Smoking-Attributable Mortality -- Mexico, 1992

Cigarette smoking causes neoplastic, respiratory, and cardiovascular diseases that contribute substantially to disability, death, and medical-care expenditures (1). In the United States, cigarette smoking is the leading preventable cause of premature death (1). Although the prevalence of cigarette smoking in Mexico (26% in 1993 {2}) is similar to that in the United States, smoking-attributable mortality has not been recently estimated for Mexico or most other developing countries that are experiencing increases in chronic diseases. To assist in the development of programs for preventing tobacco use, the Ministry of Health of Mexico used a modified version of the software program Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) to estimate smoking-related mortality (3). This report summarizes trends in the occurrence of smoking-related diseases in Mexico and estimates smoking-attributable mortality and years of potential life lost before age 65 years (YPLL-65) in 1992.

Data from the Ministry of Health for 1970, 1980, and 1990 were used to calculate age-adjusted death rates per 100,000 persons for lung cancer, coronary heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, and other smoking-related cancers (e.g., mouth, esophagus, larynx, cervix, bladder, and kidney) (4); rates were directly adjusted to the 1992 population (5). SAMMEC uses smoking prevalence and relative risks for smoking-related diseases to calculate smoking-attributable fractions (the proportions of deaths attributable to cigarette smoking). Because relative risks for smoking-related diseases were unavailable for Mexico, smoking-attributable fractions were estimated (5,6) by using an index based on lung cancer death rates in the United States and Mexico (cigarette smoking accounts for most lung cancer deaths {6}; therefore, the lung cancer death rate in Mexico was used as an overall measure of risk for disease).

The lung cancer index was calculated separately for men and women. For men, the lung cancer rate among women was used as the baseline because the prevalence of smoking among women in Mexico has been low until recently, and the prevalence of other risk factors for lung cancer has been similar among men and women in Mexico. For women, the lung cancer rate among U.S. never smokers was used as the baseline (6,7). The index was multiplied by SAMMEC disease-specific smoking-attributable fractions to obtain adjusted disease-specific smoking-attributable fractions for Mexico. The number of deaths from each smoking-related disease in 1992 was multiplied by the respective adjusted smoking-attributable fraction to estimate the smoking-attributable mortality for Mexico and was used to estimate YPLL-65 associated with cigarette smoking.

During 1970-1990, death rates for all major smoking-related diseases in Mexico increased substantially, ranging from a 60% increase in the death rate for cerebrovascular disease to a 220% increase in the death rate for lung cancer (Table_1, page 379).

When the lung cancer rate among women was used to estimate the baseline risk for men, the numbers of smoking-attributable deaths and YPLL-65 among men in 1992 were 6875 and 25,172, respectively (Table_2, page 379). When the lung cancer rate among U.S. never smokers was used to estimate the baseline risk among women in Mexico, the numbers of smoking-attributable deaths and YPLL-65 among women in Mexico in 1992 were 3378 and 14,996, respectively. The total numbers of smoking-attributable deaths and YPLL-65 in Mexico in 1992 were 10,253 and 40,168, respectively. Most smoking-attributable deaths and YPLL-65 among men and women were associated with cardiovascular diseases, chronic obstructive pulmonary disease, and lung cancer. Reported by: R Tapia Conyer, MD, P Kuri Morales, MD, F Meneses Gonzales, MD, Ministry of Health, Mexico City, Mexico. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Data for Decision Making Project, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The findings in this report document the substantial impact of cigarette smoking on premature mortality in adults in Mexico. Death rates from the leading causes of smoking-related deaths have nearly tripled since 1970 in Mexico. Based on this analysis, the proportion of deaths attributable to smoking in Mexico is 9%, compared with 32% in the United States for the same categories of deaths considered in this report. These differences may be attributable to lower cigarette consumption in Mexico compared with the United States. However, as the population of Mexico ages and the average duration of smoking increases, the number of smoking-attributable deaths probably will increase.

The estimates of the total number of smoking-attributable deaths and YPLL-65 in Mexico during 1992 probably are low for at least three reasons. First, baseline lung cancer rates for U.S. never smokers probably reflect effects of occupational or environmental exposures and, therefore, may have produced lower estimates of excess risk in Mexico. Second, estimates of smoking-attributable mortality in Mexico do not include deaths from burns, stillbirths, and sudden infant death syndrome or deaths occurring during the perinatal period because these risks are unknown and could not be extrapolated from known risks in the United States. Third, smoking-attributable mortality estimates for 1992 reflect the lower prevalences of smoking in previous decades and may not fully capture increases in mortality resulting from recent changes in smoking patterns. In addition, because this study used adjusted smoking-attributable fractions, the association between smoking-related behaviors (i.e., duration and amount of smoking, depth of inhalation, or use of filtered-tip cigarettes) and smoking-related diseases could not be examined. Ongoing examination of the relation between smoking and disease in Mexico will improve the accuracy of future estimates.

