State-Specific Smoking-Attributable Chronic Obstructive Pulmonary Disease Mortality -- United States, 1986

Estimates of mortality caused by smoking-attributable chronic obstructive pulmonary disease (SA-COPD) indicate substantial differences by state and region, with higher rates in the West (1). To examine these variations, CDC analyzed 1986 state-specific current smoking prevalence rates, quit ratios (2), and age-adjusted SA-COPD mortality rates for adults aged greater than or equal to 35 years.

For this report, current smokers are defined as persons who have smoked at least 100 cigarettes and who continue to smoke; former smokers as persons who have smoked 100 cigarettes but who no longer smoke; and ever smokers as current and former smokers combined. Regional patterns in smoking cessation are based on state-specific "quit ratios," defined as the proportion of ever smokers who are former smokers (3).

SA-COPD mortality estimates are derived from relative risk estimates for death from COPD in current and former smokers aged greater than or equal to 35 years (4); these relative risks are based on a prospective mortality study sponsored by the American Cancer Society (3,5). State-specific SA-COPD mortality rates are sex- and age-adjusted to the 1986 U.S. population, and attributable risk percentages are calculated by standard methods (6).

Current smoking prevalence among persons aged greater than or equal to 35 years ranged from 10% in Utah to 35% in Alaska. The quit ratio ranged from 39% in Alaska to 54% in Utah (Table 1). Regional variations included higher current smoking prevalence in the eastern and southern states (Figure 1) but higher quit ratios in the West (Figure 2).

SA-COPD mortality rates ranged from 28.0 per 100,000 persons in Hawaii to 87.4 per 100,000 in Wyoming (Table 1). The geographic distribution of state-specific SA-COPD mortality rates (Figure 3) was similar to the pattern for total COPD death rates (1), with the highest SA-COPD mortality rates in the western states. Reported by: Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The regional pattern for SA-COPD mortality differs from that of prevalence of current smoking among adults. One explanation for this difference may relate to migration patterns of persons with SA-COPD who relocate to the West before dying from their disease (7). Alternatively, the difference may reflect the regional distribution of current smoking, quit ratios, and the mortality patterns for other smoking-related diseases (i.e., coronary heart disease, lung cancer, and stroke).

In general, current smokers die younger than never smokers or former smokers (8). Therefore, regional variations in the prevalence of smoking and smoking cessation may contribute substantially to regional mortality patterns for several chronic diseases. The regional concentration of higher age-adjusted mortality rates for stroke (9), coronary heart disease (10), and lung cancer (11) in the East and South more closely approximates the distribution of higher current smoking prevalence. Conversely, the regional distribution of SA-COPD mortality is similar to the regional distribution of higher quit ratios. Thus, the incidence of premature death due to stroke, coronary heart disease, and lung cancer may be reduced in populations characterized by lower current smoking prevalence rates and higher quit ratios. However, these populations ultimately may have higher SA-COPD mortality rates because of previous smoking exposure. Additional epidemiologic analyses are necessary to assess the possible link between smoking-attributable chronic disease mortality patterns and changes in smoking behavior.

Efforts to prevent initiation of smoking and promote cessation of smoking are known to reduce mortality associated with COPD and other chronic diseases (3). Public health programs and primary-care providers should intensify efforts to prevent initiation of smoking in younger age groups and to support smoking cessation among adults, especially in states with high prevalences of smoking.

References

1. CDC. Chronic disease reports: chronic obstructive pulmonary disease

mortality--United States, 1986. MMWR 1989;38:549-52. 2. Marcus AC, Shopland DR, Crane LA, Lynn WL. Prevalence of cigarette smoking in the United States: estimates from the Current Population Survey. JNCI 1989;81:409-14.

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

4. Walter SD. The estimation and interpretation of attributable risk in health research. Bio metrics 1976;32:829-49.

5. Stellman SD, Garfinkel L. Smoking habits and tar levels in a new American Cancer Society prospective study of 1.2 million men and women. JNCI 1986;76:1057-63.

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

7. Lebowitz MD, Burrows B. Tucson epidemiologic study of obstructive lung diseases. II. Effects of in-migration factors on the prevalence of obstructive lung diseases. Am J Epidemiol 1975;102:153-63.  8. Lew EA, Garfinkel L. Differences in mortality and longevity by sex, smoking habits and health status. Trans Soc Actuaries 1987;39:107-30.

9. CDC. Chronic disease reports: stroke. MMWR 1989;38:191-3. 10. CDC. Chronic disease reports: coronary heart disease mortality--United States, 1986. MMWR 1989;38:285-8. 11. CDC. Chronic disease reports: deaths from lung cancer--United States, 1986. MMWR 1989; 38:501-5.

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