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.     

The Contribution of Smoking to Black-White Differences in U.S. Mortality

Smoking has significantly impacted American mortality and remains a major cause of morbidity and mortality. No previous study has systematically examined the contribution of smoking-attributable deaths to mortality trends among blacks or to black-white mortality differences at older ages over time in the United States. In this article, we employ multiple methods and data sources to provide a comprehensive assessment of this contribution. We find that smoking has contributed to the black-white gap in life expectancy at age 50 for males, accounting for 20 % to 48 % of the gap between 1980 and 2005, but not for females. The fraction of deaths attributable to smoking at ages above 50 is greater for black males than for white males; and among men, current smoking status explains about 20 % of the black excess relative risk in all-cause mortality at ages above 50 without adjustment for socioeconomic characteristics. These findings advance our understanding of the contribution of smoking to contemporary mortality trends and differences and reinforce the need for interventions that better address the needs of all groups.     

Mortality attributable to obesity among middle-aged adults in the united states

Obesity is considered a major cause of premature mortality and a potential threat to the longstanding secular decline in mortality in the United States. We measure relative and attributable risks associated with obesity among middle-aged adults using data from the Health and Retirement Study (1992–2004). Although class II/III obesity (BMI _ 35.0 kg/m2) increases mortality by 40% in females and 62% in males compared with normal BMI (BMI = 18.5-24.9), class I obesity (BMI = 30.0-34.9) and being overweight (BMI = 25.0-29.9) are not associated with excess mortality. With respect to attributable mortality, class II/III obesity (BMI _ 35.0) is responsible for approximately 4% of deaths among females and 3% of deaths among males. Obesity is often compared with cigarette smoking as a major source of avoidable mortality. Smoking-attributable mortality is much larger in this cohort: about 36% in females and 50% in males. Results are robust to confounding by preexisting diseases, multiple dimensions of socioeconomic status (SES), smoking, and other correlates. These findings challenge the viewpoint that obesity will stem the long-term secular decline in U.S. mortality.     

Geographic Divergence in Mortality in the United States

The United States trails other developed countries in adult mortality, a process that has become more pronounced over the past several decades. However, comparisons are complicated by substantial geographic variations in mortality within the United States. The second half of the twentieth century was characterized by a substantial divergence in adult mortality between the South and the rest of the United States. The article examines trends in US geographic variation in mortality between 1965 and 2004, in particular the aggregate divergence in mortality between the southern states and states with more favorable mortality experience. Relatively high smoking‐attributable mortality in the South explains 50–100 percent of the divergence for men between 1965 and 1985 and up to 50 percent for women between 1985 and 2004. There is also a geographic correspondence between the contribution of smoking and other factors, suggesting that smoking may be one piece of a more complex health‐related puzzle.     

Estimating the Effect of Smoking on Slowdowns in Mortality Declines in Developed Countries

Declines in mortality rates for females at older ages in some developed countries, including the United States, have slowed in recent decades even as decreases have steadily continued in some other countries. This study presents a modified version of the indirect Peto-Lopez method, which uses lung cancer mortality rates as a proxy for smoking exposure, to analyze this trend. The modified method estimates smoking-attributable mortality for more-specific age groups than does the Peto-Lopez method. An adjustment factor is also introduced to account for low mortality in the indirect method’s study population. These modifications are shown to be useful specifically in the estimation of deaths attributable to smoking for females at older ages, and in the estimation of smoking-attributable mortality more generally. In a comparison made between the United States and France with the modified method, smoking is found to be responsible for approximately one-half the difference in life expectancy for females at age 65.     

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.     

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.     

A Comparison of US and Canadian Mortality in 1998

On average, Americans die earlier than Canadians. An estimate based on comparing the number of actual US deaths with the number that would have obtained had Canadian age‐ and sex‐specific death rates applied to the US population shows an excess number of US deaths in 1998 amounting approximately to 253,000. Excess US deaths were especially numerous among older women, middle‐aged men, and nonwhites. Circulatory diseases were the major cause of excess deaths. Prevalences of two of the major risk factors for circulatory deaths—smoking and hypertension—were higher in Canada than in the US. But obesity was higher in the US, suggesting a likely important role that obesity plays in higher mortality in the US relative to Canada. Comparisons of the level, age pattern, and causes of US and Canadian mortality, however, raise more questions than currently available data can answer.     

The Contribution of Health Care and Other Interventions to Black–White Disparities in Life Expectancy, 1980–2007

Black–white mortality disparities remain sizable in the United States. In this study, we use the concept of avoidable/amenable mortality to estimate cause-of-death contributions to the difference in life expectancy between whites and blacks by gender in the United States in 1980, 1993, and 2007. We begin with a review of the concept of “avoidable mortality” and results of prior studies using this cause-of-death classification. We then present the results of our empirical analyses. We classified causes of death as amenable to medical care, sensitive to public health policies and health behaviors, ischemic heart disease, suicide, HIV/AIDS, and all other causes combined. We used vital statistics data on deaths and Census Bureau population estimates and standard demographic decomposition techniques. In 2007, causes of death amenable to medical care continued to account for close to 2 years of the racial difference in life expectancy among men (2.08) and women (1.85). Causes amenable to public health interventions made a larger contribution to the racial difference in life expectancy among men (1.17 years) than women (0.08 years). The contribution of HIV/AIDS substantially widened the racial difference among both men (1.08 years) and women (0.42 years) in 1993, but its contribution declined over time. Despite progress observed over the time period studied, a substantial portion of black–white disparities in mortality could be reduced given more equitable access to medical care and health interventions.     

