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Perspectives in Disease Prevention and Health Promotion Smoking-Attributable Mortality -- Kentucky, 1988

Smoking is the single most important preventable cause of death in the United States (1). Among states participating in the Behavioral Risk Factor Surveillance System (BRFSS), Kentucky has consistently ranked at or near the top in prevalence of smoking (2). In 1988, the BRFSS indicated that 34% of adults in Kentucky were current smokers, compared with a median prevalence of 24% for all states surveyed (3). To better characterize the public health burden of smoking in Kentucky, the Kentucky Department for Health Services recently estimated smoking-attributable mortality (SAM) and years of potential life lost (YPLL) in that state during 1988. This report summarizes results from that analysis.

SAM and YPLL were calculated using SAMMEC II (Smoking-Attributable Mortality, Morbidity, and Economic Costs) computer software (4). Calculations were made for 22 smoking-related diseases among adults aged greater than or equal to 35 years (Table 1). The analysis also included smoking-related burn fatalities for persons of all ages and four perinatal conditions related to maternal smoking (5). Age- and sex-specific mortality data for 1988 were obtained from the state's vital records system. Age- and sex-specific smoking prevalence rates for 1988 were obtained from the state's BRFSS. YPLL were calculated to life expectancy using 1985 data from CDC's National Center for Health Statistics (6).

The smoking-attributable fraction (SAF) was derived from age- and sex-specific relative risks of death (based on the American Cancer Society's Cancer Prevention Study II (1)) and prevalence data for current and former smokers from the 1988 BRFSS. Total SAM was calculated by multiplying the number of deaths in each disease category by the specific SAF. Total smoking-attributable YPLL was calculated by multiplying the age-specific SAM by YPLL for each premature death.

In 1988, 8230 deaths in Kentucky were attributable to smoking, accounting for 22% of all deaths in the state during the year. Fifty-three percent of smoking-attributable deaths were from lung cancer and ischemic heart disease (Table 1). Sixty-eight percent of SAM occurred among men (Table 2). Sixty-seven percent of deaths occurred in persons greater than or equal to 65 years of age. However, when smoking-attributable deaths were calculated as a percentage of total deaths, persons aged 45-64 years had a higher percentage of deaths caused by smoking than did persons aged greater than or equal to 65 years (Figure 1). For men aged 55-64 years, 41% of all deaths were attributable to smoking. When considered as a separate cause of death, SAM was the most common cause of death in men, the third most common cause in women, and, for both sexes, the second most common cause in Kentucky (Table 2).

In 1988, 115,458 YPLL before life expectancy in Kentucky were attributable to smoking. Fifty-five percent of smoking-attributable YPLL occurred in persons aged less than 65 years. The mean YPLL was 14 years per smoking-attributable death. Reported by: R Finger, MD, State Epidemiologist, Dept for Health Svcs, Kentucky Cabinet for Human Resources. JM Shultz, PhD, Dept of Epidemiology and Public Health, Univ of Miami School of Medicine, Miami, Florida. Program Svcs Activity, Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion; Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: This analysis quantifies the premature mortality caused by smoking in a state with a historically high prevalence of tobacco use. The high prevalence of smoking among middle-aged persons in Kentucky (38.4% among those aged 35-49 years and 34.9% among those aged 50-64 years) (2) is of special concern. The data indicate a need to intensify cessation efforts among these persons before the onset of chronic diseases associated with smoking. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990, describes the important reductions in risk that may be associated with smoking cessation at any age (7).

To reduce the burden of SAM in Kentucky, greater efforts are also necessary to prevent smoking among young persons. During the 1990 legislative session in Kentucky, the legislature enacted a law prohibiting the sale of tobacco products to all persons less than 16 years of age. This law also established fines for vendors who sell tobacco products to persons aged less than 16 years and requires that signs stating the age limit for purchase of tobacco be posted at the point of sale. Enforcement of laws such as this is critical to reducing tobacco use (8).

SAMMEC II software can be used to estimate the effects of smoking and has been distributed to all 50 states and the District of Columbia. Additional state-specific estimates may be made using this software to provide public health workers and policymakers with important updated information regarding the impact of smoking in their respective states (9).


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

  2. Anda RF, Waller MN, Wooten KG, et al. Behavioral risk factor surveillance, 1988. In: CDC surveillance summaries, June 1990. MMWR 1990;39(no. SS-2):1-21.

  3. CDC. Cigarette smoking--Behavioral Risk Factor Surveillance System, 1988. MMWR 1989;38:845-8.

  4. Shultz JM, Novotny TE, Rice DP. SAMMEC II: computer software and documentation. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, April 1990.

  5. McIntosh ID. Smoking and pregnancy: attributable risks and public health implications. Can J Public Health 1984;75:141-8.

  6. NCHS. Vital statistics of the United States, 1985: life tables. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (PHS)88-1108.

  7. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416.

  8. CDC. State laws restricting minors' access to tobacco. MMWR 1990;39:349-53.

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

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