors in some
detail. Thus, data are unavailable for building an
optimal model of smoking habits and lung cancer risk.

  Nevertheless, tobacco consumption is highly
correlated with lung cancer; the SAF has been calcu-
lated at over 90 percent for countries that have popu-
lations with a long history of high prevalence of heavy
smokers (Table 31). This strong association suggests
that lung cancer mortality can be used as a surrogate
to measure the impact of smoking on a population.

  The following index (0 uses lung cancer mortal-
ity rates for the population aged 55-64. This index, a
measure of smoking maturity in a population, con-
tains population risk factor information related to the

o It falls between 0 and 1 for countries with a lung
cancer rate between the U.S. rate for never smokers
and the overall U.S. rate, and the value increases as
the country's rate approaches that of the United
States.
  This index can be used to develop estimates of

SAM for countries in Latin America and the Carib-
bean. For a given country, the lung cancer rate and
index are calculated, and this lung cancer index is used
to adjust all diseases. The index is multiplied bv the
disease-specific SAF for the United States to obtain an
adjusted disease-specific SAF for a specific country.
The number of deaths from a specific cause is then
multiplied by the adjusted SAF to obtain the SAM.

  Thus, the index adjusts the SAF downward-to
a level appropriate for the extent of lung cancer in the
population. The index is nonlinear; large changes in
the upper range of lung cancer rates have only a small
effect on the SAF. But changes in the lower range, closer
to the rate for never smokers, have a proportionately
larger effect on the SAF. In Table 31, the SAF is given
with and without the index adjustment. The index
uniformly offers a more conservative estimate of SAF.

  Because of the potential for diagnosis of lung
cancer to be more inadequate in some elderly popula-
tions than in younger populations, and because of the
need to choose a relatively stable measure of smoking
habits, the lung cancer rate for persons aged 55 to 64
was used in creating the index. If older age groups are
used, significant diagnostic misclassification occurs,
and the relationship to smoking is more tenuous. The low
rates for younger age groups render the rate estimates

90  Preztalence and Mortality


Table 30.  Estimated number of deaths due to tobacco use in 27 countries of the World Health Organization
     (WHO) European Region*

Country

Austria
Belgium
Bulgaria
Czechoslovakia
Denmark
Finland
France
German Democratic Republic
Germany, Federal Republic of
Greece
Hungary
Iceland
Ireland
Israel
Italy
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Spain
Sweden
Switzerland
United Kingdom
Yugoslavia

Total for region

Total worldwide

Year

1985
1984
1984
1984
1985
1984
1984
1984
1985
1984
1985
1984
1983
1984
1981
1985
1985
1985
1984
1985
1985
1984
1980
1985
1985
1984
1982

1991

Male         Female

5,527         3,354
8,905         2,664
6,129         3,215
14,693         7,363
5,531         3,311
4,094         1,900
25,751        10,102
12,393         6,178
49,572        26,433
5,305         1,718
10,742         5,541
  115            78
2,754         1,449
1,416           859
39,489        15,324
  298            121
  115            54
12,140.         3,892
3,046         1,553
23,858         7,337
3,656         1,778
12,178         7,907
14,492         5,738
7,104         4,339
4,299         1,610
60,764        33,916
9,103         3,732

343,469        161,466

  Total

  8,881
11,569
  9,344
22,056
  8,842
  5,994
35,853
18,571
76,005
  7,023
16,283
   193
  4,203
  2,275
54,813
   419
   169
16,032
  4,599
31,195
  5,434
20,085
20,230
11,443
  5,909
94,680
12,835

504,935

3,000,000

Source:  WHO (1988, 1991 [for worldwide estimate]).
Represents about 6OYG of the regional population. Tobacco is held responsible for about 90% of all deaths from lung cancer,
75% of bronchitis/emphysema deaths, and 257c of all deaths from ischemic heart disease. The estimate for each country is
based on the most current data provided to WHO by the countries themselves.

unstable. Further, the use of a single, well-defined
group at risk has the virtue of simplicity-data di-
rectly available to a country are used, and adjustment
that might be necessary for cross-country compari-
sons is avoided.

