iii

Foreword

We take high pleasure in paying tribute to Larry Garfinkel for his lifelong contribution

to the study of smoking and health. Few individuals have contributed as much to our

present-day knowledge about the disease consequences of smoking. Since joining the

American Cancer Society in 1947, he has played a critical role in this process of discovery,

from organizing the earliest prospective studies in the 1950s, to the work that forms the

basis of this monograph, and all the important steps in between. I would like to express

my deep admiration and appreciation to Larry Garfinkel for his lifelong leadership in

combating this Nation's most important health problem.

 Richard D. Klausner, M.D.

 Director

 National Cancer Institute

 December 1996
iii

Foreword

Foreword

This volume presents a detailed and comprehensive picture of the

disease consequences that result directly from smoking cigarettes. Concern

about the disease risks associated with the use of tobacco dates back two

centuries. According to one medical historian, Dr. John Hill (1716?-1775)

should be credited with the first report documenting an association between

tobacco use and cancer for his work Cautions Against the Immoderate Use of

Snuff. Others credit J.J. Holland for noting a relationship between cancer of

the lip and tobacco use. Soemmering, in 1795, made a similar observation.

By the early part of this century, tobacco use was strongly suspected

as a cause of cancer of the mouth because most cases were found among

people who either smoked or chewed. However, at the beginning of the

20th century, the disease burden produced by tobacco use was largely

unknown, and the staggering epidemic of disease that would be produced

by cigarettes was yet to occur. The first successful national marketing of a

modern blended cigarette, Camels, occurred in 1913. These new blended

cigarettes quickly became the tobacco product of choice among consumers,

and the deeper inhalation of tobacco smoke into the lungs that characterized

the use of these products transformed the pattern of disease in the United

States. Over a relatively short interval, the addictive nature of cigarettes

and their widespread acceptance by society resulted in cigarette smoking

becoming the largest preventable cause of death and disability in the United

States and most of the developed world.

By 1930 a majority of males were already regular cigarette smokers, most

having switched to cigarettes around the time of World War I; moreover,

the popularity of smoking among females was increasing steadily as social

taboos about females smoking gave way in a more “enlightened” era. Lung

cancer deaths also began to increase, first among males and then, some 20 to

30 years later, among females. Before 1930 lung cancer was a rare disease

not listed on the International Classification of Disease system in the United

States. However, by the end of the 1930’s a rapidly increasing lung cancer

death rate among males had been noted by several scientists, including

Dr. Harold Diehl and cancer surgeon Dr. Alton Ochsner of Tulane University.

Dr. Ochsner recalled being aroused from his bed as a third-year medical

student to witness a rare medical event that, according to his professors,

he would probably not see again in his lifetime—an autopsy of a man who

died of lung cancer. As a young cancer surgeon, he saw six lung cancer

patients in a single year and concluded that an epidemic of lung cancer

must be under way. All these patients were male, and all had a history

of heavy cigarette smoking. This observation was among the first to link

lung cancer and the new U.S. epidemic of lung cancer.

In 1950 four separate retrospective epidemiological studies demonstrated

a clear link between cigarette smoking and lung cancer, and in 1951 two
Smoking and Tobacco Control Monograph No. 8

iv

major prospective mortality studies were initiated in an effort to resolve the

remaining scientific questions. Sir Richard Doll and Sir Austin Bradford Hill,

under the auspices of the Medical Research Council, enrolled 40,000 British

physicians in a prospective study. This cohort now has been successfully

followed for 40 years. In the United States, Drs. E. Cuyler Hammond and

Daniel Horn, under the aegis of the American Cancer Society (ACS), enrolled

187,783 white males residing in 9 States at the beginning of 1952. In time,

a total of 11 prospective mortality studies would form the cornerstone of our

knowledge about the disease risks that accompany cigarette smoking. The

most recent data from five of these studies are presented in this volume; they

once again establish the overwhelming nature of proof that smoking is the

largest preventable cause of cancer and other chronic diseases.

Thousands of scientists have contributed to the body of evidence that

proves smoking causes disease, including the authors and scientific editors

of this volume, but I would like to single out one for his singular dedication

and seminal contributions to this field of research.

Assisting Hammond and Horn in their first prospective study was a

young scientist named Lawrence Garfinkel. Larry began working for the

American Cancer Society in 1947, where he was directly responsible for

coordinating much of the field work, including training the thousands

of ACS volunteers in data collection techniques. When ACS decided to

undertake an even larger study in 1959 by enrolling 1 million people in its

Cancer Prevention Study I (CPS-I), Larry’s role changed from that of research

support to co-principal investigator. He became increasingly involved in

both data analysis and publication of results, and in 1961 he coauthored,

with Cuyler Hammond, the article “Smoking Habits of Men and Women,”

which appeared in the August issue of the Journal of the National Cancer

Institute. This article reported some of the first results from CPS-I.

During the 1960’s Larry Garfinkel contributed to more than two dozen

major papers on the relationship between smoking and health. (See

pages xxvii - xxxiii for a complete chronological list of Mr. Garfinkel’s

publications.) Along with colleagues Cuyler Hammond and Oscar Auerbach,

Larry coauthored the reported results of some of the first studies that

combined epidemiology with pathology. These study results appeared in a

series of articles in the New England Journal of Medicine and provided some of

the earliest evidence of smoking’s histological damage to the lung. During

the 1970’s and 1980’s Larry wrote more than 70 papers advancing our

knowledge of the effects of cigarette smoking on life expectancy, coronary

heart disease, and stroke; benefits of quitting smoking; and risks of smoking

cigarettes with different tar and nicotine yields.

When Cuyler Hammond retired from ACS in 1979, Larry became director

of the ACS research program, and under his guidance, ACS initiated CPS-II,

which included participants from all 50 States, the District of Columbia, and

Puerto Rico. CPS-II remains the largest epidemiological study of its kind ever

attempted in the history of medical science. In 1988 Larry Garfinkel and

coauthor Steve Stellman published results on females from CPS-II that
v

Foreword

shocked many in public health. Their analyses demonstrated that the

lung cancer mortality rate among smoking females in CPS-II had increased

nearly fivefold compared with females who smoked in CPS-I. The data for

nonsmoking females showed no increase in lung cancer between the two

studies—thus providing convincing evidence that lung cancer was almost

exclusively a disease found among smokers. Larry Garfinkel is not only a

contributor to this monograph; he is also one of its scientific editors.

In closing, I would like to take this opportunity to personally recognize

Larry Garfinkel for his lifelong contribution to this important field of

scientific inquiry. Few individuals have contributed as much to our

knowledge about the disease consequences of smoking as Larry Garfinkel.

He has played critical roles in this process of discovery, from organizing

the earliest prospective studies to the work that forms the basis of the current

volume and all the steps in between. I know I speak not only for the National

Cancer Institute but also for the entire scientific community in recognizing

Larry’s leadership in combating this Nation’s most important health problem.

Richard D. Klausner, M.D.

Director

National Cancer Institute
Smoking and Tobacco Control Monograph No. 8

vi
vii

Preface

Preface

This, the eighth monograph in the Smoking and Tobacco Control series

published by the National Cancer Institute (NCI), is in many respects also the

most significant. Contained in this volume are new results from five of the

world’s largest prospective epidemiological studies defining the magnitude

of disease risks caused by cigarette smoking.

Thirty years ago, in January 1966, NCI published a similar monograph

titled Epidemiological Approaches to the Study of Cancer and Other Chronic

Diseases. The report of the Surgeon General’s Advisory Committee on

Smoking and Health had been released in 1964 and had relied extensively

on data from prospective mortality studies to delineate the relationship

between cigarette smoking and various chronic diseases. The 1966 NCI

monograph provided a detailed examination of the outcomes of several

of the large prospective mortality studies presented in the 1964 advisory

committee report. At that time, the outcomes available from these studies

were based on 3 to 6 years of followup; with the exception of the American

Cancer Society’s (ACS) Cancer Prevention Study I (CPS-I), studies in the 1966

NCI monograph did not include substantial numbers of females. This

monograph includes three new prospective mortality studies (CPS-II

[Chapter 5], the Nurses’ Health Study [Chapter 8], and the Kaiser Permanente

Prospective Mortality study [Chapter 6]), provides the outcomes of the CPS-I

study after 12 years of followup (Chapter 3), and provides 26 years of

followup of the study of U.S. veterans (Chapter 7). Data from these studies

provide the most comprehensive description of the disease consequences

produced by smoking available to date and are accompanied by a detailed

description of the changes in smoking behaviors of the U.S. population over

the past century. Prospective mortality studies continue to play a critical role

in quantifying the relative mortality risks of smoking for the individual as

well as in estimating the overall disease burden caused by cigarette smoking

in our society. The goal of this monograph is to facilitate both these tasks

by providing, in one volume, comprehensive descriptions of smoking

behaviors and the disease risks that result from those behaviors.

BRIEF HISTORICAL During the early part of this century, knowledge about the

PERSPECTIVE relationship between tobacco use and disease was based largely

on clinical observations and a few small case-control studies of patients

with lung cancer. A turning point in the understanding of smoking’s

relationship to disease occurred in 1950 with the publication of four

retrospective studies of smoking habits among lung cancer patients and

control subjects. Although many epidemiologists were satisfied that the

relationship between smoking and lung cancer was established by these

retrospective studies, others turned for confirmation to prospective studies

that followed large numbers of “healthy” individuals to identify the causes

of their subsequent mortality. Facts about an individual’s lifestyle (including

smoking), family history, medical and occupational data, place of residence,
Smoking and Tobacco Control Monograph No. 8

viii

and other personal information were recorded at the start of such a study

and could be related to the frequency with which individuals with these

characteristics died of specific diseases.

The first major prospective study was started in Great Britain in 1951

by Sir Richard Doll and Sir Austin Bradford Hill, who enrolled 40,000 British

physicians. Doll and colleagues have recently published 40-year followup

data on this unique cohort. The first U.S. prospective study was initiated

in 1952 by two ACS investigators, E. Cuyler Hammond and Daniel Horn.

They enrolled 188,000 white males residing in 9 States. Hammond and Horn

released preliminary results from their study at the 103d annual meeting of

the American Medical Association in June 1954. The results of these early

studies astounded both the medical community and the public.

Significantly elevated death rates among smokers compared to neversmokers were found, not only for lung cancer but also for several other

major causes of death. The elevation in risk was much greater for those who

smoked cigarettes rather than pipes and cigars, and there was a gradient in

risk that increased with the increasing amount smoked.

National Cancer Institute investigator Harold Dorn envisioned an

even larger prospective study than that attempted by ACS. In January 1954

Dorn mailed questionnaires on smoking habits to veterans holding U.S.

Government life insurance policies. Nearly 300,000 veterans replied; most

were veterans of World War I, and almost all policyholders were white males.

This cohort has been successfully traced for nearly three decades. The 26-year

followup data are reported in this volume (Chapter 7).

Also in 1954 Weir and colleagues started to trace 68,000 California males

in various occupations. During 1955 in Canada, Best and colleagues initiated

a prospective study involving 92,000 Canadian pensioners. The Canadian

Pensioners Study was the first to include significant numbers of females—

nearly 14,000. Taken as a group, the prospective studies involved more than

600,000 individuals, but except for the Canadian study, they included few

females. In the British Doctors study, only 6,000 enrollees were female, and

in the Dorn study of U.S. veterans, less than 1 percent were female.

During 1959 ACS began its Cancer Prevention Study I and purposefully

included large numbers of females in the study design. Between October

1959 and April 1960, ACS volunteers enrolled more than 1 million males and

females from 25 States (562,671 females and 440,558 males). Participants

completed confidential questionnaires about their family medical history,

physical complaints, occupations, personal health behaviors, and other

factors.

Substantial differences in the disease risks produced by smoking for males

compared with those for females were evident in these early epidemiological

investigations. For example, based on a 6-year followup from CPS-I, male

smokers experienced a 70-percent greater overall mortality risk and a

1,000-percent higher risk from lung cancer than male never-smokers.
ix

Preface

However, among females, overall mortality risks were much lower—only 20

to 30 percent higher than that of a never-smoker, and lung cancer mortality

among females who smoked was only 200 percent greater than that of neversmoking females. Findings from other prospective and retrospective studies

conducted in the United States and abroad during the 1950’s and early 1960’s

confirmed these results.

These differences between males and females found in early

epidemiological studies are largely explained by differences in smoking

behaviors (Chapter 2). The epidemiological studies were started during the

1950’s and 1960’s, and the females most at risk for contracting smokingrelated chronic diseases in these studies were older and had been born around

or prior to the turn of the century. Among the oldest birth cohorts (those

born before 1915 and most at risk during the 1950’s), there were significant

differences between males and females in their total lifetime smoking

behaviors. Fifty percent or more of the males born between 1885 and 1915

became regular cigarette smokers at some time during their lives, with some

cohorts attaining an ever-smoking rate of 80 percent. No female cohorts

attained a smoking rate greater than 45 percent (see Chapter 2), and the

very oldest cohorts of these females never exceeded a 20-percent eversmoking prevalence. There were also important differences in the age at

which these cohorts first began to regularly smoke cigarettes. Among males,

the majority of ever-smokers had initiated regular smoking before age 21.

However, among females born during these early years, smoking initiation

frequently occurred as late as their thirties and forties.

This difference between males and females in the age at which

they first began to smoke regularly resulted in substantial differences in

duration of smoking between males and females in these early prospective

studies. Because the magnitude of the risk produced by smoking is closely

related to the duration of smoking, the difference in duration of smoking

between males and females in the early epidemiological studies translated

into differences in the size of the mortality ratios for smokers and neversmokers. Male smokers had longer average durations of smoking at any

given age than female smokers, so they also had higher overall mortality

ratios. Male smokers also smoked a greater number of cigarettes per day and

were more likely to inhale compared with female smokers. These differences

in smoking behaviors, rather than a difference in biological susceptibility,

explained the apparent difference in the risks of smoking for males and

females found in early epidemiological studies.

RESULTS FROM This volume presents results from three large, more contemporary

CONTEMPORARY prospective mortality studies and provides longer followup for

STUDIES two of the older studies dating from the 1950’s. All these studies

contain large numbers of subjects, and with the exception of the U.S. veterans

study, all contain large numbers of females. When observations from the

more contemporary studies are compared with those from the 1950’s, one

important but disturbing conclusion is apparent—mortality risks among

continuing smokers, both males and females, have increased. In fact, relative
Smoking and Tobacco Control Monograph No. 8

x

risks for smokers compared to never-smokers have increased for all major

smoking-related diseases—coronary heart disease (CHD), lung cancer, other

smoking-related cancers, stroke, and chronic obstructive pulmonary disease

(COPD). This increase over time in the relative risks for smokers compared

to never-smokers has occurred despite a dramatic decline in cardiovascular

disease (CVD) death rates in the U.S. population, suggesting that the decline

in CVD death rates has been proportionately greater among never-smokers

than among continuing smokers.

Perhaps the best example of this can be seen when 6-year followup

data from the two ACS studies are compared side by side (Chapter 4).

Both CPS-I (initiated in 1959) and CPS-II (initiated in 1982) followed more

than 1 million people each. Both used nearly identical study designs and

methodologies, and they essentially represent two different groups of

smokers born approximately a generation apart. After 6 years of followup,

there had been 76,888 deaths among CPS-I participants and 79,802 deaths

among CPS-II participants.

The increase in relative risk between the two studies is striking.

Relative risks increased for overall mortality and for all the major smokingrelated chronic diseases from CPS-I to CPS-II (see Table 1). Lung cancer risk

among males who smoked doubled when the two studies were compared,

increasing from 11.9 to 23.2. Among females, the lung cancer risk more

than quadrupled, increasing from less than 3.0 in CPS-I to 12.8 in CPS-II.

Risks for COPD also increased dramatically from 9.3 to 11.7 among males

and from 6.7 to 12.8 among females.

The increase in relative risks between CPS-I and CPS-II translates into

considerable increases in the percentage of deaths attributable to smoking

among current cigarette smokers. Among active smokers, 57 percent of all

male deaths and nearly half of all female deaths are attributed to smoking.

More than 90 percent of the lung cancer that occurs among smokers is

attributable to smoking for both males and females in CPS-II, and 71 percent

(male) and 61 percent (female) of other smoking-related cancers are

attributed to smoking (see Chapters 4 and 5).

The data for all-cause mortality among females from the Kaiser

Permanente study (Chapter 6) and the Nurses’ Health Study (Chapter 8)

confirm the results found in CPS-II. The Kaiser Permanente study has

followed more than 60,000 participants, including 36,035 females, since

1979, whereas the Nurses’ Health Study enrolled 121,700 female nurses

in 1976.

In both studies, all-cause mortality among females who smoked was

1.9-fold higher than among females who did not smoke. In the Kaiser

Permanente study, cause-specific relative risks for female smokers were lung

cancer, 15.1; CHD, 1.7; and COPD, 9.0. These findings are nearly identical

to those reported for females in CPS-II.
xi

Preface

Table 1

Changes in cigarette-related mortality risks between Cancer Prevention Study I (1959-1965)

and Cancer Prevention Study II (1982-1988) and percentage of deaths attributable to active

cigarette smoking

CPS-I CPS-II

Males

Relative Relative

Risk Percent Risk Percent

Overall Mortality 1.7 42.2 2.3 57.1

Lung Cancer 11.9 91.6 23.2 95.7

Coronary Heart Disease 1.7 41.5 1.9 46.2

Chronic Obstructive Pulmonary

Disease 9.3 89.2 11.7 91.4

Stroke 1.3 21.9 1.9 46.8

Other Smoking-Related Cancersa 2.7 63.4 3.5 71.2

Females

Overall Mortality 1.2 18.7 1.9 47.9

Lung Cancer 2.7 63.4 12.8 92.2

Coronary Heart Disease 1.4 27.0 1.8 45.1

Chronic Obstructive Pulmonary

Disease 6.7 85.0 12.8 92.2

Stroke 1.2 15.2 1.8 45.7

Other Smoking-Related Cancersa 1.8 45.0 2.6 60.8

aSites include larynx, oral cavity, esophagus, bladder, kidney, other urinary, and pancreas.

Based on the previously described differences between males and

females in their durations of smoking, the increase in female relative risks

was expected as females with longer durations of smoking reached the ages

where they were at high risk for disease. However, the increase in relative

risk between CPS-I and CPS-II for males was less expected. The increase

among males is partly explained by the greater number of cigarettes smoked

per day by males in CPS-II compared with CPS-I, and much of the difference

between the two sets of relative risks disappears when duration and number

of cigarettes smoked per day are held constant.

A difference still persists among smokers of long duration; part of this

difference may be explained by the large proportion of males in CPS-I who

did not start out smoking cigarettes but changed from other forms of tobacco

to mass-produced cigarettes just before and during World War I. The modern
Smoking and Tobacco Control Monograph No. 8

xii

blended cigarette did not become popular until 1913 when Camel cigarettes

were first introduced. Before their introduction, few people smoked massproduced, machine-made cigarettes. For example, in 1910, of the 8.59 pounds

of tobacco consumed per person in the United States, only 0.41 pound was

consumed in the form of machine-made cigarettes (see Figure 1, Chapter 2).

In contrast, nearly 4.5 pounds of tobacco were consumed in the form of cigars

or as smoking tobacco used in pipes and roll-your-own cigarettes.

EFFECT OF This monograph documents in detail the increased disease risks among

QUITTING more contemporary cohorts of cigarette smokers and also sheds

SMOKING ON considerable light on the positive benefits of quitting. The 26-year

MORTALITY followup information from the U.S. veterans study (Chapter 7), as well

as data from the other major prospective studies, clearly documents that

quitting smoking results in substantial benefits for one’s health, regardless

of how long or how much one has smoked.

For all-cause mortality, the difference in risk between continuing smokers

and those who quit increases with increasing duration of time since cessation.

This difference is present when the data on risks are examined as relative risks

or as differences in death rates. However, in the veterans study, male smokers

had to have quit for 5 years or more before an appreciable reduction in overall

mortality was evident. Similar findings are observed among females as well as

males in the other epidemiological studies.

The residual risk produced by past smoking in former smokers is less

among those who had smoked fewer cigarettes per day compared with those

who had smoked two or more packs per day. However, because the death

rates among smokers of two or more packs per day are so much higher than

the rates for those who smoke one-half pack per day, the difference in death

rates between continuing smokers and those who quit is greatest for those

who have the greatest risk (heavy smokers). Expressed somewhat differently,

the more one smokes, the greater one’s risk of disease and, correspondingly,

the more risk one can avoid by quitting.

The benefits of cessation are composed of avoidance of the additional

risk that accumulates with a longer duration of smoking and the reversal of

risk with increased years off cigarettes. Heavy smokers appear to retain some

degree of elevated risk for lung cancer when compared to never-smokers, even

after 20 years of cessation. In contrast, the risks for CHD for heavy smokers

may eventually return to those of never-smokers after 20 years of cessation.

Among veterans who reported smoking two or more packs of cigarettes daily

and who had quit smoking for more than 30 years, overall mortality was still

slightly elevated compared to never-smokers; a similar result was evident for

smokers of more than two packs per day in the CPS-I study. For both studies,

no excess overall mortality was demonstrated for light smokers who had quit

for 20 years or more.
xiii

Preface

PUBLIC HEALTH This volume presents the most detailed and comprehensive

IMPLICATIONS epidemiological description of the disease consequences of

smoking ever assembled in one publication. It once again strongly reinforces

what the public health community has been saying for more than 40 years:

The best, and possibly the only, way to avoid the death and disability caused

by cigarette smoking is to never begin, and the return on public health

interventions that prevent smoking initiation, although a long time in

arriving, is enormous.

For those who do start smoking, the less they smoke and the sooner they

quit, the more risk they can avoid. Heavy smokers and smokers of longer

duration are at greatest risk, but correspondingly, they also have the most

to gain from cessation.

Preventing adolescent onset of regular smoking may have the greatest

benefit for the individual and society in the long run, but it often takes

decades before prevention has any measureable effect on national death

rates. That option is not available to the nearly 50 million adult Americans

who currently smoke cigarettes: The benefits of cessation will take 30 or

more years before they affect U.S. death rates. The benefits of cessation are

available to individuals who currently smoke, are greatest for those at greatest

risk, and can affect death rates in as little as 5 years.

The clearest message that is drawn from the enormous quantity of

data presented in this monograph is that smoking prevention and cessation

efforts are complementary, not alternative, solutions to the current epidemic

of diseases caused by smoking. We must accomplish both prevention and

cessation if we are to successfully reduce the tragic burden of death and

disability currently produced by cigarette smoking.

Peter G. Greenwald, M.D., Dr.P.H.

Director

Division of Cancer Prevention

and Control

National Cancer Institute
Smoking and Tobacco Control Monograph No. 8

xiv
xv

Acknowledgments

Acknowledgments

Changes in Cigarette-Related Disease Risks and Their Implication for Prevention

and Control was developed under the general editorship of the Smoking and

Tobacco Control Program (STCP), National Cancer Institute (NCI), Donald R.

Shopland, Coordinator.

The scientific editors for this monograph were David M. Burns, M.D.,

Professor of Medicine and Medical Director of Respiratory Therapy, University

of California, San Diego Medical Center, San Diego, California; Lawrence

Garfinkel, M.A., Special Consultant, Epidemiology, American Cancer Society,

New York, New York; and Jonathan M. Samet, M.D., Chairman, Department

of Epidemiology, School of Hygiene and Public Health, Johns Hopkins

University, Baltimore, Maryland.

The editors and STCP staff members gratefully acknowledge the

many researchers and authors who made this monograph possible.

Attributions for each chapter are as follows:

Chapter 1. Introduction, Summary, David M. Burns, M.D.

and Conclusions Professor of Medicine

Medical Director of

Respiratory Therapy

University of California,

San Diego Medical Center

San Diego, CA

Lawrence Garfinkel, M.A.

Special Consultant,

Epidemiology

American Cancer Society

New York, NY

Jonathan M. Samet, M.D.,

M.S.

Professor and Chair

Department of Epidemiology

The Johns Hopkins

University School of

Hygiene and Public Health

Baltimore, MD

Chapter 2. Cigarette Smoking Behavior David M. Burns, M.D.

in the United States Professor of Medicine

Medical Director of

Respiratory Therapy

University of California,

San Diego Medical Center

San Diego, CA
Smoking and Tobacco Control Monograph No. 8

xvi

Lora Lee

Statistician

University of San Diego

San Diego, CA

Larry Z. Shen, Ph.D.

Statistician

Biometrics and Statistical

Sciences

Proctor & Gamble

Cincinnati, OH

Elizabeth Gilpin

Statistician

Cancer Center

University of California,

San Diego

La Jolla, CA

H. Dennis Tolley, Ph.D.

Consulting Statistician

Department of Statistics

Brigham Young University

Provo, UT

Jerry Vaughn

Programmer

Tobacco Control Policies

Project

University of California,

San Diego Medical Center

San Diego, CA

Thomas G. Shanks

Statistician

Baha’i World Centre

Haifa

ISRAEL

Chapter 3. The American Cancer Society David M. Burns, M.D.

Cancer Prevention Study I: Professor of Medicine

12-Year Followup of 1 Million Medical Director of

Men and Women Respiratory Therapy

University of California,

San Diego Medical Center

San Diego, CA
xvii

Acknowledgments

Thomas G. Shanks

Statistician

Baha’i World Centre

Haifa

ISRAEL

Won Choi, M.P.H.

Staff Research Associate

University of California,

San Diego

La Jolla, CA

Michael J. Thun, M.D., M.S.

Co-Director, Analytic

Epidemiology

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Clark W. Heath, Jr., M.D.

Vice President

Epidemiology and

Surveillance Research

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Lawrence Garfinkel, M.A.

Special Consultant,

Epidemiology

American Cancer Society

New York, NY

Chapter 4. Trends in Tobacco Smoking Michael J. Thun, M.D., M.S.

and Mortality From Cigarette Co-Director, Analytic

Use in Cancer Prevention Epidemiology

Studies I (1959 through 1965) Department of Epidemiology

and II (1982 through 1988) and Surveillance

American Cancer Society

Atlanta, GA

Cathy Day-Lally, M.S.P.H.

Research Analyst II

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA
Smoking and Tobacco Control Monograph No. 8

xviii

Dena G. Myers

Research Analyst I

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Eugenia E. Calle, Ph.D.

Co-Director, Analytic

Epidemiology

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

W. Dana Flanders, M.D., D.Sc.

Professor

Epidemiology Division

Emory University

School of Public Health

Atlanta, GA

Bao-Ping Zhu, Ph.D., M.B.B.S.,

M.S.

Research Scientist

Center for Public Health

Research and Evaluation

Battelle Memorial Institute

Atlanta, GA

Mohan M. Namboodiri,

M.P.H.

Statistical Programmer Analyst

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Clark W. Heath, Jr., M.D.

Vice President

Epidemiology and

Surveillance Research

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA
xix

Acknowledgments

Chapter 5. Age and the Exposure- Michael J. Thun, M.D., M.S.

Response Relationships Co-Director, Analytic

Between Cigarette Smoking Epidemiology

and Premature Death in Department of Epidemiology

Cancer Prevention Study II and Surveillance

American Cancer Society

Atlanta, GA

Dena G. Myers

Research Analyst I

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Cathy Day-Lally, M.S.P.H.

Research Analyst II

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Mohan M. Namboodiri,

M.P.H.

Statistical Programmer Analyst

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Eugenia E. Calle, Ph.D.

Co-Director, Analytic

Epidemiology

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

W. Dana Flanders, M.D., D.Sc.

Professor

Epidemiology Division

Emory University

School of Public Health

Atlanta, GA

Stacy L. Adams

Research Assistant

Emory University

Atlanta, GA
Smoking and Tobacco Control Monograph No. 8

xx

Clark W. Heath, Jr., M.D.

Vice President

Epidemiology and Surveillance

Research

Department of Epidemiology

and Surveillance

American Cancer Society

Atlanta, GA

Chapter 6. Smoking and Mortality: Gary D. Friedman, M.D., M.S.

The Kaiser Permanente Director

Experience Division of Research

Kaiser Permanente Medical

Care Program

Oakland, CA

Irene Tekawa, M.A.

Biostatistician

Division of Research

Kaiser Permanente Medical

Care Program

Oakland, CA

Marianne Sadler, M.P.H.

Programmer/Analyst

Division of Research

Kaiser Permanente Medical

Care Program

Oakland, CA

Stephen Sidney, M.D., M.P.H.

Senior Epidemiologist

Division of Research

Kaiser Permanente Medical

Care Program

Oakland, CA

Chapter 7. Former Cigarette Smoking Zdenek Hrubec, Sc.D.

and Mortality Among U.S. Expert Consultant

Veterans: A 26-Year Followup, National Cancer Institute

1954 to 1980 Parkville, MD

Joseph K. McLaughlin, Ph.D.

President

International Epidemiology

Institute, Ltd.

Rockville, MD
xxi

Acknowledgments

Chapter 8. Smoking Cessation and Ichiro Kawachi, M.B., Ch.B.

Decreased Risks of Total Assistant Professor of Medicine

Mortality, Stroke, and Channing Laboratory

Coronary Heart Disease Department of Medicine

Incidence Among Women: Harvard Medical School

A Prospective Cohort Study Brigham and Women’s

Hospital

Department of Health and

Social Behavior

Harvard School of Public

Health

Boston, MA

Graham A. Colditz, Dr.P.H.,

M.B.B.S.

Associate Professor of Medicine

Channing Laboratory

Department of Medicine

Harvard Medical School

Brigham and Women’s Hospital

Department of Epidemiology

Harvard School of Public

Health

Boston, MA

Meir J. Stampfer, M.D.

Professor of Epidemiology

and Nutrition

Departments of Epidemiology

and Nutrition

Harvard School of Public Health

Channing Laboratory

Department of Medicine

Harvard Medical School

Brigham and Women’s Hospital

Boston, MA

Walter C. Willett, M.D.

Professor of Medicine

Channing Laboratory

Department of Medicine

Harvard Medical School

Brigham and Women’s Hospital

Frederick Stare Professor of

Epidemiology and Nutrition

Departments of Epidemiology

and Nutrition

Harvard School of Public

Health

Boston, MA
Smoking and Tobacco Control Monograph No. 8

xxii

JoAnn E. Manson, M.D.

Associate Professor of Medicine

Channing Laboratory

Division of Preventive

Medicine

Departments of Medicine

and Ambulatory Care

and Prevention

Harvard Medical School

Brigham and Women’s

Hospital

Boston, MA

Bernard Rosner, Ph.D.

Professor of Medicine and

Biostatistics

Channing Laboratory

Department of Preventive

Medicine

Harvard Medical School

Department of Biostatistics

Harvard School of Public

Health

Boston, MA

David J. Hunter, M.B.B.S., Sc.D.

Associate Professor of

Epidemiology

Department of Epidemiology

Harvard School of Public

Health

Channing Laboratory

Department of Medicine

Harvard Medical School

Brigham and Women’s

Hospital

Boston, MA
xxiii

Acknowledgments

Charles H. Hennekens, M.D.,

Dr.P.H.

Professor of Ambulatory Care

and Prevention

John Snow Professor of

Medicine

Channing Laboratory

Division of Preventive

Medicine

Departments of Medicine

and Ambulatory Care

and Prevention

Department of Preventive

Medicine

Harvard Medical School

Brigham and Women’s

Hospital

Professor of Epidemiology

Department of Epidemiology

Harvard School of Public

Health

Boston, MA

Frank E. Speizer, M.D.

Edward H. Kass Professor of

Medicine

Channing Laboratory

Department of Medicine

Harvard Medical School

Brigham and Women’s

Hospital

Professor of Environmental

Science

Department of

Environmental Health

Harvard School of Public

Health

Boston, MA
Smoking and Tobacco Control Monograph No. 8

xxiv

We gratefully acknowledge the following distinguished scientists,

researchers, and others, both in and outside Government, who

contributed critical reviews or assisted in other ways:

Glen Bennett, M.P.H.

Coordinator

Advanced Technologies Applications and Health Education

Office of Prevention, Education, and Control

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD

Susan S. Devesa, Ph.D.

Chief

Descriptive Studies Section

Division of Cancer Etiology

National Cancer Institute

National Institutes of Health

Bethesda, MD

Richard Doll, F.R.S., F.R.C.P.

Emeritus Professor of Medicine

Radcliffe Infirmary

University of Oxford

Oxford

UNITED KINGDOM

Terry Dwyer, M.B.B.S., M.D., M.P.H.

Professor and Director

Health Research

Menzies Centre for Population

University of Tasmania

Hobart

AUSTRALIA

Luis G. Escobedo, M.D., M.P.H.

Medical Epidemiologist

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

Dorothy L. Faulkner, Ph.D., M.P.H.

Epidemiologist

Epidemic Intelligence Service

Centers for Disease Control and Prevention

Atlanta, GA
xxv

Acknowledgments

Gary A. Giovino, Ph.D., M.S.

Chief

Epidemiology Branch

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

Jay Lubin, Ph.D.

Mathematical Statistician

Biostatistics Branch

Division of Cancer Etiology

National Cancer Institute

National Institutes of Health

Bethesda, MD

Ann M. Malarcher, Ph.D.

Epidemiologist

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

Robert K. Merritt, M.A.

Behavioral Scientist

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

Donald J. Sharp, M.D.

Preventive Medicine Resident

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

Jesse Steinfeld, M.D.

U.S. Surgeon General (retired)

San Diego, CA

Scott L. Tomar, D.M.D., Dr.P.H.

Epidemiologist

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

Ernst L. Wynder, M.D.

President

American Health Foundation

New York, NY
Smoking and Tobacco Control Monograph No. 8

xxvi

Bao-Ping Zhu, Ph.D., M.B.B.S., M.S.

Research Scientist

Center for Public Health Research and Evaluation

Battelle Memorial Institute

Atlanta, GA

Finally, the editors and STCP staff members would also like to acknowledge

the contributions of the following staff members of MasiMax Resources, Inc.,

Rockville, Maryland, and R.O.W. Sciences, Inc., Rockville, Maryland, who

provided technical and editorial assistance in the preparation of this monograph.

In particular, we would like to acknowledge the contribution of Richard H.

Amacher, M.S., who served as Project Manager from September 1989 through

August 1995 for the contract under which this publication was produced. We

would also like to thank Marilyn M. Massey, M.P.H., MasiMax Resources, and

Jacqueline M. Tressler, R.O.W. Sciences, who currently serve as Project

Manager and Subcontract Manager, respectively, for the contract under which

this publication was produced, for their valuable contribution during the final

phases of monograph development. Special recognition is also due to James R.

Libbey, M.P.I.A., who served as Managing Editor for this publication.

Douglas Bishop, M.B.A., Art Director

Rebecca A. Charton, M.S., Senior Librarian

Ruth E. Clark, Word Processing Supervisor

Daria T. Donaldson, Quality Control Proofreader

Catherine Godfrey, Word Processing Supervisor

Frances B. Nebesky, M.A., Senior Copyeditor

Esther M. Roberts, Word Processing Specialist

Donna Selig, Copyeditor/Proofreader

Barbara Shine, Proofreader

Keith W. Stanger, Graphics Services Coordinator

Donna Cay Tharpe, Quality Control Proofreader

Sonia Van Putten, Word Processing Specialist
xxvii

Acknowledgments

Publications List

Lawrence Garfinkel

1. Auerbach, O., Gere, J.B., Pawlowski, J.M.,

Garfinkel, L. The rate of healing of

pulmonary tuberculosis as affected by

chemotherapy. Am Rev Tuberc 76: 988-1001,

1957.

2. Garfinkel, L., Ringel, A. The Arizona cancer

registry. Ariz Med 15: 380-383, 1958.

3. Garfinkel, L., Craig, L., Seidman, H. An

appraisal of left and right breast cancer.

J Natl Cancer Inst 23: 617-631, 1959.

4. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Microscopic examination of

bronchial epithelium in children. Am Rev

Resp Dis 82: 640-648, 1960.

5. Auerbach, 0., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Changes in the bronchial

epithelium in relation to cigarette smoking

and in relation to lung cancer. N Engl J Med

265: 253-267, 1961.

6. Hammond, E.C., Garfinkel, L. Smoking

habits of men and women. J Natl Cancer Inst

27: 419-442, 1961.

7. Auerbach, 0., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Bronchial epithelium in

former smokers. N Engl J Med 267: 119-125,

1962.

8. Auerbach, 0., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Changes in bronchial

epithelium in relation to sex, age, residence,

smoking, pneumonia. N Engl J Med 267:

111-118, 1962.

9. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Changes in the tracheobronchial tree in connection with cigarette

smoking. In: Tobacco and Health, G. James

and T. Rosenthal (Editors). Springfield, IL:

Charles C. Thomas, 1962, pp. 136-143.

10. Seidman, H., Garfinkel, L., Craig, L. Death

rates in New York City by socioeconomic

class and religious group, and by country

of birth, 1949-1951. Jewish J Soc 4: 254-272,

1962.

11. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Smoking habits and age in

relation to pulmonary changes. Rupture

of alveolar septums, fibrosis and thickening

of walls of small arteries and arterioles.

N Engl J Med 269: 1045-1054, 1963.

12. Garfinkel, L. Several studies show higher

death rates for smokers than for nonsmokers. Public Health News N J Dept Health

44: 211-214, 1963.

13. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Changes in bronchial

epithelium in relation to smoking habits.

Acta-Unio Internationalis Contra Cancrum

XX(3): 732-737, 1964.

14. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Interrelationships among

various histologic changes in bronchial

tubes and in lung parenchyma. Am Rev

Resp Dis 90: 867-876, 1964.

15. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Rauchen and Lungkrebs.

Fortschr Med 82 JG., Nr. 11: 405-408, 1964.

16. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. The role of smoking in the

development of lung cancer. Proc 5th Nat

Cancer Conf 497-501, 1964.

17. Hammond, E.C., Garfinkel, L. Changes

in cigarette smoking. J Natl Cancer Inst

33: 49-64, 1964.

18. Auerbach, O., Hammond, E.C., Garfinkel,

L. Smoking in relation to atherosclerosis

of the coronary arteries. N Engl J Med 273:

775-779, 1965.

19. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Histologic changes in the

esophagus in relation to smoking habits.

Arch Environ Health 2: 4-15, 1965.

20. Gellin, G.A., Kopf, A.W., Garfinkel, L. Basal

cell epithelioma. Arch Dermatol 91: 38-45,

1965.
Smoking and Tobacco Control Monograph No. 8

xxviii

21. Lightstone, A.C., Kopf, A.W., Garfinkel, L.

Diagnostic accuracy–-a new approach to

its evaluation. Arch Derm 91: 497-502,

1965.

22. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Histologic evidence of

emphysema and other pulmonary

changes in relation to smoking. Post Med

40: 95-100, 1966.

23. Hammond, E.C., Garfinkel, L. The

influence of health on smoking habits.

Epidemiological Approaches to the Study of

Cancer and Other Chronic Diseases, W.

Haenszel (Editor). National Cancer

Institute Monograph No. 19. Bethesda,

MD: U.S. Department of Health and

Human Services, Public Health Service,

National Institutes of Health, 1966,

pp. 269-285.

24. Auerbach, O., Hammond, E.C., Kirman,

D., Stout, A.P., Garfinkel, L. Histologic

changes in bronchial tubes of cigarette

smoking dogs. CA Cancer J Clin 20: 2055-

2066, 1967.

25. Auerbach, O., Kirman, D., Hammond,

E.C., Garfinkel, L. Production of

emphysema in dogs by cigarette

smoking. JAMA 199: 241-246, 1967.

26. Auerbach, O., Stout, A.P., Hammond, E.C.,

Garfinkel, L. Multiple primary bronchial

carcinoma. Cancer 20: 699-705, 1967.

27. Garfinkel, L. Changes in cigarette smoking

habits among physicians, 1959-1965. CA

Cancer J Clin 17(4): 193-195, 1967.

28. Lieb, N.D., Silverman, S.I., Garfinkel, L.

An analysis of soft tissue contours of the

lip in relation to the maxillary cuspids.

J Prosthet Dent 18: 292-303, 1967.

29. Auerbach, O., Hammond, E.C., Garfinkel,

L. Thickening of walls of arterioles and

small arteries in relation to age and

smoking habits. N Engl J Med 278: 980-

984, 1968.

30. Garfinkel, L. The association between

cigarette smoking and coronary heart

disease and other cardiovascular diseases.

Bull N Y Acad Med 44: 1495-1501, 1968.

31. Hammond, E.C., Garfinkel L. Changes in

cigarette smoking, 1959-1965. Am J Public

Health 58: 30-45, 1968.

32. Hammond, E.C., Garfinkel, L. Coronary

heart disease, stroke, and aortic aneurysm.

Arch Environ Health 19: 167-182, 1969.

33. Auerbach, O., Hammond, E.C., Garfinkel,

L. Histologic changes in the larynx in

relation to smoking habits. Cancer 25: 82-

104, 1970.

34. Hammond, E.C., Auerbach, O., Kirman,

D., Garfinkel, L. Effects of cigarette

smoking on dogs. I. Design of experiment,

mortality and findings in lung

parenchyma. II. Pulmonary neoplasms.

Arch Environ Health 21: 740-768, 1970.

35. Stolman, L.P., Kopf, A.W., Garfinkel, L.

Are palmar keratoses a sign of internal

malignancy? Arch Dermatol 101: 52-55,

1970.

36. Hammond, E.C., Auerbach, O., Kirman,

D., Garfinkel, L. Effects of cigarette

smoking on dogs. CA Cancer J Clin 21: 78-

94, 1971.

37. Hammond, E.C., Auerbach, O., Kirman,

D., Garfinkel, L. Thickness of walls of

myocardial arterioles in relation to

smoking and age. Findings in men and

dogs. Arch Environ Health 22: 20-27, 1971.

38. Hammond, E.C., Garfinkel, L., Seidman,

H. Longevity of parents and grandparents

in relation to coronary heart disease and

associated variables. Circulation 43: 31-44,

1971.

39. Litvak, H., Silverman, S.I., Garfinkel, L.

Oral stereognosis in dentulous and

edentulous subjects. J Prosthet Dent 25(3):

139-151, 1971.

40. Auerbach, O., Hammond, E.C., Garfinkel,

L., Benante, C. Relation of smoking and

age to emphysema. Whole-lung section

study. N Engl J Med 286: 853-857, 1972.

41. Kantor, M.E., Silverman, S.I., Garfinkel, L.

Centric relation recording techniques–-a

comparative investigation. J Prosthet Dent

28: 593-600, 1972.
xxix

Acknowledgments

42. Calagna, L.J., Silverman, S.I., Garfinkel, L.

Influence of neuro-muscular conditioning

on centric relation registrations. J Prosthet

Dent 30: 598-604, 1973.

43. Hoffman, J., Silverman, S.I., Garfinkel, L.

Comparison of condylar position in centric

relation and in centric occlusion in

dentulous subjects. J Prosthet Dent 30: 582-

588, 1973.

44. Mashberg, A., Morrissey, B., Garfinkel, L.

A study of the appearance of early

asymptomatic oral squamous cell

carcinoma. Cancer 32: 1436-1445, 1973.

45. Auerbach, O., Hammond, E.C., Garfinkel, L.

Relation of smoking and age to findings in

lung parenchyma: A microscopic study.

Chest 65: 29-35, 1974.

46. Garfinkel, L., Hammond, E.C. Breast cancer

and hypertension. The Lancet 2: 1381, 1974.

47. Percy, C., Garfinkel, L., Krueger, D.E.,

Dolman, A.B. Apparent changes in cancer

mortality, 1968. A study of the effects of

the introduction of the Eighth Revision,

International Classification of Diseases.

Public Health Rep 89: 418-428, 1974.

48. Auerbach, O., Garfinkel, L., Parks, V.R.

Histologic type of lung cancer in relation to

smoking habits, year of diagnosis and sites

of metastasis. Chest 67: 382-387, 1975.

49. Garfinkel, L. Research methodology: What

the clinician should know. CA Cancer J Clin

25: 58-61, 1975.

50. Hammond, E.C., Garfinkel, L. Aspirin and

coronary heart disease: Findings in a

prospective study. Br Med J 1: 269-271,

1975.

51. Auerbach, O., Carter, H.W., Garfinkel, L.,

Hammond, E.C. Cigarette smoking and

coronary artery disease. A macroscopic and

microscopic study. Chest 70: 697-705, 1976.

52. Ehrenreich, T., Porush, T.G., Churg, J.,

Garfinkel, L., Glabman, S., Goldstein, M.H.,

Grishman, E., Yunis, S.L. Treatment of

idiopathic membranous nephropathy. N

Engl J Med 295: 741-746, 1976.

53. Garfinkel, L. Cigarette smoking among

physicians and other health professionals,

1959-1972. CA Cancer J Clin 26: 373-375,

1976.

54. Garfinkel, L. Methodology for determining

beneficial effect of less harmful cigarettes

on lung cancer risk. Proceedings of

3rd World Conference on Smoking and

Health. Vol. 1, Modifying the Risk for the

Smoker. DHEW Publication No. 76-1221.

Rockville, MD: U.S. Department of Health,

Education and Welfare, 1976, pp. 119-124.

55. Hammond, E.C., Garfinkel, L., Seidman,

H., Lew, E.A. “Tar” and nicotine content

of cigarette smoke in relation to death

rates. Environ Res 12: 263-274, 1976.

56. Light, J., Silverman, S.I., Garfinkel, L. The

use of an intraoral training aid in the

speech rehabilitation of laryngectomy

patients. J Prosthet Dent 35(4): 430-440,

1976.

57. Silverman, S., Silverman, S.I., Silverman,

B., Garfinkel, L. Self-image and its relation

to denture acceptance. J Prosthet Dent 35:

131-141, 1976.

58. Auerbach, O., Hammond, E.C., Selikoff,

I.J., Parks, V.R., Kaslow, H.D., Garfinkel, L.

Asbestos bodies in lung parenchyma in

relation to ingestion and inhalation of

mineral fibers. Environ Res 14: 286-304,

1977.

59. Auerbach, O., Saccomanno, G., Kuschner,

M., Brown, R.D., Garfinkel, L. Histologic

findings in the tracheobronchial tree of

uranium miners and non-miners with

lung cancer. Cancer 42: 483-489, 1978.

60. Garfinkel, L. Benefits of stopping smoking.

Prevention and Detection of Cancer. Part I—

Prevention, Vol. 1. New York: Marcel

Dekker, 1978, pp. 777-779.

61. Hammond, E.C., Garfinkel, L., Lew, E.A.

Longevity, selective mortality and

competitive risks in relation to chemical

carcinogenesis. Environ Res 16: 153-173,

1978.

Publications List
Smoking and Tobacco Control Monograph No. 8

xxx

62. Mashberg, A., Garfinkel, L. Early diagnosis of

oral cancer: The erythroplastic lesion in high

risk areas. CA Cancer J Clin 28: 297-303,

1978.

63. Auerbach, O., Garfinkel, L., Parks, V.R. Scar

cancer of the lung: Increase over a 21-year

period. Cancer 43: 636-642, 1979.

64. Auerbach, O., Hammond, E.C., Garfinkel, L.

Changes in bronchial epithelium in relation

to cigarette smoking, 1955-1960 vs. 1970-

1977. N Engl J Med 300: 381-386, 1979.

65. Garfinkel, L. Cardiovascular mortality and

cigarette smoking. World Smoking and Health

4: 42-45, 1979.

66. Garfinkel, L. Changes in cigarette

consumption of smokers in relation

to changes in tar/nicotine content of

cigarettes smoked. Am J Public Health 69:

1274-1276, 1979.

67. Garfinkel, L. Classification of data in

research. CA Cancer J Clin 29: 2-5, 1979.

68. Hammond, E.C., Garfinkel, L., Selikoff, I.J.,

Nicholson, W.J. Mortality experience of

residents in the neighborhood of an asbestos

factory. Ann N Y Acad Sci 330: 417-422,

1979.

69. Kripke, D.F., Simons, R.N., Garfinkel, L.,

Hammond, E.C. Short and long sleep

and sleeping pills. Is increased mortality

associated? Arch Gen Psychiatry 36: 103-116,

1979.

70. Lew, E.A., Garfinkel, L. Variations in

mortality by weight among 750,000 men

and women. J Chron Dis 32: 536-576, 1979.

71. Rickert, R., Auerbach, O., Garfinkel, L.,

Hammond, E.C., Frasca, J.M. Adenomatous

lesions of the large bowel. Cancer 43: 1847-

1856, 1979.

72. Silling, G., Rauch, M.A., Pentel, L.,

Halberstadt, G., Garfinkel, L. The

significance of cephalometrics in treatment

planning. Angle Ortho 49: 259-262, 1979.

73. Auerbach, O., Conston, A., Garfinkel, L.,

Parks, V.R., Kaslow, H.D., Hammond, E.C.

Presence of asbestos bodies in organs other

than the lung. Chest 77: 133-137, 1980.

74. Auerbach, O., Garfinkel, L. Atherosclerosis

and aneurysm of aorta in relation to

smoking habits and age. Chest 78: 805-809,

1980.

75. Auerbach, O., Hammond, E.C., Garfinkel,

L. Changes in bronchial epithelium: Then

and now. In: Banbury Report 3: A Safe

Cigarette? Cold Spring Harbor, NY: Cold

Spring Harbor Laboratory, 1980, pp. 19-28.

76. Garfinkel, L. Cancer mortality in

nonsmokers: Prospective study by the

American Cancer Society. J Natl Cancer

Inst 65: 1169-1173, 1980.

77. Garfinkel, L. Changes in number of

cigarettes smoked compared to changes in

tar and nicotine content over a 13-year

period. In: Banbury Report 3: A Safe

Cigarette? Cold Spring Harbor, NY: Cold

Spring Harbor Laboratory, 1980, pp. 141-

154.

78. Garfinkel, L. The impact of low tar/

nicotine cigarettes. World Smoking Health

5: 4-8, 1980.

79. Garfinkel, L., Poindexter, C.E., Silverberg,

E. Cancer in black Americans. CA Cancer J

Clin 30(1): 39-44, 1980.

80. Hammond, E.C., Garfinkel, L. General air

pollution and cancer in the United States.

Prev Med 9: 206-211, 1980.

81. Phillips, R.L., Garfinkel, L., Kuzma, J.W.,

Beeson, W.L., Lotz, J., Brin, B. Mortality

among California Seventh-Day Adventists

for selected cancer sites. J Natl Cancer Inst

65: 1109-1114, 1980.

82. Auerbach, O., Garfinkel, L. Myocardial

mural arterial fibrosis and cigarette

smoking: A comparative study, 1955-1960

versus 1970-1977. Bull N Y Acad Med 57:

759-775, 1981.

83. Garfinkel, L. Time trends in lung cancer

mortality among nonsmokers and a note

on passive smoking. J Natl Cancer Inst

66(6): 1061-1066, 1981.

84. Garfinkel, L. A tribute to Harold S. Diehl,

MD (1891-1973); changing patterns of

smoking and disease. CA Cancer J Clin 31:

114-119, 1981.
xxxi

Acknowledgments

85. Lee, P.N., Garfinkel, L. Mortality and type

of cigarette smoked. J Epid Community

Health 35: 16-22, 1981.

86. Mashberg, A., Garfinkel, L., Harris, S.

Alcohol as a primary factor in oral

squamous carcinoma. CA Cancer J Clin

31: 146-155, 1981.

87. Garfinkel, L., Sarokhan, B. Trends in brain

cancer tumor mortality in the United

States. Ann N Y Acad Sci 381: 1-5, 1982.

88. Auerbach, O., Garfinkel, L., Parks, V.R.,

Conston, A.S., Galdi, V.A., Joubert, L.

Histologic type of lung cancer and asbestos

exposure. Cancer 54: 3017-3021, 1984.

89. Garfinkel, L. Cigarette smoking and

coronary heart disease in blacks:

Comparison to whites in a prospective

study. Am Heart J 108: 802-807, 1984.

90. Garfinkel, L. Passive smoking and cancer–-

American experience. Prev Med 13: 691-

697, 1984.

91. Kripke, D.F., Garfinkel, L. Excess nocturnal

deaths related to sleeping pill and

tranquilizer use. The Lancet 1: 99, 1984.

92. Stellman, S.D., Garfinkel, L. Cancer

mortality among woodworkers. Am J Ind

Med 5: 343-357, 1984.

93. Garfinkel, L. Overweight and cancer. Ann

Intern Med 103: 1034-1036, 1985.

94. Garfinkel, L. Selection, follow-up, and

analysis in the American Cancer Society

prospective studies. Natl Cancer Inst Monogr

67: 49-52, 1985.

95. Garfinkel, L., Auerbach, O., Joubert, L.

Involuntary smoking and lung cancer: A

case control study. J Natl Cancer Inst 75:

463-469, 1985.

96. Lew, E.A., Garfinkel, L. Mortality at age 65

and over in a middleclass population.

Trans Soc Act 36: 257-295, 1985.

97. Auerbach, O., Garfinkel, L. Histologic

changes in pancreas in relation to smoking

and coffee-drinking habits. Digest Dis Sci

31: 1014-1020, 1986.

98. Garfinkel, L. Cancer epidemiology. In:

Fundamentals of Surgical Oncology. R.J.

McKenna and G.P. Murphy (Editors).

New York: MacMillan, 1986, pp. 28-39.

99. Garfinkel, L. Overweight and mortality.

Cancer 58: 1826-1829, 1986.

100. Garfinkel, L., Stellman, S.D. Cigarette

smoking among physicians, dentists, and

nurses. CA Cancer J Clin 36: 2-8, 1986.

101. Kuller, L.H., Garfinkel, L., Correa, P.,

Haley, N., Hoffman, D., Preston-Martin, S.,

Sandler, D. Contribution of passive

smoking to respiratory cancer. Environ

Health Perspect 70: 57-69, 1986.

102. Stellman, S.D., Garfinkel, L. Artificial

sweetener use and one-year weight change

among women. Prev Med 15: 195-202,

1986.

103. Stellman, S.D., Garfinkel, L. Smoking

habits and tar levels in a new American

Cancer Society prospective study of 1.2

million men and women. J Natl Cancer

Inst 76: 1057-1063, 1986.

104. Garfinkel, L. Cancer clusters. CA Cancer

J Clin 37: 20-25, 1987.

105. Lew, E.A., Garfinkel, L. Differences in

mortality and longevity by sex, smoking

habits and health status. Trans Soc Act 39:

19-37, 1987.

106. Boffetta, P., Stellman, S.D., Garfinkel, L.

Diesel exhaust exposure and mortality

among males in the American Cancer

Society prospective study. Am J Ind Med

14: 408-415, 1988.

107. Garfinkel, L., Boffetta, P., Stellman, S.D.

Alcohol and breast cancer: A cohort study.

Prev Med 17: 686-693, 1988.

108. Garfinkel, L. Stellman, S.D. Mortality by

relative weight and exercise. Cancer 62:

1844-1850, 1988.

109. Garfinkel, L., Stellman, S.D. Smoking and

lung cancer in women: Findings in a

prospective study. Cancer Res 48: 6951-

6955, 1988.

Publications List
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xxxii

110. Stellman, S.D., Boffetta, P., Garfinkel, L.

Smoking habits of 800,000 American

men and women in relation to their

occupations. Am J Ind Med 13: 43-58, 1988.

111. Auerbach, O., Garfinkel, L. Histologic

change in the urinary bladder in relation

to cigarette smoking and use of artificial

sweeteners. Cancer 64: 983-987, 1989.

112. Boffetta, P., Stellman, S.D., Garfinkel, L. A

case-control study of multiple myeloma

nested in the American Cancer Society

prospective study. Int J Cancer 43: 554-559,

1989.

113. Garfinkel, L., La Verda, N. Dietary patterns

in nurses. Proceedings of the 5th National

Conference on Cancer Nursing. New York:

American Cancer Society, 1989.

114. Stellman, S.D., Garfinkel, L. Lung cancer

risk is proportional to cigarette tar yield:

Evidence from a prospective study. Prev Med

18: 515-525, 1989.

115. Stellman, S.D., Garfinkel, L. Proportion

of cancer deaths attributable to cigarette

smoking in women. Women Health 15:

19-28, 1989.

116. Boffetta, P., Garfinkel, L. Alcohol drinking

and mortality among men enrolled in an

American Cancer Society prospective study.

Epidemiology 1: 242-248, 1990.

117. Garfinkel, L. The environment and

cancer. Putting the risks into perspective.

(Editorial.) CA Cancer J Clin 40: 261-263,

1990.

118. Garfinkel, L., Boffetta, P. Association

between smoking and leukemia in two

American Cancer Society prospective

studies. Cancer 65: 2356-2360, 1990.

119. Garfinkel, L., Boffetta, P. Smoking and

estrogen-related studies. Data from

American Cancer Society studies. In:

Smoking and Hormone-Related Disorders,

N. Wald and J. Baron (Editors). London:

Oxford University Press, 1990.

120. Garfinkel, L., Silverberg, E. Lung cancer and

smoking trends in the United States over

the past 25 years. Ann N Y Acad Sci 609:

146-158, 1990.

121. Lew, E.A., Garfinkel, L. Cancer. In: Medical

Risks—Trends in Mortality by Age and Time

Elapsed: A Reference Volume, E.A. Lew and J.

Gajewski. (Editors.) New York: Praeger,

1990.

122. Lew, E.A., Garfinkel, L. Mortality at ages 75

and older in the Cancer Prevention Study

(CPS I). CA Cancer J Clin 40: 210-224, 1990.

123. Auerbach, O., Garfinkel, L. The changing

pattern of lung carcinoma. Cancer 68:

1973-1977, 1991.

124. Garfinkel, L. Cancer statistics and trends.

(Chapter 1.) In: American Cancer Society

Textbook of Clinical Oncology, A.I. Holleb,

D.J. Fink, and G.P. Murphy. (Editors.)

Atlanta, GA: American Cancer Society,

1991, pp. 1-6.

125. Garfinkel, L. The epidemiology of cancer in

black Americans. Stat 72: 11-17, 1991.

126. Garfinkel, L. Nutrition and cancer: Current

status. (Editorial.) CA Cancer J Clin 41: 325-

327, 1991.

127. Garfinkel, L., Silverberg, E. Lung cancer

and smoking trends in the United States

over the past 25 years. CA Cancer J Clin 41:

137-145, 1991.

128. Menck, H.R., Garfinkel, L., Dodd, G.D.

Preliminary report of the National Cancer

Data Base. CA Cancer J Clin 41: 7-18, 1991.

129. Boffetta, P., Mashberg, A., Winkelman, R.,

Garfinkel, L. Carcinogenic effect of tobacco

smoking and alcohol drinking on anatomic

sites of the oral cavity and oropharynx.

Int J Cancer 52: 530-533, 1992.

130. Istvan, J.A., Cunningham, T.W., Garfinkel,

L. Cigarette smoking and body weight in

the Cancer Prevention Study I. Int J

Epidemiol 21: 849-853, 1992.

131. Lee, P.Y., Silverman, M.K., Rigel, D.S.,

Vossaert, K.A., Kopf, A.W., Bart, R.S.,

Garfinkel, L., Levenstein, M.J. Level of

education and the risk of malignant

melanoma. J Am Acad Dermatol 26: 59-63,

1992.
xxxiii

Acknowledgments

132. Thun, M.J., Calle, E.E., Namboodiri, M.M.,

Flanders, W.P., Coates, R.J., Byers, T.,

Boffetta, P., Garfinkel, L., Heath, C.W. Risk

factors for fatal colon cancer in a large

prospective study. J Natl Cancer Inst 84: 1491-

1500, 1992.

133. Garfinkel, L. Current trends in breast cancer.

(Editorial). CA Cancer J Clin 43: 5-6, 1993.

134. Garfinkel, L. The National Cancer Data Base:

A cancer treatment resource. (Editorial.)

CA Cancer J Clin 43: 69-70, 1993.

135. Mashberg, A., Boffetta, P., Winkelman, R.,

Garfinkel, L. Tobacco smoking, alcohol

drinking and cancer of the oral cavity and

oropharynx among U.S. veterans. Cancer 72:

1369-1375, 1993.

136. Smart, C.R., Hartman, W.H., Beahrs, O.H.,

Garfinkel, L. Insights into breast cancer

screening of younger women. Evidence from

the 14-year followup of the Breast Cancer

Detection Demonstration Project. Cancer

72(Suppl): 1449-1456, 1993.

137. Garfinkel, L. Evaluating cancer statistics.

(Editorial.) CA Cancer J Clin 44: 5-6, 1994.

138. Garfinkel, L., Boring, C.C., Heath, C.W.,

Jr. Changing trends. An overview of breast

cancer incidence and mortality. Cancer 74:

222-227, 1994.

139. Garfinkel, L., Mushinski, M. Cancer

incidence, mortality and survival: Trends

in four leading sites. Stat 75: 19-27, 1994.

140. Garfinkel, L. Cancer statistics and trends.

In: American Cancer Society Textbook of

Clinical Oncology, Second Edition, G.P.

Murphy, W. Lawrence, Jr., and R.E.

Lenhard. (Editors.) Atlanta, GA: American

Cancer Society, 1995, pp. 1-9.

141. Garfinkel, L. Perspectives on cancer

prevention. CA Cancer J Clin 45: 5-7, 1995.

142. Garfinkel, L. Probability of developing or

dying of cancer. United States, 1991. Stat

76: 31-37, 1995.

143. Pion, I.A., Rigel, D.S., Garfinkel, L.,

Silverman, M.K., Kopf, A.W. Occupation

and the risk of melanoma. Cancer

75(Suppl): 637-644, 1995.

Publications List
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xxxiv
xxxv

Contents

Contents

Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Publications List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii

Chapter 1: Introduction, Summary, and Conclusions . . . . . . . . . . . . . . . . . . . . 1

Trends in Smoking Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Trends in Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Disease Consequences of Smoking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Changes in Disease Risk Over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Public Health Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 2: Cigarette Smoking Behavior in the United States . . . . . . . . . . . . . 13

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Timing of Events Linked to Smoking Behavior . . . . . . . . . . . . . . . . . . . . . . 15

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Prevalence of Ever-Smoking, by Birth Cohort . . . . . . . . . . . . . . . . . . . . . . . 22

Prevalence of Current Smoking, by Birth Cohort . . . . . . . . . . . . . . . . . . . . 29

Smoking Cessation Rates, by Birth Cohort . . . . . . . . . . . . . . . . . . . . . . . . . 35

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appendix A: Five-Year, Birth-Cohort-Specific Ever-Smoking

and Current Smoking Prevalence and Cessation

Rates, by Age and Calendar Year . . . . . . . . . . . . . . . . . . . . . . 43

Chapter 3: The American Cancer Society Cancer Prevention

Study I: 12-Year Followup of 1 Million Men and Women . . . . . . 113

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Smoking and Tobacco Control Monograph No. 8

xxxvi

Analysis of CPS-I Data Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Appendix A: Cause-Specific Risk Ratio of Mortality for

White Males and Females for All Causes

of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Appendix B: Excess Mortality and Relative Risk (Rate Ratio) of

Death for Current Smokers, by Duration, Number

of Cigarettes Per Day, and Attained Age . . . . . . . . . . . . . . . . 171

Appendix C: Summary of Person-Years of Observation and

Dealths, by Subject Group . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Appendix D: Tables of Observed and Fitted Death Rates

for Never-Smokers, by Sex and Age Group . . . . . . . . . . . . . . 301

Chapter 4: Trends in Tobacco Smoking and Mortality From

Cigarette Use in Cancer Prevention Studies I

(1959 through 1965) and II (1982 through 1988) . . . . . . . . . . . . . . 305

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Subjects and Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Appendixes 1 Through 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Chapter 5: Age and the Exposure-Response Relationships

Between Cigarette Smoking and Premature

Death in Cancer Prevention Study II . . . . . . . . . . . . . . . . . . . . . . . . . 383

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

Background and Issues Considered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384

Subjects and Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
xxxvii

Contents

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

Appendixes 1 Through 59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415

Chapter 6: Smoking and Mortality: The Kaiser Permanente

Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477

Study Population and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

Comment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497

Appendix A: Portions of the Smoking Habit Questionnaire

Used in This Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499

Chapter 7: Former Cigarette Smoking and Mortality Among

U.S. Veterans: A 26-Year Followup, 1954 to 1980 . . . . . . . . . . . . . . 501

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526

Appendix A: Cause-of-Death Groups (ICD-7 [World Health

Organization, 1957]) Used in SMR, Rate, and RR Analyses . . 

and in Kahn (1966) and Rogot and Murray (1980) . . . . . . . . 529

Chapter 8: Smoking Cessation and Decreased Risks of Total

Mortality, Stroke, and Coronary Heart Disease

Incidence Among Women: A Prospective Cohort Study . . . . . . . 531

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Smoking and Tobacco Control Monograph No. 8

xxxviii
1

Chapter 1

Introduction, Summary, and Conclusions

David M. Burns, Lawrence Garfinkel, and Jonathan M. Samet

Cigarette smoking is the largest preventable cause of death and

disability in developed countries and is a rapidly growing health problem

in developing countries. The magnitude and nature of the risks associated

with smoking can be estimated using data from prospective epidemiological

studies of smokers and nonsmokers and information on smoking in the

population. In 1966 the National Cancer Institute (NCI) published the

monograph Epidemiological Approaches to the Study of Cancer and Other Chronic

Diseases (Haenszel, 1966), which included detailed presentations of the

information available up to that time from several large prospective mortality

studies examining relationships between smoking behavior and disease.

Since then, several new large prospective mortality studies have been

initiated, and additional years of followup are available for analysis for some

of the studies whose results were presented in 1966. This new information

can be used to more sharply characterize the risks of smoking.

The goal of this monograph is to provide detailed presentations of

disease risks caused by smoking using data from these more recent studies

and the more extensive followup data available from the American Cancer

Society (ACS) Cancer Prevention Study I (CPS-I). This volume also contains

descriptions of the quantitative relationships between various aspects of

smoking behavior and disease occurrence as well as detailed tabular data

contained in various chapter appendixes. Appendix data are presented in

greater detail than would be required by most readers to facilitate use of

this volume as a resource by investigators attempting to model or control

for the effects of smoking in other epidemiological studies.

Five major prospective epidemiological studies are featured in this

volume. CPS-I and CPS-II each followed more than 1 million individuals,

with findings on followup of 6 years for CPS-II and 12 years for CPS-I reported

in this volume. Because these two studies were initiated more than 20 years

apart, they afford the opportunity to examine changes in mortality risks for

smokers and nonsmokers incomparable populations over time; the mortality

experiences during the first 6 years of followup for both studies are compared

in Chapter 4 of this volume.

The Dorn study of U.S. veterans (Kahn, 1966) has the longest duration of

followup of the prospective mortality studies, but it lacks repeat measures of

smoking status during the followup period. It groups smokers who continued

to smoke during followup and those who quit during the followup interval.

Because of this limitation, analyses of this study are most informative for

disease risks after prolonged periods of abstinence from smoking (Chapter 7).

The mortality experience after 26 years of followup of veterans who were

former smokers at the start of the study is used to describe the magnitude

of disease risks in former smokers compared to lifelong never-smokers.
Smoking and Tobacco Control Monograph No. 8

2

The Kaiser Permanente Prospective Mortality study (Chapter 6) followed

60,000 individuals enrolled in the Kaiser Permanente Health Plan and

included a large proportion of Asian and African-American participants.

The Nurses’ Health Study (Chapter 8) enrolled 121,700 female registered

nurses in 1976 and provides detailed risk estimates for these females,

particularly those of younger and middle age.

Detailed estimates of the changes in smoking status with age and

calendar year for white and black males and females by 5-year birth cohorts

also are presented (Chapter 2).

Considerable effort was made to standardize the presentation of data

among the studies, but significant differences exist in ascertainment of

smoking status and in reporting of duration of smoking in the analyses.

All the analyses accrued deaths and person-years of observation (PYO’s)

into age groups defined by age of the subject at death or in the year of

followup (age was advanced during followup) and assumed that smoking

status remained unchanged from the last followup measure of smoking

status (CPS-I [Chapter 3] and the Nurses’ Health Study) or from entry into

the study (CPS-II [Chapter 5], Kaiser Permanente, and veterans studies).

Analyses of the American Cancer Society CPS-I and the Kaiser Permanente

study accrued deaths and PYO’s into duration-of-smoking groups defined

by duration of smoking at death or at the year of followup (duration was

advanced during followup), but only CPS-I had questionnaire validation

of smoking status during followup. Analyses of CPS-II accrued deaths and

PYO’s into duration-of-smoking groups defined by duration of smoking

at entry into the study (duration was not advanced during followup).

The study of U.S. veterans (Chapter 7) and the Nurses’ Health Study do

not present analyses by duration of smoking.

Understanding the impact of cigarette smoking on disease occurrence

requires estimates of both the risks and prevalence rates of smoking. This

volume provides descriptions of smoking behavior over time during the

past century as well as disease-specific mortality estimates from several large

prospective mortality studies. The goal is to provide, in one volume, as much

information as possible on smoking and mortality to facilitate understanding

of smoking-induced disease.

TRENDS IN SMOKING Cigarette smoking as a form of tobacco use has largely

PREVALENCE been a 20th century phenomenon. Before 1910 almost

all tobacco was consumed in pipes and cigars or as chewing tobacco and

snuff. Beginning in 1913 mass marketing efforts of Camel and other

cigarette brands were followed by a rapid rise in the number of cigarettes

sold. Cigarette smoking was predominantly a male behavior at that time,

and among males, it increased dramatically during and subsequent to World

War I. Smoking was relatively uncommon behavior among females until

the 1930’s. The increase in smoking among females also coincided with a

major national advertising campaign. Lucky Strike’s “Reach for a Lucky

Instead of a Sweet” campaign was one of the first tobacco advertising

campaign to directly target females.
3

Chapter 1

The prevalence of current smoking among sequential 5-year birth cohorts

of white males and white females is presented in Figures 1 and 2, respectively.

A birth cohort consists of all individuals born during specific calendar years,

and birth cohort analyses present the experience of those individuals as they

age. Birth cohort analyses are presented in Figures 1 and 2 for 5-year birth

cohorts of white males and females born between 1885 and 1969.

Differences in smoking behavior over time explain many of the

differences in U.S. lung cancer death rates among white and black males

and females. Lung cancer had been a rare disease at the turn of the century,

but lung cancer death rates rose rapidly among males beginning in the 1930’s,

about 20 to 25 years after the upsurge of cigarette smoking among males.

Figure 3 presents race- and gender-specific, age-adjusted U.S. lung cancer

death rates for the calendar years 1950 to 1993. Male lung cancer rates

continued to rise into the 1980’s, whereas female lung cancer death rates

began to increase sharply only in the late 1960’s. A major reason for the

temporal differences between male and female lung cancer rates relates to

the differences in smoking behavior presented in Figures 1 and 2. Females

did not initiate smoking in large numbers until the 1930’s, 20 to 25 years

after the upswing in prevalence among males. As expected, female lung

cancer death rates did not begin to increase steeply until the late 1960’s,

about 20 to 30 years after the beginning of rapid increases in male lung

cancer death rates.

Peak rates of smoking prevalence were much higher among males earlier

in this century, consistent with the higher lung cancer rates among males

across the country. Prevalence rates of smoking in all birth cohorts among

white males have been declining since the late 1950’s (Figure 1), which is

probably the major reason for the leveling off and subsequent decline in

male lung cancer death rates evident during the late 1980’s (Figure 3)

(20 to 25 years after cessation).

Black males born before 1915 and black females born before 1920 had

lower rates of smoking initiation than white males and females. Blacks born

later in the century had rates of smoking that equaled or exceeded those of

whites. Current smoking prevalence among black males is substantially

higher than among white males, reflecting both higher rates of initiation

and lower rates of cessation.

Comparison of smoking prevalence rates for birth cohorts of white and

black males shows a similar relationship between differences in smoking

behavior and differences in white and black lung cancer death rates. Before

1950 most cohorts of white males had higher lung cancer rates than the

comparable cohorts of black males. By 1965 the pattern had inverted,

with most cohorts of white males having lower lung cancer rates than the

comparable cohorts of black males. The expected differences between white

and black male lung cancer death rates are evident in Figure 3. Before 1960

white male lung cancer death rates exceeded those for black males, but by

the mid-1960’s lung cancer death rates among black males began to exceed

those for white males, and they are currently dramatically higher among

black males.
Smoking and Tobacco Control Monograph No. 8

4

Figure 1

Prevalence of current cigarette smoking by 5-year birth cohorts of white males

Figure 2

Prevalence of current cigarette smoking by 5-year birth cohorts of white females
5

Chapter 1

Figure 3

U.S. lung cancer death rates, 1950 to 1993
Smoking and Tobacco Control Monograph No. 8

6

TRENDS IN SMOKING Successful cessation of cigarette smoking was uncommon

CESSATION prior to 1950, probably due to the addictive nature of

cigarette smoking and the lack of a widespread understanding that smoking

caused disease. White males began to quit smoking during the mid 1950’s,

when the substantial disease risks associated with smoking were first widely

publicized. A large increase in cessation occurred among males and females

of both races during the years 1967 to 1970, which coincided with a

substantial tobacco control effort by governmental and nongovernmental

agencies concerned about public health as well as with a large counteradvertising campaign on television. Cessation rates declined slightly

following 1970 and then increased in the late 1970’s and early 1980’s.

The 20th century has seen dramatic changes in both smoking initiation

and smoking cessation, and these changes are responsible for the epidemic

of disease among smokers documented in this volume. Changes in smoking

behavior, and in male lung cancer incidence, suggest that we have reached

the peak of the disease epidemic among males and may expect declining

rates of smoking-induced disease in the future. There is some preliminary

evidence that the lung cancer rate was decreased between 1990 and 1995

(Cole and Rodu, 1996). The pattern of smoking behavior and the increasing

rates of lung cancer among females suggest that the peak rates of disease

among females are yet to be reached; ultimately, however, mortality rates

among females also should decline, as they have among females younger

than age 45 (Ries et.al., 1994). The projected future decline in disease is not

inevitable; it is dependent on continued success in achieving cessation and

preventing initiation. Recent data on the prevalence of smoking among high

school seniors, as well as among 8th- and 10th-graders, are presented in

Figure 4; they suggest that rates of smoking initiation may once again be

rising. Recent national adult prevalence data (Centers for Disease Control

and Prevention, 1996) also suggest that the decline in adult smoking

prevalence may have stopped and that smoking may be increasing even

among adults. These trends are of enormous public health concern, and they

could eliminate any future decreases in disease-specific death rates.

DISEASE The disease consequences of smoking are well documented in

CONSEQUENCES reports of the Surgeon General (U.S. Department of Health and

OF SMOKING Human Services, 1989 and 1990) and in a previous NCI monograph

(Haenszel, 1966). This volume updates many of these findings and provides

a more comprehensive understanding of the relationships among age,

number of cigarettes smoked per day, duration of smoking, and duration of

cessation in causation of disease. Estimates based on data from CPS-II

demonstrate that 52 percent of deaths from all causes among male current

smokers are attributable to cigarette smoking. Among female current

smokers, 43 percent of deaths from all causes are attributable to smoking.

If overall relative risks for all causes of death for current smokers, former

smokers, and never-smokers from CPS-II are used to estimate the smokingattributable fraction for the entire U.S. population older than age 35, the

smoking prevalence rates in 1993 would generate smoking-attributable
7

Figure 4 Prevalence of daily cigarette smoking among 8th-, 10th-, and 12th-grade students, 1975 to 1994
Smoking and Tobacco Control Monograph No. 8

8

percentages of 35.25 percent for all male deaths and 21.00 percent for all

female deaths. This translates into approximately 569,000 excess deaths

in 1993, 354,000 among males and 216,000 deaths among females.

These estimates are higher than those calculated using disease-specific

relative risks and number of deaths for each cause of death. For example,

the American Cancer Society estimates a total of 419,000 each year. They

may overestimate the number of deaths because they include both causes

of death for which smoking is synergistic with other factors in causing

disease and diseases for which the association of smoking and disease is

not causal (e.g., cirrhosis of the liver) and because they are based on the age

distribution of the living population rather than the deaths. On the other

hand, estimates derived from counts of specific causes of death ignore the

contribution of smoking to overall poor health status. Poor general health

may compromise survival for a broad range of diseases, including those not

caused by cigarette smoking, and may limit the treatment options available

for the patient. The excess deaths that result from poor health status would

be excluded from estimates based only on those diseases caused by smoking.

It is also possible that smoking makes small causal contributions to a variety

of diseases other than those usually listed as caused by smoking. These small

contributions might be difficult to identify in disease-specific epidemiologic

analyses but would contribute to the all-cause mortality.

It is likely that the true contribution of smoking to overall mortality

lies somewhere between the numbers generated by these two estimation

techniques. Clearly, tobacco is a dominant causal factor for a wide variety

of diseases and needs to be a principal focus for disease prevention efforts

among cigarette smokers.

Excess rates of disease caused by cigarette smoking vary with a smoker’s

age, the number of cigarettes smoked per day, and the duration of smoking.

Early age of initiation results in a longer duration of smoking at any given

age. However, there is little evidence from the 12-year followup of CPS-I

that early initiation results in an increase in lung cancer risk, independent of

its contribution to duration of smoking. The excess risk of specific diseases

among smokers also varies with age of the smoker. Among younger smokers,

the largest excess disease risk results from coronary heart disease (CHD), with

a rapid rise in excess lung cancer death rates developing after the smoker

reaches age 55. Excess death rates from chronic obstructive pulmonary

disease (COPD) rise even later, increasing dramatically after age 65.

CHANGES IN DISEASE U.S. death rates for CHD, COPD, and lung cancer have

RISK OVER TIME have changed dramatically over the past 40 years and

vary substantially between males and females. As was discussed earlier,

much of the difference between male and female lung cancer death rates

can be explained by differences in smoking behaviors. A similar pattern of

male and female death is also observed for COPD. Women began to smoke

in large numbers later in the century than men; therefore, they have shorter

average durations of smoking at any given age than men. In addition, they

tend to smoke fewer cigarettes per day and are more likely to use filtered or
9

Chapter 1

low-tar and -nicotine cigarettes. However, lung cancer rates among white

females in CPS-I are lower than those of white males, even when stratified by

number of cigarettes smoked per day and duration of smoking. This suggests

that factors other than number of cigarettes per day and duration of smoking

play a role in the differences between male and female lung cancer death

rates. These factors may include differences in pattern of inhalation or

type of cigarette smoked as well as other factors.

One of the major changes in cause of death over the past 40 years

is the decline in deaths from CHD. Substantial changes in cigarette

smoking, diet, and treatment of high blood pressure have occurred during

this period, which are likely to be directly related to the decline in CHD

deaths. Comparison of the CHD death rates in CPS-I and CPS-II (studies

begun more than 20 years apart) reveals that CHD death rates declined

between CPS-I and CPS-II among both current smokers and never-smokers.

The temporal trend was so large that smokers in CPS-II had lower CHD death

rates than lifelong never-smokers in CPS-I. However, the fall in CHD death

rates between the two studies was slightly larger in proportionate terms

among never-smokers than among current smokers.

