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Surveillance for Smoking-Attributable Mortality and Years of Potential Life Lost, by State -- United States, 1990

David E. Nelson, M.D., M.P.H. Randahl S. Kirkendall, M.P.H.

Richard L. Lawton, Ph.D.

Jeffrey H. Chrismon Robert K. Merritt, M.S. David A. Arday, M.D., M.P.H. Gary A. Giovino, Ph.D., M.S.

Office on Smoking and Health National Center for Chronic Disease Prevention

and Health Promotion

Abstract

Problem/Condition: Mortality and years of potential life lost attributable to cigarette smoking.

Reporting Period Covered: 1990.

Description of System: Mortality and years of potential life lost were estimated for each state by using the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) software. These estimates were based on attributable risk formulas for smoking-related causes of death. Estimates of smoking prevalence were obtained from the Behavioral Risk Factor Surveillance System and the U.S. Bureau of the Census, and mortality data were obtained from CDC.

Results: The median estimate for the number of smoking-attributable deaths among states was 5,619 (range: 402 {Alaska} to 42,574 {California}). Within each state, the number of smoking-attributable deaths among males was approximately twice as high as among females. Utah had the lowest mortality rate (218.0 per 100,000 population) and the lowest percentage of all deaths attributable to cigarette smoking (13.4%). Nevada had the highest mortality rate (478.1 per 100,000 population) and the highest percentage of deaths from smoking (24.0%). The number of years of potential life lost ranged from 6,720 (Alaska) to 498,297 (California).

Interpretation: The number of deaths attributable to cigarette smoking in 1990 remained high. Efforts are needed to control tobacco use in all states.

Actions Taken: SAMMEC data are used in many states to assist policymakers in strengthening tobacco control efforts.

INTRODUCTION

Cigarette smoking is the single most preventable cause of premature death in the United States (1). In 1990, smoking accounted for more than 400,000 deaths nationwide (2). Although national estimates of smoking- attributable mortality (SAM) and years of potential life lost (YPLL) have been made periodically (1-11), state-specific SAM and YPLL estimates for all states have been published only for 1985 (12,13). SAM and YPLL data can be used by states to document the toll of smoking-related health problems and to encourage tobacco control efforts in a variety of settings (14-18).

METHODS

For this report, state-specific cigarette smoking prevalence, SAM, and YPLL from smoking were estimated by using the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) software package (version 2.1) (19) developed by CDC's Office on Smoking and Health. SAMMEC estimates the number of smoking-related deaths from neoplastic, cardiovascular, and respiratory conditions and diseases of infants by using attributable risk formulas based on smoking prevalence and relative risks for certain conditions among current and former smokers (compared with risks for nonsmokers) (Table_1). Injury surveillance studies are used to estimate burn deaths associated with cigarette smoking (19) (Table_1).

State estimates of cigarette smoking prevalence in 1990 were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) for 44 states and the District of Columbia. For the six states not participating in BRFSS in 1990 (Alaska, Arkansas, Kansas, Nevada, New Jersey, and Wyoming), prevalence estimates were obtained from the 1989 Current Population Survey conducted by the U.S. Bureau of the Census (U.S. Bureau of the Census, unpublished data, 1990). Mortality data for 1990 were obtained from CDC's National Center for Health Statistics (NCHS). To estimate deaths among infants (i.e., deaths among children less than 1 year of age), the 1989 national estimate of cigarette smoking prevalence of 20% among pregnant women was used for all states (20). SAM rates per 100,000 were calculated for persons greater than or equal to 35 years of age * and were age- adjusted to the 1990 U.S. population to provide comparable estimates across states. YPLL that accounts for life expectancy at age of death was calculated by using standard methodology (19).

RESULTS

State-specific estimates of cigarette smoking prevalence among persons ages 35-64 years ranged from 21.8% to 39.7% for men and from 14.6% to 30.8% for women (Table_2). For persons greater than or equal to 65 years of age, the prevalence ranged from 9.1% to 26.0% for men and from 4.7% to 19.1% for women.