Estimates of Smoking-Attributable Mortality in
the Americas

Unadjusted Estimates

  Before adjustment, approximately 375,000
deaths in the Americas were attributable to smc.king
around 1985 (Table 32). These were distributed by
disease as follows:

Disease                     Total SAM
Coronary heart disease             144,200
Cerebrovascular disease             46,800
Lung cancer                  128,600
Oral, laryngeal, and esophageal cancer     23,200
Bladder cancer                  5,700
COPD                      27,300
  In Latin America and the Caribbean, an interme-

diate estimate of 64,000 smoking-attributable deaths
was obtained, and most of these deaths were from
coronary heart disease (about 18,500), cerebrovascular
disease (about 17,000), and lung cancer (about 13,000).
The largest contribution to SAM in Latin America was
made by Brazil, followed closely by the Southern Cone
subregion.

Prezlalence and Mortality   91


Table 31.  Smoking-attributable fraction (SAF) and adjusted SAF for lung cancer mortality,
     selected industrialized countries, 1978-1981

                                         Index of
                 Crude lung
Country            Sex     cancer rate*     SAF    smoking
                               maturity  A%Fd

Canada             M       142.8       .90        .92        .85
                 F        34.0        .71        .77        .60

England and Wales      M        228.5        .94       1 .oo        .92
                 F        63.3       .80       1.00        .78

Japan              M        64.8        .83         .58        .53
                 F        21.0        .58        .50        .39

Sweden             M         85.0       .83        .69        .63
                  F         28.0       .57        .66        .51
United State&         M        166.7       .92       1 .oo        .92
                  F        50.0        .78       1.00        .78

Source:  Adapted from International Agency for Research on Cancer (1986).
:For persons aged 35 or older. The calculation actually uses the rate for persons aged 5544 years.

Difference
between SAF
and adjusted
  SAF

.05
.ll

.02
.02

.30
.19

.20
.06

.oo
.oo

:Calculated by multiplying the SAF for the United States by the country-specific index of smoking maturity; see text.
+Total population.

  SAM was calculated as the percentage of deaths    exclusion of deaths attributed to ill-defined causes.
for persons aged 35 or older (last column of Table 32).   SAM was adjusted for the first four of these factors as
For the Latin American subregions, the proportion    follows. For the United States, the estimate of SAM
was highest for men in the Southern Cone and lowest   was calculated and compared with that made for 1985
for men in Central America. In the Southern Cone, the   KJSDHHS 1989). The latter estimate, which provided
difference in the rate for men and women reflects a   a benchmark, was 37.2 percent larger than the estimate
large historical difference in the rate of tobacco con-   computed in this analysis. The percent difference be-
sumption (see "Prevalence of Smoking" earlier in this   tween these two estimates was used to alter upward
chapter). The lung cancer mortality rate for women in    the estimates for the other countries in the Americas.
Peru was less than that for U.S. women who were   The adjustments were made by cause (Table 33, see
never smokers. The index was zero, and by this   footnotes), since the degree of underestimate varied
method, no deaths were attributable to smoking.       with the condition.

Adjusted Estimates

  The estimates of SAM (Table 32) are under-
estimates for several reasons: (1) COPD was un-
dercounted due to differences in cause-of-death
groupings; (2) cancers of the kidney and pancreas
were omitted; (3) the SAF for cancers of the oral cavity,
esophagus, and larynx is an underestimate (the three
cancers were grouped, and the smallest SAF for the
three was used); (4) other categories of disease or death
were omitted, including other types of cardiovascular
and respiratory disease, cervical cancer, infant deaths
due to maternal smoking during pregnancy and post-
natal exposure to environmental tobacco smoke, lung
cancer deaths due to passive smoking, and deaths
from smoking-related fires; and (5) an undercount of
deaths due to both underregistration of cases and the