Age-adjusted death rates for lung cancer increased dramatically

between CPS-I and CPS-II among both male and female smokers. Rates

for never-smokers changed little between the two studies. The dramatic

changes in birth-cohort-specific smoking behavior among white females

over time would be expected to result in these differences between the two

studies among females. Careful examination of differences between the

smoking behaviors of males in the two studies also suggests that much

of the difference between male lung cancer death rates can be explained

by differences between the smoking behaviors of males in the two studies.

However, when age-, duration-of-smoking-, and cigarettes-per-day-specific

strata are compared, lung cancer death rates for male smokers of 20 cigarettes

per day who have smoked for more than 40 years are higher in CPS-II

than in CPS-I.

These changes over time in the relative risks of death for smokers

compared to never-smokers also have been reported for another large

prospective mortality study, the British Doctors study. The results of

40 years of followup of these physicians (Doll et al., 1994) reveal that

relative risks for all-cause mortality among smokers ages 45 to 64 years

compared to never-smokers of the same ages increased threefold when

the last 20 years of followup were compared with the first 20 years.

A similar twofold increase was found for those ages 65 to 84.

CESSATION One of the principal goals of tobacco control efforts is mitigation of the

disease consequences of cigarette smoking through promoting smoking

cessation. New data on disease risks following cessation of smoking are

presented in this volume, and those data reinforce our existing knowledge

(U.S. Department of Health and Human Services, 1990) that smoking

cessation dramatically reduces the risk of smoking-related illness in

comparison with the risks for the continuing smoker.
Smoking and Tobacco Control Monograph No. 8

10

Timing of this alteration in risk differs with different disease processes.

The relative risk of death from CHD among former smokers in the CPS-I,

Kaiser Permanente study, U.S. veterans study, and Nurses’ Health Study

populations approximates that of never-smokers once the smoker has been

tobacco-free for 15 or more years. For shorter periods following cessation,

the relative risk of CHD death is elevated but declines as the duration

following cessation grows longer. In the U.S. veterans study, a small but

statistically significant elevated relative risk (RR = 1.1) persisted among

former smokers, even using the longest followup period (26 to 36 years).

The relative risk of death from lung cancer is essentially unchanged

for the first 5 years following cessation, probably reflecting the long period

between carcinogenic transformation of an individual cell and the death

that results due to growth or metastatic spread of the lung cancer. Relative

risk declines steadily over the period from 5 to 20 years following cessation.

However, in contrast to CHD, the risk of death from lung cancer among

former smokers remains elevated above that of never-smokers among the

U.S. veterans, Kaiser Permanente, and CPS-I study populations, even 20 or

more years following cessation.

Changes in relative risk of death from COPD following cessation mimic

those for lung cancer. There is a slow decline in risk among former smokers

compared to continuing smokers, but an increased risk persists among former

smokers in comparison to never-smokers even 20 or more years following

cessation.

PUBLIC HEALTH Data in this monograph describe the enormous disease burden

IMPLICATIONS produced by cigarette smoking. The best way to entirely avoid

the disease consequences of smoking is to never start smoking. Prevention

of smoking initiation has been a major focus of tobacco control efforts, and

these efforts have resulted in a substantial reduction in the proportion of

adolescents and young adults who become cigarette smokers. As these

younger individuals age, the disease burden produced by tobacco among

their cohorts also will fall.

However, the vast majority of tobacco-related diseases occur among

older individuals, and large numbers of these older individuals are either

current or former smokers. Reduction in disease rates among current

smokers is best achieved through cessation, and since the mid-1960’s

substantial increases in cessation rates among smokers have resulted in

more than half of the ever-smokers in the United States becoming former

smokers. Translation of this achievement in cessation into reductions in

disease-specific death rates is slow but will accelerate as larger numbers

of the older population become former smokers of long duration. Early

evidence of this effect is reflected in the decline in CHD deaths over the

past few decades and the more recent suggestion that white male lung

cancer incidence and death rates have leveled off and begun to decline.

However, even if everyone who is currently smoking were to quit and

no new smokers were to begin, the data presented in this volume suggest
11

Chapter 1

that a substantial burden of smoking-caused disease would persist for the next

several decades because of the residual lung cancer and COPD risks that exist

for long-term former smokers. The difference between the current enormous

number of deaths caused by smoking and this residual disease burden is a

disease prevention goal potentially achievable through comprehensive

tobacco control programs.

REFERENCES

Centers for Disease Control and Prevention. Cigarette

smoking among adults—United States, 1994.

MMWR. Morbidity and Mortality Weekly Report 45(27):

588-590, 1996.

Cole, P., Rodu, B. Declining cancer mortality in the

United States. Cancer, 78(10).2045-2048, 1996

Doll, R.; Peto, R.; Wheatley, K.; Gray, R.; Sutherland, I.

Mortality in relation to smoking: 40 years’

observations on male British doctors. British

Medical Journal 309(6959): 901-911, 1994.

Haenszel, W. (Editor). Epidemiological Approaches to the

Study of Cancer and Other Chronic Diseases. National

Cancer Institute Monograph No. 19. Bethesda, MD:

U.S. Department of Health, Education, and Welfare,

Public Health Service, National Institutes of Health,

1966.

Kahn, H.A. The Dorn study of smoking and mortality

among U.S. veterans: Report on eight and one-half

years of observation. In: Epidemiological Approaches

to the Study of Cancer and Other Chronic Diseases, W.

Haenszel (Editor). National Cancer Institute

Monograph No. 19. Bethesda, MD: U.S. Department

of Health, Education, and Welfare, Public Health

Service, National Institutes of Health, 1966, pp. 1-

125.

Ries, L.A., Miller, B.A., Hankey, B.F., Kosary, C.L.

Harras, A., Edwards, B.K. (Editors). SEER Cancer

Statistics Review, 1973-1991: Tables and Graphs.

NIH Publication No. 94-2789. Bethesda, MD:

U.S. Department of Health and Human Services,

Public Health Service, National Institutes of Health,

National Cancer Institute, 1994.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking: 25 years

of Progress. A Report of the Surgeon General, 1989.

DHHS Publication No. (CDC) 89-8411. Rockville,

MD: U.S. Department of Health and Human

Services, Public Health Service, Centers for Disease

Control, Center for Chronic Disease Prevention and

Health Promotion, Office on Smoking and Health,

1989.

U.S. Department of Health and Human Services. The

Health Benefits of Smoking Cessation: A Report of the

Surgeon General, 1990. DHHS Publication No. (CDC)

90-8416. Rockville, MD: 1990. U.S. Department of

Health and Human Services, Public Health Service,

Centers for Disease Control, Center for Chronic

Disease Prevention and Health Promotion, Office

on Smoking and Health, 1990.
Smoking and Tobacco Control Monograph No. 8

12
13

Chapter 2

Cigarette Smoking Behavior in the

United States

David M. Burns, Lora Lee, Larry Z. Shen, Elizabeth Gilpin,

H. Dennis Tolley, Jerry Vaughn, and Thomas G. Shanks

INTRODUCTION Native Americans were using tobacco products in the Americas prior

to the arrival of Columbus. Tobacco was commonly used in the American

colonies and subsequently in the United States as chewing tobacco and

snuff and in pipes and cigars during the 18th and 19th centuries. However,

widespread use of tobacco in cigarettes is more recent, occurring largely

during the 20th century. Figure 1 presents the per capita use of tobacco

used in the United States as different product types during the past 115 years.

Figure 2 shows total and per capita consumption of cigarettes from 1900 to

1995. There have been substantial changes in the use of tobacco products

over time, with a shift toward cigarettes and away from other forms of

tobacco. A dramatic rise and fall in the per capita and total number of

cigarettes smoked also has occurred in the past century.

Cross-sectional surveys of the U.S. population reveal differences in

smoking prevalence among various demographic categories (U.S. Department

of Health and Human Services, 1989a). Males have a higher prevalence of

Pounds of Tobacco Per Capita

Year

1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

0

2

4

6

8

10

12

14

Cigarettes

Cigars

Chewing

Tobacco

Snuff

Pipe/roll

your own

Figure 1

Per capita consumption of different forms of tobacco in the United States, 1880-1995

Source: U.S. Department of Agriculture, 1996.
14

Smoking and Tobacco Control Monograph No. 8

Figure 2

Total and per capita cigarette consumption in the United States, 1900-1995 Total Cigarette Production

Year

Per Capita Consumption

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

0

100

200

300

400

500

600

700

0

1,000

2,000

3,000

4,000

5,000

6,000

Total cigarette production 7,000

(billions)

Per capita consumption

(age 18 and older)

smoking than females (U.S. Department of Health and Human Services, 1980;

Centers for Disease Control and Prevention, 1994); there are differences in

smoking prevalence among different age and racial groups; and smoking

prevalence and cessation vary with educational attainment (Pierce et al.,

1989). Differences in smoking prevalence among racial, gender, and age

groups have also changed over time. Men began smoking in large numbers

earlier in this century than women (U.S. Department of Health and Human

Services, 1980; Harris, 1983), and differences among racial groups also have

varied over time (Tolley et al. 1991; U.S. Department of Health and Human

Services, 1986; Harris, 1983). Patterns of smoking prevalence, initiation, and

cessation vary across racial, gender, and age categories and are different for

individuals born in different years.

Differences in smoking behavior by year of birth make interpretation of

age-specific estimates from multiple cross-sectional samples over time difficult

and often confusing. A given age group in cross-sectional surveys done at

different points in time will contain individuals who were born in different

years. Changes in smoking behaviors within the specified age group over time

may be produced by either temporal (calendar year) or cohort (year-of-birth)

effects. Analyses in this chapter are presented by race- and gender-specific

5-year birth cohorts. A birth cohort comprises individuals born during

specific calendar years (5-year groups in this presentation) and followed as

they age. Birth cohort analyses presented in this chapter describe changes

in smoking behavior among groups of individuals born during the same

calendar years as they advance in age. This format presents a more accurate

picture of the life history of smoking than can be derived from examination

of differences in smoking behavior among different age groups in single or

Source: U.S. Department of Agriculture, 1996.
15

Chapter 2

multiple independent, cross-sectional samples of the population. Crosssectional surveys describe smoking behaviors for specific age groups. Because

changes in smoking behavior across age groups in a single study may be

produced by either calendar year or year-of-birth effects, it is not valid to

assume that differences in age-specific rates in a single study are attributable

to age alone. Multiple cross-sectional studies define changes in age-specific

rates at different points in time, but the difference in age-specific rates may

be due to temporal (calendar year) effects or to age-specific rates in surveys

done in different years that represent different birth cohorts. These different

cohorts may have had different rates of smoking initiation and cessation and

therefore wind up with different rates of smoking prevalence independent

of changes relating to calendar year, which makes interpreting changes in

age-specific smoking prevalences across multiple survey years difficult.

Presentation of smoking behavior in multiple birth cohorts over time allows

separation of calendar year trends from changes associated with aging.

Prevalence of smoking, duration of smoking, and number of cigarettes

smoked per day are powerful predictors of the tobacco-related diseases

described in other chapters of this monograph (U.S. Department of Health

and Human Services, 1982, 1983, 1984, 1989a, and 1990). This chapter

describes changes in smoking prevalence, initiation, and cessation for the

U.S. population during approximately the past 115 years. The description

is based on a pooling of data from the National Health Interview Surveys

(NHIS) conducted between 1965 and 1991, which asked questions on

smoking behavior.

TIMING OF EVENTS Smoking behaviors for the birth cohorts presented in this

LINKED TO SMOKING chapter have been profoundly influenced by events and

BEHAVIOR trends in the larger social environment within which

smoking occurs (Burns, 1991) as well as by the addictive properties of

cigarettes acting within the psychologic and physiologic structure of the

individual (U.S. Department of Health and Human Services, 1988).

Interpretation of the data on smoking behavior presented in this chapter

requires an understanding of the social and political contexts within which

smoking developed and which have led smokers to quit. Some of the

events that influenced smoking behavior are listed in Table 1.

Cigarette smoking as a form of tobacco use was uncommon prior to 1900

(Figure 1). Per capita consumption of cigarettes in the United States was 54

in 1900 (U.S. Department of Health and Human Services, 1989a) compared

with its peak of 4,345 in 1963 (Figure 2). Conversion of tobacco use from

pipes, cigars, and chewing tobacco to cigarettes was enabled by the invention

of machines that could mass produce cigarettes, eliminating the need for

hand rolling, and by the development of safety matches that allowed a

convenient, portable means of lighting cigarettes (Whelan, 1984). However,

the real growth in cigarette sales occurred after advertising and mass

marketing techniques were applied to cigarettes during the second decade

of this century. The remarkable growth in sales of Camel cigarettes after a

national promotional campaign in 1913 established the power of advertising
16

Smoking and Tobacco Control Monograph No. 8

Table 1

Temporal events influencing cigarette use

Date Event Reference

1884 Invention of a machine to manufacture cigarettes Whelan, 1984

1889 Invention of safety matches Whelan, 1984

1913 Introduction and mass marketing of Camel brand Burrough and Helyar,

cigarettes by R.J. Reynolds Tobacco Company 1990

1914-18 World War I

1928 Introduction of cigarette advertisements targeting Burns, 1994

women, including the "Reach for a Lucky Instead of a Health Advocacy Center,

Sweet" campaign 1986

1929 Beginning of the Great Depression in the United States

1941-45 United States involvement in World War II

1950 Publication of retrospective studies linking tobacco and U.S. Department of Health

disease and Human Services, 1989a

1954 Publication of prospective mortality studies linking U.S. Department of Health

cigarettes and lung cancer and Human Services, 1989a

1955 Marketing of filtered cigarettes U.S. Department of Health

and Human Services, 1981

1956 Founding of the Council for Tobacco Research Freedman and Cohen, 1993

1964 Release of the U.S. Surgeon General's report on U.S. Department of Health,

smoking and health Education, and Welfare, 1964

1967-70 Counteradvertising on television Warner, 1977

1968 Introduction of Virginia Slims and other brands targeted Burns, 1994

at women

1970 Cigarette advertisements banned from television; end of U.S. Department of Health

free time for counteradvertisements and Human Services, 1989a

1970 Nonsmokers' rights movement begins Steinfeld, 1972

1983 Increase in the Federal excise tax on cigarettes by 8 cents Burns, 1991

1986 Release of U.S. Surgeon General's report on involuntary U.S. Department of Health

smoking and Human Services,

1986

1992 Release of the U.S. Environmental Protection Agency U.S. Environmental

report on environmental tobacco smoke Protection Agency, 1992
17

Chapter 2

in promoting sales (Burrough and Helyar, 1990). It set the stage for mass

marketing of other brands of cigarettes and for a dramatic jump in cigarette

use during the next several decades (Burrough and Helyar, 1990). Initially,

cigarette marketing targeted males, but in the 1930's, advertising campaigns

directed toward women began to appear (Health Advocacy Center, 1986).

The most notorious of these campaigns was the "Reach for a Lucky Instead

of a Sweet" series of advertisements that began a marketing theme linking

cigarette smoking to weight control, a campaign that continues with other

brands of cigarettes to this day (Health Advocacy Center, 1986; Burns, 1994).

Dramatic changes have occurred in per capita consumption of cigarettes

during each of the World Wars, with mobilization of many men into the

military during both wars and mobilization of women into the war industries

during World War II. Gen. John J. Pershing is reported to have requested

tobacco for his troops, and cigarettes were made part of the daily ration in

1918 (Whelan, 1984). Marketing and free distribution of cigarettes to military

personnel during the Second World War is likely to have played a prominent

role in generating the high prevalences (approximately 80 percent) of eversmoking (smoking at least 100 cigarettes in a lifetime) among those cohorts

of males who were of the correct ages to have served in the military during

World War II (Burns, 1991).

Concern among members of the scientific community that cigarette

smoking caused disease grew with the publication of retrospective

epidemiologic studies of lung cancer in the late 1940's and early 1950's.

The first major prospective mortality studies defining the disease risks of

smoking cigarettes were published and widely disseminated through the lay

press during the mid-1950's (U.S. Department of Health and Human Services,

1989a). Initial public health sector response to this knowledge included a

public information campaign and development of smoking cessation

interventions for individuals (Burns, 1991). The tobacco industry's response

was creation of the Council for Tobacco Research (Freedman and Cohen,

1993), which legitimized the tobacco industry's media campaign to confuse

the public about the strength of the scientific evidence linking cigarette

smoking and disease (Whelan, 1984; Burns, 1994). At the same time,

cigarette companies introduced and marketed filter cigarettes and

low-tar-and-nicotine-yield cigarettes to counter growing health concerns

among smokers (U.S. Department of Health and Human Services, 1981;

Burns, 1994).

On June 2, 1967, the Federal Communications Commission required

that significant amounts of free air time be made available for antismoking

commercials to balance the cigarette advertisements on television and

radio (U.S. Department of Health and Human Services, 1989a). As a result,

from 1967 to 1970, many antismoking television spots were broadcast

free by the major television networks. The time allotted for the spots was

worth approximately $75 million per year in 1970 dollars (Lydon, 1970).

Substantial tobacco control efforts were also made by voluntary health

agencies and other concerned groups during these years (U.S. Department
18

Smoking and Tobacco Control Monograph No. 8

of Health and Human Services, 1989a; Burns, 1991). Cigarette advertising

was banned from television and radio in 1970, and the number of

antismoking spots broadcast declined by an estimated 80 percent (Lewit et al.,

1981). The effectiveness of this antitobacco advertising is supported by

decreases in U.S. per capita consumption between 1967 and 1970, the period

of the most intense broadcast activity (Hamilton, 1972; Warner, 1977 and

1989; Doron, 1979; Fugii, 1980; Schneider et al., 1981; Warner, 1981; Baltagi

and Levin, 1986) (Figure 2). Per capita consumption declined 6.9 percent

between 1967 and 1970 in contrast to a 2-percent increase during the years

immediately preceding the media campaign (1965-1967). When cigarette

advertising was banned from broadcast media after 1970, antismoking

spots also were removed, and a variety of other social changes that might

have influenced smoking also occurred; per capita consumption increased

4.1 percent from 1971 to 1973 (Warner, 1977; U.S. Department of

Agriculture, 1994). Evidence for an overall effect of all antitobacco

activities over the past three decades also has been presented by Warner and

Murt (1983) and Warner (1989), particularly in relation to the prevalence

they projected would have been found if earlier birth cohort trends in

smoking behavior had persisted.

Concerns about exposure to environmental tobacco smoke (ETS) and

the social acceptability of smoking surfaced about 1970 (Steinfeld, 1972)

and grew rapidly in the 1970's and early 1980's (U.S. Department of Health

and Human Services, 1986). These concerns were reinforced with the

demonstration of a causal link between ETS and lung cancer in the mid1980's (U.S. Department of Health and Human Services, 1986; U.S.

Environmental Protection Agency, 1992).

METHODS The National Center for Health Statistics, through the annual National

 Health Interview Survey, has collected health information since 1964 from

a probability sample of the civilian, noninstitutionalized population of the

United States. Since 1965, a section on tobacco use has been included in the

survey. We have combined all the NHIS surveys that have questions about

smoking behavior into a single data set for the analyses presented below.

Individual surveys represent cross-sectional samples of the U.S. population

at different times, have different sample sizes, and have different sets of

questions on smoking behavior.

Background Material Smoking supplements to the NHIS were undertaken during

Concerning National 15 calendar years: 1965, 1966, 1970, 1974, 1976, 1977, 1978,

Health Interview 1979, 1980, 1983, 1985, 1987, 1988, 1990, and 1991. The

Surveys sampling methods for these surveys change every decade, and

details concerning the survey methodology are reported elsewhere (Fiore et

al., 1989; U.S. Department of Health and Human Services, 1989b). Eversmokers were defined as those who had smoked at least 100 cigarettes in

their lifetime. Surveys before 1974 included smoking information on all

adult members of a household, collected from a single adult from the same

household; however, in 1974 and later, smoking information was collected

from a randomly selected member of the household, with the survey
19

Chapter 2

undertaken by telephone if the person was not present during the initial

household interview. The 1965, 1966, and 1970 surveys included data from

self-respondents and proxy respondents. Although there were differences in

the demographic characteristics of both types of respondents, an analysis of

the 1970 data showed that the smoking prevalence of self-respondents in

1970 was consistent with the prevalence obtained for the same demographic

subgroup in the more representative self-respondent survey of 1974.

Accordingly, we limit our analysis to only the self-report data from the

1970 and earlier surveys. Since 1984, the sampling frame has included an

oversampling for blacks so that more precise estimates can be made about

this minority population (U.S. Department of Health and Human Services,

1989b). For our analysis we have included only adults age 20 and older so

that the age range of the sample is uniform across all survey years. Sample

sizes varied between 10,000 and 90,000 adults, and each survey included

questions on smoking behavior. Birth year, a data element present for every

respondent, was used to categorize each respondent into one of seventeen

5-year birth cohorts (1885-1889, 1890-1894, 1895-1899, 1900-1904, 1905-

1909, 1910-1914, 1915-1919, 1920-1924, 1925-1929, 1930-1934, 1935-1939,

1940-1944, 1945-1949, 1950-1954, 1955-1959, 1960-1964, 1965-1969).

The total number of observations available for analysis is 460,254.

Comparability of the We examined distribution of age of initiation for individual

Distribution of Age birth cohorts measured in different surveys conducted across

of Initiation Across a 20-calendar-year span and found no statistically significant

Survey Years differences in the distributions, allowing us to combine the

distributions of age of initiation for individual birth cohorts across all the

surveys that contained initiation data.

Smoking Six surveys (1970, 1978, 1979, 1980, 1987, and 1988) asked all everInitiation smokers the question, "How old were you when you began to smoke

cigarettes fairly regularly?"; 94.7 percent of ever-smokers in those survey

years gave an age of smoking initiation. Overall, data from 85,628 eversmokers were available for analysis. A separate analysis was conducted

for each birth-cohort/race/gender subgroup. Analyses of initiation were

formulated as survival analyses in which the entire subgroup was considered

to be present in the population at time of birth, and the age given by

individuals for when they started smoking fairly regularly was taken as

the age or time of an event (starting to smoke). All persons without

event(s) were censored at the age attained in the survey in which they were

interviewed. The result of this analysis is a curve, It

(a), which shows the

percentage of the cohort remaining nonsmokers, by age. The survival

analyses were performed through the procedure LIFETEST of the Statistical

Analysis System (SAS) software package (The SAS Institute, 1988).

A second set of survival analyses was performed to estimate the

percentage of the cohort remaining nonsmokers using calendar year rather

than age as the measurement of time. From birth year and reported age

of initiation, the calendar year when a person started smoking could be

computed.
20

Smoking and Tobacco Control Monograph No. 8

Differential The computed ever-smoking prevalence curves were adjusted to account

Mortality for the fact that, compared to never-smokers, ever-smokers have less

chance of being alive to be interviewed as they age; therefore, the prevalence

of ever-smokers in a birth cohort declines at older ages. The impact of

smoking on ever-smoking prevalence does not become prominent until

the individual is older than 50 years (Kahn, 1966); however, we have

conservatively analyzed our data to include effects beginning at age 30. For

each birth cohort/race/gender subgroup, we computed the point prevalence

of ever-smoking for each of the 15 surveys, using all individuals meeting the

inclusion criteria. Point prevalence was computed as the sum of all recorded

current and former smokers divided by the total number of individuals in

the cohort. We adjusted upward the point prevalences from surveys taken

prior to complete smoking initiation for a cohort by dividing the observed

point prevalence at that age by the percentage of ever-smokers to initiate

by that age.

The parameters b1 and b2 of the following exponential function were

estimated (within each race/gender subgroup) by means of a weighted

(weights were the total number of respondents meeting the standard

inclusion criteria in each survey) nonlinear least-squares procedure (The SAS

Institute, 1988) to obtain the best fit to the 15 adjusted point-prevalence

estimates:

prevalence = b1 - exp(b2(age-30)).

The fitted curve has a maximum value at age 30 and decreases

exponentially as age increases beyond 30. The modeling was done separately

for each birth cohort/race/gender subgroup to achieve the best fit to the

point prevalence specific to the subgroup. Because of the small numbers of

individuals in the cohorts for blacks, the results of modeling were unstable

for the b2 parameter, so the values of b2 for corresponding white cohorts

were used for both races. The curves were then standardized to 100 percent

by dividing each of them by its maximum value to generate the age-specific

differential mortality adjustment factors for each birth cohort.

For each birth cohort/race/gender subgroup, the modeled parameters

were used to adjust the initiation curve. At age 30, the modeled peak

prevalence is b1-1, which represents the peak ever-smoking prevalence for

the birth cohort. The age-specific initiation curve was adjusted upward by

the multiplication of each point on the curve by the ratio of the modeled

peak prevalence (b1-1) and the unadjusted peak prevalence for that birth

cohort. For ages older than 30, the resulting curve then was multiplied by

the differential mortality adjustment factor. Therefore, the initiation curves

retained the same general shape of the distribution of age of initiation, but

all the values on the curve were adjusted to reflect differential mortality of

ever-smokers compared to never-smokers. The adjusted initiation curve will

be referred to below as It(a). A similar adjustment was made to the initiation

curve expressed by calendar year. Because differential mortality is an agerelated phenomenon, the ratios that were computed for the analysis by age
21

Chapter 2

also were used for the analysis by calendar year. The translation was made

by addition of the median birth year of the cohort to data expressed in terms

of age.

Adjustment for differential mortality was applied only to the first

12 birth cohorts; later birth cohorts were assumed to be young enough when

surveyed that there would be no bias due to differential mortality. The

adjusted initiation curve is referred to below as Im

t

′(a). A similar adjustment

was made to initiation curves expressed by calendar year. Because

differential mortality is an age-related phenomenon, the ratios that were

computed for the analysis by age were also used for the analysis by calendar

year. The translation was made by addition of the median birth year of the

cohort to data expressed in terms of age.

Smoking Cessation Twelve surveys (1965, 1966, 1970, 1978, 1979, 1980, 1983,

Rates 1985, 1987, 1988, 1990, and 1991) asked the question, "About

how long has it been since you last smoked cigarettes fairly regularly?"

Responses of former smokers were recorded as time in days, weeks, months,

or years since cessation. With this information and age of the respondent

at the time of the survey, the age or calendar year at which the respondent

quit smoking could be calculated. Among those classified as former

smokers, 91.5 percent provided information on when they quit. Data on

205,108 ever-smokers were available for analysis.

A survival analysis was performed using all ever-smokers in a given birth

cohort/race/gender subgroup as the base population, with age of cessation as

the time of the event. To reduce the effect of quit attempts that eventually

fail on the birth cohort quit rates, all smokers were censored 2 years before

the year of the survey in which they participated. Thus, only those who

reported having successfully quit at least 2 years before a survey were

counted as having events. The percentage of former smokers quitting

in the 2 years prior to a survey was 25.1 percent overall and varied from

32.1 percent for black females to 21.6 percent for white males. The

procedure LIFETEST of the SAS software package was used for the survival

analyses (The SAS Institute, 1988). Ce(a) is the computed survival curve for

smoking cessation by age. A similar procedure was used for cessation rates

by calendar year. Rates could be computed up to 1988, 3 years before the

most recent survey, and rates are expressed as the percentage of current

smokers at the start of a calendar year who successfully quit in that year.

Prevalence of Ever-smoker prevalence curves, after adjustment for differential

Current Smoking mortality, were used to estimate current smoking prevalence.

Within a particular birth cohort/race/gender subgroup, at any given age

a person is either a never-smoker, former smoker, or current smoker.

The prevalence of current smoking is thus given by the percentage of the

population that has initiated by a given age (Im

t

′(a)) multiplied by the

fraction of those ever-smokers that age who had quit (Ce(a)). The prevalence

equation becomes:

prevalencet(a) = Im

t

′(a) * Ce(a).
22

Smoking and Tobacco Control Monograph No. 8

The subscript "t" indicates the computation is based on the total

subgroup, and the subscript "e" indicates that computation is based only

on ever-smokers.

As a check on validity of the adjustments for differential mortality and

the methods used to calculate prevalence of current smoking, we tabulated

the percentage agreement between the computed prevalence curves and the

point-prevalence estimates of current smoking from each NHIS survey for

each race/gender subgroup over all birth cohorts. If the computed curve

at a given age passed through the 95-percent confidence limits of a point

estimate for that age (median age of the cohort), it was considered to be in

agreement. For white males the agreement was 86 percent, for black males

94 percent, for white females 85 percent, and for black females 89 percent.

The higher percentage agreement for blacks is because of the wider

confidence intervals for the point-prevalence estimates.

We also computed prevalence curves by calendar year, using cessation

curves by year and initiation curves by year, adjusted for differential

mortality.

RESULTS Analyses are presented as birth cohort-, race-, and gender-specific

prevalences of ever-smoking and current smoking, and annual rates of

long-term successful cessation. Rates for each cohort are presented in tabular

form in Appendix A for both attained age and calendar year. Figures of

ever-smoking prevalence are provided for attained age. Current smoking

prevalence and quit rates are presented for calendar year. Two figures are

presented for each race/gender group to allow examination of older and

more recent cohorts separately. The 1925-1929 cohort is presented in

both figures to facilitate comparison of cohorts across both sets of graphs.

PREVALENCE OF EVER- Figures 3 through 12 present prevalence of ever-smoking

SMOKING, BY BIRTH for each birth cohort, by attained age. Ever-smoking

COHORT prevalence is adjusted for differences in age-specific

mortality rates between ever-smokers and never-smokers, which lowers the

prevalence of ever-smoking as the cohort ages. The greater mortality rate

in ever-smokers than in never-smokers results in fewer smokers surviving

to the older ages, and therefore the prevalence of ever-smokers declines at

older ages.

Initiation of regular smoking within each birth cohort is manifest as

a rapid increase in prevalence during adolescence and early adulthood.

Examination of Figures 3 through 12 reveals that initiation is largely

confined to adolescence and early adulthood. With the exception of the

older cohorts of women, most smokers become regular smokers before

achieving adulthood. Two descriptors are of interest in relation to initiation:

the percentage of the cohort that become cigarette smokers and the age

distribution of initiation within the cohort. Both of these phenomena

vary among the different gender and racial groups presented in Figures 3

through 12.
23

Chapter 2

Figure 3

Ever-smoking prevalence, by age, for 5-year birth cohorts of white males born between 1885

and 1929

Figure 4

Ever-smoking prevalence, by age, for 5-year birth cohorts of white males born between 1925

and 1969

1925 – 1929

1930 – 1934

1935 – 1939

1940 – 1944

1945 – 1949

1950 – 1954

1955 – 1959

1960 – 1964

1965 – 1969

Birth years

Ever-Smokers (percentage)

Age

0 10 20 30 40 50 60 70 80 90

0

20

40

60

80

100
24

Smoking and Tobacco Control Monograph No. 8

Figure 5

Ever-smoking prevalence, by age, for 5-year birth cohorts of white females born between 1885

and 1929

Figure 6

Ever-smoking prevalence, by age, for 5-year birth cohorts of white females born between 1925

and 1969

1925 – 1929

1930 – 1934

1935 – 1939

1940 – 1944

1945 – 1949

1950 – 1954

1955 – 1959

1960 – 1964

1965 – 1969

Birth years

Ever-Smokers (percentage)

Age

0 10 20 30 40 50 60 70 80 90

0

20

40

60

80

100
25

Chapter 2

Figure 7

Ever-smoking prevalence among 5-year birth cohorts of white males, by age

Figure 8

Ever-smoking prevalence among 5-year birth cohorts of white females, by age
26

Smoking and Tobacco Control Monograph No. 8

Figure 9

Ever-smoking prevalence, by age, for 5-year birth cohorts of black males born between 1900

and 1929

Figure 10

Ever-smoking prevalence, by age, for 5-year birth cohorts of black males born between 1925

and 1969
27

Chapter 2

1925 – 1929

1930 – 1934

1935 – 1939

1940 – 1944

1945 – 1949

1950 – 1954

1955 – 1959

1960 – 1964

1965 – 1969

Birth years

Ever-Smokers (percentage)

Age

0 10 20 30 40 50 60 70 80 90

0

20

40

60

80

100

Figure 11

Ever-smoking prevalence, by age, for 5-year birth cohorts of black females born between 1900

and 1929

Figure 12

Ever-smoking prevalence, by age, for 5-year birth cohorts of black females born between 1925

and 1969
28

Smoking and Tobacco Control Monograph No. 8

White Males Figure 3 presents prevalence of ever-smoking among white males,

by 5-year birth cohorts born between 1885 and 1929. Prevalence of eversmoking increases with each succeeding cohort until 1910. The next four

cohorts have similar patterns of smoking uptake. A different pattern of

smoking is evident among cohorts born after 1930 (Figure 4). The percentage

of the population that ever smoked declines steadily with each succeeding

cohort of white males. This decline in smoking prevalence almost certainly

reflects the tobacco control activities that have focused on preventing

adolescent smoking initiation over the past 40 years (Warner and Murt,

1983), and the result is more than a 50-percent reduction in smoking

initiation between the white males born between 1925 and 1929 and

the most recent cohort. However, the distribution of age of first regular

smoking among those who do begin to smoke has changed only modestly

among these cohorts.

White Females The pattern of initiation among white females is strikingly different

from that among white males among those cohorts born before 1930

(Figure 5). Differences are evident in both prevalence of ever-smoking and

distribution of age of initiation. The percentage of females who took up

smoking increases with each sequential cohort from 1895 until 1944

(Figures 5 and 6), but the most dramatic differences between white males and

white females are in the age distribution over which initiation occurs. In the

most recent cohorts, initiation is confined to adolescence and early adulthood

for both genders. However, in the earlier cohorts of white females, substantial

initiation occurred during the third, fourth, and fifth decades of life. These

gender differences in initiation are explained by differences in uptake of

smoking by calendar year. Prior to 1930, cigarette smoking was largely a male

behavior. However, during the 1930's and 1940's, initiation occurred across

all birth cohorts of females. Therefore, initiation was spread across all age

groups and not confined to adolescence and early adulthood. Ever-smoking

prevalence increases with sequential cohorts, suggesting that those forces

promoting initiation among females during the 1930's and 1940's were more

effective among younger females in later cohorts and resulted in lower rates

of initiation among mature females.

An additional and disturbing difference in rates of initiation between

white males and white females is observed when recent cohorts are examined.

Figures 7 and 8 show three-dimensional graphic depictions of all cohorts of

white males and white females. Each succeeding cohort of white males born

after 1925 shows a progressively lower prevalence of ever-smoking. A decline

in initiation also occurs among succeeding cohorts of white females born

from 1940 to 1954. However, the cohort born during the period 1955-1959

has an increased rate of initiation compared with the 1950-1954 cohort, and

the 1960-1964 cohort has rates of initiation similar to the 1950-1954 cohort.

This interruption or reversal of declining rates of initiation among a recent

cohort of white females is in contrast to the continued decline in smoking

initiation found among the same birth year cohorts of white males. Either

more recent cohorts of white females were less responsive to tobacco control

messages than their predecessors or, more likely, targeting of white females by
29

Chapter 2

tobacco manufacturers has been successful in promoting initiation among

those adolescent females exposed to messages linking smoking to

women's liberation and a thin female figure. These advertising themes

were prominent in the promotional campaigns for brands of cigarettes

that would appeal to females, which were introduced in the late 1960's,

(Burns, 1994) when the 1955-1959 cohort of white females was in

adolescence.

Black Males Initiation of smoking among black males (Figures 9 and 10) is similar,

but not identical, to that of white males. Older cohorts of black males were

less likely to become smokers than white males, with cohorts born before

1915 having a lower peak prevalence of ever-smoking. In addition, the age

distribution of initiation is shifted toward older adolescence and early

adulthood among black males compared with white males.

Among cohorts born after 1915, black males were more likely to become

cigarette smokers than white males. The pattern of a higher prevalence of

ever-smoking among black males may be shifting with recent cohorts. Peak

prevalence of ever-smoking among black and white males born between

1960 and 1964 is similar, and prevalence of ever-smoking is lower among

black males than white males for those born between 1965 and 1969. It

remains unclear whether this recent shift in pattern of initiation reflects a

true change in smoking behavior among black males or the difficulty of

obtaining representative samples of young black males in surveys such as

the NHIS.

Black Females Initiation of regular smoking among black females (Figures 11 and 12)

is more similar to that of white females than to that of black males.

Prevalence of ever-smoking increases steadily among successive cohorts

of black females until the cohort 1940-1944 is reached and then declines

slightly among later cohorts. Black females have similar or lower rates of

peak prevalence of ever-smoking than white females among all cohorts, in

contrast to the higher prevalence rates of ever-smokers noted among black

males in comparison with white males. This trend is particularly evident

among the older cohorts and appears to have reemerged with more recent

cohorts. As is noted for black males, the distribution of age of initiation is

shifted toward later adolescence among black females compared with white

females.

PREVALENCE OF Prevalence of current smoking, by birth cohort and by

CURRENT SMOKING, calendar year, is presented for black and white males and

BY BIRTH COHORT females in Figures 13 through 20. Tables in Appendix A

present current smoking rates, by both age and calendar year. The

differences between the ever-smoker curves and current smoker curves

for a given cohort are produced by cessation of smoking within the cohort.

Cessation rates, by birth cohort, are presented in the final section of this

chapter. Current smoker prevalence is presented by calendar year, rather

than age, to permit examination of changes in smoking behavior in relation

to temporal events over the past century.
30

Smoking and Tobacco Control Monograph No. 8

White Males The rapid increase in smoking prevalence that occurs during

adolescence is evident in all the white male cohorts (Figures 13 and 14)

and is manifest in these figures as a rapid increase in prevalence occurring

5 calendar years apart for each succeeding cohort. The percentage of the

cohort who become smokers increases for the first several cohorts of white

males. These increasing rates of initiation occurred between 1910 and 1920,

coinciding with a rise in per capita consumption after 1910 (Figure 2).

This change across the cohorts coincides with the introduction and mass

marketing of machine-manufactured cigarettes around 1913 (Burrough and

Helyar, 1990). The oldest cohorts were in early adulthood when tobacco

manufacturers began to use mass marketing approaches to induce males to

become cigarette smokers and, therefore, may have been less vulnerable to

advertising approaches than younger cohorts. Those cohorts born after 1900

were subjected to tobacco advertising and promotion throughout adolescence,

took up smoking in large numbers (more than 80 percent as shown in

Figure 3), and began to smoke predominantly prior to age 25.

Cohorts born after 1900 and before 1934 have relatively similar patterns

of uptake and rates of peak cohort smoking prevalence. The major difference

in the pattern of current smoking among these cohorts, and between these

cohorts and the more recent cohorts, is the width of the plateau that occurs

around peak prevalence and the rate of decline in current smoking prevalence

over time. Older cohorts have broad plateaus, indicating that little cessation

occurred before 1950. More recent cohorts have a narrower plateau, with a

rapid decline in prevalence occurring almost as soon as the peak prevalence

is achieved. A rapid decline in smoking prevalence is evident across all the

older cohorts after 1955, and the rate of decline accelerates in the late 1960's.

The first major prospective mortality studies linking cigarettes to disease were

published in the mid-1950's, and a concerted tobacco control effort, including

a highly visible television antismoking campaign, occurred between 1967

and 1970. Data for white males suggest that the effects of these tobacco

control influences were felt across all cohorts of adult smokers and

resulted in substantial changes in smoking behavior among white males

of all ages.

The pattern of current smoking prevalence observed among those cohorts

born after 1930 (Figure 14) is one of declining peak prevalences with each

succeeding cohort. This pattern results in the actual prevalence of smoking

in any given calendar year being similar across all the recent cohorts, again

suggesting that temporal events may have a more powerful influence on

smoking prevalence than age has.

White Females Smoking initiation among older cohorts of white females shows a

clear relationship with calendar year (Figure 15). Few females smoked before

1925, and a rapid rise in smoking prevalence is evident during the 1930's

across several cohorts. This dramatic change in smoking behavior among

females coincides with the tobacco industry's efforts to target females through

advertising during the 1930's and 1940's (Health Advocacy Center, 1986).
31

Chapter 2

Figure 13

Current smoking prevalence, by calendar year, for 5-year birth cohorts of white males born

between 1885 and 1929

Figure 14

Current smoking prevalence, by calendar year, for 5-year birth cohorts of white males born

between 1925 and 1969
32

Smoking and Tobacco Control Monograph No. 8

Figure 15

Current smoking prevalence, by calendar year, for 5-year birth cohorts of white females born

between 1885 and 1929

Figure 16

Current smoking prevalence, by calendar year, for 5-year birth cohorts of white females born

between 1925 and 1969
33

Chapter 2

Figure 17

Current smoking prevalence, by calendar year, for 5-year birth cohorts of black males born

between 1900 and 1929

Figure 18

Current smoking prevalence, by calendar year, for 5-year birth cohorts of black males born

between 1925 and 1969 Current Smokers (percentage)

Calendar Year

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

0

20

40

60

80

100

1900 – 1904

1905 – 1909

1910 – 1914

1915 – 1919

1920 – 1924

1925 – 1929

Birth years
34

Smoking and Tobacco Control Monograph No. 8

Figure 19

Current smoking prevalence, by calendar year, for 5-year birth cohorts of black females born

between 1900 and 1929

Figure 20

Current smoking prevalence, by calendar year, for 5-year birth cohorts of black females born

between 1925 and 1969
35

Chapter 2

Peak prevalence of smoking among white females is lower than that of

comparable cohorts of white males for all but the two most recent cohorts.

However, the decline in prevalence seen among successive cohorts of white

males once peak prevalence has been reached is not as evident among white

females (Figure 16). Even the more recent cohorts have a broad plateau of the

prevalence curve with relatively low rates of decline in prevalence, indicating

that there has been less cessation among white females than among the same

cohorts of white males. It is unclear whether these observed differences in

the magnitude and breadth of peak prevalences are because differences in

the response of white males and white females to tobacco control influences

or the competing influence of increased targeting of advertising and

promotional activities toward females. Whatever the etiology of these

differences among older cohorts, the most recent two cohorts of white males

and white females have similar patterns of current smoking behavior. It

remains to be determined whether differences in these cohorts will emerge

as they age because of differences in cessation behavior or whether the

differences in cessation behavior that were observed among earlier cohorts

of white males and white females also will disappear.

Black Males Current smoking prevalence, by calendar year, is presented for cohorts

of black males born after 1900 (Figures 17 and 18). The NHIS contains too

few observations for earlier cohorts of black males to allow reliable estimation

of smoking prevalence. Cohorts of black males born before 1915 had lower

rates of peak smoking prevalence than comparable cohorts of white males,

but those cohorts born after 1915 had similar or higher rates of peak smoking

prevalence than their white male contemporaries. Most cohorts of black

males have higher smoking prevalences than white males in the same

cohorts, and this higher current prevalence is produced by both a higher

peak prevalence among blacks in the cohort and a lower rate of decline in

smoking prevalence after the peak.

Black Females With the exception of differences in age of initiation and lower rates

of smoking prevalence among the older cohorts of black females, the

prevalence of smoking among cohorts of black females is similar to that

among white females of the same cohort (Figures 19 and 20).

SMOKING CESSATION Cessation rates presented in this section are annual rates

RATES, BY BIRTH of long-term (2+ years) successful cessation as a percentage

COHORT of current smokers. Those rates represent the percentage of

current smokers in a given year who reported having quit in that year and

who remained nonsmokers for at least the next 2 years. Individuals who had

quit for less than 2 years at the time of the survey were censored from the

cohort, thereby avoiding inclusion of individuals who had quit recently and

were likely to relapse. The data were smoothed (Chambers and Hastie, 1991)

to moderate a digit bias for 5-calendar-year increments in reporting remote

cessation among the older cohorts.

Cessation rates are generally higher at older ages, but there is no pattern

across the cohorts for the age at which cessation begins or for the absolute

cessation rate at a given age. However, when the rates are plotted against
36

Smoking and Tobacco Control Monograph No. 8

calendar year (Figures 21 through 26), a clearer picture of cessation behavior

is evident. Among cohorts born before 1935, cessation rates appear to be

influenced predominantly by calendar year, with a smaller influence of

chronological age. In contrast, the more recent cohorts appear to have

cessation rates that are determined by age.

White Males Annual quit rates for white males are presented in Figures 21 and 22,

by the year in which the cessation occurred. In general, older cohorts have

higher rates of cessation than more recent cohorts, suggesting an effect of

age. However, all the cohorts show similar increases in cessation rates

during the same calendar years. There were low rates of cessation before

1950 (Figure 21). Cessation rates began to increase in the mid-1950's and

increased dramatically during the late 1960's among those cohorts that had

reached adulthood. Many cohorts showed a downturn in cessation rates

after 1970, with rates again increasing in the late 1970's and early 1980's.

Changes during the 1950's coincided with the publication and widespread

dissemination in the lay press of the first major prospective mortality studies

defining the disease risks of smoking cigarettes. During the period 1967 to

1970, antismoking television spots were broadcast free by the networks, and

in large numbers, to counter cigarette advertising; substantial tobacco control

efforts also were made by voluntary health agencies and other concerned

groups. When cigarette advertising was banned from television and radio

in 1970, the antismoking spots were no longer broadcast in large numbers.

Concerns about exposure to ETS and about the social unacceptability of

smoking grew rapidly in the late 1970's. The interaction of these social and

environmental changes and cessation rates is unclear, but the uniformity of

the temporal changes across multiple cohorts (who are at different ages in

the same year) makes a strong case for calendar-year events influencing

smokers across all cohorts.

White Females Cessation rates are generally lower among white females than among

white males for cohorts born before 1950 (Figures 23 and 24). Later cohorts

have similar cessation rates among white males and white females. The

increase in cessation rates noted among white males during the late 1950's

is much less prominent among white females, but the rise of those rates for

white females during the 1960's is almost as dramatic. The emphasis of early

epidemiologic studies of risks attributable to smoking was on white males,

who were then showing the greatest evidence of smoking-related disease.

Uptake of smoking occurred much later in the century among females than

among males. This difference resulted in lower relative risks for females in

the early prospective mortality studies and led to a perception that females

might be relatively protected from the disease consequences of smoking.

It is unclear what role the emphasis on males in the studies or the

underestimation of risks for females may have played in generating this

pattern of lower rates of cessation among females.

Black Males Small numbers of observations among black smokers did not allow

and Black estimation of cessation rates for cohorts born before 1900 and required

Females use of 10 year birth cohorts to generate stable estimates for males and

females (Figures 25 and 26).
37

Chapter 2

Figure 21

Annual smoking cessation rates, by calendar year, for 5-year birth cohorts of white males born

between 1890 and 1929

Figure 22

Annual smoking cessation rates, by calendar year, for 5-year birth cohorts of white males born

between 1925 and 1969
38

Smoking and Tobacco Control Monograph No. 8

Figure 23

Annual smoking cessation rates, by calendar year, for 5-year birth cohorts of white females

born between 1890 and 1929

Figure 24

Annual smoking cessation rates, by calendar year, for 5-year birth cohorts of white females

born between 1925 and 1969
39

Chapter 2

Figure 25

Annual smoking cessation rates, by calendar year, for 10-year birth cohorts of black males born

between 1900 and 1969

Figure 26

Annual smoking cessation rates, by calendar year, for 10-year birth cohorts of black females

born between 1900 and 1969
40

Smoking and Tobacco Control Monograph No. 8

Black males have markedly lower rates of cessation than white males

across all cohorts where comparisons could be made. Cessation rates among

black males were generally lower than rates for comparable cohorts of white

females but were similar to those for black females. There is little evidence

of an increase in cessation rates among blacks during the 1950's, and the

cessation response during the late 1960's was also more modest than that

seen among whites. However, cessation rates do appear to have risen during

the late 1970's and 1980's among all cohorts of black males and black

females.

DISCUSSION The analyses presented here represent the first birth cohort analyses of

multiple NHIS's as a combined data set. Previous analyses (U.S. Department

of Health and Human Services, 1980 and 1985; Harris, 1983; Tolley et al.,

1991) have been based on a single NHIS or combinations of two or three

surveys. The larger number of observations available in the current analyses

allow presentation of the data as 5-year cohorts instead of 10-year cohorts as

have been presented previously.

Use of tobacco has varied substantially across time and is different

among racial and gender groups. Much of the difference in tobacco-related

disease rates among males and females can be explained by differences in

their smoking behavior by birth cohort. Females began smoking later in the

century and therefore lagged behind males in rates of lung cancer and other

diseases. Smoking prevalence among males peaked in the early 1950's and

declined, resulting in lung cancer death rates that have now peaked among

white males and are expected to decline. In contrast, the rates of smoking

among females have declined only moderately, and lung cancer rates are

continuing to rise among white females.

Differences in smoking prevalence among black males also may explain

a part of the substantially higher rates of lung cancer among black males

compared with white males. Black males have similar, but slightly higher,

rates of ever-smoking prevalence and substantially lower rates of smoking

cessation, leading to longer durations of smoking among ever-smokers. This

longer duration of smoking would be expected to result in higher rates of

lung cancer and may explain a part of the dramatic difference between black

and white male lung cancer death rates.

Analyses of smoking initiation and cessation by calendar year suggest

that cigarette smoking is a behavior substantially influenced by changes in

the environment surrounding current smokers and those vulnerable to

initiation or relapse of attempted cessation. Age appears to play a primary

role in defining the window of vulnerability to smoking initiation and a

minor role in increasing rates of cessation.
41

Chapter 2

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43

Chapter 2

Appendix A

Five-Year, Birth-Cohort-Specific Ever-Smoking and Current

Smoking Prevalence and Cessation Rates, by Age and Calendar

Year
44Table 1

Ever-smoking prevalence among 5-year birth cohorts of white males, by age
45

Table 1 (continued)
46Table 1 (continued)
47

Table 2 Ever-smoking prevalence among 5-year birth cohorts of white females, by age
48Table 2 (continued)
49

Table 2 (continued)
50Table 3

Ever-smoking prevalence among 5-year birth cohorts of black males, by age
51

Table 3 (continued)
52Table 3 (continued)
53

Table 4 Ever-smoking prevalence among 5-year birth cohorts of black females, by age
54Table 4 (continued)
55

Table 4 (continued)
56Table 5

Ever-smoking prevalence among 5-year birth cohorts of white males, by year
57

Table 5 (continued)
58Table 5 (continued)
59

Table 6 Ever-smoking prevalence among 5-year birth cohorts of white females, by year
60Table 6 (continued)
61

Table 6 (continued)
62Table 6 (continued)
63

Table 7 Ever-smoking prevalence among 5-year birth cohorts of black males, by year
64Table 7 (continued)
65

Table 7 (continued)
66Table 8

Ever-smoking prevalence among 5-year birth cohorts of black females, by year
67

Table 8 (continued)
68Table 8 (continued)
69

Table 9 Current smoking prevalence among 5-year birth cohorts of white males, by age
70Table 9 (continued)
71

Table 9 (continued)
72Table 10

Current smoking prevalence among 5-year birth cohorts of white females, by age
73

Table 10 (continued)
74Table 10 (continued)
75

Table 11 Current smoking prevalence among 5-year birth cohorts of black males, by age
76

Table 11 (continued)
77

Table 11 (continued)
78

Table 12

Current smoking prevalence among 5-year birth cohorts of black females, by age
79

Table 12 (continued)
80

Table 12 (continued)
81

Table 13 Current smoking prevalence among 5-year birth cohorts of white males, by year
82

Table 13 (continued)
83

Table 13 (continued)
84

Table 13 (continued)
85

Table 14 Current smoking prevalence among 5-year birth cohorts of white females, by year
86

Table 14 (continued)
87

Table 14 (continued)
88

Table 14 (continued)
89

Table 15 Current smoking prevalence among 5-year birth cohorts of black males, by year
90

Table 15 (continued)
91

Table 15 (continued)
92

Table 16

Current smoking prevalence among 5-year birth cohorts of black females, by year
93

Table 16 (continued)
94

Table 16 (continued)

96Table 17 (continued)
97

Table 18 Annual quit rates among 5-year birth cohorts of white females, by age
98Table 18 (continued)
99

Chapter 2

Table 19

Annual quit rates among 10-year birth cohorts of black males, by age
Smoking and Tobacco Control Monograph No. 8

100

Table 19 (continued)
101

Chapter 2

Table 20

Annual quit rates among 10-year birth cohorts of black females, by age
Smoking and Tobacco Control Monograph No. 8

102

Table 20 (continued)
103

Table 21 Annual quit rates among 5-year birth cohorts of white males, by year
104Table 21 (continued)
105

Table 21 (continued)
106Table 22 Annual quit rates among 5-year birth cohorts of white females, by year
107

Table 22 (continued)
108Table 22 (continued)
109

Chapter 2

Table 23

Annual quit rates among 10-year birth cohorts of black males, by year
Smoking and Tobacco Control Monograph No. 8

110

Table 23 (continued)
111

Chapter 2

Table 24

Annual quit rates among 10-year birth cohorts of black females, by year
Smoking and Tobacco Control Monograph No. 8

112

Table 24 (continued)
113

Chapter 3

The American Cancer Society Cancer

Prevention Study I: 12-Year Followup

of 1 Million Men and Women

David M. Burns, Thomas G. Shanks, Won Choi, Michael J. Thun,

Clark W. Heath, Jr., and Lawrence Garfinkel

INTRODUCTION The American Cancer Society (ACS) Cancer Prevention Study I

(CPS-I) is the largest prospective mortality study of diseases caused by

tobacco use ever conducted in terms of person-years of observation (PYO's).

The study, which began in 1959 and continued through September 1972,

was designed and directed by Dr. E. Cuyler Hammond (Garfinkel, 1985).

The publication in 1966 of the 3-year followup of this population

(Hammond, 1966) played a critical role in establishing the causal linkage

between smoking and several diseases, and it remains one of the most

comprehensive presentations of the disease risks caused by smoking.

The ACS used 68,116 volunteers to enroll the 1,078,894 men and women

in the study. The 12-year followup of this cohort, the population used in

the analyses presented in this report, includes more than 11 million personyears. Previous analyses of the 12-year followup of this study were more

limited in the detail presented (Hammond et al., 1977; U.S. Department

of Health and Human Services, 1989); the results in this chapter represent

the most complete description of the 12-year followup of this cohort reported

to date. The data are presented in as much detail as possible, recognizing

that a unique contribution of this study is the large number of PYO’s available

for analysis. Because the data cover the spectrum of tobacco-related diseases,

a comprehensive description of all the findings is not feasible within the

limitations of this chapter. The major focus of the chapter is to present

descriptive analyses of all-cause mortality and cause-specific mortality for

lung cancer, coronary heart disease (CHD), cerebrovascular disease (CVD),

and chronic obstructive pulmonary disease (COPD). A more extensive

presentation of cause-specific mortality is included in Appendix A. A set

of detailed tables presenting the major cause mortality experience of the

cohort by number of cigarettes, attained age, and duration of smoking is

contained in Appendix B.

METHODS Recruitment of the study population of 1,078,894 subjects was

accomplished by 68,116 ACS volunteers. Each volunteer was

Description of the asked to recruit about 10 households with at least one person

Study Population older than 45 years of age. All household members older than

30 years were asked to complete a questionnaire. Volunteers were asked not

to recruit strangers or casual acquaintances. Enrollment was completed in fall

1959. Approximately 3 percent of the questionnaires were discarded because

they were incomplete or the respondents were not traced for administrative
114

Smoking and Tobacco Control Monograph No. 8

reasons. Annual followup questionnaires were collected for the first 6 years

and again in 1972 for the 12-year followup. The 12-year followup includes

more than 11 million PYO’s. Current cigarette smokers whose data are

reported in this chapter include all who answered yes to the question

"Do you smoke now?," excluding those who also reported current use of

pipes or cigars.

Approximately 7 percent of the study population was nonwhite, and

95 percent of the subjects lived in the United States or Canada. The 25 States

represented are Arizona, California, Florida, Georgia, Illinois, Indiana, Iowa,

Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota,

Mississippi, Missouri, New York, North Carolina, Ohio, Oregon, Pennsylvania,

South Carolina, Tennessee, Texas, and Virginia. Deaths were reported by the

volunteers, and death certificates were obtained from the appropriate State

health departments. Approximately 18 percent of the subjects traced died

within the 12 years of followup, and death certificates were obtained in

95 percent of the reported deaths. Deaths were coded according to the

Manual of the International Statistical Classification of Diseases, Injuries, and

Causes of Death (World Health Organization, 1957, pp. 78-98), in a version

that used two digits. The overall standardized mortality at the 12-year

followup reached 81 percent of that of the United States.

ANALYSIS OF CPS-I Analyses have been performed separately for white males and

DATA SET white females. There were not sufficient numbers of deaths or

PYO’s to perform all analyses with these methods for blacks. Except where

noted, data were not pooled across gender or race.

Followup Most subjects were enrolled for participation during October through

December 1959, although some were enrolled in early 1960. For analysis, the

period of followup began July 1, 1960, allowing a period for death caused by

preexisting conditions at the beginning of the study; subjects dying before

July 1, 1960, were excluded. Followup surveys were conducted according to

the following schedule, with questionnaires completed at the dates marked

with an asterisk:

September 30, 1960 September 30, 1964

September 30, 1961* September 30, 1965*

September 30, 1962 September 30, 1971

September 30, 1963* September 30, 1972*

When subjects were lost to followup, the last completed survey date prior

to loss to followup was used as the censoring date.

Date of death was taken as the first day of the month of death. Personmonths of observation (PMO's) accrued month by month until the date of

loss to followup, date of death, or end of study on September 30, 1972, in

which case subjects were censored alive. A maximum of 147 months of

observation was accrued by participants who completed the whole period
115

Chapter 3

of the study. Deaths were tallied according to age at death, and PMO's were

accrued dynamically during the period of followup across several age groups.

The CPS-I data set includes information on 456,491 males, with known

death dates for 117,199, and 594,551 females, with known death dates for

88,353.

Descriptive Tables Analyses were restricted to never-smokers and individuals

for CPS-I Data Set who smoked cigarettes only. Current cigar and pipe smokers

were excluded, as were users of smokeless tobacco. Never-smokers were

individuals who indicated at the time of the initial survey that they never

smoked cigarettes regularly. Current smokers were individuals who indicated

current cigarette smoking at the time of the initial survey. Former smokers

were individuals who indicated at the time of the initial survey that they

were former cigarette smokers and did not indicate current smoking at any

subsequent followup surveys or who indicated that they had quit for at least

2 years on the followup surveys. Followup time for former smokers began

to accrue after they had quit for at least 2 years.

Age-specific PYO’s and numbers of deaths for the white male and female

groups separated into never-smoker, current smoker, and former smoker

categories and black male and female groups separated into never-smoker and

current smoker categories are presented in Appendix C. The appendix tables

present deaths due to lung cancer, CHD, CVD, COPD, and all-cause mortality

during the period of followup. Lung cancer deaths include lung cancer as

primary, secondary (contributing cause), or tertiary (any mention on the

death certificate) cause of death (code 62); the other diseases are for primary

cause of death only (CHD = 00 or 01; CVD = 07, 08, 09; COPD = 3C, 34, 3D).

Mortality Rate Tables 1 through 14 present mortality rates, rate ratios, and rate

Ratios differences for current smokers and former smokers in comparison

with never-smokers. These ratios are calculated by dividing the rate for

current smokers or former smokers by the rate for never-smokers of the same

age group. The rate ratio for all levels of cigarette consumption combined for

a particular age group is calculated by weighting the smoking-specific rates by

the PMO's for each level of consumption. Rate ratio across age groups also is

presented, calcula4ed by standardization to the U.S. 1980 census population.

All rates reported in this chapter are based on observed rates. Some tables for

black smokers show a second set of risk estimates calculated using death rates

for black smokers and white never-smokers of the same sex. Respondents

whose levels of consumption were unknown are included in the calculation

for combined levels of consumption.

Tables 1 and 2 present risk ratio of mortality by years of duration of

smoking and level of cigarette consumption. Because each level of duration

has contributions from several different levels of attained age, standardization

was carried out by age within each cell. Within each cell of duration by

consumption, age standardization was accomplished by weighting the

contribution of the age-specific never-smoker comparison group using the

PMO's of the same-age smoker group; that is, rates for never-smokers were
116

Table 1Mortality rate ratios for white male current smokers, by level of duration of smoking—comparison never-smokergroup weighted to match smoker person-years of observation for each (age x duration x cigarettes per day) cella

Duration

Cigarettes

Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 

Lung Cancer

1-9 1.26 4.42 0.47 3.45 4.06 4.29 3.69 4.31 10-19 2.30 2.83 2.37 5.69 6.93 8.55 9.64 9.00 15.04 20 4.86 9.16 3.24 6.18 11.03 9.85 14.07 14.17 16.10 17.00 21-39 3.51 8.18 4.77 14.00 16.91 17.43 20.77 25.20 25.10 40+ 7.83 11.07 15.98 19.45 22.25 28.28 24.47 29.98 Combined 1.26 3.98 4.20 5.47 10.30 11.68 14.04 15.29 15.54 17.05 

Coronary Heart Disease

1-9 0.89 1.21 0.73 1.18 1.43 1.37 1.25 1.32 1.31 1.24 10-19 0.75 1.44 1.67 1.96 1.88 1.75 1.74 1.52 1.48 1.52 20 1.67 1.29 1.91 2.23 2.45 2.15 1.92 1.71 1.71 1.64 21-39 1.41 0.99 2.68 2.84 2.42 2.16 2.02 1.81 1.71 1.76 40+ 5.54 0.74 3.08 3.23 3.13 2.66 2.34 1.97 1.97 1.87 Combined 1.47 1.21 1.82 2.24 2.30 2.08 1.90 1.68 1.63 1.59 

Cerebrovascular Disease

1-9 1.48 0.63 1.11 0.98 0.84 1.40 1.34 1.26 1.07 10-19 1.84 1.53 1.82 1.15 1.14 1.57 1.49 1.46 1.07 20 1.36 1.48 1.67 1.46 1.69 1.76 1.61 1.61 1.19 21-39 1.93 2.40 2.15 2.02 1.78 2.24 1.87 1.81 1.18 40+ 1.71 2.64 2.26 2.64 2.28 2.41 1.57 1.74 Combined 1.57 1.28 1.74 1.51 1.62 1.85 1.68 1.56 1.18 
117

Table 1 (continued) Duration

Cigarettes

Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 

Chronic Obstructive Pulmonary Disease

1-9 3.36 2.17 3.09 9.27 8.97 12.18 11.57 10-19 3.06 5.73 4.47 5.32 7.51 8.07 11.44 13.60 20 29.95 10.76 6.86 3.60 2.69 7.45 12.92 15.23 13.80 15.47 21-39 5.69 9.28 4.07 7.22 11.94 18.73 21.34 20.75 40+ 6.23 10.99 18.92 17.44 25.56 20.51 Combined 7.50 3.30 3.59 4.59 3.67 7.03 12.15 14.01 15.42 15.47 

All-Cause Mortality

1-9 0.60 1.22 0.80 1.11 1.25 1.26 1.32 1.39 1.42 1.44 10-19 0.77 1.19 1.29 1.50 1.63 1.65 1.66 1.66 1.63 1.66 20 1.24 1.02 1.41 1.73 2.05 1.96 2.04 1.95 1.92 1.83 21-39 1.20 1.01 1.66 1.98 2.17 2.23 2.25 2.15 2.21 2.17 40+ 2.37 0.73 2.04 2.44 2.78 2.71 2.63 2.56 2.38 2.21 

Combined 1.01 1.07 1.37 1.72 2.00 2.00 2.03 1.94 1.89 1.81 a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smok

group using the person-months of observation (PMO's) of the same-age smoker group; that is, rates for never-smokers were standardized by ag

smoker PMO's within each cell.
118

Table 2Mortality rate ratios for white female current smokers, by level of duration of smoking—comparison never-smokergroup weighted to match smoker person-years of observation for each (age x duration x cigarettes per day) cella

Duration

Cigarettes

Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 

Lung Cancer

1-9 0.52 1.04 1.22 0.17 1.97 1.71 1.40 0.40 1.0110-19 2.07 2.18 2.34 2.96 3.26 4.37 3.00 3.82 7.9320 1.55 2.01 5.87 4.41 7.09 7.05 6.75 9.23 6.41 15.5521-39 9.99 4.88 7.27 12.25 12.35 13.08 12.30 20.43 12.3240+ 24.15 4.29 12.27 11.16 12.75 18.92 19.37 28.26Combined 1.63 0.89 3.00 2.91 5.00 5.21 5.72 5.63 4.81 7.73

Coronary Heart Disease

1-9 1.24 0.90 1.08 1.13 1.21 0.99 1.01 0.97 1.22 1.05 10-19 2.28 1.43 1.90 1.93 1.96 1.77 1.64 1.58 1.48 1.25 20 1.61 2.05 2.48 2.18 2.25 1.96 1.86 1.76 1.51 1.46 21-39 3.04 3.02 2.44 2.77 2.56 2.22 1.75 1.57 1.08 40+ 5.14 5.41 2.00 2.99 3.20 2.33 2.27 1.56 1.36 0.82Combined 1.58 1.40 1.73 1.75 1.88 1.67 1.60 1.46 1.40 1.21 

Cerebrovascular Disease

1-9 1.80 1.15 1.28 0.95 1.00 0.93 1.10 0.81 0.77 0.20 10-19 1.46 1.18 1.88 1.59 1.65 1.59 1.43 1.63 1.13 0.89 20 2.18 1.45 2.07 1.96 2.17 2.02 1.78 1.24 1.08 1.29 21-39 2.99 1.78 2.54 1.74 2.39 1.79 1.49 0.97 0.76 40+ 5.49 3.82 2.61 4.18 2.53 3.16 2.36 2.48 1.62 1.79Combined 1.77 1.33 1.69 1.55 1.60 1.61 1.49 1.27 1.00 0.74 
119

Table 2 (continued) Duration

Cigarettes

Per Day 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 

Chronic Obstructive Pulmonary Disease

1-9 1.36 2.11 4.33 3.6110-19 5.85 2.61 2.15 3.76 6.29 8.69 10.19 11.68 16.05 20 3.56 6.89 5.90 7.70 11.57 15.99 20.79 16.62 13.3221-39 8.15 4.26 9.10 17.37 25.45 35.19 29.0840+ 11.33 12.19 15.00 32.25 11.02 70.37 Combined 1.52 1.48 1.66 3.42 4.69 7.87 10.94 11.30 10.41 11.27 

All-Cause Mortality

1-9 1.07 0.95 0.98 1.06 1.11 1.01 1.16 0.98 1.00 0.95 10-19 1.11 0.96 1.29 1.29 1.47 1.38 1.46 1.47 1.35 1.12 20 1.15 1.22 1.52 1.54 1.69 1.72 1.69 1.68 1.55 1.70 21-39 0.42 1.23 1.51 1.70 1.86 2.00 2.04 1.87 1.72 1.57 40+ 1.76 1.55 1.95 2.31 2.16 2.26 2.22 2.37 2.12 2.22 

Combined 1.08 1.04 1.26 1.34 1.49 1.47 1.53 1.45 1.34 1.25 a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of the age-specific never-smok

group using the person-months of observation (PMO's) of the same-age smoker group; that is, rates for never-smokers were standardized by age 

smoker PMO's within each cell.
120

Smoking and Tobacco Control Monograph No. 8

standardized by age to observed smoker PMO's within each cell. Respondents

whose level of consumption was unknown are included in the calculation for

combined levels of consumption. The rate ratios shown in these tables reflect

the weighted sums across age levels within each category of duration and

smoking level and, therefore, include the effect modification produced by

both age and duration within any cell rather than being standardized by age

to a defined population.

Tables 3 and 4 present rate ratio of mortality by years of duration of

cessation for former smokers by level of former smoking. The comparison

never-smoker rates are age standardized within each cell to the PMO's of

former smokers using the same method as in Tables 1 and 2. There were

not enough black former smokers in the survey to complete these tables for

blacks.

Tables 5 through 10 present mortality rates and rate ratio of mortality by

15-year age groups, level of consumption, and sex and race, all standardized

to U.S. 1980 population by 5-year age groups within cells. The "all-ages"

value across age groups also is presented, calculated by standardization to

U.S. 1980 standard population, age 30 and older. Respondents whose level

of consumption was unknown are included in the calculation for combined

levels of consumption.

Duration-Specific The tables in Appendix B present duration-specific mortality

Mortality Rate Ratios rate ratios and excess mortality rates by number of cigarettes

and Attributable Rates smoked per day and attained age. These tables are calculated

using modeled, rather than observed, death rates for never-smokers.

Modeling of never-smoker rates was used to stabilize estimates for death

rates among younger groups of never-smokers. The low numbers of deaths

in age groups younger than 50 years often resulted in rates of zero or rates

that were considered unstable. Modeling allowed estimation of rates for the

younger age groups of never-smokers that were above zero and increased

smoothly with age. Followup data were tabulated for 92,307 white male

never-smokers and 375,649 white female never-smokers. Deaths were

tabulated in the age group for age at the time of death. Death certificates

list primary causes of death, secondary contributing causes, and underlying

conditions. Lung cancer deaths were tabulated for any mention of lung

cancer on the death certificate; only the primary cause of death was used

to calculate death rates from CHD, CVD, and COPD. Therefore, some

deaths may have been included in both lung cancer and other-cause-ofdeath categories. PMO's were accrued on a month-by-month basis to the

current age group. These results allowed calculation of the rate of deaths

per 100,000 person-years of observation (PYO's) (PYO's/12 = PMO's) for

each age group.

Never-smoker rates were modeled using both Poisson regression and

linear regression of log(rate) techniques, all regressed to the median age of

5-year intervals between 40 and 85 years of age. A close fit of the data to

an exponential curve was demonstrated, with close agreement between the

models. Tables 1 through 5 in Appendix D show the observed death rates
121

Chapter 3

Table 3

Mortality rate ratios for white male former smokers by duration of cessation and level of

cigarette consumption—comparison never-smoker group weighted to match former smoker

person-years of observation for each (age x duration x cigarettes per day) cella

Duration of Cessation

Cigarettes

Per Day 2-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39

Lung Cancer

1-9 2.83 1.68 1.22 0.58 1.38 1.89

10-19 7.96 3.50 2.91 2.04 0.96 2.16 1.68

20 11.68 10.49 5.03 2.22 1.86 1.12 1.55 4.10

21-39 14.30 9.18 4.85 4.88 2.04 4.13 3.69

40+ 27.88 12.36 7.77 3.74 3.99 0.89

Combined 13.12 8.44 4.61 2.89 2.04 1.19 1.84 3.18

Coronary Heart Disease

1-9 1.55 1.36 1.38 1.08 0.71 1.01 0.83 0.46

10-19 2.53 1.56 1.26 0.93 0.93 0.92 0.77 0.62

20 3.00 1.56 1.20 1.09 0.97 0.98 1.13 0.70

21-39 2.65 2.03 1.55 1.29 1.13 1.09 0.95 0.56

40+ 2.96 1.68 1.72 1.15 1.02 0.98 1.25 0.39

Combined 2.66 1.64 1.37 1.13 0.99 0.96 0.93 0.55

Cerebrovascular Disease

1-9 1.72 1.45 1.29 1.42 0.69 0.57 0.37 0.92

10-19 1.62 1.33 1.14 0.95 0.73 0.84 0.68 0.57

20 1.33 1.05 1.03 0.95 1.17 0.84 0.79 0.58

21-39 1.46 0.75 0.90 0.76 0.53 0.56 1.58

40+ 2.27 1.41 1.05 1.23 1.36 0.90 0.97 1.23

Combined 1.62 1.16 1.05 1.01 0.93 0.78 0.80 0.65

Chronic Obstructive Pulmonary Disease

1-9 6.46 2.25 2.67 3.29

10-19 21.03 12.35 9.02 2.07 0.95 0.85 1.01 2.49

20 41.10 15.27 11.85 7.05 3.75 1.13 2.89

21-39 31.00 28.14 11.39 5.57 1.40 1.98

40+ 57.03 34.25 10.33 9.37 4.00 4.99

Combined 36.14 18.89 10.33 5.64 2.80 1.42 2.28 2.49

All-Cause Mortality

1-9 1.74 1.37 1.25 1.08 0.67 0.83 0.80 0.73

10-19 2.18 1.43 1.24 1.01 0.87 0.93 0.80 0.59

20 2.84 1.64 1.30 1.10 1.01 1.04 1.06 0.74

21-39 2.57 1.92 1.48 1.23 1.00 1.01 1.06 0.56

40+ 3.18 2.13 1.74 1.30 1.16 1.08 1.23 0.79

Combined 2.58 1.69 1.39 1.15 0.98 0.96 0.91 0.66

a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of

the age-specific never-smoker comparison group using the person-months of observation (PMO's) of the same-age

smoker group; that is, rates for never-smokers were standardized by age to observed smoker PMO's within each cell.
122

Smoking and Tobacco Control Monograph No. 8

Table 4

Mortality rate ratios for white female former smokers by duration of cessation and level of

cigarette consumption—comparison never-smoker group weighted to match former smoker

person-years of observation for each (age x duration x cigarettes per day) cella

Duration of Cessation

Cigarettes

Per Day 2-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39

Lung Cancer

1-9 2.13 1.89 0.45 2.38 1.81

10-19 0.95 0.61 3.06 2.42 3.65

20 4.31 0.76 0.98 1.66

21-39 16.99 10.90

40+

Combined 2.85 1.51 0.58 3.19 2.52 2.61

Coronary Heart Disease

1-9 1.41 1.46 0.82 0.69 0.75 1.08 0.64 0.64

10-19 3.15 1.52 1.13 0.79 0.83 0.45 0.53 0.35

20 3.45 1.79 1.08 1.12 1.27 0.97 0.25

21-39 1.99 0.88 0.51 0.63

40+ 5.52 1.49 0.86 1.48 1.99

Combined 2.23 1.53 0.98 0.84 0.88 0.96 0.63 0.63

Cerebrovascular Disease

1-9 1.78 0.90 1.10 0.80 0.69 0.42 0.63 0.83

10-19 0.99 0.88 1.47 0.93 0.62 1.01 0.42

20 4.41 1.33 1.14 1.20 1.41 1.10 0.59 1.11

21-39 4.29 4.07 1.83 1.45 1.41

40+ 6.67 3.70 2.11 3.47

Combined 2.28 1.18 1.25 1.01 1.11 0.84 0.57 0.92

Chronic Obstructive Pulmonary Disease

1-9 16.08 5.97 4.13 8.64

10-19 3.82 4.61 5.79 4.67

20 9.52 2.91 7.35 33.48

21-39 28.31

40+ 47.91

Combined 16.08 9.46 5.15 5.45 4.67 13.74

All-Cause Mortality

1-9 1.97 1.16 1.10 0.82 0.94 0.93 0.79 0.65

10-19 1.92 1.34 1.22 0.88 0.79 0.84 0.75 0.56

20 2.84 1.53 1.18 1.16 1.22 1.33 1.17 0.52

21-39 2.87 1.27 0.95 1.08 1.36 0.60 0.87 0.95

40+ 2.56 1.67 1.50 1.26 1.29 1.75 1.09

Combined 2.17 1.31 1.15 0.94 0.98 1.02 0.88 0.63

a Within each cell of duration by consumption, age standardization was accomplished by weighting the contribution of

the age-specific never-smoker comparison group using the person-months of observation (PMO's) of the same-age

smoker group; that is, rates for never-smokers were standardized by age to observed smoker PMO's within each cell.
123

Chapter 3

Table 5

Mortality rates among white male current smokers, by level of cigarette consumption—

standardized absolute mortality rates per 100,000a

Age

Cigarettes

Per Day 35-49 50-64 65-79 All Ages

Lung Cancer

1-9 7.70 46.81 168.61 59.04

10-19 11.67 103.45 367.79 122.33

20 26.46 160.73 535.38 185.63

21-39 28.29 218.18 785.54 268.71

40+ 39.71 274.33 888.75 315.26

Combined 25.16 170.95 503.51 175.87

Coronary Heart Disease

1-9 101.78 544.37 1,852.05 770.47

10-19 142.38 682.76 2,087.90 893.66

20 167.73 764.25 2,184.38 968.59

21-39 170.50 758.91 2,209.83 962.02

40+ 239.46 902.64 2,396.22 1,127.88

Combined 169.94 753.17 2,137.95 939.17

Cerebrovascular Disease

1-9 13.76 77.24 563.07 248.03

10-19 22.63 75.41 572.95 268.30

20 18.98 93.15 563.70 250.89

21-39 24.71 105.89 581.79 255.82

40+ 21.19 128.08 646.63 284.09

Combined 20.86 97.15 576.45 263.86

Chronic Obstructive Pulmonary Disease

1-9 30.51 182.11 72.24

10-19 4.33 25.87 239.55 79.79

20 0.79 48.71 318.75 112.30

21-39 1.40 49.89 384.47 116.31

40+ 66.29 466.72 149.06

Combined 1.32 45.90 295.70 100.71

All-Cause Mortality

1-9 281.91 1,190.41 4,702.79 1,971.17

10-19 341.35 1,445.34 5,387.83 2,319.19

20 417.24 1,697.89 5,849.46 2,499.91

21-39 429.12 1,823.46 6,511.74 2,710.34

40+ 586.29 2,195.01 6,910.57 2,966.77

Combined 422.43 1,715.30 5,756.71 2,465.47

a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate

adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age.
124

Smoking and Tobacco Control Monograph No. 8

Table 6

Mortality rates among white female current smokers, by level of cigarette consumption—

standardized absolute mortality rates per 100,000a

Age

Cigarettes

Per Day 35-49 50-64 65-79 All Ages

Lung Cancer

1-9 1.79 11.15 27.46 8.81

10-19 3.71 26.72 71.26 26.07

20 14.36 49.57 132.39 49.07

21-39 28.13 89.17 281.21 164.49

40+ 20.86 119.01 208.39 79.37

Combined 9.90 37.92 84.76 33.61

Coronary Heart Disease

1-9 15.36 106.14 741.69 331.19

10-19 22.58 174.20 1,075.58 457.27

20 24.26 206.90 1,060.19 450.07

21-39 42.26 220.24 1,301.99 561.03

40+ 35.25 272.41 790.83 438.95

Combined 24.05 173.61 958.01 411.82

Cerebrovascular Disease

1-9 9.67 44.21 320.71 153.70

10-19 15.48 76.58 362.93 185.36

20 18.74 76.30 430.75 191.77

21-39 19.44 70.22 542.96 200.22

40+ 20.86 120.03 579.24 146.39

Combined 15.75 69.02 375.14 176.39

Chronic Obstructive Pulmonary Disease

1-9 0.89 3.89 15.61 7.23

10-19 1.00 8.34 64.75 19.57

20 1.60 17.43 102.95 25.72

21-39 1.02 15.24 154.11 58.60

40+ 3.04 31.54 189.02 44.30

Combined 1.24 11.21 62.17 18.85

All-Cause Mortality

1-9 150.17 556.24 2,278.22 1,073.12

10-19 195.82 743.52 2,773.20 1,283.95

20 237.70 843.56 3,148.53 1,403.89

21-39 275.14 965.07 3,739.58 1,730.44

40+ 324.06 1,219.96 3,196.19 1,586.20

Combined 211.60 759.29 2,749.85 1,271.06

a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate
125

Chapter 3

Table 7

Mortality rates among black male current smokers, by level of cigarette consumption—

standardized absolute mortality rates per 100,000a

Age

Cigarettes

Per Day 35-49 50-64 65-79 All Ages

Lung Cancer

1-9 42.17 174.87 324.78 123.70

10-19 14.63 140.36 317.61 103.30

20 37.82 230.00 612.15 190.25

21-39 90.81 26.79

40+ 618.24 182.41

Combined 27.08 184.86 389.73 133.44

Coronary Heart Disease

1-9 86.80 542.86 1,542.04 794.07

10-19 43.88 637.54 1,384.31 690.06

20 157.79 607.03 1,718.76 735.12

21-39 79.21 800.24 2,920.68 787.25

40+ 372.28 109.84

Combined 91.36 601.71 1,515.39 740.87

Cerebrovascular Disease

1-9 86.80 348.13 1,074.99 464.84

10-19 176.20 816.90 198.96

20 104.59 212.68 865.73 391.66

21-39 199.50 58.86

40+ 1,616.46 290.82

Combined 53.49 236.85 918.86 353.53

Chronic Obstructive Pulmonary Disease

1-9 39.40 41.02 65.91

10-19 29.34 317.61 65.80

20 72.36 345.87 83.57

21-39 140.10 41.33

40+ 206.08 60.80

Combined 54.01 217.65 76.88

All-Cause Mortality

1-9 606.06 2,363.62 5,366.52 2,672.09

10-19 490.44 1,908.51 6,418.90 2,566.44

20 876.34 2,100.09 6,476.93 2,486.80

21-39 1,031.23 2,273.09 4,315.21 1,781.42

40+ 2,365.67 4,849.38 1,570.43

Combined 675.94 2,121.92 5,984.92 2,586.29

a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate

adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years.
126

Smoking and Tobacco Control Monograph No. 8

Table 8

Mortality rate ratios for black male current smokers, by level of cigarette consumption—

standardized rate ratios for black male current smokers compared with white male neversmokersa

Age

Cigarettes

Per Day 35-49 50-64 65-79 All Ages

Lung Cancer

1-9 15.72 14.86 8.78 7.83

10-19 5.45 11.93 8.59 6.54

20 14.10 19.54 16.55 12.05

21-39 7.72 1.70

40+ 52.52 11.55

Combined 10.09 15.71 10.53 8.45

Coronary Heart Disease

1-9 2.09 1.54 1.03 1.29

10-19 1.05 1.81 0.92 1.12

20+ 3.79 1.72 1.14 1.20

21-39 1.90 2.27 1.94 1.28

40+ 1.06 0.18

Combined 2.20 1.71 1.01 1.21

Cerebrovascular Disease

1-9 15.49 7.55 2.42 2.18

10-19 3.82 1.84 0.93

20 18.66 4.61 1.95 1.84

21-39 4.33 0.28

40+ 3.64 1.37

Combined 9.54 5.14 2.07 1.66

Chronic Obstructive Pulmonary Disease

1-9 9.54 1.79 7.17

10-19 7.10 13.83 7.15

20 17.52 15.06 9.09

21-39 33.92 4.49

40+ 49.89 6.61

Combined 13.08 9.48 8.36

All-Cause Mortality

1-9 3.32 3.01 1.55 1.73

10-19 2.68 2.43 1.85 1.66

20 4.80 2.68 1.87 1.61

21-39 5.64 2.90 1.25 1.15

40+ 3.02 1.40 1.02

Combined 3.70 2.70 1.73 1.67

a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate

adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age.
127

Chapter 3

Table 9

Mortality rates among black female current smokers, by level of cigarette consumption—

standardized absolute mortality rates per 100,000a

Age

Cigarettes

Per Day 35-49 50-64 65-79 All Ages

Lung Cancer

1-9 15.19 39.16 11.53

10-19 12.89 92.65 86.36 47.05

20

21-39

40+ 668.43 197.22

Combined 3.80 42.33 45.56 21.92

Coronary Heart Disease

1-9 55.13 264.00 938.90 460.68

10-19 55.72 319.15 663.17 231.54

20 28.31 271.87 330.63 148.87

21-39 751.63 221.76

40+ 1,336.87 394.43

Combined 49.51 301.68 781.49 391.50

Cerebrovascular Disease

1-9 19.11 160.91 516.85 177.06

10-19 61.04 159.70 153.94 196.92

20 28.31 473.79 94.42

21-39 775.80 251.58

40+

Combined 46.80 129.35 429.88 170.34

Chronic Obstructive Pulmonary Disease

1-9 15.19 4.48

10-19

20

21-39

40+

Combined 8.22 2.43

All-Cause Mortality

1-9 319.48 1,004.55 3,438.59 1,576.38

10-19 393.11 1,380.88 1,671.75 937.97

20 421.01 822.07 3,842.67 1,070.41

21-39 775.80 1,343.00 647.82

40+ 2,005.30 591.65

Combined 364.45 1,098.49 3,076.47 1,419.34

a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate

adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age.
128

Smoking and Tobacco Control Monograph No. 8

Table 10

Mortality rate ratios for black female current smokers, by level of cigarette consumption—

standardized rate ratios for black female current smokers compared with white female

never-smokersa

Age

Cigarettes

Per Day 35-49 50-64 65-79 All Ages

Lung Cancer

1-9 1.79 1.68 1.20

10-19 7.86 10.89 3.71 4.89

20

21-39

40+ 78.55 20.48

Combined 2.32 4.97 1.96 2.28

Coronary Heart Disease

1-9 7.15 3.20 1.37 1.49

10-19 7.22 3.87 0.96 0.75

20 3.67 3.30 0.48 0.48

21-39 9.12 0.72

40+ 16.23 1.27

Combined 6.42 3.66 1.14 1.26

Cerebrovascular Disease

1-9 3.15 5.14 1.73 1.07

10-19 10.07 5.10 0.52 1.19

20 4.67 1.59 0.57

21-39 127.92 1.52

40+

Combined 7.72 4.13 1.44 1.03

Chronic Obstructive Pulmonary Disease

1-9 10.50 1.17

10-19

20

21-39

40+

Combined 5.68 0.63

All-Cause Mortality

1-9 2.12 2.08 1.64 1.50

10-19 2.61 2.86 0.80 0.89

20 2.79 1.70 1.84 1.02

21-39 5.15 2.78 0.62

40+ 4.15 0.56

Combined 2.42 2.27 1.47 1.35

a Rates adjusted within 15-year group by 5-year age-specific rates to 1980 U.S. standard population. All-ages rate

adjusted by 5-year age-specific rates to 1980 U.S. standard population older than 30 years of age.
129

Chapter 3

for each age interval as well as the fitted values for each type of regression,

all weighted to the square root of PMO's, for white males and females for

lung cancer, CHD, CVD, COPD, and all-cause mortality.

