Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990–2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.     

Underlying and multiple causes of death related to smoking

Although smoking has been linked to various causes of death, there is no systematic account of the underlying and multiple cause-of-death distributions associated with various smoking statuses. We analyze such patterns by age and gender for the USA in 1986. Our study is based on a one-percent random sample of decedents 25 and over in the USA for whom survey data from informants were linked to death certificate data. Smoking is related to several underlying causes of death, the most common being circulatory diseases. Lung cancer is less prevalent than circulatory diseases or other cancers among ever smokers. Multiple medical conditions are common for both smokers and nonsmokers, but particular combinations vary among persons with different smoking statuses. Former smokers who quit soon before death and were under frequent medical care are most likely to have had lung cancer. Amount of smoking is tied to variations in cause-of-death patterns. Differences by age and gender are not substantial, although other cancers appear frequently for both smokers and non-smokers among women. The distribution of medical causes of death for ever smokers is not radically different from that of never smokers. However, differences in cause patterns are seen when smoking statuses are detailed by amount of smoking and timing of quitting. These similarities and differences in cause patterns must be related to the fundamental fact that the average smoker will die earlier than the average nonsmoker. Such findings should especially influence programs for diseases whose links to smoking have been underestimated.     

The Cause-Deleted Index: Estimating Cause of Death Contributions to Mortality

Causes underlying mortality disparities are often determined by causal decomposition. This method is based on the decomposition of differences in mortality or life expectancy into parameters representing the contribution of underlying causes. It quantifies disparities as differences in mortality rates and does not account for the fact that many underprivileged groups are more likely to die from nearly all causes. Results are driven by the frequency of cause of death. Alternatively, the cause deleted index quantifies the role of underlying causes in mortality disparities as the change in the relative risk of dying that is related to deleting a specific cause. The consistency between the methods in estimating cause of death contributions is analyzed using 2000 U.S. mortality data and simulated mortality profiles. The two methods often produce divergent results because causal decomposition relies on the prevalence of causes of death.     

Trends in Causes of Death in Low‐Mortality Countries: Implications for Mortality Projections

This study examines the potential role that information about trends in causes of death could have in improving projections of mortality in low‐mortality countries. The article first summarizes overall trends in mortality by cause since the middle of the twentieth century. Special attention is given to the crucial impact of the smoking epidemic on mortality and on cause‐of‐death patterns. The article then discusses the implications for projections and reaches two conclusions. First, mortality projections can be improved by taking into account the distorting effects of smoking. Mortality attributable to smoking has risen in the past but has now leveled off or declined, thus boosting improvements in life expectancy. Second, making cause‐specific projections is not likely to be helpful. Trends in specific medical causes of death have exhibited discontinuities in the past, and future trends are therefore difficult to predict.     

Mortality Attributable to Cigarette Smoking in the United States

Cigarette smoking is an especially pernicious behavior because of its high prevalence and mortality risk. We use the powerful methodology of life tables with covariates and employ the National Health Interview Survey‐Multiple Cause of Death file to illuminate the interrelationships of smoking with other risk factors and the combined influences of smoking prevalence and population size on mortality attributable to smoking. We find that the relationship between smoking and mortality is only modestly affected by controlling for other risk factors. Excess deaths attributable to smoking among adults in the United States in the year 2000 were as high as 340,000. Better knowledge of the prevalence and mortality risk associated with different cigarette smoking statuses can enhance the future health and longevity prospects of the population.     

Projecting the Effect of Changes in Smoking and Obesity on Future Life Expectancy in the United States

We estimate the effects of declining smoking and increasing obesity on mortality in the United States over the period 2010–2040. Data on cohort behavioral histories are integrated into these estimates. Future distributions of body mass indices are projected using transition matrices applied to the initial distribution in 2010. In addition to projections of current obesity, we project distributions of obesity when cohorts are age 25. To these distributions, we apply death rates by current and age-25 obesity status observed in the National Health and Nutrition Examination Survey, 1988–2006. Estimates of the effects of smoking changes are based on observed relations between cohort smoking patterns and cohort death rates from lung cancer. We find that changes in both smoking and obesity are expected to have large effects on U.S. mortality. For males, the reductions in smoking have larger effects than the rise in obesity throughout the projection period. By 2040, male life expectancy at age 40 is expected to have gained 0.83 years from the combined effects. Among women, however, the two sets of effects largely offset one another throughout the projection period, with a small gain of 0.09 years expected by 2040.     