  After adjustment, an estimated 526,000 annual
deaths in the Americas are attributable to tobacco use;
about 100,000 of these are in Latin America and the
Caribbean. About two-thirds of these deaths occur in
Brazil and the Southern Cone. The estimated 36,000
deaths for Bermuda, Canada, and St. Pierre and
Miquelon correspond closely with estimates derived
by using several different methods and previously
reported for Canada alone (Collishaw, Tostowaryk,
Wigle 1988; PAHO 1992). As discussed below, the
100,000 annual deaths in Latin America and the Car-
ibbean, estimated from data for the mid-1980s, is
conservative. If the current U.S. SAF is applied and if
Latin American and Caribbean countries follow a tra-
jectory similar to that of North America, over 1 million
smoking-attributable deaths per year will occur in
Latin America and the Caribbean by the year 2030.

92  Prevalence and Mortality


A Comment on the Methodology
  The attribution of mortality requires an empiri-
cal approach. In the method used here, which varies
somewhat in detail, but not in fundamental approach,
from other methods (WHO 19891, at least five basic
empirical decisions were made. First, the analysis
excluded mortality data for which cause of death was
inadequately specified, and no attempt was made to
adjust for the underreporting of deaths. Second, syn-
thetic estimates of mortality structure were used for
countries with little or no data. Third, a proration was
used to adjust for causes of death that could not be
analyzed by using PAHO data. Fourth, an empirical
index was developed to adjust for the many factors
that influence the risk that smoking imposes on a
population. Fifth, the SAM calculation made for the
United States (USDHHS 1989) was used as a bench-
mark for adjusting the estimates derived in this anal-
ysis. Each of these decisions influenced the final
estimate; in addition, some specific features of the
index and factors related to attributable risk in general
also had an influence.

The net effect of the empirical decisions is diffi-
cult to assess, but the first decision-no correction for
underreporting and no proration for ill-defined
causes-probably dominates and results in a sizable
underestimate. The order of magnitude of the under-
estimate can be approximated by comparing the esti-
mate of total mortality in Latin America derived for
this analysis (2,060,OOO [Table 251) with an estimate,
derived by using regression methods, that attempted
to account for underreporting (3,197,OOO [Hakulinen
et al. 19861). Based on this difference in overall mor-
tality of about 55 percent, the number of smoking-
attributable deaths might be as high as 155,000. The
more conservative estimate of 100,000 smoking-
attributable deaths was deemed more appropriate be-
cause it directly relates to the data with which
ministries of health in Latin American and Caribbean
countries actually work. In addition, the conservative
method allows a simple, uniform decision rule to be
used by all countries of the region in making their own
computations. Finally, this approach allows for in-
creasingly credible estimates of SAM to be made as
better mortality data become available and the esti-
mates are gradually refined.

  The index of smoking maturation is based on a
comparison of lung cancer rates. Although accurate
information is more readily available for lung cancer
than for other conditions, it may not be the optimal
condition for use in calculating the index. Although
tar levels affect the risk for lung cancer, they appar-
ently do not affect the risk for cardiovascular disease

and COPD (USDHHS 1981). Further, the lag between
increased consumption of tobacco and a rise in lung
cancer mortality may not be representative of the lag
for other diseases. In addition, use of the 55 to 64 age
group for calculating the index underestimates the
population's exposure to smoking in most Latin
American and Caribbean countries because peak
tobacco-consumption rates have not yet been reached.
  Because the index is empirical, there is no clear
methodologic justification for the square root transfor-
mation. Many transformations are available; the
square root was used because of properties appropri-
ate to the analysis. Specifically, taking the square root
of numbers less than one produces a nonlinear effect:
it increases all numbers that are less than one, but it
has a greater effect on numbers close to zero than on
numbers close to one. Thus, upward revision is pro-
portionately greater for countries with low rates than
for countries with high rates. This choice modulates,
to some extent, the conservative nature of the index.
On the other hand, no deaths were attributed to smok-
ing in countries with lung cancer rates less than those
for U.S. never smokers. Since smoking is not uni-
formly distributed in such countries, rates may be
higher for some subgroups, and at least some deaths
should have been attributed to smoking.
  Finally, this methodology is weakened by a lack
of information on multiple risk factors. The SAF may
be higher or lower when risks other than smoking play
a significant role in disease causation. Because smok-
ing is the dominant risk factor for lung cancer, this
effect is probably negligible. In cardiovascular disease,
however, smoking interacts with hypertension, hyper-
cholesterolemia, physical inactivity, obesity, diabetes,
and possibly other risk factors as well, and this effect
may be considerable.