Number of deaths and PMO's were tabulated for current smokers, with

breakdowns along dimensions of age of initiation of smoking, duration

of smoking, number of cigarettes smoked per day, and attained age. The

difference between age of initiation and current monthly age was used

to calculate duration of smoking for current smokers.

RESULTS All-cause mortality risk due to smoking changes with the

age of the smoker. A long time lag exists between beginning

Changes in the Risk smoking and onset of an increase in risk, and the biologic

of Smoking With Age changes induced by smoking over time are cumulative in

their effect on mortality. Smoking-related increased risk is commonly

expressed as a ratio of the mortality rate in smokers compared with that

of never-smokers (rate ratio), and a single summary rate ratio for smoking

often is presented derived across all categories of smokers. However, the

mortality rate in never-smokers changes with age, and the difference in

mortality rates between smokers and never-smokers also changes with age.

As a result, rate ratios for smoking are not constant across all age groups.

The absolute magnitude of the excess mortality rate among smokers required

to produce a rate ratio of two is much larger at age 80 than it is at age 40.

Understanding changes in smoking risk with age requires an appreciation

of both change in rate ratio with age and change in excess mortality rates

with age.

Figure 1 presents age-specific rate ratios for all-cause mortality for white

male cigarette smokers in contrast to the absolute difference in mortality

rates between smokers and never-smokers of the same ages. Rate ratios for

all-cause mortality peak at 2.66 among the 45- to 49-year-old age group and

then decline steadily with further increases in age. Differences between

smoker and never-smoker mortality rates increase steadily with age and are

greatest for that age group with the lowest rate ratio (age 85 and older). The

inference that might be drawn from the rate ratio data alone that the impact

of smoking on mortality declines at older ages would be incorrect, or at least

incomplete. The impact of smoking on absolute, as opposed to relative,

mortality continues to grow with age.

A similar effect is noted when rate ratios and excess mortality rates for

white males are presented for four major causes of death linked to cigarette

smoking (Figures 2 and 3). Rate ratios for lung cancer and COPD are much

higher than those for CHD and CVD because of the multiplicity of other

etiologic factors for vascular disease, in contrast to the relative specificity of

cigarette smoking as a cause of lung cancer and COPD. There is a decline in

rate ratio for all these causes of death among older age groups.

The age at which an increased rate ratio is first manifest is not the same

for each cause of death. The rate ratio for CHD increases by the mid- to late30-year-old age group, peaks with the 40- to 44-year-old age group, and then
130

Smoking and Tobacco Control Monograph No. 8

1.0

1.2

35-39 40-44 45-49 50-54 55-59 60-64

Age Group

Rate Ratio

Difference in Smoker and

Nonsmoker Death Rates

65-69 70-74 75-79 80-84 85+

1.4

1.6

0

1.8

2.0

2.2

2.4

2.6

2.8

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Figure 1

White male age-specific all-cause rate ratio and excess mortality between smokers and

never-smokers

declines. An increased risk for lung cancer is first evident in the mid- to late40-year-old age group, and an increased rate ratio for death from COPD is

not evident until the late 50-year-old age group. This pattern is more evident

when the differences between smoker and never-smoker mortality rates are

examined (Figure 3). The impact of smoking on excess mortality prior to

age 60 is largely manifest through its effect on deaths from CHD. Between

ages 60 to 70 years, excess lung cancer mortality first increases rapidly,

followed by a rapid increase in excess COPD mortality during the next

decade of life. After age 80, each of these disease processes make an

equivalent contribution to excess mortality. Thus, excess cause-specific

mortality and all-cause mortality increase with age, but the fraction of

excess all-cause mortality attributable to CHD is greater at younger ages.

Tables 11 through 14 present 5-year age-specific smoking risks by level

of cigarette consumption per day for white males and females. Risks are

presented as rate ratios (Tables 11 and 13) and as excess mortality rates, and

the difference in mortality rates is presented between smokers and neversmokers (Tables 12 and 14). Risks are presented for each of four causes of

death and for all-cause mortality. Never-smoker rates used in these tables

are observed age-specific rates. Tables 5 to 7 and 9 present age- and causespecific death rates for smokers of specified numbers of cigarettes per day.

Fifteen-year age groups are presented for whites and blacks of both genders

to allow comparison across race and gender of actual death rates for smokers

in each stratum of age and number of cigarettes smoked per day. Rates were

adjusted within 15-year age groups by 5-year age-specific rates to the U.S.

1980 standard population, but no attempt was made to adjust for differences

in duration of smoking across strata or within strata for the different race and
131

Chapter 3

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

Lung cancer

30-34 35-39 40-44

0

2

4

6

8

85+

10

12

14

16

18

20

Rate Ratio

Age Group

Coronary heart disease Cerebrovascular disease Chronic obstructive pulmonary disease

Figure 2

White male cause-specific rate ratios for smoking by age

gender groups. Fifteen-year age groups were used because of the small

number of deaths occurring among blacks for some of the causes of death.

In general, the small numbers of deaths among black never-smokers for

many of the causes of death preclude generation of black-specific rate ratios.

For example, there were only two lung cancer deaths among black male

never-smokers. However, Tables 8 and 10 present rate ratios for black males

and females by cause of death and all-cause mortality using the death rates

among black smokers compared with the death rates among white neversmokers. These rate ratios allow rough comparison of the rate ratios for

blacks by number of cigarettes smoked per day but should be interpreted

with caution because of the small number of deaths among black smokers

and the likely confounding of age and duration of smoking in these crossrace comparisons.

White Males– Rate ratios for all-cause mortality among white males increase

Tables 5, 11, and 12 with increasing number of cigarettes smoked per day and are

higher at younger ages (45 to 54). Death rates for never-smokers are also
132

Smoking and Tobacco Control Monograph No. 8

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

Lung cancer

30-34 35-39 40-44

0

200

400

600

800

85+

1,000

1,200

1,400

Difference Between Smoker and

Nonsmoker Death Rates

Age Group

Coronary heart disease Cerebrovascular disease Chronic obstructive pulmonary disease

Figure 3

White male cause-specific excess mortality for smoking by age

lower at younger ages, particularly for those diseases for which smoking

causes most of the disease occurrence (lung cancer and COPD). A low death

rate among never-smokers can produce a large rate ratio for smokers even if

the actual death rates among smokers are modest. This effect is manifest

among white males by high rate ratios for lung cancer and COPD at younger

ages despite low excess death rates for these diseases. In contrast, the largest

contribution to excess mortality among smokers at younger ages results from

CHD even though the rate ratios for CHD are much lower than those for lung

cancer. This seeming discordance between rate ratios and excess mortality is

the result of the relatively high death rates from CHD among never-smokers,

and these higher CHD death rates in never-smokers occur because several

factors other than smoking (e.g., hypertension, elevated cholesterol) make

substantial causal contributions to CHD death rates.

Rate ratios for all-cause mortality and for disease-specific mortality

decline among white males at older ages; however, the excess mortality

rates among smokers for lung cancer, CHD, and COPD become similar in

magnitude as age increases (Table 12).

Increased rate ratios for CVD are evident at younger ages, but there is an

inconsistent dose-response relationship, possibly caused by low rates of death

from this cause at these ages. Rate ratios approach 1 among the older age

groups, and there is no clear dose-response relationship with the summary

rate ratios standardized to the U.S. 1980 population. Excess mortality rates

among smokers for CVD rise only modestly with age.
133

Table 11 Age-specific rate ratios for white male current smokers, by level of cigarette consumption Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 8

Lung Cancer

1-9 9.75 3.85 3.19 4.65 3.58 4.80 5.41 1.49 310-19 2.45 8.90 6.00 8.00 10.69 7.94 11.85 10.41 3.75 520 3.82 21.40 11.58 13.02 15.11 12.96 16.16 14.60 9.41 421-39 5.18 18.85 18.91 15.88 20.44 18.54 25.90 19.97 14.72 840+ 7.10 23.82 16.88 23.18 26.35 21.41 23.22 27.62 16.76 9Combined 4.15 18.43 12.77 13.60 16.05 12.82 15.41 12.84 6.47 4

Coronary Heart Disease

1-9 2.07 3.20 2.27 1.68 1.70 1.41 1.35 1.16 1.21 1.01 110-19 3.09 3.43 3.51 2.40 2.16 1.65 1.57 1.45 1.21 1.25 120 3.20 5.63 3.67 3.07 2.27 1.82 1.64 1.52 1.27 1.29 121-39 2.46 5.92 3.88 3.12 2.17 1.83 1.65 1.62 1.21 1.31 140+ 5.12 9.66 4.45 3.57 2.75 2.12 1.78 1.61 1.45 1.53 1Combined 3.15 5.73 3.73 2.97 2.26 1.79 1.61 1.47 1.25 1.22 1

Cerebrovascular Disease

1-9 2.13 2.78 1.56 1.62 1.75 1.35 1.03 1.40 0.93 110-19 2.45 3.63 1.13 1.75 1.76 1.58 1.34 1.15 1.01 120 2.54 3.41 1.68 2.19 2.06 1.73 1.26 1.11 1.12 021-39 3.46 4.09 2.36 2.25 2.30 1.72 1.39 1.11 0.82 140+ 1.89 3.02 2.62 3.22 2.60 1.77 1.43 1.36 1.60 0Combined 2.64 3.51 1.92 2.24 2.10 1.66 1.28 1.18 1.05 1
134

Table 11 (continued)

Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 8

Chronic Obstructive Pulmonary Disease

1-9 11.48 9.93 7.03 14.20 5.00 11.01 610-19 2.61 5.41 8.87 9.16 11.85 10.39 14.01 320 3.79 13.69 15.74 10.58 19.33 12.80 15.39 821-39 3.23 10.30 18.25 16.47 22.94 13.49 8.50 840+ 5.53 23.78 18.78 14.68 24.98 21.05 16.60 9Combined 3.47 12.81 14.93 11.53 17.70 11.01 13.36 6

All-Cause Mortality

1-9 0.65 1.73 1.93 1.50 1.61 1.46 1.35 1.36 1.36 1.20 110-19 1.83 1.36 2.28 1.94 1.96 1.73 1.70 1.61 1.42 1.31 120 1.82 2.17 2.65 2.43 2.21 2.03 1.84 1.79 1.51 1.48 121-39 1.79 2.40 2.65 2.70 2.27 2.22 2.07 2.01 1.65 1.42 140+ 2.91 3.20 3.39 3.18 2.94 2.55 2.25 2.01 1.82 1.65 1

Combined 1.87 2.21 2.66 2.47 2.25 2.03 1.85 1.73 1.48 1.36 1a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age.
135

Table 12 Age-specific excess mortality (rate difference) for white male current smokers, by level of cigarette consumption Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85

Lung Cancer

1-9 22.89 19.56 25.89 63.54 81.17 127.00 230.57 42.50 32810-19 8.64 20.68 34.34 82.72 168.57 217.87 362.75 492.37 236.74 55220 16.77 53.39 72.61 142.09 245.51 375.74 506.74 711.21 723.54 49321-39 24.91 46.72 123.01 175.87 338.39 550.86 832.15 922.17 1,179.83 93340+ 36.34 59.71 109.02 262.19 441.22 641.10 742.55 1,392.55 1,355.08 1,093Combined 18.74 45.62 80.84 148.98 261.88 371.41 481.62 619.34 470.08 490

Coronary Heart Disease

1-9 20.36 65.55 104.60 114.39 227.41 242.52 333.75 248.57 525.22 27.22 102210-19 40.02 72.39 207.11 233.74 376.52 390.65 546.88 688.21 513.71 908.26 71320 41.99 137.82 219.72 347.63 410.68 489.03 614.33 785.94 661.58 1,037.30 2,33121-39 27.98 146.61 237.29 355.29 380.78 496.87 626.62 949.34 515.53 1,112.00 94640+ 78.81 257.81 284.62 430.87 566.40 671.50 749.11 928.92 1,112.27 1,923.57 3,288Combined 41.03 140.85 225.05 329.64 408.95 475.19 590.15 714.66 609.62 790.90 1,359

Cerebrovascular Disease

1-9 10.13 16.34 14.24 23.56 59.54 63.30 13.45 369.67 -128.81 25810-19 12.96 24.12 3.26 28.76 60.26 106.43 149.35 139.92 13.05 88920 13.79 22.10 17.22 45.25 83.80 132.40 113.89 103.32 213.03 -37321-39 21.93 28.34 34.54 47.79 102.98 131.64 173.37 97.25 -322.44 12840+ 7.98 18.54 41.08 84.56 126.54 140.89 192.51 328.73 1,082.91 -1,146Combined 14.64 23.00 23.29 47.44 87.47 119.78 123.71 166.72 82.28 247
136

Table 12 (continued)

Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85

Chronic Obstructive Pulmonary Disease

1-9 28.17 58.93 87.79 234.34 183.23 496.49 69510-19 5.52 11.86 51.95 118.72 192.71 429.74 645.51 35720 9.57 34.11 97.28 139.46 325.50 540.03 713.66 90921-39 7.67 24.97 113.91 225.20 389.57 571.42 372.33 93340+ 15.56 61.19 117.35 199.19 425.66 917.47 773.86 1,093Combined 8.46 31.74 91.99 153.29 296.42 457.97 613.11 697

All-Cause Mortality

1-9 -42.08 136.52 237.92 214.68 442.25 585.96 749.00 1,243.74 2,138.83 1,933.24 1,20710-19 100.69 67.82 327.25 400.96 702.45 914.51 1,488.61 2,111.39 2,464.95 3,029.94 5,34220 98.95 218.62 422.08 611.99 885.56 1,295.23 1,792.11 2,710.24 3,021.68 4,616.55 3,98021-39 95.58 262.19 419.81 728.21 924.43 1,531.48 2,289.19 3,485.47 3,826.43 4,081.91 6,31540+ 231.47 412.95 610.53 935.53 1,416.44 1,954.96 2,658.94 3,475.43 4,858.38 6,220.61 5,100

Combined 105.09 226.63 423.11 630.09 911.25 1,302.30 1,809.07 2,515.85 2,872.05 3,493.70 3,716a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age.
137

Table 13 Age-specific rate ratios for white female current smokers, by level of cigarette consumption Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 8

Lung Cancer

1-9 1.69 0.81 1.06 1.56 1.27 1.68 0.88 1.01 10-19 2.62 2.10 3.49 2.56 3.32 3.19 3.36 2.72 3.38 20 8.48 8.89 7.71 6.41 4.74 8.34 6.33 3.06 1.25 321-39 18.20 11.87 12.80 9.54 10.06 11.86 9.31 14.41 6740+ 10.78 13.64 15.07 24.17 7.89 5.48 15.37 6.75 Combined 6.28 5.39 5.53 4.80 3.83 4.80 3.80 2.59 1.27 2

Coronary Heart Disease

1-9 9.20 0.68 1.89 1.59 1.41 1.17 1.06 1.07 1.09 1.18 010-19 7.37 2.36 2.72 2.63 2.43 1.85 1.77 1.55 1.47 1.33 120 3.63 3.24 3.81 2.96 2.02 1.86 1.78 1.21 1.19 121-39 19.48 5.82 3.59 4.16 2.91 2.25 1.79 1.91 1.93 1.54 140+ 6.47 4.02 4.34 3.87 2.82 1.86 1.18 0.78 0.57 1Combined 6.53 2.90 2.83 2.96 2.43 1.77 1.58 1.45 1.26 1.23 1

Cerebrovascular Disease

1-9 2.30 1.69 1.26 1.49 1.45 1.36 0.98 1.30 0.98 0.89 010-19 5.53 1.31 2.33 2.58 2.41 2.42 1.63 1.09 1.15 1.05 020 3.42 2.73 3.23 2.91 2.44 2.25 1.86 1.40 1.32 1.03 021-39 4.87 0.91 4.26 3.14 2.11 1.97 1.29 1.19 2.39 0.73 040+ 2.69 5.30 4.23 4.30 3.43 1.96 1.17 2.40 Combined 3.81 1.86 2.67 2.54 2.21 2.07 1.48 1.25 1.18 0.95 0
138

Table 13 (continued)

Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 8

Chronic Obstructive Pulmonary Disease

1-9 2.54 4.65 1.68 2.79 1.30 310-19 6.29 3.40 6.65 6.74 6.16 4.58 11.34 2.01 320 6.02 4.05 10.95 18.38 14.12 11.44 12.35 1.49 21-39 6.39 4.57 7.42 16.97 5.45 23.55 22.17 25.11 40+ 19.09 13.16 43.24 6.73 19.44 34.61 Combined 5.20 2.80 7.23 11.54 7.00 7.01 8.23 1.51 2

All-Cause Mortality

1-9 0.79 1.01 1.11 1.13 1.20 1.13 1.04 1.10 1.11 1.07 010-19 1.47 1.03 1.40 1.40 1.64 1.54 1.41 1.29 1.30 1.16 020 1.17 1.73 1.71 1.75 1.84 1.67 1.74 1.63 1.27 1.25 021-39 1.67 1.85 1.90 1.93 1.96 2.06 1.56 1.74 1.96 1.25 140+ 0.83 2.51 2.67 2.29 2.78 2.47 1.68 1.62 1.37 1.15 1

Combined 1.21 1.39 1.53 1.53 1.66 1.53 1.40 1.34 1.24 1.14 0a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age.
139

Table 14 Age-specific excess mortality (rate difference) for white female current smokers, by level of cigarette consumption Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85

Lung Cancer

1-9 1.14 -0.71 0.32 3.85 3.94 11.34 -2.48 0.52 10-19 2.68 4.04 12.46 10.86 33.36 36.81 49.65 66.11 113.10 20 12.40 29.09 33.59 37.52 53.81 123.18 112.01 79.26 11.88 1621-39 28.52 40.05 59.07 59.25 130.38 182.15 174.66 514.86 3,9040+ 16.22 46.58 70.43 160.76 99.14 75.20 302.05 220.68 Combined 8.75 16.18 22.66 26.39 40.72 63.81 58.90 60.92 12.80 6

Coronary Heart Disease

1-9 11.80 -2.69 13.28 17.32 27.69 26.69 21.27 50.53 119.09 421.16 -4310-19 9.17 11.25 25.85 48.25 96.27 137.26 265.62 378.22 625.83 762.21 1,1320 21.84 33.62 83.11 131.50 164.55 299.76 534.54 276.20 444.43 9921-39 26.61 39.99 38.82 93.28 128.16 200.77 274.82 622.77 1,224.47 1,226.77 2,8840+ 45.34 45.31 98.71 192.69 292.97 297.02 125.97 -284.21 -975.03 3,58Combined 7.96 15.78 27.46 58.00 95.86 124.47 200.49 308.87 343.81 534.95 31

Cerebrovascular Disease

1-9 3.74 4.56 2.43 8.77 11.34 19.54 -2.21 81.72 -15.71 -154.32 -1,0010-19 13.03 2.05 12.61 28.18 35.66 76.21 79.24 23.83 96.61 66.24 -4120 6.96 11.45 21.18 34.14 36.55 67.33 107.42 111.29 209.21 47.15 -7321-39 11.15 -0.60 30.90 38.21 28.24 52.03 36.72 51.00 901.14 -374.91 -1,2040+ 11.24 40.79 57.58 83.66 130.72 120.36 47.94 906.45 Combined 8.09 5.73 15.86 27.42 30.74 57.70 60.19 69.50 118.65 -63.65 -81
140

Table 14 (continued)

Age

Cigarettes

Per Day 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85

Chronic Obstructive Pulmonary Disease

1-9 1.96 7.19 3.11 14.86 4.48 10910-19 2.79 2.80 7.20 11.29 23.51 29.74 154.84 40.31 11220 2.64 3.56 12.67 34.22 59.82 86.71 169.91 19.43 21-39 2.84 4.17 8.18 31.44 20.31 187.36 316.98 964.99 40+ 9.53 15.50 83.18 26.10 153.22 503.16 Combined 2.21 2.10 7.94 20.75 27.36 49.96 108.16 20.35 79

All-Cause Mortality

1-9 -21.35 1.34 23.91 41.64 87.38 92.58 44.13 214.02 404.33 490.61 -2,02610-19 47.72 4.36 84.93 129.08 280.45 389.08 496.21 587.89 1,149.69 1,116.98 -51720 17.30 109.32 151.47 244.61 369.14 484.22 890.65 1,295.42 1,018.92 1,725.55 -62021-39 67.52 127.80 192.80 301.71 419.22 762.73 671.52 1,511.79 3,625.62 1,705.75 7,09840+ -17.31 225.59 358.70 421.11 777.79 1,055.52 817.63 1,268.50 1,393.41 1,057.78 2,546

Combined 21.45 59.01 112.76 171.32 287.53 384.15 487.15 700.73 907.02 964.11 -1,172a Standardized to U.S. 1980 population by 5-year strata greater than 30 years of age.
141

Chapter 3

White Females– All-cause and cause-specific mortality rate ratios are generally

Tables 6, 13, and 14 lower for white females than for white males. Excess mortality

rates among smokers also are lower for each cause of death among white

females compared to white males. The general pattern of dose-response

relationships and change in risk with age is similar for white males and

females once the difference in magnitude of risks is considered. Part of the

difference between white males and white females in relative and excess

mortality is attributable to differences in duration of smoking between males

and females of the same age, particularly among the older age groups. Males

began to smoke cigarettes in large numbers in the early part of this century,

whereas females initiated smoking during the late 1930's and 1940's (see

Chapter 2). Female smokers in CPS-I also smoked fewer cigarettes per day

than male smokers, contributing to their lower age-specific rate ratios.

Black Males– Numbers of deaths and PMO's among black males were substantially

Tables 7 and 8 smaller than those among whites of both genders. There were only

two deaths from lung cancer and no deaths from COPD among black male

never-smokers. Among black male smokers there were 62 deaths from lung

cancer and 24 deaths from COPD. Mortality rates for black male smokers are

presented for age groups where deaths occurred (Table 7). To allow some

approximation of the risks occurring among black male smokers, white male

age-specific never-smoker death rates are compared with rates among black

male smokers to generate rate ratio estimates (Table 8).

The patterns seen in lung cancer and CHD rate ratios with number of

cigarettes per day and age-specific changes in rate ratio are similar for black

and white males. The absence of deaths from COPD among black male neversmokers precludes estimation of the rate ratios, but when white male neversmoker rates are used, an overall COPD rate ratio of 8.39 is calculated for

black males compared with 10.96 among white males.

No smoking-related increased risk for CVD is evident among black male

smokers, and the increased risk demonstrated when white male never-smoker

rates are used probably reflects the higher rates of CVD among all black males.

Black Females– Numbers of deaths and PMO's among black females were larger than

Tables 9 and 10 those available for black males but were still substantially smaller

than those for white males or females. Only modest increases in risks for

lung cancer and CHD are demonstrable among black female smokers, and

there does not appear to be an increased risk for CVD or all-cause mortality.

There were too few deaths from COPD among black female smokers and

never-smokers for meaningful estimation.

Changes in the Risk Risks of smoking cigarettes have traditionally been expressed

of Smoking With in relation to the age of the smoker, using age-specific

Duration of Smoking rates for never-smokers as a comparison group. However,

individuals begin smoking at different ages, and a given age group of smokers

may contain individuals with markedly different durations of exposure.

Therefore, categorizing disease risks by duration of smoking, rather than age,

may be a more accurate method of examining this exposure. Tables 1 and 2
142

Smoking and Tobacco Control Monograph No. 8

present rate ratio of cigarette smoking stratified by duration of smoking and

number of cigarettes smoked per day. The comparison rate of never-smokers

is a weighted average of never-smoker age-specific rates corresponding to

those age groups of smokers each duration category. The age-specific rates

of never-smokers are weighted by the PMO's in each age group of smokers

within the duration category. Therefore, these rate ratios include any effect

modification due to the differences in distribution by age of the population

contained in the duration-specific strata.

Three variables define the temporal dimensions of smoking exposure:

attained age, age of initiation, and duration of smoking. Once any two of

these variables are specified for an individual smoker, the third is fixed, and

attained age and duration of smoking become collinear variables. Because

these variables are time based and because much smoking initiation occurs

during a narrow period of adolescence and young adulthood, attained age for

a population is an index of duration of exposure. Presentation of rate ratios

in relation to the duration of cigarette use allows examination of risk with

both principal determinants of smoking-related risk (duration and number

of cigarettes smoked per day) stratified in the same table.

White Males– In contrast to age-specific rate ratios for lung cancer and COPD,

Table 1 which increase, peak, and then decline with age, duration-specific

risks for these diseases increase steadily with increasing duration, excluding

the 60+-years-of-duration category. The pattern for CHD is different, with

rate ratios increasing to the 30- to 34-years-of-duration category and then

declining. Cigarette smoking is the dominant etiologic factor for lung cancer

and COPD in the population, and duration is a powerful determinant of that

risk; however, CHD has a multifactorial etiology, and duration of exposure

plays a less powerful role in determining risk. The pattern for CVD rate ratios

is also an increase and then a decline, with the peak in rate ratios occurring

at a somewhat longer duration than for CHD.

A second observation from these data is the lag time between initiation

of smoking and the onset of an increased risk of the different diseases. Rate

ratios for lung cancer and CHD are low, and there is no clear dose-response

relationship with number of cigarettes smoked per day until the 20- to 24-

years-of-duration category. The rate ratios for COPD begin to rise with the

35- to 39-years-of-duration category, and this is the first category with a

consistent dose-response. A pattern for CVD is not clearly manifest but may

be similar to that for CHD. The rate ratios for all-cause mortality first show

a consistent dose-response with the 20- to 24-years-of-duration category.

White Females– Table 2 presents rate ratios for female smokers stratified by the

Table 2 the major differences between males and females in smoking

behavior: duration of smoking and number of cigarettes smoked per day.

Rate ratios for lung cancer and all-cause mortality among females are

generally well below the rate ratios for males in the same strata. Figure 4

presents duration-specific lung cancer rate ratios for males and females who

smoke 20 cigarettes per day and for all levels of consumption combined.
143

Chapter 3

25-29 30-34 35-39 40-44 45-49 50-54 55-59

0

2

4

6

8

10

12

18

16

Male—20 cigarettes per day

14

Mortality Rate Ratio

Duration of Cigarette Smoking (years)

Female—20 cigarettes per day

Female—all levels combined

Male—all levels combined

Figure 4

Rate ratio by duration of cigarette smoking for white males and females who smoked

20 cigarettes per day and for all levels of consumption

The lung cancer risks for males are higher than those for females for all levels

of consumption combined and for a specific dose (20 cigarettes per day).

The rate ratios for 20 cigarettes per day are similar to the all-levels-combined

ratios for males, but the combined rate ratios are lower than the 20-cigarettesper-day level for females. This suggests that there are additional reductions

in female combined rate ratios produced by the relative distribution of

female smokers into those strata with lower numbers of cigarettes smoked per

day. Differences between male and female lung cancer risks are not entirely

explained by differences in duration and current number of cigarettes smoked

per day in this population. Differences in number of cigarettes smoked per

day in the past, in tar yield of the cigarettes smoked, in depth of inhalation,

or in other factors may explain these differences in lung cancer risks, as may

differences between males and females in the age distributions of the

individual strata.

When rate ratios for COPD are compared for males and females in the

same dose and duration strata, rate ratios are similar or slightly higher for

white females. Combined rate ratios are lower because of differences in

distribution of dose and duration among females, but rate ratios for specified

dose and duration categories are similar or elevated. There are a smaller

number of deaths from COPD among women, making the rate ratios

estimates somewhat unstable; there also may be a lower COPD death

rate among female never-smokers compared with male never-smokers.
144

Smoking and Tobacco Control Monograph No. 8

Changes in the Risk Rate ratios for all-cause and tobacco-related disease-specific

of Smoking With mortality decline with cessation of cigarette smoking.

Duration of Cessation Mortality risks within the first year of cessation are often

reported to be higher than those for continuing smokers because many

individuals quit following diagnosis of disease. For this reason, we have

reported rate ratios beginning after the second year of cessation and have

excluded those deaths and person-years of followup that occurred during

the first 24 months of cessation.

White Males– A steady decline in all-cause rate ratios occurs with continuing

Table 3 cessation; by 20 to 24 years of cessation, all-cause rate ratios have

returned to one. Rate ratios for lung cancer also decline but seem to plateau

once 20 years of cessation has been reached. Rate ratios remain elevated at

approximately 1.5 to 2 times that of never-smokers even for long durations

of smoking. Rate ratios for CHD decline more rapidly than those for lung

cancer, but an increased risk appears to remain for 20 years following

cessation. A similar pattern of rate ratio decline occurs with cessation

for CVD.

Rate ratios for COPD decline steadily with cessation, but the risks for the

first 9 years of cessation are higher than those of continuing smokers. This

may be attributable to the high rate of cessation that occurs following the

development of clinically significant lung disease. A substantial amount of

lung injury must occur to result in symptoms from COPD. This injury is

not reversed with cessation, and a substantial period usually occurs between

onset of symptoms and death from respiratory failure. In many patients,

COPD will progress and eventually cause death, even if the patients stop

smoking. It is likely that these clinically symptomatic individuals who quit

smoking elevate the COPD death rate among former smokers for several years

following cessation. As with lung cancer, the rate ratios for COPD do not

return to 1 and appear to remain elevated even after prolonged cessation.

White Females– The number of former smokers among white females was much

Table 4 smaller than among males, particularly for former smokers of long

duration. Clear declines in rate ratio were evident for CHD, CVD, and allcause mortality, but the limited number of observations do not allow a clear

conclusion to be drawn about rate ratios for lung cancer and COPD.

Changes in the Risk Early age of initiation may increase the risk of smoking-related

of Smoking With disease in two ways. One, early age of initiation increases

Age of Initiation the duration of smoking at any given age, and two, duration

is a powerful determinant of smoking-related risk. However, it also has been

postulated that the dose-to-produce-an-effect relationship for carcinogenic

transformation may be lower at younger ages, making early age of initiation

a factor in defining risk independent of its contribution to duration of

smoking (Moolgavkar et al., 1989). The hypothesis that early age of

initiation may increase risk has been incorporated into some models of

tobacco carcinogenesis (Moolgavkar et al., 1989). Appendix B presents data

on age-specific, duration-specific, and number-of-cigarettes-per-day-specific

mortality. These data can be used to examine the effect of early age of
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Chapter 3

initiation, independent of its contribution to duration, by comparing rates

for groups with different ages of initiation but the same durations of

smoking.

Attained age, age of initiation, and duration of smoking are three timebased variables determining smoking risk. If a constant duration category is

defined, only one of the other terms (age of initiation or attained age) can be

varied, because fixing age of initiation and duration specifies the attained

age of the smoker. Tables in Appendix B and figures 5 and 6 in this chapter

are presented by attained age rather than age of initiation because attained

age was recorded in single years, whereas age of initiation was recorded as a

categorical variable. However, attained age is linked to age of initiation

in these tables and figures, and can be converted to age of initiation by

subtracting the duration from attained age.

Age of Initiation Figure 5 presents rate ratios for lung cancer for those cells in

and Rate Ratio in Appendix B of constant durations. Risks are plotted against

of Lung Cancer attained age, and regression lines are presented for points

representing specific numbers of cigarettes smoked per day. Each graph

within the figure is for a single duration-of-exposure category.

No clear pattern emerges in slopes of the regression lines of the rate

ratios until the 40- to 44-years-of-duration category is reached, and then

a clear negative slope with increasing attained age occurs for most of the

regression lines. Interpretation of changes in rate ratios with attained

age is complicated by the previously described decline in rate ratio with

increasing age.

The authors postulated that an effect of age of initiation, independent

of its effect on duration of exposure, also would be manifest as a decrease in

excess mortality rates with increasing attained age among smokers with

similar durations of smoking. Figure 6 presents the log of excess mortality

rates for smokers of constant durations. Risks are plotted against attained

age, and regression lines are presented for points representing specific

numbers of cigarettes smoked per day. Each graph within the figure is for a

single duration-of-exposure category. Slopes of the lines with increasing age

within duration categories tend to be positive for the three shortest duration

categories. However, the slopes of the lines for the five longest categories are

not significantly greater than zero. An independent effect of age of initiation

should result in higher excess mortality at the younger ages within constant

duration categories. A constant duration line should then have a negative

slope with increasing attained age because an older attained age for the same

duration of smoking means that smoking must have been initiated later in

life.

We conclude from these analyses that the major contribution of early

age of initiation to increased risk of lung cancer is mediated through the

longer duration of smoking at any given age that occurs with earlier age of

initiation. An independent effect of age of initiation, if any exists, would

be small.
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Smoking and Tobacco Control Monograph No. 8

Figure 5

Rate ratios for lung cancer for white males for smoking by duration, level of consumption,

and age

Key: cpd = cigarettes per day.
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Chapter 3

Figure 6

Excess mortality for white males for smoking by duration, level of consumption, and age

Key: cpd = cigarettes per day.
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Smoking and Tobacco Control Monograph No. 8

An increase in excess mortality rates for smokers with increasing attained

age is observed for the three shortest duration-of-exposure categories. The

age-specific rates for never-smokers already have been subtracted from the

rate for smokers, so any independent additive effect of age should already

have been removed from the values in the graphs. This positive slope with

attained age might represent an interaction of age and smoking such that

smoking at an older age carries with it an increased risk in comparison to the

same intensity of smoking at a younger age. If this interaction is present,

a positive slope could be expected among the longer duration-of-exposure

categories, and there is none. It is possible that an interaction with age

might be small or might have a maximum effect that is reached at shorter

durations. The interaction then might be overwhelmed by the larger effect

of duration of exposure at longer durations.

An additional likely possibility is that individuals with short durations

of smoking and older attained ages (i.e., who began smoking later in life)

may have begun smoking cigarettes after having smoked pipes or cigars

for several years. This would result in these smokers, when reporting their

duration of smoking cigarettes, underestimating their total duration of

exposure to tobacco smoke and overestimating the risk of smoking for a

given duration. Many males switched from smoking pipes and cigars to

smoking cigarettes in the early part of this century (see Chapter 2), and the

older age groups of smokers in the CPS-I population are likely to contain

many individuals who switched to cigarettes earlier in life.

APPENDIXES Appendix A is a set of risk ratio tables for age and number of cigarettes

smoked per day for an expanded list of causes of death. This appendix

allows examination of dose-response relationships for these causes of death

as well as presenting summary risk ratios. Tables are presented for white

males and white females separately.

Appendix B is a series of detailed tables of risk by duration of smoking.

Risks are presented for age-specific and number-of-cigarettes-smoked-per-dayspecific categories for each duration of exposure. Never-smoker rates used in

these tables are based on a logistic regression of the never-smoker age-specific

rates for each cause of mortality. Risk estimates for white males and white

females are presented for lung cancer, CHD, CVD, COPD, and all-cause

mortality. Tables 1a-1f through 10a-10f present observed number of deaths,

PYO's, never-smoker rates, excess mortality rates, and rate ratios for smokers

compared with never-smokers.

Appendix C lists the number of deaths and PYO's for lung cancer, CHD,

CVD, COPD, and all-cause mortality by age group for black never-smokers

and current smokers of both genders and white never-smokers, current

smokers, and former smokers of both genders.

Appendix D gives the age-specific rates by disease, and for all-cause

mortality, for never-smokers. The rates are presented as observed death rates

and fitted death rates resulting from Poisson regression and linear regression

of the log rates.
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REFERENCES

Garfinkel, L. Selection, follow-up, and analysis in the

American Cancer Society prospective studies.

National Cancer Institute Monographs 67: 49-52,

1985.

Hammond, E.C. Smoking in relation to the death

rates of one million men and women. In:

Epidemiological Approaches to the Study of Cancer

and Other Chronic Diseases, W. Haenszel (Editor).

National Cancer Institute Monograph No. 19.

Bethesda, MD: U.S. Department of Health,

Education, and Welfare, Public Health Service,

National Institutes of Health, 1966, pp. 127-204.

Hammond, E.C., Garfinkel, L., Seidman, H., Lew, E.A.

Some recent findings concerning cigarette

smoking. In: Origins of Human Cancer. Book A:

Incidence of Cancer in Humans, H.H. Hiatt, J.D.

Watson, and J.A. Winsten (Editors). Cold Spring

Harbor Conference on Cell Proliferation, Vol. 4.

Cold Spring Harbor, NY: Cold Spring Harbor

Laboratory, 1977, pp. 101-122.

Moolgavkar, S.H., Dewanji, A., Luebeck, G. Cigarette

smoking and lung cancer: Reanalysis of the British

doctors' data. Journal of the National Cancer Institute

81(6): 415-420, 1989.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking: 25

Years of Progress. A Report of the Surgeon General,

1989. DHHS Publication No. (CDC) 89-8411.

Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, Centers

for Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health, 1989.

World Health Organization. Manual of the International

Statistical Classification of Diseases, Injuries, and

Causes of Death (7th ed. rev. of the International

Lists of Diseases and Causes of Death, adapted

1955). Vol. 1. Geneva: World Health Organization,

1957.
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Chapter 3

Appendix A

Cause-Specific Risk Ratio of Mortality for White Males and Females for All

Causes of Death

The tables in this appendix depict mortality risk ratio by cause of death

for current smokers compared to never-smokers by level of cigarette

consumption for 15-year age groups.

Cigarette consumption groups:

• 1-19 cigarettes per day;

• 20 cigarettes per day;

• 21+ cigarettes per day; and

• combined levels.

Age groups:

• 35-49 years;

• 50-64 years;

• 65-79 years;

• 80+ years; and

• combined ages.

The minimum requirement for a cell to display a ratio is two deaths in

the category for both current smokers and never-smokers. All ratios are

standardized by 5-year age-specific rates to the 1980 U.S. population.
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Appendix B

Excess Mortality and Relative Risk (Rate Ratio) of Death for Current Smokers,

by Duration, Number of Cigarettes Per Day, and Attained Age

For each category of 5-year duration of smoking, 5-year attained age,

and number of cigarettes per day, a complete breakdown is given of the

following:

• Observed deaths.

• Total person-years of observation (PYO’s).

• Never-smoker rate for specific attained age; the modeled rate is

provided by Poisson regression of never-smoker rates by age and

weighted to the square root of PYO’s. For combined ages, the rate is

adjusted to match the distribution of PYO’s by age for the comparable

current smoker group.

• Excess mortality—current smoker rate minus never-smoker rate.

• Relative risk—current smoker rate divided by never-smoker rate.

Duration is given for 5-year groups from 0 to 80 years duration of

smoking. Attained age is given for 5-year groups from 40 to 85 years of age.

Reported cigarettes per day is given in categories of 1-9, 10-19, 20, 21-39, and

40+, and current smokers of any number of cigarettes. Combined rates are

reported across both duration and age, with reported rates weighted to

observed PYO’s within the category.

Table Subject Group

1 White male lung cancer (1°, 2°, and 3° cause of death)

2 White male coronary heart disease

3 White male cerebrovascular disease

4 White male chronic obstructive pulmonary disease (COPD)

5 White male all-cause mortality

6 White female lung cancer (1°, 2°, and 3° cause of death)

7 White female coronary heart disease

8 White female cerebrovascular disease

9 White female COPD

10 White female all-cause mortality
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Table Number of Cigarettes Per Day

Subgroup

A 1-9 cigarettes per day

B 10-19 cigarettes per day

C 20 cigarettes per day

D 21-39 cigarettes per day

E 40+ cigarettes per day

F Current smokers of any number of cigarettes
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Appendix C

Summary of Person-Years of Observation and Deaths, by Subject Group

Each table provides person-years of observation (PYO’s) and number of

deaths due to lung cancer (1°, 2°, and 3° cause of death), coronary heart

disease, cerebrovascular disease, chronic obstructive pulmonary disease, and

all-cause mortality by 5-year age groups. Total PYO’s and deaths for each

category and total number of subjects (N) are given.

Table Subject Group

1 White male never-smoker

2 White male current smoker

3 White male former smoker

4 White female never-smoker

5 White female current smoker

6 White female former smoker

7 Black male never-smoker

8 Black male current smoker

9 Black female never-smoker

10 Black female current smoker
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Chapter 3

Appendix D

Tables of Observed and Fitted Death Rates for Never-Smokers, by Sex and

Age Group

For 5-year age groups between 40 and 85 years, the observed death rates

and the fitted death rates for white never-smokers are given by sex. The

modeled rates include Poisson regression and linear regression of log (rate).

Modeled rates are weighted to the square root of the total person-years of

observation for the cells.

Table Cause of Death

1 Lung cancer (1°, 2°, and 3° cause of death)

2 Coronary heart disease (1° cause of death)

3 Cerebrovascular disease (1° cause of death)

4 Chronic obstructive pulmonary disease (COPD) (1° cause of death)

5 All-cause mortality
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Chapter 4

Trends in Tobacco Smoking and Mortality

From Cigarette Use in Cancer Prevention

Studies I (1959 Through 1965) and II

(1982 Through 1988)

Michael J. Thun, Cathy Day-Lally, Dena G. Myers, Eugenia E. Calle, W. Dana

Flanders, Bao-Ping Zhu, Mohan M. Namboodiri, and Clark W. Heath, Jr.

INTRODUCTION Despite the vast literature on the adverse effects of tobacco smoking

and on trends in the diseases caused by smoking in the general population,

there are almost no descriptive data on how death rates in smokers and

never-smokers have changed over time. The 1989 U.S. Surgeon General’s

report (U.S. Department of Health and Human Services, 1989) noted that in

the 20-year period from the mid-1960’s through the early 1980’s, the relative

risk of fatal lung cancer approximately doubled in male cigarette smokers

and increased nearly fivefold in female cigarette smokers; smaller increases

were observed for coronary heart disease (CHD) and stroke. The Surgeon

General based these observations on preliminary comparisons of Cancer

Prevention Studies I and II (CPS-I and CPS-II) of the American Cancer Society

(ACS) that cover the years 1959 through 1965 and 1982 through 1986,

respectively.

Because CPS-I and CPS-II provide smoking information and mortality

data on populations studied with comparable techniques in the 1960’s and

1980’s, these data can be used to gain a longitudinal perspective on changes

in smoking-specific mortality over time (Shopland et al., 1991). This chapter

extends the analyses in the 1989 Surgeon General’s report (U.S. Department

of Health and Human Services, 1989) by (1) comparing patterns of cigarette

smoking (i.e., prevalence, amount, age of initiation, and duration) in CPS-I,

CPS-II, and two nationally representative surveys from the same periods;

(2) extending followup of CPS-II for 2 additional years through 1988;

(3) presenting death rates, rate ratios (RR’s) (death rate in smokers divided

by that in never-smokers), and rate differences (RD’s) (death rate in smokers

minus the rate in never-smokers) for lung cancer, CHD, chronic obstructive

pulmonary disease (COPD), stroke, other smoking-related cancers, and all

causes combined among current cigarette smokers and lifelong neversmokers in CPS-I and CPS-II; and (4) examining the extent to which the

rise in lung cancer death rates from CPS-I to CPS-II can be explained by

cigarette consumption.
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SUBJECTS AND Subjects in the analyses were drawn from CPS-I (Garfinkel, 1985;

METHODS Hammond, 1964 and 1966) and CPS-II (Garfinkel, 1985; Garfinkel

and Stellman, 1988; Peto et al., 1992; Stellman and Garfinkel,

Study Population 1986); selected characteristics are shown in Table 1. Subjects were

recruited in fall 1959 for CPS-I and in fall 1982 for CPS-II from among the

friends, neighbors, and acquaintances of ACS volunteers. Enrollment was

based on those who were part of a household, excluding persons in

institutions or military service and itinerants who would be difficult to

trace (Garfinkel, 1985). Volunteers sought to enroll all household members

30 years of age or older if at least one family member was 45 years or older.

CPS-I included subjects from 25 States; CPS-II included subjects from

50 States, the District of Columbia, Puerto Rico, and Guam. Participants in

both studies were older, more educated, and more frequently married and

part of the middle class than the general U.S. population (Garfinkel, 1985;

Stellman and Garfinkel, 1986). Whites made up 97 percent of CPS-I and

93 percent of CPS-II.

Because the age distributions of subjects in CPS-I and CPS-II were similar

at the time of enrollment, the two studies represent birth cohorts separated

by approximately 20 years (Figure 1). CPS-I includes predominantly cohorts

born between 1880 and 1919, whereas CPS-II participants were mostly from

cohorts born from 1900 to 1939 and who became adults during the peak

years of cigarette smoking in America (U.S. Department of Health and Human

Table 1

Selected characteristics of CPS-I and CPS-II

Full Cohorts CPS-I CPS-II

Followup Perioda 1959-1965 1982-1988

Study Participants 1,051,038 1,185,106

Vital Status, Number (percent)b

Alive: 959,121 (91.3) 1,083,600 (91.4)

Dead: 76,888 (7.3) 79,802 (6.7)

Lost: 15,029 (1.4) 21,704 (1.8)

Exclusions

Former smokers 70,108 262,790

Ever pipe/cigar 149,828 101,600

Smoking data incomplete or unclassifiablec 44,715 109,353

Total exclusions 264,651 473,743

Analytic Cohorts

Current cigarette smoker 298,687 228,682

Lifelong never-smoker 487,700 482,681

Total analytic cohort 786,387 711,363

a Analyses restricted to first 6 years of followup to enhance comparability.

b Vital status as of September 30, 1965, for CPS-I and August 31, 1988, for CPS-II. Followup terminated before

September 30, 1965, for 1,005 CPS-I participants because of administrative reasons (see text).

c Excludes subjects with incomplete or unclassifiable data on status, pipe or cigar smoking, cigarettes per day, or

duration of smoking.

Key: CPS = Cancer Prevention Study.
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Chapter 4

Figure 1

Distribution of CPS-I and CPS-II participants by 10-year birth cohort

40

CPS-I CPS-II

30

20

10

0

1850 1870 1890 1910

Decade of Birth

Percent

1930 1950

Services, 1989). The number of subjects in each birth cohort and the

relationship between year of birth and age at enrollment are shown in

Appendix 1.

Table 1 shows the composition of the included and excluded subjects

analyzed in this chapter. Death rate analyses were based on more than

220,000 current smokers (defined below) and more than 480,000 lifelong

never-smokers in each study, excluding former smokers, persons who ever

smoked pipes or cigars, and those whose information on smoking was

incomplete or unclassifiable. Analyses of smoking prevalence were based

on the full cohorts. Certain analyses of lung cancer were restricted to current

cigarette smokers, ages >50 years, who reported smoking 20 or 40 cigarettes

per day for at least 30 years at baseline.

Followup The participants’ vital status was determined through personal inquiry by

the volunteers for 12 years in CPS-I and 6 years in CPS-II. For comparability,

the analyses were restricted to the first 6 years in each study: for CPS-I from

enrollment through September 30, 1965, and for CPS-II from enrollment

through August 31, 1988. Persons lost to followup were considered alive

until the date last observed, which in CPS-II was considered to be the

end of followup. Included in the group “lost to followup” in CPS-I were

1,005 participants for whom followup was terminated early because of

the inability of some local field units to continue the study (Table 1)

(Hammond, 1966). Death certificates were obtained for deceased subjects.

The underlying cause of death was coded according to abbreviated versions
Smoking and Tobacco Control Monograph No. 8

308

of the Manual of the International Statistical Classification of Diseases, Injuries,

and Causes of Death (ICD-7) (World Health Organization, 1957) for CPS-I and

the Manual of the International Statistical Classification of Diseases, Injuries, and

Causes of Death (ICD-9) (World Health Organization, 1977) for CPS-II.

Smoking Information At enrollment in the two studies, participants completed a

four-page questionnaire that had similar questions on smoking. Participants

in CPS-I were asked, “Do you now smoke?,” and if the answer was yes, “How

many cigarettes do you usually smoke a day?”; parallel questions were asked

about pipe and cigar smoking (men only) and former smoking. Participants

in CPS-II were asked, “Do you now or have you ever smoked cigarettes at least

one a day for 1 year’s time?” For men this question also mentioned cigars

and pipes. Current and former smokers were asked to complete separate

sections on the age of starting, average number of cigarettes smoked per day,

duration of smoking, and depth of inhalation. In the prevalence analyses,

current smokers were defined as any current cigarette smokers regardless of

their use of pipes or cigars. In the rate analyses, current smoker status was

restricted to persons who smoked cigarettes only and to those with complete

data on amount and duration. Never-smokers were defined as persons who

never smoked any tobacco product.

Smoking Prevalence We compared baseline data on the prevalence of cigarette

smoking (with or without pipes or cigars) among subjects in CPS-I and CPS-II.

Also assessed was how data from these cohorts represent national smoking

patterns by comparing age-, race-, and sex-specific data as well as age-adjusted

prevalence in CPS-I and CPS-II to corresponding data for persons ages ≥30 in

the National Health Interview Surveys (NHIS) conducted in 1965 (NHIS-65),

1983 (NHIS-83), and 1987 (NHIS-87) (National Center for Health Statistics,

1975; Kovar and Poe, 1985; Massey et al., 1989). These probability samples of

the civilian, noninstitutionalized population of the United States provided

weighted, nationally representative estimates of smoking in the Nation near

the baseline interviews of CPS-I (1959) and CPS-II (1982). NHIS-83 did not

include questions on pipe or cigar smoking. The percentage of men in NHIS83 who smoked only pipes or cigars was therefore estimated from NHIS-87.

The age-specific percentage of men in NHIS-83 who smoked only cigarettes

was estimated from the age-specific percentage in NHIS-83 who never

smoked cigarettes minus the percentage in NHIS-87 who smoked only pipes

or cigars. The definition of current smoking differed slightly between NHIS

and CPS-I and CPS-II. In NHIS, current smoking was defined as smoking at

least 100 cigarettes (in addition to at least some smoking cigars and/or pipes)

in a lifetime plus smoking during the past 30 days. Smoking prevalence was

adjusted for age using direct standardization with weighting by the combined

baseline age distribution for CPS-I and CPS-II (Appendix 2).

Cigarettes The data on daily cigarette consumption reflected current (at time of

Smoked enrollment), but not past, usage in both studies. The CPS-I data were

Per Day precategorized (1-9, 10-19, 20, 21-39, 40, ≥41 cigarettes per day). Using

these categories, we compared the percentage distribution of smokers in

CPS-I, CPS-II, NHIS-65, and NHIS-83 within 5-year age groups. We also
309

Chapter 4

estimated the mean daily consumption of cigarettes within age groups,

based on published midpoints for the CPS-I categories (4.8, 12, 20, 29.2, 40,

58.6 cigarettes) (Hammond et al., 1977) and the continuous data in CPS-II.

The mean`number of cigarettes currently smoked per day in CPS-I and CPS-II

were compared with the corresponding values in NHIS-65 and NHIS-83.

Age of Smoking In CPS-I, the age when subjects began smoking also was

Initiation precategorized (<10, 10-14, 15-19, 20-24, . . . ≥50 years). Using

these categories, we compared the cumulative percentage of cigarette

smokers in each of the four studies who had begun smoking by various ages

(<15, <20, <25, <30) within 10-year birth cohorts. We also converted the

age of initiation categories to their estimated midpoints (9, 12, 17, . . . 50)

and compared the mean age of smoking initiation within 10-year birth

cohorts in the four studies.

Duration of Smoking The number of years that current smokers had smoked

cigarettes prior to enrollment was calculated in CPS-I by subtracting the

estimated age of initiation from age at enrollment. In CPS-II, the duration

value reported by the respondents was used, or if that value was missing,

it was calculated as in CPS-I. Because there was no information on changes

in smoking status in CPS-II, the duration was considered to be fixed

throughout the followup in both studies.

Endpoints Analyses were restricted to the major causes of smoking-related mortality:

lung cancer, CHD, COPD, stroke, other smoking-related cancers (oropharynx,

larynx, esophagus, pancreas, bladder, and kidney), and all causes of death

combined. ICD-7 (World Health Organization, 1957) and ICD-9 (World

Health Organization, 1977) codes corresponding to each disease category

are listed in footnotes in the relevant tables. As in many other prospective

studies of smoking (Doll and Hill, 1966; Doll and Peto, 1976; Hammond,

1964 and 1966; Kahn, 1966; U.S. Department of Health and Human Services,

1989), our analyses included persons with prevalent cancers reported at the

time of enrollment, unless otherwise indicated.

Rate Analyses Age-specific and age-adjusted death rates (per 100,000 person-years)

were computed based on the number of person-years at risk by attained age

through September 30, 1965, for CPS-I and through August 31, 1988, for

CPS-II. Age-adjusted death rates were directly standardized to the combined

person-year distribution of CPS-I and CPS-II (Appendix 2). These rates were

used to compute RR’s and RD’s. Ninety-five-percent confidence intervals

for the RR and RD were calculated using approximate variance formulas

(Flanders, 1984; Rothman, 1986).

Death rates were compared among all current cigarette smokers and

lifelong never-smokers for each endpoint. For lung cancer, death rates

also were compared in CPS-I and CPS-II according to specified numbers of

cigarettes smoked daily at enrollment and duration of smoking. Because

of sample size considerations, these comparisons were possible only among

persons ages ≥50 years who had smoked for at least 30 years. The most

precise and potentially least confounded comparison was based on persons
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310

who reported smoking 20 or 40 cigarettes daily at baseline, the two categories

for which daily cigarette consumption in CPS-I had not been grouped into

broad intervals. First, lung cancer death rates were compared at equivalent

levels of current consumption and duration for all races and baseline cancer

status (Appendixes 3 and 4). Further analyses were restricted to whites to

eliminate potential confounding by race and also excluded persons with

prevalent cancer other than nonmelanoma skin cancer (Appendixes 5 and 6).

The exclusion of prevalent cancers minimized the possibility that cigarette

smokers with cancer might differentially participate in CPS-II. These

comparisons are presented only as stratified analyses because of the

constraints on standardization discussed elsewhere (Chapter 5).

Attributable Risk In CPS-I and CPS-II, the percentage of deaths attributable to

in Smokers smoking among current cigarette smokers was estimated by using

standard formulas for attributable proportion for an exposed population

(Rothman, 1986). Also estimated were the proportionate contributions of

lung cancer, CHD, and other conditions to the overall increase in death rates

by dividing the cause-specific RD by the all-cause RD, expressed as a

percentage.

RESULTS The following is the order of presentation: Baseline smoking

practices are compared in CPS-I (1959), CPS-II (1982),

Order of Presentation NHIS-65 (1965), and NHIS-83 (1983); specific causes of death

are discussed in order of their contribution to smoking-related mortality in

CPS-II (lung cancer, CHD, COPD, stroke, and other smoking-related cancers);

and all causes of death combined are presented by smoking status and study.

For each cause, death rates in current cigarette smokers are compared

with those in lifelong never-smokers. Lung cancer rates are measured in

relation to daily cigarette use and duration of smoking in CPS-I and CPS-II.

The percentage of deaths attributable to smoking among current cigarette

smokers is examined for each endpoint in the two studies.

Baseline Smoking Table 2 shows the percentage of black and white men and women

Practices who currently smoke, formerly smoked, and never smoked

cigarettes at the time of enrollment in CPS-I and CPS-II. AgePrevalence adjusted prevalence decreased from 44.8 to 24.3 percent in white

men. Smaller decreases occurred in black men and white women, whereas

the prevalence in black women increased slightly. The percentage who

were former smokers more than doubled among white men, more than

quadrupled among white women, more than tripled among black men, and

almost quadrupled among black women. The percentage of never-smokers

remained essentially unchanged in black men, rose slightly in white men,

and decreased in women of both races.

Trends in smoking prevalence from CPS-I to CPS-II resembled those in

the general U.S. population, as reflected by NHIS-65 and NHIS-83 (Table 2).

The prevalence in CPS-I was somewhat lower than in NHIS-65 and was

lower in CPS-II than in NHIS-83, consistent with the higher educational

background of CPS participants. However, temporal trends in prevalence
311

Chapter 4

Table 2

Age-adjusted prevalencea of current, former, and never cigaretteb smoking at baseline by race,

sex, and study

Percent

Race/Sex Smoking Status CPS-I CPS-II NHIS-65 NHIS-83

White Men

Current 44.8 24.3 47.4 33.3

Former 16.7 39.3 25.5 40.8

Never 21.5 25.6 15.2 18.8

Black Men

Current 47.7 34.3 55.0 43.5

Former 8.1 26.9 16.1 29.5

Never 23.2 24.4 13.8 21.1

White Women

Current 24.2 20.4 28.3

Former 5.1 21.3 8.1 19.2

Never 68.8 52.1 62.1 52.4

Black Women

Current 20.0 24.8 23.9 31.5

Former 3.5 13.8 6.3 13.4

Never 71.6 48.2 69.4 55.0

a Prevalence in the full cohorts (Table 1), age-adjusted to the baseline age distribution of CPS-I and CPS-II

(Appendix 2).

b Cigarette smoking with or without pipes or cigars.

Key: CPS = Cancer Prevention Study; NHIS = National Health Interview Survey.

from the 1960’s to the 1980’s were similar, comparing CPS-I with CPS-II and

NHIS-65 with NHIS-83 within race and sex subgroups.

Appendixes 7 through 10 show that the age-specific prevalence of

current cigarette smoking decreased markedly with age in all studies,

although patterns of smoking differed among older participants in the two

studies. In the 1960’s (CPS-I and NHIS-65), older subjects included a larger

proportion of never-smokers, reflecting the lower prevalence of beginning to

smoke among persons born prior to 1900. In the 1980’s (CPS-II and NHIS83), older subjects included a larger proportion of former smokers as well as

never-smokers, showing the increased contribution of smoking cessation.

The combined influences of smoking cessation, lower uptake in earlier birth

cohorts, and higher mortality in older smokers caused smokers to constitute

a smaller fraction of the population with increasing age.

Cigarettes Smoked Figure 2 illustrates that the mean number of cigarettes smoked per

Per Day day was higher at every age in CPS-II than in CPS-I and was greater

in men than in women (except in CPS-II men age 85 and older). The mean

difference in daily consumption between CPS-I and CPS-II at baseline did not

exceed six cigarettes per day at any age except for women age 85 and older

(mean values shown in Appendix 11). Men in CPS-I and CPS-II averaged

22.4 and 25.4 cigarettes per day, respectively, with age-specific differences
Smoking and Tobacco Control Monograph No. 8

312

Figure 2

Mean number of cigarettes smoked daily at baseline by current smokers according to age at

enrollment

in mean number of cigarettes smoked per day from 5 to 23 percent higher

in CPS-II. The mean number of cigarettes smoked per day among women

increased from 15.3 to 19.6, with the age-specific mean number of cigarettes

per day from 27 to 107 percent higher in CPS-II. The average number of

cigarettes smoked per day by all current smokers decreased in all groups after

approximately 50 years of age. This age-related decline possibly reflected

a combination of reduced consumption by individuals, higher mortality

among heavier smokers, and lower cigarette consumption among earlier

birth cohorts (Burns, 1994). More detailed categorical data on age-specific

consumption patterns are shown in Appendixes 12 through 15 and reveal

a consistent increase in the fraction of smokers in CPS-II who smoked 40

and 40+ cigarettes per day in every age group, although the NHIS data are

imprecise because of the small number of subjects older than age 75. This

trend also is observed in the NHIS data.

Age of Initiating Persons in more recent birth cohorts began smoking at progressively

Smoking younger ages, particularly women born after 1910 and men born after

1890 (Table 3). Temporal trends were similar in CPS-I and CPS-II. The mean

age of initiation was nearly identical in the two studies where the birth

cohorts overlapped. Age of initiation in CPS-I and CPS-II closely paralleled

published data from NHIS-87 and NHIS-88 (Centers for Disease Control,
313

Chapter 4

Table 3

Average age of initiation among cigarette smokersa by sex and birth cohort, CPS-I and CPS-II

Birth Cohort

Sex Study 1870 1880 1890 1900 1910 1920 1930 1940

1950

Men

CPS-I 23.8 21.8 19.8 18.9 18.4 17.7 – – –

CPS-II – – 19.2 18.8 18.2 17.8 17.6 17.2 17.2

NHIS 87-88 –––– 17.5 17.2 17.1 17.0 17.0

Women

CPS-I 42.4 39.3 34.2 27.1 21.8 19.8 – – –

CPS-II – – 33.7 27.1 22.4 20.9 19.6 18.4 18.1

NHIS 87-88 –––– 22.9 21.0 19.4 18.7 17.5

a Based on age of initiation among current cigarette smokers in the analytic cohorts of CPS-I and CPS-II (Table 1)

and published data from the National Health Interview Surveys of 1987 and 1988, whites (Burns, 1994).

Key: CPS = Cancer Prevention Study; NHIS = National Health Interview Survey.

1991). Birth cohort data in Appendix 16 show the cumulative percentage

of persons who began smoking before various ages. This percentage increased

with later birth cohorts except among men who began smoking before

15 years of age. In this group the pattern was reversed, and the cumulative

percentage decreased with later birth cohorts for unclear reasons. The fraction

of smokers who initiated smoking before 15 years of age was substantially

higher for CPS-II than for CPS-I among males for those cohorts where the

two studies overlap.

Duration of Smoking Figure 3 shows the mean duration of smoking at baseline

according to age at enrollment. Male current smokers of comparable age

had smoked for a similar number of years in CPS-I and CPS-II at ages younger

than 60, but the mean number of years of smoking was higher in CPS-II

among older age groups of males (although for those men age 85 and older

the difference was slight). Women had smoked longer in CPS-II than in CPS-I.

The largest divergence between CPS-I and CPS-II occurred among women

ages 65 to 69 and 70 to 74 at enrollment. For these groups, the duration was

approximately 11 years longer in CPS-II than in CPS-I (Appendix 17). This

difference in smoking duration reflected primarily the younger age at which

women began smoking in CPS-II. For males older than age 60, the mean

difference in duration for 5-year age groups varied from 0.4 to 2.2 years.

Depth of Inhalation A larger percentage of women reported inhaling cigarette smoke

moderately or deeply in CPS-II than in CPS-I (Table 4). The distribution

among male smokers did not change significantly according to self-report.

Tar Content The measured tar content of cigarettes, as determined by machine smoking,

of Cigarettes decreased markedly from CPS-I (Garfinkel, 1979) to CPS-II (Federal Trade

Commission, 1983). Figure 4 shows that most cigarette brands smoked by

men at enrollment in CPS-I exceeded 17.0 mg, whereas most brands currently

smoked in CPS-II had lower tar ratings. A similar shift in distribution was seen
Smoking and Tobacco Control Monograph No. 8

314

Figure 3

Mean number of years of smoking cigarettes at baseline by current smokers according to

age at enrollment

0

10

30

CPS-II men

CPS-I men

CPS-II women

CPS-I women

50

40

60

70

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age at Enrollment

Mean Years of Smoking 20

Table 4

Self-reported depth of inhalation among current cigarette smokers by sex and stu$y

Men (%) Women (%)

CPS-I CPS-II CPS-I CPS-II

Depth of Inhalation (N = 146,459) (N = 101,888) (N = 152,228) (N = 126,794)

Do Not Inhale 5.8 5.5 13.0 6.8

Inhale Slightly 13.3 12.6 23.1 16.5

Inhale Moderately 55.6 53.2 51.4 60.4

Inhale Deeply 24.9 26.8 12.1 14.1

Unknown 0.5 1.8 0.4 2.3

Key: CPS = Cancer Prevention Study.

among women, although the tar content was lower in women’s than in

men’s cigarettes (Appendix 18). These data reflect the brand smoked at the

time of enrollment, and they may underestimate the tar content of cigarettes

smoked earlier in life because the official ratings have decreased since the

early 1950’s (U.S. Department of Health and Human Services, 1993).
315

Chapter 4

Figure 4

Percentage distribution of tar content, as measured by machine smoking, of the cigarette brand

smoked at enrollment

40

50

<6.0

30

20

10

0

6.0-11.9 12.0-16.9 17.0-20.9

Tar Content (mg)

Men

Percent

21.0-25.7 25.8-35.7

CPS-II

CPS-I

40

50

30

20

10

0

Women

Percent

CPS-II

CPS-I

<6.0 6.0-11.9 12.0-16.9 17.0-20.9

Tar Content (mg)

21.0-25.7 25.8-35.7
Smoking and Tobacco Control Monograph No. 8

316

Summary of Changes Substantive changes in smoking practices occurred between CPS-I

in Smoking From and CPS-II, but the direction of these changes was mixed and

CPS-I to CPS-II varied by sex: Prevalence decreased markedly in men but not

in women; average daily cigarette consumption and duration of smoking

increased in women more than in men but increased in CPS-II in both sexes;

and machine-measured tar content decreased for both sexes. The increase

in measured tobacco consumption from CPS-I to CPS-II was much larger in

women than in men. The potential for unmeasured differences in cigarette

smoking behavior between the two studies is discussed below.

Specific Causes of Death Age-specific death rates from lung cancer among current

cigarette smokers and lifelong never-smokers are shown

Lung Cancer in Current in Figure 5 and Appendixes 19 and 20. Lung cancer death

Smokers vs. Never-Smokers rates were much higher in smokers than in never-smokers,

except among women in CPS-I. Rates among both male and female smokers

were substantially higher in CPS-II than in CPS-I for all ages older than 50.

The absolute increase in death rates from CPS-I to CPS-II was similar among

male and female smokers.

Among lifelong never-smokers, the lung cancer death rates changed

relatively little from CPS-I to CPS-II (Appendixes 19 and 20). The age-specific

death rates were slightly higher in CPS-II than CPS-I among nonsmoking men

older than 70 and nonsmoking women 50 and older although differences

among CPS-II and CPS-I women did not become substantial until age 70

and older.

Age-adjusted death rates from lung cancer per 100,000 person-years

(Table 5) increased from CPS-I to CPS-II among current cigarette smokers

from 187.1 to 341.3 in men and from 26.1 to 154.6 in women. Among neversmokers the age-adjusted death rate did not change substantially between

studies in either sex.

Taken together, the trends in lung cancer death rates among all current

smokers (Figure 5 and Table 5) show that the epidemic in women smokers

followed that in men by approximately 20 years. In CPS-I, the lung cancer

death rate among male smokers was nearly twelvefold that for never-smokers,

whereas the rate in women smokers had just begun to increase above that in

never-smokers. Two decades later, the death rate among women smokers in

CPS-II closely approached that of male smokers in CPS-I, whereas the rate in

male smokers had again nearly doubled from CPS-I to CPS-II.

Lung Cancer Mortality The differences between smokers in CPS-I and CPS-II with

by Amount and Duration regard to number of cigarettes smoked per day and duration

of Smoking of smoking are potential explanations for the differences in

age-specific lung cancer death rates between the two studies. Because of the

difficulties in standardizing duration-specific rates described in Chapter 5,

the most direct comparison of the lung cancer risks attributable to smoking

between CPS-I and CPS-II is to compare stratum-specific lung cancer death

rates in the two studies for 5-year age- and duration-specific strata among

smokers of 20 and 40 cigarettes per day. Appendixes 3 and 4 present 5-year
317

Chapter 4

Figure 5

Age-specific death rates from lung cancer among current cigarette smokers and lifelong neversmokers, based on smoking status at enrollment in CPS-I or CPS-II, according to attained age

a Rate per 100,000 person-years.
Smoking and Tobacco Control Monograph No. 8

318

Table 5

Age-adjusted death rates, rate ratios, and rate differences for lung cancera

—current cigarette

smokers vs. never-smokers in CPS-I and CPS-IIb

CPS-I CPS-II

Current Current

Never- Cigarette Never- Cigarette

Sex Smokers Smokers Smokers Smokers

Men

Number of deaths 85 1,035 124 1,781

Ratec 15.7 187.1 14.7 341.3

Rate ratio 1.0 11.9 1.0 23.2

 (95% CI) (9.5-14.9) (19.3-27.9)

Rate differencec 171.4 326.6

 (95% CI) (157-186) (309-344)

Women

Number of deaths 212 157 310 1,014

Ratec 9.6 26.1 12.0 154.6

Rate ratio 1.0 2.7 1.0 12.8

 (95% CI) (2.1-3.5) (11.3-14.7)

Rate differencec 16.6 142.6

 (95% CI) (11-22) (132-153)

a Disease codes refer to the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of

Death (ICD-7) and Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death

(ICD-9) (World Health Organization, 1957 and 1977, respectively) for CPS-I and CPS-II, respectively. Codes from

ICD-7 and ICD-9 for lung cancer are 162-63 and 162, respectively. b Based on followup from 1959-65 (CPS-I) and 1982-88 (CPS-II) and tobacco smoking status at enrollment.

c Age-adjusted death rates are directly standardized to the combined CPS-I and CPS-II person-years. Death rates

and rate differences are expressed per 100,000 person-years.

Key: CPS = Cancer Prevention Study; CI = confidence interval.

age- and duration-specific strata among smokers of 20 and 40 cigarettes per

day for males and females of all races with duration of smoking fixed at entry

into the study and without excluding individuals who had cancer at entry

into the study. Table 6 presents the lung cancer death rates for both studies

for those strata in Appendix 3 with five or more lung cancer deaths and the

results of subtracting the rates in CPS-II from those in CPS-I in strata where

five or more deaths occurred in each study. There were too few deaths among

women in CPS-I for meaningful comparison. The 50-plus duration category

is excluded because of the potential for residual confounding by age and

duration in this category, given the longer durations of smoking found

among current smokers in CPS-II.

Consistent and substantial increases in lung cancer death rates were

found among males in the two longer duration (and correspondingly older

age) categories for smokers of 20 cigarettes per day. There was no trend

toward higher rates in the difference between CPS-I and CPS-II for the two

shorter duration categories for 20 cigarettes per day. When smokers of

40 cigarettes per day are examined, CPS-II has modestly higher rates (5 to

10 percent) in all age and duration categories.
319

Table 6 Comparison of lung cancer death rates between CPS-I and CPS-II for males of all races with prevalent cancers include Lung Cancer Death Rates for Males of All Races, 20 Cigarettes Per Day, Duration Fixed at Entry Into the Study, 5+ Deaths in Cell

CPS-I Rates CPS-II Rates CPS-II – CPS-I Differ

Duration Duration Duratio

Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 4050-54 64.5 154.7 50-54 100 107.4 50-54 35.5 -47.355-59 122.8 127.4 149.9 55-59 101.3 225.9 289.5 55-59 -21.5 98.5 1360-64 220.7 269.5 312.6 60-64 139.9 323.9 440.5 60-64 -80.8 565-69 330.2 449.5 65-69 550.5 583.7 563.2 65-69 2570-74 304.1 70-74 722.9 551.9 70-74 

75-79 75-79 2,225.5 75-79Lung Cancer Death Rates for Males of All Races, 40 Cigarettes Per Day, Duration Fixed at Entry Into the Study, 5+ Deaths in Cell

CPS-I Rates CPS-II Rates CPS-II – CPS-I Differ

Duration Duration Duratio

Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 4050-54 67.8 50-54 188 174.4 50-54 120.255-59 136.1 189.8 327.1 55-59 161.5 235.2 354.8 55-59 25.4 45.4 260-64 319.7 478.6 374.6 60-64 540.7 526.0 404.4 60-64 221 465-69 803.5 785.7 65-69 811.1 851.7 836.6 65-69 4

70-74 70-74 1,380.3 1356.2 70-74Note: Rates are those presented in Appendix 3. Rates are presented for all cells with five or more lung cancer deaths. Subtractions for the rates 

CPS-I are done only for cells with five or more deaths in the cell for both studies. Person-years of observation and deaths accrue in the age 

individual was in at the year of followup (age advanced) but accrue to the duration category at the time of entry to the study (duration fixed)

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

320

We tested the possibility that including prevalent cases of lung cancer

or smokers of various races could bias these results. Appendixes 5 and

6 present 5-year age- and duration-specific strata among smokers of 20 and

40 cigarettes per day for white males and females and with persons reporting

prevalent cancers excluded. Table 7 presents the lung cancer death rates for

both studies for those st2ata in Appendix 5 with five or more lung cancer

deaths and the results of subtracting the rates in CPS-II from those in CPS-I

in strata where five or more deaths occurred in each study. No clear trend in

the differences between the two studies is evident for smokers of 40 cigarettes

per day or for smokers of 20 cigarettes per day who had smoked for less than

40 years. White males who smoked 20 cigarettes for longer than 40 years

had lung cancer death rates that were higher in CPS-II than in CPS-I.

