Skip Navigation LinksSkip Navigation Links
Centers for Disease Control and Prevention
Safer Healthier People
Blue White
Blue White
bottom curve
CDC Home Search Health Topics A-Z spacer spacer
spacer
Blue curve MMWR spacer
spacer
spacer

The content, links, and pdfs are no longer maintained and might be outdated.

  • The content on this page is being archived for historic and reference purposes only.
  • For current, updated information see the MMWR website.

Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses --- United States, 2000--2004

Cigarette smoking and exposure to tobacco smoke are associated with premature death from chronic diseases, economic losses to society, and a substantial burden on the United States health-care system. Smoking is the primary causal factor for at least 30% of all cancer deaths, for nearly 80% of deaths from chronic obstructive pulmonary disease, and for early cardiovascular disease and deaths (1). In 2005, to assess the economic and public health burden from smoking, CDC published results of an analysis of smoking-attributable mortality (SAM), years of potential life lost (YPLL), and productivity losses in the United States from smoking during 1997--2001 (2). The analysis was based on data from CDC's Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) system,* which estimates SAM, YPLL, and productivity losses based on data from the National Health Interview Survey and death certificate data from the National Center for Health Statistics. This report presents an update of that analysis for 2000--2004, the most recent years for which source data are available. The updated analysis indicated that, during 2000--2004, cigarette smoking and exposure to tobacco smoke resulted in at least 443,000 premature deaths, approximately 5.1 million YPLL, and $96.8 billion in productivity losses annually in the United States. Comprehensive, national tobacco-control recommendations have been provided to the public health community with the goal of reducing smoking so substantially that it is no longer a significant public health problem in the United States (3,4).

The adult and the maternal and child health SAMMEC software modules were used to estimate SAM, YPLL, and productivity losses attributed to diseases caused by smoking. Sex- and age-specific smoking-attributable deaths were calculated by multiplying the total number of deaths for 19 adult and four infant disease categories (Table) by estimates of the smoking-attributable fraction (SAF) of preventable deaths. The attributable fractions provide estimates of the public health burden of each risk factor and the relative importance of risk factors for multifactorial diseases. Because of the effect of interactions between various risk factors, attributable fractions for a given disease can total more than 100%. For adults, SAFs were derived using sex-specific relative risk (RR) estimates from the American Cancer Society's Cancer Prevention Study-II (CPS-II) for current and former smokers for each cause of death for the period 1982--1988. For ischemic heart disease and cerebrovascular disease deaths, RR estimates also were stratified by age (35--64 years and >65 years). Sex- and age-specific (35--64 years and >65 years) current and former cigarette smoking prevalence estimates from the National Health Interview Survey also were used to calculate SAFs. For infants, SAFs were calculated by using pediatric RR estimates and maternal smoking prevalence estimates from birth certificates. Smoking-attributable YPLL and productivity losses were estimated by multiplying sex- and age-specific SAM by remaining life expectancy (5) and lifetime earnings data (6). In addition, smoking-attributable residential fire-related deaths (7) and lung cancer and heart disease deaths attributable to exposure to secondhand smoke (8,9) were included in the SAM, but not in YPLL and productivity loss estimates.

During 2000--2004, smoking resulted in an estimated annual average of 269,655 deaths among males and 173,940 deaths among females in the United States (Table). The three leading specific causes of smoking-attributable death were lung cancer (128,922), ischemic heart disease (126,005), and chronic obstructive pulmonary disease (COPD)§ (92,915). Among adults aged >35 years, 160,848 (41.0%) smoking-attributable deaths were caused by cancer, 128,497 (32.7%) by cardiovascular diseases, and 103,338 (26.3%) by respiratory diseases (excluding deaths from secondhand smoking and from residential fires). Smoking during pregnancy resulted in an estimated 776 infant deaths annually during 2000--2004. An estimated 49,400 lung cancer and heart disease deaths annually were attributable to exposure to secondhand smoke. The average annual SAM estimates also included 736 deaths from smoking-attributable residential fires.

During 2000--2004, on average, smoking accounted for an estimated 3.1 million YPLL for males and approximately 2.0 million YPLL for females annually, excluding deaths from smoking-attributable residential fires and adult deaths from secondhand smoke. Estimates for average annual smoking-attributable productivity losses were approximately $96.8 billion ($64.2 billion for males and $32.6 billion for females) during this period (Table).

Reported by: B Adhikari, PhD, J Kahende, PhD, A Malarcher, PhD, T Pechacek, PhD, V Tong, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

During 2000--2004, an estimated 443,000 persons in the United States died prematurely each year as a result of smoking or exposure to secondhand smoke. This figure is higher than the average annual estimate of approximately 438,000 deaths during 1997--2001 (2). The number of smoking-attributable deaths varies according to trends in smoking prevalence and the number of deaths from diseases caused by smoking. SAM estimates also change when a causal relationship is established between smoking and a disease not previously included in SAMMEC (1). Although smoking prevalence has declined dramatically since its peak in the 1960s, the number of smoking-attributable deaths has remained relatively unchanged, primarily because of increases in population size (particularly among older age groups). Even with declines in the rates of various smoking-related diseases (e.g., coronary heart disease), the absolute number of deaths is increasing as the total population increases. In addition, cohorts of smokers with the highest peak prevalence have now reached the ages with the highest incidence of smoking-attributable diseases.