The median estimate for the number of smoking-attributable deaths was 5,619 (range: from 402 {Alaska} to 42,574 {California}) (Table_3). Within each state, males had approximately twice as many smoking- attributable deaths as females. When the data were totaled across all states, 415,226 deaths were attributable to smoking. The median SAM rate was 363.3 per 100,000 population; this rate ranged from 218.0 per 100,000 in Utah to 478.1 per 100,000 in Nevada. The median percentage of all deaths attributable to smoking was 19.2% (range: from 13.4% {Utah} to 24.0% {Nevada}). The median estimate for YPLL was 66,959 (range: from 6,720 {Alaska} to 498,297 {California}) (Table_4).

DISCUSSION

These findings indicate that, in 1990, cigarette smoking contributed substantially to premature mortality. SAM rates tended to be higher in the southeastern states, but all states continued to report substantial numbers of premature deaths caused by cigarette use. Although different data sources were used for cigarette smoking prevalence and state-specific estimates of deaths from environmental tobacco smoke were lacking, the total of 415,226 deaths totaled across the states is similar to the recent 1990 national estimate of 418,690 deaths from smoking (2). If the state- based estimate were augmented by the 3,000 deaths from environmental tobacco smoke that were included in the national estimate, the two estimates would differ by less than 1%.

State SAMMEC estimates have been published in health journals and state reports to notify scientists, policymakers, and the public of the magnitude of mortality associated with smoking (14-18,21). For example, in Oregon, a report on tobacco use that relied heavily on SAMMEC calculations was used for assisting tobacco control efforts (21), and the state legislature enacted legislation to increase the state excise tax on cigarettes.

For at least three reasons, these estimates for SAM and YPLL are underestimated. First, these estimates were based on data for cigarette smoking prevalence from 1990. Most smoking-attributable deaths for that year resulted from smoking during preceding decades, when smoking prevalence was considerably higher (10). Second, the state-specific SAMMEC estimates do not include deaths from other conditions (e.g., such as environmental tobacco smoke {22}, leukemia {23}, and peptic ulcer disease {1 }) that may also be associated with smoking, nor do they include mortality caused by other forms of tobacco use. Third, these data are not comparable with 1985 state-specific estimates because of substantial differences in SAMMEC methodology, in sources of data on state smoking prevalence, and in age adjustment of mortality rates (12,13).

To reduce the health impact of cigarette use, continued progress must be made in reducing smoking prevalence. Although smoking prevalence has declined substantially since the 1960s (1), about 20% of deaths in the United States can be attributed to cigarette smoking (2). Vigorous efforts are needed to prevent the initiation of smoking, encourage smoking cessation, and protect nonsmokers from the adverse effects of environmental tobacco smoke. Because many factors influence smoking initiation and smoking cessation, multiple approaches are necessary (1). Examples of these approaches include increasing educational efforts, reducing minors' access to tobacco products, increasing tobacco excise taxes, implementing more extensive and intensive counseling by health-care providers on smoking prevention and cessation, developing and enacting strong policies and laws for clean indoor air, and restricting or eliminating advertising to which persons less than 18 years old are likely to be exposed (2,24).

References

  1. CDC. Reducing the health consequences of smoking: 25 years of progress -- a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-8411.

  2. CDC. Cigarette smoking-attributable mortality and years of potential life lost -- United States, 1990. MMWR 1993;42:645-9.

  3. Ravenholt RT. Cigarette smoking: magnitude of the hazard {Letter}. Am J Public Health 1964; 54:1923-6.

  4. Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. J Natl Cancer Inst 1980;65:1169-73.

  5. Ravenholt RT. Addiction mortality in the United States, 1980: tobacco, alcohol, and other substances. Pop Dev Rev 1984;10:697-724.

  6. Ravenholt RT. Tobacco's impact on twentieth-century U.S. mortality patterns. Am J Prev Med 1985;1:4-16.

  7. US Office of Technology Assessment. Smoking-related deaths and financial costs. Washington: Health Program, US Congress, 1985.