Coronary Heart Disease Age-specific death rates from CHD are shown in Figure 6

and Appendixes 21 and 22. In both sexes, CHD death rates were higher in

smokers than in never-smokers in both CPS-I and CPS-II. However, CHD

death rates decreased markedly from CPS-I to CPS-II regardless of smoking

status. The temporal trend was so large that smokers in CPS-II generally had

lower death rates from CHD than did lifelong never-smokers in CPS-I (men

beginning at age 65 and women beginning at age 60). Because the fall in

death rates occurs among lifelong never-smokers as well as active cigarette

smokers, reasons for the fall in age-specific death rates must include factors

other than smoking cessation.

Age-adjusted death rates from CHD (Table 8) decreased from CPS-I to

CPS-II by more than 50 percent. The fall in background CHD rates was

slightly larger in proportionate terms among never-smokers than among

smokers. Thus, on a relative scale the RR associating current cigarette

smoking and CHD death increased from 1.7 to 1.9 in men and from 1.4 to

1.8 in women from CPS-I to CPS-II, respectively. On an absolute scale, the

fall in background death rates caused the RD (per 100,000 person-years) to

decrease from 486.8 to 253.4 in men and from 113.9 to 96.8 in women.

CHD also contributed a smaller proportion of the total excess mortality

among smokers in CPS-II than in CPS-I (see below).

Chronic Obstructive Table 9 shows that age-adjusted death rates from COPD (per

Pulmonary Disease 100,000 person-years) increased among current male cigarettee

smokers from 73.6 in CPS-I to 103.9 in CPS-II and from 17.6 to 61.6 among

female cigarette smokers. Age-specific death rates from COPD (Appendixes 23

and 24) in smokers rose from CPS-I to CPS-II at nearly all ages in women and

in those older than age 65 in men. The increase over time in death rates from

COPD among smokers resembles the pattern seen with lung cancer, although

COPD causes fewer excess deaths due to cigarette smoking.

Stroke Age-adjusted death rates from stroke (Table 10) decreased by more than

55 percent from CPS-I to CPS-II among both smokers and never-smokers.

As with CHD, the fall in background death rates was proportionately larger

in never-smokers than smokers. Thus, the RR between current cigarette

smoking and death from stroke increased from 1.3 to 1.9 in men and from
321

Table 7 Comparison of lung cancer death rates between CPS-I and CPS-II for white males with prevalent cancers excluded Lung Cancer Death Rates for White Males, 20 Cigarettes Per Day, Duration Fixed at Entry Into the Study, 5+ Deaths in Cell

CPS-I Rates CPS-II Rates CPS-II – CPS-I Diffe

Duration Duration Duratio

Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 4050-54 64 138.2 50-54 80.1 85.6 50-54 16.1 -52.655-59 120.9 124.8 135.1 55-59 101.7 197.8 235.5 55-59 -19.2 73 1060-64 209.8 254.4 289.8 60-64 156.6 296.4 395.6 60-64 -53.2 465-69 342.7 442.6 65-69 542.7 509 587.7 65-69 16

70-74 320.1 70-74 687 533.2 70-74 Lung Cancer Death Rates for White Males, 40 Cigarettes Per Day, Duration Fixed at Entry Into the Study, 5+ Deaths in Cell

CPS-I Rates CPS-II Rates CPS-II – CPS-I Diffe

Duration Duration Duratio

Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 40-44 45-49 Age 30-34 35-39 4050-54 69.1 50-54 187.6 185.5 50-54 118.555-59 139.6 194.3 333.9 55-59 107.3 228.2 341.6 55-59 -32.3 33.9 60-64 247.3 466.1 60-64 568.4 475.9 434.2 60-64 321.1 65-69 850.1 814.2 65-69 855.3 930.1 747.7 65-69 8

70-74 70-74 1,062.5 70-74Note: Rates are those presented in Appendix 5. Rates are presented for all cells with five or more lung cancer deaths. Subtractions for the rates 

CPS-I are done only for cells with five or more deaths in the cell for both studies. Person-years of observation and deaths accrue in the ag

individual was in at the year of followup (age advanced) but accrue to the duration category at the time of entry to the study (duration fixed)

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

322

Figure 6

Age-specific death rates from coronary heart disease among current cigarette smokers and

lifelong never-smokers, based on status at enrollment in CPS-I or CPS-II, according to attained

age

a Rate per 100,000 person-years.

0

100

300

CPS-I current smoker

CPS-I nonsmoker

CPS-II current smoker

CPS-II nonsmoker

500

400

600

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Attained Age (years)

Men

Death Rate

200

800

900

700

0

100

300

CPS-I current smoker

CPS-I nonsmoker

CPS-II current smoker

CPS-II nonsmoker

500

400

600

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Attained Age (years)

Death Rate

200

800

900

700

Women
323

Chapter 4

Table 8

Age-adjusted death rates, rate ratios, and rate differences for coronary heart diseasea—current

cigarette smokers vs. never-smokers in CPS-I and CPS-IIb

CPS-I CPS-II

Current Current

Never- Cigarette Never- Cigarette

Sex Smokers Smokers Smokers Smokers

Men

Number of deaths 3,769 6,068 2,536 2,722

Ratec 681.2 1,168.0 294.6 548.0

Rate ratio 1.0 1.7 1.0 1.9

 (95% CI) (1.6-1.8) (1.8-2.0)

Rate differencec 486.8 253.4

 (95% CI) (440-533) (227-280)

Women

Number of deaths 7,065 1,248 3,717 1,161

Ratec 305.6 419.5 118.3 215.1

Rate ratio 1.0 1.4 1.0 1.8

 (95% CI) (1.3-1.5) (1.7-2.0)

Rate differencec 113.9 96.8

 (95% CI) (79-149) (82-111)

a Disease codes refer to the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of

Death (ICD-7) and Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death

(ICD-9) (World Health Organization, 1957 and 1977, respectively), for CPS-I and CPS-II, respectively. Codes for

coronary heart disease are 420 and 410-414, respectively.

b Based on followup from 1959-65 (CPS-I) and 1982-88 (CPS-II) and tobacco smoking status at enrollment.

c Age-adjusted death rates are directly standardized to the combined CPS-I and CPS-II person-years.

Death rates and rate differences are expressed per 100,000 person-years.

Key: CPS = Cancer Prevention Study; CI = confidence interval.

1.2 to 1.8 in women from CPS-I to CPS-II. The RD (per 100,000 person-years)

between smokers and never-smokers changed minimally, decreasing from

55.5 to 50.4 in men and increasing from 25.1 to 34.0 in women. Appendixes

25 and 26 present age-, sex-, and smoking-specific death rates for stroke.

Other Smoking- As shown in Table 11, age-adjusted death rates from smoking-related

Related Cancers cancers other than lung cancer increased among smokers from 102.5

to 120.1 in men and from 45.8 to 53.4 in women from CPS-I to CPS-II.

Both the RR and the RD increased as well, paralleling the pattern seen with

lung cancer. Age-specific death rates from other cancers were higher in

CPS-I compared with CPS-II among smokers of both sexes at nearly every

age, although the trend was less consistent among women (Appendixes 27

and 28).

All-Cause Mortality Age-adjusted death rates from all causes (Table 12) decreased

substantially from CPS-I to CPS-II among lifelong never-smokers, reflecting

smokers the decrease in death rates from vascular diseases was partially

offset by increased smoking-related deaths from lung cancer, other cancers,
Smoking and Tobacco Control Monograph No. 8

324

Table 9

Age-adjusted death rates, rate ratios, and rate differences for COPDa

—current cigarette

smokers vs. never-smokers in CPS-I and CPS-IIb

CPS-I CPS-II

Current Current

Never- Cigarette Never- Cigarette

Sex Smokers Smokers Smokers Smokers

Men

Number of deaths 44 284 78 422

Ratec 8.0 73.6 8.9 103.9

Rate ratio 1.0 9.3 1.0 11.7

 (95% CI) (6.6-12.9) (9.1-15.0)

Rate differencec 65.7 95.0

 (95% CI) (54-77) (83-107)

Women

Number of deaths 61 56 143 303

Ratec 2.6 17.6 4.8 61.6

Rate ratio 1.0 6.7 1.0 12.8

 (95% CI) (4.4-10.2) (10.4-15.9)

Rate differencec 15.0 56.8

 (95% CI) (9-21) (49-65)

a Disease codes refer to the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of

Death (ICD-7) and Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death

(ICD-9) (World Health Organization, 1957 and 1977, respectively), for CPS-I and CPS-II, respectively. Codes from

ICD-7 and ICD-9 for chronic obstructive pulmonary disease are 500-502, 527.1, and 490-492, 496, respectively. b Based on followup from 1959-65 (CPS-I) and 1982-88 (CPS-II) and tobacco smoking status at enrollment.

c Age-adjusted death rates are directly standardized to the combined CPS-I and CPS-II person-years.

Death rates and rate differences are expressed per 100,000 person-years.

Key: CPS = Cancer Prevention Study; CI = confidence interval.

and COPD. Thus, the all-cause RR increased from 1.7 to 2.3 in men and

from 1.2 to 1.9 in women in CPS-I and CPS-II, respectively. The all-cause RD

(per 100,000 person-years) was essentially unchanged in men but increased

in women from 244.6 to 508.7.

Age-specific and smoking-specific death rates from all causes are shown

in Appendixes 29 and 30. The all-cause death rate in men ages 40 to 69 was

about three times higher in smokers than never-smokers in CPS-II and was

about twice as high in CPS-I (Peto et al., 1992). The increased RR in middleaged men reflected both the increasing risk of lung cancer in smokers and

the decreasing cardiovascular mortality, regardless of smoking status.

Attributable Risk Table 13 shows that the proportion of all deaths among current

in Smokers cigarette smokers attributable to cigarette smoking (etiologic

fraction in the exposed group) increased from CPS-I to CPS-II from 42.2 to

57.1 percent in men and from 18.7 to 47.9 percent in women. Table 14

shows the percentage of the all-cause RD contributed by various diseases.

Lung cancer contributed a larger proportion of the all-cause RD in CPS-II.

This proportion increased from 14.7 to 28.1 percent in men and from
325

Chapter 4

Table 10

Age-adjusted death rates, rate ratios, and rate differences for strokea—current cigarette smokers

vs. never-smokers in CPS-I and CPS-IIb

CPS-I CPS-II

Current Current

Never- Cigarette Never- Cigarette

Sex Smokers Smokers Smokers Smokers

Men

Number of deaths 1,126 960 501 476

Ratec 198.1 253.6 57.3 107.6

Rate ratio 1.0 1.3 1.0 1.9

 (95% CI) (1.2-1.4) (1.6-2.2)

Rate differencec 55.5 50.4

 (95% CI) (30-81) (38-63)

Women

Number of deaths 3,319 537 1,331 423

Ratec 141.1 166.2 40.6 74.5

Rate ratio 1.0 1.2 1.0 1.8

 (95% CI) (1.0-1.4) (1.6-2.1)

Rate differencec 25.1 34.0

 (95% CI) (3-47) (26-42)

a Disease codes refer to the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of

Death (ICD-7) and Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death

(ICD-9) (World Health Organization, 1957 and 1977, respectively), for CPS-I and CPS-II, respectively. Codes from

ICD-7 and ICD-9 for stroke are 33033-4 and 430-438, respectively. b Based on followup from 1959-65 (CPS-I) and 1982-88 (CPS-II) and tobacco smoking status at enrollment.

c Age-adjusted death rates are directly standardized to the combined CPS-I and CPS-II person-years.

Death rates and rate differences are expressed per 100,000 person-years.

Key: CPS = Cancer Prevention Study; CI = confidence interval.

6.8 to 28.0 percent in women in CPS-I and CPS-II, respectively (Table 14).

The corresponding proportions contributed by CHD decreased from 41.7 to

21.8 percent in men and from 46.6 to 19.0 percent in women.

DISCUSSION We found that the risk of premature death among active cigarette

smokers continued unabated from the 1960’s to the 1980’s. Despite major

changes in cigarettes, patterns of smoking, and background death rates

from cardiovascular diseases, the absolute difference in all-cause death rates

between smokers and lifelong never-smokers more than doubled in women

and remained nearly constant in men over this interval. In relative terms,

the overall death rate for men ages 40 to 69 in CPS-II was about three times

higher in smokers than in never-smokers compared with the doubling

observed in CPS-I (Peto et al., 1992).

Of the various diseases caused by smoking, the largest increase in death

rates was because of lung cancer. Although remaining essentially constant

in lifelong never-smokers, lung cancer death rates increased almost sixfold

among female smokers and nearly doubled among male cigarette smokers

from CPS-I to CPS-II (Table 5). This increase in the 6-year CPS-II followup
Smoking and Tobacco Control Monograph No. 8

326

is slightly larger than that seen in the 4-year CPS-II followup reported in the

1989 U.S. Surgeon General’s report (U.S. Department of Health and Human

Services, 1989). Both analyses suggest that the epidemic of lung cancer in

the United States has been confined largely to smokers, at least among the

white, predominantly middle-class populations that CPS-I and CPS-II

participants represent. The rising lung cancer risk among smokers is

presumably an important factor in sustaining lung cancer death rates in

the general U.S. population. Although the percentage of men who currently

smoke cigarettes has decreased from 52 percent in 1965 to 28 percent in

1992 (Centers for Disease Control and Prevention, 1994; U.S. Department

of Health and Human Services, 1993), the lung cancer death rate in U.S.

men has leveled rather than declined since 1980 (Boring et al., 1994).

The substantial decrease in lung cancer risk that occurs 5 to 15 years after

cessation (U.S. Department of Health and Human Services, 1990) may be

partially offset by increasing risk among persons who continue to smoke.

Table 11

Age-adjusted death rates, rate ratios, and rate differences for other smoking-related cancersa

—

current cigarette smokers vs. never-smokers in CPS-I and CPS-IIb

CPS-I CPS-II

Current Current

Never- Cigarette Never- Cigarette

Sex Smokers Smokers Smokers Smokers

Men

Number of deaths 205 536 290 610

Ratec 37.5 102.5 34.6 120.1

Rate ratio 1.0 2.7 1.0 3.5

 (95% CI) (2.3-3.3) (3.0-4.0)

Rate differencec 64.9 85.6

 (95% CI) (53-77) (74-97)

Women

Number of deaths 567 190 553 332

Ratec 25.2 45.8 21.0 53.4

Rate ratio 1.0 1.8 1.0 2.6

 (95% CI) (1.5-2.3) (2.2-2.9)

Rate differencec 20.6 32.4

 (95% CI) (11-30) (26-39)

a Disease codes refer to the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of

Death (ICD-7) and Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death

(ICD-9) (World Health Organization, 1957 and 1977, respectively), for CPS-I and CPS-II, respectively. Codes from

ICD-7 and ICD-9 for other smoking-related cancers include lip/oral cavity/pharynx, 140-148 and 140-149,

respectively; esophagus, 150 in both versions; pancreas, 157 in both versions; larynx, 161 in both versions;

kidney/bladder/other urinary, 180-181 and 188-189, respectively.

b Based on followup from 1959-65 (CPS-I) and 1982-88 (CPS-II) and tobacco smoking status at enrollment.

c Age-adjusted death rates are directly standardized to the combined CPS-I and CPS-II person-years (Appendix 2).

Death rates and rate differences are expressed per 100,000 person-years.

Key: CPS = Cancer Prevention Study; CI = confidence interval.
327

Chapter 4

Table 12

Age-adjusted death rates, rate ratios, and rate differences for deaths from all causes—current

cigarette smokers vs. never-smokers in CPS-I and CPS-IIa

CPS-I CPS-II

Current Current

Never- Cigarette Never- Cigarette

Sex Smokers Smokers Smokers Smokers

Men

Number of deaths 8,919 13,551 7,448 9,899

Rateb 1,605 2,773 874.0 2,037

Rate ratio 1.0 1.7 1.0 2.3

 (95% CI) (1.7-1.8) (2.3-2.4)

Rate differenceb 1,168.1 1,162.7

 (95% CI) (1,095-1,241) (1,113-1,213)

Women

Number of deaths 24,007 4,921 15,450 6,232

Rateb 1,047 1,291 550.0 1,059

Rate ratio 1.0 1.2 1.0 1.9

 (95% CI) (1.2-1.3) (1.9-2.0)

Rate differenceb 244.6 508.7

 (95% CI) (186-303) (478-540)

a Based on followup from 1959-65 (CPS-I) and 1982-88 (CPS-II) and tobacco smoking status at enrollment.

b Age-adjusted death rates are directly standardized to the combined CPS-I and CPS-II person-years (Appendix 2).

Death rates and rate differences are expressed per 100,000 person-years.

Key: CPS = Cancer Prevention Study; CI = confidence interval.

Table 13

Percentage of deaths attributable to active smoking among current cigarette smokers in CPS-I

and CPS-IIa

Percent in Men Percent in Women

Disease CPS-I CPS-II CPS-I CPS-II

Lung Cancer 91.6 95.7 63.4 92.2

Coronary Heart Disease 41.5 46.2 27.0 45.1

Chronic Obstructive

 Pulmonary Disease 89.2 91.4 85.0 92.2

Stroke 21.9 46.8 15.2 45.7

Other Smoking-Related Cancers 63.4 71.2 45.0 60.8

All Causes 42.2 57.1 18.7 47.9

a Attributable risk among exposed persons (Rothman, 1986) based on Tables 5 and 8 through 12.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

328

Caution is urged in interpreting the comparison of lung cancer death

rates at “equivalent” levels of self-reported smoking. Information on the

number of cigarettes smoked at enrollment may not mirror the lifelong

patterns of smoking that cause lung cancer. Cigarette consumption during

adolescence and early adulthood was probably heavier among smokers in

CPS-II than in CPS-I for several reasons. First, manufactured cigarettes were

more available in the 1940’s and 1950’s than in the 1920’s and 1930’s (U.S.

Department of Health and Human Services, 1989). CPS-II smokers born in

the late 1920’s typically began smoking after World War II when cigarettes

were plentiful and there were few prohibitions against smoking. Second,

birth cohort analyses of the U.S. general population show that the peak

prevalence of smoking among white men increased with each successive

birth cohort from 1900 to 1929 and decreased thereafter (Burns, 1994).

Similarly, age-specific death rates from lung cancer death rates have

decreased among U.S. men born after 1930 (Devesa et al., 1989; Gilliland and

Samet, 1994). Thus, the large increase in death rates from CPS-I to CPS-II

probably reflects unmeasured heavier smoking in CPS-II during the 1940’s

and 1950’s as well as the measured increase in daily consumption and

duration of smoking.

Other factors that could influence the intensity of cigarette smoking are

that CPS-II smokers may include more addicted “hard core” smokers who

cannot quit despite health and social concerns. Partly to compensate for the

lower tar and nicotine content of modern cigarettes (U.S. Department of

Health and Human Services, 1989), CPS-II smokers may inhale more deeply,

take more puffs per cigarette, or retain the smoke longer in their lungs than

did smokers in the past (Benowitz et al., 1983 and 1986; Herning et al., 1981;

Russell et al., 1980; U.S. Department of Health and Human Services, 1988).

Strong social prohibitions against smoking may have caused CPS-II smokers

to underreport usage or to reduce their consumption in an effort to quit.

Table 14

Percentage of the total rate difference for all causes between smokers and never-smokers

contributed by various diseasesa

Percent in Men Percent in Women

Disease CPS-I CPS-II CPS-I CPS-II

Lung Cancer 14.7 28.1 6.8 28.0

Coronary Heart Disease 41.7 21.8 46.6 19.0

Chronic Obstructive

 Pulmonary Disease 5.6 8.2 6.1 11.2

Stroke 4.7 4.3 10.3 6.7

Other Smoking-Related Cancers 5.6 7.4 8.4 6.4

Other Conditions 27.7 30.2 21.8 28.7

a Based on the cause-specific rate difference divided by the all-cause rate difference in Tables 5 and 8 through 12.

Key: CPS = Cancer Prevention Study.
329

Chapter 4

Smokers in the 1980’s also may have been more vulnerable to the carcinogens

in tobacco smoke because of lower dietary intake of fresh fruits and vegetables

(Subar et al., 1990; Willett, 1990). Finally, the large decrease in cardiovascular

mortality from CPS-I to CPS-II could contribute somewhat to the increasing

lung cancer death rates, although most potential confounding resulting from

competing causes was eliminated by stratifying person-years at risk into 5-year

age intervals.

Despite the many uncertainties that constrain the ability to compare the

intrinsic carcinogenicity of cigarettes from these two eras, the net effect of

all changes in the cigarette and the smoking of cigarettes has been a large

increase rather than decrease in lung cancer mortality in smokers. Although

low-tar, filter-tip cigarettes have been shown to slightly reduce lung cancer

risk compared with nonfiltered cigarettes in several epidemiologic studies

(Hammond, 1980; Hammond et al., 1976; Lubin et al., 1984a and 1984b;

Vutuc and Kunze, 1982; Wynder et al., 1970), the potential benefits of these

products are clearly overwhelmed by the more potent adverse changes in

smoking behavior and perhaps by other unidentified factors. The evaluation

of cigarettes has not protected smokers from fatal lung cancer.

The falling death rates from CHD and stroke seen in this study reflect

major nationwide declines that began for CHD in the mid-1960’s and for

stroke in the 1940’s or earlier (Cooper et al., 1978; Higgins and Thom, 1989;

Moriyama et al., 1971; Ragland et al., 1988; Russell et al., 1980). Data suggest

that much of the decline results from factors other than smoking cessation

because mortality decreased among both current smokers and lifelong neversmokers, groups largely unaffected by smoking cessation. Much of the

nationwide decline in CHD mortality probably reflects reduced mortality

resulting from therapeutic advances. We measured mortality rather than

incidence and could not distinguish between changes in incidence because

of diet, exercise, antihypertensive or antithrombotic therapy, control of lipids,

or improvement in survival because of medical care. Most of these factors, as

well as smoking cessation, are thought to play some role in the nationwide

CHD decline (Cooper et al., 1978; Higgins and Thom, 1989; Moriyama et al.,

1971; Ragland et al., 1988; Russell et al., 1980), although their relative

importance is unknown.

Because CPS-I and CPS-II include mostly white middle-class Americans

(Garfinkel, 1985; Stellman and Garfinkel, 1986), it cannot be concluded

that the trend of falling CHD mortality will affect all segments of the U.S.

population equally. For the poor and minorities in particular, more limited

access to medical treatment and prevention may result in a slower decline

in CHD mortality (Cooper et al., 1978) and proportionately greater CHD

mortality as a cause of excess death in smokers. Because the poor are

increasingly overrepresented among the 46 million Americans who smoke,

the authors’ data may underestimate the excess in CHD mortality among

smokers in the general population.
Smoking and Tobacco Control Monograph No. 8

330

In summary, CPS-I and CPS-II suggest that the epidemic of tobaccocaused deaths in the United States has not been static but has varied

dynamically over time as smoking patterns have evolved and background

risks have changed. Nonetheless, cigarette smoking remains the single

largest preventable cause of premature mortality in the United States.

CONCLUSIONS Measured changes in smoking practices from CPS-I to CPS-II were

mixed. A smaller percentage of men smoked cigarettes in 1982 than in 1959,

and cigarette brands had lower tar content as measured by machine smoking.

However, both men and women smokers consumed more cigarettes per day,

on average; women in 1982 began smoking earlier, smoked longer, and

reported inhaling cigarette smoke more deeply.

Temporal trends in cigarette smoking from CPS-I to CPS-II generally

resembled trends seen in representative U.S. surveys. A greater decrease in

smoking prevalence among men occurred comparing CPS-I and CPS-II

participants than in NHIS-65 to NHIS-83 participants, probably because of

the higher educational background of the CPS study participants.

Among cigarette smokers, lung cancer death rates from CPS-I to CPS-II

nearly doubled in men and increased almost sixfold in women. Lung cancer

rates remained essentially constant in lifelong never-smokers.

Comparisons of cigarettes-per-day-, age-, and duration-specific strata

reveal modest increases in the lung cancer death rates in CPS-II compared

with CPS-I for males of all races who smoked 40 cigarettes per day and when

prevalent cancers are included. No consistent difference between the rates

for the two studies is noted for the comparison of strata-specific rates of

white males who smoked 20 cigarettes per day until they have smoked more

than 40 years. The rates for smokers of 20 cigarettes per day who have

smoked for 40 to 49 years are substantially higher in CPS-II than in CPS-I for

males of all races with prevalent cancers included and for white males with

prevalent cancers excluded.

The evolution of cigarettes has not protected smokers from fatal lung

cancer. Rather, the potential benefits of reduced tar, as measured by

machine smoking, appear to be overwhelmed by adverse changes in smoking

practices and perhaps by other unidentified factors.

Although smoking cessation clearly reduces the risk of CHD and stroke,

much of the temporal decline in CHD and stroke mortality from CPS-I to

CPS-II appeared to reflect factors other than smoking cessation because

similar reductions were seen among current cigarette smokers and lifelong

never-smokers.

The percentage of all deaths attributable to active cigarette smoking was

higher in CPS-II than in CPS-I, increasing from 42.2 to 57.1 percent in men

and from 18.7 to 47.9 percent in women.

The two major diseases contributing to accelerated mortality among

smokers reversed from CPS-I to CPS-II: Lung cancer became the largest single

contributor in 1982, with CHD in second place.
331

Chapter 4

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333

Chapter 4

ACKNOWLEDGMENTS We thank Ms. Catherine Boring, Dr. David Burns,

Mr. Lawrence Garfinkel, Dr. Gary Giovino, Dr. Jonathan Samet, and

Dr. John Slade for their suggestions. We are also indebted to Ms. Stacy Adams,

Ms. Audrey Earles, and Ms. Kim Crews for their skill and dedication in

producing this chapter.
Smoking and Tobacco Control Monograph No. 8

334
335

Chapter 4

APPENDIXES 1 Through 30
Smoking and Tobacco Control Monograph No. 8

336
337

APPENDIX 1 Distribution of the Cancer Prevention Study (CPS)-I and CPS-II Full Cohorts, by Birth Cohort and Age at Enrollment Decade of Birth

1850 1860 1870 1880 1890 1900 1910 1920 1930 1

CPS-I

Persons 15 1,134 14,675 73,219 197,006 359,051 321,625 84,313 — Percent 0.0 0.1 1.4 7.0 18.7 34.2 30.6 8.0 — Age at enrollment 100-109 90-99 80-89 70-79 60-69 50-59 40-49 30-39 — 

CPS-II

Persons — — 13 912 13,225 88,464 261,902 415,840 322,399 7Percent — — 0.0 0.1 1.1 7.5 22.1 35.1 27.2 

Age at enrollment — — 103-112 93-102 83-92 73-82 63-72 53-62 43-52 3
Smoking and Tobacco Control Monograph No. 8

338

APPENDIX 2

Standard Populations Used To Compute Age-Standardized Death Rates and Smoking

Prevalence

Person-Years Age at Baseline

Age CPS-I and CPS-IIa CPS-I and CPS-IIb

30-34 120,780 51,203

35-39 382,619 84,593

40-44 684,255 171,619

45-49 1,591,398 382,258

50-54 2,343,338 401,847

55-59 2,296,964 361,256

60-64 1,968,333 291,430

65-69 1,506,638 213,021

70-74 1,013,392 131,189

75-79 564,855 66,945

80-84 250,957 27,283

85+ 120,886 13,321

a Represents the age distribution of all person-years during the first 6 years of followup in both studies combined, used

to standardize death rates.

b Represents the distribution of baseline age of 2,195,965 subjects in CPS-I and CPS-II, used to standardize smoking

prevalence. Excludes persons of race other than black or white.

Key: CPS = Cancer Prevention Study.
339

Chapter 4

APPENDIX 3

Deaths and Death Rates From Lung Cancer, by Amount and Duration of Current Cigarette

Smoking: Men (all races—includes prevalent cancers)

Never-Smokers

CPS-I CPS-II

(N = 66,154) (N = 94,958)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 6 105,584 5.7 7 127,821 5.5

55-59 13 95,592 13.6 7 132,430 5.3

60-64 16 76,190 21.0 14 121,174 11.6

65-69 14 60,654 23.1 22 102,124 21.5

70-74 13 43,770 29.7 25 71,536 34.9

75-79 8 25,766 31.0 21 40,363 52.0

80-84 8 11,858 67.5 16 17,946 89.2

85+ 2 5,658 35.3 7 8,069 86.8

18.8 17.7

20 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 6,690) (N = 3,150)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 25 38,751 64.5 14 14,003 100.0

55-59 22 17,921 122.8 9 8,883 101.3

60-64 2 3,246 61.6 4 2,293 174.4

65-69 2 596 335.7 3 700 428.7

70-74 0 184 — 1 222 450.1

75-79 0 90 — 0 63 —

80-84 0 25 — 0 2 —

85+ 0 18 — 0 0 —

20 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 9,008) (N = 4,921)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 21 13,576 154.7 7 6,520 107.4

55-59 36 28,260 127.4 33 14,608 225.9

60-64 23 10,423 220.7 10 7,146 139.9

65-69 4 1,854 215.8 8 1,453 550.5

70-74 1 326 306.5 2 288 693.6

75-79 0 77 — 0 85 —

80-84 0 11 — 0 23 —

85+ 0 6 — 0 4 —
Smoking and Tobacco Control Monograph No. 8

340

APPENDIX 3 (continued)

20 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 6,743) (N = 5,516)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 2 1,971 101.5 1 1,045 95.7

55-59 15 10,008 149.9 22 7,599 289.5

60-64 46 17,068 269.5 47 14,513 323.9

65-69 21 6,360 330.2 39 6,682 583.7

70-74 3 1,068 281.0 10 1,383 722.9

75-79 0 169 — 5 225 2,225.5

80-84 1 36 2,758.6 0 34 —

85+ 0 2 — 1 9 10,909.1

20 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 3,288) (N = 3,154)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 15 — 0 137 —

55-59 3 1,184 253.3 3 947 316.8

60-64 17 5,439 312.6 23 5,222 440.5

65-69 36 8,010 449.5 45 7,989 563.2

70-74 7 2,302 304.1 15 2,718 551.9

75-79 3 316 950.9 3 374 801.8

80-84 0 45 — 1 56 1,777.8

85+ 0 8 — 0 11 —

20 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 2,457) (N = 4,199)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 12 —

55-59 0 15 — 1 195 512.8

60-64 3 848 353.9 8 1,326 603.3

65-69 14 3,546 394.8 52 5,745 905.1

70-74 27 4,878 553.5 86 8,606 999.3

75-79 21 2,157 973.6 64 4,449 1,438.6

80-84 3 557 519.6 20 1,133 1,764.6

85+ 0 126 — 2 215 929.5
341

Chapter 4

APPENDIX 3 (continued)

40 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 1,967) (N = 1,750)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 8 11,807 67.8 20 10,639 188.0

55-59 7 5,144 136.1 8 4,952 161.5

60-64 2 785 254.9 4 1,027 389.5

65-69 2 140 1,431.1 1 179 558.7

70-74 0 31 — 0 56 —

75-79 0 7 — 0 9 —

80-84 0 5 — 0 5 —

85+ 0 3 — 0 1 —

40 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 2,485) (N = 3,394)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 4 4,650 86.0 10 5,735 174.4

55-59 15 7,903 189.8 25 10,631 235.2

60-64 8 2,502 319.7 22 4,069 540.7

65-69 0 366 — 5 616 811.1

70-74 0 60 — 1 87 1,152.7

75-79 0 9 — 0 14 —

80-84 0 0 — 0 0 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 1,592) (N = 3,229)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 2 718 278.7 3 981 305.8

55-59 10 3,057 327.1 21 5,919 354.8

60-64 18 3,761 478.6 45 8,555 526.0

65-69 8 996 803.5 22 2,583 851.7

70-74 0 105 — 5 362 1,380.3

75-79 0 4 — 0 49 —

80-84 0 0 — 0 6 —

85+ 0 0 — 0 0 —
Smoking and Tobacco Control Monograph No. 8

342

APPENDIX 3 (continued)

40 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 651) (N = 1,538)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 5 — 0 113 —

55-59 2 371 539.1 1 765 130.7

60-64 5 1,335 374.6 13 3,214 404.4

65-69 11 1,400 785.7 30 3,586 836.6

70-74 0 273 — 11 811 1,356.2

75-79 0 30 — 2 73 2,739.7

80-84 0 1 — 0 5 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 375) (N = 1,366)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 9 —

55-59 0 3 — 2 141 1,415.9

60-64 3 209 1,436.0 7 743 942.1

65-69 5 699 715.1 21 2,293 916.0

70-74 6 655 916.7 33 2,660 1,240.8

75-79 5 225 2,220.6 16 1,034 1,547.8

80-84 0 47 — 2 206 970.9

85+ 0 3 — 0 51 —

a Rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
343

Chapter 4

APPENDIX 4

Deaths and Death Rates From Lung Cancer, by Amount and Duration of Current Cigarette

Smoking: Women (all races—includes prevalent cancers)

Never-Smokers

CPS-I CPS-II

(N = 260,036) (N = 266,430)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 20 388,546 5.1 18 309,700 5.8

55-59 23 373,403 6.2 25 345,629 7.2

60-64 38 316,344 12.0 42 340,560 12.3

65-69 34 254,315 13.4 47 280,728 16.7

70-74 28 176,096 15.9 63 206,345 30.5

75-79 25 100,201 24.9 44 135,257 32.5

80-84 21 48,439 43.4 41 71,175 57.6

85+ 9 25,046 35.9 25 41,281 60.6

11.5 15.0

20 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 4,963) (N = 5,963)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 5 20,798 24.0 16 20,621 77.6

55-59 4 11,910 33.6 16 15,370 104.1

60-64 1 4,869 20.5 11 5,821 189.0

65-69 1 2,197 45.5 3 2,453 122.3

70-74 0 831 — 2 1,061 188.5

75-79 0 302 — 2 375 533.9

80-84 0 58 — 0 105 —

85+ 0 24 — 0 31 —

20 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 2,582) (N = 6,793)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 3,093 — 5 5,448 91.8

55-59 0 6,422 — 25 18,119 138.0

60-64 3 3,427 87.6 27 11,707 230.6

65-69 3 1,552 193.2 10 3,458 289.2

70-74 0 629 — 1 1,207 82.9

75-79 0 183 — 3 461 651.1

80-84 0 61 — 0 124 —

85+ 0 13 — 0 19 —
Smoking and Tobacco Control Monograph No. 8

344

APPENDIX 4 (continued)

20 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 771) (N = 5,690)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 97 — 0 318 —

55-59 0 785 — 8 4,976 160.8

60-64 3 1,804 166.3 23 14,857 154.8

65-69 2 1,001 199.9 9,112 384.1

70-74 0 427 — 11 2,622 419.5

75-79 0 157 — 8 857 934.0

80-84 0 32 — 3 247 1,213.3

85+ 0 11 — 0 85 —

20 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 202) (N = 2,878)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 6 —

55-59 0 41 — 0 201 —

60-64 0 211 — 7 3,207 218.3

65-69 1 471 212.1 27 8,009 337.1

70-74 0 221 — 17 3,850 441.6

75-79 0 80 — 7 866 808.6

80-84 0 36 — 1 193 518.4

85+ 0 3 — 0 54 —

20 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 98) (N = 2,450)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 0 —

55-59 0 0 — 0 14 —

60-64 0 30 — 2 240 834.2

65-69 1 118 847.5 19 2,699 703.9

70-74 0 195 — 30 5,843 513.5

75-79 0 107 — 15 3,427 437.7

80-84 0 39 — 7 977 716.6

85+ 0 6 — 3 202 1,482.7
345

Chapter 4

APPENDIX 4 (continued)

40 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 478) (N = 1,517)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 4 2,491 160.6 10 7,300 137.0

55-59 2 1,207 165.7 8 4,093 195.5

60-64 0 390 — 3 1,185 253.2

65-69 1 166 601.2 0 353 —

70-74 0 51 — 0 91 —

75-79 0 7 — 0 34 —

80-84 0 0 — 0 8 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 325) (N = 2,008)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 1 472 211.8 4 2,361 169.4

55-59 0 878 — 10 5,928 168.7

60-64 0 453 — 9 3,067 293.4

65-69 0 137 — 3 713 420.5

70-74 0 53 — 0 153 —

75-79 0 7 — 1 47 2,142.9

80-84 0 0 — 0 8 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 87) (N = 1,462)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 30 — 0 124 —

55-59 0 149 — 4 1,936 206.6

60-64 0 204 — 24 4,114 583.4

65-69 0 68 — 6 1,756 341.6

70-74 0 27 — 1 369 270.7

75-79 0 11 — 0 115 —

80-84 0 7 — 0 31 —

85+ 0 0 — 0 1 —
Smoking and Tobacco Control Monograph No. 8

346

APPENDIX 4 (continued)

40 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 20) (N = 649)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 9 —

55-59 0 3 — 0 92 —

60-64 0 25 — 6 970 618.4

65-69 0 63 — 11 1,888 582.5

70-74 0 14 — 3 591 507.3

75-79 0 2 — 1 139 720.7

80-84 0 2 — 0 19 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 10) (N = 475)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 0 —

55-59 0 0 — 0 1 —

60-64 0 5 — 0 83 —

65-69 0 21 — 4 689 580.7

70-74 0 18 — 7 1,164 601.5

75-79 0 7 — 5 467 1,071.2

80-84 0 0 — 1 108 922.4

85+ 0 0 — 0 65 —

a Rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
347

Chapter 4

APPENDIX 5

Deaths and Death Rates From Lung Cancer in Those With Comparable Histories of

Cigarette Smoking: Men (white race—excludes prevalent cancers)

Never-Smokers

CPS-I CPS-II

(N = 62,916) (N = 84,913)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 5 101,888 4.9 3 116,506 2.6

55-59 13 91,971 14.1 3 120,910 2.5

60-64 14 73,004 19.2 10 110,092 9.1

65-69 12 57,813 20.8 14 91,920 15.2

70-74 13 41,354 31.4 18 63,295 28.4

75-79 7 24,138 29.0 11 34,706 31.7

80-84 8 10,988 72.8 12 15,176 79.1

85+ 2 5,239 38.2 5 6,551 76.3

18.3 12.8

20 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 6,476) (N = 2,770)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 24 37,478 64.0 10 12,485 80.1

55-59 21 17,365 120.9 8 7,869 101.7

60-64 2 3,178 62.9 3 1,988 150.9

65-69 2 589 339.6 3 589 509.6

70-74 0 180 — 1 178 563.1

75-79 0 88 — 0 51 —

80-84 0 25 — 0 1 —

85+ 0 18 — 0 0 —

20 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 8,651) (N = 4,400)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 18 13,024 138.2 5 5,838 85.6

55-59 34 27,253 124.8 26 13,143 197.8

60-64 21 10,008 209.8 10 6,385 156.6

65-69 4 1,748 228.8 7 1,290 542.7

70-74 0 305 — 2 248 805.1

75-79 0 75 — 0 68 —

80-84 0 10 — 0 19 —

85+ 0 5 — 0 4 —
Smoking and Tobacco Control Monograph No. 8

348

APPENDIX 5 (continued)

20 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 6,486) (N = 4,850

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 1 1,885 53.0 1 955 104.7

55-59 13 9,624 135.1 16 6,794 235.5

60-64 42 16,509 254.4 38 12,819 296.4

65-69 21 6,127 342.7 30 5,894 509.0

70-74 3 1,022 293.6 8 1,180 678.0

75-79 0 168 — 4 195 2,049.5

80-84 1 36 2,758.6 0 27 —

85+ 0 2 — 0 1 —

20 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 3,123) (N = 2,782)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 15 — 0 111 —

55-59 3 1,118 268.4 3 821 365.6

60-64 15 5,176 289.8 18 4,551 395.6

65-69 34 7,682 442.6 42 7,146 587.7

70-74 7 2,187 320.1 13 2,438 533.2

75-79 1 290 344.5 3 320 937.5

80-84 0 39 — 1 47 2,127.7

85+ 0 8 — 0 11 —

20 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 2,287) (N = 3,578)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 12 —

55-59 0 14 — 1 175 572.0

60-64 1 792 126.2 7 1,168 599.4

65-69 14 3,345 418.5 43 4,984 862.8

70-74 26 4,582 567.5 75 7,365 1,018.3

75-79 18 2,024 889.5 49 3,792 1,292.2

80-84 3 525 571.2 18 973 1,849.3

85+ 0 115 — 1 183 547.7
349

Chapter 4

APPENDIX 5 (continued)

40 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 1,914) (N = 1,641)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 8 11,577 69.1 19 10,128 187.6

55-59 7 5,013 139.6 5 4,658 107.3

60-64 2 761 263.0 4 971 412.1

65-69 2 139 1,436.3 1 160 625.7

70-74 0 31 — 0 51 —

75-79 0 7 — 0 9 —

80-84 0 4 — 0 5 —

85+ 0 3 — 0 1 —

40 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 2,417) (N = 3,209)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 4 4,525 88.4 10 5,392 185.5

55-59 15 7,721 194.3 23 10,078 228.2

60-64 6 2,426 247.3 22 3,871 568.4

65-69 0 356 0.0 5 585 855.3

70-74 0 60 0.0 0 71 0.0

75-79 0 9 0.0 0 6 0.0

80-84 0 0 0.0 0 0 0.0

85+ 0 0 0.0 0 0 0.0

40 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 1,539) (N = 3,001)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 1 702 142.6 3 915 328.0

55-59 10 2,995 333.9 19 5,562 341.6

60-64 17 3,647 466.1 38 7,985 475.9

65-69 8 941 850.1 22 2,365 930.1

70-74 0 101 — 4 327 1,222.6

75-79 0 4 — 0 49 —

80-84 0 0 — 0 6 —

85+ 0 0 — 0 0 —
Smoking and Tobacco Control Monograph No. 8

350

APPENDIX 5 (continued)

40 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 626) (N = 1,419)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 5 — 0 102 —

55-59 2 365 547.6 1 704 142.0

60-64 4 1,297 308.3 13 2,994 434.2

65-69 11 1,351 814.2 25 3,344 747.7

70-74 0 261 — 8 753 1,062.5

75-79 0 25 — 2 66 3,045.7

80-84 0 0 — 0 3 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 356) (N = 1,213)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 9 —

55-59 0 3 — 2 137 1,456.3

60-64 3 207 1,449.9 5 682 732.7

65-69 5 667 750.2 15 2,083 720.3

70-74 5 625 799.6 26 2,373 1,095.8

75-79 4 220 1,815.4 15 918 1,634.1

80-84 0 44 — 1 170 589.1

85+ 0 3 — 0 38 —

a Rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
351

Chapter 4

APPENDIX 6

Deaths and Death Rates From Lung Cancer in Those With Comparable Histories of Cigarette

Smoking: Women (white race—excludes prevalent cancers)

Never-Smokers

CPS-I CPS-II

(N = 238,983) (N = 225,190)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 14 364,599 3.8 14 271,833 5.2

55-59 21 348,195 6.0 20 300,943 6.6

60-64 29 292,936 9.9 27 292,653 9.2

65-69 25 234,033 10.7 25 237,357 10.5

70-74 22 160,720 13.7 34 171,648 19.8

75-79 21 90,455 23.2 27 111,271 24.3

80-84 16 43,436 36.8 27 57,612 46.9

85+ 8 22,403 35.7 18 32,626 55.2

9.8 11.3

20 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 4,631) (N = 5,213)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 5 19,759 25.3 14 18,275 76.6

55-59 4 11,195 35.7 11 13,551 81.2

60-64 1 4,547 22.0 9 5,073 177.4

65-69 0 2,016 — 2 2,120 94.3

70-74 0 746 — 2 935 214.0

75-79 0 253 — 1 330 303.0

80-84 0 47 — 0 93 —

85+ 0 19 — 0 29 —

20 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 2,401) (N = 5,919)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 2,940 — 3 4,817 62.3

55-59 0 5,995 — 21 15,932 131.8

60-64 2 3,192 62.7 21 10,217 205.5

65-69 2 1,438 139.1 9 3,008 299.2

70-74 0 566 — 1 1,040 96.2

75-79 0 173 — 1 370 270.6

80-84 0 59 — 0 99 —

85+ 0 9 — 0 18 —
Smoking and Tobacco Control Monograph No. 8

352

APPENDIX 6 (continued)

20 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 721) (N = 4,902)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 82 — 0 255 —

55-59 0 733 — 7 4,238 165.2

60-64 3 1,702 176.3 18 13,004 138.4

65-69 2 931 214.8 28 7,881 355.3

70-74 0 402 — 8 2,243 356.7

75-79 0 157 — 7 727 962.6

80-84 0 32 — 1 206 485.6

85+ 0 11 — 0 63 —

20 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 177) (N = 2,433)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 2 —

55-59 0 41 — 0 156 —

60-64 0 196 — 7 2,750 254.6

65-69 1 406 246.6 23 6,793 338.6

70-74 0 187 — 14 3,282 426.6

75-79 0 72 — 6 744 806.2

80-84 0 30 — 0 174 —

85+ 0 2 — 0 52 —

20 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 86) (N = 2,033)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 0 —

55-59 0 0 — 0 10 —

60-64 0 24 — 0 203 —

65-69 1 100 999.2 11 2,274 483.6

70-74 0 178 — 24 4,882 491.6

75-79 0 103 — 13 2,887 450.3

80-84 0 37 — 5 811 616.2

85+ 0 2 — 3 159 1,890.8
353

Chapter 4

APPENDIX 6 (continued)

40 Cigarettes Per Day Smoked for 30 to 34 Years

CPS-I CPS-II

(N = 443) (N = 1,361)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 4 2,355 169.9 8 6,623 120.8

55-59 2 1,135 176.3 83,711 215.6

60-64 0 357 — 2 1,050 190.4

65-69 1 142 705.1 0 292 —

70-74 0 51 — 0 61 —

75-79 0 7 — 0 33 —

80-84 0 0 — 0 8 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 35 to 39 Years

CPS-I CPS-II

(N = 304) (N = 1,775)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 1 445 224.8 2 2,113 94.7

55-59 0 824 — 9 5,297 169.9

60-64 0 423 — 7 2,702 259.1

65-69 0 127 — 3 613 489.6

70-74 0 48 — 0 135 —

75-79 0 6 — 1 43 2,312.1

80-84 0 0 — 0 5 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 40 to 44 Years

CPS-I CPS-II

(N = 80) (N = 1,258)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 29 — 0 112 —

55-59 0 138 — 3 1,690 177.5

60-64 0 179 — 20 3,531 566.4

65-69 0 65 — 6 1,510 397.4

70-74 0 27 — 1 310 323.0

75-79 0 11 — 0 93 —

80-84 0 7 — 0 26 —

85+ 0 0 — 0 1 —
Smoking and Tobacco Control Monograph No. 8

354

APPENDIX 6 (continued)

40 Cigarettes Per Day Smoked for 45 to 49 Years

CPS-I CPS-II

(N = 16) (N = 554)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 6 —

55-59 0 3 — 0 72 —

60-64 0 23 — 5 830 602.1

65-69 0 48 — 10 1,623 616.2

70-74 0 7 — 3 510 588.4

75-79 0 2 — 1 128 779.7

80-84 0 2 — 0 19 —

85+ 0 0 — 0 0 —

40 Cigarettes Per Day Smoked for 50 or More Years

CPS-I CPS-II

(N = 9) (N = 401)

Number Person- Number PersonAge of Deaths Years Ratea of Deaths Years Ratea

50-54 0 0 — 0 0 —

55-59 0 0 — 0 1 —

60-64 0 4 — 0 62 —

65-69 0 16 — 4 584 685.5

70-74 0 18 — 6 1,020 588.1

75-79 0 7 — 4 389 1,029.4

80-84 0 0 — 1 97 1,029.2

85+ 0 0 — 0 54 —

a Rate per 100,000 person-years. Age-adjusted rate standardized to CPS-I and CPS-II 6-year person-years

distribution (Appendix 2).

Key: CPS = Cancer Prevention Study.
355

APPENDIX 7 Number and Percentage of Men Who Currently Smoke or Formerly Smoked Cigarettesa When Enrolled in CPS-I (1959(1982), by Age and Race

White Men

Percentage of Those Enrolled

Cigarette Smokers Pipe/Cigar

Smokers Only

Number Current Former Ever Never-Smokers U

Age CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II 30-34 10,189 7,623 59.5 31.9 10.2 18.5 4.5 3.7 21.2 44.0 35-39 17,218 9,298 57.8 33.5 12.2 25.3 5.6 5.4 18.5 33.9 40-44 31,947 15,087 56.4 31.5 13.1 31.6 5.5 6.4 19.0 28.5 45-49 94,993 68,835 54.5 28.4 15.3 34.7 5.6 7.8 18.5 27.3 50-54 92,933 87,127 51.1 26.8 16.8 38.9 6.7 7.7 18.6 24.6 55-59 71,328 91,343 45.5 24.7 18.5 43.1 7.9 8.2 20.0 21.8 60-64 52,083 79,467 38.4 21.1 19.9 44.3 9.9 8.9 21.8 22.9 65-69 35,982 58,269 31.5 18.1 19.6 45.3 11.8 8.6 25.2 24.2 70-74 20,490 35,577 25.2 14.6 17.5 46.6 14.3 9.2 29.7 24.4 75-79 9,750 17,109 18.0 11.0 14.5 44.4 16.9 10.8 35.0 26.7 80-84 3,841 5,944 13.9 8.1 11.3 41.5 20.1 12.5 38.5 28.9 85+ 1,700 2,440 7.4 5.8 6.8 34.9 23.1 16.7 45.2 32.6 
356APPENDIX 7 (continued)

Black Men

Percentage of Those Enrolled

Cigarette Smokers Pipe/Cigar

Smokers Only

Number Current Former Ever Never-Smokers U

Age CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II 30-34 539 609 67.7 42.2 5.4 14.6 3.2 2.1 21.3 36.0 35-39 800 655 68.1 42.4 5.6 18.2 4.9 2.0 17.4 30.8 40-44 1,012 938 63.1 41.7 6.0 21.1 6.2 3.9 19.7 27.7 45-49 1,790 2,809 61.1 39.8 7.0 25.0 8.2 5.3 18.9 25.5 50-54 1,746 3,191 52.8 37.0 8.0 26.8 11.5 5.8 20.3 23.9 55-59 1,355 3,149 46.1 35.4 8.9 29.6 14.8 7.2 22.2 20.5 60-64 873 2,795 38.3 29.1 8.6 30.8 16.2 8.9 26.6 23.7 65-69 736 2,072 32.1 29.1 8.0 30.0 18.6 9.9 28.7 22.1 70-74 481 1,437 27.2 24.1 11.2 29.4 19.1 10.3 29.1 23.9 75-79 273 711 21.3 18.4 10.6 28.7 19.1 12.0 36.3 25.5 80-84 102 303 16.7 12.5 11.8 27.4 16.7 16.2 30.4 26.7 

85+ 46 142 8.7 15.5 8.7 20.4 23.9 16.9 47.8 36.6 a Defined as cigarette smoking with or without pipes or cigars.

Key: CPS = Cancer Prevention Study.
357

APPENDIX 8 Number and Percentage of Women Who Currently Smoke or Formerly Smoked Cigarettesa When Enrolled in CPS-I (1CPS-II (1982), by Age and Race

White Women

Percentage of Those Enrolled

Cigarette Smokers

Number Current Former Never-Smokers U

Age CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II C30-34 17,868 11,803 42.7 25.2 7.1 17.8 48.6 53.4 35-39 34,640 18,891 41.0 26.5 7.6 23.0 49.8 46.6 40-44 73,263 44,665 39.2 24.7 7.4 23.5 51.9 47.7 45-49 114,005 92,077 36.2 24.3 7.0 22.6 55.2 48.5 50-54 102,887 106,281 29.1 22.8 6.0 22.5 63.2 49.7 55-59 79,027 108,015 21.0 21.3 4.7 22.2 72.5 51.0 60-64 58,577 92,195 14.3 18.4 3.7 21.1 80.1 53.8 65-69 42,583 68,992 10.1 15.7 3.0 21.0 84.7 54.7 70-74 25,717 44,662 6.9 11.8 2.4 18.3 88.5 59.2 75-79 13,595 23,968 4.7 8.0 2.0 13.7 90.5 66.1 80-84 6,389 9,964 2.7 5.0 1.4 9.5 93.2 71.7 85+ 3,167 5,392 1.1 2.7 1.0 5.4 94.4 77.2 
358APPENDIX 8 (continued)

Black Women

Percentage of Those Enrolled

Cigarette Smokers

Number Current Former Never-Smokers 

Age CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II CPS-I CPS-II C30-34 1,207 1,365 47.1 31.8 4.3 9.2 45.2 51.7 35-39 1,548 1,543 43.4 34.1 4.2 13.8 49.4 43.2 40-44 2,090 2,617 36.5 30.1 4.6 14.0 54.5 45.7 45-49 2,714 5,035 29.6 30.2 4.5 15.0 61.9 44.1 50-54 2,299 5,383 21.8 29.6 3.8 15.1 69.5 44.1 55-59 1,837 5,202 16.2 25.9 3.7 15.1 75.6 46.1 60-64 1,202 4,238 11.2 21.4 2.9 14.2 80.9 49.7 65-69 972 3,415 7.1 15.9 2.6 13.3 83.4 53.2 70-74 601 2,224 4.8 12.1 1.8 10.3 87.5 58.1 75-79 310 1,229 3.2 7.0 1.3 7.9 90.3 63.9 80-84 133 607 1.5 7.4 3.0 5.3 87.2 63.9 

85+ 66 368 0.0 5.7 0.0 5.4 97.0 68.2 a Assumed to be cigarette smoking only.

Key: CPS = Cancer Prevention Study.
359

APPENDIX 9 Number and Percentage of Men Who Currently Smoke or Formerly Smoked Cigarettesa When Enrolled in NHIS-I (196NHIS-II (1983), by Age and Race

White Men

Percentage of Those Enrolled

Cigarette Smokers Pipe/Cigar

Unweighted Smokers Only

Number Current Former Ever Never-Smokers Un

Age NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHI30-34 3,394 906 59.4 37.7 17.7 23.9 7.3 4.4 15.2 33.6 35-39 3,645 795 58.2 39.9 21.1 25.9 6.8 4.6 13.5 29.3 40-44 3,843 664 56.3 41.8 21.9 30.0 8.3 5.9 13.1 22.3 45-49 3,602 599 55.8 40.7 21.7 35.3 7.9 6.6 14.4 17.5 50-54 3,431 632 54.7 35.4 23.8 37.4 7.8 6.5 13.4 20.4 55-59 2,898 655 48.9 34.8 26.9 43.2 9.9 7.2 13.9 14.5 60-64 2,275 596 42.4 28.7 29.9 49.0 11.5 7.2 15.3 15.0 65-69 1,926 490 33.7 24.5 32.5 51.3 15.4 6.9 17.5 17.3 70-74 1,482 388 29.6 26.6 28.7 45.8 22.3 7.2 18.9 20.2 75-79 969 246 23.4 13.8 24.9 58.8 26.6 13.2 23.5 14.3 80-84 497 118 15.8 10.0 25.4 42.8 34.7 13.3 23.3 33.9 85+ 231 77 9.3 2.4 18.5 43.9 37.3 11.8 32.1 41.9 
360APPENDIX 9 (continued)

Black Men

Percentage of Those Enrolled

Cigarette Smokers Pipe/Cigar

Unweighted Smokers Only

Number Current Former Ever Never-Smokers Un

Age NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHI30-34 320 82 68.4 42.2 8.8 21.9 6.6 0.9 16.2 35.0 — 35-39 315 72 67.9 48.6 12.6 19.3 8.2 2.4 10.4 29.7 40-44 382 69 66.3 41.8 12.0 26.5 6.3 4.6 13.9 25.8 45-49 301 51 63.2 51.6 14.2 18.1 10.4 4.3 11.2 26.0 50-54 313 55 61.2 44.3 16.2 31.9 8.4 3.0 13.7 20.8 55-59 263 50 53.8 36.1 13.8 39.1 17.5 3.7 13.8 19.3 60-64 173 52 48.8 45.3 18.1 37.7 19.8 5.5 12.6 11.6 65-69 165 35 47.6 47.1 20.0 25.1 16.1 11.8 15.2 16.0 70-74 107 33 41.6 31.6 22.9 29.7 21.9 13.5 12.6 25.2 75-79 59 14 23.3 39.5 20.0 39.9 31.9 7.5 24.8 13.2 — 80-84 31 7 12.2 28.4 34.1 28.4 24.5 1.5 24.9 41.7 

85+ 15 2 14.0 — 5.6 — 34.1 — 46.3 — — a Defined as cigarette smoking with or without pipes or cigars.

Key: NHIS = National Health Interview Survey.
361

APPENDIX 10 Number and Percentage of Women Who Currently or Formerly Smoked Cigarettesa When Enrolled in NHIS-I (1965) (1983), by Age, Race, and Sex

White Women

Percentage of Those Enrolled

Cigarette Smokers

Unweighted Number Current Former Never-Smokers Un

Age NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS30-34 3,676 1,220 43.2 31.5 10.3 15.9 46.2 52.6 035-39 4,018 1,040 45.2 34.9 10.6 18.0 44.1 47.1 040-44 4,149 880 42.5 34.7 9.3 17.9 48.0 47.4 045-49 3,949 757 40.2 34.5 9.7 19.4 49.9 46.1 050-54 3,708 768 35.9 32.2 9.4 17.2 54.5 50.6 055-59 3,099 789 30.1 30.0 8.1 19.9 61.5 50.0 060-64 2,576 765 20.4 26.0 7.3 19.4 72.0 54.5 065-69 2,327 671 14.3 21.9 5.3 22.3 79.9 55.7 070-74 1,780 544 10.5 12.4 4.5 25.0 84.3 62.4 075-79 1,233 399 5.3 10.4 4.4 17.5 89.1 72.1 180-84 717 244 4.1 3.2 3.5 9.9 91.3 87.0 185+ 384 155 2.8 1.2 1.4 7.2 95.6 91.6 0
362APPENDIX 10 (continued)

Black Women

Percentage of Those Enrolled

Cigarette Smokers

Unweighted Number Current Former Never-Smokers Un

Age NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-65 NHIS-83 NHIS-30-34 433 171 47.4 39.0 7.4 4.0 44.8 57.0 035-39 454 128 44.9 36.5 7.3 10.3 47.6 53.2 040-44 491 92 40.8 27.3 6.7 10.1 52.4 62.6 — 45-49 424 85 37.7 48.3 5.9 11.1 55.8 40.6 050-54 358 90 25.9 38.7 8.5 9.8 65.3 51.5 055-59 277 84 18.6 32.0 6.3 20.9 75.1 46.0 — 60-64 251 60 14.1 22.1 5.4 21.5 79.7 56.4 065-69 214 49 11.6 22.0 5.1 11.6 82.3 66.4 070-74 137 42 4.4 14.4 5.4 9.1 88.8 76.4 175-79 76 36 5.8 5.2 5.9 13.1 88.3 81.7 — 80-84 44 14 3.4 13.6 — — 96.6 86.4 — 

85+ 30 17 — — — 5.5 100.0 94.5 — a Assumed to be cigarette smoking only.

Key: NHIS = National Health Interview Survey.
363

Chapter 4

APPENDIX 11

Meana Number of Cigarettes Smoked Per Day at Baseline (plus 5th and 95th percentiles)

Among Current Cigarette Smokers, by Sex, Study, and Age

Men Women

CPS-I CPS-II CPS-I CPS-II

Age Mean (5th-95th) Mean (5th-95th) Mean (5th-95th) Mean (5th-95th)

30-34 22.3 (4.8-40) 23.4 (3-40) 15.9 (4.8-29.2) 20.2 (3-40)

35-39 23.2 (4.8-40) 25.5 (4-50) 16.1 (4.8-29.2) 21.1 (3-40)

40-44 23.4 (4.8-40) 26.6 (5-50) 15.8 (4.8-29.2) 21.0 (3-40)

45-49 23.5 (4.8-40) 27.1 (5-50) 15.6 (4.8-29.2) 20.8 (4-40)

50-54 23.2 (4.8-40) 26.8 (5-50) 15.2 (4.8-29.2) 20.4 (4-40)

55-59 21.9 (4.8-40) 26.1 (5-50) 14.6 (4.8-29.2) 19.9 (4-40)

60-64 20.1 (4.8-40) 24.3 (5-40) 13.7 (4.8-29.2) 19.1 (4-40)

65-69 18.2 (4.8-40) 22.0 (5-40) 12.9 (4.8-29.2) 17.7 (4-40)

70-74 16.3 (4.8-29.2) 20.0 (4-40) 11.9 (4.8-20) 16.5 (3-40)

75-79 14.5 (4.8-29.2) 17.5 (3-40) 11.2 (4.8-20) 15.8 (3-30)

80-84 13.4 (4.8-29.2) 15.4 (2-40) 9.5 (4.8-20) 13.7 (3-30)

85+ 12.7 (4.8-29.2) 14.3 (2-40) 6.9 (4.8-20) 14.3 (2-40)

a Based on published mean values of categories in CPS-I (Hammond et al., 1977) and continuous data in CPS-II.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

364

APPENDIX 12

Number and Percentage of Current Cigarette Smokers at Each Age, by Cigarettes Smoked Per

Day: Men, CPS-I and CPS-II

Cigarettes Per Day (%)

Age Study 1-9 10-19 20 21-39 40 41+ Number of Persons

30-34 CPS-I 6.9 18.6 39.6 23.8 8.8 2.2 5,062

CPS-II 11.7 16.7 29.9 23.7 13.3 4.7 2,579

35-39 CPS-I 6.6 15.7 39.0 25.6 10.6 2.5 8,089

CPS-II 10.0 14.5 26.4 25.0 17.4 6.8 3,221

40-44 CPS-I 6.5 15.7 39.1 24.2 11.4 3.0 13,864

CPS-II 8.1 12.1 25.6 26.1 20.1 7.9 18,621

45-49 CPS-I 6.4 15.7 38.5 24.6 11.9 3.0 38,826

CPS-II 8.1 12.1 25.6 26.1 20.1 7.9 18,621

50-54 CPS-I 7.1 16.6 38.6 23.0 11.9 2.8 34,490

CPS-II 7.7 11.8 27.9 25.8 19.3 7.5 21,843

55-59 CPS-I 8.5 19.2 39.6 20.4 10.1 2.2 22,443

CPS-II 7.8 13.4 29.1 24.6 18.4 6.6 20,451

60-64 CPS-I 11.3 23.2 39.7 16.5 7.8 1.4 12,936

CPS-II 9.3 15.6 32.7 22.4 15.3 4.8 14,896

65-69 CPS-I 14.6 27.3 39.3 12.5 5.6 0.8 6,649

CPS-II 11.2 19.9 35.5 18.5 11.9 3.1 9,157

70-74 CPS-I 20.2 30.8 35.4 8.9 4.1 0.5 2,835

CPS-II 14.2 24.0 35.9 14.9 9.0 2.1 4,454

75-79 CPS-I 28.1 30.9 31.8 6.6 2.3 0.3 919

CPS-II 20.7 27.0 34.0 11.5 5.6 1.3 1,510

80-84 CPS-I 31.5 33.5 28.4 4.7 1.9 — 257

CPS-II 30.1 28.9 26.6 8.7 4.0 1.7 346

85+ CPS-I 37.9 31.0 25.9 3.4 — 1.7 58

CPS-II 43.0 18.6 26.7 3.5 5.8 2.3 86

Key: CPS = Cancer Prevention Study.
365

Chapter 4

APPENDIX 13

Number and Percentage of Current Cigarette Smokers at Each Age, by Cigarettes Smoked Per

Day: Women, CPS-I and CPS-II

Cigarettes Per Day (%)

Age Study 1-9 10-19 20 21-39 40 41+ Number of Persons

30-34 CPS-I 22.9 29.6 32.8 11.3 3.1 0.3 7,933

CPS-II 15.7 23.1 31.1 18.0 9.5 2.5 3,452

35-39 CPS-I 22.1 30.0 32.6 11.3 3.7 0.3 14,556

CPS-II 13.8 21.1 31.7 20.7 10.1 2.7 5,505

40-44 CPS-I 21.9 31.2 33.3 10.3 3.1 0.3 28,764

CPS-II 14.2 20.5 32.6 19.2 11.0 2.4 11,613

45-49 CPS-I 22.6 32.3 32.3 9.4 3.1 0.3 40,928

CPS-II 14.3 21.7 32.1 19.0 10.7 2.3 23,440

50-54 CPS-I 24.6 32.1 31.5 8.5 3.1 0.3 29,422

CPS-II 14.6 22.0 33.8 17.4 10.1 2.0 25,020

55-59 CPS-I 27.4 31.9 30.7 6.9 2.8 0.3 16,148

CPS-II 14.3 23.8 34.6 16.4 9.2 1.6 23,271

60-64 CPS-I 31.5 31.4 28.8 5.9 2.2 0.2 7,998

CPS-II 15.1 25.5 35.9 14.5 7.8 1.3 16,756

65-69 CPS-I 35.6 31.5 26.3 4.5 1.8 0.2 4,006

CPS-II 17.0 28.9 36.3 10.8 6.1 0.9 10,437

70-74 CPS-I 40.6 31.3 24.0 2.8 1.3 0.1 1,627

CPS-II 20.7 31.2 34.4 7.9 5.0 0.8 4,968

75-79 CPS-I 43.0 32.9 21.0 2.4 0.7 — 575

CPS-II 22.8 31.2 33.7 7.7 4.1 0.5 1,746

80-84 CPS-I 57.5 24.8 15.7 2.0 — — 153

CPS-II 32.2 31.6 27.8 5.1 2.4 0.9 450

85+ CPS-I 81.8 12.1 3.0 3.0 — — 33

CPS-II 31.9 30.4 26.7 4.4 5.9 0.7 135

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

366

APPENDIX 14

Number and Percentage of Current Cigarette Smokers at Each Age, by Cigarettes Smoked Per

Day: White Men, NHIS-65 and NHIS-83

Cigarettes Per Day (%)

Age Study 1-9 10-19 20 21-39 40 41+ Number of Persons

30-34 NHIS-65 10.2 16.8 43.4 15.9 10.5 3.3 1,972

NHIS-83 6.4 19.8 33.4 21.5 15.3 3.6 335

35-39 NHIS-65 10.2 16.7 39.1 17.9 12.2 3.9 2,037

NHIS-83 7.8 12.7 36.8 23.8 14.6 4.4 308

40-44 NHIS-65 9.2 16.1 39.2 17.4 13.8 4.4 2,090

NHIS-83 11.1 13.1 28.0 25.2 15.3 7.2 270

45-49 NHIS-65 10.1 17.9 38.6 16.3 13.4 3.9 1,934

NHIS-83 5.4 7.6 31.0 24.2 23.5 8.3 241

50-54 NHIS-65 10.1 17.2 40.3 15.4 12.9 4.1 1,805

NHIS-83 6.7 9.7 34.0 21.4 21.6 6.7 214

55-59 NHIS-65 14.0 19.4 37.3 13.6 12.1 3.6 1,350

NHIS-83 7.2 10.8 34.8 24.1 17.6 5.5 221

60-64 NHIS-65 17.3 22.2 36.0 13.2 8.5 2.8 914

NHIS-83 4.4 15.1 44.6 12.6 19.1 4.1 167

65-69 NHIS-65 19.8 28.5 31.8 10.2 7.4 2.4 623

NHIS-83 11.4 21.6 33.7 17.1 13.8 2.4 119

70-74 NHIS-65 25.2 27.8 32.5 8.4 5.0 1.2 409

NHIS-83 26.2 21.5 32.1 10.2 9.0 0.9 99

75-79 NHIS-65 28.5 34.0 28.1 5.2 2.7 1.5 206

NHIS-83 20.4 45.4 21.8 12.4 0.0 0.0 34

80-84 NHIS-65 34.5 31.7 26.3 4.2 3.3 0.0 69

NHIS-83 16.1 43.7 24.0 8.0 8.1 0.0 11

Key: NHIS = National Health Interview Survey.
367

Chapter 4

APPENDIX 15

Number and Percentage of Current Cigarette Smokers at Each Age, by Cigarettes Smoked Per

Day: White Women, NHIS-65 and NHIS-83

Cigarettes Per Day (%)

Age Study 1-9 10-19 20 21-39 40 41+ Number of Persons

30-34 NHIS-65 18.2 25.7 37.0 12.9 5.2 1.0 1,541

NHIS-83 14.5 24.3 36.7 14.7 8.3 1.7 378

35-39 NHIS-65 17.2 27.1 36.4 12.1 6.2 1.0 1,748

NHIS-83 11.3 22.9 41.0 12.1 10.3 2.4 354

40-44 NHIS-65 18.1 24.7 38.2 10.3 6.9 1.8 1,705

NHIS-83 6.8 19.5 41.3 17.9 12.6 1.9 295

45-49 NHIS-65 18.2 28.6 37.2 9.5 5.7 0.9 1,512

NHIS-83 10.4 17.5 40.0 16.8 11.5 3.9 249

50-54 NHIS-65 21.1 30.6 33.3 8.4 5.7 1.0 1,270

NHIS-83 12.5 19.4 40.5 15.5 10.8 1.4 244

55-59 NHIS-65 22.5 27.4 35.6 7.9 5.5 1.3 896

NHIS-83 12.1 24.6 41.1 11.5 8.2 2.4 228

60-64 NHIS-65 24.4 29.8 33.2 7.2 4.5 1.0 506

NHIS-83 14.4 29.7 36.6 10.8 6.2 2.3 189

65-69 NHIS-65 35.3 26.7 31.2 3.5 3.0 0.3 313

NHIS-83 19.5 29.3 38.1 8.5 3.9 0.7 137

70-74 NHIS-65 34.6 33.6 23.8 6.3 1.7 0.0 173

NHIS-83 23.2 20.2 36.4 12.6 7.6 0.0 68

75-79 NHIS-65 47.5 22.9 24.8 1.6 3.2 0.0 60

NHIS-83 22.4 35.2 32.9 7.2 2.3 0.0 41

80-84 NHIS-65 57.2 13.4 14.6 7.9 6.9 0.0 28

NHIS-83 12.5 24.9 62.6 0.0 0.0 0.0 8

Key: NHIS = National Health Interview Survey.
368APPENDIX 16 Cumulative Percentage of Cigarette Smokers Who Began Smoking Cigarettes Before Given Ages, by Sex, Study, and B

Age of

Sex Initiation Study 1860 1870 1880 1890 1900 1910 1920 1930 Women

<15 CPS-I — — 0.8 0.8 1.2 3.3 3.9 — 

CPS-II — — — 3.1 2.8 5.1 4.5 6.9 

<20 CPS-I — — 5.0 7.1 20.8 48.0 59.7 — 

CPS-II — — — 13.4 26.4 47.1 52.8 63.1 

<25 CPS-I — — 10.6 17.8 48.0 76.6 87.5 — 

CPS-II — — — 25.6 50.4 72.6 81.3 87.6 

<30 CPS-I — — 17.3 32.5 67.0 87.0 95.1 — 

CPS-II — — — 38.6 65.6 83.4 89.7 93.9 

Men

<15 CPS-I — 18.7 15.8 13.8 12.2 12.4 12.1 — 

CPS-II — — — 24.7 18.1 17.6 16.1 17.4 

<20 CPS-I — 53.9 55.8 61.2 66.1 70.4 77.1 — 

CPS-II — — — 61.2 66.6 69.4 74.1 74.5 

<25 CPS-I — 72.3 75.9 86.3 90.8 93.3 96.9 — 

CPS-II — — — 85.3 87.4 90.5 94.2 94.8 

<30 CPS-I — 75.8 83.2 92.3 95.8 97.5 99.2 — 

CPS-II — — — 90.0 93.5 96.4 97.7 97.9 

Key: CPS = Cancer Prevention Study.
369

Chapter 4

APPENDIX 17

Mean Number of Years Smoked at Baselinea (plus 5th and 95th percentiles) Among Current

Cigarette Smokers, by Sex, Study, and Age

Men Women

CPS-I CPS-II CPS-I CPS-II

Age Mean (5th-95th) Mean (5th-95th) Mean (5th-95th) Mean (5th-95th)

30-34 14.9 (9-21) 14.6 (7-21) 13.2 (5-17) 13.4 (5-19)

35-39 19.2 (13-26) 19.5 (11-26) 17.1 (6-22) 18.2 (8-25)

40-44 24.3 (17-31) 24.5 (16-31) 21.4 (8-27) 22.6 (10-29)

45-49 28.5 (20-36) 28.7 (20-36) 24.4 (9-32) 26.3 (12-33)

50-54 33.1 (24-41) 33.6 (23-40) 26.1 (8-36) 30.4 (15-38)

55-59 37.7 (28-45) 38.3 (27-46) 26.9 (9-40) 34.1 (17-43)

60-64 42.3 (29-51) 42.7 (30-50) 28.5 (12-44) 38.0 (20-48)

65-69 46.4 (29-56) 47.5 (35-56) 30.4 (16-48) 41.8 (20-53)

70-74 50.1 (28-61) 52.2 (38-61) 32.8 (20-53) 44.1 (20-57)

75-79 53.8 (29-66) 55.6 (35-65) 35.6 (25-56) 45.0 (16-61)

80-84 57.8 (32-70) 60.0 (30-71) 39.1 (30-64) 45.8 (13-66)

85+ 62.7 (36-78) 63.1 (10-79) 44.5 (35-69) 47.8 (20-72)

a Based on published mean values of categories in CPS-I (Hammond et al., 1977) and continuous data in CPS-II.

Key: CPS = Cancer Prevention Study.
370APPENDIX 18 Percentage Distribution of Measured Tar Contenta of Cigarette Brand Currently Smoked at Enrollment in CPS-I and C

Percentage by Tar Content (mg)

Numberb

Sex of Subjects <6.0 mg 6.0-11.9 mg 12.0-16.9 mg 17.0-20.9 mg 21.0-25.7 mg 25.Men CPS-I 128,427 — 0.4 12.4 29.2 17.5  CPS-II 91,209 19.5 23.5 38.8 11.1 7.1 Women CPS-I 135,604 — 0.7 25.3 34.9 15.7 

 CPS-II 123,442 18.9 31.7 38.6 7.5 3.3 a Tar content based on Garfinkel, 1979, and Federal Trade Commission, 1983.

b Excludes cigarette smokers who did not specify the brand of cigarettes currently smoked. Total number of smokers shown in Table 4.

