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State-Specific Smoking-Attributable Mortality and Years of Potential Life Lost --- United States, 2000--2004

Please note: An erratum has been published for this article. To view the erratum, please click here.

Smoking can cause lung and other cancers, coronary heart disease, stroke, chronic respiratory disease, and other diseases (1). In 2008, CDC reported that cigarette smoking and exposure to secondhand smoke resulted in an estimated 443,000 deaths and 5.1 million years of potential life lost (YPLL) annually in the United States during 2000--2004 (2). This report presents state-specific average annual smoking-attributable mortality (SAM) and YPLL estimates for the same period among adults aged >35 years. The report also compares 2000--2004 average annual SAM rates per 100,000 population with rates for 1996--1999. The analysis was based on data from CDC's Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) system.* Substantial variation in average annual number of deaths attributed to smoking during 2000--2004 occurred among the states (range: 492 [Alaska] to 36,687 [California]). From 1996--1999 to 2000--2004, declines in SAM rates occurred in 49 states and the District of Columbia (DC), reflecting progress made in lowering smoking prevalence in the United States during the past 40 years. Rates declined in men in 49 states and DC, but declined in women in only 32 states. To reduce SAM rates further, comprehensive evidence-based approaches for preventing smoking initiation and increasing cessation need to be implemented fully, and states should fund tobacco control activities at the level recommended by CDC (3,4).

State-specific SAM and YPLL from smoking were estimated by using SAMMEC. Sex- and age-specific SAMs were calculated by multiplying the total number of deaths among adults aged >35 years from 19 diseases caused by cigarette smoking (1) by estimates of the smoking-attributable fraction (SAF) of preventable deaths for each disease. The attributable fractions provide estimates of the public health burden of each risk factor and the relative importance of risk factors for multifactorial diseases (2). SAFs were derived using sex-specific relative risk (RR) estimates for current and former smokers for each cause of death from the American Cancer Society's Cancer Prevention Study-II (CPS-II) for the period 1982--1988. For ischemic heart disease and cerebrovascular disease mortality, RR estimates 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 Behavioral Risk Factor Surveillance System (BRFSS) were used to calculate the SAFs. Smoking-attributable YPLL were estimated by multiplying sex- and age-specific SAM by remaining life expectancy at the time of death. State-specific SAM rates per 100,000 population by sex for a given year were calculated using state SAM estimates for the year and population estimates from the U.S. Census Bureau. International Classification of Diseases, Ninth Revision (ICD-9) codes were used for cause of death in 1996--1998, whereas International Classification of Diseases, Tenth Revision (ICD-10) codes were used for 1999--2004 data. Comparability ratios (5) from ICD-9 to ICD-10 were applied to 1996--1998 data to enable comparisons with 2000--2004 data. Data for the years 2000--2004 were used in this report because they correspond to the years available to states in the SAMMEC system to calculate their state-specific SAM estimates. Infant deaths caused by smoking during pregnancy, deaths from exposure to secondhand smoke, and smoking-related fire deaths (2) were not included in the state-specific estimates.

During 2000--2004, the state-specific median estimate of the average annual number of smoking-attributable deaths among adults aged >35 years was 5,534 (range: 492 [Alaska] to 36,687 [California]). SAM estimates for males ranged from 314 (Alaska) to 21,407 (California) and the SAM estimates for females ranged from 178 (Alaska) to 15,280 (California). For every state, the annual number of smoking-related deaths was higher among males than females (Table 1).

The average annual YPLL estimates ranged from 7,762 (Alaska) to 481,529 (California). The YPLL estimates ranged from 4,586 (Alaska) to 288,823 (California) for males and from 3,176 (Alaska) to 192,706 (California) for females (Table 1).