  8. Rice DP, Hodgson TA, Sinsheimer P, Browner W, Kopstein AN. The economic costs of the health effects of smoking, 1984. Milbank Q 1986;64: 489-547.

  9. CDC. Smoking-attributable mortality and years of potential life lost -- United States, 1984. MMWR 1987;36:693-7.

  10. CDC. Smoking-attributable mortality and years of potential life lost -- United States, 1988. MMWR 1991;40:62-71.

  11. Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992;339:1268-78.

  12. CDC. State-specific estimates of smoking-attributable mortality and years of potential life lost -- United States, 1985. MMWR 1988;37: 689-93.

  13. CDC. Smoking and health: a national status report -- a report to Congress. 2nd ed. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1990; DHHS publication no. (CDC)87-8396.

  14. Breukelman FN, Zeitz PS, Novotny TE. Smoking in Delaware: economic costs and deaths attributable to cigarette smoking in the state, 1985. Delaware Med J 1988;60:735-9.

  15. Goldbaum GM, Ostroff SM, Novotny TE. The costs of smoking for Washington State. Washington Public Health 1989;7:37-8.

  16. Smith PF, Shultz JM, Morse DL. Assessing the damage from cigarette smoking in New York State. NY State J Med 1990;90:56-60.

  17. Shultz JM, Moen ME, Pechacek TF, et al. The Minnesota Plan for nonsmoking and health: the legislative experience. J Public Health Policy 1986;7:300-13.

  18. CDC. Smoking-attributable mortality -- Kentucky, 1988. MMWR 1990;39: 680-3.

  19. Shultz JM, Novotny TE, Rice DP. Smoking-attributable mortality, morbidity, and economic cost (SAMMEC) version 2.1 {software and documentation}. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992.

  20. National Center for Health Statistics. Advance report of the new data from 1989 birth certificates. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, CDC, 1992 (Monthly vital statistics report; vol 40, Suppl).

  21. Center for Health Statistics. Tobacco and Oregonians: a legacy of illness and death. Portland, OR: Oregon Department of Human Resources, Health Division, 1992.

  22. Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: Environmental Protection Agency, 1992; report no. EPA/600/6-90/006F.

  23. Siegel M. Smoking and leukemia: evaluation of a causal hypothesis. Am J Epidemiol 1993;138:1-9.

  24. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

In categories other than deaths from burns and deaths among infants, the number of deaths among persons less than 35 years of age was too small to attain statistical significance.


Table_1
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TABLE 1. Relative risks attributable to smoking and estimated smoking-attributable
mortality (SAM) for current and former smokers compared with nonsmokers, by
disease category and sex -- United States, 1990
=============================================================================================
                                                                  Relative risk
                                                      -------------------------------------
                                                           Males               Females
                                                      ----------------     ----------------
                                                      Current  Former      Current  Former
Disease category (ICD-9)                              smokers  smokers     smokers  smokers
-------------------------------------------------------------------------------------------
Diseases among adults (>=35 yrs of age)

  Neoplasms
  Lip, oral cavity, pharynx (140-149)                  27.5      8.8         5.6      2.9
  Esophagus (150)                                       7.6      5.8        10.3      3.2
  Pancreas (157)                                        2.1      1.1         2.3      1.8
  Larynx (161)                                         10.5      5.2        17.8     11.9
  Trachea, lung, bronchus (162)                        22.4      9.4        11.9      4.7
  Cervix uteri (180)                                     NA       NA         2.1      1.9
  Urinary bladder (188)                                 2.9      1.9         2.6      1.9
  Kidney, other urinary (189)                           3.0      2.0         1.4      1.2

