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183

CHAPTER 3. MORTALITY FROM
         CHRONIC
         OBSTRUCTIVE LUNG
         DISEASE DUE TO
         CIGARETTE SMOKING
185

CONTENTS
Introduction
COLD Mortality Patterns in the United States
Prospective Studies
The British Doctors Study
The American Cancer Society 25-&&e Study
The U.S. Veterans Study
The Canadian Veterans Study
The American Cancer Society g-State Study
California Men in Various Occupations
The Swedish Study
The Japanese Study of 29 Health Districts
Cigarette Smoking and Overall COLD Mortality
Retrospective Studies
Male and Female Differences in COLD Mortality
Amount Smoked and Mortality From COLD
Inhalational Practice and Mortality From COLD
Age of Initiation and COLD Mortality
Smoking Cessation and COLD Mortality
Pipe and Cigar Smoking Mortality From COLD
International Comparison of COLD Death Rates a
Smoking Habits: The Emigrant Studies
COLD Mortality Among Populations With Low SI
Rates
Summary and Conclusions
References

Introduction
The chronic obstructive lung diseases (COLD) that are causally
related to cigarette smoking are chronic bronchitis, emphysema, and
chronic obstructive pulmonary disease and allied conditions without
mention of asthma, bronchitis, or emphysema. The last classification
was introduced by the National Center for Health Statistics in
response to the changes that occurred in the late 1960s in patterns of
reporting causes of death on death certificates. During this period,
physicians increasingly recorded deaths as due to "chronic obstruc-
tive lung disease" rather than the more specific categories of
"emphysema" or "chronic bronchitis" (NCHS 1982). Because of this
shift in patterns of reporting, and in recognition of the difficulty of
clinically separating these categories from one another as a cause of
death, the discussion in this chapter combines all of these categories
for analysis, where possible, which should result in a more complete
description of death rates from COLD.
COLD Mortality Patterns in the United States
The three chronic obstructive lung diseases related to smoking
may account for almost 62,000 deaths in 1983, compared with 56,920
deaths in 1982, according to provisional mortality data recently
published by the National Center for Health Statistics. This data is
based on a 10 percent sample of all deat.h certificates for the 12-
month period ending in November (NCHS 1984). This is a dramatic
increase from 1970, when slightly over 33,000 deaths were attributed
to COLD.
Complete mortality data are available through 1980, and Table 1
presents the numbers of male and female deaths from COLD for
1970,1975, and 1980. In addition to the relatively rapid rise in COLD
deaths during these years, there was also a shift in the male to
female ratio of these deaths. In 1970 male deaths outnumbered
female deaths by a ratio of 4.3 to 1. By 1980 this ratio had declined to
2.36.
The ageadjusted death rates for COLD during the years 1960
through 1980 are presented in Figure 1 for white men, white women,
and men and women of other races. As described in the previous
chapter, however, COLD is a slowly progressive disease, and death
from COLD usually occurs only after extensive damage has devel-
oped in the diseased lungs. Many individuals with COLD will die
with their disease rather than because of it, and even those who do
die of COLD are usually symptomatic for an extended period of time
prior to death.
Therefore, death rate data may not accurately reflect the true
prevalence or incidence of COLD in the U.S. population. In addition,
COLD is often not recorded as a cause of death in hospital records
189

TABLE l.-Number of and ratio of male to female chronic
      obstructive lung disease (COLD) deaths for
      three time periods, United States
Cause of death
   1970              1975             1980
Men    Women      Men    Women      Men   Women
Chronic bronchitis
Emphysema
COLD and
allied conditions
4,262    1,564      3,260    1,452      2,380   1,348
18,901    3,820     14,649    3,946     10,133   3,744
3,601     848     13,411    4,182     24,820   10,734
Total COLD deaths      26,764    6,227     31,520    9,580      37,333   15,826
M:F ratio                 4.30              3.29             2.36
SOURCE: National Center for Health Statistics (1982, and unpublished mortality data)
                       OTHERd
15
10                           WHITE?
5                           OTHER?
1960       1965        1970        1975        1980
             YEAR
FIGURE l.-Age-adjusted COLD mortality rates for whites
       and nonwhites in the United States, 1960-1980
SOURCE National Center for Health Statistics (1962, and unpublisheddata).
(Moriyama et al. 1966) or on death certificates (Mitchell et al. 1968),
even though it may have played an important role in a person's
death. In a recent prospective study, nearly half of the excess
mortality associated with significantly lowered FEV, was attributed
to other causes (Pete et al. 1983). Relatively advanced lung disease
(as judged by pathologic examination) may also exist without clinical
190

