In the United States, smoking-related illnesses account for an estimated 438,000 deaths each year. On average, these deaths occur 12 years earlier than would be expected, so the aggregate annual loss exceeds 5 million life-years.[1] These deaths are due to a myriad of cancers (see below), cardiovascular diseases, chronic lung diseases, and other causes. It has been estimated that 30% of cancer deaths and 20% of all premature deaths in the United States are attributable to smoking.[2]

Tobacco products are the single, major avoidable cause of cancer, causing more than 155,000 deaths among smokers in the United States annually due to various cancers.[3] The majority of cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, nasal cavity, and esophagus are attributable to tobacco products, particularly cigarettes. Smoking is also associated with cancer of the pancreas, kidney, bladder, myeloid leukemia, liver, stomach, and cervix,[4] and has been linked to colorectal adenomas and cancer.[5]

Smoking also has substantial effects on the health of nonsmokers. Environmental or second-hand tobacco smoke is implicated in causing lung cancer and coronary heart disease.[6,7] Environmental tobacco smoke has the same components as inhaled mainstream smoke, although in lower absolute concentrations, between 1% and 10%, depending on the constituent. Carcinogenic compounds in tobacco smoke include the polycyclic aromatic hydrocarbons (PAHs), including the carcinogen benzo[a]pyrene (BaP) and the nicotine-derived tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). In rodents, total doses of both PAH and NNK are similar to doses received by humans in a lifetime of smoking induced pulmonary tumors.[8] Elevated biomarkers of tobacco exposure, including urinary cotinine, tobacco-related carcinogen metabolites, and carcinogen-protein adducts, are seen in passive or second-hand smokers.[9-12]

Smoking during pregnancy causes perinatal deaths, low birth weights, and preterm deliveries. It may also increase the risk for sudden infant death syndrome, middle ear effusions, and lower respiratory tract infections in children, as well as exacerbating childhood asthma.[13] Cigarettes are also responsible for about 25% of deaths from residential fires.[13]

In 2004, 23.4% of adult men and 18.5% of adult women in the United States were current smokers.[14] (Also available online.) Cigarette smoking is particularly common among American Indians and Alaska Natives. The prevalence of smoking also varies inversely with education and was highest among adults who had earned a General Educational Development (GED) diploma (39.6%) and high school dropouts (34.0%), and generally decreased with increasing years of education.[14] Cigarette smoking prevalence among male and female high school students increased substantially during the early 1990s, in all ethnic groups but appears to have been declining since approximately 1996.[15,16] (Also available online.)

The effect of tobacco use on population-level health statistics is illustrated by the example of lung cancer mortality trends. Smoking by women increased between 1940 and the early 1960s, resulting in a greater than 600% increase in female lung cancer mortality since 1950. Lung cancer is now the leading cause of cancer death in women.[13,15] In the last 30 years, prevalence of current cigarette use has generally decreased, though far more rapidly in males. Lung cancer mortality in men peaked in the 1980s, and has been declining since then; this decrease has occurred predominantly in squamous cell and small cell carcinomas, the histologic types most strongly associated with smoking.[15] Variations in lung cancer mortality rates by state also more or less parallel long-standing state-specific differences in tobacco use. For example, among men, average annual age-adjusted lung cancer death rates for 1990 to 1996 were highest in Kentucky (103.4 per 100,000), where 33.1% of men were current smokers in 1997, and lowest in Utah (45.8 per 100,000), where only 16.1% of men smoked. Among women, lung cancer death rates were highest in Nevada (45.8 per 100,000), where 29.8% of women were current smokers, and lowest in Utah (13.9 per 100,000), where only 11.5% of women smoked.[15]

References

1. Nelson DE, Kirkendall RS, Lawton RL, et al.: Surveillance for smoking-attributable mortality and years of potential life lost, by state--United States, 1990. Mor Mortal Wkly Rep CDC Surveill Summ 43 (1): 1-8, 1994.  [PUBMED Abstract]
   
   
2. American Cancer Society.: Cancer Facts and Figures 2007. Atlanta, Ga: American Cancer Society, 2007. Also available online. Last accessed July 21, 2008. 
   
   
3. Centers for Disease Control and Prevention.: Targeting Tobacco Use: The Nation's Leading Cause of Death 2005. Atlanta, Ga: CDC, 2005. Also available online. Last accessed April 8, 2008. 
   
   
4. Ontario Task Force on the Primary Prevention of Cancer.: Recommendations for the Primary Prevention of Cancer. Toronto, Canada: Queen's Printer for Ontario, 1995. 
   
   
5. U.S. Department of Health and Human Services.: The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available online. Last accessed July 29, 2008. 
   
   
6. Hackshaw AK, Law MR, Wald NJ: The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 315 (7114): 980-8, 1997.  [PUBMED Abstract]
   
   
7. National Cancer Institute.: Health Effects of Exposure to Environmental Tobacco Smoke: the Report of the California Environmental Protection Agency. Bethesda, Md: National Cancer Institute, 1999. NIH Pub. No. 99-4645. 
   
   
8. Cinciripini PM, Hecht SS, Henningfield JE, et al.: Tobacco addiction: implications for treatment and cancer prevention. J Natl Cancer Inst 89 (24): 1852-67, 1997.  [PUBMED Abstract]
   
   
9. Fielding JE, Phenow KJ: Health effects of involuntary smoking. N Engl J Med 319 (22): 1452-60, 1988.  [PUBMED Abstract]
   
   
10. Finette BA, O'Neill JP, Vacek PM, et al.: Gene mutations with characteristic deletions in cord blood T lymphocytes associated with passive maternal exposure to tobacco smoke. Nat Med 4 (10): 1144-51, 1998.  [PUBMED Abstract]
    
    
11. Benowitz NL: Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 18 (2): 188-204, 1996.  [PUBMED Abstract]
    
    
12. Hecht SS: Human urinary carcinogen metabolites: biomarkers for investigating tobacco and cancer. Carcinogenesis 23 (6): 907-22, 2002.  [PUBMED Abstract]
    
    
13. U.S. Preventive Services Task Force.: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, Md: Williams & Wilkins, 1996. 
    
    
14. Centers for Disease Control and Prevention (CDC).: Cigarette smoking among adults--United States, 2004. MMWR Morb Mortal Wkly Rep 54 (44): 1121-4, 2005.  [PUBMED Abstract]
    
    
15. Wingo PA, Ries LA, Giovino GA, et al.: Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking. J Natl Cancer Inst 91 (8): 675-90, 1999.  [PUBMED Abstract]
    
    
16. Johnston LD, O'Malley PM, Bachman JG: Monitoring the Future: National Survey Results on Drug Use, 1975-2001. Volume I: Secondary School Students. Bethesda, Md: National Institute on Drug Abuse, 2002. NIH Pub. No. 02-5106. Also available online. Last accessed April 8, 2008. 
    
    

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