Key: CPS = Cancer Prevention Study.
371

Chapter 4

APPENDIX 19

Age-Specific Deaths and Death Rates From Lung Cancer as Underlying Cause Among Lifelong

Never-Smokers and Current Cigarette Smokers: Men, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 0 — 3 8.1 1 4.6 1 5.9

40-44 1 4.0 16 28.1 0 — 4 18.7

45-49 4 6.0 66 45.6 4 6.0 26 41.4

50-54 6 5.7 162 75.3 7 5.5 136 115.3

55-59 13 13.6 217 131.5 7 5.3 260 206.1

60-64 16 21.0 229 231.2 14 11.6 381 361.1

65-69 14 23.1 183 341.1 22 21.5 400 581.6

70-74 13 29.7 97 403.4 25 34.9 343 909.0

75-79 8 31.0 53 612.7 21 52.0 170 1,118.3

80-84 8 67.5 8 334.9 16 89.2 51 1,227.7

85+ 2 35.3 1 178.5 7 86.8 9 919.0

Total 85 1,035 124 1,781

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

372

APPENDIX 20

Age-Specific Deaths and Death Rates From Lung Cancer as Underlying Cause Among Lifelong

Never-Smokers and Current Cigarette Smokers: Women, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 0 — 0 — 1 2.0 1 4.0

40-44 1 0.7 11 9.5 0 — 4 8.9

45-49 13 4.3 28 13.6 4 1.9 43 42.4

50-54 20 5.1 41 19.4 18 5.8 93 64.7

55-59 23 6.2 21 15.6 25 7.2 175 119.9

60-64 38 12.0 29 41.3 42 12.3 215 176.6

65-69 34 13.4 17 48.2 47 16.7 232 286.3

70-74 28 15.9 8 51.6 63 30.5 142 310.0

75-79 25 24.9 2 34.5 44 32.5 77 400.0

80-84 21 43.4 0 — 41 57.6 24 417.6

85+ 9 35.9 0 — 25 60.6 8 499.6

Total 212 157 310 1,014

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
373

Chapter 4

APPENDIX 21

Age-Specific Deaths and Death Rates From Coronary Heart Disease as Underlying Cause

Among Lifelong Never-Smokers and Current Cigarette Smokers: Men, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 2 12.9 18 48.7 2 9.1 5 29.6

40-44 10 39.7 101 177.4 3 13.4 18 84.1

45-49 54 80.7 443 305.9 18 26.8 92 146.6

50-54 174 164.8 1,065 495.1 72 56.3 251 212.9

55-59 329 344.2 1,289 781.0 157 118.6 407 322.7

60-64 477 626.1 1,215 1,226.8 277 228.6 576 545.9

65-69 596 982.6 914 1,703.7 414 405.4 531 772.1

70-74 707 1,615.3 586 2,437.1 490 685.0 437 1,158.2

75-79 650 2,522.7 272 3,144.4 497 1,231.3 254 1,670.9

80-84 392 3,305.7 116 4,856.3 340 1,894.6 113 2,720.3

85+ 377 6,663.3 45 8,030.9 266 3,296.6 37 3,778.1

Total 3,768 6,064 2,536 2,721

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

374

APPENDIX 22

Age-Specific Deaths and Death Rates From Coronary Heart Disease as Underlying Cause

Among Lifelong Never-Smokers and Current Cigarette Smokers: Women, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 1 1.4 5 8.3 1 2.0 0 —

40-44 12 7.9 22 19.1 5 5.9 4 8.9

45-49 44 14.6 82 39.9 8 3.8 28 27.6

50-54 131 33.7 177 83.9 25 8.1 66 45.9

55-59 253 67.8 220 163.4 84 24.3 112 76.7

60-64 585 184.9 219 311.9 211 62.0 198 162.6

65-69 989 388.9 208 589.8 353 125.7 249 307.2

70-74 1,281 727.4 156 1,005.7 523 253.5 219 478.2

75-79 1,415 1,412.2 89 1,537.3 717 530.1 163 846.7

80-84 1,152 2,378.3 44 2,634.7 694 975.1 73 1,270.2

85+ 1,201 4,795.2 24 5,657.0 1,096 2,655.0 48 2,997.7

Total 7,064 1,246 3,717 1,160

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
375

Chapter 4

APPENDIX 23

Age-Specific Deaths and Death Rates From Chronic Obstructive Pulmonary Disease as

Underlying Cause Among Lifelong Never-Smokers and Current Cigarette Smokers: Men, CPS-I

and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 0 — 0 — 0 — 0 —

40-44 0 — 2 3.5 0 — 0 —

45-49 0 — 2 1.4 0 — 2 3.2

50-54 1 0.9 16 7.4 2 1.6 15 12.7

55-59 2 2.1 54 32.7 3 2.3 28 22.2

60-64 7 9.2 65 65.6 4 3.3 46 43.6

65-69 9 14.8 56 104.4 8 7.8 102 148.3

70-74 4 9.1 45 187.1 18 25.2 98 259.7

75-79 11 42.7 31 358.4 15 37.2 85 559.2

80-84 2 16.9 10 418.6 13 72.4 33 794.4

85+ 8 141.4 3 535.4 15 185.9 13 1,327.4

Total 44 284 78 422

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

376

APPENDIX 24

Age-Specific Deaths and Death Rates From Chronic Obstructive Pulmonary Disease as

Underlying Cause Among Lifelong Never-Smokers and Current Cigarette Smokers: Women,

CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 0 — 0 — 0 — 0 —

40-44 1 0.7 2 1.7 0 — 0 —

45-49 1 0.3 4 1.9 0 — 2 2.0

50-54 3 0.8 7 3.3 2 0.6 12 8.3

55-59 1 0.3 9 6.7 6 1.7 24 16.4

60-64 6 1.9 11 15.7 11 3.2 44 36.1

65-69 5 2.0 6 17.0 16 5.7 68 83.9

70-74 9 5.1 9 58.0 24 11.6 65 141.9

75-79 15 15.0 7 120.9 24 17.7 39 202.6

80-84 14 28.9 1 59.9 29 40.7 30 522.0

85+ 6 24.0 0 — 31 75.1 19 1,186.6

Total 61 56 143 303

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
377

Chapter 4

APPENDIX 25

Age-Specific Deaths and Death Rates From Stroke as Underlying Cause Among Lifelong

Never-Smokers and Current Cigarette Smokers: Men, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 0 — 3 8.1 0 0 2 11.9

40-44 4 15.9 14 24.6 1 4.5 1 4.7

45-49 7 10.5 48 33.1 4 6.0 14 22.3

50-54 33 31.3 111 51.6 6 4.7 28 23.7

55-59 46 48.1 140 84.8 13 9.8 49 38.8

60-64 80 105.0 177 178.7 35 28.9 83 78.7

65-69 114 188.0 170 316.9 52 50.9 91 132.3

70-74 201 459.2 146 607.2 80 111.8 83 220.0

75-79 225 873.3 91 1,052.0 113 280.0 81 532.8

80-84 213 1,796.2 42 1,758.3 108 601.8 36 866.6

85+ 203 3,587.9 18 3,212.4 89 1,103.0 8 816.9

Total 1,126 960 501 476

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

378

APPENDIX 26

Age-Specific Deaths and Death Rates From Stroke as Underlying Cause Among Lifelong NeverSmokers and Current Cigarette Smokers: Women, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 2 2.7 6 10.0 1 2.0 1 4.0

40-44 14 9.2 15 13.0 1 1.2 3 6.7

45-49 31 10.3 50 24.3 6 2.9 22 21.7

50-54 85 21.9 100 47.4 16 5.2 36 25.0

55-59 102 27.3 84 62.4 23 6.7 58 39.7

60-64 203 64.2 88 125.3 55 16.1 50 41.1

65-69 340 133.7 64 181.5 104 37.0 78 96.2

70-74 458 260.1 56 361.0 135 65.4 81 176.9

75-79 654 652.7 39 673.6 215 159.0 61 316.9

80-84 687 1,418.3 24 1,437.1 273 383.6 19 330.6

85+ 741 2,958.6 7 1,650.0 501 1,213.6 13 811.9

Total 3,317 533 1,330 422

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
379

Chapter 4

APPENDIX 27

Age-Specific Deaths and Death Rates From Other Smoking-Related Cancers as Underlying

Cause Among Lifelong Never-Smokers and Current Cigarette Smokers: Men, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 1 6.5 0 0.0 0 0.0 1 5.9

40-44 0 0.0 6 10.5 2 8.9 3 14.0

45-49 5 7.5 29 20.0 1 1.5 17 27.1

50-54 10 9.5 92 42.8 16 12.5 54 45.8

55-59 18 18.8 112 67.9 31 23.4 93 73.7

60-64 34 44.6 108 109.1 45 37.1 133 126.0

65-69 39 64.3 102 190.1 53 51.9 118 171.6

70-74 37 84.5 48 199.6 56 78.3 103 273.0

75-79 33 128.1 26 300.6 50 123.9 58 381.6

80-84 24 202.4 12 502.4 20 111.4 25 601.8

85+ 4 70.7 1 178.5 16 198.3 5 510.6

Total 205 536 290 610

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

380

APPENDIX 28

Age-Specific Deaths and Death Rates From Other Smoking-Related Cancers as Underlying

Cause Among Lifelong Never-Smokers and Current Cigarette Smokers: Women, CPS-I and

CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 0 0.0 0 0.0 2 4.0 1 4.0

40-44 3 2.0 8 6.9 2 2.4 2 4.4

45-49 10 3.3 22 10.7 4 1.9 10 9.9

50-54 29 7.5 34 16.1 20 6.5 27 18.8

55-59 42 11.2 43 32.0 31 9.0 41 28.1

60-64 64 20.2 31 44.1 68 20.0 73 60.0

65-69 95 37.4 18 51.0 97 34.6 78 96.2

70-74 115 65.3 23 148.3 119 57.7 55 120.1

75-79 103 102.8 7 120.9 95 70.2 28 145.4

80-84 69 142.4 3 179.6 66 92.7 12 208.8

85+ 35 139.7 1 235.7 48 116.3 5 312.3

Total 565 190 552 332

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
381

Chapter 4

APPENDIX 29

Age-Specific Deaths and Death Rates From All Causes Among Lifelong Never-Smokers and

Current Cigarette Smokers: Men, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 19 122.7 85 229.8 16 72.9 37 219.3

40-44 48 190.6 236 414.6 21 93.7 65 303.6

45-49 168 251.1 958 661.6 102 151.8 268 427.1

50-54 437 413.9 2,181 1,013.8 283 221.4 800 678.5

55-59 741 775.2 2,694 1,632.3 487 367.7 1,367 1,083.8

60-64 1,011 1,326.9 2,603 2,628.3 815 672.6 1,925 1,824.2

65-69 1,298 2,140.0 2,161 4,028.0 1,120 1,096.7 1,984 2,884.9

70-74 1,566 3,577.8 1,433 5,959.6 1,321 1,846.6 1,760 4,664.5

75-79 1,497 5,810.0 764 8,832.2 1,389 3,441.2 1,113 7,321.7

80-84 1,100 9,276.2 308 12,894.2 981 5,466.5 434 10,447.8

85+ 1,026 18,134.2 118 21,058.9 899 11,141.6 135 13,784.9

Total 8,911 13,541 7,434 9,888

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
Smoking and Tobacco Control Monograph No. 8

382

APPENDIX 30

Age-Specific Deaths and Death Rates From All Causes Among Lifelong Never-Smokers and

Current Cigarette Smokers: Women, CPS-I and CPS-II

CPS-I CPS-II

Current Current

Cigarette Cigarette

Never-Smokers Smokers Never-Smokers Smokers

Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

35-39 73 100.1 67 111.4 40 80.6 22 88.8

40-44 230 150.7 230 199.2 93 109.3 50 110.9

45-49 638 211.4 600 291.6 255 122.4 256 252.6

50-54 1,247 320.9 932 442.0 564 182.1 501 348.5

55-59 1,696 454.2 906 673.1 927 268.2 874 598.8

60-64 2,371 749.5 756 1,076.6 1,401 411.4 1,140 936.3

65-69 3,140 1,234.7 545 1,545.4 1,871 666.5 1,243 1,533.7

70-74 3,700 2,101.1 425 2,739.9 2,216 1,073.9 1,020 2,227.0

75-79 3,933 3,925.1 241 4,162.7 2,487 1,838.7 658 3,417.9

80-84 3,406 7,031.6 147 8,802.4 2,245 3,154.2 285 4,959.2

85+ 3,552 14,182.1 55 12,964.1 3,331 8,069.2 171 10,679.2

Total 23,986 4,904 15,430 6,220

a Death rate per 100,000 person-years.

Key: CPS = Cancer Prevention Study.
383

Chapter 5

Age and the Exposure-Response Relationships

Between Cigarette Smoking and Premature

Death in Cancer Prevention Study II

Michael J. Thun, Dena G. Myers, Cathy Day-Lally, Mohan M. Namboodiri,

Eugenia E. Calle, W. Dana Flanders, Stacy L. Adams, and Clark W. Heath, Jr.

INTRODUCTION In the United States and other developed countries, cigarette

smoking causes most cases of lung cancer and chronic obstructive pulmonary

disease (COPD) (U.S. Department of Health, Education, and Welfare, 1964

and 1979; U.S. Department of Health and Human Services, 1984, 1989, and

1990) and a substantial fraction of deaths from coronary heart disease (CHD)

(U.S. Department of Health, Education, and Welfare, 1964, 1971, and 1979;

U.S. Department of Health and Human Services, 1983, 1989, and 1990)

and stroke (U.S. Department of Health, Education, and Welfare, 1964; U.S.

Department of Health and Human Services, 1983, 1989, and 1990). Because

of the vast number of deaths caused by tobacco, there is a continuing need to

quantify the epidemic, both in developed countries, where cigarette smoking

has evolved over several generations (Peto et al., 1992 and 1994), and in

other countries, where manufactured cigarettes have only recently been

introduced (U.S. Department of Health and Human Services, 1992).

Cancer Prevention Study II (CPS-II), begun by the American Cancer

Society (ACS) in 1982 (Garfinkel, 1985; Stellman and Garfinkel, 1986;

Garfinkel and Stellman, 1988), is the largest and most recent prospective

study of smoking and disease. The large size of the cohort facilitates

quantification of the dose-response relation between cigarette smoking and

premature mortality and estimation of the smoking-attributable risks for

many diseases (Shopland et al., 1991). Relative risk estimates from CPS-II

(disregarding dose) already have been used extensively to estimate smokingattributable mortality in the United States (U.S. Department of Health and

Human Services, 1989; Shultz et al., 1991 and 1992), Latin America (U.S.

Department of Health and Human Services, 1992), and nearly 50 other

developed countries (Peto et al., 1992 and 1994).

This chapter extends previous analyses of CPS-II data by examining the

exposure-response relation between current age, years of smoking, cigarettes

smoked per day, and premature mortality from major tobacco-related

diseases. It considers particularly whether the quantitative relationships

differ according to the age of the smoker and the epidemiologic measure

used to assess risk. Thun and colleagues (Chapter 4) consider whether these

quantitative relationships changed over the time between Cancer Prevention

Study I (CPS-I) (1959 through 1965) and CPS-II (1982 through 1988).
384

Smoking and Tobacco Control Monograph No. 8

BACKGROUND The excess risk of mortality of smokers is typically measured as the

AND ISSUES rate ratio (RR = death rate in smokers divided by that in lifelong

CONSIDERED nonsmokers) (Rothman, 1986; Cornfield and Haenszel, 1960). An

alternative measure is the rate difference (RD = death rate in smokers

Measures of minus that in never-smokers) (Rothman, 1986). These measures

Increased Risk provide different insights into the risk associated with smoking. The

RR generally is used to assess etiologic or causal associations. It expresses the

death rate among smokers as a multiple of that in never-smokers, indirectly

reflecting the proportion of deaths attributable to smoking among the

exposed. The RD represents the absolute increase in death rates among

exposed persons. It reflects more directly the burden of premature mortality

on individuals and society (Rothman, 1986).

The Effect of Age Age-related factors profoundly influence many chronic diseases.

on the RR and RD Because background death rates are included in the calculations

of both the RR and RD, age-related changes in background risk potentially

influence both measures. For CHD and stroke in particular, hypertension

and other age-related factors cause mortality to increase dramatically with

age in nonsmokers as well as in smokers (U.S. Department of Health and

Human Services, 1983). In countries where background CHD mortality is

high, the age-related increase in background risk causes the RR to decrease

and the RD to increase with aging (Hennekens et al., 1984). In the British

Doctors Study, death rates from CHD were 5.7 times higher among cigarette

smokers than among nonsmokers at ages 35 to 44 but were approximately

equal to those of nonsmokers at ages 75 to 84 (Doll and Hill, 1966; Rothman,

1986). Similar patterns were seen in CPS-I (Hammond, 1966) and the U.S.

Veterans' Study (Kahn, 1966). Although the age-related changes in RR have

not been emphasized, calculations of deaths from smoking have considered

at least two age groups (35 to 64, ≥65) in estimating deaths from CHD and

stroke in several recent reports on smoking and disease (Peto et al. 1992 and

1994; U.S. Department of Health and Human Services, 1992).

Age and There are at least two hypotheses on the relationship of age to cancer

Susceptibility risk; these arguments have been extended to lung cancer and smoking.

to Cancer Peto and colleagues (1975 and 1985) contend that increasing age alone

does not increase biologic susceptibility to cancer but merely allows time for

exposures to accumulate, genetic damage to occur, and tumors to become

manifest. Others theorize that aging impairs immunity, reduces DNA

(deoxyribonucleic acid) repair, and causes loss of cell regulation, which may

amplify injury by carcinogens (Anisimov, 1989; Miller, 1991; Holiday, 1984).

Understanding the relative effects of age and years of smoking is particularly

important in an era when many cigarette smokers begin smoking in

adolescence and continue through life. The concept that age might

accelerate the carcinogenic process has potential implications for both

cancer prevention and research emphasis.
385

Chapter 5

Age, Years of Most studies have not been large enough to sharply separate the

Smoking, and effects of age, years of smoking, and daily cigarette consumption.

Cigarettes Smoked Widely cited and informative analyses were published by Doll

Per Day and Peto (Doll and Peto, 1978; Peto, 1986) based on a 20-year

followup of the British Doctors Study (Doll and Peto, 1976). Among men

who currently were smoking ≤40 cigarettes per day and who began smoking

between ages 16 and 25, lung cancer incidence was proportional to the

fourth or fifth power of duration, as estimated by [age (in years)—22.5], but

only to the second power of the number of cigarettes smoked per day (Doll

and Peto, 1978; Peto, 1986). Age-22.5 served as a proxy for the number of

years of smoking. The results have been widely interpreted as showing that

the duration of smoking has a greater effect on lung cancer risk than does

the daily number of cigarettes smoked (Moolgavkar et al., 1989; Higgenson,

1988). However, the statistical modeling was based on only 124 cases of

lung cancer (Doll and Peto, 1978), and the use of age-22.5 to reflect duration

left open the possibility that older smokers might be more susceptible to

a given duration of smoking and amount of daily cigarette consumption

because effect modification by age could not be assessed in these analyses

(Moolgavkar et al., 1989; U.S. Department of Health and Human Services,

1990; Wu-Williams and Samet, 1994; Burns, 1994).

CPS-II provides an unusual opportunity to examine age as a potential

modifier of the effect of smoking because the study provides direct

information on both age and years of smoking, includes 3,229 lung cancer

deaths, and is sufficiently large to support stratified analyses, which require

fewer assumptions than statistical modeling.

SUBJECTS AND Subjects in the analyses were drawn from CPS-II (Garfinkel, 1985;

METHODS Garfinkel and Stellman, 1988), a nationwide prospective mortality

study of 1,185,106 men and women, begun by the ACS in 1982.

Selection Criteria CPS-II subjects were recruited by ACS volunteers in all 50 States,

the District of Columbia, Puerto Rico, and Guam. Volunteers contacted their

friends, neighbors, and acquaintances and sought to enroll all household

members age 30 or older if at least one family member was 45 years or older

(Garfinkel, 1985). A similar approach was used effectively in the HammondHorn or 10-State study (Hammond and Horn, 1958a and 1958b) and the

CPS-I (Hammond, 1964 and 1966; Hammond and Garfinkel, 1961; U.S.

Department of Health and Human Services, 1990).

Followup The authors' analyses are based on 6-year followup, from the month

of enrollment in 1982 through August 31, 1988. In this interval, the

participants' vital status was determined every 2 years through personal

contact by the volunteers. The analyses were restricted to deaths

identified by the volunteers during the first 6 years. In the entire cohort,

79,802 participants (6.7 percent) had died, 1,083,600 (91.4 percent) were

alive, and 21,704 (1.8 percent) were lost to followup during this interval.

Persons lost to followup were considered alive until the end of followup.

Death certificates were obtained for 94.1 percent of the persons known

to have died. The underlying cause of death was coded according to an
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Smoking and Tobacco Control Monograph No. 8

abbreviated version of the Manual of the International Statistical Classification

of Diseases, Injuries, and Causes of Death (ICD-9) (World Health Organization,

1977).

Information on At enrollment, participants completed a four-page questionnaire

Tobacco Smoking on demographic and lifestyle factors, including tobacco use

(questions on smoking appear as Appendix 1). The distribution of smoking

responses among all CPS-II participants is shown in Table 1. "Neversmokers," subsequently called nonsmokers, were persons who answered

"no" to question 2 and did not respond to questions 3 through 7. "Current

cigarettes only" included persons who answered "yes" to question 2, who had

never smoked pipes or cigars, and who left blank the questions on former

smoking. Current smokers were considered to have complete data if they

specified the "age began smoking" and "average number smoked per day."

The duration of smoking was defined as "total years smoked" reported by the

respondent or, if missing, the difference between age of initiation and age at

enrollment. In the dose-response analyses, duration was considered fixed at

the time of enrollment, except as otherwise specified. However, person-years

of observation (PYO's) and deaths accrued at the age of the individual during

the year of followup. That is, smokers were considered to be continuing

smokers for purposes of age classification (age was advanced), but the years

of smoking were fixed at entry into the study.

Analytic Cohort All analyses were restricted to 482,681 lifelong nonsmokers and

228,682 current cigarette (only) smokers with complete data on years of

smoking and daily cigarette consumption. We excluded former cigarette

smokers, persons ever smoking pipes or cigars, and those whose smoking

status was unclassifiable (Table 1). Dose-response analyses were further

restricted to persons ages 50 to 79 years who were either lifelong nonsmokers

or current cigarette smokers of ≥20 years duration on enrollment.

Rate Comparisons We compared death rates from lung cancer (ICD-9, 162),

in Never-Smokers CHD (ICD-9, 410-414), stroke (ICD-9, 430-438), COPD

and Current Smokers (ICD-9, 490-492, 496) (World Health Organization, 1977),

and all combined causes of death among current cigarette smokers and

lifelong nonsmokers. The numerators used in calculating the rates were

age-, gender-, and cause-specific deaths as coded by underlying (Tables 2

through 12) or contributing (Appendixes 2 and 3) causes of death as stated

on death certificates. The denominators were person-years at risk within the

corresponding age and gender (Appendix 4). Figures 1 through 10, using

age-specific death rates, RR’s, and RD’s, illustrate how age modifies the

apparent effect of smoking on premature mortality. Age-adjusted death rates

(Tables 2 through 12) were directly standardized to the 1980 U.S. population

(Appendix 5) (U.S. Department of Health and Human Services, 1985).

Ninety-five percent confidence intervals for the age-adjusted RR’s and RD’s

were calculated using approximate variance formulas (Rothman, 1986). For

each fatal endpoint, we calculated the percentage of deaths attributable to

smoking among all current cigarette smokers (Table 4) ([death rate in smokers

minus rate in nonsmokers]/death rate in smokers) × 100, or alternatively
387

Chapter 5

Table 1

Smoking habits of Cancer Prevention Study II participants

Men Women

Smoking Habits N % N % Total

Never-Smokersa 127,163 (25.0) 355,518 (52.6) 482,681

Current Cigarettes Only

 Data complete 101,888 (20.0) 126,794 (18.7) 228,682

 Data incompleteb 3,196 (0.6) 8,298 (1.2) 11,494

Former Cigarettes Only

 Data complete 140,988 (27.7) 122,059 (18.0) 263,047

 Data incompleteb 9,558 (1.9) 16,896 (2.5) 26,454

Ever Pipe or Cigar 101,600 (20.0) NAc NAc 101,600

Unclassifiable 24,186 (4.8) 46,962 (6.9) 71,148

Total 508,579 676,527 1,185,106

Total in Analysesd 229,051 482,312 711,363

a "Never-smokers"definedasneverhavingsmokedatleastonecigarette,cigar,orpipedailyfor1year'stime.

b Datamissingonyearsofsmokingordailycigaretteconsumption.

c Women not asked about pipe or cigar smoking.

d Excludespersonswithincompleteorunclassifiabledata,formersmokers,andthosewhoeversmokedpipesor

cigars.

Key: NA=notavailable.

(RR–1/RR) × 100 (Rothman, 1986). We estimated this smoking-attributable

fraction (SAF) within 5-year age intervals and over all ages.

Exposure-Response We calculated death rates from lung cancer, CHD, and all

Analyses combined causes of death by attained age (50 to 59, 60 to 69,

70 to 79), years of smoking at baseline (20 to 29, 30 to 39, 40 to 49, ≥50),

cigarettes smoked per day (1 to 19, 20, 21 to 39, 40, 41+), and sex

(Appendixes 6 through 17). Stratification was possible only for the most

common diseases in persons ages 50 to 79 and those reporting at least

20 years of smoking. Within each stratum of age, smoking, and sex we

measured the RR and RD compared with lifelong nonsmokers of comparable

age and sex.

Figure 11 shows the RD values for lung cancer in relation to cigarette

exposure using three rather than five categories of cigarettes per day

(Appendixes 18 through 21) to increase the stability of the rate estimates.

All the RD values based on three or more deaths in both smokers and

nonsmokers were positive. However, those based on fewer than three

deaths (not shown) were sometimes negative. We did not use these values.

We repeated the analyses allowing the years of smoking to progress during

followup as well as age (Appendixes 22 through 25). Based on a comparison

of Appendixes 18 through 21 and 22 through 25, we assessed whether
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Smoking and Tobacco Control Monograph No. 8

continued smoking during followup was distorting the apparent effect

of age on the exposure-response relationships.

Many other exposure-response analyses not discussed here are included

in the appendixes for archival purposes. These stratify on either age and

cigarettes per day (Appendixes 26 through 37) or age and years of smoking

(Appendixes 38 through 59) but not on all three variables simultaneously.

Stratified vs. The description of exposure-response relationships over all ages

Standardized was constrained by several factors. First, even in a large study

Exposure-Response like CPS-II, cause-specific deaths and person-years at risk are

Analyses sparse when stratified simultaneously by several variables.

Although broader categories of age and years of smoking might improve the

statistical power of subgroup analyses, there would be concern for residual

confounding. Second, because most deaths caused by smoking occurred at

least 30 years after initiation and because age and years of smoking were

strongly collinear, the PYO's largely lie along the diagonal from middle age/

medium duration to old age/long duration. Death rates in cells off this

diagonal were estimated poorly because there were essentially no PYO's.

Neither direct nor indirect standardization could be used to summarize the

effect of years of smoking across all age strata. Direct standardization would

necessarily assign finite weights to empty cells, treating these rates as zeros

rather than as unmeasurable. Indirect standardization would weight smokers

with short duration more heavily toward younger ages and long-term

smokers toward older ages.

RESULTS Death rates from all combined causes were substantially higher

in men and women who smoked cigarettes than in lifelong

Never-Smokers vs. nonsmokers (Figure 1 and Tables 2 and 3). Because the death

Current Smokers rates increased more steeply with age in smokers than in

nonsmokers (Figure 1), the absolute difference in death rates

All Causes of Death (RD) increased with the age of the smoker (Figure 2). The RD

associated with any current cigarette smoking peaked among smokers at

4,981.3 deaths per 100,000 person-years in men (Table 2) and 1,805 in

women (Table 3) at the oldest ages. (Note: Death rates in Figure 1 are

presented per 10,000 person-years, whereas those in Tables 2 and 3 are

per 100,000.)

In contrast, when the death rate in smokers was expressed relative to

that in nonsmokers, the effect of smoking as reflected by the RR decreased

rather than increased beyond age 65 (Figure 2). Among men, all-cause death

rates between ages 35 and 59 were about three times higher in smokers

than nonsmokers, whereas rates were 1.9 times higher at age 80 and older

(Table 2). Among women, the all-cause RR peaked at 2.3 times higher for

smokers vs. nonsmokers at ages 60 to 69 and decreased to 1.6 times higher

in the oldest age group (Table 3). The decline in the all-cause RR with age

indicates that, even though the death rate of smokers increases faster with

age than that of nonsmokers, it does not keep pace on a multiplicative scale

with the rising background risk in nonsmokers beyond age 59 in men and

age 69 in women.
389

Chapter 5

Figure 1

All-cause death rates in current cigarette smokers and lifelong nonsmokers, by age

and sex

The age-related decline in RR also implies that the percentage of deaths

from all causes attributable to smoking decreases among older cigarette

smokers (Table 4). This proportion varies with the RR; in CPS-II it peaked at

69 percent among male smokers ages 40 to 44 (Table 4) and at 57 percent

among female smokers ages 65 to 69. Among smokers of all ages, 52 percent

of deaths in men and 43 percent in women were attributable to smoking.
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Smoking and Tobacco Control Monograph No. 8

Table 2

All-cause mortality among lifelong nonsmokers and current cigarette smokers: Men, Cancer

Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 16 72.9 37 219.3 3.0 146.4

40-44 21 93.7 65 303.6 3.2 209.9

45-49 102 151.8 268 427.1 2.8 275.3

50-54 283 221.4 800 678.5 3.1 457.1

55-59 487 367.7 1,367 1,083.8 3.0 716.0

60-64 815 672.6 1,925 1,824.2 2.7 1,151.7

65-69 1,120 1,096.7 1,984 2,884.9 2.6 1,788.2

70-74 1,321 1,846.6 1,760 4,664.5 2.5 2,817.9

75-79 1,389 3,441.2 1,113 7,321.7 2.1 3,880.5

80+ 981 5,466.5 434 10,447.8 1.9 4,981.3

Total 6,535 9,753

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 751.7 1,560.0

Rate Ratio 1.0 2.1

 (95% CI) – (2.0-2.2)

Rate Differencea – 808.1

 (95% CI) – (750.6-865.5)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

Lung Cancer Death rates from lung cancer (per 100,000 person-years) diverged

markedly with age between smokers and nonsmokers (Figure 3 and Tables 5

and 6). Background death rates were much lower for lung cancer than for

other diseases in nonsmokers but increased rapidly between ages 45 and

74 years in smokers (Figure 3). Figure 4 illustrates that the absolute

difference (RD) between the rates of smokers and nonsmokers increased

dramatically with age, especially in men. However, the ratio of death rates

(RR) was biphasic, first increasing (in men) and later decreasing (in both

sexes). The RR in men increased from 7 (at ages 45 to 49) to 39 (at ages 55

to 59) and then decreased to 13.8 (at age 80 and older) (Table 5). In women,

there were insufficient observations to evaluate death rates in those younger

than age 45, but the RR decreased from 22.1 at ages 45 to 49 years to 7.3 at

age 80 and older (Table 6).

Much less variability with age occurred in the percentage of fatal lung

cancers attributable to smoking (SAF, Table 4) than in the RR (Table 5

and Figure 4). The SAF among smokers averaged 95 percent in men and
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Chapter 5

Table 3

All-cause mortality among lifelong nonsmokers and current cigarette smokers: Women, Cancer

Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 40 80.6 22 88.8 1.1 8.2

40-44 93 109.3 50 110.9 1.0 1.6

45-49 255 122.4 256 252.6 2.1 130.2

50-54 564 182.1 501 348.5 1.9 166.4

55-59 927 268.2 874 598.8 2.2 330.6

60-64 1,401 411.4 1,140 936.3 2.3 525.0

65-69 1,871 666.5 1,243 1,533.7 2.3 867.2

70-74 2,216 1,073.9 1,020 2,227.0 2.1 1,153.1

75-79 2,487 1,838.7 658 3,417.9 1.9 1,579.1

80+ 2,245 3,154.2 285 4,959.2 1.6 1,805.0

Total 12,099 6,049

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 485.5 842.8

Rate Ratio 1.0 1.8

 (95% CI) – (1.7-1.8)

Rate Differencea – 357.3

 (95% CI) – (320.4-394.2)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

92 percent in women in all age 35 and older combined, always exceeding

85 percent (Table 4). The relative stability of this measure reflects the

nonlinear relation between it and the RR (SAF = (RR–1)/RR × 100); 50 percent

of its impact occurs as the RR decreases from 2.0 to 1.0. RR values above 10

(Table 5 and Figure 4) correspond to SAF values above 90 percent (Table 4).

Coronary Heart Age-specific death rates from coronary heart disease followed a pattern

Disease similar to that for all-cause mortality; smokers had higher death rates

at all ages, yet the background risk among nonsmokers rose substantially

with age (Figure 5). Consequently, the difference in death rates (RD) rose

progressively with age (for women it declined slightly only for those older

than age 79), whereas the ratio (RR) peaked at 6.3 in men (ages 40 to 44)

and at 7.2 in women (ages 45 to 49) and declined progressively with

further aging (Figure 6 and Tables 7 and 8). The percentage of CHD deaths

attributable to smoking among cigarette smokers declined more dramatically

with age than did the percentage of lung cancer deaths (increasing slightly
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Smoking and Tobacco Control Monograph No. 8

Figure 2

All-cause rate ratios and rate differences in current cigarette smokers and lifelong

nonsmokers, by age and sex

only in men age 80 and older) (Table 4). The SAF decreased in men from

84 percent at ages 40 to 44 years to 26 percent at ages 75 to 79 years and

in women from 86 percent at ages 45 to 49 years to 23 percent at age 80

and older. As the RR approached 1.0 at older ages (Tables 7 and 8), the

attributable percentage (Table 4) diminished rapidly, as anticipated.

Stroke Age-specific patterns of stroke mortality (Figures 7 and 8, Tables 9 and 10)

were similar to those seen with CHD. The RD's increased progressively with

age, whereas the RR's in men followed a biphasic pattern and in women
393

Chapter 5

Table 4

Percentage of deaths attributable to smoking (SAF)a

 among current cigarette smokers in Cancer

Prevention Study II

Age

All Ages

35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Combined

Men

Lung cancer – – 86 95 97 97 96 96 95 93 95

CHD 69 84 82 74 63 58 47 41 26 31 41

Stroke – – 73 80 75 63 62 49 47 31 36

COPD – – – 88 90 92 95 90 93 91 91

All causes 67 69 64 67 66 63 62 60 53 48 52

Women

Lung cancer – – 95 91 94 93 94 90 92 86 92

CHD – – 86 82 68 62 59 47 38 23 37

Stroke – – 87 79 83 61 62 63 50 – 28

COPD – – – 92 89 91 93 92 91 92 93

All causes 9 2 51 48 55 56 57 52 46 36 43

a Smoking-attributablefraction(SAF)= . SAFforallagesisbasedonRRvaluesdirectlystandardizedto

1980U.S.agedistribution.

Key: CHD=coronaryheartdisease;COPD=chronicobstructivepulmonarydisease;RR=rateratio.

fluctuated somewhat before decreasing consistently after age 74. The

percentage of fatal strokes attributable to cigarette smoking also declined

dramatically with age among smokers (Table 4). In men this fraction fell from

80 percent at ages 50 to 54 years to 31 percent at ages ≥80 years; in women it

decreased erratically from 87 percent at ages 45 to 49 years to virtually

0 percent at ages ≥80 years.

Chronic Obstructive Chronic obstructive pulmonary disease resembled lung cancer

Pulmonary Disease in the wide divergence in death rates between smokers and

nonsmokers (Figure 9) and the high proportion of deaths attributable to

cigarettes among smokers (Tables 4, 11, and 12). Although the RD's

consistently increased with age (Figure 10), the RR's fluctuated somewhat

erratically between 8 and 19 in men (Table 11) and between 9.5 and 15 in

women (Table 12). The SAF remained at or above 88 percent at all ages in

both sexes.

Summary of Rates The magnitude of the adverse effects of cigarette smoking

in Current Smokers on mortality among all smokers differed quantitatively

vs. Lifelong Nonsmokers depending on the disease, the age and sex of the smoker,

and the epidemiologic measure used to assess risk. The absolute risk of a

smoker dying prematurely in CPS-II increased with the age of the smoker,

whereas the relative risk first increased and then decreased with age. The

percentage of deaths attributable to smoking (SAF) varied more with age

for cardiovascular diseases than for lung cancer or COPD because the
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Smoking and Tobacco Control Monograph No. 8

Figure 3

Lung cancer death rates in current cigarette smokers and lifelong nonsmokers, by

age and sex

mathematical relation between the RR and attributable risk was nonlinear

and the attributable percentage decreased rapidly as the RR approached 1.0.

Dose-Response Whereas the previous analyses considered mortality risks among

Among Current all cigarette smokers together in relation to age, the next section

Cigarette Smokers examines the separate and joint effects of age, years of smoking,

and current daily cigarette consumption on death rates.
395

Chapter 5

Table 5

Mortality from lung cancer as underlying cause of death among lifelong nonsmokers and current

cigarette smokers: Men, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 1 4.6 1 5.9 – 1.4

40-44 0 – 4 18.7 – 18.7

45-49 4 6.0 26 41.4 7.0 35.5

50-54 7 5.5 136 115.3 21.1 109.9

55-59 7 5.3 260 206.1 39.0 200.8

60-64 14 11.6 381 361.1 31.3 349.5

65-69 22 21.5 400 581.6 27.0 560.1

70-74 25 34.9 343 909.0 26.0 874.1

75-79 21 52.0 170 1,118.3 21.5 1,066.3

80+ 16 89.2 51 1,227.7 13.8 1,138.6

Total 117 1,772

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 11.3 229.4

Rate Ratio 1.0 20.3

 (95% CI) – (16.4-25.1)

Rate Differencea – 218.1

 (95% CI) – (202.0-234.2)

aDeathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

Lung Cancer Figure 11 illustrates that the excess death rates (RD) from lung cancer

Dose-Response increased with age, years of smoking, and cigarettes smoked per day.

In this stratified presentation, death rates within each subgroup of age,

cigarette smoking, and sex (e.g., men ages 60 to 69 who at enrollment had

smoked 1 to 19 cigarettes per day, for 20 to 29 years) were compared with

rates in age-comparable lifelong nonsmokers (Appendixes 18 to 21 and

Tables 5 and 6). In men, the RD was higher in older smokers than in

younger smokers for a comparable amount of reported smoking. For

example, men ages 60 to 69 who had smoked for 20 to 29 years and reported

smoking 1 to 19 cigarettes per day currently had excess death rates from lung

cancer similar to those of younger men, ages 50 to 59, who had smoked for

10 to 29 years longer (Figure 11 and Appendix 20). There is potential for

substantial residual confounding between age and years of smoking within

these 10-year categories, and the confounding may be particularly strong

\in the 50-plus duration category. Such residual confounding limits

interpretation of the differences in age-specific rates for duration-specific

categories in Figure 11 and Appendix 20. However, within these broad
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Smoking and Tobacco Control Monograph No. 8

Table 6

Mortality from lung cancer as underlying cause of death among lifelong nonsmokers and current

cigarette smokers: Women, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 1 2.0 1 4.0 – 2.0

40-44 0 – 4 8.9 – 8.9

45-49 4 1.9 43 42.4 22.1 40.5

50-54 18 5.8 93 64.7 11.3 58.9

55-59 25 7.2 175 119.9 16.6 112.7

60-64 42 12.3 215 176.6 14.3 164.3

65-69 47 16.7 232 286.3 17.1 269.5

70-74 63 30.5 142 310.0 10.2 279.5

75-79 44 32.5 77 400.0 12.3 367.5

80+ 41 57.6 24 417.6 7.3 360.0

Total 285 1,006

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 8.6 101.3

Rate Ratio 1.0 11.9

 (95% CI) – (10.1-13.7)

Rate Differencea – 92.7

 (95% CI) – (83.7-101.7)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

intervals of age, years of smoking, and daily cigarette consumption, older

males, but not females, have consistently higher excess lung cancer death

rates (RD) than younger individuals in the same duration category.

Coronary Heart Appendixes 10 to 17 present exposure-response data on CHD

Disease and and all-cause mortality stratified by age, years of smoking, and

All-Cause Mortality current daily cigarette consumption. Interpretation of these

data as complicated by substantial potential for selection bias. Persons who

experience nonfatal symptoms of CHD or who reduce their smoking because

of other known risk factors may thereby distort the underlying dose-response

relationships. This potential for survivor bias among older persons who

continue to smoke heavily is greater for CHD than for lung cancer. The allcause mortality pattern represents a hybrid of major smoking-related diseases

and is similarly vulnerable to selection bias among older smokers.

DISCUSSION Our principal findings were that active cigarette smoking consistently

and strongly increased the risk of death from lung cancer, CHD, stroke,
397

Chapter 5

Figure 4

Lung cancer rate ratios and rate differences in current cigarette smokers and

lifelong nonsmokers, by age and sex

COPD, and death from all causes. However, the magnitude of these adverse

effects differed depending on the cause-of-death category, the smoker's age,

the number of years of smoking, and the number of cigarettes smoked per

day. Relative and absolute measures of risk had different patterns of variation

with age for some outcomes. Our results have different implications for the

various audiences, including individuals who smoke, epidemiologists who

measure the impact of the evolving tobacco epidemic, and researchers

interested in carcinogenesis.
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Smoking and Tobacco Control Monograph No. 8

Figure 5

Coronary heart disease death rates in current cigarette smokers and lifelong

nonsmokers, by age and sex

Significance The enormous contribution of cigarette smoking to premature mortality

to Smokers is evident: An estimated 52 percent of deaths in men and 43 percent

of deaths in women who continued to smoke were attributable to smoking.

This percentage has been rising in U.S. women (Chapter 4) because women

began to smoke during adolescence later in this century than did U.S. men.

CPS-II demonstrates that the absolute risk of a smoker being killed by

cigarette smoking increases rather than decreases with age. Because some
399

Chapter 5

Figure 6

Coronary heart disease rate ratios and rate differences in current cigarette smokers

and lifelong nonsmokers, by age and sex

of this risk is reversible (Shopland et al., 1991), an important message for

smokers is that "the damage is not yet done." The 1990 U.S. Surgeon General's

Report shows that smokers who quit by age 50 experience only modest

increased mortality compared with lifelong nonsmokers and that there are

substantial benefits from quitting at any age (Shopland et al., 1991). Middleaged smokers should be considered a high-priority group for smoking cessation

programs and for research to improve the success rate of attempted quitting.
400

Smoking and Tobacco Control Monograph No. 8

Table 7

Mortality from coronary heart disease as underlying cause of death among lifelong nonsmokers

and current cigarette smokers: Men, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 2 9.1 5 29.6 3.3 20.5

40-44 3 13.4 18 84.1 6.3 70.7

45-49 18 26.8 92 146.6 5.5 119.8

50-54 72 56.3 251 212.9 3.8 156.6

55-59 157 118.6 407 322.7 2.7 204.1

60-64 277 228.6 576 545.9 2.4 317.3

65-69 414 405.4 531 772.1 1.9 366.7

70-74 490 685.0 437 1,158.2 1.7 473.2

75-79 497 1,231.3 254 1,670.9 1.4 439.6

80+ 340 1,894.6 113 2,720.3 1.4 825.7

Total 2,270 2,684

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 240.9 408.0

Rate Ratio 1.0 1.7

 (95% CI) – (1.6-1.8)

Rate Differencea – 167.1

 (95% CI) – (138.3-195.8)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

Implications Relative risk estimates among current smokers in CPS-II have

for Estimating been used to estimate the number of deaths caused by cigarette

Attributable Risk smoking in the United States (U.S. Department of Health and

Human Services, 1989; Shultz et al., 1991 and 1992), Latin America (U.S.

Department of Health and Human Services, 1992), and many other developed

countries (Peto et al., 1992 and 1994). All these applications use age-adjusted

rather than age-specific RR estimates, yet the age variability observed in

CPS-II is not likely to alter substantively the estimates of smoking-related

deaths for several reasons.

First, these methods provide approximate rather than precise estimates

of the number of deaths caused by tobacco. The estimates are necessarily

crudest in countries where mortality registration is incomplete and prevalence

data on smoking are limited. Methods developed by Peto and colleagues

(1992 and 1994) and jointly by the Centers for Disease Control and Prevention

(CDC) and the Pan-American Health Organization (U.S. Department of Health

and Human Services, 1992) use lung cancer mortality to index past smoking
401

Chapter 5

Table 8

Mortality from coronary heart disease as underlying cause of death among lifelong nonsmokers

and current cigarette smokers: Women, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 1 2.0 0 – – (2.0)

40-44 5 5.9 4 8.9 1.5 3.0

45-49 8 3.8 28 27.6 7.2 23.8

50-54 25 8.1 66 45.9 5.7 37.8

55-59 84 24.3 112 76.7 3.2 52.4

60-64 211 62.0 198 162.6 2.6 100.6

65-69 353 125.7 249 307.2 2.4 181.5

70-74 523 253.5 219 478.2 1.9 224.7

75-79 717 530.1 163 846.7 1.6 316.6

80+ 694 975.1 73 1,270.2 1.3 295.1

Total 2,621 1,112

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 115.4 181.9

Rate Ratio 1.0 1.6

 (95% CI) – (1.4-1.7)

Rate Differencea – 66.5

 (95% CI) – (48.7-84.3)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

habits. The RR values from CPS-II are adjusted, based on the death rate from

lung cancer in the country of interest relative to that of nonsmokers in the

United States. These evolving methods provide interim estimates, pending

the availability of regional data on the prevalence of smoking and associated

death rates.

The CDC's Office of Smoking and Health has assessed the effect of age

variability in RR estimates on its estimates of deaths from tobacco smoking in

the United States. When age-specific rather than age-adjusted RR estimates

from CPS-II are included in the calculations, the attributable risk estimates

decrease by approximately 10 percent in men. This decrease is similar to the

difference between the CDC estimate (418,690 deaths from smoking) (Centers

for Disease Control and Prevention, 1993) and the Peto and colleagues'

estimate (461,000 deaths) (Peto et al., 1992 and 1994) for the United States

in 1990. Both estimates are intended to be general approximations that could

reasonably differ by at least 10 percent in either direction. In a recent study
402

Smoking and Tobacco Control Monograph No. 8

Figure 7

Stroke death rates in current cigarette smokers and lifelong nonsmokers,

by age and sex

in Oregon, the CDC estimates were shown to agree well with physician

reporting on death certificates (McAnulty et al., 1994).

Future refinements in the attributable risk calculations should consider

stabilizing the age standard with which the RR estimates are weighted and

perhaps choosing weights that resemble the age distribution of deaths from

smoking-related causes. Information on years of smoking or cigarettes

1,000

800

600

400

200

Rate Per 100,000 Person-Years

0

Men

800

600

400

200

Rate Per 100,000 Person-Years

0

Women

35-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

Age (years)

Current smoker 

Never-smoker

Current smoker 

Never-smoker

35-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

Age (years)
403

Chapter 5

Figure 8

Stroke rate ratios and rate differences in current cigarette smokers and lifelong

nonsmokers, by age and sex

smoked per day probably will not improve these estimates in the near future

because longitudinal information on dose is rarely available.

Age and Biological Our findings raise the possibility that age may increase a

Susceptibility smoker's biological susceptibility to lung cancer, although

the evidence is limited by the data available on smoking. Current

cigarette consumption reported at enrollment in CPS-II may systematically

underestimate past consumption among older smokers because average

daily consumption decreases with age after approximately age 50 in
404

Smoking and Tobacco Control Monograph No. 8

Table 9

Mortality from stroke as underlying cause of death among lifelong nonsmokers and current

cigarette smokers: Men, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 0 0.0 2 11.9 – 11.9

40-44 1 4.5 1 4.7 – 0.2

45-49 4 6.0 14 22.3 3.8 16.3

50-54 6 4.7 28 23.7 5.1 19.0

55-59 13 9.8 49 38.8 4.0 29.0

60-64 35 28.9 83 78.7 2.7 49.8

65-69 52 50.9 91 132.3 2.6 81.4

70-74 80 111.8 83 220.0 2.0 108.2

75-79 113 280.0 81 532.8 1.9 252.8

80+ 108 601.8 36 866.6 1.4 264.8

Total 412 468

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 55.5 87.2

Rate Ratio 1.0 1.6

 (95% CI) – (1.3-1.9)

Rate Differencea – 31.7

 (95% CI) – (17.8-45.6)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

cross-sectional surveys (Chapter 4). The broad categories by which we

stratified age, years of smoking, and cigarettes smoked per day leave ample

room for residual confounding. Cigarette smokers who report taking up the

habit after age 30 may differ in their smoking practices, reporting patterns, or

other unidentified ways from those who begin in adolescence. The absolute

excess death rate from lung cancer (RD) also may differ from the RR in its

relation to age or other factors.

Statistical and Even if age does not modify the carcinogenic response to cigarette

Methodological smoke in a biological sense, it does affect the empirical quantitative

Implications relationships between smoking and both the RD and RR for lung

cancer. One implication is that epidemiologists should consider including

interaction terms between smoking and age in statistical models that

consider either the RR or RD as the measure of effect. A second implication

is that residual confounding by cigarette smoking should be minimized

by including variables on age, years of smoking, cigarettes per day, and

interaction terms when controlling for smoking in studies in which other

risk factors are of primary interest. Otherwise, it will be difficult to
405

Chapter 5

Table 10

Mortality from stroke as underlying cause of death among lifelong nonsmokers and current

cigarette smokers: Women, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 1 2.0 1 4.0 2.0 2.0

40-44 1 1.2 3 6.7 5.7 5.5

45-49 6 2.9 22 21.7 7.5 18.8

50-54 16 5.2 36 25.0 4.9 19.8

55-59 23 6.7 58 39.7 6.0 33.0

60-64 55 16.1 50 41.1 2.5 25.0

65-69 104 37.0 78 96.2 2.6 59.2

70-74 135 65.4 81 176.9 2.7 111.5

75-79 215 159.0 61 316.9 2.0 157.9

80+ 273 383.6 19 330.6 0.9 (53.0)

Total 829 409

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 44.1 61.1

Rate Ratio 1.0 1.5

 (95% CI) – (1.2-1.7)

Rate Differencea – 17.1

 (95% CI) – (6.9-27.2)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

distinguish weak associations with occupation or nutrition, for example, from

residual confounding by smoking.

CONCLUSIONS

• Among current cigarette smokers in CPS-II, 52 percent of deaths from

all causes in men and 43 percent in women were attributable to

cigarette smoking, based on age-adjusted death rates standardized

to the 1980 U.S. population.

• Cigarette smoking was strongly associated with death from lung

cancer, CHD, stroke, and COPD. However, the magnitude of its

adverse effect on premature mortality varied with the disease, the

age and sex of the smoker, the years of smoking and daily cigarette

consumption, and the epidemiologic measure used to assess risk.

• The absolute risk of dying prematurely because of cigarette smoking

increased with the age of the smoker as reflected by the rising RD.

Thus, the burden of risk that smoking imposes on an individual and

society increases rather than decreases with the smoker's age.
406

Smoking and Tobacco Control Monograph No. 8

Figure 9

Chronic obstructive pulmonary disease death rates in current cigarette smokers

and lifelong nonsmokers, by age and sex

• In relative terms, the RR associated with cigarette smoking initially

increased and then decreased with age for all the major smokingrelated diseases. The initial increase reflected the time lag required

for tobacco-induced injury to progress to fatal disease. The decrease
407

Chapter 5

Figure 10

Chronic obstructive pulmonary disease rate ratios and rate differences in current

cigarette smokers and lifelong nonsmokers, by age and sex

20

16

10

6

0

Rate Ratio

Men

800

200

600

0

Rate ratio

Rate difference

18

12

14

8

4

2

400

20

16

10

6

0

Rate Ratio

Women

800

200

600

0

Rate Differences (per 100,000) Rate Differences (per 100,000)

Rate ratio

Rate difference

18

12

14

8

4

2

400

35-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

Age (years)

35-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

Age (years)

at older ages occurred because factors other than smoking caused a

larger fraction of deaths in older than in younger smokers.

• Age-specific patterns of CHD and stroke were generally similar, as

were the patterns for lung cancer and COPD. The etiologic fraction

(percentage of deaths attributable to smoking) decreased more sharply

with age for CHD and stroke than for lung cancer or COPD, in part

reflecting the nonlinear relation between the RR and attributable risk

as the RR approaches 1.0.
408

Smoking and Tobacco Control Monograph No. 8

Table 11

Mortality from chronic obstructive pulmonary disease as underlying cause of death among

lifelong nonsmokers and current cigarette smokers: Men, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 0 – – – – –

40-44 0 – – – – –

45-49 0 – 2 3.2 – 3.2

50-54 2 1.6 15 12.7 8.1 11.1

55-59 3 2.3 28 22.2 9.8 19.9

60-64 4 3.3 46 43.6 13.2 40.3

65-69 8 7.8 102 148.3 18.9 140.5

70-74 18 25.2 98 259.7 10.3 234.5

75-79 15 37.2 85 559.2 15.1 522.0

80+ 13 72.4 33 794.4 11.0 722.0

Total 63 409

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 8.5 89.9

Rate Ratio 1.0 10.6

 (95% CI) – (7.9-14.3)

Rate Differencea – 81.4

 (95% CI) – (66.6-96.2)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

• Excess mortality from all causes of death increased with the smoker's

age and the years of smoking.

• Whether or not age alters biological susceptibility to tobacco-induced

lung cancer, it changes the quantitative relation between any cigarette

smoking and premature death and alters the exposure-response

relations of defined levels of smoking. Epidemiologists should include

interaction terms between age and smoking when studying or

controlling for the effect of smoking.

• The reliance on RR as the sole epidemiologic measure of association

between a particular risk factor and a disease provides an incomplete

picture of that disease's occurrence. Prospective studies also should

examine and present death rates and RD's associated with the

exposure.
409

Chapter 5

Table 12

Mortality from chronic obstructive pulmonary disease as underlying cause of death among

lifelong nonsmokers and current cigarette smokers: Women, Cancer Prevention Study II

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 0 – 0 – – –

40-44 0 – 0 – – –

45-49 0 – 2 2.0 – 2.0

50-54 2 0.6 12 8.3 12.9 7.7

55-59 6 1.7 24 16.4 9.5 14.7

60-64 11 3.2 44 36.1 11.2 32.9

65-69 16 5.7 68 83.9 14.7 78.2

70-74 24 11.6 65 141.9 12.2 130.3

75-79 24 17.7 39 202.6 11.4 184.9

80+ 29 40.7 30 522.0 12.8 481.3

Total 112 284

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 4.2 56.8

Rate Ratio 1.0 13.4

(95% CI) – (10.5-17.2)

Rate Differencea – 52.6

(95% CI) – (42.1-63.0)

a Deathrateandratedifferenceper100,000person-years.

Key: RR=rateratio;RD=ratedifference;CI=confidenceinterval.

• Programs that prevent young people from starting smoking and enable

those who already smoke to quit by middle age would have the greatest

short- and long-term impact on the tobacco epidemic.
410

Smoking and Tobacco Control Monograph No. 8

Figure 11

Excess death rates (RD) from lung cancer, by age, years of smoking, and cigarettes per day—

Cancer Prevention Study II: Duration fixed at time of enrollmenta

a GraphsportrayonlypositiveRDvaluesbasedoncellscontainingthreeormoredeathsinsmokersand

never-smokers.
411

Chapter 5

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413

Chapter 5

ACKNOWLEDGMENTS We thank Ms. Catherine Boring, Dr. David Burns,

Mr. Lawrence Garfinkel, Dr. Gary Giovino, Dr. Jonathan Samet, and

Dr. John Slade for their suggestions. We also are indebted to Ms. Audrey Earles

for her skill and dedication in producing this chapter.
414

Smoking and Tobacco Control Monograph No. 8
415

Chapter 5

Appendixes 1 Through 59
416

Smoking and Tobacco Control Monograph No. 8
417

Chapter 5

a Questions for women did not include those on cigar and pipe habits but were otherwise the same as for men.

APPENDIX 1

Questions on Tobacco Smoking in Men—Cancer Prevention Study II Baselinea
418

Smoking and Tobacco Control Monograph No. 8

APPENDIX 2

Mortality From Lung Cancer as any Mention on Death Certificate Among Lifelong Nonsmokers

and Current Cigarette Smokers: Cancer Prevention Study II, Men

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 1 4.6 1 5.9 1.3 1.3

40-44 0 0.0 4 18.7 – 18.7

45-49 4 6.0 27 43.0 7.2 37.0

50-54 7 5.5 143 121.3 22.2 115.8

55-59 7 5.3 269 213.3 40.4 208.0

60-64 14 11.6 402 381.0 33.0 369.4

65-69 23 22.5 428 622.4 27.6 599.9

70-74 26 36.3 367 972.7 26.8 936.4

75-79 24 59.5 184 1,210.4 20.4 1,150.9

80+ 16 89.2 57 1,372.2 15.4 1,283.0

Total 122 1,882

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 11.9 246.4

Rate Ratio 1.0 20.6

 (95% CI) – (16.8-25.4)

Rate Differencea – 234.5

 (95% CI) – (217.6-251.3)

a Death rate and rate difference per 100,000 person-years.

Key: RR = rate ratio; RD = rate difference; CI = confidence interval.
419

Chapter 5

APPENDIX 3

Mortality From Lung Cancer as any Mention on Death Certificate Among Lifelong Nonsmokers

and Current Cigarette Smokers: Cancer Prevention Study II, Women

Age Specific

Current Cigarette

Nonsmokers Smokers

Age Deaths Ratea Deaths Ratea RR RDa

35-39 1 2.0 1 4.0 2.0 2.0

40-44 0 0.0 4 8.9 – 8.9

45-49 4 1.9 44 43.4 22.6 41.5

50-54 18 5.8 96 66.8 11.5 61.0

55-59 29 8.4 178 122.0 14.5 113.6

60-64 45 13.2 225 184.8 14.0 171.6

65-69 53 18.9 241 297.4 15.8 278.5

70-74 67 32.5 152 331.9 10.2 299.4

75-79 44 32.5 79 410.4 12.6 377.9

80+ 42 59.0 26 452.4 7.7 393.4

Total 303 1,046

Age Standardized to 1980 U.S. Population

Current Cigarette

Nonsmokers Smokers

Death Ratea 9.2 106.4

Rate Ratio 1.0 11.6

 (95% CI) – (10.0-13.4)

Rate Differencea – 97.2

 (95% CI) – (87.8-106.6)

a Death rate and rate difference per 100,000 person-years.

Key: RR = rate ratio; RD = rate difference; CI = confidence interval.
420

Smoking and Tobacco Control Monograph No. 8

APPENDIX 4

Person-Years at Risk In Lifelong Nonsmokers and Current Cigarette Smokers

(Cancer Prevention Study II: 1982-88)

Never-Smokers Current Cigarette Smokers

Age Men Women Men Women

30-34 9,189 17,552 6,203 8,077

35-39 21,944 49,633 16,869 24,784

40-44 22,407 85,111 21,408 45,081

45-49 67,204 208,331 62,754 101,349

50-54 127,821 309,700 117,909 143,772

55-59 132,430 345,629 126,134 145,951

60-64 121,174 340,560 105,523 121,752

65-69 102,124 280,728 68,771 81,048

70-74 71,536 206,345 37,732 45,801

75-79 40,363 135,257 15,201 19,252

80-84 17,946 71,175 4,154 5,747

85+ 8,069 41,281 979 1,601
421

Chapter 5

APPENDIX 5

Standard Populations Used To Compute Age-Standardized Death Rates

Age 1980 U.S.a

30-34 77,516

35-39 61,644

40-44 51,510

45-49 48,951

50-54 51,689

55-59 51,271

60-64 44,528

65-69 38,767

70-74 30,008

75-79 21,160

80-84 12,956

85+ 9,888

a 1980 U.S. represents the age distribution of all persons ages 30 and older per stand!rd million in

1980 (U.S. Department of Health and Human Services. Vital Statistics of the United States, 1980,

Vol. II, Mortality, Part A. DHHS Publication No. 85-1101. Hyattsville, MD: U.S. Department of Health

and Human Services, Public Health Service, National Center for Health Statistics, 1985).
422

Smoking and Tobacco Control Monograph No. 8

APPENDIX 6

Number of Deaths and Death Ratesa From Lung Cancer in Current Cigarette Smokers,

by Amount and Duration of Smoking: Cancer Prevention Study II, Men

Number of Years Smoked

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Rate Deaths Rate Deaths Rate Deaths Rate

1-19 50-59 7 62.5 28 99.2 10 173.7 0 –

60-69 4 170.3 16 154.6 83 346.8 16 330.1

70-79 1 227.1 3 265.5 27 575.3 105 842.5

20 50-59 8 68.5 63 143.1 26 267.3 1 482.7

60-69 6 359.9 25 215.7 154 447.6 60 848.5

70-79 2 870.8 3 455.1 33 702.1 150 1,149.0

21-39 50-59 8 78.3 77 181.0 19 211.4 0 –

60-69 3 348.2 20 226.3 124 485.8 37 876.5

70-79 0 – 3 1,206.4 19 886.1 73 1,203.5

40 50-59 8 115.9 63 197.1 25 321.4 2 1,328.9

60-69 1 156.9 32 543.2 110 613.2 28 922.4

70-79 0 – 1 603.9 18 1,389.3 49 1,326.7

41+ 50-59 4 159.5 30 254.4 16 458.8 0 –

60-69 0 – 10 484.7 44 755.7 5 552.0

70-79 0 – 1 2,020.2 6 1,687.8 19 2,183.7

a Rates per 100,000 person-years.
423

Chapter 5

APPENDIX 7

Number of Deaths and Death Ratesa From Lung Cancer in Current Cigarette Smokers, by

Amount and Duration of Smoking: Cancer Prevention Study II, Women

Number of Years Smoked

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Rate Deaths Rate Deaths Rate Deaths Rate

1-19 50-59 9 28.8 37 66.6 3 62.6 0 –

60-69 7 66.2 35 132.3 50 143.8 7 235.5

70-79 3 102.8 6 124.9 18 170.3 28 238.0

20 50-59 14 53.8 62 104.1 8 145.5 0 –

60-69 11 141.9 51 217.6 92 261.5 21 714.5

70-79 3 190.4 8 257.8 43 524.8 45 485.5

21-39 50-59 12 97.8 54 157.8 12 381.4 0 –

60-69 4 199.9 24 238.4 58 362.0 5 395.2

70-79 3 1,279.3 3 489.7 14 222.0 19 689.8

40 50-59 6 95.5 32 162.6 4 185.1 0 –

60-69 1 86.2 15 282.0 47 538.4 4 518.1

70-79 1 525.2 1 307.6 5 411.8 12 736.0

41+ 50-59 2 180.6 7 169.1 1 213.9 0 –

60-69 0 – 1 116.1 7 494.9 0 –

70-79 0 – 0 – 2 1,028.8 2 786.9

a Rates per 100,000 person-years.
424

Smoking and Tobacco Control Monograph No. 8

APPENDIX 8

Rate Difference (RD) and Rate Ratio (RR) From Lung Cancer, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Fixed. Cancer Prevention Study II, Men

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 57.1 11.6 93.8 18.4 168.3 32.2 – –

60-69 154.2 10.6 138.5 9.6 330.7 21.5 314.0 20.5

70-79 – – 224.4 6.5 534.2 14.0 801.4 20.5

20 50-59 12.7 137.7 26.5 261.9 49.5 – –

60-69 343.8 22.4 199.6 13.4 431.5 27.8 832.4 52.7

70-79 – – 414.0 11.1 661.0 17.1 1,107.9 28.0

21-39 50-59 72.9 14.5 175.6 33.5 206.0 39.1 – –

60-69 332.1 21.6 210.2 14.1 469.7 30.2 860.4 54.4

70-79 – – 1,165.3 29.4 845.0 21.6 1,162.4 29.3

40 50-59 110.5 21.5 191.7 36.5 316.0 59.5 – –

60-69 – – 527.1 33.7 597.1 38.1 906.3 57.3

70-79 – – – – 1,348.2 33.8 1,285.6 32.3

41+ 50-59 154.1 29.5 249.0 47.1 453.4 85.0 – –

60-69 – – 468.6 30.1 739.6 46.9 535.9 34.3

70-79 – – – – 1,646.7 41.1 2,142.6 53.1

a Rate differences per 100,000 person-years.
425

Chapter 5

APPENDIX 9

Rate Difference (RD) and Rate Ratio (RR) From Lung Cancer, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Fixed. Cancer Prevention Study II, Women

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 22.2 4.4 60.0 10.1 56.0 9.5 – –

60-69 51.9 4.6 118.0 9.3 129.5 10.1 221.2 16.5

70-79 71.5 3.3 93.6 4.0 139.0 5.4 206.7 7.6

20 50-59 47.2 8.2 203.2 31.8 138.9 22.0 – –

60-69 127.6 9.9 203.3 15.2 247.2 18.3 700.2 50.0

70-79 159.1 6.1 226.5 8.2 493.5 16.8 454.2 15.5

21-39 50-59 91.2 14.8 151.2 23.9 374.8 57.8 – –

60-69 185.6 14.0 224.1 16.7 347.7 25.3 380.9 27.6

70-79 1,248.0 40.9 458.4 15.6 190.7 7.1 658.5 22.0

40 50-59 88.9 14.5 156.0 24.6 178.5 28.0 – –

60-69 – – 267.7 19.7 524.1 37.8 503.8 36.2

70-79 – – – – 380.5 13.2 704.7 23.5

41+ 50-59 – – 162.5 25.6 – – – –

60-69 – – – – 480.6 34.6 – –

70-79 – – – – – – – –

a Rate differences per 100,000 person-years.
426

Smoking and Tobacco Control Monograph No. 8

APPENDIX 10

Number of Deaths and Death Ratesa From CHD in Current Cigarette Smokers, by Amount and

Duration of Smoking: Cancer Prevention Study II, Men

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Rate Deaths Rate Deaths Rate Deaths Rate

1-19 50-59 27 241.1 78 276.3 16 277.9 0 0.0

60-69 8 340.6 58 560.3 154 643.5 42 866.5

70-79 8 1,816.5 16 1,416.2 38 809.8 164 1,315.9

20 50-59 25 213.9 120 272.6 48 493.4 2 965.4

60-69 5 299.9 59 509.0 251 729.5 77 1,088.9

70-79 5 2,177.0 4 606.8 55 1,170.2 207 1,585.7

21-39 50-59 20 195.8 101 237.4 33 367.2 0 0.0

60-69 2 232.2 31 350.8 155 607.2 47 1,113.4

70-79 0 0.0 3 1,206.4 19 886.1 88 1,450.8

40 50-59 10 144.9 90 281.6 25 321.4 1 664.5

60-69 3 470.8 27 458.3 109 607.6 30 988.3

70-79 0 0.0 2 1,207.9 14 1,080.5 50 1,353.8

41+ 50-59 5 199.4 32 271.3 19 544.8 0 0.0

60-69 0 0.0 4 193.9 28 480.9 8 883.2

70-79 0 0.0 0 0.0 0 0.0 7 804.5

a Rates per 100,000 person-years.
427

Chapter 5

APPENDIX 11

Number of Deaths and Death Ratesa From Coronary Heart Disease in Current Cigarette

Smokers, by Amount and Duration of Smoking: Cancer Prevention Study II, Women

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Rate Deaths Rate Deaths Rate Deaths Rate

1-19 50-59 17 54.3 20 36.0 2 41.7 0 –

60-69 11 104.0 45 170.1 75 215.8 9 302.8

70-79 12 411.0 34 707.8 44 416.2 78 662.9

20 50-59 9 34.6 45 75.6 9 163.6 0 –

60-69 16 206.4 49 209.0 100 284.2 15 510.4

70-79 4 253.9 16 515.6 41 500.4 74 798.3

21-39 50-59 6 48.9 28 81.8 3 95.4 0 –

60-69 3 149.9 16 158.9 45 280.9 4 316.2

70-79 3 1,279.3 5 816.1 11 488.4 17 617.2

40 50-59 5 79.6 13 66.1 5 231.4 0 –

60-69 0 – 7 131.6 19 217.7 7 906.6

70-79 1 525.2 2 615.2 7 576.5 11 674.6

41+ 50-59 0 – 5 120.8 1 213.9 0 –

60-69 0 – 0 – 4 282.8 0 –

70-79 0 – 0 – 0 – 1 393.4

a Rates per 100,000 person-years.
428

Smoking and Tobacco Control Monograph No. 8

APPENDIX 12

Rate Difference (RD) and Rate Ratio (RR) From Coronary Heart Disease, by Amount and

Duration of Cigarette Smoking and Current Age: Duration Fixed. Cancer Prevention Study II,

Men

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 153.1 2.7 188.3 3.1 189.9 3.2 – –

60-69 31.1 1.1 250.8 1.8 334.0 2.1 557.0 2.8

70-79 934.5 2.1 534.2 1.6 -72.2 0.9 433.9 1.5

20 50-59 125.9 2.4 184.6 3.1 405.4 5.6 – –

60-69 9.6 1.0 199.5 1.6 420.0 2.4 779.4 3.5

70-79 1,295.0 2.5 275.2 0.7 288.2 1.3 703.7 1.8

21-39 50-59 107.8 2.2 149.4 2.7 279.2 4.2 – –

60-69 – – 41.3 1.1 297.7 2.0 803.9 3.6

70-79 – – 324.4 1.4 4.1 1.0 568.8 1.6

40 50-59 56.9 1.6 193.6 3.2 233.4 3.7 – –

60-69 161.3 1.5 148.8 1.5 298.1 2.0 678.8 3.2

70-79 – – – – 198.5 1.2 471.8 1.5

41+ 50-59 111.4 2.3 183.3 3.1 456.8 6.2 – –

60-69 – – -115.6 0.6 171.4 1.6 573.7 2.9

70-79 – – – – – – -77.5 0.9

a Rate differences per 100,000 person-years.
429

Chapter 5

APPENDIX 13

Rate Difference (RD) and Rate Ratio (RR) From Coronary Heart Disease, by Amount and

Duration of Cigarette Smoking and Current Age: Duration Fixed. Cancer Prevention Study II,

Women

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 37.7 3.3 19.4 2.2 – – – –

60-69 13.2 1.1 79.3 1.9 125.0 2.4 212.0 3.3

70-79 48.0 1.1 344.8 1.9 53.2 1.1 299.9 1.8

20 50-59 18.0 2.1 59.0 4.5 147.0 9.8 – –

60-69 115.6 2.3 118.2 2.3 193.4 3.1 419.6 5.6

70-79 -109.1 0.7 152.6 1.4 137.4 1.4 435.3 2.2

21-39 50-59 32.3 2.9 65.2 4.9 78.8 5.7 – –

60-69 59.1 1.7 68.1 1.8 190.1 3.1 225.4 3.5

70-79 916.3 3.5 453.1 2.2 125.4 1.3 254.2 1.7

40 50-59 63.0 4.8 49.5 4.0 214.8 13.9 – –

60-69 – – 40.8 1.4 126.9 2.4 815.8 10.0

70-79 – – – – 213.5 1.6 311.6 1.9

41+ 50-59 – – 104.2 7.3 – – – –

60-69 – – – – 192.0 3.1 – –

70-79 – – – – – – – –

a Rate differences per 100,000 person-years.
430

Smoking and Tobacco Control Monograph No. 8

APPENDIX 14

Number of Deaths and Death Ratesa From All Causes in Current Cigarette Smokers, by Amount

and Duration of Smoking: Cancer Prevention Study II, Men

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Rate Deaths Rate Deaths Rate Deaths Rate

1-19 50-59 66 589.3 249 882.2 56 972.7 0 –

60-69 33 1,405.1 166 1,603.6 466 1,947.2 135 2,785.1

70-79 13 2,951.8 46 4,071.7 194 4,134.0 687 5,512.4

20 50-59 70 599.0 375 852.0 137 1,408.3 7 3,378.9

60-69 28 1,679.5 183 1,578.6 834 2,424.0 261 3,691.0

70-79 12 5,224.9 21 3,185.8 219 4,659.4 802 6,143.5

21-39 50-59 63 616.6 334 784.9 114 1,268.7 1 740.2

60-69 15 1,741.1 129 1,459.6 576 2,256.4 160 3,790.2

70-79 0 – 11 4,423.5 96 4,476.9 364 6,000.9

40 50-59 51 739.2 307 960.7 110 1,414.1 6 3,986.7

60-69 5 784.6 113 1,918.1 462 2,575.5 105 3,459.1

70-79 2 6,234.4 6 3,623.6 75 5,788.6 233 6,308.7

41+ 50-59 18 717.9 113 958.2 60 1,720.5 0 –

60-69 0 – 35 1,696.5 148 2,541.8 31 3,422.3

70-79 0 – 2 4,040.4 14 3,938.1 53 6,091.4

a Rates per 100,000 person-years.
431

Chapter 5

APPENDIX 15

Number of Deaths and Death Ratesa From All Causes in Current Cigarette Smokers, by Amount

and Duration of Smoking: Cancer Prevention Study II, Women

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Rate Deaths Rate Deaths Rate Deaths Rate

1-19 50-59 108 345.0 220 396.1 22 459.2 0 –

60-69 78 737.5 206 778.8 392 1,127.7 45 1,513.8

70-79 45 1,541.4 118 2,456.5 203 1,920.3 302 2,566.7

20 50-59 102 391.8 310 520.5 37 672.7 0 –

60-69 79 1018.9 281 1,198.8 486 1,381.3 67 2,279.7

70-79 30 1,904.1 83 2,674.8 217 2,648.3 307 3,312.0

21-39 50-59 46 375.1 203 593.2 26 826.4 0 –

60-69 18 899.7 91 903.9 247 1,541.7 26 2,055.2

70-79 13 5,543.7 13 2,121.9 60 2,663.9 87 3,158.7

40 50-59 28 445.5 133 675.8 20 925.7 0 –

60-69 6 517.3 62 1,165.7 138 1,580.9 19 2,460.9

70-79 7 3,676.1 11 3,383.7 33 2,717.7 63 3,863.8

41+ 50-59 6 541.8 32 773.0 5 1,069.5 0 –

60-69 0 – 7 813.0 33 2,333.0 3 1,508.1

70-79 0 – 3 8,391.6 5 2,571.9 5 1,967.2

a Rates per 100,000 person-years.
432

Smoking and Tobacco Control Monograph No. 8

APPENDIX 16

Rate Difference (RD) and Rate Ratio (RR) From All Causes, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Fixed. Cancer Prevention Study II, Men

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 293.4 2.0 586.3 3.0 676.8 3.3 – –

60-69 538.5 1.6 737.0 1.9 1,080.6 2.2 1,918.5 3.2

70-79 530.0 1.2 1,649.9 1.7 1,712.2 1.7 3,090.6 2.3

20 50-59 303.1 2.0 556.1 2.9 1,112.4 4.8 3,083.0 11.4

60-69 812.9 1.9 712.0 1.8 1,557.4 2.8 2,824.4 4.3

70-79 2,803.1 2.2 764.0 1.3 2,237.6 1.9 3,721.7 2.5

21-39 50-59 320.7 2.1 489.0 2.7 972.8 4.3 – –

60-69 874.5 2.0 593.0 1.7 1,389.8 2.6 2,923.6 4.4

70-79 – – 2,001.7 1.8 2,055.1 1.8 3,579.1 2.5

40 50-59 443.3 2.5 664.8 3.2 1,118.2 4.8 3,690.8 13.5

60-69 -82.0 0.9 1,051.5 2.2 1,708.9 3.0 2,592.5 4.0

70-79 – – 1,201.8 1.5 3,366.8 2.4 3,886.9 2.6

41+ 50-59 422.0 2.4 662.3 3.2 1,424.6 5.8 – –

60-69 – – 829.9 2.0 1,675.2 2.9 2,555.7 3.9

70-79 – – – – 1,516.3 1.6 3,669.6 2.5

a Rate differences per 100,000 person-years.
433

Chapter 5

APPENDIX 17

Rate Difference (RD) and Rate Ratio (RR) From All Causes, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Fixed. Cancer Prevention Study II, Women

Number of Years Smoking

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 117.5 1.5 168.6 1.7 231.7 2.0 – –

60-69 210.9 1.4 252.2 1.5 601.1 2.1 987.2 2.9

70-79 164.6 1.1 1,079.7 1.8 543.5 1.4 1,189.9 1.9

20 50-59 164.3 1.7 293.0 2.3 445.2 3.0 – –

60-69 492.3 1.9 672.2 2.3 854.7 2.6 1,753.1 4.3

70-79 527.3 1.4 1,298.0 1.9 1,271.5 1.9 1,935.2 2.4

21-39 50-59 147.6 1.6 365.7 2.6 598.9 3.6 – –

60-69 373.1 1.7 377.3 1.7 1,015.1 2.9 1,528.6 3.9

70-79 4,166.9 4.0 745.1 1.5 1,287.1 1.9 1,781.9 2.3

40 50-59 218.0 2.0 448.3 3.0 698.2 4.1 – –

60-69 -9.3 1.0 639.1 2.2 1,054.3 3.0 1,934.3 4.7

70-79 2,299.3 2.7 2,006.9 2.5 1,340.9 2.0 2,487.0 2.8

41+ 50-59 314.3 2.4 545.5 3.4 842.0 4.7 – –

60-69 – – 286.4 1.5 1,806.4 4.4 981.5 2.9

70-79 – – 7,014.8 6.1 1,195.1 1.9 590.4 1.4

a Rate differences per 100,000 person-years.
434

Smoking and Tobacco Control Monograph No. 8

APPENDIX 18

Deaths and Death Ratesa From Lung Cancer, by Amountb and Duration of Cigarette Smoking

and Current Age: Duration Fixed at Time of Enrollment: Cancer Prevention Study II, Men

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

1-19 50-59 7 62.5 28 99.2 10 173.7 0 –

60-69 4 170.3 16 154.6 83 346.8 16 330.1

70-79 1 227.1 3 265.5 27 575.3 105 842.5

20-39 50-59 16 73.0 140 161.7 45 240.5 1 292.2

60-69 9 355.9 45 220.3 278 463.9 97 859.0

70-79 2 676.4 6 660.9 52 759.7 223 1,166.3

40+ 50-59 12 127.6 93 212.6 41 363.9 2 1,047.7

60-69 1 123.7 42 528.0 154 648.1 33 837.3

70-79 0 – 2 929.8 24 1,453.5 68 1,490.1

a Death rate per 100,000 person-years. Only rates based on three or more deaths are included in Figure 11.

b Cigarettes per day categorized into three strata because of the limited number of deaths in many strata.
435

Chapter 5

APPENDIX 19

Deaths and Death Ratesa From Lung Cancer, by Amountb and Duration of Cigarette Smoking

and Current Age: Duration Fixed at Time of Enrollment. Cancer Prevention Study II, Women

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

1-19 50-59 9 28.8 37 66.6 3 62.6 0 –

60-69 7 66.2 35 132.3 50 143.8 7 235.5

70-79 3 102.8 6 124.9 18 170.3 28 238.0

20-39 50-59 26 67.9 116 123.7 20 231.3 0 –

60-69 15 153.8 75 223.8 150 292.9 26 618.5

70-79 6 331.5 11 296.0 57 545.6 64 532.3

40+ 50-59 8 108.2 39 163.7 5 190.3 0 –

60-69 1 744.2 16 258.9 54 532.4 4 411.9

70-79 1 456.6 1 277.2 7 496.9 14 742.8

a Death rate per 100,000 person-years. Only rates based on three or more deaths are included in Figure 11.

b Cigarettes per day categorized into three strata because of the limited number of deaths in many strata.
436

Smoking and Tobacco Control Monograph No. 8

APPENDIX 20

Rate Difference (RD) and Rate Ratio (RR) From Lung Cancer, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Fixed at Time of Enrollment. Cancer Prevention

Study II, Men

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 57.1 11.6 93.8 18.4 168.3 32.2 – –

60-69 154.2 10.6 138.5 9.6 330.7 21.5 314.0 20.5

70-79 – – 224.4 6.5 534.2 14.0 801.4 20.5

20-39 50-59 67.6 13.5 156.3 29.9 235.1 44.5 – –

60-69 339.8 22.1 204.2 13.7 447.8 28.8 842.9 53.4

70-79 – – 619.8 16.1 718.6 18.5 1,125.2 28.4

40+ 50-59 122.2 23.6 207.2 39.4 358.5 67.4 – –

60-69 – – 511.9 32.8 632.0 40.3 821.2 52.0

70-79 – – – – 1,412.4 35.4 1,449.0 36.3

a Rate differences per 100,000 person-years graphed in Figure 11.
437

Chapter 5

APPENDIX 21

Rate Difference (RD) and Rate Ratio (RR) From Lung Cancer, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Fixed at Time of Enrollment. Cancer Prevention

Study II, Women

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 22.2 4.4 60.0 10.1 56.0 9.5 – –

60-69 51.9 4.6 118.0 9.3 129.5 10.1 221.2 16.5

70-79 71.5 3.3 93.6 4.0 139.0 5.4 206.7 7.6

20-39 50-59 61.3 10.3 117.1 18.7 224.7 35.0 – –

60-69 139.5 10.8 209.5 15.7 278.6 20.5 604.2 43.3

70-79 300.2 10.6 264.7 9.5 514.3 17.4 501.0 17.0

40+ 50-59 101.6 16.4 157.1 24.8 183.7 28.8 – –

60-69 – – 244.6 18.1 518.1 37.2 397.6 28.8

70-79 – – – – 465.6 15.9 711.5 23.7

a Rate differences per 100,000 person-years graphed in Figure 11.
438

Smoking and Tobacco Control Monograph No. 8

APPENDIX 22

Deaths and Death Ratesa From Lung Cancer, by Amountb and Duration of Cigarette Smoking

and Current Age: Duration Progresses Over Time. Cancer Prevention Study II, Men

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

1-19 50-59 1 27.6 28 92.6 15 113.6 1 709.9

60-69 0 – 2 54.5 80 384.9 37 388.2

70-79 0 – 0 – 12 518.7 124 891.3

20-39 50-59 2 33.9 94 116.6 105 249.8 2 388.8

60-69 1 160.9 11 188.6 261 399.0 158 715.1

70-79 0 – 3 1,121.6 23 787.8 257 1,237.1

40+ 50-59 0 – 75 192.2 71 305.7 2 553.2

60-69 0 – 7 316.2 152 596.1 71 849.2

a Death rate per 100,000 person-years.

b Cigarettes per day categorized into three strata because of the limited number of deaths in many strata.
439

Chapter 5

APPENDIX 23

Deaths and Death Ratesa From Lung Cancer, by Amountb and Duration of Cigarette Smoking

and Current Age: Duration Progresses Over Time. Cancer Prevention Study II, Women

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age Deaths Ratea Deaths Ratea Deaths Ratea Deaths Ratea

1-19 50-59 2 15.0 34 48.8 15 92.3 0 –

60-69 1 21.0 18 119.4 61 122.2 22 241.2

70-79 1 73.8 1 33.7 10 134.4 44 244.7

20-39 50-59 6 42.3 102 99.2 55 197.2 0 –

60-69 1 25.7 27 167.5 176 260.3 63 491.9

70-79 0 – 3 145.2 32 498.8 105 597.7

40+ 50-59 2 75.3 34 141.2 17 218.5 0 –

60-69 0 – 3 111.9 57 442.2 15 542.4

70-79 0 – 1 495.4 2 264.9 20 771.9

a Death rate per 100,000 person-years.