During 2000--2004, overall average annual SAM rates per 100,000 population were lowest in Utah (138.3), Hawaii (167.6), and Minnesota (215.1), and highest in Kentucky (370.6), West Virginia (344.3), and Nevada (343.7) (Table 2). Median SAM rates per 100,000 population overall were 288.1 for 1996--1999 and 263.3 for 2000--2004 (Table 2). Changes in smoking-attributable deaths per 100,000 population during these two periods varied among states; SAM rates among adults declined the most in Nevada (-44.4 deaths per 100,000 population), California (-37.8), and Virginia (-33.4). Average annual overall SAM rates decreased from 1996--1999 to 2000--2004 in all states except Oklahoma, which experienced an increase of 26.9 deaths per 100,000. Compared with 1996--1999, average annual SAM rates declined in 2000--2004 among men in all states except Oklahoma, but increased among women in several states (Alabama, Arizona, Arkansas, Georgia,

Indiana, Kansas, Kentucky, Louisiana, Mississippi, Michigan, North Carolina, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas) and DC (Table 2).

Reported by: B Adhikari, PhD, J Kahende, PhD, A Malarcher, PhD, C Husten, MD, K Asman, MSPH, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

During 2000--2004, substantial variation occurred in the estimated absolute number of deaths caused by cigarette smoking across the 50 states and DC. Such variations have been observed previously and are the result of differences across states in total population size, demographic characteristics of state populations, and in smoking prevalence (6,7). Estimates of absolute SAM within states do not appear to have decreased from 1990 to 2004 (7) despite declines in smoking prevalence in the majority of states.§ The lack of change in absolute SAM over time is likely attributable to long-term population increases and the inclusion of additional smoking-related diseases in the SAM calculation as recent scientific studies have identified additional diseases caused by smoking (1).

The analysis in this report used the latest SAMMEC methodology to retrospectively calculate SAM rates in 1996--1999 and compare those with SAM rates in 2000--2004. The results showed that SAM rates decreased in 49 states and DC, but declined in women in only 32 states. This overall progress in decreasing SAM rates in the United States reflects the growth and effectiveness of tobacco control programs and progress in decreasing SAM rates. However, the results also indicate that more progress was made in reducing SAM rates in men than in women and that further efforts are needed to reduce SAM rates among both sexes.

The findings in this report are subject to at least five limitations. First, the estimates understate deaths attributable to all tobacco use because estimates of deaths attributable to cigar smoking, pipe smoking, and smokeless tobacco use were not included. Second, RRs were based on deaths during 1982--1988 among birth cohorts who might have had different smoking histories than current or former smokers in 2000--2004 (e.g., age of initiation and duration of smoking before quitting). CDC is continuing to monitor whether the RRs for smoking are changing over time. CDC is considering whether to use updated RRs for future SAMMEC estimates, particularly for females, because more recent cohorts of female smokers took up smoking at younger ages than did earlier cohorts (8). Third, RRs from CPS-II were adjusted for the effects of age but not for other possible confounders (e.g., alcohol use and education level). However, research suggests that alcohol and other confounders had little effect on SAM estimates for lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, and cerebrovascular disease (2). Fourth, BRFSS does not survey persons in households without landline telephones, raising concerns about the representativeness of landline telephone surveys. However, persons without landlines are more likely to be younger than age 35 years (9) and therefore less likely to be included in these estimates. Finally, some states have low response rates for BRFSS. Lower response rates indicate a potential for response bias; however, BRFSS estimates for current cigarette smoking are comparable to smoking estimates from other surveys with higher response rates (10).

SAM is one measure that is used to monitor the public health burden of cigarette smoking in the United States (2) and in each state. These most recent SAM estimates indicate that in recent years cigarette smoking continued to impose a substantial health burden on U.S. adults in all states. Changes in SAM rates across time quantify the potential gain that can be realized from effective tobacco control programs that decrease smoking initiation and increase smoking cessation (3).** The Institute of Medicine has called for aggressive action to end the tobacco epidemic (4). Fully implementing effective state comprehensive tobacco control programs, as recommended by CDC (3), can further reduce smoking prevalence and deaths caused by cigarette smoking in all states and increase life expectancy.