  Thus, the empirical choices and the specifics of
the analysis may have differing effects, but the final
estimate of 526,000 annual deaths attributable to
smoking in the Americas is almost certainly conserva-
tive. This estimate-perhaps best viewed as the first
point on a continuum of such estimates-provides an
order of magnitude for the number of smoking-related
deaths in the Americas.

  If, as suggested in the first half of this chapter,
the prevalence of cigarette smoking is increasing in
some areas, accurate assessment of SAM is of consid-
erable importance. As noted, the lack of some critical
data diminishes the precision of the estimates and
fosters a greater reliance on empirical decisions. As
data systems develop, individual countries will be
better able to apply these methods for calculating
SAM for their own populations.


Table 32.  Smoking-attributable mortality* for men and women in the Americas, c. 1985

Region and
country

Men
Latin America
Andean Area
  Colombia
  Peru
  Venezuela
Southern Cone'
Argentina
  Chile
Brazil
Central America**
Mexico
Latin Caribbean
Cuba

Caribbean

North America++
Canada
United States

All regions of the
Americas

Women
Latin America
Andean Area
  Colombia
  Peru
  Venezuela
Southern Cone'
Argentina
  Chile
Brazil
Central America**
Mexico
Latin Caribbean
Cuba

Caribbean
North America++
Canada
United States

All regions of the
Americas

Lung cancer
mortality rateS

Index of
smoking
maturity
--__

   -

   -
.302
.140
.444
   -
.829
.566
.456
   -
,376
   -
.716

(aged ~65)
SAfl "

(aged 265)    (aged ~65)

SAM"
-___

SAF   SAM    SAF   SAM

  -

  -
34.1
19.5
55.6
  -
155.5
80.6
57.8
  -
44.3
  -
119.8

-   8,426       -   6,432       -    7,090
-    785       -    557      -     462
.136    386    ,063    287    .154     237
.063     24    .029     25    .072      24
,200    354    .093    228    .226     167
-   2,583       -   2,245       -    2,151
.373   1,983    .174   1,156    .423    1,659
.255    290    .119    344    .288     261
.205   3,411    .096   1,844    .233   3,652
-     71       -     89       -      36
,169    708    ,079    559    .192     435
-    867       -   1,138       -     355
,322    711    ,150    974    .365     298

-

-        -    128       -     108       -     129

  -           -
209.0       .975
219.0      1.000

-  36,907       -  48,251       -    5,696
.439   3,376    .205   4,044    .497     449
.450  33,526    .210 44,204    .510    5,243

-                    -  45,460       -   54,791       -   12,914

-

-
16.1
7.8
23.7
-
16.6
19.5
15.0
-
16.4
-
42.2

-

-
,267
-
,409
-
,279
,338
,240
.2;
-
.632

-

-
,710
-
,167
-
.114
,139
.098
-
.112
-
,259

1,848
346
198

-   1,837
-     234
,032     126
-       -
,049     108
-    403
,033     259
.041     119
,029    505
      28
,033     207
-    459
,076     405

-

-
149
236
162
63
706
20
209
331
299

-
,147
-
,225
-
.153
,186
,132
-
,151
-
,347

857
101
59

-
42
223
149
58
313
10
113
98
85

-

-
75.1
90.1

-

  -

.901
1 .ooo

  -

-

-
.369
,410

  30

11,315
768
10,547

-     27       -

-  28,854       -
.108   1,919    .496
.120  26,934    .550

29

5,343
386
4,957

-   13,194       -  30,718       -    6,229

Coronary
heart disease    Coronary
           heart disease

Cerebro-
vascular
disease

Source:  Pan American Health Organization (1990b).
"Mortality from defined causes for persons aged
`Cancer of the lip, oral cavity, and pharynx.   35 or older, in thousands.
tThe lung cancer rate for U.S. never smokers used for the index calculation was 15.5 per 100,000 men aged 5.564 and 10.4
per 100,000 women aged 55-64.