b Cigarettes per day categorized into three strata because of the limited number of deaths in many strata.
440

Smoking and Tobacco Control Monograph No. 8

APPENDIX 24

Rate Difference (RD) and Rate Ratio (RR) From Lung Cancer, by Amount and Duration of

Cigarette Smoking and Current Age. Duration Progresses Over Time: Cancer Prevention

Study II, Men

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 – – 87.2 17.2 108.2 21.1 – –

60-69 – – – – 268.7 17.7 372.1 24.1

70-79 – – – – 477.6 12.6 850.2 21.7

20-39 50-59 – – 111.2 21.7 244.5 46.4 – –

60-69 – – 172.5 11.7 382.9 24.7 698.9 44.4

70-79 – – 1,080.5 27.3 746.6 19.2 1,196.0 30.1

40+ 50-59 – – 186.9 35.7 300.3 56.8 – –

60-69 – – 300.0 19.6 579.9 37.0 833.1 52.7

70-79 – – – – 890.3 22.7 1,739.0 43.3

a Rate differences per 100,000 person-years.
441

Chapter 5

APPENDIX 25

Rate Difference (RD) and Rate Ratio (RR) From Lung Cancer, by Amount and Duration of

Cigarette Smoking and Current Age: Duration Progresses Over Time. Cancer Prevention

Study II, Women

Duration of Smoking: Years

20-29 30-39 40-49 50+

Cigarettes

Per Day Age RDa RR RDa RR RDa RR RDa RR

1-19 50-59 – – 42.2 7.4 85.8 14.1 – –

60-69 – – 105.1 8.3 107.8 8.5 226.9 16.8

70-79 – – – – 103.1 4.3 213.4 7.8

20-39 50-59 35.7 6.4 92.7 15.1 190.7 30.1 – –

60-69 – – 153.2 11.7 245.9 18.2 477.6 34.3

70-79 – – 113.9 4.6 467.5 15.9 566.4 19.1

40+ 50-59 – – 134.6 21.5 212.0 33.3 – –

60-69 – – 97.6 7.8 427.9 30.9 528.1 37.9

a Rate differences per 100,000 person-years.
442

Smoking and Tobacco Control Monograph No. 8

APPENDIX 26

Person-Years at Risk in Lifelong Nonsmokers and Current Cigarette Smokers, by Age and

Cigarettes Per Day: Cancer Prevention Study II, Men

Cigarettes Per Day

Never

Age Smoked 1-9 10-19 20 21-39 40 41+

30-34 9,189 744 1,087 1,827 1,484 782 280

35-39 21,944 1,843 2,684 4,822 4,046 2,540 935

40-44 22,407 1,945 2,833 5,749 5,307 4,050 1,525

45-49 67,204 5,098 7,832 16,290 16,243 12,325 4,966

50-54 127,821 9,528 13,933 31,287 30,769 23,316 9,077

55-59 132,430 9,657 15,511 35,942 32,064 24,009 8,952

60-64 121,174 8,917 15,085 32,027 25,142 18,134 6,219

65-69 102,124 6,898 11,961 23,159 14,499 9,454 2,802

70-74 71,536 4,647 8,149 13,465 6,430 4,020 1,021

75-79 40,363 2,483 3,833 5,322 2,112 1,180 271

80-84 17,946 1,006 1,145 1,292 446 222 44

85+ 8,069 330 259 256 59 52 23
443

Chapter 5

APPENDIX 27

Person-Years at Risk in Lifelong Nonsmokers and Current Cigarette Smokers, by Age and

Cigarettes Per Day: Cancer Prevention Study II, Women

Cigarettes Per Day

Never

Age Smoked 1-9 10-19 20 21-39 40 41+

30-34 17,552 1,277 1,901 2,525 1,454 726 192

35-39 49,633 3,711 5,450 7,668 4,845 2,443 668

40-44 85,111 6,147 9,429 14,571 8,885 4,913 1,137

45-49 208,331 14,642 21,403 32,757 19,385 10,784 2,378

50-54 309,700 20,712 31,286 47,139 26,421 15,110 3,104

55-59 345,629 21,227 33,253 49,761 24,833 14,138 2,739

60-64 340,560 17,947 29,645 42,749 19,181 10,438 1,792

65-69 280,728 12,823 21,746 29,114 10,618 5,834 912

70-74 206,345 8,439 13,700 16,253 4,476 2,555 378

75-79 135,257 4,116 6,113 6,569 1,454 861 140

80-84 71,175 1,494 1,840 1,811 369 193 41

85+ 41,281 539 480 419 81 71 12
444

APPENDIX 28Number of Deaths From All Causes, by Number of Cigarettes Currently Smoked

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 14 20 1 1 1 2 3 4 4 1 2 3 35-39 16 40 6 4 2 4 11 10 10 1 6 3 40-44 21 93 2 9 4 7 19 14 12 11 20 5 45-49 102 255 24 31 29 38 63 88 53 46 67 43 50-54 283 564 53 47 105 97 194 166 199 100 176 68 55-59 487 927 87 83 142 168 399 301 320 180 301 120 60-64 815 1,401 127 106 242 238 594 433 463 205 388 135 65-69 1,120 1,871 155 139 288 304 721 503 419 181 298 95 70-74 1,321 2,216 183 131 370 276 650 412 298 114 215 79 75-79 1,389 2,487 154 124 247 181 408 245 177 63 102 40 80-84 981 2,245 97 53 114 92 155 100 43 26 21 12 

85+ 899 3,331 46 40 35 52 37 61 14 10 1 8 
445

APPENDIX 29 Age-Specific and Age-Adjusted Death Ratesa From All Causes, by Number of Cigarettes Currently Smoked Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 15.2 11.4 ( ) ( ) ( ) (10.5) [16.4] 15.8 27.0 ( ) (25.6) [41.3] 35-39 7.3 8.1 32.6 10.8 (7.5) 7.3 22.8 13.0 24.7 ( ) 23.6 [12.3] (40-44 9.4 10.9 (10.3) 14.6 14.1 7.4 33.1 9.6 22.6 12.4 49.4 10.2 45-49 15.2 12.2 47.1 21.2 37.0 17.8 38.7 26.9 32.6 23.7 54.4 39.9 50-54 22.1 18.2 55.6 22.7 75.4 31.0 62.0 35.2 64.7 37.9 75.5 45.0 55-59 36.8 26.8 90.1 39.1 91.6 50.5 111.0 60.5 99.8 72.5 125.4 84.9 160-64 67.3 41.1 142.4 59.1 160.4 80.3 185.5 101.3 184.2 106.9 214.0 129.3 165-69 109.7 66.7 224.7 180.4 240.8 139.8 311.3 172.8 289.0 170.5 315.2 162.8 370-74 184.7 107.4 393.8 155.2 454.0 201.5 482.7 253.5 463.5 254.7 534.8 309.3 475-79 344.1 183.9 620.2 301.3 644.4 296.1 766.6 373.0 837.9 433.3 864.1 464.6 980-84 546.7 315.4 964.1 354.7 995.9 500.1 1,200.0 552.2 964.7 705.1 945.2 622.0 9

85+ 1,114.2 806.9 1,392.5 742.6 1,350.0 1,083.9 1,446.3 1,455.0 2,386.4 1,238.4 ( ) 1,128.1 (8AgeAdjusteda 75.2 48.6 135.9 61.5 140.4 77.2 163.9 97.3 174.0 98.4 152.2 108.4 1a Age-adjusted death rates per 10,000 person-years standardized to 1980 U.S. population.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
446

APPENDIX 30Number of Deaths From Lung Cancer, by Number of Cigarettes Currently Smoked

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 1 1 0 0 0 0 0 0 1 0 0 1 40-44 0 0 0 1 1 0 1 0 1 2 0 0 45-49 4 4 0 2 1 2 7 17 4 7 7 13 50-54 7 18 4 4 14 14 26 27 35 25 37 16 55-59 7 25 11 9 16 25 72 58 70 53 61 27 60-64 14 42 23 9 29 36 95 78 111 45 92 43 65-69 22 47 25 14 43 44 151 100 74 46 79 24 70-74 25 63 26 9 70 28 115 64 67 27 50 11 75-79 21 44 18 5 22 14 73 37 28 12 18 8 80-84 16 41 5 1 17 7 21 11 5 4 2 1 

85+ 7 25 3 1 1 3 3 3 1 1 0 0 
447

APPENDIX 31 Age-Specific and Age-Adjusted Death Ratesa From Lung Cancer, by Number of Cigarettes Currently Smoked Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 – – – – – – – – – – – – 35-39 ( ) ( ) – – – – – – – – – – 40-44 – – – ( ) ( ) – ( ) – ( ) (22.5) – – 45-49 6.0 1.9 – 13.7 ( ) (9.3) 43.0 51.9 24.6 36.1 56.8 120.5 150-54 5.5 5.8 42.0 19.3 100.5 44.7 83.1 57.3 113.8 94.6 158.7 105.9 255-59 5.3 7.2 113.9 42.4 103.2 75.2 200.3 116.6 218.3 213.4 254.1 191.0 360-64 11.6 12.3 257.9 50.1 192.2 121.4 296.6 182.5 441.5 234.6 507.3 412.0 465-69 21.5 16.7 362.4 109.2 359.5 202.3 652.0 343.5 510.4 433.2 835.7 411.4 970-74 34.9 30.5 559.5 106.6 859.0 204.4 854.0 393.8 1,042.1 603.2 1,243.8 430.6 1,475-79 52.0 32.5 725.0 121.5 573.9 229.0 1,371.7 563.3 1,325.5 825.5 1,524.9 929.2 4,080-84 89.2 57.6 496.9 ( ) 1,485.1 380.5 1,625.8 607.4 1,121.7 1,084.7 (900.2) ( ) 

85+ 86.8 60.6 [908.2] ( ) ( ) [625.3] [1,172.6] [715.6] ( ) ( ) – – AgeAdjusteda 11.3 8.6 138.4 33.5 164.5 71.6 244.6 122.2 257.5 184.1 273.4 166.0 5a Age-adjusted death rates per 100,000 person-years standardized to 1980 U.S. population.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
448

APPENDIX 32Number of Deaths From Coronary Heart Disease, by Number of Cigarettes Currently Smoked

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 0 0 0 0 0 0 0 0 0 1 0 0 35-39 2 1 2 0 0 0 0 0 1 0 1 0 40-44 3 5 1 0 1 0 6 2 3 1 5 0 45-49 18 8 9 3 11 7 23 9 16 4 24 5 50-54 72 25 14 7 35 13 67 19 65 18 51 7 55-59 157 84 27 5 48 19 129 48 91 20 75 16 60-64 277 211 44 20 86 40 205 81 116 38 107 18 65-69 414 353 45 29 92 66 191 103 119 31 62 17 70-74 490 523 53 30 90 72 179 80 65 23 46 14 75-79 497 717 32 30 57 47 94 62 47 15 21 8 80-84 340 694 25 19 32 21 40 27 9 3 7 2 

85+ 266 1,096 12 9 8 23 11 14 5 1 0 1 
449

APPENDIX 33 Age-Specific and Age-Adjusted Death Ratesa From Coronary Heart Disease, by Number of Cigarettes Currently Smoke

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 – – – – – – – – – ( ) ( ) – 35-39 (0.9) ( ) (10.9) – – – – – ( ) – ( ) – 40-44 [1.3] 0.6 ( ) – ( ) – 10.4 (1.4) [5.7] ( ) 12.4 – (45-49 2.7 0.4 17.7 [2.1] 14.1 3.3 14.1 2.8 9.9 2.1 19.5 4.6 50-54 5.6 0.8 14.7 3.4 25.1 4.2 21.4 4.0 21.1 6.8 21.9 4.6 55-59 11.9 2.4 28.0 2.4 31.0 5.7 35.9 9.7 28.4 8.1 31.2 11.3 60-64 22.9 6.2 49.4 11.1 57.0 13.5 64.0 19.0 46.1 19.8 59.0 17.3 65-69 40.5 12.6 65.2 22.6 76.9 30.4 82.5 35.4 82.1 29.2 65.6 29.1 70-74 68.5 25.4 114.1 35.6 110.4 52.6 132.9 49.2 101.0 51.4 114.4 54.8 75-79 123.1 53.0 128.9 72.9 148.7 76.9 176.6 94.4 222.5 103.2 177.9 92.9 [180-84 189.5 97.5 248.5 127.2 279.6 114.2 309.7 149.1 201.9 81.4 315.1 (103.7) 

85+ 329.7 265.5 363.3 167.1 308.6 479.4 430.0 333.9 852.3 ( ) ( ) ( ) Age

Adjusteda 24.1 11.5 37.0 13.1 38.2 20.3 44.7 20.2 46.9 16.2 37.6 15.9 aAge-adjusted death rates per 10,000 person-years standardized to 1980 U.S. population.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
450

APPENDIX 34Number of Deaths From Stroke, by Number of Cigarettes Currently Smoked

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 0 1 0 0 0 1 0 0 0 0 0 0 35-39 0 1 0 0 0 0 0 1 1 0 1 0 40-44 1 1 0 0 0 0 0 2 1 0 0 0 45-49 4 6 1 7 0 3 6 3 2 6 2 3 50-54 6 16 4 1 4 7 7 15 5 6 6 6 55-59 13 23 3 1 3 14 14 24 14 12 12 7 60-64 35 55 6 6 10 11 32 19 14 8 16 5 65-69 52 104 13 4 12 28 39 30 15 11 10 4 70-74 80 135 13 12 20 20 28 37 13 7 8 5 75-79 113 215 11 14 24 17 26 23 14 4 5 2 80-84 108 273 14 2 8 6 10 6 3 2 1 2 

85+ 89 501 3 3 3 3 1 5 1 2 0 0 
451

APPENDIX 35 Age-Specific and Age-Adjusted Death Ratesa From Stroke, by Number of Cigarettes Currently Smoked Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 – ( ) – – – ( ) – – – – – – 35-39 – ( ) – – – – – ( ) ( ) – ( ) – 40-44 ( ) ( ) – – – – – (13.7) ( ) – – – 45-49 6.0 2.9 ( ) 47.8 – 14.0 36.8 [9.3] (12.3) 31.0 (16.2) [27.8] 50-54 4.7 5.2 42.0 ( ) 28.7 22.4 22.4 31.8 16.3 22.7 25.7 39.7 55-59 9.8 6.7 [31.1] ( ) [19.3] 42.1 39.0 48.2 43.7 48.3 50.0 49.5 60-64 28.9 16.1 67.3 33.4 66.3 37.1 99.9 44.4 55.7 41.7 88.2 47.9 65-69 50.9 37.0 188.5 31.2 100.3 128.8 168.4 103.0 103.5 105.8 68.6 (71.4) 70-74 111.8 65.8 279.8 142.2 245.4 146.0 207.9 227.6 202.0 156.4 199.0 195.7 75-79 280.0 159.0 443.0 340.2 626.1 278.1 488.5 350.2 662.8 275.1 423.6 (232.3) 80-84 601.8 383.6 1,391.4 (133.9) 698.9 326.2 774.2 331.3 [673.0] (542.4) ( ) (1036.7) 

85+ 1,103.0 1,213.6 [908.2] [556.9] [1157.2] [625.3] ( ) (2,476.8) – – – – AgeAdjusteda 55.5 44.1 102.0 41.4 86.0 60.4 79.2 72.3 99.5 90.6 61.3 59.7 a Age-adjusted death rates per 100,000 person-years standardized to 1980 U.S. population.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
452

APPENDIX 36Number of Deaths From Chronic Obstructive Pulmonary Disease, by Number of Cigarettes Currently Smoked

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 0 0 0 0 0 0 0 0 0 0 0 0 40-44 0 0 0 0 0 0 0 0 0 0 0 0 45-49 0 0 1 0 0 0 0 2 1 0 0 0 50-54 2 2 1 0 1 1 2 6 4 3 3 2 55-59 3 6 1 1 2 1 8 12 9 5 7 4 60-64 4 11 4 2 6 9 15 18 12 3 8 10 65-69 8 16 6 13 16 11 40 24 15 11 19 9 70-74 18 24 10 11 18 7 37 32 18 11 12 3 75-79 15 24 8 3 15 15 32 15 17 4 11 2 80-84 13 29 4 2 97 13 1 2 5 7 1 2 

85+ 15 31 6 1 32 2 1 3 2 1 0 2 
453

APPENDIX 37 Age-Specific and Age-Adjusted Death Ratesa From Chronic Obstructive Pulmonary Disease, by Number of Cigarettes C

Smoked

Cigarettes Per Day

Never Smoked 1-9 10-19 20 21-39 40 

Age M F M F M F M F M F M F 30-34 – – – – – – – – – – – – 35-39 – – – – – – – – – – – – 40-44 – – – – – – – – – – – – 45-49 – – ( ) – – – – (6.1) ( ) – – – 50-54 (1.6) (0.6) ( ) – ( ) ( ) (6.1) 12.7 13.0 [11.4] [12.9] (13.2) 455-59 [2.3] 1.7 ( ) ( ) (12.9) ( ) 22.3 24.1 28.1 20.1 29.2 28.3 60-64 3.3 3.2 44.9 (11.1) 39.8 30.4 46.8 42.1 47.7 [15.6] 44.1 95.8 65-69 7.8 5.7 87.0 101.4 133.8 50.6 172.7 82.4 103.5 103.6 201.0 154.3 270-74 25.2 11.6 215.2 130.3 220.9 51.1 274.8 196.9 280.0 245.8 298.5 [117.4] [2975-79 37.2 17.7 322.2 [72.9] 391.3 245.4 601.3 228.4 804.8 275.1 931.9 (232.3) 7380-84 72.4 40.7 397.5 (133.9) 786.3 380.5 1006.5 662.6 1,121.7 1,898.3 ( ) (1,036.7) 

85+ 185.9 75.1 1,816.5 ( ) [1,157.2] (416.9) (781.8) 3,100.8 (3,409.1) ( ) – (2,820.2) AgeAdjusteda 8.5 4.2 74.7 23.4 76.0 33.1 88.7 97.7 140.3 96.2 79.2 106.0 1a Age-adjusted death rates per 100,000 person-years standardized to 1980 U.S. population.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
454

APPENDIX 38Person-Years at Risk in Lifelong Nonsmokers and Current Cigarette Smokers, by Years of Smoking: Men

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55

30-34 9,189 137 538 2,741 2,454 295 33 6 0 0 0 0 35-39 21,944 250 603 3,758 7,649 3,992 549 67 2 0 0 0 40-44 22,407 119 224 1,070 4,084 9,562 5,437 782 122 10 0 0 45-49 67,204 233 376 919 2,426 10,872 25,046 19,886 2,548 426 25 0 50-54 127,821 393 546 1,094 2,233 8,156 23,515 52,045 25,104 4,222 572 29 55-59 132,430 254 367 668 1,080 3,661 7,178 29,497 51,894 27,497 3,446 565 60-64 121,174 209 250 388 556 1,628 2,453 7,692 24,172 47,057 17,189 3,405 465-69 102,124 125 150 223 264 810 795 2,254 4,619 19,579 23,801 13,767 1,970-74 71,536 70 97 136 107 278 281 755 982 3,876 7,641 16,201 5,575-79 40,363 45 35 53 32 110 102 247 268 694 978 4,629 4,680-84 17,946 16 13 26 25 44 35 70 72 122 137 597 7

85+ 8,069 7 2 29 13 9 4 16 5 17 16 67 
455

APPENDIX 39 Person-Years at Risk in Lifelong Nonsmokers and Current Cigarette Smokers, by Years of Smoking: Women NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 17,552 396 906 3,865 2,697 207 6 0 0 0 0 0 35-39 49,633 802 1,713 6,172 10,827 4,857 404 9 0 0 0 0 40-44 85,111 820 1,416 3,044 8,947 20,970 9,189 670 26 0 0 0 45-49 208,331 1,471 2,080 3,560 7,134 25,979 41,840 18,381 855 51 0 0 50-54 309,700 1,629 2,098 3,874 5,998 16,505 35,081 61,243 16,417 909 20 0 55-59 345,629 1,223 1,570 3,085 4,015 10,571 14,836 43,871 51,607 14,530 607 36 60-64 340,560 760 1,125 2,198 2,685 6,594 8,066 16,609 32,976 41,252 8,803 680 65-69 280,728 462 605 1,417 1,477 3,361 3,656 7,183 9,370 24,365 21,690 7,171 70-74 206,345 312 332 741 799 1,747 1,764 3,160 3,234 7,076 10,563 13,847 275-79 135,257 140 166 323 309 756 682 1,222 1,264 2,380 2,409 5,867 280-84 71,175 53 74 116 103 213 219 372 420 718 525 1,221 

85+ 41,281 19 21 43 22 43 54 113 101 220 152 297 
456

APPENDIX 40Number of Deaths From All Causes, by Number of Years of Smoking: Men

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 14 0 0 3 6 1 1 0 0 0 0 0 35-39 16 0 1 6 16 12 2 0 0 0 0 0 40-44 21 0 1 3 13 32 13 2 1 0 0 0 45-49 102 0 0 4 7 36 101 97 16 7 0 0 50-54 283 2 1 2 10 40 140 347 205 47 6 0 55-59 487 1 2 4 8 29 59 290 536 375 49 13 60-64 815 2 4 1 5 18 30 103 345 896 415 96 65-69 1,120 3 3 3 3 15 18 56 122 485 690 501 70-74 1,321 2 4 4 3 8 9 18 39 133 335 790 375-79 1,389 0 3 5 2 8 2 12 17 56 74 304 380-84 981 1 1 3 1 5 1 5 3 12 14 53 

85+ 899 1 1 4 0 1 1 1 0 3 1 7 
457

APPENDIX 41 Age-Specific Death Rates From All Causes, by Number of Years of Smoking: Men Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55

30-34 15.2 – – [11.0] 24.5 ( ) ( ) – – – – – 35-39 7.3 – ( ) 16.0 20.9 30.1 (36.5) – – – – – 40-44 9.4 – ( ) [28.1] 31.8 33.5 23.9 (25.6) ( ) – – – 45-49 15.2 – – 43.5 28.9 33.1 40.3 48.8 62.8 164.5 – – 50-54 22.1 (50.9) ( ) (18.3) 44.8 49.0 59.5 66.7 81.7 111.3 104.9 – 55-59 36.8 ( ) (54.5) 59.9 74.1 79.2 82.2 98.3 103.3 136.4 142.2 230.0 ( 60-64 67.3 (95.8) 159.9 ( ) 90.0 110.6 122.3 133.9 142.7 190.4 241.4 282.0 1865-69 109.7 [239.5] [199.8] [134.4] [113.5] 185.3 266.6 248.4 264.1 247.7 289.9 363.9 3570-74 184.7 (286.4) 411.7 294.1 [279.5] 287.3 320.4 238.4 397.0 343.1 438.4 487.6 5575-79 344.1 – [869.6] 934.4 (631.6) 727.8 (196.2) 485.3 634.1 807.3 756.8 656.7 7580-84 546.7 ( ) ( ) [1,135.7] ( ) 1,147.2 ( ) 716.0 [417.2] 987.0 1,020.7 887.4 1,06

85+ 1,114.2 ( ) ( ) 1,367.5 – ( ) ( ) ( ) – [1,722.5] ( ) 1,046.1 1,32

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
458

APPENDIX 42Number of Deaths From All Causes, by Number of Years of Smoking: Women

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 20 0 0 5 5 2 0 0 0 0 0 0 35-39 40 2 1 2 11 6 0 0 0 0 0 0 40-44 93 1 1 1 10 25 11 1 0 0 0 0 45-49 255 2 3 4 12 53 102 77 2 1 0 0 50-54 564 7 5 7 17 53 102 230 74 6 0 0 55-59 927 4 7 12 18 63 72 282 312 100 4 0 60-64 1,401 5 6 16 23 48 60 142 289 421 121 9 65-69 1,871 11 4 12 22 38 35 85 131 368 386 146 70-74 2,216 5 1 19 11 35 35 72 66 146 211 342 75-79 2,487 6 5 11 15 17 8 48 42 78 83 209 80-84 2,245 1 3 7 5 9 9 18 27 37 27 53 

85+ 3,331 1 2 3 2 2 2 7 12 23 16 37 
459

APPENDIX 43 Age-Specific Death Rates From All Causes, by Number of Years of Smoking: Women Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-

30-34 11.4 – – 12.9 18.5 (96.8) – – – – – – – 35-39 8.1 (24.9) ( ) (3.2) 10.2 12.4 – – – – – – – 40-44 10.9 ( ) ( ) ( ) 11.2 11.9 12.0 ( ) – – – – – 45-49 12.2 (13.6) [14.4] 11.2 16.8 20.4 24.4 41.9 (23.4) ( ) – – – 50-54 18.2 43.0 23.8 18.1 28.3 32.1 29.1 37.6 45.1 66.0 – – – 55-59 26.8 32.7 44.6 38.9 44.8 59.6 48.5 64.3 60.5 68.8 65.9 – – 60-64 41.1 65.8 53.4 72.8 85.7 72.8 74.4 85.5 87.6 102.1 137.5 132.3 – 65-69 66.7 238.1 66.1 84.7 149.0 113.1 95.7 118.3 139.8 151.0 178.0 203.6 18070-74 107.4 160.3 ( ) 256.3 137.6 200.4 198.4 227.8 204.1 206.3 199.8 247.0 33575-79 183.9 427.6 301.5 340.7 484.9 224.9 117.3 392.9 332.3 327.8 344.6 356.3 37280-84 315.4 ( ) [403.6] 602.6 484.3 423.0 410.8 483.3 642.7 515.3 514.7 434.3 554

85+ 806.9 ( ) (952.4) [692.3] (895.5) (467.8) (372.1) 619.5 1,184.2 1,044.3 1,051.5 1,244.4 1,383Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
460

APPENDIX 44Number of Deaths From Lung Cancer, by Number of Years of Smoking: Men

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 1 0 0 0 1 0 0 0 0 0 0 0 40-44 0 0 0 0 0 1 1 1 1 0 0 0 45-49 4 0 0 0 0 1 11 10 2 2 0 0 50-54 7 0 0 0 0 2 19 69 37 8 1 0 55-59 7 0 0 0 1 5 9 44 111 76 11 3 60-64 14 1 1 0 0 1 6 11 61 200 76 22 65-69 22 1 0 0 0 3 4 8 23 89 150 107 70-74 25 0 0 0 0 0 1 1 8 29 57 153 75-79 21 0 0 0 0 0 2 1 1 6 11 43 80-84 16 0 0 0 0 1 0 0 0 2 1 3 

85+ 7 0 0 0 0 0 0 0 0 1 0 1 
461

APPENDIX 45 Age-Specific Death Rates From Lung Cancer, by Number of Years of Smoking: Men Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-

30-34 – – – – – – – – – – – – 35-39 ( ) – – – ( ) – – – – – – – 40-44 – – – – – ( ) ( ) ( ) ( ) – – – 45-49 6.0 – – – – ( ) 43.9 50.3 (78.5) (470.0) – – 50-54 5.5 – – – – (24.5) 80.8 132.6 147.4 189.5 ( ) – 55-59 5.3 – – – ( ) 136.6 125.4 149.2 213.9 276.4 319.2 [530.7] 60-64 11.6 ( ) ( ) – – ( ) 244.6 143.0 252.4 425.0 442.2 646.2 (4165-69 21.5 ( ) – – – [370.6] 503.5 354.9 498.0 454.6 630.2 777.2 6070-74 34.9 – – – – – ( ) ( ) 814.3 748.1 746.0 944.4 1,2775-79 52.0 – – – – – (1,962.4) ( ) ( ) 865.0 1,125.0 928.9 1,2380-84 89.2 – – – – ( ) – – – (1,645.0) ( ) [502.3] 1,04

85+ 86.8 – – – – – – – – – – ( ) 
462

APPENDIX 46Number of Deaths From Lung Cancer, by Number of Years of Smoking: Women

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 1 0 0 0 1 0 0 0 0 0 0 0 40-44 0 0 0 0 2 2 0 0 0 0 0 0 45-49 4 1 0 1 2 6 20 13 0 0 0 0 50-54 18 0 0 0 2 8 16 49 18 0 0 0 55-59 25 0 2 1 0 5 14 51 74 28 0 0 60-64 42 0 0 1 1 5 7 26 67 84 22 2 65-69 47 1 0 3 1 2 9 10 23 71 77 34 70-74 63 0 1 0 1 3 4 3 6 21 38 55 75-79 44 0 1 0 0 2 1 4 5 9 14 24 80-84 41 0 0 0 0 1 0 2 0 3 2 4 

85+ 25 0 0 0 0 0 0 0 0 0 0 3 
463

APPENDIX 47 Age-Specific Death Rates From Lung Cancer, by Number of Years of Smoking: Women Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55

30-34 – – – – – – – – – – – – 35-39 ( ) – – – ( ) – – – – – – – 40-44 – – – – (22.4) (9.5) – – – – – – 45-49 1.9 ( ) – ( ) (28.0) 23.1 47.8 70.7 – – – – 50-54 5.8 – – – (33.3) 48.5 45.6 80.0 109.6 – – – 55-59 7.2 – (127.4) ( ) – 47.3 94.4 116.2 143.4 192.7 – – 60-64 12.3 – – ( ) ( ) 75.8 86.8 156.5 203.2 203.6 249.9 (294.0) 65-69 16.7 ( ) – [211.8] ( ) (59.5) 246.2 139.2 245.5 291.4 355.0 474.1 70-74 30.5 – ( ) – ( ) [171.8] 226.7 [94.9] 185.5 296.8 359.8 397.2 4875-79 32.5 – ( ) – ( ) 327.4 395.6 378.2 581.3 409.1 375.6 7480-84 57.6 – – – – ( ) – (537.0) – [417.8] (381.3) 327.7 46

85+ 60.6 – – – – – – – – – – [1,009.0] Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
464

APPENDIX 48Number of Deaths From Coronary Heart Disease, by Number of Years of Smoking: Men

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 0 0 1 0 0 0 0 0 35-39 2 0 0 2 2 1 0 0 0 0 0 0 40-44 3 0 0 0 5 11 2 0 0 0 0 0 45-49 18 0 0 2 2 12 32 35 5 4 0 0 50-54 72 0 0 1 0 13 43 110 66 17 1 0 55-59 157 0 0 3 2 11 20 92 153 108 15 3 60-64 277 1 1 1 2 7 7 31 100 253 135 35 65-69 414 2 1 1 0 3 1 18 30 126 183 137 70-74 490 0 3 3 1 3 6 5 13 28 79 195 75-79 497 0 0 3 1 4 0 4 3 6 13 70 80-84 340 1 1 3 0 0 0 1 0 4 6 19 

85+ 266 1 0 0 0 0 1 0 0 1 0 3 
465

APPENDIX 49 Age-Specific Death Ratesa From Coronary Heart Disease, by Number of Years of Smoking: Men Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 – – – – – – ( ) – – – – – 35-39 (0.9) – – (5.3) (2.6) ( ) – – – – – – 40-44 [1.3] – – – 12.2 11.5 (3.7) – – – – – 45-49 2.7 – – (21.8) (8.3) 11.0 12.8 17.6 19.6 94.0 – – 50-54 5.6 – – ( ) – 15.9 18.3 21.1 26.3 40.3 ( ) – 55-59 11.9 – – [44.9] (18.5) 30.1 27.9 31.2 29.5 39.3 43.5 [53.1] 60-64 22.9 ( ) ( ) ( ) (36.0) 43.0 28.5 40.3 41.4 53.8 78.5 102.8 65-69 40.5 (159.7) ( ) ( ) – [37.1] ( ) 79.9 65.0 64.4 76.9 99.5 170-74 68.5 – [308.8] [220.6] ( ) [107.8] 213.6 66.2 132.3 72.2 103.4 120.4 175-79 123.1 – – [566.0] ( ) 363.9 – 161.8 [111.9] 86.5 133.0 151.2 180-84 189.5 ( ) ( ) [1,135.7] – – – ( ) – 329.0 437.4 318.1 2

85+ 329.7 ( ) – – – – ( ) – – ( ) – [448.3] [5

a Death rates are reported per 10,000 person-years of observation rather than per 100,000 person-years of observation.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
466

APPENDIX 50Number of Deaths From Coronary Heart Disease, by Number of Years of Smoking: Women

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 1 0 0 0 0 0 0 0 35-39 1 0 0 0 0 0 0 0 0 0 0 0 40-44 5 0 0 0 0 3 1 0 0 0 0 0 45-49 8 0 0 0 1 10 9 8 0 0 0 0 50-54 25 0 0 3 3 11 10 24 13 2 0 0 55-59 84 0 0 0 4 11 5 27 47 17 1 0 60-64 211 1 0 2 7 9 8 28 39 76 27 1 65-69 353 5 3 3 1 8 5 22 28 75 65 33 70-74 523 2 0 10 1 8 5 21 14 24 34 85 75-79 717 0 2 1 5 5 2 14 8 20 25 51 80-84 694 0 1 2 0 3 2 5 12 12 3 10 

85+ 1,096 0 1 0 0 1 0 2 2 7 5 9 
467

APPENDIX 51 Age-Specific Death Ratesa From Coronary Heart Disease, by Number of Years of Smoking: Women Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 – – – – ( ) – – – – – – – 35-39 ( ) – – – – – – – – – – – 40-44 0.6 – – – – [1.4] ( ) – – – – – 45-49 0.4 – – – ( ) 3.9 2.2 4.4 – – – – 50-54 0.8 – – [7.7] [5.0] 6.7 2.9 3.9 7.9 (22.0) – – 55-59 2.4 – – – 10.0 10.4 3.4 6.2 9.1 11.7 ( ) – 60-64 6.2 ( ) – (9.1) 26.1 13.7 9.9 16.9 11.8 18.4 30.7 ( ) 65-69 12.6 108.2 [49.6] [21.2] ( ) 23.8 13.7 30.6 29.9 30.8 30.0 46.0 70-74 25.4 (64.1) – 134.9 ( ) 45.8 28.3 66.5 43.3 33.9 32.2 61.4 75-79 53.0 – (120.6) ( ) 161.6 66.2 (29.3) 114.6 63.3 84.1 103.8 86.9 80-84 97.5 – ( ) (172.2) – [141.0] (91.3) 134.3 285.7 167.1 [57.2] 81.9 1

85+ 265.5 – ( ) – – ( ) – (177.0) (197.4) 317.8 328.6 302.7 6

a Rates are reported per 10,000 person-years of observations rather than per 100,000 person-years of observations.

Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
468

APPENDIX 52Number of Deaths From Stroke, by Number of Years of Smoking: Men

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 0 0 0 0 0 2 0 0 0 0 0 0 40-44 1 0 0 0 0 1 0 0 0 0 0 0 45-49 4 0 0 1 0 6 2 4 1 0 0 0 50-54 6 0 0 0 1 2 9 8 7 1 0 0 55-59 13 0 0 0 0 1 3 5 19 16 5 0 60-64 35 0 0 0 0 1 1 5 15 47 11 3 65-69 52 0 0 0 0 0 3 1 5 22 40 15 70-74 80 1 0 0 0 0 0 1 3 3 13 41 75-79 113 0 0 1 0 0 0 0 0 6 4 30 80-84 108 0 0 0 0 0 0 0 1 0 1 5 

85+ 89 0 0 1 0 0 0 0 0 0 0 0 
469

APPENDIX 53 Age-Specific Death Rates From Stroke, by Number of Years of Smoking: Men Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55

30-34 – – – – – – – – – – – – 35-39 – – – – – (50.1) – – – – – – 40-44 ( ) – – – – ( ) – – – – – – 45-49 6.0 – – ( ) – 55.2 (8.0) 20.1 ( ) – – – 50-54 4.7 – – – ( ) (24.5) 38.3 15.4 27.9 ( ) – – 55-59 9.8 – – – – ( ) [41.8] 17.0 36.6 58.2 145.1 – 60-64 28.9 – – – – ( ) ( ) 65.0 62.1 99.9 64.0 [88.1] 65-69 50.9 – – – – – [377.6] ( ) 108.3 112.4 168.1 109.0 2570-74 111.8 ( ) – – – – – ( ) [305.4] [77.4] 170.1 253.1 3075-79 280.0 – – ( ) – – – – – 865.0 409.1 648.1 5780-84 601.8 – – – – – – – ( ) – ( ) 837.2 91

85+ 1,103.0 – – ( ) – – – – – – – – Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
470

APPENDIX 54Number of Deaths From Stroke, by Number of Years of Smoking: Women

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 1 0 0 0 1 0 0 0 0 0 0 0 35-39 1 0 0 0 0 1 0 0 0 0 0 0 40-44 1 0 0 0 0 2 1 0 0 0 0 0 45-49 6 0 2 0 0 4 6 9 1 0 0 0 50-54 16 3 0 0 0 3 7 18 5 0 0 0 55-59 23 0 0 0 1 2 6 18 24 7 0 0 60-64 55 1 0 1 0 1 4 3 17 13 8 2 65-69 104 0 0 2 0 0 4 5 11 28 23 5 70-74 135 0 0 2 0 0 3 5 7 10 15 29 75-79 215 0 0 1 3 1 2 5 4 5 10 19 80-84 273 0 0 0 1 0 0 2 1 1 5 5 

85+ 501 0 0 0 0 0 1 0 1 2 2 3 
471

APPENDIX 55 Age-Specific Death Rates From Stroke, by Number of Years of Smoking: Women Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55

30-34 ( ) – – – ( ) – – – – – – – 35-39 ( ) – – – – ( ) – – – – – – 40-44 ( ) – – – – (9.5) ( ) – – – – – 45-49 2.9 – (96.2) – – 15.4 14.3 49.0 ( ) – – – 50-54 5.2 [184.2] – – – [18.2] 20.0 29.4 30.5 – – – 55-59 6.7 – – – ( ) (18.9) 40.4 41.0 46.5 48.2 – – 60-64 16.1 ( ) – ( ) – ( ) 49.6 [18.1] 51.6 31.5 90.9 (294.0) 65-69 37.0 – – (141.2) – – 109.4 69.6 117.4 114.9 106.0 69.7 70-74 65.4 – – (269.8) – – [170.0] 158.2 216.4 141.3 142.0 209.4 3875-79 159.0 – – ( ) [969.8] ( ) (293.3) 409.2 316.5 210.1 415.2 323.9 3780-84 383.6 – – – ( ) – – (537.0) ( ) ( ) 953.1 409.7 

85+ 1,213.6 – – – – – ( ) – ( ) (908.1) (1,314.3) [1,009.0] Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
472

APPENDIX 56Number of Deaths From Chronic Obstructive Pulmonary Disease, by Number of Years of Smoking: Men

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 0 0 0 0 0 0 0 0 0 0 0 0 40-44 0 0 0 0 0 0 0 0 0 0 0 0 45-49 0 0 0 0 0 0 0 2 0 0 0 0 50-54 2 0 0 0 0 0 4 5 6 0 0 0 55-59 3 0 0 0 0 0 0 6 10 8 2 1 60-64 4 0 0 0 0 0 1 5 8 18 11 3 65-69 8 0 0 0 0 0 1 2 3 20 41 33 70-74 18 0 0 0 1 0 0 1 2 8 17 47 75-79 15 0 0 0 0 0 0 0 3 10 6 19 80-84 13 0 0 0 0 0 0 1 0 1 0 2 

85+ 15 0 0 0 0 0 0 0 0 1 0 0 
473

APPENDIX 57 Age-Specific Death Rates From Chronic Obstructive Pulmonary Disease, by Number of Years of Smoking: Men Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-

30-34 – – – – – – – – – –––– 35-39 – – – – – – – – – –––– 40-44 – – – – – – – – – –––– 45-49 – – – – – – – (10.1) – –––– 50-54 (1.6) – – – – – 17.0 9.6 23.9 –––– 55-59 [2.3] – – – – – – 20.3 19.3 29.1 (58.0) ( ) ( 60-64 3.3 – – – – – ( ) 65.0 33.1 38.3 64.0 [88.1] – 65-69 7.8 – – – – – ( ) (88.7) [65.0] 102.1 172.3 239.7 (1070-74 25.2 – – – ( ) – – ( ) (203.6) 206.4 222.5 290.1 3275-79 37.2 – – – – – – – [1,119.1] 1,441.6 613.7 410.4 4680-84 72.4 – – – – – – ( ) – ( ) – (334.9) 91

85+ 185.9 – – – – – – – – ( ) – – – Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
474

APPENDIX 58Number of Deaths From Chronic Obstructive Pulmonary Disease, by Number of Years of Smoking: Women

Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 0 0 0 0 0 0 0 0 0 0 0 0 35-39 0 0 0 0 0 0 0 0 0 0 0 0 40-44 0 0 0 0 0 0 0 0 0 0 0 0 45-49 0 0 0 0 0 0 1 1 0 0 0 0 50-54 2 0 0 0 1 0 4 5 2 0 0 0 55-59 6 0 0 0 0 0 1 7 12 4 0 0 60-64 11 1 0 0 0 1 2 5 11 16 8 0 65-69 16 1 0 1 2 1 1 5 9 17 21 10 70-74 24 0 0 0 0 2 2 2 6 9 15 21 75-79 24 0 0 0 0 1 0 3 1 3 2 22 80-84 29 0 1 0 0 0 2 0 2 3 3 9 

85+ 31 0 0 0 0 0 0 2 0 1 1 5 
475

APPENDIX 59 Age-Specific Death Rates From Chronic Obstructive Pulmonary Disease, by Number of Years of Smoking: Women Number of Years Smoked

NeverAge Smokers 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 5

30-34 – – – – – – – – – – – – 35-39 – – – – – – – – – – – – 40-44 – – – – – – – – – – – – 45-49 – – – – – – ( ) ( ) – – – – 50-54 (0.6) – – – ( ) – 11.4 8.2 (12.2) – – – 55-59 1.7 – – – – – ( ) 16.0 23.3 27.5 – – 60-64 3.2 ( ) – – – ( ) (24.8) 30.1 33.4 38.8 90.9 – 65-69 5.7 ( ) – ( ) (135.5) ( ) ( ) 69.6 96.1 69.8 96.8 139.4 70-74 11.6 – – – – (114.5) (113.4) (63.3) 185.5 127.2 142.0 151.7 375-79 17.7 – – – – ( ) – [245.5] ( ) [126.1] (83.0) 375.0 280-84 40.7 – ( ) – – – (912.9) – (476.1) [417.8] [571.9] 737.4 5

85+ 75.1 – – – – – – (1,769.9) – ( ) ( ) 1,681.6 3,0Key: – = 0 deaths; ( ) = 1 death; (rate) = 2 deaths; [rate] = 3 deaths.
476

Smoking and Tobacco Control Monograph No. 8
477

Chapter 6

Smoking and Mortality: The Kaiser

Permanente Experience

Gary D. Friedman, Irene Tekawa, Marianne Sadler, and Stephen Sidney

INTRODUCTION The Kaiser Permanente Medical Care Program cohort study

described here obtained detailed baseline information about smoking habits

from more than 60,000 subjects, age 35 and older, who entered the cohort

between 1979 and 1986 and were followed up for mortality through 1987.

This study population is ethnically and socioeconomically diverse,

permitting interracial comparisons of the effects of cigarette smoking.

STUDY POPULATION In 1979 the Division of Research (then called the Department

AND METHODS of Medical Methods Research), Kaiser Permanente Medical

Care Program, Northern California Region, began a prospective cohort

study aimed at assessing the risks associated with various aspects of tobacco

smoking. The program provides comprehensive prepaid medical care to

its subscribers, who number about 30 percent of the population in the

areas served. The subscribers, most of whom join through employment

groups, are ethnically, racially, and socioeconomically heterogeneous and

are reflective of the local population except for being somewhat more

educated, on average, and underrepresentative of the extremes of wealth

and poverty (Hiatt and Friedman, 1982; Krieger, 1992). The program offered

multiphasic health checkups (Collen and Davis, 1969) at its Oakland and

San Francisco Medical Centers as a routine health appraisal, and starting

in July 1979, persons receiving these checkups were asked to complete a

detailed questionnaire about their smoking habits for a followup study.

Altogether, 83 percent complied on at least one checkup. The multiphasic

checkup program was discontinued in San Francisco in mid-1980 but is

still operated in a modified form in Oakland. Administration of these

smoking questionnaires continued in Oakland until late October 1986.

About 2,000 persons who received another form of preventive health

examination in San Francisco in 1981 also completed these questionnaires

and are included in the total cohort of more than 100,000 persons.

The questions used to classify persons into the various smoking and

racial categories are listed in Appendix A. Persons who did not specify

a race were included in the "Other" category. Never-smokers were persons

who responded that they had never used any tobacco product, without

contradiction in their response to the questions about ever smoking

cigarettes regularly for at least 1 year and still smoking cigarettes. If they

did not affirm never using any tobacco product, never-smokers had to

deny ever smoking cigarettes regularly for at least 1 year and either answer

negatively or not at all to the question about their still smoking cigarettes.

Former smokers were persons who responded "yes" to ever smoking cigarettes
Smoking and Tobacco Control Monograph No. 8

478

regularly for at least 1 year and who reported having quit smoking cigarettes

at least 2 years before completing the questionnaire. Current smokers were

persons who responded "yes" to the question about ever smoking cigarettes

regularly for at least 1 year and "yes" or "occasionally" to the question about

still smoking cigarettes regularly. Only those reporting never using cigars or

pipes regularly were included in any of these categories.

Followup for mortality used the California Automated Mortality

Linkage System (CAMLIS) (Arellano et al., 1984) program for linkage

with deaths within the State of California. If linkages were questionable,

additional information was obtained from program membership data and

medical records to rule in or out the match. In a test subset consisting of

4,696 members of this study cohort, this method was found to produce

more false negatives (11 percent vs. 6 percent of known dead classified as

alive) and fewer false positives (0.07 percent vs. 1.2 percent of known alive

classified as dead) when compared with utilization of the National Death

Index (Stampfer et al., 1984) in ascertainment of mortality (Arellano et al.,

1984). In a previous study, similar mortality followup resulted in death

ascertainment that was estimated to be 82 to 92 percent complete (Freidman

et al., 1979). Causes of death and their coding by State vital statistics

personnel were accepted as recorded. Another test revealed 97 percent

agreement between these codes and the judgment of a physician in our

department (Sidney et al., 1987). During the followup period, all deaths

were coded by the International Classification of Diseases: 9th Revision.

Clinical Modification (ICD-9-CM) (U.S. Department of Health and Human

Services, 1991).

Followup of each subject started with his or her first health checkup,

in which the tobacco questionnaire was completed, and ended at death or

December 31, 1987.

Cigarette Smoking Person-years of followup were allocated to age categories using

and Mortality attained age for each subject. Deaths were summarized for age

categories by age at death, and age-specific rates were reported as deaths per

1,000 person-years. Age-specific relative risks for former and current smokers

compared with nonsmokers were simple rate ratios. Relative risks adjusted

for age were obtained using the Mantel-Haenszel (MH) method as applied to

cohort studies (Breslow and Day, 1988). Tests of homogeneity over age also

were performed.

The data from smaller subgroups were initially examined and frequently

found to contain small numbers of events. It was decided to combine

subgroups for age, number of cigarettes smoked per day, number of years

of smoking, and number of years of cessation into the larger categories.

These were as follows: number of cigarettes smoked per day (<20, >20),

years of smoking (<20, 20-39, >40), years of cessation (2-10, 11-20, >20),

and age (35-49, 50-64, 65-74, >75 years). Years of smoking in current

smokers, years of cessation in former smokers, and age were incremented

throughout followup under the assumption that smoking habits remained

as initially reported.
479

Chapter 6

Mortality rates and relative risk estimates (rate ratios) were calculated

for all-cause, lung cancer, coronary heart disease (CHD), stroke, and chronic

obstructive pulmonary disease (COPD) mortality. In addition to these

5 categories, analyses were performed for major cause-of-death groupings

and causes of death with at least 10 deaths among current smokers and

nonsmokers in both sexes combined. Smokers vs. nonsmokers in Asians,

blacks, and whites were compared for the five cause-of-death categories

listed above.

Relative risks are described as statistically significant if the 95-percent

confidence interval, before rounding, did not include 1.0. The results of

most of our analyses are presented in a descriptive fashion, and statements

concerning differences among subgroups or trends do not necessarily imply

that these were statistically significant.

RESULTS The 60,838 study subjects, age 35 and older, had a mean age at

entry to the study of 50.9 years and comprised 36,035 (59 percent)

Study Population women and 24,803 (41 percent) men. More than half, 58 percent,

of the subjects were white, 25 percent were black, 11 percent were Asian,

and 6 percent were of other or unknown race. Overall, there were

16,279 (27 percent) current smokers, 11,935 (20 percent) former smokers,

and 32,624 (54 percent) never-smokers (percentages are rounded). The

percentage of current smokers among blacks was 36 percent, among

whites was 25 percent, among Asians was 15 percent, and among those

of other or unknown race was 25 percent. The distributions of study

subjects and person-years of followup by sex, race, and smoking status

are shown in Table 1. The mean length of followup was 6.1 years for all

subjects.

Current Smoker/ There was approximately a doubling in all-cause mortality

Never-Smoker Mortality rates in current smokers as compared with never-smokers

Risks by Sex and Race in both black and white women. In women who were

for All and Selected Asian or of other or unknown race, relative risks were

Causes of Death lower, but confidence intervals were wide because of

few deaths and were compatible with a twofold increase

All Causes (Figure 1).

In black and white men the overall current smoker/never-smoker relative

risk for all-cause mortality was slightly less than two. However, these

combined relative risks do not reflect the significant heterogeneity among

the age subgroups (Table 2). In blacks this heterogeneity was expressed as

a progressive downward trend in elevated risk starting with the youngest

men, ages 35 to 49 years. In whites smokers in the 50- to 64-year-old age

range had the highest relative risk. The overall current smoker/never-smoker

relative risk was lower in Asian men and men of other or unknown race,

but confidence intervals were wide. There were too few men in these racial

groups for the apparent substantial variation among age subgroups to be

statistically significant.
Smoking and Tobacco Control Monograph No. 8

480

Table 1

Study subjects and person-years of followup by sex, race, and cigarette smoking status

Cigarette Smoking Status

Never Former Current Total

Person- Person- Person- PersonSubjects N Years N Years N Years N Years

Women–Total 21,080 131,955 5,871 35,261 9,084 55,166 36,035 222,382

Black 5,213 32,316 1,092 6,624 3,123 18,678 9,428 57,618

White 11,111 69,590 4,321 25,782 5,133 31,315 20,565 126,687

Asian 3,355 21,004 223 1,395 355 2,209 3,933 24,608

Other/unknown 1,401 9,045 235 1,460 473 2,964 2,109 13,469

Men–Total 11,544 69,887 6,064 36,927 7,195 43,718 24,803 150,532

Black 2,159 12,953 1,228 7,589 2,315 13,948 5,702 34,490

White 6,931 41,739 4,024 24,392 3,804 23,084 14,759 89,215

Asian 1,714 10,586 501 3,017 650 4,063 2,865 17,666

Other/unknown 740 4,609 311 1,929 426 2,623 1,477 9,161

Total 32,624 201,842 11,935 72,188 16,279 98,884 60,838 372,914

a By Mantel-Haenszel method.

bChi-squared test for heterogeneity showed significant (p < 0.05) variation in relative risks by age.

Figure 1

Age-adjusted relative risks (with 95-percent confidence intervals)a of death due to all causes

in current smokers as compared with never-smokers
481

Table 2 Age-specific relative risks of death due to all causes by sex and race in current smokers as compared with never-smokmortality rates per 1,000 person-years

Ages 35-49 Years Ages 50-64 Years Ages 65-74 Years Ages 

Cigarette No. of Mort. Rel. No. of Mort. Rel. No. of Mort. Rel. No. of 

Race-Sex Smoking Status Deaths Rate Risk Deaths Rate Risk Deaths Rate Risk Deaths Black Women Never 17 1.3 – 34 2.7 – 44 8.5 – 32 

Current 18 1.8 1.4 42 6.0 2.2 33 23.6 2.8 5 

White Women Never 12 0.6 – 56 2.3 – 107 6.9 – 245 

Current 16 1.3 2.2 63 5.1 2.2 77 14.3 2.1 41 

Asian Women Never 6 0.7 – 20 2.1 – 14 6.6 – 4 

Current 1 1.0 1.5 2 2.0 1.0 0 0.0 0.0 1 

Other Women Never 2 0.5 – 8 2.3 – 6 4.7 – 18 

Current 2 1.3 2.4 2 1.9 0.9 5 16.0 3.4 0 

Black Men Never 4 0.7 – 21 4.8 – 37 19.2 – 33 

Current 25 3.6 5.3 57 10.5 2.2 34 25.4 1.3 12 

White Men Never 37 2.2 – 54 3.9 – 97 12.5 – 144 

Current 36 3.3 1.5 95 11.0 2.8 72 24.5 2.0 41 

Asian Men Never 2 0.4 – 12 2.8 – 20 15.7 – 18 

Current 1 0.5 1.1 8 5.0 1.8 4 13.5 0.9 2 

Other Men Never 6 2.6 – 10 6.3 – 7 13.3 – 8 

Current 4 2.9 1.1 9 9.1 1.5 6 31.0 2.3 5 
Smoking and Tobacco Control Monograph No. 8

482

Lung Cancer Current smoker/never-smoker age-adjusted relative risks of dying of

lung cancer were high in black women and white women and were only

moderately high in Asian women, but confidence limits were wide in all

three racial groups due to small numbers of deaths. There were no lung

cancer deaths among women of other or unknown race. Among men these

age-adjusted relative risks were highest in whites, next highest in blacks, and

lowest in Asians and were indeterminate in those of other or unknown race.

The confidence intervals in Asian women and men were compatible with

either large or absent risk elevation in the current smokers (Figure 2).

Chronic Obstructive Current smoker/never-smoker age-adjusted relative risks of dying

Pulmonary Disease of COPD were high in both black and white women and were

indeterminate in the other two female racial groups. They were high in

white men, fairly high in Asian men, and indeterminate in black men and

those men of other or unknown race. Statistically significant elevation

above a relative risk of 1.0 was seen in white women and men (Figure 3).

Coronary Heart The risk of dying from CHD was elevated in current-smoking as

Disease compared with never-smoking women of all racial groups. Relative

risk was highest and about equal in black and Asian women and was next

highest in white women but was only slightly increased in women of other

or unknown race. White men showed an elevated current smoker/neversmoker relative risk similar to that in black and Asian women, but they also

a By Mantel-Haenszel method.

b Indeterminate relative risk due to absence of deaths among both never-smokers and current smokers.

c Indeterminate relative risk due to absence of deaths among never-smokers.

Figure 2

Age-adjusted relative risks (with 95-percent confidence intervals)a of death due to lung cancer

in current smokers as compared with never-smokers
483

Chapter 6

Figure 3

Age-adjusted relative risks (with 95-percent confidence intervals)a of death due to COPD in

current smokers as compared with never-smokers

showed significant heterogeneity of relative risk among the age subgroups.

Relative risk elevation was fairly small in Asian men, virtually absent in black

men, and reversed, with nonsmokers higher, in men of other or unknown

race. Risk elevations were statistically significant in black and white women

and white men (Figure 4).

Stroke Age-adjusted current smoker/never-smoker relative risks for stroke death

were moderately elevated in black women and mildly elevated in women of

other or unknown race (neither statistically significant), were not elevated

in white women, and were indeterminate in Asian women. Among men

relative risk was not elevated in blacks or whites and was indeterminate in

Asians and those of other or unknown race (Figure 5).

Age-Specific Relative Women in each age group showed an increase in risk

Risks for Mortality of dying from any cause according to the number of

cigarettes smoked (Table 3). This trend was most marked

Quantity Smoked in the two intermediate age groups, 50 to 64 years and

65 to 74 years, and was least marked among those 75 years or older. Lung

cancer showed striking increases in relative risk among female smokers,

with greater than twentyfold elevations over the nonsmoker mortality rate

noted forfemale smokers of 20 or more cigarettes per day in those ages 35

to 49 years, 65 to 74 years, and 75 years and older and for female smokers of

fewer than 20 cigarettes per day in the 65- to 74-year age group. There were

a By Mantel-Haenszel method.

b Indeterminate relative risk due to absence of deaths among never-smokers.

c Indeterminate relative risk due to absence of deaths among both never-smokers and current smokers.

0.5

 Black

1 2 5

Relative Risk (log scale)

10 20 40

6.7

White 7.8

Asianb

Otherc/Unknown

Blackb

White 14.8

Asian 3.4

Otherc/Unknown

Men

Women

Friedman et al. Figure 3
Smoking and Tobacco Control Monograph No. 8

484

a By Mantel-Haenszel method.

b Chi-squared test for heterogeneity showed significant (p < 0.05) variation in relative risks by age.

Figure 4

Age-adjusted relative risks (with 95-percent confidence intervals)a of death due to CHD

in current smokers as compared with never-smokers

Figure 5

Age-adjusted relative risks (with 95-percent confidence intervals)a of death due to stroke

in current smokers as compared with never-smokers

a By Mantel-Haenszel method.

b Indeterminate relative risk due to absence of deaths among current smokers.

c Indeterminate relative risk due to absence of deaths among both never-smokers and current smokers.

 Black

0.25 0.5 1

Relative Risk (log scale)

2 5 10 20

2.3

White

1.6

Asian 2.2

Other/Unknown

1.3

Black

1.0

b

White 2.2

Asian 1.4

Other/Unknown

0.4

Men

Women

0.25

 Black

0.5 1

Relative Risk (log scale)

2 4 8 10

2.2

White

0.9

Asianb

Other/Unknown

1.6

Black

1.0

White

0.9

Asianb

Otherc/Unknown

Men

Women
485

Table 3 Age-specific relative risks of death due to all causes, lung cancer, COPD, CHD, and stroke in never-smokers and currby quantity of cigarettes smoked—women

Number of Deaths Relative Riska

Cigarette Quantity

Age Smoking (Cigarettes Person- All Lung All Lung(Years) Status Per Day) Years Causes Cancer COPD CHD Stroke Causes Cancer COPD 35-49 Never – 45,768 37 1 0 2 1 1.0 1.0 1.0 

Current <19 12,086 12 1 0 0 1 1.2 3.8 b 

Current 20+ 12,851 25 7 0 3 3 2.4 24.9 – 

50-64 Never – 49,744 118 5 0 17 10 1.0 1.0 1.0 

Current <19 10,205 40 5 1 5 2 1.7 4.9 – 

Current 20+ 10,950 69 16 1 12 5 2.7 14.5 – 

65-74 Never – 24,159 171 2 2 33 16 1.0 1.0 1.0 

Current <19 3,582 45 8 0 8 3 1.8 27.0 0.0 

Current 20+ 3,583 70 11 5 11 4 2.8 37.1 16.9 

75+ Never – 12,285 299 3 4 82 38 1.0 1.0 1.0 

Current <19 806 23 1 2 7 1 1.2 5.1 7.6 

Current 20+ 588 24 5 1 4 1 1.7 34.8 5.2 

All agesa Never – 131,956 625 11 6 134 65 1.0 1.0 1.0 

Current <19 26,680 120 15 3 20 7 1.5 8.5 5.4 

Current 20+ 27,973 188 39 7 30 13 2.5 21.7 13.9 

a Relative risk for all ages is age-adjusted by the MH method using the four age strata shown.b Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: COPD = chronic obstructive pulmonary disease; CHD = coronary heart disease; MH = Mantel-Haenszel.
Smoking and Tobacco Control Monograph No. 8

486

few deaths from COPD among women, yielding unstable rates and relative

risks. Female smokers age 75 years or older and those ages 65 to 74 years

who smoked 20 or more cigarettes all showed markedly elevated risks. CHD

death was increased in a graded fashion in women ages 50 to 64 and 65 to

74 years, but there was virtually no increase in smokers age 75 and older.

The few CHD deaths in women ages 35 to 49 years showed an uneven trend,

with smokers of 20 or more cigarettes per day showing the highest risk and

smokers of fewer than 20 cigarettes per day having the lowest risk. Smokingassociated relative risks of stroke tended to decrease with age; the risks were

highest in women smokers ages 35 to 49 years and were lower in current

smokers compared with never-smokers in women age 75 or older.

Among men there was a clear moderate dose-response trend in all-cause

mortality according to quantity smoked in the 35- to 49- and 50- to 64-year

age group (Table 4). Findings became less clear-cut in the older groups, with

both smoking-quantity groups having about equal risk elevations in men

ages 65 to 74 years and a mildly elevated risk found only in the 20-or-more

cigarettes per day smokers among men age 75 and older. For lung cancer,

zero cases in never-smokers made relative risk not determinable in the 35-

to 49-year-olds, but large elevations in risk with a dose-response trend were

noted in all the other age groups. Interestingly, these risk elevations were

less marked than in women (differences not statistically significant). Large

increases in risk also were noted in most of the male smoking groups for

COPD, but small numbers of deaths limit the interpretability of the finding.

CHD deaths were relatively elevated in all the male smoking groups except

those age 75 or older who smoked fewer than 20 cigarettes per day. Doseresponse was not apparent in 35- to 49-year-old men. Stroke mortality risk

was elevated in all the fewer-than-20 cigarettes per day smokers except those

ages 35 to 49 years. Smokers of at least 20 cigarettes per day showed no risk

elevation except for men ages 35 to 49 years, but numbers of deaths were

small.

Duration of Smoking Although there were some irregularities and inconsistencies,

age-specific relative risks for all-cause mortality generally increased with

duration of smoking in women (Table 5). This was even more apparent for

lung cancer, where there were no deaths among those who smoked less than

20 years. Death due to COPD occurred in a few never-smoking women, but

among smokers, it occurred only in those who had smoked at least 40 years.

CHD showed positive trends in risk, with increasing duration in the two

younger groups of women but with negative trends in the two older groups.

Somewhat similar age-related diversity in risk trends by duration of smoking

was seen for stroke.

Among men all-cause mortality was associated with increasing duration

of smoking in 35- to 49- and 50- to 64-year-olds (Table 6). Excluding the

relatively few less-than-20-year smokers in the older groups, with respect

to all-cause mortality risk, duration was not associated in those ages 65 to

74 years and was inversely associated in those age 75 or older. Lacking

relative risk estimates for lung cancer in 35- to 49-year-old men because
487

Table 4 Age-specific relative risks of death due to all causes, lung cancer, COPD, CHD, and stroke in never-smokers and curreby quantity of cigarettes smoked—men

Number of Deaths Relative Riska

Cigarette Quantity

Age Smoking (Cigarettes Person- All Lung All Lung

(Years) Status Per Day) Years Causes Cancer COPD CHD Stroke Causes Cancer COPD C35-49 Never – 29,916 49 0 0 5 3 1.0 1.0 1.0 

Current <19 7,895 17 0 0 3 0 1.3 b – 2

Current 20+ 13,304 49 6 2 4 2 2.2 – – 

50-64 Never – 24,020 97 5 1 29 3 1.0 1.0 1.0 

Current <19 5,575 49 6 3 14 2 2.2 5.2 12.9 2

Current 20+ 10,838 116 18 3 39 1 2.7 8.0 6.6 

65-74 Never – 11,466 161 5 2 52 10 1.0 1.0 1.0 

Current <19 1,740 44 3 3 11 2 1.8 4.0 9.9 

Current 20+ 2,995 71 13 6 23 0 1.7 10.0 11.5 

75+ Never – 4,486 203 4 1 66 19 1.0 1.0 1.0 

Current <19 490 22 2 0 4 3 1.0 4.6 0.0 Current 20+ 545 37 5 1 9 1 1.5 10.3 8.2 

All agesa Never – 69,887 510 14 4 152 35 1.0 1.0 1.0 

Current <19 15,700 132 11 6 32 7 1.6 4.7 9.2 

Current 20+ 27,682 273 42 12 75 4 2.0 10.4 10.9 2

a Relative risk for all ages is age-adjusted by the MH method using the four age strata shown.

b Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: COPD = chronic obstructive pulmonary disease; CHD = coronary heart disease; MH = Mantel-Haenszel.
488Table 5 Age-specific relative risks of death due to all causes, lung cancer, COPD, CHD, and stroke in never-smokers and curre

by duration of smoking—women

Number of Deaths Relative Riska

Cigarette Duration

Age Smoking (Years Person- All Lung All Lung

(Years) Status Smoked) Years Causes Cancer COPD CHD Stroke Causes Cancer COPD C35-49 Never – 45,768 37 1 0 2 1 1.0 1.0 1.0 

Current <20 8,962 8 0 0 1 0 1.1 0.0 b 2

Current 20-39 15,162 28 8 0 2 4 2.3 24.1 – 3

50-64 Never – 49,744 118 5 0 17 10 1.0 1.0 1.0 

Current <20 2,454 5 0 0 1 0 0.9 0.0 – Current 20-39 14,115 56 11 0 7 4 1.7 7.8 – Current 40+ 3,761 40 7 2 7 3 4.5 18.5 – 5

65-74 Never – 24,159 171 2 2 33 16 1.0 1.0 1.0 

Current <20 502 6 0 0 2 0 1.7 0.0 0.0 2Current 20-39 2,125 39 4 0 8 4 2.6 22.7 0.0 2Current 40+ 4,236 64 14 5 7 3 2.1 39.9 14.3 

75+ Never – 12,285 299 3 4 82 38 1.0 1.0 1.0 

Current <20 100 3 0 0 1 0 1.2 0.0 0.0 Current 20-39 366 10 1 0 3 2 1.1 11.2 0.0 Current 40+ 830 30 5 3 5 0 1.5 24.7 11.1 

All agesa Never – 131,956 625 11 6 134 65 1.0 1.0 1.0 

Current <20 12,018 22 0 0 5 0 1.2 0.0 0.0 Current 20-39 31,768 133 24 0 20 14 1.9 12.0 0.0 

Current 40+ 8,827 134 26 10 19 6 2.3 27.5 16.2 

a Relative risk for all ages is age-adjusted by the MH method using the four age strata shown.b Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: COPD = chronic obstructive pulmonary disease; CHD = coronary heart disease; MH = Mantel-Haenszel.
489

Table 6 Age-specific relative risks of death due to all causes, lung cancer, COPD, CHD, and stroke in never-smokers and curreby duration of smoking—men

Number of Deaths Relative Riska

Cigarette Duration

Age Smoking (Years Person- All Lung All Lung

(Years) Status Smoked) Years Causes Cancer COPD CHD Stroke Causes Cancer COPD C35-49b Never – 29,916 49 0 0 5 3 1.0 1.0 1.0 1

Current <20 5,940 16 1 0 1 1 1.6 c – 1

Current 20-39 14,563 48 5 2 5 1 2.0 – – 2

50-64 Never – 24,020 97 5 1 29 3 1.0 1.0 1.0 1

Current <20 1,174 7 0 0 3 0 1.5 0.0 0.0 2Current 20-39 10,205 80 7 2 28 2 1.9 3.3 4.7 2Current 40+ 4,367 74 17 4 21 1 4.2 18.7 22.0 4

65-74 Never – 11,466 161 5 2 52 10 1.0 1.0 1.0 1

Current <20 212 0 0 0 0 0 0.0 0.0 0.0 0Current 20-39 963 23 3 1 7 0 1.7 7.1 6.0 1Current 40+ 3,285 80 12 7 22 1 1.7 8.4 12.2 1

75+ Never – 4,486 203 4 1 66 19 1.0 1.0 1.0 1

Current <20 90 0 0 0 0 0 0.0 0.0 0.0 0Current 20-39 138 12 1 0 4 0 1.9 8.1 0.0 2Current 40+ 740 42 5 1 8 3 1.3 7.6 6.1 0

All agesa Never -- 69,887 510 14 4 152 35 1.0 1.0 1.0 1

Current <20 7,416 23 1 0 4 1 1.0 2.1 0.0 0Current 20-39 25,868 163 16 5 44 3 1.9 6.0 7.6 2

Current 40+ 8,401 196 34 12 51 5 2.0 11.4 13.1 1

a Relative risk for all ages age-adjusted by the MH method using the four age strata shown.b One man who reported smoking 40+ years was excluded.c Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: COPD = chronic obstructive pulmonary disease; CHD = coronary heart disease; MH = Mantel-Haenszel.
Smoking and Tobacco Control Monograph No. 8

490

of an absence of cases in never-smokers, one may still conclude from

inspection of the number of cases and person-years that duration of smoking

was associated with risk in that group. There were no lung cancer deaths

in the less-than-20-year smokers in the three older age groups, but judging

from smokers of longer duration, duration was strongly related to risk in

50- to 64-year-olds but not in 65- to 74-year-olds or those 75 years or older.

Although inconclusive due to small numbers of cases, men's risk of death

from COPD was related to duration, being highest in those who had smoked

for at least 40 years. Risk of dying from CHD was related to increasing

duration of smoking in a positive fashion among the 35- to 49- and 50- to

64-year-olds and, ignoring the few smokers of less than 20 years duration,

in a slightly negative and markedly negative fashion in those ages 65 to

74 years and 75+ years or older, respectively. Little can be said about the

relation of stroke to duration of smoking in men because of the paucity of

deaths.

Duration of Quitting Among the women in the 50- to 64- and 65- to 74-year age

group, all-cause mortality showed an inverse relationship to duration of

quitting, with those who had quit for more than 20 years among the 50- to

64-year-olds having a lower risk than never-smokers (Table 7). In persons at

least 75 years of age, those who had quit for 11 to 20 years and those who

had quit for more than 20 years had virtually the same all-cause mortality

risks. In the youngest group, the 35- to 49-year-olds, all-cause mortality was

highest in those who had quit smoking for more than 20 years, but this was

based on only two deaths. Lung cancer deaths among women were also few

in number, and the expected decline in risk with increasing duration of

quitting smoking was observed in the 50- to 64- and 75+-year age groups.

Deaths due to COPD and stroke among the female ex-smokers were too few

for meaningful observation of trends. A clearly declining trend in risk of

death from CHD with increasing duration of quitting was seen only in

women ages 65 to 74 years.

All-cause deaths among men showed decreasing risks with increased

duration of quitting only in the 50- to 64- and 75+-year age groups (Table 8).

This was also true for lung cancer but only in men ages 50 to 64 years. In

the 65- to 74-year-olds who had quit for at least 20 years and those 75 years

or older who had quit for 11 to 19 years, the risk of dying from lung cancer

was lower than that of never-smokers. Based on small numbers of deaths,

risk of dying from COPD was inversely related to duration of quitting

smoking in the 65- to 74- and 75+-age groups, with large relative risks seen

in men who had quit for less than 20 years. Declining risks of death due to

CHD were associated with increased duration of quitting in men ages 50 to

64 and 75+ years. Former smokers in the 65- to 74-year age group had

relative risks that were the same or lower than that of nonsmokers. A

progressively declining trend of stroke deaths with increasing duration

of quitting was seen only in the 65- to 74-year age group of men. Numbers

of stroke deaths were very small, thereby hampering inference.
491

Table 7 Age-specific relative risks of death due to all causes, lung cancer, COPD, CHD, and stroke in never-smokers and formeby duration of quitting—women

Number of Deaths Relative Riska

Cigarette Duration

Age Smoking (Years Person- All Lung All Lung

(Years) Status Smoked) Years Causes Cancer COPD CHD Stroke Causes Cancer COPD C35-49 Never – 45,768 37 1 0 2 1 1.0 1.0 1.0 1

Former 2-10 5,493 0 0 0 0 0 0.0 0.0 b 0

Former 11-20 6,027 4 0 0 0 1 0.8 0.0 – 0Former >20 1,279 2 0 0 0 0 1.9 0.0 – 0

Never – 49,744 118 5 0 17 10 1.0 1.0 1.0 1

Former 2-10 3,750 15 3 1 0 0 1.7 8.0 – 0Former 11-20 5,467 16 1 0 2 2 1.2 1.8 – 1Former >20 4,405 7 0 0 0 1 0.7 0.0 – 0

65-74 Never – 24,159 171 2 2 33 16 1.0 1.0 1.0 1

Former 2-10 1,572 15 2 0 4 0 1.3 15.4 0.0 1Former 11-20 2,505 21 2 1 5 1 1.2 9.6 4.8 1Former >20 2,641 20 3 1 2 2 1.1 13.7 4.6 0

75+ Never – 12,285 299 3 4 82 38 1.0 1.0 1.0 1

Former 2-10 394 15 1 0 5 1 1.6 10.4 0.0 1Former 11-20 722 23 1 0 7 2 1.3 5.7 0.0 1Former >20 852 27 1 1 10 2 1.3 4.8 3.6 1

All agesa Never – 131,956 625 11 6 134 65 1.0 1.0 1.0 1

Former 2-10 11,209 45 6 1 9 1 1.3 8.4 3.8 1Former 11-20 14,722 64 4 1 14 6 1.2 3.8 2.2 1

Former >20 9,178 56 4 2 12 5 1.1 4.4 4.0 1

a Relative risk for all ages is age-adjusted by the MH method using the four age strata shown.b Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: COPD = chronic obstructive pulmonary disease; CHD = coronary heart disease; MH = Mantel-Haenszel.
492Table 8 Age-specific relative risks of death due to all causes, lung cancer, COPD, CHD, and stroke in never-smokers and forme

by duration of quitting—men

Number of Deaths Relative Riska

Cigarette Duration

Age Smoking (Years Person- All Lung All Lung

(Years) Status Smoked) Years Causes Cancer COPD CHD Stroke Causes Cancer COPD C35-49 Never – 29,916 49 0 0 5 3 1.0 1.0 1.0 

Former 2-10 5,571 12 1 0 1 1 1.3 b – 

Former 11-20 6,210 5 0 1 1 0 0.5 – – Former >20 1,149 3 0 0 2 0 1.6 – – 1

50-64 Never – 24,020 97 5 1 29 3 1.0 1.0 1.0 

Former 2-10 3,625 26 6 0 9 0 1.8 8.0 0.0 Former 11-20 6,107 29 2 0 11 2 1.2 1.6 0.0 Former >20 4,670 19 1 0 6 1 1.0 1.0 0.0 

65-74 Never – 11,466 161 5 2 52 10 1.0 1.0 1.0 

Former 2-10 977 14 2 2 1 2 1.0 4.7 11.7 Former 11-20 2,548 52 6 3 11 2 1.5 5.4 6.8 Former >20 3,507 43 1 1 12 0 0.9 0.7 1.6 

75+ Never – 4,486 203 4 1 66 19 1.0 1.0 1.0 

Former 2-10 253 16 3 2 7 1 1.4 13.3 35.5 Former 11-20 671 40 0 2 16 4 1.3 0.0 13.4 Former >20 1,442 67 4 0 22 8 1.0 3.1 0.0 

All agesa Never – 69,887 510 14 4 152 35 1.0 1.0 1.0 

Former 2-10 10,424 68 12 4 18 4 1.4 8.5 10.9 Former 11-20 15,536 126 8 6 39 8 1.2 2.7 7.2 

Former >20 10,767 132 6 1 42 9 1.0 1.6 0.9 

a Relative risk for all ages is age-adjusted by the MH method using the four age strata shown.b Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: COPD = chronic obstructive pulmonary disease; CHD = coronary heart disease; MH = Mantel-Haenszel.
493

Chapter 6

Current Smoker/Never- A survey of current smoker/never-smoker relative risk

Smoker Relative Risks for for a broad range of causes of death is provided in

Other Causes of Death Tables 9 and 10. Shown are the numbers of deaths and

age-adjusted relative risks for all the major cause-of-death groupings in the

ICD-9-CM classification (U.S. Department of Health and Human Services,

1991) plus selected individual causes. Although all major groupings of causes

are shown regardless of numbers of deaths, individual causes with fewer than

10 deaths in the total of female and male current smokers and never-smokers

are not shown. Thus, certain causes that were of interest because of findings

in previous studies are not shown here because of small numbers of deaths

(e.g., cancer of the cervix in women, one death among current smokers and

one death among never-smokers, respectively, and cancer of the urinary

bladder, three and two deaths among male current smokers and neversmokers, respectively, and zero and four deaths among female current

smokers and never-smokers, respectively).

Among women (Table 9) and men (Table 10) statistically significant

elevations of relative risk in the current smokers were found for all causes of

death combined, all neoplasms combined, cancer of the lung, all circulatory

diseases combined, coronary (ischemic) heart disease, "other" heart and

circulatory disease, all diseases of the respiratory system combined, COPD,

and other (nonmotor vehicle) accidents.

Other statistically significant elevations were found for cancer of the

pancreas and cirrhosis of the liver in women and for cancer of the stomach

and all diseases of the digestive system combined in men.

COMMENT These data generally confirm the association of cigarette smoking with

elevated risks of mortality from all causes combined, lung cancer, COPD,

and CHD. This study cohort provided relatively short followup; the maximum

was 81/2 years after completion of the questionnaire.

Racial diversity is an important feature of this cohort, but the relatively

few decedents in the Asian and other or unknown race subgroups made

their findings uncertain. Although they often differed from blacks and

whites in the direction of lower risks associated with cigarette smoking, the

confidence intervals for these findings were usually wide and overlapped the

risk estimates for blacks and whites. Blacks were fairly similar to whites in

their risk estimates for the major causes of death studied, except that black

men and white women did not show the elevated risks for CHD and stroke,

respectively, that were present in white men and black women.

Although there were some inconsistencies in the data, risk of total

mortality and mortality from some of the major causes studied generally

increased with both amount and duration of smoking. An inverse relationship

of risk with duration of quitting was often but not consistently seen.