Period‐Based Mortality Change: Turning Points in Trends since 1950

We investigate a major turning point in mortality trends at adult ages that occurred for many low‐mortality countries in the late 1960s or early 1970s. We analyze patterns of total and cause‐specific mortality over the past 60 years using data from the Human Mortality Database and the World Health Organization. We focus on four broad categories of causes of death: heart diseases, cerebrovascular diseases, smoking‐related cancers, and all other cancers. We use a two‐slope regression model to assess the timing and magnitude of turning points in mortality trends over this era, making separate analyses by sex, age, and cause of death. The age pattern of temporal changes is given particular attention. Our results demonstrate convincingly that period‐based factors were very significant in the onset of the “cardiovascular revolution” in the years around 1970. In general, although cohort processes cannot be ruled out as a driver of mortality change in recent decades (especially for mortality due to smoking‐related cancers), the evidence reviewed here suggests that period factors have been the dominant force behind the mortality trends of high‐income countries during this era.     

Life Course Changes in Smoking by Gender and Education: A Cohort Comparison Across France and the United States

Widening of educational disparities and a narrowing female advantage in mortality stem in good part from disparities in smoking. The changes in smoking and mortality disparities across cohorts and countries have been explained by an epidemic model of cigarette use but are also related to life course changes. To better describe and understand changing disparities over the life course, we compare age patterns of smoking in three cohorts and two nations (France and the US) using smoking history measures from the 2010 French health barometer (N = 20,940) and the 2010 US National Health Interview Survey Sample Adult File (N = 20,444). The results demonstrate statistically significant widening of gender and educational differences from adolescence to early and middle adulthood, thus accentuating the disparities already emerging during adolescence. In addition, the widening disparities over the life course have been changing across cohorts: age differences in educational disparities have grown in recent cohorts (especially in France), while age differences in gender disparities have narrowed. The findings highlight the multiple sources of inequality in smoking and health in high-income nations.     

Estimates Of U.S. Multiple Cause Life Tables

Cause elimination life tables estimated from multiple cause of death data for four race/sex groups are presented for the U.S. population in 1969. These “multiple cause” life tables are then compared to cause elimination life tables where the mortality risk eliminated is that of the cause of death only in its occurrence as the underlying cause of death. An evaluation is made of the possible effects of the multiple cause data on our perception of the relative importance of the major causes of death. The reconceptualization of mortality risks made possible by the multiple cause of death data is also assessed in terms of its providing further insight into the “Taeuber paradox.”     

Mortality in Poland in the period 1950-1990

"In this paper, crude, specific [mortality] rates as well as nonstandardized and standardized indices of regional mortality differentials are analysed [for Poland] for the period 1950-1990, in order to show mortality differentiation, its increase by age, sex, and place of residence. Taking into account cause specific death rates, the pattern of causes of deaths was found to be similar to that existing in the western countries, although the level of standardized mortality is higher in Poland. Values of calculated indices of regional mortality differentials point to significant differences in mortality by voivodship."     

Occupational careers and mortality of elderly men

This article presents findings from an analysis of occupational differentials in mortality among a cohort of males aged 55 years and older in the United States for the period 1966-1983. Using the National Longitudinal Survey of Mature Men, we construct event histories for 3,080 respondents who reach the exact age of 55. The dynamics that characterize socioeconomic differentials in mortality are analyzed by evaluating the differential effects of occupation over the career cycle. Maximum likelihood estimates of hazard-model parameters show that the mortality of current or last occupation differs substantially from that of longest occupation, controlling for education, income, health status, and other sociodemographic factors. In particular, the rate of mortality is reduced by the substantive complexity of the longest occupation while social skills and physical and environmental demands of the latest occupation lower mortality.     