recognition because of the lung's large ventilatory reserve (Mitchell
et al. 1968; Hepper et al. 1969). A joint committee of the American
College of Chest Physicians and the American Thoracic Society
(ACCP-ATS 1975) has developed standardized definitions of these
conditions that may improve the accuracy of mortality reporting in
the future.
As discussed in the chapter on morbidity in this Report, COLD in
an individual is usually a combination of mucus hypersecretion,
airway narrowing, and emphysema. The extent of damage represent-
ed by each of these three processes can vary substantially from
individual to individual, both in the absolute magnitude of the
damage and in the proportional contribution of each of these three
components. The majority of those with smoking-induced lung
damage do not have enough damage to result in clinically significant
disease, and only some of those with clinically significant disease
have damage to the lung that results in death from COLD. The
progressive loss of FEV, in smokers described in the preceding
chapter is one measure of the extent and progression of lung
damage, and individuals with a markedly reduced FEV, are far more
likely to die of COLD (Peto et al. 1983). These deaths commonly occur
secondary to the failure of these severely damaged lungs to carry out
the gas exchange required for survival.
Because death from COLD is the end result of lung damage
accumulated over many years, these deaths would be expected to
occur disproportionately in the older age groups; therefore, the
presentation of a single age-adjusted death rate might not reflect a
true picture of the changes in this disease with time. Figure 2
presents the age-specific death rates in 1977 for COLD in the
different sexes and racial groups. Death rates increase rapidly over
the age of 45, and this increase is particularly dramatic over the age
of 65. In addition, the bulk of the difference between white men and
men of other races, evident in Figure 2, occurs in those over age 65.
Indeed, the COLD death rates for nonwhite men are actually higher
than that for white men under age 55.
The examination of age-specific death rates over time also presents
a somewhat different picture from that presented by the age-
adjusted numbers in Figure 1. The age-adjusted rates for white men
in Figure 1 seem to have changed only slightly between 1968 and
1980. However, when the age-specific rates for the years 1968 and
1977 are examined (Figure 31, this apparent stability can be seen to
be a product of counterbalancing trends in those under and over 65
years of age. The death rates from COLD declined in white men
under age 65 between 1968 and 1977, but COLD death rates
increased in white men over age 65 during the same years; this
increase was particularly dramatic in those over age 75.
191

I
25-34
AGE
FIGURE 2.-Age-specific COLD mortality rates for whites
       and nonwhites in the United States, 1977
SOURCE: National Center for Health Statida, (1982).
Figure 4 presents the age-specific COLD mortality rates for white
women in 1960, 1968, and 1977. As with the male rates, the female
COLD death rates rise rapidly with age, but they are substantially
lower than the male rates. In contrast with the male rates, however,
the white female death rates increased steadily with time from 1960
through 1977 both above and below age 65. In each of the age groups
over the age of 45, where significant numbers of COLD deaths would
be expected, there was a steady increase in rates from 1960 to 1968
and from 1966 to 1977. As is discussed later in this chapter, these
differences between men and women over time are consistent with
their differences in smoking behavior.
The effect of the normal aging process on the lung is small, rarely
limits maximal exercise, and never results in ventilator-y failure.
Therefore, death from chronic obstructive lung disease is never a
natural part of the aging process; it is the result of an infectious or
other disease process or of the cumulative damage of environmental
respiratory toxins. The most important of these toxins in the United
States is cigarette smoke.
192

25-34 35-44 45-54   55-64 65-74   75-84   85+
FIGURE 3.-Age-specific COLD mortality rates for white
      men in the United States, 1960, 1968, and 1977
SOURCE: National Center for Health Statistics (1982).
In spite of the large ventilator-y reserve possessed by the lung,
death from COLD is a major cause of U.S. mortality. This mortality
is closely linked to cigarette smoking and has been examined
extensively. Figure 5 shows the differences in COLD death rates for
smokers and nonsmokers at different ages. From the rarity of COLD
death in nonsmokers and the magnitude of the increased risk
associated with smoking, it is clear that the overwhelming impor-
tance of cigarette smoking as a determinant of abnormal lung
function demonstrated in the previous chapter is matched by the
importance of cigarette smoking as a determinant of death from
COLD. Examination of the death rates from COLD in smokers and
nonsmokers suggests that from 85 to 90 percent of the COLD deaths
in the United States can be attributed to cigarette smoking.
Prospective Studies
The relationship between smoking and death from COLD has been
evaluated in a large number of prospective mortality studies. There
are eight major prospective studies of the disease consequences of
smoking. They involve large numbers of smokers and nonsmokers
193