  Cardiovascular diseases
  Hypertensive diseases (401-404)                       1.9      1.3         1.7      1.2
  Ischemic heart disease (410-414)
    Persons ages 35-64 yrs                              2.8      1.8         3.0      1.4
    Persons ages >=65 yrs                               1.6      1.3         1.6      1.3
  Other heart diseases (390-398, 415-417, 420-429)      1.9      1.3         1.7      1.2
  Cerebrovascular diseases (430-438)
    Persons ages 35-64 yrs                              3.7      1.4         4.8      1.4
    Persons ages >=65 yrs                               1.9      1.3         1.5      1.0
  Atherosclerosis (440)                                 4.1      2.3         3.0      1.3
  Aortic aneurysm (441)                                 4.1      2.3         3.0      1.3
  Other arterial diseases (442-448)                     4.1      2.3         3.0      1.3

  Respiratory diseases
  Pneumonia and influenza (480-487)                     2.0      1.6         2.2      1.4
  Bronchitis and emphysema (491-492)                    9.7      8.8        10.5      7.0
  Chronic airways obstruction (496)                     9.7      8.8        10.5      7.0
  Other respiratory diseases (010-012, 493)             2.0      1.6         2.2      1.4

Diseases among infants (<1 yr of age)
  Short gestation, low birth weight (765)                   1.8                  1.8
  Respiratory distress syndrome (769)                       1.8                  1.8
  Other respiratory conditions of newborn (770)             1.8                  1.8
  Sudden infant death syndrome (798)                        1.5                  1.5

Deaths * from burns (E890-E899)                              NA                   NA
-------------------------------------------------------------------------------------------
* Estimated to be 50% of deaths on the basis of injury surveillance studies (19).
NA = not applicable.
ICD-9 = International Classification of Diseases, 9th revision.
=============================================================================================


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Table_2
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TABLE 2. State-specific estimates of cigarette smoking prevalence, by age and sex --
United States, 1990
===========================================================================================
                                          Age (yrs)
                       -----------------------------------------------
                              35-64                      >=65
                       ---------------------     ---------------------
State                  Men (%)     Women (%)     Men (%)     Women (%)
----------------------------------------------------------------------
Alabama                  31.1         22.9         15.0          6.2
Alaska                   33.3         24.5         17.8         13.2
Arizona                  24.0         21.0         11.0         10.1
Arkansas                 35.9         29.8         16.4          6.7
California               21.8         21.7         16.8         16.6
Colorado                 24.2         26.4         12.5         11.4
Connecticut              27.4         22.9         11.8         12.0
Delaware                 23.7         28.0         11.3          8.4
District of Columbia     30.4         21.0         21.2          6.8
Florida                  33.7         21.6         17.4         13.1
Georgia                  34.8         25.9         19.4         13.0
Hawaii                   26.5         20.4         12.1          7.5
Idaho                    23.7         20.8         12.5         11.8
Illinois                 34.0         23.9         17.0         17.7
Indiana                  33.1         26.4         16.8         11.7
Iowa                     28.2         22.0         12.1          8.4
Kansas                   30.7         18.7         14.2          6.7
Kentucky                 39.7         29.0         19.1         11.3
Louisiana                32.7         24.7         14.9          8.6
Maine                    33.2         24.3         17.0         12.7
Maryland                 27.5         20.6         15.2         13.5
Massachusetts            28.2         20.1         16.5         15.3
Michigan                 34.1         28.2         17.2         11.7
Minnesota                24.6         23.1         12.3          7.9
Mississippi              33.3         21.3         20.8         11.3
Missouri                 31.9         23.6         14.9         11.2
Montana                  25.2         25.1         12.2         15.6
Nebraska                 33.3         25.5         20.9          7.9
Nevada                   38.4         30.1         15.0         12.1
New Hampshire            25.2         21.5         16.3         14.5
New Jersey               28.8         25.1         13.0         15.1
New Mexico               22.8         25.1         15.7         11.7
New York                 23.1         30.2         10.6         12.6
North Carolina           31.2         29.3         20.6          9.5
North Dakota             26.5         26.5         11.8          4.7
Ohio                     30.3         27.7          9.1         12.9
Oklahoma                 30.5         30.8         19.5         12.2
Oregon                   27.7         22.1         11.3         13.7
Pennsylvania             27.7         25.1         10.8         13.3
Rhode Island             28.5         26.4         18.5         10.3
South Carolina           39.4         24.8         26.0         13.6
South Dakota             25.8         21.8         18.3          9.9
Tennessee                33.0         28.4         25.1         12.1
Texas                    27.0         25.9         18.3         14.9
Utah                     25.2         14.6         10.8          7.3
Vermont                  26.1         20.9         11.3         10.0
Virginia                 28.7         24.7         16.3         14.4
Washington               26.7         19.9         15.7         15.5
West Virginia            32.7         26.2         18.3         16.4
Wisconsin                28.1         26.4         10.0          9.7
Wyoming                  28.2         27.6         20.1         19.1