Temporal trends in U. S. multiple cause of death mortality data: 1968 to 1977

An analysis is made of the mortality trends over the period 1968 to 1977 indicated by two types of cause-specific mortality data. The first type of data is “underlying cause” of death data—the data heretofore used in national vital statistics reports on cause-specific mortality. The second type of data is “multiple cause” data which contain a listing of all medical conditions recorded on the death certificate. A comparison of trends in the two types of data yields useful insights on mortality declines over the study period for two reasons. First, these declines were largely due to a reduction in the mortality rates of circulatory diseases. Second, the multiple cause data contain considerably more information than the underlying cause data on the role of circulatory diseases, and many other chronic diseases, in causing death. This additional information is especially useful in examining mortality patterns among the elderly, where the prevalence at death of chronic degenerative diseases is high.     

The Epidemiologic Transition Revisited: Compositional Models for Causes of Death by Age and Sex

For decades, researchers have noted systematic shifts in cause‐of‐death patterns as mortality levels change. The notion of the “epidemiologic transition” has influenced thinking about the evolution of health in different societies and the response of the health system to these changes. This article re‐examines the epidemiologic transition in terms of empirical regularities in the cause composition of mortality by age and sex since 1950, and considers whether the theory of epidemiologic transition presents a durable framework for understanding more recent patterns. Age‐sex‐specific mortality rates from three broad cause groups are analyzed: Group 1 (communicable diseases, maternal and perinatal causes, and nutritional deficiencies); Group 2 (noncommunicable diseases); and Group 3 (injuries), using the most extensive international database on mortality by cause, including 1,576 country‐years of observation, and new statistical models for compositional data. The analyses relate changes in cause‐of‐death patterns to changing levels of all‐cause mortality and income per capita. The results confirm that declines in overall mortality are accompanied by systematic changes in the composition of causes in many age groups. These changes are most pronounced among children, for whom Group 1 causes decline as overall mortality falls, and in younger adults, where strikingly different patterns are found for men (shift from Group 3 to Group 2) compared to women (shift toward Group 2 then Group 3). The underlying patterns that emerge from this analysis offer insights into the epidemiologic transition from high‐mortality to low‐mortality settings.     

Sex differentials in premature death among professionals Part II

This is Part II of a two-part article. It explores two hypotheses proposed to explain a reversal of the sex differential in mortality which appears in the 1968–72 death rates of Wisconsin professionals. The first hypothesis proposes that the observed effect is attributable to differentials in the distribution of behavioural risk factors for leading causes of death. Explanatory variables include childlessness, late age at first full-term pregnancy, and relatively high rates of smoking and drinking. Professional men had very low mortality rates from conditions implicating behavioural causes, leading to optimism that low-risk living can introduce a new phase into the epidemiological transition. The second hypothesis posits that the effect may be due to differentials in occupational variables which have systematic gender-divergent outcomes. Occupational levels, tasks, environments and careers all have the potential for such effects. The overall conclusion of the study is that health is systematically related to the quality of support and other conditions in the two major micro-environments for living: work and home.     

Cigarette Use and the Narrowing Sex Differential in Mortality

What explains the recent reversal in many countries of century‐long trends toward a growing female advantage in mortality? And might the reversal indicate that new roles and statuses of women have begun to harm their health relative to men? Using data on 21 high‐income countries that separate smoking deaths from other deaths, this study answers the first question by showing that the reversal in the direction of change in the sex differential results from increased levels of smoking among women relative to men. Using additional cross‐national data on cigarette consumption and indicators of gender equality, this article answers the second question in the negative by showing that the declining female advantage in smoking mortality results from patterns of the diffusion of cigarette use rather than from improvements in women's status. Evidence of continued improvement in the female mortality advantage net of smoking deaths, and the likely decline of smoking among women in the future, imply that the recent narrowing of the differential will reverse.     