References

  1. CDC. 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. Smoking-attributable mortality, years of potential life lost, and productivity losses---United States, 2000--2004. MMWR 2008;57:1226--8.
  3. 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.
  4. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: National Academies Press; 2007.
  5. Anderson RN, Minino AM, Hoyert DL, Rosenberg HM. Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates. Natl Vital Stat Rep 2001;49(2):1--32. 
  6. Ezzati M, Friedman AB, Kulkarni SC, Murray CJL. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Med 2008;5:e66. Available at http://www.plosmedicine.org.
  7. Nelson DE, Kirkendall RS, Lawton RL, et al. Surveillance for smoking-attributable mortality and years of potential life lost, by state---United States, 1990. MMWR 1994;43(No. SS-1).
  8. CDC. Women and smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2001. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001.
  9. Blumberg SJ, Luke JV. Wireless substitution: early release of estimates based on data from the National Health Interview Survey, July--December 2006. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless200705.pdf.
  10. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Social Prev Med 2001;46:S3--42.

* SAMMEC estimates state-specific SAM and YPLL based on data from the Behavioral Risk Factor Surveillance System and death certificate data from the National Center for Health Statistics. 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.

§ State-level data on tobacco use prevention and control are available through the State Tobacco Activities and Evaluation (STATE) System at http://apps.nccd.cdc.gov/statesystem.

Data on cigarette smoking prevalence used to calculate the state-specific SAM estimates are from BRFSS, which uses a multistage sampling design primarily to generate state estimates. When aggregated, these state SAM estimates are comparable to the national estimate (2), which was calculated using cigarette smoking prevalence data from the National Health Interview Survey (after excluding infant deaths caused by smoking during pregnancy, deaths from exposure to secondhand smoke, and smoking-related fire deaths).

** Additional information on effective tobacco-control programs is available from CDC's Guide to Community Preventive Services at http://www.thecommunityguide.org/tobacco.

Table 1

TABLE 1. Estimated annual smoking-attributable mortality (SAM) and years of potential life lost (YPLL), by state and sex  Smoking-Attributable Mortality, Morbidity, and Economic Costs system, United States, 20002004*
State
SAM
YPLL
Male
Female
Total
Male
Female
Total
Alabama
4,860
2,725
7,585
70,913
38,113
109,026
Alaska
314
178
492
4,586
3,176
7,762
Arizona
4,090
2,770
6,859
51,137
36,640
87,777
Arkansas
3,109
1,806
4,915
42,682
26,626
69,308
California
21,407
15,280
36,687
288,823
192,706
481,529
Colorado
2,586
1,804
4,390
32,007
22,898
54,905
Connecticut
2,639
2,146
4,785
34,536
28,161
62,697
Delaware
710
488
1,198
9,737
6,661
16,398
District of Colombia
439
283
722
7,198
4,424
11,622
Florida
17,073
11,536
28,609
230,840
151,559
382,399
Georgia
6,642
3,904
10,547
101,839
60,435
162,274
Hawaii
801
359
1,160
10,775
5,305
16,080
Idaho
935
576
1,511
12,379
8,087
20,466
Illinois
9,963
6,638
16,601
139,125
90,498
229,623
Indiana
5,858
3,873
9,731
83,025
55,890
138,915
Iowa
2,845
1,599
4,444
36,696
20,321
57,017
Kansas
2,383
1,501
3,884
31,295
19,246
50,541
Kentucky
4,808
3,040
7,848
68,526
44,234
112,760
Louisiana
4,099
2,401
6,500
59,497
36,273
95,770
Maine
1,310
925
2,235
17,312
12,705
30,017
Maryland
3,931
2,930
6,861
55,680
40,412
96,092
Massachusetts
4,983
4,032
9,016
66,004
53,901
119,905
Michigan
8,602
5,922
14,523
120,649
88,498
209,147
Minnesota
3,404
2,130
5,534
42,072
27,305
69,377
Mississippi
3,122
1,634
4,757
45,536
25,141
70,677
Missouri
5,818
3,767
9,585
80,812
55,515
136,327
Montana
849
572
1,421
10,463
6,608
17,071
Nebraska
1,460
812
2,272
17,631
10,710
28,341
Nevada
1,935
1,376
3,311
25,617
19,907
45,524
New Hampshire
1,001
763
1,763
13,878
10,144
24,022
New Jersey
6,330
4,873
11,203
88,749
64,808
153,557
New Mexico
1,278
828
2,106
16,156
11,130
27,286
New York
14,294
11,139
25,433
190,074
154,036
344,110
North Carolina
7,620
4,645
12,265
112,010
69,556
181,566
North Dakota
593
282
875
7,575
3,558
11,133
Ohio
11,046
7,547
18,593
154,657
109,652
264,309
Oklahoma
3,748
2,461
6,209
50,117
35,091
85,208
Oregon
2,909
2,070
4,979
36,775
27,717
64,492
Pennsylvania
11,888
8,139
20,027
159,521
112,814
272,335
Rhode Island
956
739
1,695
11,780
9,973
21,753
South Carolina
3,901
2,227
6,127
58,830
34,871
93,701
South Dakota
707
361
1,068
8,099
5,059
13,158
Tennessee
6,063
3,649
9,712
90,044
52,257
142,301
Texas
15,089
9,483
24,571
218,133
132,276
350,409
Utah
799
356
1,155
10,275
4,796
15,071
Vermont
482
348
831
6,599
4,833
11,432
Virginia
5,583
3,659
9,242
80,084
52,073
132,157
Washington
4,439
3,180
7,619
59,695
44,366
104,061
West Virginia
2,279
1,542
3,821
33,627
22,529
56,156
Wisconsin
4,402
2,841
7,243
57,576
39,880
97,456
Wyoming
420
282
702
5,181
3,625
8,806
* Estimated smoking-attributable mortality rates among adults aged >35 years. Deaths resulting from secondhand smoke and smoking-related fires, which are included in national estimates, are not included in these estimates.
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Table 2