AGE
FIGURE 4.-Age-specific COLD mortality rates for white
       women in the United States, 1960, 1968, and
         1977
SOURCE Natmnal Center for Health Statmtics / 19H2 I
and have examined the death rates from COLD in both groups.
These studies cumulatively represent more than 17 million person-
years of observation and over 330,000 deaths. The size of the
populations studied allows a detailed examination of the relationship
between smoking and death rates. The characteristics of the
populations studied are summarized in Table 2 and are briefly
reviewed here.
The British Doctors Study
The British doctors study (Doll and Hill 1954, 1956, 1964a, 1964b,
1966; Doll and Peto 1976, 1977; Doll and Pike 1972; Doll et al. 1980)
of 40,000 male and female physicians in Britain was the first
prospective study and is the longest running. Deaths from chronic
bronchitis and emphysema were combined. Deaths from car pulmo-
nale (i.e., heart failure secondary to lung disease) were separately
analyzed by smoking category and probably include some deaths
from chronic bronchitis and emphysema.
194

450
400
100
FIGURE
                    -                    -1
                                           !
                               I
,
._
I
!
I
Z-Death rate for bronchitis, emphysema, or both,
per 100,000 population, by age and smoking
      status I, U.S. veterans study, 16-year followup
`Smoker LS defined as all people who smoke agarettes and those who have ever smoked other tohocco products
SOURCE- Adapted fmm Fbgot and Murray / 19801
The American Cancer Society 25State Study
The American Cancer Society 25-State study (Hammond 1965,
1966; Hammond and Garfinkel 1969; Hammond et al. 1976; Lee and
Garfinkel 1981) represents the largest investigation. Deaths from
emphysema were separately analyzed by smoking habit; deaths from
car pulmonale were also separately recorded.
The U.S. Veterans Study
The mortality experience of approximately 294,000 U.S. veterans
who held U.S. Government life insurance policies in December 1953
was examined in the U.S. veterans study (Darn 1959; Kahn 1966;
Rogot 1974a, b; Rogot and Murray 1980). Deaths from COLD were
recorded as "bronchitis and/or emphysema"; "bronchitis, underlying
or contributory"; and "emphysema without bronchitis."
The Canadian Veterans Study
Initiated in 1955 by the Canadian Department of National Health
and Welfare, the Canadian veterans study (Best 1966; Best et al.
1961) included 78,000 men and 14,000 women. Over the next 6 years
of followup, there were 9,491 male and 1,794 female deaths. The
cause of death in most of these cases was confirmed by autopsy.
195

z - TABLE 2 .-Outline of eight major prospective studies
                      Doll                    Darn                     kat                    Weir        GxiwkJf
        Aulhon         Hill        Hammond       Krhn       H~nyama        JOUC        ltammmd        Dunn      fibsy
                     Pet0                Roaol                    Walker        HW!l        laden        HNbc
                     Rke                                                                BraloW        Lonch
                               Melee and             Total population                          Ghfomu     ProtaMity
                    Bntinh        femalea        US          of         Gnadlan     while m&a             rmple of
      Sub@a                     I"                    29hdth                             nuke I"
                     do2lon                                                       I"
                                           votorura                                                      the
                                 25                    dmtncLs I"                             "UWU
                                                                 peMlolW"     nme stata                 SW&h
                                SlAkB               JW                           mupllom     pophtion
     Population aize      wm       l.~.~      mw     266.ooo ' 9zoal       187,oal       wax)        mm
        FellUka        WQ       562.671        (1%        lw?57        14,ma                           n.700
      AIF nn%       B435+        3M.4         3544          40          3cao
                                          d up                   504         D-64         18.4
        Year of         1961          1960         1W          1966          1966
        cnrdlment                               1967                                1962         1954         1969
        Yeem of
      fdlowup         20-22       UY-      16 YAM      13 y-      6y-      4 Y-         54
                     Y-                                                             10 yean
                                                                           Y-
         Number
          Of         ll.166       150,ooO      ICnJoo        39.100        11,oal       I2m        4.700        4aO
         death
     Person y-
          of         woo0      J%~.~      35Qo.w      3.W~      WoaJ       670,ooO       @A~       We
      cxpricmx