The narrowing sex differential in life expectancy in high-income populations: effects of differences in the age pattern of mortality

Using data from the Human Mortality Database for 29 high-income national populations (1751-2004), we review trends in the sex differential in e(0). The widening of this gap during most of the 1900s was due largely to a slower mortality decline for males than females, which previous studies attributed to behavioural factors (e.g., smoking). More recently, the gap began to narrow in most countries, and researchers tried to explain this reversal with the same factors. However, our decomposition analysis reveals that, for the majority of countries, the recent narrowing is due primarily to sex differences in the age pattern of mortality rather than declining sex ratios in mortality: the same rate of mortality decline produces smaller gains in e(0) for women than for men because women's deaths are less dispersed across age (i.e., survivorship is more rectangular).     

Declining sex differences in mortality from lung cancer in high-income nations

After decades of widening, the difference in mortality from lung cancer between men and women has begun to narrow in recent years. Recognizing that the increase in smoking among women relative to men is the proximate cause of the changing sex difference in rates of lung cancer, I analyzed two approaches to identify the more distant sources of the changes. A gender-equality argument suggests that the difference is related to the more general equalization of women's and men's work and family roles, which also encourages the adoption of harmful behaviors such as smoking by women. An alternative explanation suggests that the convergence in mortality from lung cancer among men and women is the byproduct of a lag in the adoption, diffusion, and abatement of smoking by women. Using mortality data on 21 nations from 1955 to 1996, an analysis of logged rates of men's and women's lung cancer mortality and the logged ratio of the rates demonstrated little relationship between the sex difference and gender equality. However, I found a strong and consistent relationship between the sex difference and the stage of diffusion of the use of cigarettes.     

The 1918 Influenza Epidemic's Effects on Sex Differentials in Mortality in the United States

The 1918 influenza epidemic had a marked and fairly long‐lasting effect on the sex differential in mortality in the United States. After 1918 women lost most of their mortality advantage over men and the female/male gap did not regain its pre‐epidemic level until the 1930s. An analysis of causes of deaths shows a link with tuberculosis. We conjecture the existence of a selection effect, whereby many 1918 influenza deaths were among tuberculous persons, so that tuberculosis death rates dropped in later years, disproportionately among males. Age‐ and sex‐specific data by cause of death corroborate this hypothesis.     

Population-level adult mortality following the expansion of antiretroviral therapy in Rakai,Uganda

There are limited data on the impact of antiretroviral therapy (ART) on population-level adult mortality in sub-Saharan Africa. We analysed data for 2000–14 from the Rakai Community Cohort Study (RCCS) in Uganda, where free ART was scaled up after 2004. Using non-parametric and parametric (Weibull) survival analysis, we estimated trends in average person-years lived between exact ages 15 and 50, per capita life-years lost to HIV, and the mortality hazards of people living with HIV (PLHIV). Between 2000 and 2014, average adult life-years lived before age 50 increased significantly, from 26.4 to 33.5?years for all women and from 28.6 to 33.8?years for all men. As of 2014, life-years lost to HIV had declined significantly, to 1.3?years among women and 0.4?years among men. Following the roll-out of ART, mortality reductions among PLHIV were initially larger in women than men, but this is no longer the case.     

Mortality and life expectancy in Poland 10 years before the end of the century

"In the article we discuss the mortality rates in Poland by [voivodship] at the end of the 80's. In the comparative analysis, we employed general standardized rates of deaths for men and women, and coefficients presenting the levels of mortality resulting from...circulatory system diseases and malignant neoplasms.... In the second part of the paper, we examine the differences in...life expectancy by sex and administrative provinces."     

Estimating the completeness of reporting of adult deaths in populations that are approximately stable

An elaboration of Preston's (Preston and Hill, 1980) procedure for determining the completeness with which deaths are recorded in approximately stable populations is presented. Both the procedures of Preston and that of Brass are conventionally limited to mortality beyond early childhood, to mortality above age 5 or age 10. The method considered here is based on characteristics of stable populations, i.e., populations that have been subject for a long time to little variation in age-specific mortality schedules or in overall levels of fertility. The essential features of a stable population are maintained even if fertility has changed. This is the case as long as no strong trend in fertility existed more than 15 or 20 years before the date at which the population is observed. Recent changes in fertility may affect the structure of the population at adult ages, but the effect on estimates of completeness of death records can generally be kept within tolerably narrow limits. Prior to showing how explicit estimates of the relative completeness of recording of numbers of deaths and persons can be derived from counts of deaths and persons by age, it is noted that a life table for a stable population can be constructed directly from the recorded distribution of deaths by age, or from the recorded distribution of persons. The procedures described are applied to several different populations in order to illustrate the computational steps necessary to estimate the completeness of death records at ages above childhood in populations that are approximately stable.     

