Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964-2012

Abstract

Importance: January 2014 marks the 50th anniversary of the first surgeon general's report on smoking and health. This seminal document inspired efforts by governments, nongovernmental organizations, and the private sector to reduce the toll of cigarette smoking through reduced initiation and increased cessation.

Objective: To model reductions in smoking-related mortality associated with implementation of tobacco control since 1964.

Design, setting, and participants: Smoking histories for individual birth cohorts that actually occurred and under likely scenarios had tobacco control never emerged were estimated. National mortality rates and mortality rate ratio estimates from analytical studies of the effect of smoking on mortality yielded death rates by smoking status. Actual smoking-related mortality from 1964 through 2012 was compared with estimated mortality under no tobacco control that included a likely scenario (primary counterfactual) and upper and lower bounds that would capture plausible alternatives.

Exposures: National Health Interview Surveys yielded cigarette smoking histories for the US adult population in 1964-2012.

Main outcomes and measures: Number of premature deaths avoided and years of life saved were primary outcomes. Change in life expectancy at age 40 years associated with change in cigarette smoking exposure constituted another measure of overall health outcomes.

Results: In 1964-2012, an estimated 17.7 million deaths were related to smoking, an estimated 8.0 million (credible range [CR], 7.4-8.3 million, for the lower and upper tobacco control counterfactuals, respectively) fewer premature smoking-related deaths than what would have occurred under the alternatives and thus associated with tobacco control (5.3 million [CR, 4.8-5.5 million] men and 2.7 million [CR, 2.5-2.7 million] women). This resulted in an estimated 157 million years (CR, 139-165 million) of life saved, a mean of 19.6 years for each beneficiary (111 million [CR, 97-117 million] for men, 46 million [CR, 42-48 million] for women). During this time, estimated life expectancy at age 40 years increased 7.8 years for men and 5.4 years for women, of which tobacco control is associated with 2.3 years (CR, 1.8-2.5) (30% [CR, 23%-32%]) of the increase for men and 1.6 years (CR, 1.4-1.7) (29% [CR, 25%-32%]) for women.

Conclusions and relevance: Tobacco control was estimated to be associated with avoidance of 8 million premature deaths and an estimated extended mean life span of 19 to 20 years. Although tobacco control represents an important public health achievement, efforts must continue to reduce the effect of smoking on the nation's death toll.

Figure 1

Estimated ever-smoker prevalence at age 30 by gender (male=blue, female=red) [actual (heavy), counterfactuals (light)].

Figure 2

Estimated prevalence of current smokers: actual (solid), primary counterfactual (dashed) and bounds (dotted).

Figure 3

Life expectancy at age 40: actual (heavy), primary counterfactuals (dashed), bounds (dotted), and never-smokers (light).