In Mexico, because chronic diseases (including neoplasms and cardiovascular disease) are emerging as leading causes of death (4), the prevention of tobacco use is a major priority. The findings in this report will assist in refining policies to reduce the prevalence of cigarette smoking and risks for associated diseases and to counter the impact of increased tobacco advertising and other marketing strategies (8). Priority measures may include preventing the initiation of cigarette smoking among children and adolescents, increasing smoking cessation among adult smokers, developing health education programs, and establishing legislative policies (e.g., regulating and restricting the advertisement and promotion of tobacco products, restricting or banning tobacco sales to minors, and increasing tobacco taxes and prices {9}).

References

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, CDC, 1989; DHHS publication no. (CDC)89-8411.

2. General Office for Epidemiology. National Addiction Survey, 1993 {Spanish}. Mexico DF: Ministry of Health, 1993.

3. 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.

4. National Institutes for Statistics, Geography, and Informatics. Total deaths by cause, sex, and age -- United States of Mexico, 1970, 1980, 1990: population by age, 1992. Mexico DF: Ministry of Health, General Office for Statistics, National Institutes for Statistics, Geography, and Informatics, 1993; publication no. (IFDN)968-811-239-9.

5. Rothman KJ. Modern epidemiology. Boston: Little, Brown, and Company, 1986.

6. CDC. Smoking and health in the Americas: a 1992 report of the Surgeon General, in collaboration with the Pan American Health Organization. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992; DHHS publication no. (CDC)92-8419.

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

8. Stebbins R. Making a killing south of the border: transnational cigarette companies in Mexico and Guatemala. Soc Sci Med 1994;38:105-15.

9. Roemer R. Development and implementation of a policy on tobacco control. In: Legislative action to combat the world tobacco epidemic. 2nd ed. Geneva: World Health Organization 1993:155-80.

TABLE 1. Annual death rates * for leading causes of smoking-related
deaths -- Mexico, 1970, 1980, and 1990
=========================================================================
Disease (ICD-9 + code)                  1970     1980     1990
-------------------------------------------------------------------------
Lung cancer (162)                       1.8      3.3      5.8
Coronary heart disease (410-414)       11.9     18.6     34.3
Cerebrovascular disease (430-438)      14.0     17.5     22.8
Chronic obstructive pulmonary
  disease (491-492 and 496)              &       0.9      6.3
Other smoking-related cancers @         3.4      4.8      7.8

-------------------------------------------------------------------------
* Per 100,000 population, directly adjusted to the age distribution of
  the 1992 population of Mexico.
+ International Classification of Diseases, Ninth Revision.
& ICD-9 group codes were not available.
@ Cancer of the mouth (ICD-9 codes 140-149), esophagus (150), larynx
  (161), cervix (180), bladder (188), and kidney (189).

Source: Vital Statistics Section, Ministry of Health, Mexico.
=========================================================================

Table 2. Estimated smoking-attributable mortality (SAM) and smoking-attributable
years of potential life lost before age 65 (YPLL-65), by sex -- Mexico, 1992.
=================================================================================
                                             Men +            Women &
                                         ------------       ------------
Disease(ICD-9* code)                     SAM  YPLL-65       SAM  YPLL-65
---------------------------------------------------------------------------------
Neoplasms
  Lip, oral cavity, or pharynx
    (140-149)                            111     380          30     127
  Esophagus (150)                        105     369          34     153
  Pancreas (157)                          67     349          77     350
  Larynx (161)                           152     463          27      86
  Trachea, lung, or bronchus (162)       997   3,219         307   1,269
  Cervix uteri (180)                                         325   3,093
  Urinary bladder (188)                   50     112          13      36
  Kidney or other urinary (189)           67     342           8      44

Cardiovascular diseases
  Hypertension (401-404)                  76     285          43     130
  Ischemic heart disease (410-414)     1,522   8,515         620   2,509
  Other heart disease
    (390-398, 415-417, and
    420-429)                             675   2,017         349   1,274
  Cerebrovascular disease (430-438)      768   3,604         417   3,432
  Atherosclerosis (440)                   92      88          49      30
  Aortic aneurysm (441)                   26      81           6      19
  Other arterial disease (442-448)        79     214          35     114

Respiratory diseases
  Pneumonia and influenza (480-487)      479   1,693         229     667
  Bronchitis or emphysema (491-492)      346     349         219     256
  Chronic airway obstruction (496)       919   1,007         454     514
  Other respiratory diseases
    (010-012 and 493)                    344   2,085         136     893


Total                                  6,875  25,172       3,378  14,996
---------------------------------------------------------------------------------

* International Classification of Diseases, Ninth Revision.
+ Baseline for Mexican men based on lung cancer rates for Mexican women.
& Baseline for Mexican women based on lung cancer rates for U.S. never smokers.
=================================================================================

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