Cardiovascular and Tuberculosis Mortality: The Contrasting Effects of Changes in Two Causes of Death

Tuberculosis was the largest source of deaths among younger adults, and cardiovascular disease among older adults, in the America of 1900. Decreases in deaths from tuberculosis since 1900 and cardiovascular disease since 1940 explain most of the mortality drops in those age groups over the century. This article, building on previous work by White and Preston, shows the results of increased survival from these two causes on the US population structure. Standard demographic cause-specific mortality calculations are used to generate life tables without deaths from cardiovascular disease or tuberculosis. Then fixed rates for these diseases from early in the century are assumed while all other causes of death are allowed to change as they did historically. Improvements in cardiovascular mortality and tuberculosis produce some seemingly illogical contrasts. More people are alive today because of the decrease in tuberculosis. Yet more deaths from cardiovascular disease have been prevented, and cardiovascular improvements have raised life expectancy more. Lower tuberculosis mortality had virtually no effect on the average age of the population. Lower cardiovascular mortality alone has raised that average more than all twentieth-century causes of improved mortality combined.     

Racial/Ethnic and Nativity Patterns of U.S. Adolescent and Young Adult Smoking

We document racial/ethnic and nativity differences in U.S. smoking patterns among adolescents and young adults using the 2006 Tobacco Use Supplement to the Current Population Survey (n = 44,202). Stratifying the sample by nativity status within five racial/ethnic groups (Asian American, Mexican–American, other Hispanic, non-Hispanic black, and non-Hispanic white), and further by sex and age, we compare self-reports of lifetime smoking across groups. U.S.-born non-Hispanic whites, particularly men, report smoking more than individuals in other racial/ethnic/nativity groups. Some groups of young women (e.g., foreign-born and U.S.-born Asian Americans, foreign-born and U.S.-born Mexican–Americans, and foreign-born blacks) report extremely low levels of smoking. Foreign-born females in all of the 25–34 year old racial/ethnic groups exhibit greater proportions of never smoking than their U.S.-born counterparts. Heavy/moderate and light/intermittent smoking is generally higher in the older age group among U.S.-born males and females, whereas smoking among the foreign-born of both sexes is low at younger ages and remains low at older ages. Taken together, these findings highlight the importance of considering both race/ethnicity and nativity in assessments of smoking patterns and in strategies to reduce overall U.S. smoking prevalence and smoking-attributable health disparities.     

Marriage behavior response to prime-age adult mortality: evidence from malawi

This article examines the effect of AIDS-related mortality of the prime-age adult population on marriage behavior among women in Malawi. A rise in prime-age adult mortality increases risks associated with the search for a marriage partner in the marriage market. A possible behavioral change in the marriage market in response to an increase in prime-age adult mortality is to marry earlier to avoid exposure to HIV/AIDS risks. We test this hypothesis by using micro data from Malawi, where prime-age adult mortality has drastically increased. In the analysis, we estimate the probability of prime-age adult mortality that sample women have observed during their adolescent period by utilizing retrospective information on deaths of their siblings. Empirical analysis shows that excess prime-age adult mortality in the local marriage market lowers the marriage age for females and shortens the interval between the first sex and first marriage.     

The peculiar pattern of mortality of Jews in Moscow, 1993-95

Russian Jews, particularly men, have a large mortality advantage compared with the general Russian population. We consider possible explanations for this advantage using data on 445,000 deaths in Moscow, 1993-95. Log-linear analysis of the distribution of deaths by sex, age, ethnic group, and cause of death reveals a relatively high concentration of endogenous causes and a relatively low concentration of exogenous and behaviourally induced causes among Jews. There is also a significant concentration of deaths from breast cancer among Jewish women. Mortality estimates using the 1994 micro-census population as the denominator reveal an 11-year Russian-Jewish gap in the life expectancy of males at age 20, but only a 2-year life-expectancy gap for women. Only 40 per cent of the Russian-Jewish difference for men, but the entire difference for women, can be eliminated by adjustment for educational differences between the two ethnic groups. Similarities with other Jewish populations and possible explanations are discussed.     

The role of smoking in the explanation of the Israeli Jewish pattern of sex differentials in mortality

The difference in life expectancy between women and men among Israeli Jews is very low relative to the difference in other developed countries, and the reasons for this are not fully understood. This paper explores the contribution of smoking to the observed patterns of sex-specific mortality among Israeli Jews, and to the sex difference in mortality exhibited by this population. The results show that the mortality of Israeli Jewish men is low owing to the relatively weak impact of smoking-related mortality, and that this also contributes to an explanation of the small sex difference. The result is explained by the high level of health-protective behaviour of Israeli Jewish men, including a low intensity of smoking (though not a low prevalence). The findings could have implications for some debates on the determinants of divergences and convergences in mortality, and research into the relationship between mortality and the Mediterranean diet.