TABLE 2. Estimates of average annual smoking-attributable mortality (SAM) rates per 100,000 population, by state, year, and sex  Smoking-Attributable Mortality, Morbidity, and Economic Costs system, United States, 19962004*
SAM rates
Percentage-point change
19961999
20002004
19961999 to 20002004
State
Male
Female
Overall
Male
Female
Overall
Male
Female
Overall
Alabama
536.9
184.3
323.5
504.3
192.5
317.5
-32.6
8.2
-5.9
Alaska
396.7
218.9
300.4
374.0
188.2
270.4
-22.7
-30.7
-30.0
Arizona
376.5
165.9
256.3
337.6
176.7
247.4
-38.9
10.9
-8.9
Arkansas
525.1
200.0
333.5
492.1
203.9
323.7
-33.0
3.9
-9.8
California
391.5
189.3
272.8
327.4
167.6
235.0
-64.1
-21.7
-37.8
Colorado
394.0
174.0
261.9
337.0
168.6
237.6
-57.0
-5.3
-24.3
Connecticut
369.4
183.0
256.7
330.4
174.8
238.3
-39.0
-8.1
-18.4
Delaware
455.7
207.7
307.6
397.7
196.8
280.9
-58.0
-10.9
-26.7
District of Colombia
419.7
159.6
261.8
379.9
160.5
249.9
-39.8
0.9
-11.9
Florida
404.8
191.3
283.8
359.4
180.3
258.8
-45.4
-11.0
-25.0
Georgia
513.3
179.1
308.5
469.6
188.0
299.4
-43.7
8.9
-9.1
Hawaii
296.7
110.2
195.6
261.7
93.4
167.6
-35.0
-16.8
-28.0
Idaho
391.4
160.9
258.9
337.8
159.6
237.4
-53.6
-1.3
-21.5
Illinois
445.6
188.0
290.7
390.9
175.4
263.1
-54.7
-12.6
-27.6
Indiana
500.9
206.0
323.3
457.2
207.7
308.9
-43.7
1.7
-14.4
Iowa
431.6
152.0
263.3
392.7
149.1
248.0
-38.9
-2.9
-15.3
Kansas
430.0
157.4
267.1
395.1
170.9
262.7
-34.9
13.5
-4.4
Kentucky
604.0
238.2
383.9
555.8
244.4
370.6
-48.2
6.3
-13.3
Louisiana
510.2
187.5
316.6
459.8
189.1
299.8
-50.4
1.6
-16.8
Maine
447.0
215.4
308.2
412.1
203.5
289.8
-34.9
-11.9
-18.4
Maryland
422.5
199.1
288.1
366.1
189.1
261.9
-56.4
-10.0
-26.2
Massachusetts
397.7
189.0
269.7
350.1
182.3
249.4
-47.6
-6.7
-20.3
Michigan
466.3
194.2
303.0
403.8
196.4
281.9
-62.5
2.2
-21.1
Minnesota
357.8
143.8
229.5
323.0
140.3
215.1
-34.8
-3.5
-14.4
Mississippi
592.1
179.4
343.0
542.1
193.8
333.6
-49.9
14.4
-9.4
Missouri
508.1
220.1
335.1
458.9
204.0
307.8
-49.2
-16.1
-27.3
Montana
439.5
200.3
300.3
383.8
195.9
276.0
-55.7
-4.3
-24.3
Nebraska
429.5
150.2
261.7
373.5
142.0
235.8
-56.0
-8.2
-25.9
Nevada
496.7
299.0
388.1
437.0
266.4
343.7