Findings for other specific causes of death in relation to cigarette smoking

were often inconclusive due to small numbers. Thus, considerably more

followup time is needed before this study cohort can provide substantial
Smoking and Tobacco Control Monograph No. 8

494

Table 9

Age-adjusted relative risks of death due to other selected causes in current smokers as

compared with never-smokers—women

Relative Risk

Cause of Death Current Never (95-percent CI)

All Causes 308 625 1.9 (1.7 - 2.2)

Infectious and Parasitic Diseases (ICD-9-CM 001-139) 0 11 0

Neoplasms (ICD-9-CM 140-239) 133 192 2.3 (1.9 - 2.9)

Cancer: Esophagus (ICD-9-CM 150) 1 2 3.7 (0.3 - 41.1)

Cancer: Stomach (ICD-9-CM 151) 3 14 0.8 (0.2 - 2.8)

Cancer: Colon (ICD-9-CM 153) 7 28 0.9 (0.4 - 2.1)

Cancer: Liver and biliary tract (ICD-9-CM 155-156) 5 4 3.5 (0.9 - 13.6)

Cancer: Pancreas (ICD-9-CM 157) 12 11 3.9 (1.7 - 9.3)

Cancer: Trachea, bronchus, lung (ICD-9-CM 162) 54 11 15.1 (7.7 - 29.7)

Cancer: Breast (ICD-9-CM 174-175) 15 35 1.2 (0.6 - 2.2)

Cancer: Corpus uteri (ICD-9-CM 182) 3 11 1.1 (0.3 - 4.2)

Cancer: Ovary (ICD-9-CM 183-183.0) 7 11 2.2 (0.8 - 5.9)

Cancer: Kidney (ICD-9-CM 189-189.1) 1 4 0.8 (0.1 - 7.5)

Cancer: Brain tumors (ICD-9-CM 191-192) 1 2 1.1 (0.1 - 11.9)

Cancer: Leukemias (ICD-9-CM 204-208) 2 5 1.3 (0.2 - 6.9)

Cancer: Other hematopoietic/lymphatic (ICD-9-CM 202-203) 2 5 1.7 (0.3 - 8.9)

Endocrine, Nutritional, and Metabolic Diseases and

Immunity Disorders (ICD-9-CM 240-279) 4 16 0.9 (0.3 - 2.8)

Diabetes (ICD-9-CM 250) 3 14 0.7 (0.2 - 2.6)

Diseases of Blood and Blood-Forming Organs

(ICD-9-CM 280-289) 3 4 2.8 (0.6 - 13.9)

Mental Disorders (ICD-9-CM 290-319) 1 4 1.5 (0.1 - 14.4)

Diseases of the Nervous System (ICD-9-CM 320-389) 4 11 1.6 (0.5 - 5.3)

Diseases of the Circulatory System (ICD-9-CM 390-459) 109 283 1.7 (1.4 - 2.2)

Ischemic heart disease (ICD-9-CM 410-414) 50 134 1.7 (1.2 - 2.4)

Hypertensive heart disease (ICD-9-CM 402, 404) 5 10 2.2 (0.7 - 6.5)

Cerebrovascular disease (ICD-9-CM 430-438) 20 65 1.3 (0.8 - 2.2)

Other heart and circulatory disease (ICD-9-CM 390-459) 33 68 2.1 (1.4 - 3.2)

Diseases of the Respiratory System (ICD-9-CM 460-519) 18 31 2.7 (1.5 - 4.9)

Asthma (ICD-9-CM 493) 2 6 1.5 (0.3 - 7.8)

Pneumonia (ICD-9-CM 480-486) 3 12 1.3 (0.4 - 4.7)

COPD, including chronic bronchitis (ICD-9-CM 491),

 emphysema (ICD-9-CM 492), and other chronic airway

 obstruction (ICD-9-CM 496) 10 6 9.0 (3.0 - 26.6)

Other respiratory disease (ICD-9-CM 460-519) 3 7 1.6 (0.4 - 6.3)

Diseases of the Digestive System (ICD-9-CM 520-579) 11 22 1.9 (0.9 - 3.9)

Cirrhosis of the liver (ICD-9-CM 571) 7 7 2.9 (1.0 - 8.4)

Diseases of the Genitourinary System (ICD-9-CM 580-629) 2 9 1.3 (0.3 - 6.6)

Complications of Pregnancy, Childbirth, and the

Puerperium (ICD-9-CM 630-676) 0 0 a

Diseases of Skin and Subcutaneous Tissue (ICD-9-CM 680-709) 0 1 0
495

Chapter 6

Table 9 (continued)

Relative Risk

Cause of Death Current Never (95-percent CI)

Diseases of the Musculoskeletal System and Connective

Tissue (ICD-9-CM 710-739) 1 3 2.9 (0.3 - 27.5)

Congenital Anomalies (ICD-9-CM 740-759) 1 1 2.2 (0.1 - 36.1)

Certain Conditions Originating in the Perinatal Period

(ICD-9-CM 760-779) 0 0 a

Symptoms, Signs, and Ill-Defined Conditions

(ICD-9-CM 780-799) 2 2 3.3 (0.4 - 26.3)

Injury and Poisoning (ICD-9-CM 800-999) 19 35 1.6 (0.9 - 2.9)

Motor Vehicle Accidents (ICD-9-CM 810-825, 929-929.0) 3 6 1.3 (0.3 - 5.6)

Other Accidents (ICD-9-CM 800-807, 826-828, 829.1-949) 10 14 2.5 (1.1 - 5.8)

Suicide (ICD-9-CM 950-959) 4 8 1.3 (0.4 - 4.4)

Homicide (ICD-9-CM 960-969) 1 6 0.5 (0.1 - 4.1)

a Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: CI = confidence interval; ICD-9-CM = International Classification of Diseases: 9th Revision. Clinical Modification

(U.S. Department of Health and Human Services, 1991); COPD = chronic obstructive pulmonary disease.

Table 10

Age-adjusted relative risks of death due to other selected causes in current smokers as

compared with never-smokers—men

Relative Risk

Cause of Death Current Never (95-percent CI)

All Causes 308 625 1.9 (1.7 - 2.2)

Infectious and Parasitic Diseases (ICD-9-CM 001-139) 10 18 0.9 (0.4 - 2.0)

Neoplasms (ICD-9-CM 140-239) 135 135 2.3 (1.8 - 2.9)

Cancer: Esophagus (ICD-9-CM 150) 4 3 3.3 (0.7 - 15.8)

Cancer: Stomach (ICD-9-CM 151) 12 11 2.4 (1.0 - 5.5)

Cancer: Colon (ICD-9-CM 153) 5 20 0.5 (0.2 - 1.4)

Cancer: Liver and biliary tract (ICD-9-CM 155-156) 3 6 0.9 (0.2 - 3.8)

Cancer: Pancreas (ICD-9-CM 157) 8 10 2.1 (0.8 - 5.6)

Cancer: Trachea, bronchus, lung (ICD-9-CM 162) 53 14 8.1 (4.4 - 15.0)

Cancer: Prostate (ICD-9-CM 185) 10 19 1.6 (0.7 - 3.6)

Cancer: Kidney (ICD-9-CM 189-189.1) 2 4 1.6 (0.3 - 8.8)

Cancer: Brain tumors (ICD-9-CM 191-192) 3 5 1.1 (0.3 - 4.7)

Cancer: Leukemias (ICD-9-CM 204-208) 5 7 1.7 (0.5 - 5.5)

Cancer: Other hematopoietic/lymphatic (ICD-9-CM 202-203) 2 10 0.5 (0.1 - 2.4)

Endocrine, Nutritional, and Metabolic Diseases and

Immunity Disorders (ICD-9-CM 240-279) 8 10 1.5 (0.6 - 3.9)

Diabetes (ICD-9-CM 250) 1 7 0.3 (0.0 - 2.7)

Diseases of Blood and Blood-Forming Organs

(ICD-9-CM 280-289) 1 1 2.8 (0.2 - 46.2)

Mental Disorders (ICD-9-CM 290-319) 5 4 2.3 (0.6 - 8.8)

Diseases of the Nervous System (ICD-9-CM 320-389) 3 10 0.8 (0.2 - 3.1)
Smoking and Tobacco Control Monograph No. 8

496

Table 10 (continued)

Relative Risk

Cause of Death Current Never (95-percent CI)

Diseases of the Circulatory System (ICD-9-CM 390-459) 162 237 1.7 (1.3 - 2.0)

Ischemic heart disease (ICD-9-CM 410-414) 109 152 1.7 (1.3 - 2.2)

Hypertensive heart disease (ICD-9-CM 402, 404) 9 8 2.6 (1.0 - 6.9)

Cerebrovascular disease (ICD-9-CM 430-438) 11 35 0.8 (0.4 - 1.7)

Other heart and circulatory disease (ICD-9-CM 390-459) 32 38 2.0 (1.2 - 3.2)

Diseases of the Respiratory System (ICD-9-CM 460-519) 36 33 2.9 (1.8 - 4.7)

Asthma (ICD-9-CM 493) 1 1 2.0 (0.1 - 33.1)

Pneumonia (ICD-9-CM 480-486) 12 19 1.9 (0.9 - 3.9)

COPD, including chronic bronchitis (ICD-9-CM 491),

 emphysema (ICD-9-CM 492), and other chronic airway

 obstruction (ICD-9-CM 496) 18 4 10.0 (3.3 - 30.9)

Other respiratory disease (ICD-9-CM 460-519) 5 9 1.5 (0.5 - 4.4)

Diseases of the Digestive System (ICD-9-CM 520-579) 17 18 2.1 (1.1 - 4.2)

Cirrhosis of the liver (ICD-9-CM 571) 10 10 1.7 (0.7 - 4.1)

Diseases of the Genitourinary System (ICD-9-CM 580-629) 0 2 0

Diseases of Skin and Subcutaneous Tissue (ICD-9-CM 680-709) 0 2 0

Diseases of the Musculoskeletal System and Connective

Tissue (ICD-9-CM 710-739) 0 1 0

Congenital Anomalies (ICD-9-CM 740-759) 0 0 a

Certain Conditions Originating in the Perinatal Period

 (ICD-9-CM 760-779) 0 0 a

Symptoms, Signs, and Ill-Defined Conditions

(ICD-9-CM 780-799) 1 1 2.0 (0.1 - 33.1)

Injury and Poisoning (ICD-9-CM 800-999) 33 38 1.6 (1.0 - 2.5)

Motor vehicle accidents (ICD-9-CM 810-825, 929-929.0) 4 9 0.8 (0.3 - 2.8)

Other accidents (ICD-9-CM 800-807, 826-828, 829.1-949) 16 9 3.3 (1.4 - 7.6)

Suicide (ICD-9-CM 950-959) 7 13 1.0 (0.4 - 2.5)

Homicide (ICD-9-CM 960-969) 6 6 1.5 (0.5 - 4.8)

a Indicates indeterminate relative risk due to absence of deaths among never-smokers.

Key: CI = confidence interval; ICD-9-CM = International Classification of Diseases: 9th Revision. Clinical Modification

(U.S. Department of Health and Human Services, 1991); COPD = chronic obstructive pulmonary disease.

information about these less frequent causes of mortality and about racial

differences.

REFERENCES

Arellano, M.G., Petersen, G.R., Petitti, D.B., Smith, R.E.

The California Automated Mortality Linkage System

(CAMLIS). American Journal of Public Health 74:

1324-1330, 1984.

Breslow, N.E., Day, N.E. (Editors). Statistical Methods

in Cancer Research, Volume II. The Design and Analysis

of Cohort Studies. IARC Scientific Publications.

No. 82. Oxford: Oxford University Press, 1988.

Collen, M.F., Davis, L.F. The multitest laboratory in

health care. Journal of Occupational Medicine

11: 355-360, 1969.

Friedman, G.D., Dales, L.G., Ury, H.K. Mortality

in middle-aged smokers and nonsmokers. New

England Journal of Medicine 300: 213-217, 1979.

Hiatt, R.A., Friedman, G.D. The frequency of kidney

and urinary tract diseases in a defined population.

Kidney International 22: 63-68, 1982.

Krieger, N. Overcoming the absence of socioeconomic

data in medical records: Validation and application

of a census-based methodology. American Journal of

Public Health 82: 703-710, 1992.
497

Chapter 6

Sidney, S., Friedman, G.D., Siegelaub, A.B. Thinness

and Mortality. American Journal of Public Health

77: 317-322, 1987.

Stampfer, M.J., Willett, W.C., Speizer, F.E., Dysert, D.C.,

Lipnick, R., Rosner, B., Hennekens, C.H. Test of the

National Death Index. American Journal of

Epidemiology 119: 837-839, 1984.

U.S. Department of Health and Human Services.

International Classification of Diseases: 9th Revision.

Clinical Modification. Volume 1, 4th Edition. DHHS

Publication No. (PHS) 91-1260. Rockville, MD: U.S.

Department of Health and Human Services, Public

Health Service, Health Care Financing

Administration, 1991.

ACKNOWLEDGMENTS This study was initially funded by contract EC1-SHP-77-132

from Enviro Control, Inc. It was then supported by contract NCI-N1-CP15681, grant R01 CA 36074, and currently by grant R35 CA 49761, all from

the National Cancer Institute (NCI). Additional support for these analyses

was provided by the Smoking and Tobacco Control Program within NCI.

Dr. Diana Petitti formerly served as project director and contributed

importantly to the progress of this investigation.
Smoking and Tobacco Control Monograph No. 8

498
499

Chapter 6

Appendix A

Portions of the Smoking Habit Questionnaire Used in This Study
Smoking and Tobacco Control Monograph No. 8

500
501

Chapter 7

Former Cigarette Smoking and Mortality

Among U.S. Veterans: A 26-Year Followup,

1954 to 1980

Zdenek Hrubec and Joseph K. McLaughlin

INTRODUCTION This chapter presents a detailed analysis of data from the most

recent mortality followup of almost 300,000 U.S. veterans whose tobacco use

was surveyed by questionnaire in the 1950's. The study, commonly referred

to as the Dorn study, was initiated by Harold Dorn in an effort to help resolve

the then ongoing controversy regarding the role of smoking in the etiology

of lung cancer. Together with six other large cohort studies (Doll and Hill,

1956; Hammond and Horn, 1958; Dunn et al., 1960 and 1963; Best et al.,

1961; Hammond, 1963) and several case-control studies, the early results

of this investigation (Dorn, 1958 and 1959) provided the basis for the first

of a series of reports by the U.S. Surgeon General on the health effects of

smoking, which identified lung cancer and a number of other causes of death

as smoking related (U.S. Department of Health, Education, and Welfare, 1964).

Subsequent followup of subjects in these investigations, including this study

of veterans, has contributed to achieving a consensus on the harmful health

effects of smoking and the benefits of cessation.

Although an important contribution at the time, Dorn's analyses of

mortality in this cohort covered a short followup time and included few

deaths. Mortality was evaluated for several major cause-of-death groups, but

the main focus was on all deaths and on lung cancer (Dorn, 1958 and 1959).

A definitive examination of a broad range of death causes, carried out by Kahn

(1966), was based on a followup of 8.5 years through December 1962 and

covered 46,270 deaths and 2,626,000 person-years, including nonrespondents.

A subsequent comprehensive review extended followup to 16 years, through

1969 (Rogot, 1974; Rogot and Murray, 1980). It covered 107,563 deaths and

3,500,000 person-years. This chapter evaluates deaths by cause over 26 years

through September 30, 1980. By that time, 198,172 of the subjects were

deceased, and 5,429,000 person-years had accumulated in the entire cohort.

The study covers a longer period of mortality monitoring and a greater

number of person-years of observation than any single investigation of

the long-term effects of exposure to tobacco.

Smoking status in this study was assessed from replies to the original

questionnaire, and no information is available on subsequent changes in

smoking. During the long mortality followup of these subjects, there was

a considerable decline in smoking among men in the United States, which

undoubtedly also occurred in this cohort. Therefore, the results presented

here are restricted to those who reported never having smoked regularly or
Smoking and Tobacco Control Monograph No. 8

502

having quit smoking cigarettes at the time of the study. Although some

who reported quitting smoking later may have resumed it, few of the neversmokers in this group of mature men are likely to have started smoking

following the questionnaire. The long followup period permits assessment

of smoking-related mortality over the entire range of middle and older ages.

Analyses by calendar period and by duration of cessation evaluate the

persistence of the smoking-related excess mortality. This study work was

designed to make the data in this chapter as comparable as possible with

previous reports on the veterans' study and also with the other chapters

in this volume.

METHODS The methods used have been described in detail (Dorn, 1958; Kahn, 1966;

Rogot, 1974 and 1978; Rogot and Murray, 1980; Rogot and Hrubec, 1989a

and 1989b). Study subjects were identified in 1953 as holders of active

Government life insurance policies administered by the Veterans

Administration (VA) and as veterans who had served in the U.S. Armed

Forces at some time from 1917 through 1940. A questionnaire, mailed

to these subjects early in 1954, inquired primarily about tobacco use,

occupation, and industry of employment. The first mailing produced

a 68-percent response rate, and a remailing to nonrespondents in 1957

resulted in a final response rate of 84 percent. Almost all the subjects

were white, and less than 0.5 percent were females (Kahn, 1966).

In the 1962 and 1969 followups, mortality was ascertained by means

of life insurance claims to the VA. In the most recent followup, through

September 30, 1980, the entire sample was processed through the VA's

Beneficiary Identification and Records Locator Subsystem (BIRLS). BIRLS

records deaths of veterans even when they have allowed their policies to

lapse and has been shown to be 96-percent complete for World War I

veterans with more than 15 days of service who are thus eligible for life

insurance (Beebe and Simon, 1969). This high level of completeness

was confirmed independently of the VA's record systems by matching a

systematic sample of 1,000 study subjects against the death tapes of the

Social Security Administration. Causes of death were coded by nosologists

trained in the Manual of the International Statistical Classification of

Diseases, Injuries, and Causes of Death (ICD-7) (World Health Organization,

1957) to maintain consistency with the original coding. An underlying

cause of death is coded for 95 percent of the deaths.

This analysis is based primarily on the 95,783 never-regular and

former-regular cigarette smokers, as determined from either the 1954 or

1957 questionnaire. This group generated 60,549 deaths and 1,807,479

person-years of followup. Causes of death also have been obtained for

nonrespondents and for those who at time of the questionnaire smoked

cigarettes or used other forms of tobacco, but these data are not examined

here. To achieve maximum comparability with the previous reports (Kahn,

1966; Rogot and Murray, 1980; Rogot and Hrubec, 1989a and 1989b) and

with available analytic software (Monson, 1974), 50 death causes or causeof-death groups have been constructed (see Appendix A at the end of this

chapter).
503

Chapter 7

Never-smokers are those who reported never regularly smoking cigarettes,

cigars, or pipes (n = 55,049). Regular smoking is considered lifetime

consumption (at time of questionnaire) of more than 5 to 10 packs of

cigarettes, 50 to 75 cigars, or 3 to 5 packages of pipe tobacco if this

consumption involved, respectively, smoking daily at least one cigarette,

cigar, or pipeful of tobacco. Former cigarette smokers smoked cigarettes

regularly at any time in the past but did not regularly smoke cigarettes,

cigars, or pipes (n = 40,734) at time of questionnaire.

It would be useful to exclude from the former smoker group subjects

who stopped smoking shortly prior to the questionnaire, because some of

them may have later resumed smoking. The available data identify those

who stopped smoking in the 5 years prior to the questionnaire, but these

subjects cannot be subdivided into more detailed categories of time since

smoking stopped. Excluding the 39 percent who stopped within 5 years of

the questionnaire did not appreciably affect findings for all former smokers.

The entire group was examined explicitly by years since smoking stopped

for total deaths and for the major smoking-related death causes. Other

variables employed in the analysis were the highest number of cigarettes

formerly smoked per day (none, 1 to 9, 10 to 20, 21 to 39, 40+), age at which

subject started smoking cigarettes (<15, 15 to 19, 20 to 24, 25+), calendar year

interval of followup (1954 to 1959, 1960 to 1964, 1965 to 1969, 1970 to 1974,

1975 to 1980), and age attained at followup (in 5-year age groups from 30 to

34 to 100 to 104 and 105+).

The data were evaluated by means of internally standardized relative

risks (RR’s), standardized mortality ratios (SMR’s), and standardized annual

mortality rates. In these analyses, person-years were accumulated from the

year of questionnaire response, January 1, 1954, or 1957, to the date of

death or to September 30, 1980, for those then alive. The 181 subjects

with unknown year of death were retained until the cutoff date.

The RR’s were computed by fitting Poisson regression models with

maximum likelihood methods using the above-described variable groupings

(Breslow and Day, 1988). The RR’s for former smokers were obtained with

respect to the never-smokers (RR = 1.0). Score tests of significance of trends

were carried out (Preston et al., 1990). The RR analyses were adjusted for

attained age in 5-year groups and for the calendar-year periods given above.

Time-specific RR’s are based on never-smoker mortality in the corresponding

period. The procedures are described in detail in the footnotes following the

tables.

The SMR’s were obtained through a modification of the program by

Monson (1974), who developed expected numbers of deaths for a number

of causes or cause-of-death groupings by applying U.S. white male mortality

rates for 5-year age and calendar-year groups. Because these external rates

were based on different revisions of the ICD codes in effect during the period

of followup, acceptable consistency over time could be established only for a

limited number of cause-of-death groups. The correspondence between the

definitions of groups in the RR and SMR analyses is shown in Appendix A.
Smoking and Tobacco Control Monograph No. 8

504

The SMR’s also could not be obtained for some of the cause groups used

in the Kahn (1966) and Rogot and Murray (1980) analyses or for other

groups of particular interest. In some cases, SMR groupings correspond

only approximately. When SMR’s could not be obtained, only the internally

standardized RR’s are presented, which compare well with the methods used

by Rogot and Murray (1980) and Kahn (1966). The definitions of the groups

used in the earlier sources also are given in Appendix A.

The rates were standardized directly to the age distribution of the 1980

total U.S. population older than age 30. Within the same calendar periods

used for standardizing the RR’s, in each 10-year group of attained age, the

number of deaths was divided by the corresponding person-years and then

multiplied by the proportion of the U.S. population older than 30 years in

that age group during that time. The standardized rate is the sum of these

computations over the age and calendar-time groups.

RESULTS In the entire cohort (n = 293,916), including nonrespondents, mortality

from all causes was low; the overall SMR was 77. Among all questionnaire

All Deaths respondents (n = 248,046), the SMR was 73; among never-smokers, 58;

and among former smokers, 70. Compared with the risk of death of neversmokers, the risk of death from all causes was elevated for former cigarette

smokers (RR = 1.2). Mortality was highest for those starting smoking younger

than age 15, but even those who started at age 25 years or older were at

excess risk (Table 1). The RRs were 1.3 from 1954 through 1964, 1.2 from

1965 through 1969, and 1.1 subsequently (Table 2). The SMR’s were 70

in all periods, except 1970 through 1974, when the value was 69, but the

standardized rates declined over time. Among never-smokers, with the 1954

to 1964 period as the baseline, the RR’s for the 4 periods were, respectively,

1.0, 1.0, 0.9, and 0.8 (linear trend, p < 0.001). The RR’s increased with

amount of former smoking (p < 0.001, Table 3). Former cigarette smokers did

not experience an appreciably reduced risk until 5 or more years following

cessation. The RR for all those who stopped 40 or more years ago was 1.0

and appreciably increased only for those who had smoked 40+ cigarettes per

day (RR = 1.2, 95-percent lower confidence limit = 1.01) (see Table 3).

Lung Cancer The RR for lung cancer for former cigarette smokers of all ages was 3.6

(Table 1). Mortality was elevated among those who started smoking before

age 15 and decreased regularly with later starting ages (Table 1). The RR

varied unevenly in intervals of the 1954 to 1974 period but dropped to 2.8 in

the 1975 to 1980 period with a significant linear trend (Table 2). The SMR

was 54 during the 1954 to 1964 period but subsequently declined to 40. The

RR’s of never-smokers for lung cancer, with the 1954 to 1964 period as the

baseline (RR = 1.0), were elevated in the subsequent periods, but there was no

linear trend (RR = 1.4, 1.1, and 1.3, respectively). The RR was 6.9 for those

smoking 40+ cigarettes per day (Table 4). During the first 5 years following

stopping smoking, the risk of former cigarette smokers was high (RR = 16.1),

but as cessation continued, it declined steeply. After 40 years of stopping

smoking and among those who had smoked fewer than 10 cigarettes per day,

the risk approximated that of never-smokers.
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Chapter 7

Table 1

U.S. veterans, former cigarette smokers:a relative risks based on never-smokers (RR = 1.0),b

lower and upper 95-percent confidence limits on RR, standardized mortality ratio,c agestandardized rates per 100,000 person-years,d

 and number of deaths by causee and age

started cigarettes

Age All Lung Coronary Heart Chronic Obstructive

Started Deaths Cancer Disease Pulmonary Disease

Total– RR 1.2 3.6 1.2 4.1

 all agesf LL 1.2 3.2 1.2 3.6

UL 1.2 4.1 1.2 4.8

SMR 70 45 68 –

Rate 1,574 38 582 34

Deaths 26,722 781 10,369 650

<15 RR 1.3 5.2 1.3 6.7

LL 1.3 4.1 1.2 5.2

UL 1.4 6.6 1.4 8.6

SMR 77 64 72 –

Rate 1,791 52 612 45

Deaths 2,377 91 884 82

15-19 RR 1.2 4.4 1.2 4.7

LL 1.2 3.8 1.2 4.0

UL 1.3 5.1 1.3 5.6

SMR 72 54 69 –

Rate 1,585 47 568 35

Deaths 10,998 388 4,258 295

20-24 RR 1.2 3.2 1.2 3.8

LL 1.1 2.7 1.1 3.1

UL 1.2 3.8 1.2 4.6

SMR 68 39 67 –

Rate 1,487 36 577 29

Deaths 7,978 213 3,142 181

25+ RR 1.1 2.0 1.1 2.6

LL 1.1 1.6 1.1 2.1

UL 1.2 2.6 1.2 3.4

SMR 66 27 64 –

Rate 1,538 20 531 23

Deaths 5,179 86 2,008 88

p of trendg <0.001 <0.001 <0.001 <0.001

a No cigar or pipe at time of questionnaire, but includes former cigar or pipe.

b Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

c 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and

calendar-time-specific mortality rates by the corresponding person-years and summing appropriately.

d Standardized to the age distribution of the total U.S. 1980 population within 5-year calendar periods.

e For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to the Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957). f Includes unknown age started smoking cigarettes.

g Score test for linear trend, excluding unknown age started, the other age–started groups coded 12.5, 17.5, 22.5,

and 33.5, adjusted for attained age and calendar time.

Key: RR = relative risk; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit;

SMR = standardized mortality ratio.
Smoking and Tobacco Control Monograph No. 8

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Table 2

U.S. veterans, former cigarette smokers:a

 relative risks based on never-smokers (RR = 1.0),b

lower and upper 95-percent confidence limits on RR, standardized mortality ratio,c age–

standardized rates per 100,000 person-years,d and number of deaths by causee and year of

followup

Age All Lung Coronary Heart Chronic Obstructive

Started Deaths Cancer Disease Pulmonary Disease

1954-1964 RR 1.3 4.8 1.3 8.3

LL 1.3 3.8 1.3 6.0

UL 1.4 6.0 1.4 11.4

SMR 70 54 77 –

Rate 1,688 46 704 36

Deaths 8,587 318 3,709 247

1965-1969 RR 1.2 3.0 1.1 4.3

LL 1.2 2.3 1.1 3.1

UL 1.2 3.9 1.2 6.0

SMR 70 43 68 –

Rate 1,662 39 608 38

Deaths 5,636 165 2,200 128

1970-1974 RR 1.1 3.6 1.1 3.0

LL 1.1 2.6 1.0 2.2

UL 1.2 4.8 1.2 4.0

SMR 69 38 61 –

Rate 1,440 35 508 34

Deaths 5,982 147 2,212 125

1975-1980f RR 1.1 2.8 1.1 2.7

LL 1.1 2.1 1.1 2.1

UL 1.2 3.6 1.2 3.5

SMR 70 40 62 –

Rate 1,337 35 454 26

Deaths 6,517 151 2,248 150

p of trendg <0.001 0.004 <0.001 <0.001

a No cigar or pipe at time of questionnaire but includes former cigar or pipe.

b Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

c 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and calendar-timespecific mortality rates by the corresponding person-years and summing appropriately.

d Standardized to the age distribution of the total U.S. 1980 population.

e For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to the Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957). f Includes unknown duration of followup.

g Score test for linear trend, followup interval groups coded 1960, 1967, 1972, and 1977, adjusted for attained age and

amount smoked.

Key: RR = relative risk; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit;

SMR = standardized mortality ratio.
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Chapter 7

Table 3

U.S. veterans: relative risks based on never-smokers (RR = 1.0),a lower and upper 95-percent

confidence limits on RR, standardized mortality ratio,b

 age-standardized rates per 100,000

person-years,c and number of deaths from all causesd among never-smokers and former

cigarette smokerse

 by duration of nonsmoking

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup All Deaths

Totalf RR 1.0 1.0 1.2 1.3 1.5 1.2

LL – 1.0 1.2 1.3 1.4 1.2

UL – 1.1 1.2 1.4 1.5 1.2

SMR 58 61 68 75 84 70

Rate 1,429 1,450 1,545 1,661 1,932 1,574

Deaths 33,827 5,014 12,103 6,953 2,652 26,722

<5 RR – 1.5 1.8 1.9 2.2 1.8

LL – 1.2 1.6 1.7 1.8 1.7

UL – 2.0 2.0 2.2 2.7 2.0

SMR – 75 88 93 106 90

Rate – 649 882 896 998 879

Deaths – 59 287 200 87 633

5-9 RR – 1.3 1.4 1.8 1.7 1.5

LL – 1.1 1.3 1.6 1.5 1.5

UL – 1.5 1.5 1.9 1.9 1.6

SMR – 67 71 90 86 78

Rate – 927 1,128 1,320 1,263 1,181

Deaths – 178 733 592 213 1,716

10-19 RR – 1.2 1.3 1.5 1.6 1.4

LL – 1.1 1.3 1.4 1.5 1.3

UL – 1.2 1.4 1.6 1.8 1.4

SMR – 64 72 82 90 76

Rate – 1,394 1,481 1,602 1,946 1,539

Deaths – 757 2,974 2,020 813 6,564

20-29 RR – 1.1 1.1 1.3 1.4 1.2

LL – 1.0 1.1 1.2 1.3 1.2

UL – 1.1 1.2 1.3 1.5 1.2

SMR – 63 67 75 84 70

Rate – 1,459 1,533 1,536 1,847 1,525

Deaths – 1,058 3,598 2,287 892 7,835

30-39 RR – 1.0 1.1 1.1 1.2 1.1

LL – 0.9 1.0 1.0 1.1 1.0

UL – 1.1 1.1 1.2 1.4 1.1

SMR – 58 64 65 74 63

Rate – 1,421 2,093 1,504 1,600 1,964

Deaths – 1,004 2,226 1,049 395 4,674
Smoking and Tobacco Control Monograph No. 8

508

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup All Deaths

40+ RR – 1.0 1.1 1.0 1.2 1.0

LL – 1.0 1.0 1.0 1.0 1.0

UL – 1.1 1.1 1.1 1.3 1.1

SMR – 63 65 64 71 64

Rate – 1,663 1,461 1,376 1,634 1,483

Deaths – 1,303 1,755 656 226 3,940

p of trendg – 0.001 <0.001 <0.001 <0.001 <0.001

a Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

b 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and calendar-timespecific mortality rates by the corresponding person-years and summing appropriately.

c Standardized to the age distribution of the total U.S. 1980 population within 5-year calendar periods.

d For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to the Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957). e No cigar or pipe at time of questionnaire but includes former cigar or pipe.

f Includes unknown years since smoked.

g Score test for linear trend, excluding unknown years; the years-since-smoked groups coded 2.5, 7.5, 15.0, 25.0, 35.0,

and 45.0, adjusted for attained age and calendar time.

Key: RR = relative risk; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit;

SMR = standardized mortality ratio.

Coronary Heart Disease The RR’s of former cigarette smokers for coronary heart

disease were similar to the RR’s for all deaths (RR = 1.2, Table 1). The RR was

slightly higher for those who started smoking younger than age 15 and was

lower for those who started at age 25 or older (p < 0.001). The RR was 1.3 in

the 1954 to 1964 period and thereafter decreased to 1.1 (Table 2). The SMR

was 77 during the 1954 to 1964 period but after 1970 stabilized at just more

than 60. Among never-smokers, with the RR during the 1954 to 1964 period

set to 1.0, the RR’s in the subsequent periods were, respectively, 1.0, 0.9, and

0.8 (linear trend, p < 0.001). Mortality increased with the amount formerly

smoked (p < 0.001, Table 5). The RR’s were not clearly reduced until

20 or more years after stopping smoking. After 30 or more years, the

mortality of former smokers was comparable with that of never-smokers

and was not appreciably affected by the amount they had smoked.

Chronic Obstructive The RR for chronic obstructive pulmonary disease of former

Pulmonary Disease cigarette smokers was high (RR = 4.1), with those starting at

younger ages having greater risks (Table 1). An RR of 8.3 in the 1954 to

1964 period declined progressively over time to 2.7 from 1975 through

1980 (Table 2). The standardized rate appreciably exceeded 30 per

Table 3 (continued)
509

Chapter 7

Table 4

U.S. veterans: relative risks based on never-smokers (RR = 1.0),a lower and upper 95-percent

confidence limits on RR, standardized mortality ratio,b

 age-standardized rates per 100,000

person-years,c and number of deaths from lung cancerd among never-smokers and former

cigarette smokerse

 by duration of nonsmoking

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup Lung Cancer

Totalf RR 1.0 1.4 3.3 5.0 6.9 3.6

LL – 1.0 2.8 4.2 5.6 3.2

UL – 1.8 3.9 5.9 8.5 4.1

SMR 13 18 41 60 84 45

Rate 21 15 36 54 65 38

Deaths 325 62 332 262 125 781

<5 RR – 7.6 12.5 20.6 26.9 16.1

LL – 2.3 7.1 11.9 13.6 10.4

UL – 24.9 21.7 35.6 53.4 24.8

SMR – 78 125 205 270 162

Rate – 36 61 91 112 73

Deaths – 3 20 22 11 56

5-9 RR – 3.6 5.1 11.5 13.6 7.8

LL – 1.5 3.3 7.8 8.0 5.7

UL – 9.0 8.0 17.0 22.9 10.5

SMR – 38 52 111 132 77

Rate – 33 36 90 134 65

Deaths – 5 27 38 17 87

10-19 RR – 2.2 4.3 6.8 7.8 5.1

LL – 1.3 3.4 5.4 5.6 4.2

UL – 3.6 5.4 8.7 10.9 6.1

SMR – 27 51 79 92 61

Rate – 40 39 78 58 51

Deaths – 15 104 100 42 261

20-29 RR – 1.7 3.3 3.4 5.9 3.3

LL – 1.0 2.6 2.6 4.2 2.8

UL – 2.8 4.1 4.5 8.3 4.0

SMR – 22 42 42 74 42

Rate – 11 35 34 39 31

Deaths – 16 102 61 36 215

30-39 RR – 0.5 2.1 2.8 4.5 2.0

LL – 0.2 1.5 1.9 2.6 1.6

UL – 1.3 2.9 4.3 7.9 2.6

SMR – 7 26 36 58 26

Rate – 5 22 26 50 21

Deaths – 5 39 25 13 82
Smoking and Tobacco Control Monograph No. 8

510

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup Lung Cancer

40+ RR – 1.1 1.6 1.8 2.3 1.5

LL – 0.6 1.0 0.9 0.9 1.1

UL – 1.9 2.4 3.3 6.2 2.0

SMR – 15 22 24 32 20

Rate – 11 15 13 9 13

Deaths – 12 23 10 4 49

p of trendg – <0.001 <0.001 <0.001 <0.001 <0.001

a Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

b 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and calendar-timespecific mortality rates by the corresponding person-years and summing appropriately.

c Standardized to the age distribution of the total U.S. 1980 population within 5-year calendar periods.

d For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to the Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957). e No cigar or pipe at time of questionnaire but includes former cigar or pipe.

f Includes unknown years since smoked.

g Score test for linear trend, excluding unknown years, the years-since-smoked groups coded 2.5, 7.5, 15.0, 25.0, 35.0,

and 45.0, adjusted for attained age and calendar time.

Key: RR = relative risk; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit;

SMR = standardized mortality ratio.

Table 4 (continued)

100,000 person-years from 1954 through 1974 but finally declined to 26 per

100,000. When the 1954 to 1964 period was taken as the baseline (RR = 1.0),

the RR’s of never-smokers in the subsequent periods were 1.2, 1.2, and 1.1,

respectively, with no significant linear trend. Mortality was highest among

those who had smoked 40+ cigarettes per day (RR = 6.7, Table 6). The RR’s

were much elevated during the first 10 years following cessation, and

although appreciably lower after 20 years, they remained well in excess

of 1.0. The pattern of decreased risk with longer cessation was consistent

within groups based on amount of former smoking, except among those

smoking fewer than 10 cigarettes per day.

Other Causes Statistically significant (p < 0.05) positive excess risks with former

of Death cigarette smoking were found for 27 of the 50 cause-of-death groups

examined (Table 7). The cause-of-death groups for which there was no

significantly deviant risk with former cigarette smoking are listed below

with their RR estimates in parentheses. When the rounded values of the

95-percent confidence limits in Table 7 are ambiguous, more precise

estimates of the confidence intervals are included with the RR’s:
511

Chapter 7

Table 5

U.S. veterans: relative risks based on never-smokers (RR = 1.0),a lower and upper 95-percent

confidence limits on RR, standardized mortality ratio,b

 age-standardized rates per 100,000

person-years,c and number of deaths from coronary heart diseased among never-smokers and

former cigarette smokerse

 by duration of nonsmoking

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup Coronary Heart Disease

Totalf RR 1.0 1.1 1.2 1.3 1.4 1.2

LL – 1.0 1.1 1.3 1.3 1.2

UL – 1.1 1.2 1.4 1.5 1.2

SMR 57 60 66 74 79 68

Rate 528 536 551 594 849 582

Deaths 13,257 1,966 4,685 2,723 995 10,369

<5 RR – 1.3 1.7 1.9 1.7 1.7

LL – 0.9 1.4 1.5 1.2 1.5

UL – 1.9 2.1 2.3 2.4 1.9

SMR – 76 101 108 99 100

Rate – 262 386 390 343 372

Deaths – 23 126 89 31 269

5-9 RR – 1.2 1.4 1.7 1.7 1.5

LL – 0.9 1.2 1.5 1.4 1.4

UL – 1.5 1.6 1.9 2.1 1.6

SMR – 68 81 98 98 86

Rate – 347 449 529 622 493

Deaths – 71 325 253 96 745

10-19 RR – 1.1 1.4 1.5 1.4 1.4

LL – 1.0 1.3 1.4 1.3 1.3

UL – 1.3 1.4 1.6 1.6 1.4

SMR – 66 78 84 82 78

Rate – 455 640 599 752 604

Deaths – 312 1,282 828 295 2,717

20-29 RR – 1.1 1.1 1.3 1.4 1.2

LL – 1.0 1.0 1.2 1.3 1.1

UL – 1.2 1.2 1.3 1.6 1.2

SMR – 60 62 70 81 65

Rate – 535 543 570 880 576

Deaths – 404 1,329 851 343 2,927

30-39 RR – 1.0 1.0 1.1 1.1 1.1

LL – 0.9 1.0 1.0 0.9 1.0

UL – 1.1 1.1 1.2 1.3 1.1

SMR – 59 60 62 64 60

Rate – 509 947 535 773 984

Deaths – 403 825 399 135 1,762
Smoking and Tobacco Control Monograph No. 8

512

Table 5 (continued)

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup Coronary Heart Disease

40+ RR – 1.1 1.0 1.0 1.1 1.0

LL – 1.0 0.9 0.9 0.9 1.0

UL – 1.2 1.1 1.2 1.4 1.1

SMR – 60 56 59 64 58

Rate – 981 423 404 359 568

Deaths – 502 605 244 82 1,433

p of trendg – 0.251 <0.001 <0.001 0.025 <0.001

a Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

b 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and calendar-timespecific mortality rates by the corresponding person-years and summing appropriately.

c Standardized to the age distribution of the total U.S. 1980 population within 5-year calendar periods.

d For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to the Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957). e No cigar or pipe at time of questionnaire but includes former cigar or pipe.

f Includes unknown years since smoked.

g Score test for linear trend, excluding unknown years, the years-since-smoked groups coded 2.5, 7.5, 15.0, 25.0, 35.0,

and 45.0, adjusted for attained age and calendar time.

Key: RR = relative risk; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit;

SMR = standardized mortality ratio.

• buccal cavity cancer (RR = 1.5);

• esophagus cancer (RR = 1.6, 0.99-2.17);

• stomach cancer (RR = 1.0);

• pancreas cancer (RR = 1.1);

• kidney cancer (RR = 1.1);

• skin cancer (RR = 1.1);

• brain cancer (RR = 1.1);

• malignant lymphoma (RR = 1.0);

• non-Hodgkin's lymphoma (RR = 1.0);

• Hodgkin's disease (RR = 0.9);

• multiple myeloma (RR = 1.0);

• chronic rheumatic heart disease (RR = 1.1);

• hypertension (RR = 1.1);
513

Chapter 7

Table 6

U.S. veterans: relative risks based on never-smokers (RR = 1.0),a lower and upper 95-percent

confidence limits on RR, standardized mortality ratio,b

 age-standardized rates per 100,000

person-years,c and number of deaths from chronic obstructive pulmonary diseased among

never-smokers and former cigarette smokerse

 by duration of nonsmoking

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup Chronic Obstructive Pulmonary Disease

Totalf RR 1.0 1.9 3.9 5.9 6.7 4.1

LL – 1.4 3.3 4.9 5.2 3.6

UL – 2.4 4.6 7.1 8.5 4.8

Rate 9.3 16 29 63 49 34

Deaths 243 64 282 218 86 650

<5 RR – 0.0 22.7 37.7 21.1 24.1

LL – 0.0 9.2 15.1 4.6 11.2

UL – – 56.2 93.8 97.0 51.8

Rate – 0 20 37 19 23

Deaths – 0 9 9 2 20

5-9 RR – 7.6 17.8 20.5 10.2 16.5

LL – 2.7 11.1 12.2 4.0 10.9

UL – 21.5 28.5 34.4 26.2 24.9

Rate – 22 45 46 41 42

Deaths – 4 36 26 5 71

10-19 RR – 1.3 6.9 9.8 15.4 7.8

LL – 0.5 5.3 7.4 11.0 6.3

UL – 3.1 9.0 13.0 21.6 9.7

Rate – 5 36 74 71 48

Deaths – 5 94 79 46 224

20-29 RR – 1.7 2.8 5.4 4.6 3.5

LL – 1.0 2.1 4.1 3.0 2.8

UL – 2.9 3.6 7.0 7.1 4.2

Rate – 11 22 37 27 24

Deaths – 13 67 72 22 174

30-39 RR – 2.4 2.4 2.2 2.6 2.4

LL – 1.5 1.7 1.4 1.2 1.9

UL – 4.0 3.4 3.6 5.6 3.1

Rate – 18 19 50 18 24

Deaths – 17 39 17 7 80
Smoking and Tobacco Control Monograph No. 8

514

Table 6 (continued)

Smoking at Time of Questionnaire (1954 or 1957)

Former Smoker, by Number of Cigarettes

NeverSmoker 1-9 10-20 21-39 40+ Total

Years Since

Smoked at Followup Chronic Obstructive Pulmonary Disease

40+ RR – 1.4 1.5 1.9 1.8 1.6

LL – 0.8 1.0 1.0 0.6 1.1

UL – 2.4 2.4 3.6 5.7 2.1

Rate – 38 9 9 11 21

Deaths – 15 21 10 3 49

p of trendg – 0.527 <0.001 <0.001 <0.001 <0.001

a Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

b 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and calendar-timespecific mortality rates by the corresponding person-years and summing appropriately.

c Standardized to the age distribution of the total U.S. 1980 population within 5-year calendar periods.

d For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to the Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (World Health Organization, 1957). e No cigar or pipe at time of questionnaire but includes former cigar or pipe.

f Includes unknown years since smoked.

g Score test for linear trend, excluding unknown years, the years-since-smoked groups coded 2.5, 7.5, 15.0, 25.0, 35.0,

and 45.0, adjusted for attained age and calendar time.

Key: RR = relative risk; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit;

SMR = standardized mortality ratio.

• phlebitis and pulmonary embolism (RR = 1.2, 0.98-1.42);

• general arteriosclerosis (RR = 1.1, 0.97-1.21);

• influenza and pneumonia (RR = 1.1, 0.998-1.23);

• pneumonia (RR = 1.1, 0.98-1.21);

• diabetes (RR = 0.9, 0.73-1.02);

• chronic nephritis (RR = 1.3);

• nephritis, nephrosis, other kidney diseases (RR = 1.0);

• intestinal obstruction (RR = 1.2);

• accidents other than motor vehicle (RR = 1.0); and

• motor vehicle accidents (RR = 1.0).

Mortality from Parkinson's disease was significantly lower among former

smokers (RR = 0.78, 0.65-0.95, p < 0.012) than among never-smokers.

The RR’s of former smokers changed variously over time for the

50 different cause-of-death groups (Table 8). Although some still exceeded
515

Chapter 7

Table 7

U.S. veterans, former cigarette smokers:a relative risks based on never-smokers (RR = 1.0),b

lower and upper 95-percent confidence limits on RR, standardized mortality ratio,c agestandardized rates per 100,000 person-years,d

 and number of deaths by causee

ICD-7 Cause-Of-Death Code Groupf

All Deaths: E000-999

RR 1.2

LL 1.2

UL 1.2

SMR 70

Rate 1,574

Deaths 26,722

All Cancer: 140-207

RR 1.3

LL 1.3

UL 1.4

SMR 69

Rate 266

Deaths 4,734

Buccal Cavity Cancer: 140-144 (SMR: 140-148)

RR 1.5

LL 0.9

UL 2.4

SMR 26

Rate 1.8

Deaths 33

Pharynx Cancer: 145-148 (For SMR see

 140-148 above)

RR 2.6

LL 1.1

UL 6.2

SMR —

Rate 5.3

Deaths 14

Esophagus Cancer: 150

RR 1.6

LL 1.0

UL 2.2

SMR 33

Rate 5.9

Deaths 50

Stomach Cancer: 151

RR 1.0

LL 0.9

UL 1.2

SMR 50

Rate 13

Deaths 230

Colon Cancer: 153

RR 1.4

LL 1.2

UL 1.5

SMR 100

Rate 45

Deaths 740

Rectum Cancer: 154

RR 1.3

LL 1.0

UL 1.5

SMR 71

Rate 8.9

Deaths 186

Liver Cancer: 155 (SMR: 155-156)

RR 1.5

LL 1.2

UL 2.0

SMR 84

Rate 6.7

Deaths 95

Pancreas Cancer: 157

RR 1.1

LL 0.9

UL 1.3

SMR 68

Rate 18

Deaths 265

Larynx Cancer: 161

RR 5.0

LL 2.4

UL 10.5

SMR 33

Rate 2.5

Deaths 30

Lung Cancer: 162-163

RR 3.6

LL 3.2

UL 4.1

SMR 45

Rate 38

Deaths 781
Smoking and Tobacco Control Monograph No. 8

516

Table 7 (continued)

ICD-7 Cause-Of-Death Code Groupf

Prostate Cancer: 177

RR 1.1

LL 1.0

UL 1.2

SMR 92

Rate 37

Deaths 817

Kidney Cancer: 180

RR 1.1

LL 0.9

UL 1.4

SMR 77

Rate 6.3

Deaths 111

Bladder Cancer: 181

RR 1.3

LL 1.1

UL 1.6

SMR 71

Rate 12.8

Deaths 220

Skin Cancer: 190-191

RR 1.1

LL 0.8

UL 1.5

SMR 79

Rate 3.6

Deaths 69

Brain Cancer: 193

RR 1.1

LL 0.9

UL 1.4

SMR 133

Rate 7.6

Deaths 116

Malignant Lymphoma: 200, 201, 203

RR 1.0

LL 0.8

UL 1.1

SMR 111

Rate 15

Deaths 280

Non-Hodgkin’s Lymphoma: 200

RR 1.0

LL 0.8

UL 1.2

SMR 124

Rate 8.7

Deaths 152

Hodgkin’s Disease: 201

RR 0.9

LL 0.6

UL 1.3

SMR 77

Rate 1.4

Deaths 31

Multiple Myeloma: 203

RR 1.0

LL 0.8

UL 1.3

SMR 107

Rate 4.8

Deaths 97

Leukemia: 204

RR 1.3

LL 1.1

UL 1.5

SMR 104

Rate 16

Deaths 299

All Cardiovascular Disease: 330-334, 400-468

RR 1.2

LL 1.1

UL 1.2

SMR 70

Rate 947

Deaths 16,586

Coronary Heart Disease: 420

RR 1.2

LL 1.2

UL 1.2

SMR 68

Rate 582

Deaths 10,369
517

Chapter 7

Table 7 (continued)

ICD-7 Cause-Of-Death Code Groupf

Chronic Rheumatic Heart Disease: 410-416

RR 1.1

LL 0.9

UL 1.4

SMR 86

Rate 9.7

Deaths 180

Hypertensive Heart Disease: 440-443

RR 1.2

LL 1.1

UL 1.3

SMR —

Rate 34

Deaths 523

Hypertension: 444-447

RR 1.1

LL 0.9

UL 1.4

SMR —

Rate 7.2

Deaths 165

Myocardial Degeneration: 422

RR 1.1

LL 1.0

UL 1.2

SMR —

Rate 36

Deaths 650

Stroke: 330-334

RR 1.1

LL 1.0

UL 1.1

SMR 68

Rate 159

Deaths 2,806

Aortic Aneurysm: 451

RR 2.6

LL 2.2

UL 3.1

SMR —

Rate 25

Deaths 406

Phlebitis, Pulmonary Embolism: 463-466

RR 1.2

LL 1.0

UL 1.4

SMR —

Rate 11.6

Deaths 202

General Arteriosclerosis: 450

RR 1.1

LL 1.0

UL 1.2

SMR —

Rate 47

Deaths 571

Influenza and Pneumonia: 480-493

RR 1.1

LL 1.0

UL 1.2

SMR —

Rate 33

Deaths 620

Pneumonia: 490-493

RR 1.1

LL 1.0

UL 1.2

SMR 49

Rate 31

Deaths 576

Emphysema: 527.1 (SMR: 527)

RR 5.9

LL 4.8

UL 7.3

SMR 77

Rate 21

Deaths 428

Bronchitis: 500-502

RR 3.3

LL 2.3

UL 4.5

SMR —

Rate 8.6

Deaths 108
Smoking and Tobacco Control Monograph No. 8

518

Table 7 (continued)

ICD-7 Cause-Of-Death Code Groupf

Chronic Obstructive Pulmonary Disease:

 501-502, 527.1, 527.2 for deaths in 1969-1980

RR 4.1

LL 3.6

UL 4.8

SMR —

Rate 34

Deaths 650

Asthma: 241

RR 2.3

LL 1.3

UL 3.9

SMR 39

Rate 1.5

Deaths 34

Tuberculosis: 001, 002 (SMR: 001-019)

RR 1.6

LL 1.1

UL 2.5

SMR 30

Rate 5.2

Deaths 46

Diabetes: 260

RR 0.9

LL 0.7

UL 1.0

SMR 38

Rate 13

Deaths 222

Parkinson’s Disease: 350

RR 0.8

LL 0.6

UL 0.9

SMR —

Rate 8

Deaths 162

Stomach Ulcer: 540 (SMR: 540-541)

RR 1.6

LL 1.1

UL 2.2

SMR 52

Rate 4

Deaths 62

Duodenal Ulcer: 541 (For SMR see 540-541 above)

RR 1.8

LL 1.3

UL 2.4

SMR —

Rate 5.3

Deaths 81

Liver Cirrhosis: 581

RR 1.5

LL 1.2

UL 1.9

SMR 45

Rate 9

Deaths 168

Chronic Nephritis: 592

RR 1.3

LL 0.9

UL 1.8

SMR 38

Rate 4

Deaths 55

Nephritis, Nephrosis, Other Kidney Diseases:

 590-594, 600-603 (SMR: 590-603)

RR 1.0

LL 0.8

UL 1.1

SMR 55

Rate 21

Deaths 243

Intestinal Obstruction: 570

RR 1.2

LL 0.9

UL 1.7

SMR —

Rate 5.7

Deaths 71

Accidents Other Than Motor Vehicle: E800-E809,

 E836-E962 (SMR: E800-E962 less E810-E835)

RR 1.0

LL 0.9

UL 1.1

SMR 61

Rate 37

Deaths 383
519

Chapter 7

Table 7 (continued)

ICD-7 Cause-Of-Death Code Groupf

1.0 with p < 0.05, the RR’s decreased in the most recent period for all deaths,

all cancers, most cancers at specific sites, all cardiovascular disease, coronary

heart disease, chronic rheumatic heart disease, hypertensive heart disease,

aortic aneurysm, emphysema, chronic obstructive pulmonary disease,

tuberculosis, and stomach and duodenal ulcers. There was no clear time

trend for cancers of the stomach, colon, larynx, and prostate and for

myocardial degeneration, stroke, phlebitis and pulmonary embolism, general

arteriosclerosis, influenza with or without pneumonia, bronchitis, asthma,

and diabetes. Using the 1954 to 1964 period as a base, RR’s increased

subsequently for pharynx cancer, rectum cancer, Parkinson's disease, liver

cirrhosis, chronic nephritis and suicide.

DISCUSSION Tobacco smoking adversely affects mortality, and although consensus

has developed about the major tobacco-related causes of death (International

Agency for Research on Cancer, 1986; U.S. Department of Health and Human

Services, 1989), the relationship of some death causes to smoking is unclear.

The work presented here and comprehensive analyses of earlier followups of

the veteran cohort (Kahn, 1966; Rogot and Murray, 1980) include most of

these cause-of-death groups of primary interest (Appendix A).

This chapter compares the mortality experience of subjects who reported

being former cigarette smokers with those who reported never smoking

regularly. Our ability to evaluate risks for those who were current smokers

in the 1950's is reduced by the lack of data on subsequent changes in their

Motor Vehicle Accidents: E810-835

RR 1.0

LL 0.8

UL 1.2

SMR 57

Rate 22

Deaths 193

Suicide: E963, E970-E979

RR 1.3

LL 1.1

UL 1.5

SMR 74

Rate 16

Deaths 220

a No cigar or pipe at time of questionnaire but includes former cigar or pipe.

b Estimated from a Poisson regression model, internally adjusted for attained age and (except Table 2) calendar time.

See Tables 3 through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

c 100 x observed/expected number of deaths. The expected number is obtained by multiplying age- and calendar-timespecific mortality rates by the corresponding person-years and summing appropriately.

d Standardized to the age distribution of the total U.S. 1980 population.

e For 1954 and 1957 questionnaire respondents, deaths were counted from year of questionnaire response to

September 30, 1980. The underlying cause was coded according to ICD-7 (World Health Organization, 1957). f Unless indicated in the heading, the cause-of-death group used in the rate and RR analysis is identical to that used

in the SMR analysis. When they differ, the number of deaths shown is that used for rate and RR. See Appendix A

for full definition of groups.

Key: RR = relative risk; ICD-7 = Manual of the International Statistical Classification of Diseases, Injuries, and Causes

of Death; LL = lower 95-percent confidence limit; UL = upper 95-percent confidence limit; SMR = standardized

mortality ratio.
Smoking and Tobacco Control Monograph No. 8

520

Table 8

U.S. veterans, former cigarette smokers:a

 Relative risks based on never-smokers (RR = 1.0)b for

the entire followup period (1954 to 1980) and for 1970 to 1980, 1965 to 1969, and 1954 to

1964 by cause of death

Followup

Cause-Of- Entire 1970- 1965- 1954-

Death Groupc Followup 1980 1969 1964

All Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2d 1.1d 1.2d 1.3d

All Cancers . . . . . . . . . . . . . . . . . . . . . . . . . 1.3d 1.2d 1.3d 1.5d

Buccal cavity cancer. . . . . . . . . . . . . . . . 1.5 1.2 0.7 2.3d

Pharynx cancer . . . . . . . . . . . . . . . . . . . 2.6d 3.1 7.5 1.1

Esophagus cancer . . . . . . . . . . . . . . . . . 1.5 1.1 2.0 2.0

Stomach cancer . . . . . . . . . . . . . . . . . . . 1.0 0.9 1.4d 1.0

Colon cancer . . . . . . . . . . . . . . . . . . . . . 1.4d 1.4d 1.4d 1.3d

Rectum cancer . . . . . . . . . . . . . . . . . . . . 1.3d 1.5d 1.5 1.1

Liver cancer . . . . . . . . . . . . . . . . . . . . . . 1.5d 1.5 1.0 1.9d

Pancreas cancer . . . . . . . . . . . . . . . . . . 1.1 0.9 1.1 1.3d

Larynx cancer . . . . . . . . . . . . . . . . . . . . . 5.0d 4.7d 4.5 5.4d

Lung cancer . . . . . . . . . . . . . . . . . . . . . . 3.6d 3.1d 3.0d 4.8d

Prostate cancer . . . . . . . . . . . . . . . . . . . 1.1d 1.1 1.2 1.2

Kidney cancer. . . . . . . . . . . . . . . . . . . . . 1.1 0.9 0.9 1.5d

Bladder cancer . . . . . . . . . . . . . . . . . . . . 1.3d 1.3 1.3 1.5d

Skin cancer. . . . . . . . . . . . . . . . . . . . . . . 1.1 0.9 1.2 1.6

Brain cancer . . . . . . . . . . . . . . . . . . . . . . 1.1 1.0 0.9 1.3

Malignant lymphoma . . . . . . . . . . . . . . . 1.0 0.9 0.8 1.1

Non-Hodgkin's lymphoma . . . . . . . . . . . 1.0 0.9 0.9 1.2

Hodgkin's disease . . . . . . . . . . . . . . . . . 0.9 0.6 0.4 1.1

Multiple myeloma . . . . . . . . . . . . . . . . . . 1.0 1.0 0.7 1.1

Leukemia . . . . . . . . . . . . . . . . . . . . . . . . 1.3d 1.1 1.3 1.5d

All Cardiovascular Diseases . . . . . . . . . . . . 1.2d 1.1d 1.1d 1.3d

Coronary heart disease . . . . . . . . . . . . . 1.2d 1.1d 1.1d 1.3d

Chronic rheumatic heart disease . . . . . . 1.1 1.1 0.9 1.3

Hypertensive heart disease . . . . . . . . . . 1.2d 1.0 1.2 1.3d

Hypertension . . . . . . . . . . . . . . . . . . . . . 1.1 1.1 1.0 1.1

Myocardial degeneration . . . . . . . . . . . . 1.1d 1.1 1.2 1.2d

Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1d 1.1 1.1 1.1

Aortic aneurysm . . . . . . . . . . . . . . . . . . . 2.6d 2.4d 2.8d 2.8d

Phlebitis, pulmonary embolism. . . . . . . . 1.2 1.1 1.5 1.1

General arteriosclerosis . . . . . . . . . . . . . 1.1 1.1 1.1 1.1

Influenza and Pneumonia . . . . . . . . . . . . . . 1.1 1.1 1.2 0.9

Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 1.1 1.1 0.9

Emphysema . . . . . . . . . . . . . . . . . . . . . . . . 5.9d 3.9d 4.4d 11.9d

Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3d 3.3d 3.2d 3.2d

Chronic Obstructive Pulmonary Disease . . 4.1d 2.8d 4.3d 8.2d
521

Chapter 7

Table 8 (continued)

Followup

Cause-Of- Entire 1970- 1965- 1954-

Death Groupc Followup 1980 1969 1964

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3d 2.5 1.7 2.6d

Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . 1.6d 1.4 1.0 2.0d

Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9 0.8 0.9 0.8

Parkinson's Disease . . . . . . . . . . . . . . . . . . 0.8d 0.8 1.1 0.6d

Stomach Ulcer. . . . . . . . . . . . . . . . . . . . . . . 1.6d 1.0 2.1 2.4d

Duodenal Ulcer . . . . . . . . . . . . . . . . . . . . . . 1.8d 1.3 1.5 2.2d

Liver Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . 1.5d 1.5d 2.0d 1.4

Chronic Nephritis. . . . . . . . . . . . . . . . . . . . . 1.3 1.3 1.5 1.2

Nephritis, Nephrosis, Other Kidney Diseases 1.0 0.9 1.0 1.1

Intestinal Obstruction . . . . . . . . . . . . . . . . . 1.2 1.4 0.8 1.6

Accidents Other Than Motor Vehicle . . . . . 1.0 0.9 1.0 1.1

Motor Vehicle Accidents . . . . . . . . . . . . . . . 1.0 1.0 1.2 0.8

Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3d 1.4d 1.3 1.2

a No cigar or pipe at time of questionnaire but includes former cigar or pipe.

b Estimated from a Poisson regression model, internally adjusted for attained age and calendar time. See Tables 3

through 6 for never-smokers' SMR values, rate/100,000, and number of deaths.

c See Appendix A for definitions of cause-of-death groupings.

d p < 0.05 on two-sided test of never-smokers vs. all former cigarette smokers.

Key: RR = relative risk; SMR = standardized mortality ratio.

smoking. For men in the United States, the prevalence of cigarette smoking

was at a peak near the time of the questionnaires, and it has declined since

then (U.S. Department of Health and Human Services, 1982 and 1991).

Although some study subjects who reported former smoking may have later

resumed it, there should not be many among those who stopped 5 years or

more prior to the questionnaire. All the subjects were older than 30 years at

the time of the questionnaire, and among never-smokers, few are likely to

have started smoking subsequently. Over a wide age range, veterans tend

to have more education and higher income than their civilian counterparts

(Hammond, 1980). Higher educational and occupational levels are associated

with smoking cessation (Kabat and Wynder, 1987). It may be assumed that

these veterans maintained smoking cessation during the followup period at

least as well as all U.S. males in the corresponding year-of-birth cohorts.

The three data analytic approaches used in this work give rather

consistent results, particularly for the RR’s and the SMR’s, which are

methodologically similar (Table 9). The SMR’s and standardized rates

considered only age and calendar time by evaluating the mortality of this

group in terms of a synthetic U.S. population followed over the same period.

The Poisson regression models fitted RR’s based on never-smokers and

also took into account the amount of smoking when evaluating cessation

duration.
Smoking and Tobacco Control Monograph No. 8

522

Estimates of RR’s for former smokers in this veteran cohort correspond

roughly to those for former smokers in a comprehensive review (U.S.

Department of Health and Human Services, 1989), based in part on data

from the first sample of the Cancer Prevention Study I (CPS-I). Table 10

compares, on a time-specific basis, eight cause-of-death groups in this

analysis with the corresponding groups in CPS-I. The CPS-I subjects were

enrolled during 1959 to 1960 and were followed for 6 years, from 1959

through 1965. Our RR values for the entire followup period (1954 through

1980) are considerably lower than those from the CPS-I, but the differences

appear to be primarily caused by the long followup of the veterans. The

followup to the 1954 to 1964 period approximates the CPS-I in calendar

time and duration, and the two sets of risk estimates are similar.

The entire veteran cohort experienced lower mortality than all U.S.

white males at the same age and calendar time for almost all causes

evaluated. Among all respondents, the SMR for overall mortality was 73.

Notably, the lowest SMR’s were for diseases related to alcohol use (larynx

cancer, 43; liver cirrhosis, 53; esophagus cancer, 57) and to socioeconomic

factors and medical care accessibility (tuberculosis, 26; pneumonia, 55).

Drinking problems and alcohol-related diseases are more common among

veterans of World War II and the Korean conflict than among others in the

U.S. population (Remer, 1983; Richard et al., 1989), but the extent of alcohol

use in this cohort of mostly World War I veterans is unknown.

Many different factors contribute to the low mortality of this cohort.

The subjects are veterans who were screened during an induction physical

examination. The screening took place many years prior to this study, but

the effect may have persisted and may have been enhanced by access to

medical care through the VA. In another study, World War II veterans

exhibited reduced SMR’s for various death causes, with an SMR for all cancer

of 55 from 1947 through 1951 and 89 from 1967 through 1969 (Seltzer and

Jablon, 1974).

Table 9

Comparison of RR’sa

 for former cigarette smokersb estimated from Poisson regression, SMR’s,

and annual mortality rates

Chronic

Coronary Obstructive

Source of All Lung Heart Pulmonary

Estimate Deaths Cancer Disease Disease

RR 1.2 3.6 1.2 4.1

SMR 1.2 3.5 1.2 --

Rate 1.1 1.8 1.1 3.7

a Table 7 SMR values or rate in smoking group divided by the respective value for never-smokers.

b No cigar or pipe at time of questionnaire but includes former cigar or pipe.

Key: RR = relative risk; SMR = standardized mortality ratio.
523

Chapter 7

Table 10

Relative risk of death for former smokers by source of data, calendar period, and cause

Source of Smoking Data

Present Studyb

Cancer Prevention Study, 1954- 1970- 1965- 1954-

Cause of Death 1959-1965a 1980 1980 1969 1964

Buccal Cavity Cancer 2.7 1.5 1.2 0.7 2.3

Esophageal Cancer 1.3 1.5 1.1 2.0 2.0

Pancreatic Cancer 1.3 1.1 0.9 1.1 1.3

Larynx Cancer 8.6 5.0 4.7 4.5 5.4

Lung Cancer 5.0 3.6 3.1 3.0 4.8

Kidney Cancer 1.8 1.1 0.9 0.9 1.5

Bladder Cancer 1.8 1.3 1.3 1.3 1.5

Coronary Heart Disease 1.3c 1.2 1.1 1.1 1.3

a Source: U.S. Department of Health and Human Services, 1989.

b From Table 8.

c For ages 65+ at enrollment ; relative risk = 1.6 for ages 35 to 64.

The study subjects were further selected in that all held active Government

life insurance policies in 1953. This self-selection may be related to lower

frequency of cigarette smoking among them than among all white males and

perhaps to other health-related characteristics. In a 1955 census-based survey,

a greater proportion of U.S. veterans were current cigarette smokers than were

all U.S. white males of the same age (Haenszel et al., 1956). Nevertheless, the

proportion of current smokers in the present sample was lower than among

U.S. veterans or white males generally (Table 11).

The study subjects obtained a mean value of 57.4 with a standard

deviation of 9.1 on socioeconomic scores normalized at a mean of 50 and a

standard deviation of 10. These scores were developed from income and

education distributions associated with each occupation of U.S. males (Green,

1970). Reduced mortality rates in the higher social class groups have been

reported in England, where in the period from 1970 through 1972, the SMR’s

for lung cancer among males ranged from 50 in Class I to 150 in Class V

(Registrar General, 1978). Smoking-adjusted SMR’s, obtained from the

September 1985 sample of the U.S. Current Population Survey, varied

inversely with education and income (Rogot et al., 1988).

All Deaths In the first 5 years following cessation of smoking, mortality from all

causes was comparable with that of current smokers but became dramatically

lower thereafter. Thirty years after cessation, the RR’s of moderate smokers

were indistinguishable statistically from those of never-smokers, as were

RR’s in the highest smoking group after 40 years. There is no question that

survival in the United States would improve greatly with a comprehensive

cessation of cigarette smoking. Most likely the improvement would occur
Smoking and Tobacco Control Monograph No. 8

524

Table 11

Percent of current cigarette smokers among veterans and U.S. males by source of smoking data

and age group

Source of Smoking Data

Bureau of Census, Current

Population Survey,

Study Sample February 1955

U.S. U.S.

Age Groupa Veterans Veteransb Malesb

<34 63.1 61.1 59.9

35-44 55.8 59.7 59.1

45-54 46.1 58.4 54.1

55-64 35.7 43.4 41.5

>65 29.2 28.0 21.6

Total 37.9 43.7c 41.1c

a Age at time of questionnaire.

b Source: Haenszel et al., 1956.

c Standardized to the age distribution of the study sample.

more quickly than indicated by these data because some study subjects

stopped smoking due to medical indications, and some of those who stopped

shortly before the questionnaire resumed smoking after having responded as

former smokers.

Lung Cancer The RR’s of former cigarette smokers were higher for larynx cancer,

emphysema, and chronic obstructive pulmonary disease than for lung

cancer, but the excess lung cancer risk involved more deaths (Table 7). After

40 or more years of cessation, lung cancer mortality was much reduced, but it

remained 50 percent higher than for never-smokers. Among never-smokers,

there was no time trend in the RR’s and SMR’s.

Coronary Heart During the past 30 years, mortality rates for coronary heart disease

Disease disease have been declining in the United States (Gordon and Thom,

1975; Havlik and Feinleib, 1978). The decline also occurred in the veteran

cohort of this study, and it has been especially pronounced among neversmokers (Rogot and Hrubec, 1989a). In the present analysis, the RR’s and

SMR’s considered calendar time, and, thus, the time-specific analysis has

been corrected for the secular declining trend. Adjustment for calendar time

also was carried out in the analysis showing reduced RR’s with years since

smoking ceased, and the decline in risks shown is not affected by the overall

secular trend.

Chronic Obstructive Chronic obstructive pulmonary disease is not included as

Pulmonary Disease a category in the ICD-7 code for causes of death (World Health

Organization, 1957). The category was reconstructed in this analysis (see

Appendix A) following guidelines by the National Center for Health Statistics

that were developed by surveying trends in clinical diagnosis over time.

Because all deaths in this study were coded by the same revision, the coding
525

Chapter 7

should have good internal time consistency. Death rates from chronic

obstructive pulmonary disease have been increasing in the United States

since the late 1940's, and the veteran cohort reflects this increase (Rogot and

Hrubec, 1989b). Chronic obstructive pulmonary disease mortality among

never-smokers was higher in the later periods than in the 1954 to 1964

period (p < 0.001), but the trend in the later time intervals was nonlinear.

In contrast, the RR’s of former smokers decreased steeply with calendar time

and duration of nonsmoking; however, they remained elevated even 40 or

more years after smoking stopped.

Other Causes It is accepted that smoking directly contributes to mortality from

various forms of cancer and cardiovascular and respiratory diseases

(International Agency for Research on Cancer, 1986; U.S. Department of

Health, Education, and Welfare, 1964; U.S. Department of Health and

Human Services, 1982). The meaning of the association of smoking with

cancer sites also related to alcohol use is less clear, and it is difficult to

interpret the association with renal diseases, liver cirrhosis, and intestinal

obstruction. The low SMR’s of the study subjects, particularly for liver

cirrhosis, suggest that in this group there is less confounding of smoking

with use of alcohol than in many other studies.

Although there was an overall decline in the RR estimates of former

smokers over time, the RR’s for many causes remained rather stable (Table 8).

Despite the long duration of followup, among the 24 cause-of-death groups

that had significantly (p < 0.05) elevated RR’s for former smokers during the

1954 to 1964 period, there were 11 groups that still had significantly elevated

RR’s during the 1970 to 1980 period. For rectum cancer, liver cirrhosis, and

suicide, there were significant excess risks for the 1970 to 1980 period but

not for the 1954 to 1964 period. The earliest time interval, 1954 through

1964, represents approximately the period covered by the Kahn (1966)

report, and the 1965 to 1969 period represents roughly the information

added to it by the next comprehensive mortality ascertainment (Rogot and

Murray, 1980). Our definition of former smokers corresponds to that used

by Rogot, but it differs from Kahn's, who distinguished between smokers who

stopped because of medical indications and others. The 1965 to 1969 period

is short, and, therefore, the sampling error of the estimates is somewhat

larger than that for the earliest and most recent periods. Some comparisons

with the earlier publications may be affected by variation in the definition of

the cause-of-death groups (Appendix A) and other methodologic problems.

Of the 50 cause-of-death groups examined, risks were persistently

decreased with former cigarette smoking only for Parkinson's disease. The

association between smoking and reduced Parkinson's disease mortality was

noted previously by Kahn (1966), and it was confirmed in a subsequent

case-control study (Nefzger and Quadfasel, 1968). The deficit in Parkinson's

disease risk diminished with duration of smoking cessation, and it is now

slight. For the majority of smoking-related death causes, mortality of former

smokers continues to be higher than that of never-smokers. Because of the

special nature of the veteran cohort, residual risks for all former U.S. smokers

may be greater than those presented here.
Smoking and Tobacco Control Monograph No. 8

526

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Rogot, E., Sorlie, P.D., Johnson, N.J., Glover, C.S.,

Treasure, D.W. A Mortality Study of One Million Persons

by Demographic, Social and Economic Factors: 1979-

1981 Followup. NIH Publication No. 88-2896.

Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, National

Institutes of Health, 1988.

Seltzer, C.C., Jablon, S. Effects of selection on mortality.

American Journal of Epidemiology 100: 367-372, 1974.

U.S. Department of Health, Education, and Welfare.

Smoking and Health: Report of the Advisory Committee

to the Surgeon General of the Public Health Service. PHS

Publication No. 1103. Rockville, MD: U.S.

Department of Health, Education, and Welfare,

Public Health Service, Centers for Disease Control,

1964.
Smoking and Tobacco Control Monograph No. 8

528
529

Chapter 7

Cause-of-Death Groups (ICD-7 [World Health Organization, 1957]) Used in SMR, Rate, and RR

Analyses and in Kahn (1966) and Rogot and Murray (1980)

Cause Group SMRa Rate, RR Kahn (1966) Rogot and Murray (1980)

All Cancer 140-205 140-207 (WHO codes) 140-205 140-207

Buccal cavity cancer 140-148 140-144 140-144 140-144

Pharynx cancer (See group) 145-148 145-148 145-148

above

Esophagus cancer 150 150 150 150

Stomach cancer 151 151 151 151

Colon cancer 153 153 152-153 152-153

Rectum cancer 154 154 154 154

Liver cancer 155-156 155 (primary only) — 155

Pancreas cancer 157 157 157 157

Larynx cancer 161 161 161 161

Lung cancer 162-163 162-163 162-163 162.1, 162.8, 163

Prostate cancer 177 177 177 177

Kidney cancer 180 180 180 180

Bladder cancer 181 181 181 181

Skin cancer 190-191 190-191 — —

Brain cancer 193 193 — 193

Malignant lymphoma Combined 200-201, 203 200, 201, 200, 201,

200, 201, 203 203 203, 206

Non-Hodgkin’s lymphoma 200 200 — —

Hodgkin’s disease 201 201 — —

Multiple myeloma 203 203 — —

Leukemia 204 204 204 204, 207

All Cardiovascular Disease Combined 330-334, 400-468 330-334, 330-334, 400-468

300-334, 400-468 400-468

Coronary heart disease 420 420 420 420

Chronic rheumatic 410-416 410-416 410-416 400-402, 410-416

 heart disease

Hypertensive heart disease — 440-443 440-443 440-443

Hypertension — 444-447 444-447 440-447

Myocardial degeneration — 422 421-422 422

Stroke 330-334 330-334 330-334 330-334

Aortic aneurysm — 451 451 451

Phlebitis, pulmonary — 463-466 — 463-466

 embolism

General arterioscierosis — 450 450 450

Influenza and Pneumonia — 480-493 480-493 480-481, 490-493

Pneumonia 490-493 490-493 (see group above)

Emphysema 527 527.1 527.1 527.1

Bronchitis — 500-502 500-502 500-502

COPD — 501-502, 527.1, — —

527.2 for deaths in

1969-1980

Asthma 241 241 241 241

Tuberculosis 001-019 001, 002 001-008 001, 002

Diabetes 260 260 260 260

Appendix A
Smoking and Tobacco Control Monograph No. 8

530

Cause Group SMRa Rate, RR Kahn Rogot

Parkinson’s Disease — 350 350 350

Stomach Ulcer 540-541 540 540 540, 542

Duodenal Ulcer (See group above) 541 541 541

Liver Cirrhosis 581 581 581 581

Chronic Nephritis 592 592 (see group below)

Nephritis, 590-603 590-594, 600-603 592-594 590-594, 600-603

Nephrosis, Other

Kidney Diseases

Intestinal Obstruction — 570 — —

Accidents, Other E800-E809, E800-E809, E800-E962, E800-E965,

Than Motor E836-E962 E836-E962 E970-E991 E980-E999

Vehicle

Motor Vehicle Accidents E810-E835 E810-E835 (see group above)

Suicide E963, E970-E979 E963, E960-E979 — E970-E979

a Entries in parentheses or with — indicate that corresponding SMR cause-of-death groups are not

 available. The SMR’s were not obtained for these groups.

Key: ICD-7 = Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death;

SMR = standardized mortality ratio; RR = relative risk; WHO = World Health Organization; COPD = chronic

obstructive pulmonary disease.

APPENDIX A (continued)
531

Chapter 8

Smoking Cessation and Decreased Risks Of

Total Mortality, Stroke, and Coronary Heart

Disease Incidence AmongWomen: A

Prospective Cohort Studya

Ichiro Kawachi, Graham A. Colditz, Meir J. Stampfer, Walter C. Willett,

JoAnn E. Manson, Bernard Rosner, David J. Hunter, Charles H. Hennekens,

and Frank E. Speizer

INTRODUCTION Former smokers are at lower risk of total mortality compared

with continuing smokers (Doll and Hill, 1956; Hammond and

Smoking Cessation Horn, 1958; Dunn et al., 1960; Best et al., 1961; Kahn, 1966;

in Relation to Total Hammond, 1966; Doll and Peto, 1976; U.S. Department of

Mortality Rates Health and Human Services, 1990). However, the time

required for the risk of total mortality among quitters to reach the level

of never-smokers differs among studies, ranging from 6 to 10 years in one

study (LaCroix et al., 1991) to 15 or more years in other studies (Rogot and

Murray, 1980; U.S. Department of Health and Human Services, 1990).

Few previous studies have been able to examine the temporal relationship

between smoking cessation and decline in mortality risk while adjusting

for other smoking-related factors, such as age at starting and number of

cigarettes smoked.

Data about women have been sparse. For example, some large

prospective studies with data on smoking cessation have been based solely

on men (Kahn, 1966; Doll and Peto, 1976; Rogot and Murray, 1980). The

British Female Doctors Study (Doll et al., 1980) had insufficient data to

characterize the relationship between time since quitting and decline in

mortality.

To address some of these deficiencies in the literature, we analyzed the

health benefits of smoking cessation in the Nurses' Health Study, a large

prospective cohort of women in the United States (Myers et al., 1987; Willett

et al., 1987; Colditz, 1990). Our results describe the timing and extent of

decline in risks of total and cause-specific mortality for patients considering

cessation.

aThis chapter (text, tables, and figures) is excerpted from three articles published previously. Please refer

to Kawachi and colleagues (1993a, 1993b, and 1994) in the reference list at the end of this chapter.
532

Smoking and Tobacco Control Monograph No. 8

Smoking Cessation Smoking is an established risk factor for stroke in both men

and Decreased Risk and women (Shinton and Beevers, 1989). Based on a review

of Stroke of the available evidence, a U.S. Surgeon General’s report, The

Health Benefits of Smoking Cessation. A Report of the Surgeon General,

1990, concluded that smoking cessation reduces the risk of both ischemic

stroke and subarachnoid hemorrhage compared with continued smoking

(U.S. Department of Health and Human Services, 1990).

However, the relationship of time since quitting with risk of stroke

has been addressed in only a few studies. In a review of case-control and

prospective studies, risk of stroke returned to the level of never-smokers

following smoking cessation, but time since quitting ranged from less than

5 to 15 years (U.S. Department of Health and Human Services, 1990; Donnan

et al., 1989; Wolf et al., 1988; Colditz et al., 1988).

We analyzed 12 years of followup data from the Nurses' Health Study

(Colditz, 1990) to examine the benefits of smoking cessation in relation to

stroke incidence. In particular, we sought to characterize the relationship of

time since stopping smoking with reductions in total and specific subtypes

of stroke.

Smoking Cessation Cigarette smoking is a well-established risk factor for coronary

and Decreased Risk heart disease (CHD) in men and women (U.S. Department of

of Coronary Heart Health and Human Services, 1983). Although cessation of

Disease smoking reduces morbidity and mortality from CHD

(U.S. Department of Health and Human Services, 1990), there have been

conflicting reports of the time required for the excess risk to return to

the level of never-smokers.