The American Cancer Society S-State Study
In the American Cancer Society g-State study (Hammond and
Horn 1958a, b), 187,783 white men were followed for an average of 44
months by 22,000 American Cancer Society volunteers. All deaths
from pulmonary disease (except pulmonary neoplasms) were consid-
ered as one group and included deaths from pneumonia, asthma,
tuberculosis, lung abscess, pneumoconiosis, bronchiectasis, and em-
physema.
California Men in Various Occupations
The study of California men in various occupations (Dunn et al
1960; Weir and Dunn 1970) examined the mortality experience of
68,153 men, aged 35 to 64, drawn from labor union rolls in specified
occupations. Deaths from emphysema were separately categorized.
The Swedish Study
The study of a probability sample of 55,000 Swedish men and
women (Cederlof et al. 19751, aged 18 to 69, represents a detailed
analysis of mortality by smoking status over a period of 10 years.
The cause of death was ascertained by death certificates collected by
the Central Bureau of Statistics for all of Sweden.
The Japanese Study of 29 Health Districts
In the fall of 1965, a total of 265,118 men and women in 29 health
districts in Japan were enrolled in a prospective study (Hirayama
1967,1970,1972,1975a, 1975b, 1977, 1981). Mortality data regarding
deaths from asthma and emphysema have recently been reported.
Cigarette Smoking and Overall COLD Mortality
The data from the major prospective studies relating smoking to
mortality from COLD in men and women are presented in Table 3.
These data demonstrate a uniform increase in death rates from
COLD among male and female smokers when compared with
nonsmokers of either sex. The mortality ratios for smokers compared
with nonsmokers vary markedly, however, from 2.2 in the Japanese
study to 24.7 in the study of British doctors. Some of this variability
can be attributed to different patterns of certification of cause of
death in different countries, but a number of other factors are also
important. Perhaps the most important other factor is the age range
of the population studied. As described earlier in this chapter, death
rates from COLD rise steeply with age, particularly over the age of
65. Studies of populations under age 65 may significantly underesti-
mate the impact of cigarette smoking on COLD because of the long
duration of smoking required to damage enough lung to result in
197

death from COLD. The population under 65 contains large numbers
of individuals who have significant airflow obstruction and who will
die of COLD, but who have not done so prior to age 65. This effect is
demonstrated in the American Cancer Society 25-State study, in
which the COLD mortality ratio for male smokers aged 45 to 64 was
6.55, but increased to 11.41 in male smokers aged 65 to 79.
A second reason for differences in mortality ratios is the selection
of study populations who are currently employed, particularly if the
duration of followup is relatively short. The incremental nature of
the lung injury in COLD often results in a prolonged period of
disability prior to resulting in death. This disability is usually
incompatible with full-time work, particularly in those occupations
requiring substantial exertion. Therefore, the study of a working
population excludes those with significant existing disability from
COLD and underestimates the COLD death rates in the general
population. Unless the followup period is long enough to observe the
progression of COLD from its asymptomatic stages through the
development of disability and finally death, the impact of cigarette
smoking on COLD death rates will be underestimated. This effect is
particularly important because cigarette smoking is overwhelmingly
the major determinant of COLD risk, and therefore an underestima-
tion of the true COLD prevalence leads to an underestimation of the
relative risk of smoking. As the followup period is extended for a
duration sufficient to allow the full time course of COLD to be
observed, the impact of cigarette smoking on COLD death rates also
emerges from the small background rate of COLD death certification
in nonsmokers (which includes those classified in error and those
with disease induced by agents that results in a more rapid
progression to death).
This "healthy worker" effect is present to varying extents in all of
the prospective studies and is one of the reasons the studies with the
longest followup periods also tend to have the largest COLD
mortality ratios. This is particularly evident in the study with the
longest followup. The British doctors study, with a followup of 20
years, revealed a mortality ratio for male smokers of 24.7.
A final reason for the differences in mortality ratios is the
differences in the smoking habits of the various populations. As was
discussed in the previous chapter, the extent of lung injury is
influenced by both the number of cigarettes smoked per day and the
duration of the smoking habit. As is shown in Table 4, some of the
variability in mortality ratios among the studies disappears when
the mortality ratios are reported by number of cigarettes smoked per
day. However, there are also substantial differences in the pattern of
cigarette use in different countries, particularly in the use of the
milder types of tobacco cigarettes that are more likely to be inhaled
and are smoked in the United States. For example, these cigarettes
198

TABLE 3.-COLD mortality ratios by disease category, eight prospective studies
Study
size of
population
Nonsmoker
Emphysema
Bronchitis
Both
Other
Cfimments
Brltlsh physicians
  Men
  Women
34.ooo         1.00
6.195         loo
24 7
Ratio for women by
amount smoked
only.
see Table 4
Cahforma men m
Yar\ous occupations
Canadian veterans
  Men
American Cancer Society
25-state
  Men
  Women
US veterans
  Men
Amcrlran Cancer Society
9.Stale
  Men
66.00(1
78.ooo
440.500
562.7llu
290K1.000
100
100
1.00
1.00
100
100
12 33
5 85             11.42
45-64'      6S79 '
6 55       11.41
4 89        750
1482
5 II
`Age range
1207
2.85
All pulmonary
&eases uLher than
cancer ipneumoma.
mfluen~~. TB.
asthma, bronchitis.
lung abscess. etc.1

8   TABLE 3.-Continued
                         SW.. of
Study              population     Nonsmoker      Emphysema         Bronchltls      Both      Other      Comments
Swedish
  Men
  Women
27,0(x)
28.ooo
100
100
.
2.20
' Number of deaths
too small for
statistical analysw
Includes deaths due
to asthma
Japanese
  Men
  Women
12w.M
143,GGo
loo
1.00
Data by amount
smoked
only; see Table 4