94  Prevalence and Mortality


-

-
,073
.034
,107

,199
,136
,109
-
,090

,172

5,959      -   11,549     -   5,946     -    845      -   5,819   52,066    ,071
418      -     579     -     305     -     36      -    441   3,584    ,033
222    .272     258   .236     164   ,142     17    .254    212   1,784    ,040
26    .126     33   ,109      12   ,066     2    ,118     38     184    .009
143    ,400     263   .346     116   ,209     15    ,373    148   1,434    .063
2,182      -   5,952     -   2,446     -    468      -   1,727   19,754    .124
1,527    .746   4,580   ,647   1,782   .390    368    ,697    916   14,370    ,131
315    .509     492   ,441     260   .266     35    475    553   2,549    .083
2,302    .410   2,522   .356   2,197   .214    191    ,383   1,827   17,945    .075
56      -     75     -     33     -     5      -     67     431    .013
503    .339     938   .293     322   .177     47    .316   1,409   4,920    .037
498      -   1,483     -     645     -     98      -    348   3,432    .086
399    ,644   1,334   ,558     462   ,336     86    .601    252   4,517    ,146

-      198      -     214     -     131     -     18      -    105   1,030    ,062

-    13,098      -   82,569     -   12,781     -   3,503      -  11,892  214,696    .199
.234    1,162    .878   7,249   .761    1,254   .458    367    ,819   1,245   19,147    .211
.240   11,932    ,900   75,310   ,780   11,523   .470   3,135    ,840  10,645  195,519    .198

-    19,255      -   94,331     -   18,859     -   4,366      -  17,817  267,792    ,146

-

857
101
59

-

1,567
210
102

-

673
97
64

-

-
,016
-
,025
-
.017
.020
,014
-
.016
-
.038

-
.211
-
.323
-
.220
.267
.190
-
.217
-
.499

-
,163
-
,249
-
,170
,206
.147
-
,167
-
.385

-
.099
-
.151
-
,103
,125
.089
-
,102
-
.234

103
11
7

-

2,257   12,247    .021
289   1,716    .018
151     977    .025

-
42
223
149
58
313
10
113
98
85

108
317
220
87
360
2%
389
352

33
181
116
55
207
10
74
104
89

-
5
30
22
6
30
1
10
20
17

-
,211
-
.323
-
.220
,267
,190
-
.217
-
.499

-       -
138     739
386   2,308
170   1,473
203     727
517   4,156
35     140
827   2,052
203   1,877
167   1,671

-
.039
.018
.016
,029
,023
,005
,018
.036
,069

-

29

5,343
386
4,957

-

-
.054
.060

-
.712
.790

  26

32,706
2,242
30,463

-

-
.550
,610

11

3,657
312
3,345

-    6,229      -   34,299     -   4,342

-

-
.333
,370

-

  3

1,253
105
1,148

-

-
.712
.790

33     218    ,015

7,170   95,562    ,095
532   6,631    .088
6,638   88,928    ,096

1,359      -   9,460  108,027    .067

Cerebro-
  vascular
  disease
(aged 265)
SAF    SAM

Lung
cancer

SAF   SAM   SAF   SAM   SAF   SAM   SAF   SAM

Oral,+
laryngeal, and
esophageal
   cancer

`Smoking-attributable fraction.
`iSmoking-attributablemortality.
`Includes Falkland Islands.
*`Excludes Belize.
`+lncludes Bermuda and St. Pierre and Miquelon.