Some of smoking's effects that increase CHD risk (for example, increased

platelet activation, elevated carbon monoxide levels, and coronary artery

spasm) are immediately reversible, but other effects are either irreversible

or are only slowly reversible (for example, development and progression of

atherosclerosis) (McBride, 1992). Hence, it is possible that the smoker who

stops will experience a component of rapid decline in risk compared with

those who continue to smoke and a further component of risk that gradually

falls to the level of never-smokers.

The available prospective epidemiological data are predominantly in

middle-aged men, and they suggest that smoking cessation is accompanied

by a halving of CHD risk after 1 year. These data also show that an

additional 15 years are required for the risk to decline to the level of neversmokers (U.S. Department of Health and Human Services, 1990). However,

a recent prospective study in predominantly elderly subjects suggested that

risk in former smokers returns to that of never-smokers within 5 years of

cessation (LaCroix et al., 1991). Further, several case-control studies, limited

to nonfatal myocardial infarction (MI), have suggested that the excess CHD

risk among former smokers dissipates completely less than 5 years after

cessation (Rosenberg et al., 1985 and 1990; Dobson et al., 1991).
533

Chapter 8

In the present study, we analyzed 12 years of followup data from the

Nurses' Health Study (Colditz, 1990) to examine the relationship of time

since stopping smoking with reduction in CHD incidence and mortality in

middle-aged women.

METHODS The Nurses' Health Study (Colditz, 1990) cohort was established

in 1976, when 121,700 female registered nurses 30 to 55 years

The Nurses' Health of age completed a mailed questionnaire requesting information

Study Cohort about risk factors for cancer and CHD, including current and

past smoking habits; history of myocardial infarction, angina, cancer,

diabetes, hypertension, high serum cholesterol levels, and menopause;

and parental history of myocardial infarction. In addition, questions were

included on height, weight, postmenopausal use of hormones, and history

of oral contraceptive use. Since 1976, followup questionnaires have been

mailed every 2 years to update information on smoking behavior, other

cardiovascular risk factors, and the diagnosis of major illness. If no

questionnaire was returned during the followup years, the most recent

record of exposure status was used for the subsequent followup interval

(for smoking-related variables, this occurred in less than 0.5 percent of the

cohort). Further details of the Nurses' Health Study (Colditz, 1990) have

been described elsewhere (Hennekens et al., 1979; Stampfer et al., 1985).

Exposure Data Women were categorized according to their smoking status as neversmokers, former smokers, or current smokers. Current smokers were further

classified as using 1 to 4, 5 to 14, 15 to 24, 25 to 34, 35 to 44, or 45 or more

cigarettes per day. On the 1976 questionnaire, smokers were asked the age

at which they started to smoke. In the present analysis, current and former

smokers were classified as starting smoking at younger than age 15, from

15 to 17, from 18 to 21, from 22 to 25, or at age 26 or older. For time since

stopping, former smokers were categorized as having stopped for less than 2,

between 2 and 4, between 5 and 9, between 10 and 14, or more than 15 years.

Alcohol intake may potentially confound the association between

cigarette smoking and risk of total mortality and cardiovascular disease

(CVD) because smokers tend to drink more, and alcohol intake reduces the

risk of CVD mortality (Stampfer et al., 1988; Rimm et al., 1991). In 1980, we

assessed average frequency of alcohol intake over the preceding year. The

levels of alcohol intake were categorized into 0, 0.01-4.9, 5.0-14.9, 15.0-24.9,

and 25.0-49.9 g/day. Our measure of alcohol intake has been validated as

part of an overall validation study of the food frequency questionnaire,

conducted within a random sample of 194 Boston participants (Colditz et al.,

1987; Giovannucci et al., 1991). A high correlation (Spearman r = 0.86) was

found between average daily intake of alcohol as assessed by 28 days of diet

records and intake computed from the 1980 food frequency questionnaire.

Vigorous physical activity may similarly potentially confound the

association between smoking and mortality, because smokers tend to exercise

less and exercise reduces the risk of CVD (Berlin and Colditz, 1990). We

identified women taking part in regular vigorous exercise by asking the

following question in the 1980 questionnaire: "At least once a week, do you
534

Smoking and Tobacco Control Monograph No. 8

engage in any regular activity similar to brisk walking, jogging, bicycling, et

cetera, long enough to work up a sweat?" Activity level as assessed by selfreports of sweat-inducing episodes of exercise has been shown to be strongly

correlated with resting heart rate (Washburn et al., 1987), obesity (Washburn

et al., 1987; Washburn et al., 1990), and high-density lipoprotein cholesterol

levels (Washburn et al., 1990).

Ascertainment For the analysis of smoking cessation and total mortality, the

of Endpoints endpoints constituted deaths from all causes occurring after the date

of return of the 1976 questionnaire but before June 1, 1988. The

Total Mortality deaths were further grouped into four broad categories: total CVDs

(International Classification of Diseases: 8th revision. Tabular List [ICD-8]

codes 410-440 and 795); total cancers (ICD-8 codes 140-207); total cancers,

excluding lung cancer (ICD-8 codes 140-161 and 163-207); and external

causes of injury (all ICD "E" codes), which include accidents and suicides

(U.S. Department of Health, Education, and Welfare, 1972).

The mortality surveillance included systematic searches of the National

Death Index (Stampfer et al., 1984) and vital records of the States to discover

deaths among women who did not respond during each questionnaire

cycle. This search was supplemented by reports from next of kin and postal

authorities. We estimate that more than 98 percent of the deaths in the

cohort were ascertained by these methods (Stampfer et al., 1984).

The classification of individual causes of death was carried out by a

physician review of death certificates. Deaths due to cancer, CVD, and

external causes of injury were classified as confirmed if these were listed

as the underlying causes on the death certificate.

Ascertainment of Strokes were confirmed by medical records if they were characterized

by a typical neurologic deficit, sudden or rapid in onset, lasting at

least 24 hours, and attributable to a cerebrovascular event, according to

criteria established in the National Survey of Stroke (Walker et al., 1981).

Strokes were defined as incident if they occurred after the date of return of

the 1976 questionnaire but before June 1, 1988.

Death due to stroke was ascertained by a physician review of hospital

records or autopsy reports or the listing of stroke as the underlying cause

on the death certificate. The ascertainment of death included a systematic

search of State vital records and the National Death Index (Stampfer et al.,

1984) to discover deaths among participants who did not respond during

each questionnaire cycle. This search was supplemented by reports from

next of kin and postal authorities. If death appeared to be from vascular

causes, written permission was requested from the next of kin (subject

to the regulations of vital records offices) to review the medical records.

More than 98 percent of deaths in the cohort were estimated to have

been identified by this method (Stampfer et al., 1984).

When nonfatal stroke was reported on a followup questionnaire,

permission was sought to obtain and review the medical records. The review
535

Chapter 8

was carried out by physicians blinded with respect to the risk factor status

of participants. The followup rate for nonfatal events through 1988,

calculated as a percentage of the total potential person-years of followup,

was 94.4 percent for never-smokers, 94.8 percent for former smokers, and

92.4 percent for current smokers. The criteria of the National Survey of

Stroke (Walker et al., 1981) were used to further categorize strokes as

subarachnoid hemorrhage, intracerebral hemorrhage, or ischemic stroke.

Ascertainment of Cases of CHD were defined as incident if they occurred after the

Coronary Heart date of return of the 1976 questionnaire but before June 1, 1988.

Disease Incidence Incident CHD was further categorized as nonfatal MI or fatal CHD.

Nurses who reported having a nonfatal MI on a followup questionnaire

were asked for permission to review their medical records. Nonfatal MIs

were "confirmed" if they met the diagnostic criteria of the World Health

Organization (i.e., symptoms plus either cardiac enzyme elevations or

diagnostic electrocardiographic changes) (Rose and Blackburn, 1982). All

record reviews were conducted by physicians blinded to exposure status.

A myocardial infarction was defined as probable if medical records were not

available but hospitalization was required and confirmatory information was

obtained by interview or letter. The present analyses included definite and

probable cases. Eighty-two percent of the total CHD cases included in the

present study were "definite" by our criteria. The followup rate for nonfatal

MI through 1988, calculated as a percentage of the total person-years of

followup, was 94.4 percent for never-smokers, 94.7 percent for former

smokers, and 92.4 percent for current smokers.

As for all other endpoints in the study, the ascertainment of death

included a systematic search of State vital records and the National Death

Index (Stampfer et al., 1984) to discover deaths among participants who did

not respond during each questionnaire cycle. This search was supplemented

by reports from next of kin and postal authorities. If death appeared to be

from vascular causes, written permission was requested from the next of kin

(subject to the regulations of vital records offices) to review the medical

records. Fatal CHD was defined as fatal MI confirmed by hospital records

or at autopsy or as CHD recorded on the death certificate if this was the

underlying and most probable cause given and there was previous evidence

of that condition. In no )nstance was the cause on the death certificate

accepted without corroboration. Total coronary heart disease was defined

as nonfatal MI plus fatal CHD.

Statistical Analysis The present analyses included 12 years of followup data from

June 1976 to June 1988. The primary analysis used mortality (or incidence)

rates with person-months of followup as the denominator. For each

participant, person-months were allocated according to the 1976 exposure

variables and were updated according to information on biennial followup

questionnaires. For women who died, person-months were assigned

according to the covariate status reported in the most recently completed

questionnaire, and followup was terminated at the date of death.
536

Smoking and Tobacco Control Monograph No. 8

Relative risks (RR’s) were calculated as the rate of death in each smoking

category divided by the corresponding rate in the reference category. For

analyses evaluating the relative risk of mortality among current smokers,

we used never-smokers as the reference category. To assess the impact on

mortality risk among former smokers by time since stopping, we followed

the suggestion of the 1990 U.S. Surgeon General's report (U.S. Department

of Health and Human Services, 1990) and used current smokers as the

reference category. All relative risks were age adjusted by 5-year intervals,

and 95-percent confidence intervals (CI) were calculated (Miettinen, 1976).

The attributable risk of mortality (i.e., the excess number of deaths per

100,000 person-years attributable to smoking) was calculated as the

difference between the mortality rates between current or former smokers

and never-smokers. When appropriate, we performed the Mantel test for

linear trend across categories of smoking variables and reported the 2-tailed

p values (Rothman and Boice, 1979). We also used proportional hazards

models to simultaneously control for age, cigarette smoking, and other risk

factors for CVD and cancer.

Previous reports have indicated that former smokers tend to have

smoked fewer cigarettes per day (U.S. Department of Health and Human

Services, 1990) and to have started smoking at an older age than continuing

smokers (Myers et al., 1987). Thus, at any age of quitting, former smokers

have less cumulative exposure to cigarettes, on average, than continuing

smokers. Therefore, failure to adjust for differences in cumulative exposure

between former and current smokers may exaggerate the benefits of

cessation. Wherever appropriate, we adjusted the relative risks of death

among former smokers by the daily number of cigarettes smoked and the

age at which they started smoking.

We excluded from analysis all women who had reported angina, MI,

stroke, and cancer (other than nonmelanoma skin cancer) at baseline. This

left a total cohort of 117,001 women who were available for followup.

Assessment of In a prospective study of smoking and mortality involving

Confounding by repeated measurement of smoking status, nonfatal disease

Intermediate Variables may act simultaneously as a confounding factor and an

intermediate variable in the pathway between smoking and mortality

(Robins, 1987 and 1989). For example, in analyzing the relationship between

smoking and CHD mortality, intervening morbid events (such as nonfatal MI

or angina) may act as a determinant of subsequent exposure to smoking as

well as an independent risk factor for subsequent death from coronary heart

disease.

We assessed the extent of such confounding by performing the Gcomputational algorithm, as described by Robins (1987 and 1989), on the

relationship between cigarette smoking and fatal CHD, using nonfatal MI

and angina in the analysis as the time-dependent covariates.
537

Chapter 8

RESULTS In 1976, 43.3 percent of the cohort members were never-smokers,

23.5 percent former smokers, and 33.2 percent current smokers.

Characteristics By 1988, the corresponding proportions were 42.6 percent

of Smokers never-smokers, 35.3 percent former smokers, and 22.1 percent

current smokers. Some but not all health-related habits were distributed

similarly between never-, former, and current smokers (Table 1). For

example, current smokers tended to engage less in vigorous exercise, have

slightly lower body mass index, and were more likely to drink more than

15 g of alcohol per day.

Results for Total Over the 12 years of observation, 2,847 deaths occurred during

Mortality 1,374,556 person-years. These consisted of 566 deaths from

CVDs; 247 deaths from lung cancer; 1,209 deaths from cancers,

Causes of Death excluding lung cancer; 261 deaths from external causes of injury;

and 564 deaths from other causes. The category of "External Causes of

Injury" covers ICD-8 codes E800-E999 and includes all deaths from accident,

poisoning, suicide, and other trauma (U.S. Department of Health, Education,

and Welfare, 1972).

Risks of Current Total Mortality. Compared with women who had never smoked,

Smokers current smokers experienced higher rates of total mortality (ageadjusted relative risk, 1.86; CI, 1.71 to 2.03) (Table 2). The age-adjusted

relative risk increased with the number of cigarettes smoked per day (p, trend

< 0.0001). Women who smoked 35 to 44 cigarettes per day had a relative risk

of total mortality of 2.42 (CI, 2.01 to 2.90), whereas women who smoked

Table 1

Distribution of various potential self-reported risk factors according to smoking status among

117,001 Nurses’ Health Study participantsa

Smoking Status

Variable Never-Smoker Former Smoker Current Smoker

Percent of Subjects in 1980 43.2 26.4 30.4

Total Person-Years of Followup (1976-1988) 593,026 404,359 377,171

Pack-Years Smoked 0 17.1 33.8

Body Mass Index (kg/m2

) 24.2 24.0 23.3

Hypertension 16.3% 16.9% 14.9%

Diabetes 2.2% 2.3% 2.0%

High Cholesterol 5.0% 5.8% 5.5%

Parental Myocardial Infarction Before Age 60 13.1% 14.5% 15.1%

Postmenopausal Hormone Use 18.3% 19.6% 20.2%

Vigorous Exercise At Least Once Per Week 43.1% 47.3% 37.9%

Alcohol Intake >15 g Per Day 7.5% 16.7% 21.2%

a Percentage prevalence of risk factors has been directly age standardized by 5-year age categories to the distribution

of ages in the whole cohort in 1980.
538

Smoking and Tobacco Control Monograph No. 8

Table 2

Total and cause-specific mortality by daily amounts of cigarettes consumed among current

smokers—age-adjusted and multivariate RR’s

Cigarettes Used/Day Among Current Smokersa

Never- Former Current

Event Smoker Smoker Smoker 1-14 15-24 25-34 >35

Total Mortality

 Cases 933 799 1,115 234 480 215 153

 RRb 1.00 1.28 1.86 1.41 1.99 2.06 2.57

 RRc 1.00 1.29 1.87 1.51 2.02 2.09 2.63

(1.14-1.46) (1.65-2.13) (1.26-1.81) (1.74-2.35) (1.71-2.55) (2.12-3.27)

Total Cardiovascular Diseases

 Cases 131 151 284 56 124 57 37

 RRb 1.00 1.69 3.47 2.48 3.78 4.11 4.73

 RRc 1.00 1.57 3.74 2.69 4.25 4.28 5.64

(1.17-2.12) (2.86-4.89) (1.82-3.97) (3.14-5.77) (2.86-6.41) (3.52-9.04)

Total Cancer, Including Lung

 Cases 516 438 502 95 233 93 67

 RRb 1.00 1.26 1.51 1.03 1.73 1.60 1.99

 RRc 1.00 1.28 1.42 1.05 1.68 1.62 1.95

(1.08-1.52) (1.20-1.67) (0.82-1.35) (1.29-2.17) (1.26-2.08) (1.40-2.70)

Total Cancer, Excluding Lung

 Cases 492 366 351 83 161 61 36

 RRb 1.00 1.11 1.10 0.94 1.25 1.10 1.12

 RRc 1.00 1.11 1.19 1.02 1.23 1.09 1.15

(0.91-1.34) (0.99-1.44) (0.77-1.36) (0.97-1.56) (0.78-1.53) (0.77-1.74)

External Causes of Injury

 Cases 90 68 103 27 28 20 24

 RRb 1.00 1.16 1.69 1.60 1.12 1.83 3.92

 RRc 1.00 1.26 1.73 1.83 1.25 1.95 4.19

(0.83-1.89) (1.25-2.41) (1.07-3.13) (0.73-2.16) (1.03-3.69) (2.33-7.55)

a Cigarettes smoked per day were unknown for 33 cases, including 10 cardiovascular disease deaths, 4 lung cancer

deaths, 10 cancers other than lung cancer, 4 accidents or suicides, and 5 deaths from all other causes.

b Age-adjusted RR—95-percent CI in parentheses.

c Multivariate RR, adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982

to 1984, 1984 to 1986, or 1986 to 1988), body mass index, history of hypertension, high cholesterol levels, diabetes,

parental history of myocardial infarction before age 60, postmenopausal estrogen therapy, menopausal status, past

use of oral contraceptives, and age at starting smoking.

Key: RR = relative risk; CI = confidence interval.
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Chapter 8

45 or more cigarettes per day had a relative risk of 3.57 (CI, 2.52 to 5.04).

The attributable risk of total mortality in current smokers compared with

never-smokers was 120 per 100,000 person-years. Approximately 37 percent

of all deaths among current smokers in this cohort was attributable to

cigarette smoking.

Cause-Specific Mortality. The age-adjusted relative risk of CVD mortality

among current smokers was 3.47 (CI, 2.85 to 4.22), and risk increased with

the daily number of cigarettes used (p, trend = 0.002) (Table 2). Women

who smoked only 1 to 4 cigarettes per day had an elevated risk of death from

CVD (relative risk, 2.13; CI, 1.20 to 3.79), and those who smoked 45 or more

cigarettes per day had a relative risk of 6.35 (CI, 3.26 to 12.34).

For total cancer mortality, including lung cancer, the overall age-adjusted

relative risk among current smokers was 1.51 (CI, 1.33 to 1.70), and risk

increased with the daily number of cigarettes used (p, trend < 0.0001).

However, when lung cancers were excluded, the relative risk of cancer

mortality among current smokers was not statistically significantly elevated

(RR, 1.10; CI, 0.96 to 1.26), and there was no dose-response relationship with

the daily amount of cigarettes used (p, trend > 0.2) (Table 2). This finding

was explained by the fact that breast and colorectal cancer, two of the most

common cancers in this cohort, had no association with cigarette smoking.

The relative risk of deaths due to breast cancer among current smokers was

0.87 (CI, 0.68 to 1.12) and was 1.01 for colorectal cancer (CI, 0.69 to 1.46).

On the other hand, the weak association between current smoking and total

cancer after excluding lung cancer did not preclude the presence of strong

associations between smoking and mortality from the less common cancers

of individual sites, for example, cancers of the buccal cavity and pharynx

(6 cases among current smokers; age-adjusted RR, 5.0; CI, 1.2 to 20.7),

esophagus (7 cases among current smokers; age-adjusted RR, 11.1; CI, 2.1 to

58.9), and pancreas (26 cases among current smokers; age-adjusted RR, 1.9;

CI, 1.1 to 3.4).

The age-adjusted relative risk of death from external causes of injury

among current smokers was 1.69 (CI, 1.28 to 2.24), and risk increased with

the daily number of cigarettes used (p, trend = 0.001).

Multivariate Models. The associations of cigarette smoking with total

and cause-specific mortality changed only slightly after we controlled for

potential confounders (including history of hypertension, diabetes, high

serum cholesterol, relative weight, parental history of MI before age 60, past

use of oral contraceptives, postmenopausal estrogen therapy, and age at

starting smoking) in multivariate proportional hazards models (Table 2).

Decline in Risk Total Mortality. Compared with never-smokers, the age-adjusted relative

Among Former risk of total mortality among former smokers was 1.28 (CI, 1.16 to 1.40)

Smokers (Table 2). When we examined the relationship between time since

quitting and the relative risk of total mortality, the risk among former

smokers approached the level of never-smokers after 10 to 14 years of

cessation (Table 3; Figure 1).
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Smoking and Tobacco Control Monograph No. 8

Table 3

Total and cause-specific mortality by time since quitting: Age-adjusted and multivariate RR’sa

Years Since Quitting Among Former Smokersb

Never- Current

Event Smoker Smoker <2 2-4 5-9 10-14 >15

Total Mortality

 Cases 933 1,115 127 106 131 66 231

 RRc 0.54 1.00 1.08 0.90 0.72 0.48 0.59

 RRd 0.56 1.00 1.19 1.00 0.79 0.53 0.61

(0.52-0.62) (0.95-1.50) (0.79-1.28) (0.63-0.99) (0.39-0.71) (0.51-0.74)

Total Cardiovascular Disease

 Cases 131 284 20 24 32 9 39

 RRc 0.29 1.00 0.66 0.78 0.67 0.26 0.40

 RRd 0.30 1.00 0.76 0.90 0.75 0.29 0.42

(0.24-0.37) (0.43-1.32) (0.54-1.51) (0.47-1.18) (0.13-0.63) (0.27-0.66)

Total Cancer, Including Lung

 Cases 516 502 75 48 69 37 134

 RRc 0.66 1.00 1.42 0.90 0.84 0.60 0.78

 RRd 0.72 1.00 1.56 1.00 0.93 0.69 0.81

(0.64-0.81) (1.16-2.10) (0.70-1.42) (0.69-1.27) (0.46-1.03) (0.64-1.04)

Total Cancer, Excluding Lung

 Cases 492 351 49 33 57 34 127

 RRc 0.91 1.00 1.35 0.90 1.00 0.79 1.06

 RRd 0.99 1.00 1.37 0.97 1.12 0.91 1.10

(0.86-1.13) (0.95-1.95) (0.63-1.47) (0.80-1.57) (0.60-1.39) (0.84-1.42)

External Causes of Death

 Cases 90 103 11 8 8 5 25

 RRc 0.59 1.00 1.11 0.81 0.55 0.41 0.68

 RRd 0.60 1.00 1.22 0.99 0.63 0.70 0.72

(0.45-0.80) (0.57-2.54) (0.41-2.39) (0.26-1.53) (0.25-1.99) (0.41-1.27)

a Reference category consists of current smokers.

Time since quitting was missing for 138 cases, including 27 cardiovascular disease deaths, 9 lung cancer deaths,

66 deaths from cancers other than lung, 11 accidents or suicides, and 25 deaths from all other causes.

c Age-adjusted RR—95-percent CI in parentheses.

d Multivariate RR, adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982

to 1984, 1984 to 1986, or 1986 to 1988), body mass index, history of hypertension, diabetes, high cholesterol levels,

postmenopausal estrogen therapy, menopausal status, past use of oral contraceptives, parental history of myocardial

infarction before age 60, and daily number of cigarettes smoked during the period prior to stopping smoking.

Key: RR = relative risk; CI = confidence interval.
541

Chapter 8

Figure 1

Risk of total mortality by time since quitting. Multivariate RRa of total mortality by time since

quitting (reference category: current smokers). Error bars represent 95-percent CIs.

In terms of absolute risk, if 1,000 women ages 40 to 44 years quit

smoking today, approximately 17 deaths would occur over the next 14 years,

compared with 30 deaths if they had continued smoking; that is, a net

saving of 13 lives per 1,000 women over a 14-year period. The absolute

benefits of cessation increase with age. Thus, if 1,000 women age 60 or older

quit smoking today, approximately 103 deaths would occur over a period of

14 years compared with 138 deaths if they had continued smoking; that is,

a net saving of 35 lives per 1,000 women.

A slight increase in relative risks was apparent in the category of former

smokers who had quit for more than 15 years compared with those who

had quit for 10 to 14 years. This was compatible with chance because the

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

Current

Smoker

<2 2-4 5-9 10-14 ≥15 NeverSmoker

Years Since Stopping Smoking

Relative Risk of Total Mortality

a Nonfatal CHD, stroke, and cancer (except nonmelanoma skin cancer) were excluded at baseline and at the

beginning of each successive 2-year followup period. Variables in model include age in 5-year categories, followup

period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984 to 1986, or 1986 to 1988), body mass index,

history of hypertension, high cholesterol, diabetes, parental history of myocardial infarction before age 60,

postmenopausal estrogen therapy, menopausal status, past use of oral contraceptives, age at starting smoking,

and daily number of cigarettes consumed during the period prior to cessation.

Key: RR = relative risk; CI = confidence interval.
542

Smoking and Tobacco Control Monograph No. 8

95-percent CIs of the relative risks beyond 10 years of cessation excluded the

point estimates of the risks among former smokers who had quit for shorter

durations; however, we cannot exclude the possibility that a small excess in

risk extends beyond 15 years of abstinence.

Cause-Specific Mortality. For CVD, a 24-percent reduction in the risk of

mortality was apparent within 2 years of giving up cigarettes; however, the

excess risk did not approach the level of never-smokers until 10 to 14 years

after cessation. For deaths from external causes of injury, the age-adjusted

relative risks among former smokers fell to the level of never-smokers 5 to

9 years after cessation (Table 3).

A greater risk of total cancer was observed among former smokers

compared with current smokers in the first 2 years following cessation

(age-adjusted RR, 1.42; CI, 1.12 to 1.81). The excess risk fell to the level of

never-smokers 10 to 14 years after cessation. However, when lung cancer

was excluded from the analysis of total cancer mortality, an excess risk was

apparent only within the first 2 years of quitting (age-adjusted RR, 1.35;

CI, 1.00 to 1.81) (Table 3).

The observations regarding the relationship of time since quitting

with the risks of total and cause-specific mortality remained unchanged

after controlling for potential confounding factors, including history of

hypertension, diabetes, high serum cholesterol, relative weight, parental

history of MI before age 60, past use of oral contraceptives, postmenopausal

estrogen therapy, the daily number of cigarettes used, and age at starting

(Table 3).

Age at Starting Current Smokers. We examined the relationship between age at

To Smoke starting and risk of total and cause-specific mortality among current

smokers (Table 4). The relative risk of total mortality among current smokers

who started smoking before age 15 was 2.80 (CI, 2.05 to 3.82), whereas for

those who started after age 26 or older, the relative risk was 1.59 (CI, 1.28 to

1.97) (p, trend = 0.01). Starting smoking before age 15 was associated with

the highest risk of death from CVD (age-adjusted RR, 8.72; CI, 5.58 to 13.65)

and external causes of injury (age-adjusted relative risk, 3.22; CI, 1.37 to

7.55). Adjusting for multiple risk factors, including the daily number of

cigarettes smoked, did not materially affect these observations (Table 4).

Former Smokers. Among former smokers the relationship between age

at starting and the risks of total and cause-specific mortality was weaker and

not statistically significant. These observations remained unchanged after

adjusting for multiple risk factors, including the daily number of cigarettes

consumed as well as time since quitting.

Assessment of Previous studies have suggested that recent quitters include a

the "Ill-Quitter" disproportionate number of those who have quit because they are ill

Effect (U.S. Department of Health and Human Services, 1990). This causes

a spuriously elevated risk of mortality among former smokers during the

early years following cessation. To address this problem, we carried out
543

Chapter 8

Table 4

Total and cause-specific mortality by age at starting smoking among current smokers:

Age-adjusted and multivariate RR’s

Age at Starting To Smoke Among Current Smokersa

NeverEvent Smoker <15 Years 15-17 18-21 22-25 ≥26 Years

Total Mortality

 Cases 933 38 175 657 149 88

 RRb 1.00 2.80 1.86 1.88 1.95 1.59

 RRc 1.00 3.15 1.85 1.77 1.86 1.45

(2.16-4.59) (1.51-2.28) (1.54-2.03) (1.50-2.32) (1.15-1.92)

Cardiovascular Disease

 Cases 131 15 41 157 47 24

 RRb 1.00 8.72 3.43 3.32 4.18 2.99

 RRc 1.00 9.94 3.55 3.18 4.06 2.88

(5.15-19.19) (2.27-5.56) (2.36-4.28) (2.65-6.21) (1.70-4.87)

Total Cancer, Including Lung

 Cases 516 11 77 300 73 38

 RRb 1.00 1.46 1.48 1.54 1.70 1.23

 RRc 1.00 1.64 1.43 1.43 1.69 1.10

(0.84-3.20) (1.06-1.93) (1.18-1.74) (1.24-2.29) (0.75-1.62)

Total Cancer, Excluding Lung

 Cases 492 6 52 201 56 33

 RRb 1.00 0.84 1.05 1.08 1.36 1.11

 RRc 1.00 0.88 1.07 1.00 1.35 1.00

(0.37-2.11) (0.75-1.52) (0.80-1.25) (0.96-1.90) (0.66-1.51)

External Causes of Death

 Cases 90 5 21 61 8 7

 RRb 1.00 3.22 2.00 1.69 1.22 1.39

 RRc 1.00 5.39 2.01 1.69 1.27 1.73

(1.84-15.78) (1.11-3.65) (1.09-2.61) (0.54-2.99) (0.75-4.03)

a Age at starting smoking was unknown for eight cases, including three deaths from cancers other than lung, one

accident or suicide, and four deaths from all other causes.

b Age-adjusted RR—95-percent CIs in parentheses.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, postmenopausal estrogen therapy, menopausal status, parental history of myocardial infarction before

age 60, and daily number of cigarettes consumed.

Key: RR = relative risk; CI = confidence interval.
544

Smoking and Tobacco Control Monograph No. 8

analyses in which women who reported nonfatal CVD (MI, angina, stroke) or

cancer (excluding nonmelanoma skin cancer) at each biennial questionnaire

were excluded from further followup. These exclusions left 1,980 deaths

for analysis (Tables 5 and 6). Among current smokers, the strength of the

association between daily number of cigarettes and risk of total mortality

increased after excluding diseases at the beginning of each 2-year interval

(Table 5). When we examined the relationship of time since quitting with

risk of cancer mortality (including and excluding lung cancer), there was

no longer an excess risk apparent among former smokers within the first

2 years of quitting, suggesting an association between cancer diagnosis and

stopping smoking (Table 6).

Assessment of As explained in "Methods," in a prospective study involving

Confounding by repeated measurement of smoking status, nonfatal disease may

Intermediate act simultaneously as a confounding factor and an intermediate

Variables variable in the pathway between smoking and mortality (Robins,

1987 and 1989). We assessed the extent of such confounding by applying

a method previously described (Robins, 1987 and 1989) to the association

between cigarette smoking and fatal CHD, with nonfatal MI as the

intermediate variable. When we performed this analysis, the risk estimate

of CHD mortality was virtually identical to the crude estimate of risk.

Therefore, we concluded that confounding by intermediate variables

was unlikely to be a concern in the present study.

Assessment of To examine the possible confounding effect of alcohol

Confounding by consumption and vigorous exercise on cigarette smoking,

Alcohol Intake and we analyzed data from the 1980 to 1988 followup interval.

Vigorous Exercise Although the analysis was limited to 2,356 deaths in total,

the age-adjusted association between daily number of cigarettes used and

risk of total mortality remained virtually unchanged. The relative risk of

total mortality increased from 1.56 (CI, 1.28 to 1.91) among women using

1 to 14 cigarettes per day to 2.53 (CI, 1.95 to 3.24) among women using

35 or more cigarettes per day. After adjusting for alcohol consumption and

vigorous exercise, the risk of total mortality among former smokers still

declined to the level of never-smokers 10 to 14 years after cessation.

Adjusting for alcohol intake and vigorous exercise resulted in a slight

strengthening of the association between current smoking and CVD

mortality. For example, the multivariate relative risk of CVD mortality

increased from 2.69 to 3.08 among women using 1 to 14 cigarettes per day

and from 4.28 to 4.93 among women using 25 to 34 cigarettes per day.

However, the excess risk of CVD death among former smokers still took

10 to 14 years to decline to the level of never-smokers.

The risk of death from external causes of injury among current smokers

compared with never-smokers fell from 1.69 (CI, 1.28 to 2.24) to 1.54 (CI,

1.10 to 2.17) after adjusting for alcohol intake and vigorous exercise. The

excess risk among former smokers still approached the level of never-smokers

5 to 9 years after cessation.
545

Chapter 8

Table 5

Total and cause-specific mortality by daily number of cigarettes consumed. Comparison of

analyses with and without 2-year exclusion of disease at the start of each period: Multivariate

RR’s

Cigarettes Used/Day Among Current Smokers

Never- Former

Event Smoker Smoker 1-14 15-24 25-34 >35

Total Mortality

 Casesa 933 799 234 480 215 153

 RR 1.00 1.29 1.51 2.02 2.09 2.63

 Casesb 632 410 176 381 175 130

 RR 1.00 1.15 1.56 2.17 2.23 3.16

(1.01-1.29) (1.26-1.94) (1.82-2.59) (1.77-2.80) (2.49-4.02)

Cardiovascular Disease

 Casesa 131 151 56 124 57 37

 RR 1.00 1.57 2.69 4.25 4.28 5.64

 Casesb 111 106 47 114 52 33

 RR 1.00 1.48 2.48 3.99 4.35 5.82

(1.13-1.94) (1.61-3.82) (2.84-5.59) (2.83-6.69) (3.50-9.69)

Total Cancer, Including Lung

 Casesa 516 438 95 233 93 67

 RR 1.00 1.28 1.05 1.68 1.62 1.95

 Casesb 262 172 51 168 64 50

 RR 1.00 1.03 1.11 2.13 1.82 2.96

(0.85-1.26) (0.76-1.62) (1.62-2.81) (1.24-2.65) (2.03-4.34)

Total Cancer, Excluding Lung

 Casesa 492 366 83 161 61 36

 RR 1.00 1.11 1.02 1.23 1.09 1.15

244 140 43 100 33 22

 RR 1.00 0.90 1.03 1.44 0.95 1.41

(0.73-1.11) (0.68-1.55) (1.05-1.99) (0.58-1.57) (0.82-2.40)

a Cases and multivariate RR’s after baseline exclusion of coronary heart disease, stroke, and cancer except

nonmelanoma skin cancer. Multivariate RR were adjusted for age in 5-year intervals, followup period (1976 to 1978,

1978 to 1980, 1980 to 1982, 1982 to 1984, 1984 to 1986, or 1986 to 1988), body mass index, history of hypertension,

high cholesterol levels, diabetes, parental history of myocardial infarction before age 60, postmenopausal estrogen

therapy, menopausal status, past use of oral contraceptives, and age at starting smoking.

b Cases and multivariate RR’s after exclusion of coronary heart disease, stroke, and cancer (except nonmelanoma skin

cancer) at the beginning of each 2-year followup interval (95-percent CI in parentheses).

Key: RR = relative risk; CI = confidence interval.
546

Smoking and Tobacco Control Monograph No. 8

Table 6

Total and cause-specific mortality by time since quitting. Comparison of analyses with and

without 2-year exclusion of disease at the start of each followup period: Multivariate RR’s

Years Since Quitting Among Former Smokers

Never- Current

Event Smoker Smoker <2 2-4 5-9 10-14 >15

Total Mortality

 Casesa 933 1,115 127 106 131 66 231

 RR 0.56 1.00 1.19 1.00 0.79 0.53 0.61

 Casesb 632 884 51 58 84 46 137

 RR 0.49 1.00 0.76 0.73 0.70 0.47 0.49

(0.44-0.54) (0.53-1.08) (0.53-1.01) (0.53-0.92) (0.33-0.67) (0.39-0.62)

Cardiovascular Disease

 Casesa 131 284 20 24 32 9 39

 RR 0.30 1.00 0.76 0.90 0.75 0.29 0.42

 Casesb 111 254 11 11 23 7 33

 RR 0.29 1.00 0.63 0.53 0.67 0.27 0.46

(0.23-0.37) (0.28-1.45) (0.25-1.13) (0.40-1.15) (0.11-0.65) (0.29-0.74)

Total Cancer, Including Lung

 Casesa 516 502 75 48 69 37 134

 RR 0.99 1.00 1.37 0.97 1.12 0.91 1.10

 Casesb 562 339 13 19 33 20 53

 RR 0.54 1.00 0.42 0.66 0.75 0.56 0.51

(0.46-0.64) (0.20-0.89) (0.38-1.16) (0.49-1.16) (0.33-0.96) (0.35-0.74)

Total Cancer, Excluding Lung

 Casesa 492 351 49 33 57 34 127

 RR 0.60 1.00 1.22 0.99 0.63 0.70 0.72

 Casesb 244 201 9 11 25 18 50

 RR 0.85 1.00 0.44 0.71 1.03 0.85 0.81

(0.71-1.03) (0.18-1.08) (0.34-1.48) (0.63-1.69) (0.48-1.51) (0.54-1.20)

a Cases and multivariate RR’s after baseline exclusion of coronary heart disease, stroke, and cancer except

nonmelanoma skin cancer. Multivariate RR’s were adjusted for age in 5-year intervals, followup period (1976 to 1978,

1978 to 1980, 1980 to 1982, 1982 to 1984, 1984 to 1986, or 1986 to 1988), body mass index, history of hypertension,

diabetes, high cholesterol levels, postmenopausal estrogen therapy, menopausal status, past use of oral

contraceptives, parental history of myocardial infarction before age 60, and daily number of cigarettes smoked during

the period prior to stopping smoking (95-percent CIs in parentheses).

b Cases and multivariate RR’s after exclusion of coronary heart disease, stroke, and cancer (except nonmelanoma skin

cancer) at the beginning of each 2-year followup interval.

Key: RR = relative risk; CI = confidence interval.
547

Chapter 8

Results for Stroke During the 12 years of observation, 448 incident cases of

Incidence definite stroke occurred during 1,372,918 person-years.

Theses consisted of 275 ischemic strokes, 108 subarachnoid

Risks of Current hemorrhages, 53 cerebral hemorrhages, and 12 strokes that

Smokers were classified as "unspecified."

Compared with women who had never smoked, current smokers

experienced substantially higher rates of stroke (Table 7). For all types of

stroke combined, the overall age-adjusted relative risk among current

smokers was 2.58 (95-percent CI: 2.08-3.19). However, the relative risks

differed considerably for subtypes of stroke: 4.96 (95-percent CI: 3.13-7.87)

for subarachnoid hemorrhage, 2.25 (95-percent CI: 1.72-2.95) for ischemic

stroke, and 1.46 (95-percent CI: 0.77-2.78) for cerebral hemorrhage. The risk

of stroke increased with the number of cigarettes smoked daily (Table 2).

Within the category of smokers of 35 or more cigarettes per day, women

who smoked 35 to 44 cigarettes per day had a relative risk of total stroke

of 4.05 (95-percent CI: 2.78-5.91) compared with never-smokers, whereas

women who smoked 45 or more cigarettes per day had a relative risk of

5.38 (95-percent CI: 2.59-11.18) (p, trend = 0.0004).

A statistically significant dose-response relationship also was found

between daily cigarette consumption and the risk of ischemic stroke (p, trend

= 0.03). There was a strong dose-response relationship between daily number

of cigarettes smoked and risk of subarachnoid hemorrhage (Table 7). Within

the category of smokers of 1 to 14 cigarettes per day, women who smoked

1 to 4 cigarettes per day had a relative risk of subarachnoid hemorrhage of

3.26 (95-percent CI: 1.03-10.33) compared with never-smokers, whereas

women who smoked 5 to 14 cigarettes per day had a relative risk of 3.83

(95-percent CI: 1.88-7.80) (p, trend < 0.0004).

The association between cigarette smoking and total stroke, ischemic

stroke, and subarachnoid hemorrhage persisted after control for potential

confounders in multivariate proportional hazards models (Table 7).

As expected, positive associations were found for known risk factors for

stroke, such as history of high blood pressure (RR = 1.93, 95-percent CI:

1.51-2.48) and diabetes (RR = 3.57, 95-percent CI: 2.38-5.36). However,

no associations were found between risk of total stroke and history

of high serum cholesterol (RR = 0.99, 95-percent CI: 0.66-1.49), use of

postmenopausal estrogen therapy (RR = 1.15, 95-percent CI: 0.88-1.51),

or past use of oral contraceptives (RR = 1.12, 95-percent CI: 0.91-1.39).

Too few cases of stroke (n = 2) occurred among current users of oral

contraceptives to permit meaningful analysis.

Decline in Risk The risk of total stroke for former smokers was intermediate between

Among Former nonsmokers and current smokers (RR = 1.34, 95-percent CI: 1.04-1.73).

Smokers In the analyses of the relationship of time since stopping smoking with

risks of total stroke as well as various subtypes (Table 8), we used current

smokers as the reference category. For less than 2 years after cessation, the

age-adjusted relative risk among former smokers compared with continuing
548

Smoking and Tobacco Control Monograph No. 8

Table 7

Age-adjusted RR’s of stroke (fatal and nonfatal combined), by daily number of cigarettes

consumed among current smokers

Never- Former Current

Event Smoker Smoker Smoker 1-14 15-24 25-34 >35

Total Stroke

 Cases 126 114 208 40 92 38 34

 RRb 1.00 1.34 2.58 1.79 2.84 2.70 4.23

(1.04-1.73) (2.08-3.19) (1.26-2.54) (2.19-3.67) (1.91-3.84) (2.99-6.00)

 RRc 1.00 1.35 2.73 2.02 3.34 3.08 4.48

(0.98-1.85) (2.18-3.41) (1.29-3.14) (2.38-4.70) (1.94-4.87) (2.78-7.23)

Subarachnoid

Hemorrhage

 Cases 19 25 64 13 21 17 11

 RRb 1.00 2.01 4.96 3.68 4.05 7.31 8.28

(1.12-3.61) (3.13-7.87) (1.91-7.11) (2.30-7.14) (4.15-12.85) (4.45-15.42)

 RRc 1.00 2.26 4.85 4.28 4.02 7.95 10.22

(1.16-4.42) (2.90-8.11) (1.88-9.77) (1.90-8.54) (3.50-18.07) (4.03-25.94)

Ischemic Stroke

 Cases 85 70 120 23 58 19 18

 RRb 1.00 1.20 2.25 1.54 2.69 2.06 3.43

(0.88-1.65) (1.72-2.95) (0.98-2.44) (1.95-3.72) (1.27-3.36) (2.13-5.51)

 RRc 1.00 1.27 2.53 1.83 3.57 2.73 3.97

(0.85-1.89) (1.91-3.35) (1.04-3.23) (2.36-5.42) (1.49-5.03) (2.09-7.53)

Cerebral Hemorrhage

 Cases 19 16 18 4 10 <-------- 4d ---------->

 RRb 1.00 1.27 1.46 1.18 2.01 1.18

(0.66-2.44) (0.77-2.78) (0.40-3.46) (0.94-4.28) (0.41-3.46)

 RRc 1.00 1.24 1.24 1.68 2.53 1.41

(0.64-2.42) (0.64-2.42) (0.34-5.28) (0.71-6.05) (0.39-5.05)

a Cigarettes smoked per day were unknown for four cases, including two subarachnoid hemorrhage and two ischemic

stroke.

b Age-adjusted RR.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, postmenopausal estrogen therapy, and age at starting smoking.

d These two categories were combined due to small numbers.

Key: RR = relative risk.
549

Chapter 8

smokers was 0.78, that is, a reduction in risk by 22 percent compared with

continuing smokers. Nevertheless, this level of risk among former smokers

was still about double that among never-smokers. During the interval

between 2 and 4 years following cessation, the relative risk among former

smokers was 0.46 (95-percent CI: 0.25-0.85). This indicated that almost

90 percent of the full potential benefit of cessation had occurred within those

first 2 to 4 years, as the relative risk for never-smokers compared with current

smokers was 0.39 (95-percent CI: 0.31-0.48) (Figure 2). Using never-smokers

as the reference category, the age-adjusted relative risk of total stroke was

2.58 (95-percent CI: 2.08-3.19) among current smokers and was 1.17

(95-percent CI: 0.49-2.23) among former smokers who had stopped for 2 to

4 years. A similar pattern of decline was apparent after adjusting for other

risk factors for stroke and daily number of cigarettes smoked in the followup

period prior to stopping (Table 8).

To examine the possible confounding effect of alcohol consumption on

cigarette smoking, we analyzed data from the 1980 to 1988 followup interval.

Even after adjusting for alcohol consumption, the relationship of time since

stopping smoking with risk of stroke remained virtually unchanged.

Similarly adjusting for alcohol intake made virtually no difference to the

relative risk estimate of daily number of cigarettes smoked and risks of stroke.

Subtypes Within subtypes of stroke, the number of events occurring in

of Stroke former smokers was small so that the age-adjusted relative risk

estimates tended to be imprecise, with correspondingly wide 95-percent CIs.

For ischemic stroke, the point estimate of the age-adjusted relative risk

among former smokers fell by 46 percent compared with current smokers

within the first 2 years after stopping, a fall that represented about 80 percent

of the potential benefit of stopping smoking. The risk among former

smokers returned to the level of never-smokers during the interval between

2 and 4 years following cessation. After adjusting for other risk factors for

ischemic stroke as well as for the daily number of cigarettes consumed and

the age at starting, between 60 and 70 percent of the potential benefit of

cessation still occurred within 2 years of cessation (Table 8).

The risk of subarachnoid hemorrhage among former smokers similarly

fell with increasing duration since cessation. After more than 5 years, the

age-adjusted relative risk of subarachnoid hemorrhage among former

smokers had returned to the level of never-smokers (RR = 0.24, 95-percent CI:

0.09-0.60). The few cerebral hemorrhages occurring among former smokers

precluded our ability to carry out a meaningful analysis (Table 8).

Age at Starting We analyzed, separately for former and current smokers, the

To Smoke relationship of age at starting smoking with risks of stroke. Among

current smokers, there appeared to be no relationship of the age at starting

smoking with the age-adjusted relative risk of total stroke (p, trend = 0.76) or

subtypes (Table 9). These findings remained unchanged after adjusting for

other covariates, including the daily number of cigarettes consumed.
550

Smoking and Tobacco Control Monograph No. 8

Table 8

Age-adjusted RR’s of strokes (fatal and nonfatal combined), by time since quitting

Years Since Quittinga

Never- Current

Event Smoker Smoker <2 2-4 5-9 10-14 >15

Total Stroke

 Cases 126 208 17 10 13 16 29

 RRb 0.39 1.00 0.78 0.46 0.39 0.62 0.40

(0.31-0.48) (0.48-1.28) (0.25-0.85) (0.22-0.67) (0.38-1.03) (0.27-0.58)

 RRc 0.37 1.00 0.73 0.59 0.39 0.60 0.39

(0.29-0.46) (0.40-1.33) (0.28-1.21) (0.20-0.77) (0.32-1.12) (0.24-0.64)

Subarachnoid

Hemorrhage

 Cases 19 64 7 4 <------- 4d

 ------> 7

 RRb 0.20 1.00 1.12 0.64 0.24 0.31

(0.13-0.32) (0.52-2.44) (0.23-1.73) (0.09-0.60) (0.15-0.64)

 RRc 0.21 1.00 1.12 0.84 0.26 0.34

(0.12-0.34) (0.42-2.99) (0.25-2.78) (0.08-0.85) (0.13-0.90)

Ischemic Stroke

 Cases 85 120 7 3 11 11 15

 RRb 0.44 1.00 0.54 0.23 0.55 0.73 0.36

(0.34-0.58) (0.26-1.15) (0.08-0.66) (0.30-1.02) (0.39-1.34) (0.21-0.60)

 RRc 0.40 1.00 0.56 0.96 0.50 0.69 0.35

(0.30-0.52) (0.22-1.40) (0.27-3.45) (0.23-1.07) (0.32-1.48) (0.17-0.70)

a Years since quitting was missing for 29 cases, including 3 subarachnoid hemorrhage, 23 ischemic stroke, and

3 cerebral hemorrhage.

b Age-adjusted RR.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of

oral contraceptives, postmenopausal estrogen therapy, and daily number of cigarettes consumed.

d These two categories were combined due to small numbers.

Key: RR = relative risk.

By contrast, the earlier the age at starting among former smokers, the

higher the age-adjusted relative risk of total stroke (p, trend = 0.01). This

effect was caused mainly by the trend observed for ischemic stroke (p,

trend = 0.01) but not for subarachnoid hemorrhage (p, trend = 0.55)

(Table 10). These findings remained unchanged after adjusting for other

covariates, including the daily number of cigarettes consumed as well as

time since stopping. Too few cases of cerebral hemorrhage occurred among

former smokers to permit analysis.
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Chapter 8

Figure 2

Risk of total stroke by time since quitting

Results for Coronary During 12 years of followup, 970 incident cases of definite

Heart Disease and probable CHD occurred during 1.37 million person-years.

Incidence These included 745 cases of nonfatal MI and 225 cases of

fatal CHD.

Risks Among Compared with women who had never smoked, current

Current Smokers smokers experienced substantially higher rates of CHD rates

of CHD (Table 11). The age-adjusted relative risk among current smokers was

4.13 (95-percent CI: 3.04-5.63) for fatal CHD, 3.88 (95-percent CI: 3.28-4.58)

for nonfatal MI, and 3.93 (95-percent CI: 3.39-4.55) for total CHD. Risk

increased steeply with the number of cigarettes smoked so that women

who smoked 45 or more cigarettes per day had age-adjusted relative risks

of 10.00 (95-percent CI: 4.35-22.97) for fatal CHD, 4.64 (95-percent CI: 2.34-

9.21) for nonfatal MI, and 5.74 (95-percent CI: 3.36-9.81) for total CHD.

Even women consuming just 1 to 4 cigarettes per day doubled their risk of

total CHD compared with never-smokers (age-adjusted RR = 1.94, 95-percent

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

Current

Smoker

<2 2-4 5-9 ≥10 NeverSmoker

Years Since Stopping Smoking

Relative Risk of Total Stroke

Note: Age-adjusted relative risk of total stroke in relation to time since stopping smoking. Current smoker was the

reference category. Error bars represent 95-percent confidence intervals.
552

Smoking and Tobacco Control Monograph No. 8

Table 9

Age-adjusted RR’s of stroke (fatal and nonfatal combined), by age at starting smoking among

current smokers

Age at Starting To Smoke Among Current Smokersa

NeverEvent Smoker <15 Years 15-17 18-21 22-25 >26 Years

Total Stroke

 Cases 126 6 36 107 32 23

 RRb 1.00 3.44 2.92 2.27 3.00 3.01

(1.60-7.41) (2.04-4.18) (1.76-2.92) (2.08-4.34) (1.97-4.59)

 RRc 1.00 3.62 3.26 2.37 3.42 3.35

(1.41-9.28) (2.00-5.31) (1.68-3.35) (2.09-5.61) (1.98-5.68)

Subarachnoid

Hemorrhage

 Cases 19 1 10 38 7 6

 RRb 1.00 3.26 4.65 4.97 4.71 5.44

(0.50-21.34) (2.30-9.38) (3.03-8.16) (2.14-10.37) (2.39-12.35)

 RRc 1.00 7.57 5.02 4.76 4.89 6.78

(0.68-84.07) (1.90-13.24) (2.50-9.08) (1.74-13.75) (2.21-20.81)

Ischemic Stroke

 Cases 85 4 21 58 19 16

 RRb 1.00 3.53 2.62 1.86 2.60 3.07

(1.38-9.00) (1.65-4.17) (1.34-2.59) (1.61-4.20) (1.85-5.12)

 RRc 1.00 5.96 3.16 2.08 3.15 3.79

(1.81-19.65) (1.69-5.90) (1.34-3.24) (1.68-5.90) (2.01-7.15)

a Age at starting was missing for four cases, including two subarachnoid hemorrhage and two ischemic stroke.

b Age-adjusted RR.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, postmenopausal estrogen therapy, and daily number of cigarettes consumed.

Key: RR = relative risk.

CI: 1.23-3.08). To check the possibility that women who report smoking

1 to 4 cigarettes per day may represent a group who cut down from a

previously high level of smoking, we reanalyzed the data by fixing

smoking habits at baseline, that is, without updating the daily number

smoked after each 2-year followup period. Smoking 1 to 4 cigarettes per

day was still associated with a doubling of CHD risk (RR = 2.04, 95-percent

CI: 1.32-3.16).

The strength of association between current cigarette smoking

and total CHD remained unchanged after controlling for potential

confounders, including body mass index, history of hypertension,

diabetes, high cholesterol levels, previous use of oral contraceptives,

use of postmenopausal estrogen therapy, menopausal status, parental

history of MI before age 60, and age at starting smoking.
553

Chapter 8

Table 10

Age-adjusted RR’s of stroke (fatal and nonfatal combined), by age at starting smoking among

former smokers

Age at Starting To Smoke Among Former Smokersa

NeverEvent Smoker <15 Years 15-17 18-21 22-25 >26 Years

Total Stroke

 Cases 126 3 24 65 12 4

 RRb 1.00 2.11 2.10 1.22 1.08 0.78

(0.69-6.45) (1.37-3.22) (0.91-1.65) (0.60-1.95) (0.29-2.10)

 RRc 1.00 4.30 2.07 1.23 1.14 1.30

(1.15-16.00) (1.22-3.51) (0.85-1.80) (0.57-2.28) (0.48-3.52)

Subarachnoid

Hemorrhage

 Cases 19 0 7 13 3 1

 RRb 1.00 3.67 1.62 2.14 1.60

(1.63-8.25) (0.80-3.25) (0.65-7.06) (0.22-11.50)

 RRc 1.00 1.78 1.65 3.96 9.21

(0.64-4.92) (0.72-3.78) (0.92-16.99) (1.43-59.32)

Ischemic Stroke

 Cases 85 3 15 37 9 2

 RRb 1.00 3.21 2.00 1.03 1.16 0.54

(1.08-9.49) (1.17-3.41) (0.70-1.52) (0.58-2.30) (0.13-2.20)

 RRc 1.00 7.27 1.97 1.02 1.14 0.81

(1.82-29.02) (1.02-3.81) (0.63-1.67) (0.51-2.57) (0.17-3.80)

a Age at starting was missing for six cases, including one subarachnoid hemorrhage, four ischemic stroke, and one

cerebral hemorrhage.

b Age-adjusted RR.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, postmenopausal estrogen therapy, and daily number of cigarettes consumed.

Key: RR = relative risk.

To examine the possible confounding effects of alcohol consumption

and vigorous physical exercise on cigarette smoking, we analyzed data from

the 1980 to 1988 followup interval. Controlling for these two additional

variables resulted in little change in the strength of the observed association

between smoking and total CHD risk.

Decline in Risk Risk of CHD among former smokers was intermediate between neverAmong Former smokers and current smokers. Compared with never-smokers, the

Smokers age-adjusted relative risk among former smokers was 1.63 (95-percent

CI: 1.11-2.40) for fatal CHD, 1.47 (95-percent CI: 1.19-1.83) for nonfatal MI,

and 1.51 (95-percent CI: 1.25-1.82) for total CHD. The relationship of time

since stopping with CHD risk was examined (Table 12). In Table 12, the

"baseline" consists of persisting active smokers. Thus never-smokers are at

approximately one-fifth the risk of total CHD compared with continuing
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Smoking and Tobacco Control Monograph No. 8

Table 11

Daily number of cigarettes smoked and age-adjusted and multivariate RR’s of fatal coronary

heart disease and nonfatal myocardial infarction, compared with never-smokers

Cigarettes Smoked/Day Among Current Smokersa

Never- Former

Event Smoker Smoker 1-4 5-14 15-24 25-34 35-44 >45

Fatal Coronary Heart Disease

 Cases 49 53 4 18 53 28 14 4

 RRb 1.00 1.63 1.87 2.78 4.29 5.36 5.56 10.00

(1.11-2.40) (0.69-5.09) (1.66-4.67) (3.00-6.15) (3.53-8.14) (3.26-9.50) (4.35-22.97)

 RRc 1.00 1.62 <---- 2.85 ----> 4.85 6.96 <---- 7.84 ---->

(1.09-2.40) (1.53-5.32) (3.01-7.81)(3.90-12.43) (3.71-16.57)

Nonfatal Myocardial Infarction

 Cases 166 161 15 56 189 95 54 7

 RRb 1.00 1.47 1.97 2.46 4.21 4.87 5.58 4.64

(1.19-1.83) (1.17-3.30) (1.83-3.29) (3.48-5.11) (3.87-6.13) (4.24-7.35) (2.34-9.21)

 RRc 1.00 1.44 <---- 2.45 ----> 4.77 5.21 <---- 5.32 ---->

(1.16-1.79) (1.69-3.56) (3.64-6.26) (3.73-7.28) (3.61-7.86)

Total Coronary Heart Disease

 Cases 215 214 19 74 242 123 68 11

 RRb 1.00 1.51 1.94 2.53 4.22 4.97 5.57 5.74

(1.25-1.82) (1.23-3.08) (1.96-3.26) (3.56-5.00) (4.06-6.08) (4.36-7.11) (3.36-9.81)

 RRc 1.00 1.48 <---- 2.53 ----> 4.79 5.49 <---- 5.49 ---->

(1.22-1.79) (1.84-3.50) (3.78-6.08) (4.10-7.35) (3.87-7.77)

a Daily number smoked was missing for four cases, including two cases of fatal coronary heart disease and two

nonfatal myocardial infarction.

b Age-adjusted RR.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, menopausal status, postmenopausal estrogen therapy, and age at starting smoking.

Key: RR = relative risk.

smokers. Within 2 years of cessation, the age-adjusted relative risk among

former compared with current smokers was 0.53 (95-percent CI: 0.25-1.12)

for fatal CHD, 0.85 (95-percent CI: 0.60-1.19) for nonfatal MI, and 0.77

(95-percent CI: 0.57-1.05) for total CHD. Although nearly one-third of the

excess risk of total CHD was removed within 2 years of smoking, the risk

among former smokers did not decline to the level of never-smokers until

10 years after cessation. This finding remained unchanged after adjusting

for other cardiovascular risk factors, daily number of cigarettes smoked

before stopping, and age at starting smoking.

To examine the possible confounding effects of alcohol consumption

and vigorous physical exercise on the relationship of time since stopping

with CHD risk, we analyzed data from the 1980 to 1988 followup interval.

Controlling for these variables resulted in a slight increase in the relative risks

of total CHD across categories of former smokers; however, it did not alter
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Chapter 8

Table 12

Time since quitting and age-adjusted and multivariate RR’s of fatal coronary heart disease and

nonfatal myocardial infarction, compared with current smokers

Years Since Quittinga

Never- Current

Event Smoker Smoker <2 2-4 5-9 10-14 ≥15

Fatal Coronary Heart Disease

 Cases 49 123 7 9 14 4 13

 RRb 0.24 1.00 0.53 0.68 0.68 0.26 0.31

(0.18-0.33) (0.25-1.12) (0.35-1.34) (0.39-1.19) (0.10-0.65) (0.18-0.53)

 RRc 0.23 1.00 1.47 0.58 0.72 0.28 0.32

(0.17-0.33) (0.42-5.20) (0.23-1.44) (0.36-1.42) (0.09-0.87) (0.16-0.66)

Nonfatal Myocardial Infarction

 Cases 166 418 36 22 26 13 41

 RRb 0.26 1.00 0.85 0.51 0.40 0.26 0.29

(0.22-0.30) (0.60-1.19) (0.34-0.78) (0.27-0.59) (0.15-0.43) (0.21-0.39)

 RRc 0.24 1.00 0.81 0.43 0.38 0.26 0.27

(0.20-0.28) (0.51-1.29) (0.25-0.74) (0.23-0.62) (0.13-0.49) (0.18-0.41)

Total Coronary Heart Disease

 Cases 215 541 43 31 40 17 54

 RRb 0.25 1.00 0.77 0.55 0.47 0.26 0.29

(0.22-0.30) (0.57-1.05) (0.39-0.79) (0.34-0.64) (0.17-0.40) (0.23-0.38)

 RRc 0.24 1.00 0.75 0.46 0.44 0.26 0.28

(0.20-0.28) (0.49-1.15) (0.29-0.74) (0.30-0.66) (0.14-0.45) (0.20-0.40)

a Years since quitting was missing for 29 cases, including 6 fatal coronary heart disease and 23 nonfatal myocardial

infarction.

b Age-adjusted RR.

c Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, menopausal status, postmenopausal estrogen therapy, parental history of myocardial infarction before

age 60, and daily number of cigarettes consumed.

Key: RR = relative risk.

the conclusion that 10 years of cessation were required for the risk to drop

to the level of never-smokers.

Age at Starting We analyzed, separately for former and current smokers, the

To Smoke relationship of age at starting smoking with the risk of CHD.

Among current smokers, the risk of CHD was increased at any age of starting

to smoke. However, those who started to smoke before age 15 had the

highest age-adjusted relative risks for total CHD (7.17, 95-percent CI:

4.88-10.53) (Table 13). After adjusting for potential confounding factors,

including daily number of cigarettes smoked, the relative risk for those

starting to smoke before age 15 increased to 9.25 (95-percent CI: 5.27-16.23).

The confidence interval of this estimate excluded those of other categories of

age at starting.
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Smoking and Tobacco Control Monograph No. 8

Table 13

Age at starting to smoke among current and former smokers and age-adjusted and multivariate

RR’s of total coronary heart disease, compared with never-smokers

Age at Starting To Smokea

NeverEvent Smoker <15 Years 15-17 18-21 22-25 >26 Years

Total Coronary Heart Disease—

Former Smokers

 Cases 215 4 25 140 28 12

 RRb 1.00 1.72 1.35 1.57 1.44 1.34

(0.65-4.58) (0.89-2.03) (1.27-1.94) (0.97-2.13) (0.75-2.39)

 RRc 1.00 7.55 1.42 1.66 1.83 1.67

(2.54-22.45) (0.84-2.40) (1.28-2.16) (1.12-2.98) (0.83-3.36)

Total Coronary Heart Disease—

Current Smokers

 Cases 215 21 66 336 73 40

 RRb 1.00 7.17 3.21 4.17 3.91 3.19

(4.88-10.53) (2.47-4.17) (3.55-4.89) (3.06-5.00) (2.32-4.40)

 RRd 1.00 9.25 3.41 4.53 4.30 3.17

(5.27-16.23) (2.38-4.89) (3.59-5.71) (3.03-6.12) (2.10-4.78)

a Age at starting smoking was missing for five current smokers and five former smokers.

b Age-adjusted RR.

c Adjusted for coronary heart disease risk factors, plus time since quitting smoking.

d Adjusted for age in 5-year intervals, followup period (1976 to 1978, 1978 to 1980, 1980 to 1982, 1982 to 1984, 1984

to 1986, or 1986 to 1988), history of hypertension, diabetes, high cholesterol levels, body mass index, past use of oral

contraceptives, postmenopausal estrogen therapy, and daily number of cigarettes consumed.

Key: RR = relative risk.

Among former smokers, women who started before age 15 were also at

highest risk of total CHD, although this finding was based on only a few

cases (n = 4) (Table 13). After adjusting for potential confounding factors

(including CHD risk factors, daily number of cigarettes smoked, and years

since stopping), the relative risk of former smokers who started before age 15

was 7.55 (95-percent CI:2.54-22.45).

DISCUSSION Studies of cigarette smoking carried out among women during

the 1950's and 1960's reported relative risks of total mortality

Total Mortality ranging between 1.3 and 1.4 (Doll and Hill, 1956; Hammond and

Horn, 1958; Dunn et al., 1960; Best et al., 1961; Kahn, 1966; Hammond,

1966), whereas smokers in the Nurses' Health Study (Colditz, 1990) were at

nearly 1.9 times the risk compared with never-smokers (Table 2). This may

be explained partly by the fact that that study represents a younger age

cohort, one likely to have higher relative risks. In addition, the higher

relative risk estimates may be attributable to the increasing proportion of

women in more recent birth cohorts who are heavier smokers and who

started smoking at a young age. Data from National Health Interview

Surveys indicate that the proportion of women starting to smoke before the

age of 16 increased from 7.2 percent among women born from 1910 to 1914
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Chapter 8

to 20.2 percent among those born between 1950 and 1954 (U.S. Department

of Health and Human Services, 1989). In the Nurses' Health Study (Colditz,

1990), women who started smoking before age 15 had the highest risk

(multivariate RR = 3.15) of total mortality (Table 4). Furthermore, the

observed deaths in this study were premature because they all occurred

among women who were younger than 67 years of age during the 12 years

of followup. A recent study of smoking-attributable deaths in developed

countries estimated that those killed by tobacco between ages 35 and

69 lose an average of about 23 years of life (Peto et al., 1992).

The time required for the risk of total mortality among quitters to reach

the level of never-smokers differs across studies. The Nurses' Health Study

(Colditz, 1990) data indicate that the risk among former smokers declines

to the level of never-smokers 10 to 14 years after cessation. This estimate

of the time required is somewhat shorter than that of several of the previous

studies. For example, the American Cancer Society Cancer Prevention

Study I (ACS CPS-I) found that among former smokers of 20 or more

cigarettes per day, risk of total mortality was still higher than that of

never-smokers even 10 years after cessation (Hammond, 1966). In the

more recent ACS CPS-II study, involving 4 years of followup among

521,555 men and 658,748 women, the risk of total mortality among female

former smokers declined to the level of never-smokers 16 or more years

after cessation (U.S. Department of Health and Human Services, 1990).

Also, in the U.S. Veterans Study (Rogot and Murray, 1980), the overall

mortality risk among male smokers remained elevated 15 or more years

after cessation (RR = 1.47 among smokers of 10 to 20 cigarettes per day;

RR = 1.22 among smokers of 21 to 39 cigarettes per day).

The differences among studies in estimates of the duration needed for

a former smoker to have the same overall mortality risk as a never-smoker

may be due partly to factors such as the lack of ascertainment of smoking

status after enrollment in earlier studies (Hammond, 1966; U.S. Department

of Health and Human Services, 1990; Rogot and Murray, 1980). In these

studies, persons who smoked at enrollment but subsequently quit remained

assigned to the current smoker category. This misclassification tends to

obscure the benefits of cessation in comparison with continued smoking

(U.S. Department of Health and Human Services, 1990). In contrast, the

Established Populations for Epidemiologic Studies of the Elderly (EPESE)

study (LaCroix et al., 1991), which updated smoking status at yearly

intervals, reported that the relative risk of total mortality among formerly

smoking women returned to the level of never-smokers 6 to 10 years after

cessation.

A potential limitation of the present study is that our cohort consists

 of predominantly white middle-aged women selected with respect to a

particular occupation (nursing). Although our findings might not be

generalizable to older women or other ethnic groups, the qualitatively

similar effects of smoking across population subgroups defined by age,

gender, and race suggest that the biological effects of smoking cessation
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Smoking and Tobacco Control Monograph No. 8

are also not likely to differ in major ways across demographic groups.

Smokers who quit may be unrepresentative in ways that could not be

controlled in our analysis, although we adjusted for a broad range of

potential confounding variables in our multivariate analyses. Finally,

during the 12-year followup period, current smokers were marginally

less likely to respond compared with former smokers. This could have

potentially resulted in an underestimation of the benefits of cessation.

However, the difference in response rates never exceeded 0.5 percentage

points, making this an unlikely source of major bias.

The observation of an excess cancer mortality risk within the first 2 years

of giving up smoking in the present study (Table 3) and in previous studies

(U.S. Department of Health and Human Services, 1990) has been attributed

to the ill-quitter effect. When analyses excluded women with CVD and

cancer at the beginning of each 2-year followup interval, the excess risk

among recent quitters was removed. The results in Tables 5 and 6 provide

a comparison between the impact of stopping smoking before developing

disease and the situation in which a proportion of smokers stop after the

onset of disease. The benefits of smoking cessation, in terms of a reduction

in all-cause as well as cause-specific mortality, occur sooner in the former

case. If one stops smoking before the onset of disease, one will experience a

24-percent reduction in the risk of total mortality within 2 years of quitting

(including a 37-percent reduction in CVD mortality) as well as rapid return

of the risk of cancer mortality to the level of a never-smoker (Table 6). These

benefits are more substantial and occur sooner than in the case of delaying

the cessation of smoking until the onset of disease (Table 3).

The finding of an association between cigarette smoking and suicides/

accidents has been reported in previous studies, including the British

Male Doctors Study (Doll and Peto, 1976) and the Multiple Risk Factor

Intervention Trial (MRFIT) study (Smith et al., 1992). Although a recent

report dismissed the association as causal due to lack of biologic plausibility

(Smith et al., 1992), several studies have shown an association between

cigarette smoking and depression (Perez-Stable et al., 1990; Glassman et al.,

1990; Anda et al., 1990; Glass, 1990). The Nurses' Health Study (Colditz,

1990) collected no data on the mental health of participants prior to 1992.

On the other hand, the association between smoking and external causes of

injury persisted after controlling for alcohol intake in multivariate analysis.

Whether this association is causal or whether smoking is merely correlated

with one or more factors (as yet unidentified) predisposing one to accidents/

suicide deserves further study.

Weight gain after smoking cessation is thought to be a factor

contributing to continuing smoking by women (U.S. Department of Health

and Human Services, 1990). In the Nurses' Health Study (Colditz, 1990),

women who quit smoking had an average 1.4 to 2.8 kg greater weight gain

over an 8-year followup period compared with current smokers (Colditz et

al., 1992). Our analyses of total mortality, which balance adverse as well

as desirable effects of smoking cessation, clearly indicate that the health
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Chapter 8

benefits of smoking cessation far exceed the risks posed by this magnitude

of weight gain (U.S. Department of Health and Human Services, 1990;

Colditz et al., 1992).

The best health advice remains not to start smoking at all, particularly

at a young age. However, benefits of cessation are substantial and begin to

accrue almost immediately after quitting.

Stroke Incidence The Nurses' Health Study (Colditz et al., 1992) data confirm

that cigarette smoking is a major contributor to the risk of ischemic and

hemorrhagic stroke among women (Colditz et al., 1988; Gill et al., 1989)

and that cessation leads to a decline in risk (Donnan et al., 1989; Wolf et al.,

1988; Colditz et al., 1988). For total stroke, most of the benefit of stopping

occurred 2 to 4 years following cessation. The relationship of time since

quitting with decline in risk of total stroke was independent of amount

smoked, age at starting, or the presence of other risk factors.

Our data suggest that the effect of current cigarette smoking on ischemic

stroke is due predominantly to short-term effects. Consistent with this

hypothesis was the lack of a relationship in the present study between the

age at starting and the risk of ischemic stroke among current smokers (Table

9). The acute effects of smoking on the risk of stroke appeared to overwhelm

any chronic effects, such as those mediated by atherogenesis. Once the acute

insults of smoking were removed (as in the case of former smokers), the

underlying relationship of age at starting smoking with risk of ischemic

stroke became apparent (Table 10).

Previous studies of subarachnoid hemorrhage have reported a

persistently elevated risk among former smokers (Bell and Symon, 1979;

Taha et al., 1982). In the present study, the risk among former smokers

appeared to return to the level of never-smokers more than 5 years after

cessation. However, the number of cases on which this observation is

based was small, and we cannot rule out a persisting excess risk.

Overall, the data indicate that benefits of smoking cessation in terms of

stroke reduction are available to all smokers regardless of age at starting and

amounts smoked. Current smokers who stop can anticipate substantial

reductions in their risk of stroke within 2 to 4 years following cessation.

Coronary Heart Our data confirm that cigarette smoking is a major contributor

Disease Incidence to the risk of CHD in middle-aged women (Willett et al., 1987)

and that cessation leads to a decline in risk (U.S. Department of Health and

Human Services, 1990). In the present study, the excess risk of total CHD

among former smokers dropped by one-third within 2 years of quitting. The

substantial fall in CHD risk soon after stopping was consistent with previous

reports (U.S. Department of Health and Human Services, 1990; LaCroix et al.,

1991; Rosenberg et al., 1985 and 1990; Dobson et al., 1991). Contrary to

several earlier reports indicating a relatively short time (i.e., less than 5 years)

between cessation and complete removal of risk (LaCroix et al., 1991;

Rosenberg et al., 1985 and 1990; Dobson et al., 1991), we found that CHD
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Smoking and Tobacco Control Monograph No. 8

risk among former smokers did not decline to the level of never-smokers until

10 to 14 years after cessation.

The predominant biologic effects of smoking on CVD have been thought

to be related to current use. However, both the high risk associated with early

age at starting smoking and the length of time required for complete removal

of risk after cessation suggest an important contribution of cumulative

exposure to cigarette smoking. This pattern of decline in CHD risk contrasts

with the time course of decline in stroke risk after cessation. In middle-aged

women, the hazards of smoking on stroke appear to be more strongly related

to current use (Colditz et al., 1988), with risk among former smokers rapidly

falling to the level of never-smokers 2 to 4 years after quitting (Wolf et al.,

1988; see also "Decline in Risk Among Former Smokers").

Compared with cohort studies, case-control studies (Rosenberg et al.,

1985 and 1990; Dobson et al., 1991) have tended to report shorter intervals

between smoking cessation and complete reversal of CHD risk. In a hospitalbased case control study, Rosenberg and colleagues (1985) reported that the

risk of nonfatal MI among male former smokers returned to the level of neversmokers after 23 months. In a separate study of nonfatal MI among women,

Rosenberg and coworkers (1990) found that the risk among former smokers

was indistinguishable from that of never-smokers 36 months after cessation.

In a population-based case-control study, Dobson and colleagues (1991)

found that the risk among male and female former smokers returned to the

level of never-smokers 4 years after cessation.

A case-control study, based on 263 women in the Nurses' Health Study

(Colditz, 1990) cohort who reported a nonfatal MI on the 1976 baseline

questionnaire, found that when compared with never-smokers, those who

quit 1 to 4 or 5 to 9 years earlier had a significantly elevated risk of 1.5,

whereas those who had quit 10 years or more earlier had a relative risk of

0.6 (Willett et al., 1981). However, because there were only 29 cases among

former smokers, the estimates of risk by duration of quitting were not precise.

In contrast to the majority of case-control studies, cohort studies have

generally reported longer intervals between quitting and the decline of

CHD risk among former smokers to the level of never-smokers. In their

prospective study of 188,000 white men ages 50 to 69 years, Hammond and

Horn (1958) stated that it took 10 years for the risk of CHD deaths among

former smokers to reach that of never-smokers, provided that they had

smoked less than 1 packet of cigarettes per day. If they smoked more than

1 packet per day, the relative risk was 1.6 even 10 years after cessation.

In other cohort studies, the relative risk of CHD mortality among former

smokers relative to never-smokers was 1.16-1.26 at 5 to 9 years after cessation

in the ACS CPS-I cohort (Hammond and Garfinkel, 1969); 1.4 at 5 to 9 years

after cessation in the U.S. Veterans Study (Dorn, 1959; Kahn, 1966; Rogot

and Murray, 1980); 1.3-1.4 at 5 to 9 years after cessation in the British Male

Doctors Study (Doll and Peto, 1976); 1.6 at 20 years after cessation in the

British Regional Heart Study (Cook et al., 1986; Cook and Shaper, 1986);

1.28 at 2 to 9 years after cessation in the Coronary Artery Surgery Study
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registry (Omenn et al., 1990); and 1.5 at 1 to 9 years after cessation in a

Swedish cohort study (Cederlof et al., 1975). The 22-year followup report of

the British Female Doctors Study (Doll et al., 1980) had insufficient data on

former smokers to allow examination of CHD risk according to time since

quitting.

Case-control studies have been suggested to be less susceptible to

misclassification resulting from recidivism, that is, resumption of smoking

among former smokers. In followup studies that measure smoking status

only at entry into the study, coronary events that occur among former

smokers who have resumed smoking are erroneously counted as occurring

in former smokers instead of current smokers. This may result in a longer

estimate of the time required for the risk to decline to the level of neversmokers (Rosenberg et al., 1985; Dobson et al., 1991). Although this type

of misclassification may have occurred in cohort studies that ascertained

smoking habits at baseline only (e.g., the ACS studies [Hammond, 1966;

Stellman and Garfinkel, 1986; Hammond and Garfinkel, 1969], the U.S.

Veterans Study [Dorn, 1959; Kahn, 1966; Rogot and Murray, 1980], and the

Swedish cohort study [Cederlof et al., 1975]), in the present study smoking

status was updated every 2 years. Most relapses among quitters occur within

the first 2-year period after cessation (U.S. Department of Health and Human

Services, 1990). Furthermore, within any 2-year followup period in the

Nurses' Health Study (Colditz, 1990), an average of only 1,500 quitters (or

about 4.8 percent of former smokers) resumed smoking. These numbers

were too small to explain the discrepancy between previous case-control

studies and the present study in the time taken for risk of CHD among

former smokers to decline to the level of never-smokers.

Starting smoking before age 15 is associated with a particularly high

risk of CHD. In American women, the age at initiation has been steadily

falling. Data from National Health Interview Surveys indicate that the

proportion of women starting to smoke before age 16 increased from

7.2 percent among women born from 1910 to 1914 to 20.2 percent among

women born between 1950 and 1954 (U.S. Department of Health and

Human Services, 1989). This highlights the need for public health measures

to be directed especially at preventing young women from starting to smoke.

CONCLUSIONS

• Compared with never-smokers, women who currently smoke are at

increased risks of total mortality (multivariate RR = 1.87, 95-percent CI:

1.65 to 2.13), total CHD incidence (multivariate RR = 4.23, 95-percent

CI: 3.60 to 4.96), and total stroke incidence (multivariate RR = 2.73,

95-percent CI: 2.18 to 3.41).

• Starting smoking before age 15 is associated with particularly high risks of

total mortality (multivariate RR = 3.15, 95-percent CI: 2.16 to 4.59) and

total CHD incidence (multivariate RR = 9.25, 95-percent CI:5.27 to 16.23).
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Smoking and Tobacco Control Monograph No. 8

• Compared with never-smokers, former smokers are at slightly higher risk

of total mortality (multivariate RR = 1.29, 95-percent CI: 1.14 to 1.46),

total CHD incidence (multivariate RR = 1.48, 95-percent CI: 1.22 to 1.79),

and total stroke incidence (multivariate RR = 1.35, 95-percent CI: 0.98 to

1.85).

• The risk of total mortality among former smokers approaches the level of

never-smokers 10 to 14 years after cessation. This conclusion remained

unchanged after taking account of the ill-quitter effect.

• On stopping smoking, former smokers removed one-third of the excess

risk of total CHD incidence within 2 years of cessation. The risk among

former smokers declines to the level of never-smokers during the interval

of 10 to 14 years following cessation.

• The risk of total stroke incidence among former smokers approaches the

level of never-smokers during the interval of 2 to 4 years following

cessation.

• The time course of decline in risk of total mortality, total CHD incidence,

and total stroke incidence remained unchanged after adjusting for age at

starting smoking and number of cigarettes smoked daily.

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ACKNOWLEDGMENTS The authors are indebted to the participants in the Nurses'

Health Study for their continuing cooperation and to Mark Shneyder,

Karen Corsano, Gary Chase, Barbara Egan, and Lisa Dunn for their expert

help.

This study was supported by research grants HL-34594 and CA-40356

from the National Institutes of Health. Dr. Kawachi is the recipient of

an Overseas Research Fellowship of the Health Research Council of

New Zealand. Dr. Colditz is supported by a Faculty Research Award from

the American Cancer Society—FRA 398.