Smoking and smoking cessation in relation to mortality in women

Abstract

Context: Smoking is associated with an increased risk of total and cause-specific death, but the rate of mortality risk reduction after quitting compared with continuing to smoke is uncertain. There is inadequate or insufficient evidence to infer the presence or absence of a causal relationship between smoking and ovarian cancer and colorectal cancer.

Objective: To assess the relationship between cigarette smoking and smoking cessation on total and cause-specific mortality in women.

Design, setting, and participants: Prospective observational study of 104,519 female participants in the Nurses' Health Study with follow-up from 1980 to 2004.

Main outcome measure: Hazard ratios (HRs) for total mortality, further categorized into vascular and respiratory diseases, lung cancer, other cancers, and other causes.

Results: A total of 12,483 deaths occurred in this cohort, 4485 (35.9%) among never smokers, 3602 (28.9%) among current smokers, and 4396 (35.2%) among past smokers. Compared with never smokers, current smokers had an increased risk of total mortality (HR, 2.81; 95% confidence interval [CI], 2.68-2.95) and all major cause-specific mortality. The HR for cancers classified by the 2004 surgeon general's report to be smoking-related was 7.25 (95% CI, 6.43-8.18) and 1.58 (95% CI, 1.45-1.73) for other cancers. Compared with never smokers, the HR for colorectal cancer was 1.63 (95% CI, 1.29-2.05) for current smokers and 1.23 (95% CI, 1.02-1.49) for former smokers. A significant association was not observed for ovarian cancer. Significant trends were observed for earlier age at initiation of smoking for total mortality (P = .003), respiratory disease mortality (P = .001), and all smoking-related cancer mortality (P = .001). The excess risk for all-cause mortality decreases to the level of a never smoker 20 years after quitting, with different time frames for risk reduction observed across outcomes. Approximately 64% of deaths among current smokers and 28% of deaths among former smokers were attributable to cigarette smoking.

Conclusions: Most of the excess risk of vascular mortality due to smoking in women may be eliminated rapidly upon cessation and within 20 years for lung diseases. Postponing the age of smoking initiation reduces the risk of respiratory disease, lung cancer, and other smoking-related cancer deaths but has little effect on other cause-specific mortality. These data suggest that smoking is associated with an increased risk of colorectal cancer mortality but not ovarian cancer mortality.

Figure 1. Total and Cause-Specific Mortality by time Since Quitting Smoking, 104,519 women in the Nurses’ health Study followed from 1980 to 2004*

*The y axis is on a log scale. The reference category consists of current smokers. Horizontal line indicates never-smoker's risk. Adjusted for age (months), follow-up period, history of hypertension, diabetes, high cholesterol levels, body mass index, change in weight from age 18 to baseline (1980), alcohol intake, physical activity, previous use of oral contraceptives, postmenopausal estrogen therapy and menopausal status, parental history of myocardial infarction before age 60 years, cigarettes smoked per day during the period prior to quitting, and age at starting smoking.