Inferences about abortion from foetal mortality data

Abstract In a longitudinal fertility study in Detroit the evidence indicates that the foetal mortality rate in the prospective periods are better reported than in retrospective parts of the fertility histories. While the data do not specifically differentiate between induced abortions and other foetal deaths, the foetal death rates vary in relation to other social and demographic characteristics of the couples in such a way as make induced abortion a consistently plausible explanation of differentials. Foetal mortality rates tend to be high among sub-groups which have the incentive, information and the financial means for induced abortions. If these inferences are correct, it is likely that there is a considerable practice of induced abortion.     

Population growth,life-cycle saving,and international differences in steady-state optimal saving rates

Life-cycle savings theories have been a seminal development in analyses of the relationship between rational savings patterns for individuals and the accumulation of wealth or capital at the level of the society as a whole. Applications of the theories in industrialized countries never investigated the significance of large differences in birth and death rates across societies. The strong demographic components of life-cycle saving analysis are here the center of focus. Illustrative general numerical applications of a modified version of the life-cycle approach suggest that mortality differentials comparable to those presently encountered among nations are consistent with very large differentials in steady-state optimal ratios of wealth-to-income. Specific application to Peru of the model estimated by Tobin for the United States indicates that high levels of mortality, current Peruvian birth rates, and Peruvian age-income profiles imply optimal rational savings rates far below those of the United States.     

The patterns and causes of fertility differentials in the Sudan (with reference to nomadic and settled populations)

Abstract A demographic survey was undertaken in the Sudan for the purpose of studying fertility differentials between the nomadic and settled populations. In a previous publication the magnitude of these differentials was examined. The present paper examines the nature of the differentials and possible causes are then assessed. These causes are divided into two categories: those arising from the differential marriage patterns and those which are broadly termed 'medical and physiological'. Under the former heading it was found that larger proportions of nomadic women were still single, while those who had married had tended to do so at later ages, more had experienced broken marriages, and more were in polygamous marriages. Under the latter heading it was found that the nomadic women had experienced higher rates of pregnancy loss, appeared to show a high incidence of venereal disease and malaria, and tended to breast-feed their children for periods two to three times as long as the women in agricultural communities. Nutritional standards among the nomads were also substantially lower, and may well have affected fecundity.     

Neighborhood Concentrated Disadvantage and Adult Mortality: Insights for Racial and Ethnic Differences

While racial and ethnic differences in mortality are pervasive and well documented, less is known about how mortality risk varies by neighborhood socioeconomic status across racial and ethnic identity. We conducted a prospective analysis on a sample of adults living at or below 300% poverty with 8 years of the National Health Interview Survey (N = 159,400) linked to 11,600 deaths to examine the association between neighborhood disadvantage and mortality for non-Hispanic whites, non-Hispanic blacks, and U.S.- and foreign-born Hispanics. Using multilevel logistic regression, we find that the probability of death from any cause for lower-income adults is higher in more-disadvantaged neighborhoods, compared to less-disadvantaged neighborhoods, but only for whites. The adjusted likelihood of death for blacks and foreign-born Hispanics is not associated with neighborhood disadvantage, and the likelihood of death for U.S.-born Hispanics is lower in more-disadvantaged neighborhoods. While future research and policy should focus on improving health-promoting resources in all communities, care should be given to better understanding why race/ethnic groups have differential mortality returns with respect to area-specific socioeconomic conditions.     

Measuring socioeconomic mortality differentials over time

Using 1973 Current Population Survey data matched to 1973-1978 Social Security mortality records, this study measures the relationship between the income and education of men and their subsequent mortality. The estimated relationships are compared with socioeconomic mortality differentials found by Kitagawa and Hauser in their study of 1960 census-death certificate matched data. The comparison suggests that there has been no improvement in the relative mortality experience of low socioeconomic status men. More generally, the article discusses how Social Security data could be used to monitor, on a continual basis, our progress toward eradicating significant mortality differentials in the United States.