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Progress in Chronic Disease Prevention
Smoking-Attributable Mortality, Morbidity,
and Economic Costs -- California, 1985
Cigarette smoking remains the single most important preventable
cause
of death in the United States and has long been implicated as a
major
risk factor in a variety of chronic diseases, including heart and
cerebrovascular diseases, malignant neoplasms, and respiratory and
other diseases (1). Smoking is a major health burden and has
important
economic effects.
To examine the impact of smoking, the California Chronic and
Sentinel
Disease Surveillance Program (CCSDSP), California Department of
Health
Services, estimated the health and economic costs associated with
this
risk factor in California for a single year (1985). The CCSDSP used
smoking-attributable fractions (SAFs) for 24 under- lying causes of
death (based on U.S. prevalence estimates of current and former
smokers
and neversmokers and relative risk estimates for these groups) to
estimate the number of smoking-attributable deaths in 1985 and the
number of years of potential life lost (YPLL) to age 80 (2). The
CCSDSP
also applied these SAFs to 1985 California hospital discharge data
to
estimate the number of smoking-attributable hospitalizations and
their
costs. National figures for the ratio of hospital costs to direct
costs
and the ratio of direct costs to total costs (3) were applied to
the
California hospital data to estimate these cost components for
California.
The CCSDSP determined that in 1985 smoking was directly responsible
for
31,289 deaths; 2) 310,018 YPLL; 3) 313,065 hospital discharges;
4)
$4.1 billion in hospital and other medical-care costs; and 5) more
than
$7.1 billion in total costs, including heath-care and other costs
in
the state (4). Although 77% of the hospital costs related to
smoking
were paid for by public funds, only 22% of California's adult
population currently smokes (4; California Department of Health
Services, unpublished data, 1987).
The CCSDSP also constructed a separate mortality
category--smoking-attributable mortality (SAM)--by grouping
together
all the deaths that were directly related to smoking. Smoking
directly
accounts for a substantial portion of the three major causes of
death--heart diseases, malignant neoplasms, and cerebrovascular
dis-
eases--in California and the United States and has been
demonstrated or
suspected to be a risk factor for a wide variety of other causes of
death (1). Therefore, when SAM in California was classified as a
separate category of death, it ranked second for men and third for
women after heart diseases and malignant neoplasms due to other
risk
factors (Table 1).
Smoking was responsible for greater than 50% more deaths than were
all
the following causes combined: unintentional injuries, including
motor
vehicle collisions and drug-related deaths; homicides; and
suicides.
Nearly one of every six deaths in the state is attributable to
smoking.
Reported by: GA Kaplan, PhD, WE Wright, PhD, KW Kizer, MD,
California
Dept of Health Svcs. Office of Surveillance and Analysis, and
Office on
Smoking and Health, Center for Chronic Disease Prevention and
Health
Promotion, CDC. Editorial Note
Editorial Note: The CCSDSP has demonstrated that smoking is an
important cause of mortality, morbidity, and economic costs in
California. The CCSDSP data are supported by patterns demonstrated
in
other national and state-based studies (2,3,5-7); however, specific
differences exist among findings in these studies and probably
reflect
differences in methodologic assumptions, study population and
subgroup
composition, overall mortality experience, and estimates of life
expectancies and smoking prevalences.
In an attempt to capture morbidity and related costs, CCSDSP has
also
applied SAFs to estimate the number of hospital discharges for
persons
with smoking- attributable illnesses. They have adopted the working
assumption that SAFs derived from the cohort studies investigating
smoking-related mortality may be useful surrogates for hospital
discharge SAFs (the latter not being available from other studies).
Although some of the methodologic issues of estimating discharges
of
persons hospitalized for smoking-attributable illnesses require
further
consideration, CCSDSP's results suggest that hospital discharges
for
persons with smoking-related illnesses represent a large health and
financial burden for the state.
CCSDSP's findings may underestimate actual smoking-related
mortality,
morbidity, and associated costs. Its results are based on relative
risk
estimates from prospective studies completed within the past
several
decades rather than on estimates extrapolated from more recent or
ongoing studies (1). More recent studies have yielded substantially
higher relative risk estimates for several smoking-related diseases
than did the earlier studies, especially for women. The earlier
studies
also lacked stable estimates for several diseases currently
presumed to
be related to smoking. Similarly, deaths from smoking-caused fires
and
other injury-related deaths have not been considered. Finally,
although
recent evidence shows an increased risk for lung cancer and
respiratory
diseases in nonsmokers due to involuntary (passive) smoking (1),
lack
of statewide data to estimate involuntary smoking exposures makes
determination of smoking-related deaths in such persons difficult.
By grouping SAM from all causes into one category, CCSDSP has
demonstrated that SAM actually ranks among the top three categories
of
death (after subtracting smoking-related deaths from the other
causes).
As a separate mortality category, SAM is the second leading cause
of
death for men and the third for women. However, unlike other
categories
of death (e.g., cerebrovascular diseases), the SAM category is
unique
because eliminating one risk factor--smoking--would eventually
eliminate all deaths in this category (i.e., almost one of every
six
deaths in California).
Calculation of the impact of smoking and associated diseases on the
health and economic status of a state can be used to guide
prevention
efforts and interven- tion strategies. In November 1988, a unique
opportunity to support prevention of smoking-related morbidity and
mortality in California emerged in the form of a prop- osition to
increase the excise tax on cigarettes sold in the state by 25*c per
pack. Because increasing the price of cigarettes decreases
smoking--especially among adolescents (1)--sponsors of the
proposition
sought both to decrease smoking and generate revenues for potential
use
in smoking prevention and health promotion efforts.
This tax increase on cigarettes was approved by a majority (58%) of
the
California voters and became effective January 1, 1989. The $650
million in expected revenue per year will be allocated, subject to
concurrence by the California legislature, for the following:
health
education and stop-smoking campaigns especially directed at
children,
research into tobacco-related diseases, reimbursing hospitals and
physicians for uncompensated care (including tobacco-related
illnesses), and other areas of research and prevention. An
intervention
against tobacco use of this magnitude is unique and represents an
important opportunity to demonstrate the impact of such a
commitment of
resources to the antismoking campaign.
CDC is collaborating with state health departments to establish
surveillance systems for chronic diseases. Goals of these systems
are
to estimate the occurrence of these diseases, the prevalences of
associated risk factors in the population, and related medical and
economic costs. By using surveillance information to guide
prevention
efforts, public health departments can assist residents of their
states
in promoting health and preventing chronic disease morbidity and
mortality.
References
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.CDC. Smoking-attributable mortality and years of potential life
lost--United States, 1984. MMWR 1987;36:693-7.
3.Rice DP, Hodgson TA, Sinsheimer P, Browner W, Kopstein AN. The
economic costs of the health effects of smoking, 1984. Milbank Mem
Fund
Q 1986;64:489-547.
4.California Chronic and Sentinel Disease Surveillance Program.
Health
and economic impact of smoking, California, 1985. Sacramento,
California: California Department of Health Serv- ices, Chronic
Diseases Branch, 1988.
5.Vermont Department of Health. The public health impact and
economic
costs of cigarette smoking, Vermont, 1985. Dis Control Bull, May
1987.
6.Woernle CH. The burden of cigarette smoking in Alabama. Alabama
Department of Public Health Epidemiol Rep 1987;1(5):1-2.
7.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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