Bladder
cancer

Chronic
obstructive
pulmonary
disease

Total
SAM

Total SAM
t~:~~:~l
mortality


Table 33. Adjusted estimates of smoking-attributable mortality (SAM) in the Americas, c. 1985
-

                            Chronic
                         obstructive                           Total
Region and            Total   p;;;e;;:+q           Other diseases5
country              SAM*              Cancer4     and causes    adjusted
                                                               SAM

Latin America         64,300      18,600       1,400       13,800       98,100
Andean Area         5,300       1,700          10       1,200
Southern Cone/l                                              8,200
                22,100       4,900         700       4,500       32,100
Brazil             22,100       5,400          300       4,600
Central America1                                          32,400
                     600         200          10         100          900
Mexico            7,000       5,100          100       2,000       14,200
Latin Caribbean        7,300       1,300         200       1,400       10,200

Caribbean            1,200         300          30         300        1,900

North America        310,300      43,800       12,000      60,000      426,100
United States        284,400      39,800       11,000       55,000       390,200
Other**            25,800       4,100        1,000       5,100       36,000
All regions of the
Americas          375,800      62,700       13,400       74,100       526,000

Source: Pan American Health Organization (1990b). Adjustments were based on 1985 estimates for the United States; U.S.
Department of Health and Human Services (1989). Percentages used for upward adjustment for chronic obstructive pulmo-
nary disease and other diseases and causes were specific to those diagnostic rubrics. Upward adjustment for cancers was
based on lung cancer.
*Total for men and women from Table 32.
+230% adjustment to compensate for undercounting.
*10.4% increase added to adjust for omission of cancers of the kidney and pancreas and for underestimates of smoking-
attributable fraction for cancers of oral cavity, esophagus, and larynx.
516.4% increase added to adjust for exclusion of cervical cancer, other types of cardiovascular and respiratory diseases,
deaths among newborns due to smoking by the mother, lung cancer deaths due to passive smoking, and deaths from
smoking-related fires.
IlIncludes Falkland Islands.
IExcludes Belize.
**Includes Bermuda, Canada, and St. Pierre and Miquelon.

96  Prevalence and Mortality


Conclusions

1. Certain sociodemographic phenomena-such as
change in population structure, increasing urban-
ization, increased availability of education, and
entry of women into the labor force-have in-
creased the susceptibility of the population of
Latin America and the Caribbean to smoking.

2.  The lack of systematic surveillance information
about the prevalence of smoking in most areas of
  Latin America and the Caribbean hinders com-
prehensive control efforts. Available information
reflects a variety of survey methods, analytic
schemes, and reporting formats.

3. Available data indicate that the median preva-
lence of smoking in Latin America and the Carib-
bean is 37 percent for men and 20 percent for
women. Variation among countries is consider-
able, however, and smoking prevalence is 50 per-
cent or more in some populations but less than 10
percent in others. In general, prevalence is highest
in the urban areas of the more developed coun-
tries and is higher among men than among
   women.

4. The initiation of smoking (as measured by the
prevalence of smoking among persons 20 to 24
years of age) exceeds 30 percent in selected urban
areas. Although systematic time series are not

available, the data suggest that more recent co-
horts (especially of women) in the urban areas of
more developed countries are adopting tobacco
use at a higher rate than did their predecessors.
The smoking epidemic in Latin America and the
Caribbean is not yet of long duration or high
intensity, and the mortality burden imposed by
smoking is smaller than that for North America.
By 1985, an estimated minimum of 526,000 smoking-
attributable deaths were occurring each year in all
the countries of the Americas; 100,000 of these
deaths occurred in Latin American and the Carib-
bean countries.

The estimate of 526,000 deaths annually is conser-
vative and is best viewed as the first point on a
continuum of such estimates. However, it pro-
vides an order of magnitude for the number of
smoking-attributable deaths in the Americas.
The time lag between the onset of smoking and the
onset of smoking-attributable disease is forebod-
ing. In North America, a high prevalence of smok-
ing, now declining, has been followed by an
increasing burden of smoking-attributable mor-
bidity and mortality. In Latin America and the
Caribbean, rising prevalence portends a major
burden of smoking-attributable disease.

Prezvlrrm~ md Mortality   97


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200  Prevalence and Mortality