The relative risk estimates used in the calculation of SAM have remained the same. In general, the magnitude of the relationship between smoking and the diseases it causes has remained stable over time (1). However, CDC is continuing to monitor whether the RRs for smoking are changing over time. Future SAMMEC estimates might contain updated RRs, particularly for females, because their adoption of smoking (and hence their duration of smoking) lagged that of males during the early to mid-1900s. Prevalence of smoking among females peaked in the 1960s and in recent cohorts of smokers more closely follows the trend for male smokers. Smoking-attributable fractions are higher for cancers and COPD than for cardiovascular diseases; however, because the absolute number of deaths is highest for coronary heart disease, it contributes a large number of smoking-attributable deaths.

Preventing smoking and increasing cessation rates need to remain priorities of public health professionals who are working to prevent heart disease and stroke. Dramatic declines in smoking-attributable deaths can be achieved by further reducing smoking prevalence rates. Leading causes of death, such as lung cancer and COPD, could become relatively uncommon in future generations if the prevalence of smoking was substantially reduced (1,3).

The findings in this report are subject to at least six limitations. First, the estimates understate deaths attributable to tobacco use because estimates of deaths attributable to cigar smoking, pipe smoking, and smokeless tobacco use were excluded. Although the overall prevalence rates of cigar and pipe smoking and use of smokeless tobacco have remained relatively stable, increased public health concerns about these products might warrant including estimates of deaths attributable to these tobacco products in the future. Second, RRs were based on deaths during 1982--1988 among birth cohorts who might have had different smoking histories than current or former smokers (e.g., age of initiation and duration of smoking before quitting). Third, this report used a death-certificate--based definition of COPD, including codes for bronchitis/emphysema and chronic airway obstruction (ICD-10 J44) (1). Therefore, the COPD SAM estimate used for this report might differ from other estimates that use other definitions of COPD (1). Fourth, RRs were adjusted for the effects of age but not for other potential confounders. However, research suggests that education, alcohol, and other confounders had negligible additional effects on SAM estimates for lung cancer, COPD, ischemic heart disease, and cerebrovascular disease in CPS-II. Fifth, productivity losses understate the total costs of smoking because costs associated with smoking-attributable health-care expenditures, smoking-related disability, employee absenteeism, and secondhand-smoke--attributable disease morbidity and mortality were not included. Finally, the estimates do not account for the sampling variability in smoking prevalence estimates or RRs.

Cigarette smoking continues to impose substantial health and financial costs on society. During 2001--2004, average annual smoking-attributable health-care expenditures were approximately $96 billion. Accounting for direct health-care expenditures and productivity losses (approximately $97 billion), the total economic burden of smoking is approximately $193 billion per year. By comparison, investments in comprehensive, state-based tobacco prevention and control programs in fiscal year 2007 totaled $595 million, approximately 325-times less than the smoking-attributable costs (10). Comprehensive statewide tobacco-control programs significantly accelerate declines in consumption and smoking prevalence (4). By increasing their investment in such programs to the levels recommended by CDC, states can further hasten the reduction in cigarette use and reduce the health and economic burden of smoking (3).

References

  1. CDC. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2004. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
  2. CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs---United States, 1997--2001. MMWR 2005;54:625--8.
  3. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National Academies Press; 2007.
  4. CDC. Best practices for comprehensive tobacco control programs---2007. Atlanta, GA, US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/index.htm.
  5. Arias E. United States life tables, 2004. Nat Vital Stat Rep 2006;56:1--39.
  6. Haddix AC, Teutsch SM, Corso PS. Prevention effectiveness: a guide to decision analysis and economic evaluation. 2nd ed. New York, NY: Oxford University Press; 2003.
  7. Hall JR Jr. The smoking-material fire problem. Quincy, MA: National Fire Protection Association, Fire Analysis and Research Division; 2007.
  8. CDC. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2006.
  9. California Environmental Protection Agency. Proposed identification of environmental tobacco smoke as a toxic air contaminant. Sacramento, CA: Environmental Protection Agency, Office of Environmental Health Hazard Assessment; 2005. Available at http://www.oehha.org/air/environmental_tobacco/2005etsfinal.html.
  10. Campaign for Tobacco-Free Kids. A broken promise to our children: the 1998 state tobacco settlement eight years later. Washington, DC: Campaign for Tobacco-Free Kids; 2006. Available at http://www.tobaccofreekids.org/reports/settlements/2007/fullreport.pdf.

* The computations also use other data elements; available at http://apps.nccd.cdc.gov/sammec.