Highest value            39.7        30.8          26.0         19.1
Lowest value             21.8        14.6           9.1          4.7
Median                   28.5        24.7          15.7         11.8
----------------------------------------------------------------------
Source: 1990 Behavioral Risk Factor Surveillance System for 44 states and the District of
Columbia; 1989 Current Population Survey of the U.S. Bureau of the Census for Alaska,
Arkansas, Kansas, Nevada, New Jersey, and Wyoming.
===========================================================================================


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Table_3
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TABLE 3. State-specific estimates of smoking-attributable mortality, by sex -- United
States, 1990
==================================================================================================
                                                                      Percentage of all
State                     Male    Female    Total   Rate *   Rank +        deaths
---------------------------------------------------------------------------------------
Alabama                   4,960    1,841    6,801   350.4     22            17.3
Alaska                      290      112      402   398.2     46            18.4
Arizona                   3,839    1,858    5,697   339.6     16            19.8
Arkansas                  3,410    1,296    4,706   376.3     35            19.1
California               25,821   16,753   42,574   366.3     27            19.9
Colorado                  2,658    1,513    4,171   331.4     13            19.3
Connecticut               3,337    2,025    5,362   325.7     12            19.4
Delaware                    745      433    1,178   393.1     44            20.4
District of Columbia        874      413    1,287   444.7     50            17.6
Florida                  18,865    9,731   28,596   357.5     24            21.3
Georgia                   6,692    3,002    9,694   383.5     38            18.7
Hawaii                      849      325    1,174   257.2      2            17.3
Idaho                       865      439    1,304   293.2      4            17.5
Illinois                 12,028    7,241   19,269   360.0     25            18.7
Indiana                   6,924    3,326   10,250   394.3     45            20.7
Iowa                      3,410    1,406    4,816   304.2      7            17.9
Kansas                    2,728    1,100    3,828   300.8      6            17.2
Kentucky                  5,127    2,322    7,449   428.7     47            21.2
Louisiana                 4,829    2,058    6,887   388.2     40            18.3
Maine                     1,508      868    2,376   389.4     42            21.4
Maryland                  4,593    2,777    7,370   378.1     36            19.2
Massachusetts             6,132    4,298   10,430   345.3     17            19.6
Michigan                 10,386    5,068   15,454   372.5     33            19.6
Minnesota                 4,237    1,890    6,127   295.2      5            17.6
Mississippi               3,188    1,270    4,458   375.1     34            17.7
Missouri                  6,907    3,270   10,177   383.8     39            20.2
Montana                     856      457    1,313   334.2     15            19.1
Nebraska                  1,965      710    2,675   321.0     11            18.1
Nevada                    1,517      717    2,234   478.1     51            24.0
New Hampshire             1,036      619    1,655   349.3     20            19.5
New Jersey                7,734    4,871   12,605   334.1     14            17.9
New Mexico                1,097      644    1,741   287.7      3            16.4
New York                 18,612   12,380   30,992   352.8     23            18.3
North Carolina            7,922    3,110   11,032   367.6     30            19.2
North Dakota                790      241    1,031   308.2      9            18.2
Ohio                     11,421    6,693   18,114   347.7     19            18.3
Oklahoma                  4,132    2,006    6,138   390.4     43            20.2
Oregon                    3,393    1,833    5,226   369.3     31            20.8
Pennsylvania             14,576    8,048   22,624   346.8     18            18.6
Rhode Island              1,250      631    1,881   350.3     21            19.6
South Carolina            3,928    1,691    5,619   380.1     37            18.9
South Dakota                877      298    1,175   307.9      8            18.6
Tennessee                 7,146    3,068   10,214   442.1     49            22.1
Texas                    16,705    8,747   25,452   389.1     41            20.3
Utah                        940      288    1,228   218.0      1            13.4
Vermont                     617      296      913   363.3     26            19.9
Virginia                  5,926    3,311    9,237   366.6     28            19.2
Washington                4,892    2,898    7,790   367.4     29            21.0
West Virginia             2,831    1,390    4,221   433.6     48            21.8
Wisconsin                 4,995    2,625    7,620   313.3     10            17.8
Wyoming                     419      240      659   371.0     32            20.6