-59.7
-32.6
-44.4
New Hampshire
432.4
212.5
300.1
373.1
200.3
272.4
-59.3
-12.2
-27.7
New Jersey
391.9
173.6
259.7
339.2
171.7
239.5
-52.7
-1.9
-20.2
New Mexico
374.5
169.1
255.1
331.0
161.5
234.0
-43.5
-7.6
-21.1
New York
385.7
187.7
266.4
349.4
176.5
246.1
-36.3
-11.2
-20.3
North Carolina
512.8
180.2
310.6
458.7
190.7
298.4
-54.1
10.6
-12.2
North Dakota
389.3
127.3
236.5
365.9
125.5
225.6
-23.4
-1.8
-10.9
Ohio
482.4
200.5
311.7
438.5
203.9
299.1
-43.9
3.4
-12.6
Oklahoma
465.9
193.8
305.2
481.5
225.8
332.1
15.6
32.0
26.9
Oregon
412.8
197.2
286.7
362.8
191.3
263.3
-50.0
-5.9
-23.4
Pennsylvania
425.4
178.0
275.9
384.2
173.7
259.0
-41.2
-4.3
-16.9
Rhode Island
431.9
191.6
284.5
383.9
188.2
266.8
-48.0
-3.4
-17.7
South Carolina
506.0
172.9
305.6
453.1
183.3
293.4
-52.9
10.4
-12.2
South Dakota
450.3
126.8
259.6
378.9
138.4
239.2
-71.4
11.6
-20.4
Tennessee
545.7
199.6
337.4
497.1
207.7
325.0
-48.6
8.1
-12.4
Texas
463.6
176.5
292.3
401.7
181.6
273.1
-61.9
5.1
-19.2
Utah
246.4
79.0
149.3
221.3
75.6
138.3
-25.1
-3.4
-11.0
Vermont
415.5
178.2
274.0
349.3
176.0
247.5
-66.2
-2.2
-26.5
Virginia
467.9
192.6
300.4
395.5
180.0
267.0
-72.4
-12.6
-33.4
Washington
402.8
199.7
284.0
359.2
189.4
261.0
-43.6
-10.3
-23.0
West Virginia
563.3
236.2
365.8
501.7
235.8
344.3
-61.6
-0.4
-21.5
Wisconsin
404.5
162.2
260.3
362.7
162.2
244.2
-41.8
0.0
-16.1
Wyoming
439.6
207.9
302.5
395.0
201.4
283.1
-44.6
-6.5
-19.4
Median
431.9
187.7
288.1
383.9
183.3
263.3
-48.0
-4.4
-24.8
* Estimated smoking-attributable mortality rates among adults aged >35 years. Deaths resulting from secondhand smoke and smoking-related fires, which are included in national estimates, are not included in these estimates. Comparability ratios were applied so that 19961998 estimates using International Classification of Diseases, Ninth Revision (ICD-9) codes are comparable to estimates for 20002004 using International Classification of Diseases, Tenth Revision (ICD-10) codes.
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Date last reviewed: 1/22/2009

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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