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

§ COPD includes bronchitis/emphysema (International Classification of Diseases, Tenth Revision [ICD-10] codes J40--J42 and J43) and chronic airway obstruction (ICD-10 J44) (1).

Table

TABLE. Annual deaths and estimates* of smoking-attributable mortality (SAM), years of potential life lost (YPLL), and productivity losses, by sex and cause of death — United States, 2000–2004
Male
Female
Causes of death (ICD-10 code†)
Deaths
SAM
YPLL
Productivity
losses (in thousands)
($)
Deaths
SAM
YPLL
Productivity
losses (in
thousands)
($)
Malignant neoplasm
Lip, oral cavity, pharynx (C00–C14)
5,126
3,749
65,336
1,613,319
2,494
1,144
19,047
354,635
Esophagus (C15)
9,707
6,961
108,847
2,464,063
2,926
1,631
25,382
433,273
Stomach (C16)
7,056
1,900
27,602
600,702
5,024
584
8,971
157,891
Pancreas (C25)
14,845
3,147
50,201
1,162,577
15,481
3,536
53,334
884,761
Larynx (C32)
2,984
2,446
38,012
853,914
778
563
9,914
186,317
Trachea/lung/bronchus (C33–C34)
90,025
78,680
1,118,359
23,189,096
66,874
46,842
770,655
13,597,333
Cervix uteri (C53)
0
0
0
0
3,774
447
11,918
307,412
Kidney and renal pelvis (C64–65)
7,469
2,827
43,898
997,062
4,527
216
3,722
70,680
Urinary bladder (C67)
8,508
3,907
44,166
742,898
3,951
1,076
13,245
174,529
Acute myeloid leukemia (C92.0)
3,889
855
12,527
272,429
3,189
337
5,496
99,772
Subtotal
149,609
104,472
1,508,948
31,896,060
109,018
56,376
921,684
16,266,603
Cardiovascular diseases
Ischemic heart disease (I20–I25)
248,506
50,884
804,551
19,019,062
238,845
29,121
389,974
6,068,242
Other heart disease (I00–I09, I26–I51)
72,312
12,944
55,621
1,134,588
95,304
8,060
31,745
428,084
Cerebrovascular disease (I60–I69)
61,616
7,896
127,280
3,075,304
97,681
8,026
140,894
2,878,017
Atherosclerosis (I70–I71)
5,000
1,282
11,814
155,198
8,430
611
5,475
40,423
Aortic aneurysm (I71)
8,861
5,628
70,512
1,339,220
5,862
2,791
34,192
445,625
Other circulatory diseases (I72–I79)
4,238
505
6,636
134,357
5,715
749
9,386
133,702
Subtotal
400,533
79,139
1,076,414
24,857,729
451,837
49,358
611,666
9,994,093
Respiratory diseases
Pneumonia, influenza (J10–J18)
27,517
6,042
29,828
448,507
35,008
4,381
23,438
273,061
Bronchitis, emphysema (J40–J42, J43)
8,321
7,536
42,842
708,007
7,941
6,391
40,844
532,162
Chronic airways obstruction (J44)
49,774
40,217
421,721
6,306,543
52,328
38,771
462,973
5,545,304
Subtotal
85,612
53,795
494,391
7,463,057
95,277
49,543
527,255
6,350,527
Perinatal conditions
Short gestation/low birth weight (P07)
2,557
219
16,315
—
2,030
174
13,898
—
Respiratory distress syndrome (P22)
550
18
1,358
—
382
13
1,007
—
Other respiratory (newborn) (P23–28)
786
35
2,611
—
556
25
1,983
—
Sudden infant death syndrome (R95)
1,357
173
12,878
—
935
119
9,531
—
Subtotal
5,250
445
33,161
—
3,903
331
26,419
—
Residential fire
1,600
416
—
—
1,270
320
—
—
Secondhand smoke
Lung cancer
—
2,131
—
—
—
1,269
—
—
Ischemic heart disease
—
29,256
—
—
—
16,744
—
—
Subtotal
—
31,388
—
—
—
18,012
—
—
Total
269,655
3,112,914
64,216,846
173,940
2,087,024
32,611,223
* CDC estimates from 2000–2004 National Health Interview Survey responses and 2000–2004 National Center for Health Statistics death certificate data; smoking-attributable residential fire-related death estimates from 2002–2005 data; productivity losses in 2004 dollars.
† International Classification of Diseases and Health Conditions, 10th Revision; available at http://www.who.int/classifications/apps/icd/icd10online.
Return to top.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.


References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

Date last reviewed: 11/13/2008

HOME  |  ABOUT MMWR  |  MMWR SEARCH  |  DOWNLOADS  |  RSSCONTACT
POLICY  |  DISCLAIMER  |  ACCESSIBILITY

Safer, Healthier People

Morbidity and Mortality Weekly Report
Centers for Disease Control and Prevention
1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A

USA.GovDHHS

Department of Health
and Human Services