Highest value            25,821   16,753   42,574   478.1                   24.0
Lowest value                290      112      402   218.0                   13.4
Median                    3,839    1,841    5,619   363.3                   19.2
---------------------------------------------------------------------------------------
* Per 100,000 population among adults ages >=35 years, age-adjusted to the 1990 U.S. population;
  rates exclude deaths among infants and burn deaths among persons ages 1-34 years.
+ Based on mortality rate.
==================================================================================================


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Table_4
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TABLE 4. Estimated smoking-attributable years of potential life lost, *
by sex -- United States, 1990
=========================================================================
                          Years of potential life lost
                         -------------------------------
State                      Male       Female      Total
--------------------------------------------------------
Alabama                   62,287      28,073      90,360
Alaska                     4,711       2,009       6,720
Arizona                   42,421      24,538      66,959
Arkansas                  39,425      19,317      58,742
California               290,416     207,881     498,297
Colorado                  29,800      19,200      49,000
Connecticut               35,943      24,592      60,535
Delaware                   9,102       6,146      15,248
District of Columbia      13,512       7,660      21,172
Florida                  206,881     121,310     328,191
Georgia                   88,396      45,772     134,168
Hawaii                    10,135       5,087      15,222
Idaho                      9,052       5,656      14,708
Illinois                 143,258      92,675     235,933
Indiana                   79,155      44,429     123,584
Iowa                      34,121      16,400      50,521
Kansas                    28,713      13,827      42,540
Kentucky                  61,404      33,198      94,602
Louisiana                 62,828      32,058      94,886
Maine                     16,879      10,540      27,419
Maryland                  55,786      36,411      92,197
Massachusetts             68,822      48,818     117,640
Michigan                 123,337      72,263     195,600
Minnesota                 44,365      23,470      67,835
Mississippi               39,230      18,609      57,839
Missouri                  79,112      43,024     122,136
Montana                    8,741       5,750      14,491
Nebraska                  20,060       9,015      29,075
Nevada                    19,291      10,963      30,254
New Hampshire             11,675       7,318      18,993
New Jersey                90,653      61,120     151,773
New Mexico                12,710       8,446      21,156
New York                 219,751     157,779     377,530
North Carolina            99,223      48,587     147,810
North Dakota               8,028       3,689      11,717
Ohio                     140,831      90,666     231,497
Oklahoma                  46,252      26,805      73,057
Oregon                    36,425      22,792      59,217
Pennsylvania             168,532     103,307     271,839
Rhode Island              14,006       7,535      21,541
South Carolina            52,910      26,159      79,069
South Dakota               9,033       3,651      12,684
Tennessee                 87,627      45,008     132,635
Texas                    201,112     116,519     317,631
Utah                      10,552       4,020      14,572
Vermont                    7,042       3,589      10,631
Virginia                  74,535      45,181     119,716
Washington                53,757      35,465      89,222
West Virginia             32,784      18,223      51,007
Wisconsin                 54,529      31,816      86,345
Wyoming                    4,509       2,789       7,298

Highest value            290,416     207,881     498,297
Lowest value               4,509       2,009       6,720
Median                    42,421      24,538      66,959
--------------------------------------------------------
* Calculated by using life expectancy at age of death.
=========================================================================


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