Projected Smoking-Related Deaths Among Youth -- United States

On August 23, 1996, the Food and Drug Administration (FDA) issued a regulation restricting the sale and distribution of cigarettes and smokeless tobacco to children and teenagers to reduce the number of youth who use these products and to reduce the life-threatening consequences associated with tobacco use (1). Despite widespread efforts to educate U.S. youths about the health consequences associated with smoking (2), the prevalence of smoking among this group has been increasing since 1992 (3). To assess the need for continued public health efforts to prevent nicotine addiction, CDC used a model including data from the Behavioral Risk Factor Surveillance System (BRFSS) to project the future impact of smoking on the health of children and teenagers. This report presents the findings of the analysis, which indicate that, if current tobacco-use patterns persist, an estimated 5 million persons who were aged 0-17 years in 1995 will die prematurely from a smoking-related illness.

State-specific data on the prevalence of current smoking among adults aged 18-30 years in all 50 states and the District of Columbia were obtained from the BRFSS for 1994 and 1995 (4). Current smokers were respondents who reported having smoked 100 cigarettes during their lifetimes and who reported currently smoking. Because the prevalence of smoking in a birth cohort peaks during early adulthood (2), the average prevalence of smoking among adults aged 18-30 years for each state during 1994-1995 was used to estimate the future prevalence of smoking during early adulthood for the birth cohorts currently aged 0-17 years. The number of persons aged 0-17 years in 1995 in each state was obtained from U.S. census reports (5) and was multiplied by the estimated prevalence of future smoking to calculate the estimated number of youths who may become regular smokers in each state. Overall, the estimated number of future smokers among the cohort of persons who were aged 0-17 years in 1995 was 16,620,878 for the United States (range: 15,398 {District of Columbia} to 1,446,550 {California}) (Table_1).

The projected number of smoking-related deaths among youth smokers was based on the combined estimates of young adult smokers who continue to smoke throughout their lifetimes and estimates of premature death attributable to smoking among continuing smokers (6) and among those who quit after age 35 years (7). Based on data from the 1986 National Mortality Followback Survey (NMFS), 55% (95% confidence interval {CI}= plus or minus 1%) of persons who had ever smoked greater than or equal to 100 cigarettes during their lifetimes continued to smoke until 1 year before their deaths, and 45% (95% CI= plus or minus 1%) quit smoking earlier in their adult lives (CDC, unpublished data, 1995). Based on data from long-term cohort studies, an estimated 50% of deaths among continuing smokers will be attributable to smoking (6). Although estimates of the number of smoking-attributable deaths among former smokers range from 10% to 37%, a conservative estimate of 10% was used in this analysis (7; CDC, unpublished data, 1996). The future probability of smoking-attributable mortality (PSAM) among youth was computed to be PSAM={(0.55 X 0.5)+(0.45 X 0.1)}=0.32. Estimates for the variance of the two smoking-attributable fractions (50% and 10%) within the PSAM were computed from the Cancer Prevention Study II (8). These two variances were combined with the variances for the probabilities of continued smoking or quitting using a Taylor Series approximation method, which yielded an estimate of 0.00422 of the relative error of the PSAM. To reflect the uncertainty of the multiple assumptions about future smoking and mortality patterns, this error estimate for the PSAM was increased by a factor of 2.5, yielding an estimated standard error of 0.0106.

Based on application of this PSAM to the state-specific estimates of potential smokers, the overall number of potential future smoking-attributable deaths among persons aged 0-17 years during 1995 was 5,318,681 for the United States (range: 4927 {District of Columbia} to 462,896 {California}) (Table_1). Based on the estimated PSAM variance and the state-specific sampling errors from the BRFSS estimates of smoking prevalence, the estimated number of smoking-related deaths for the United States overall was predicted to vary by less than or equal to 160,000 deaths.

Reported by the following BRFSS coordinators: J Durham, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; S Loyd, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, New Mexico; T Melnik, DrPH, New York; G Lengerich, VMD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; J Ferguson, DrPh, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; J Stones, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. P Mowery, MA, J Shulman, PhD, Battelle Memorial Institute, Baltimore, Maryland. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that, if current patterns of smoking behavior persist, an estimated 5 million U.S. persons who were aged 0-17 years in 1995 could die prematurely from smoking-related illnesses. These projected patterns of smoking and smoking-related deaths could result in an estimated $200 billion (in 1993 dollars) in future health-care costs (i.e., $12,000 per smoker) (9) and approximately 64 million years of potential life lost (i.e., 12-21 years per smoking-related death) (6,9,10), underscoring the need for intensifing efforts to prevent smoking initiation among youth.

The projection method used in this analysis is subject to at least three limitations. First, although this method has been recommended for estimating future tobacco-related deaths in developed countries (6), alternative methods may be more precise (e.g., life-table procedures used to project future disease-specific outcomes, particularly lung cancer). Second, this method assumes that future smoking patterns and smoking-related disease rates will be similar to those observed in recent generations. However, future patterns may differ: for example, the estimates of future smoking prevalence in this analysis may be underestimated because smoking prevalences among teenagers have been increasing in recent years (3). Third, the estimated risks for smoking-attributable death and the smoking-attributable fractions among quitters (i.e., 10%) and continuing smokers (i.e., 50%) are based on studies of adults who began smoking during the mid 1900s (6,7). More recent data indicate that relative risks of smoking for more recent birth cohorts of both men and women have been increasing rather than decreasing (8). Factors related to changes in the intensity and duration of smoking may account in part for the substantial increase in the relative risks of smoking from the 1960s to the 1980s (e.g., relative risks of lung cancer increased from 11.4 to 22.4 for men and from 2.7 to 11.9 for women) (8). These increases in risk occurred despite changes in the composition of tobacco products commonly smoked, including the widespread adoption of filter-tipped, potentially lower "tar" cigarettes (8). While future changes in tobacco products could reduce health risks associated with smoking, smoking intensity and duration are likely to remain the major predictors of future risk (8). Therefore, unless U.S. persons who were aged 0-17 years during 1995 and who are current or potential smokers alter their future smoking behavior relative to patterns of previous generations (e.g., smoke fewer cigarettes per day or quit earlier in life), the relative risks of smoking probably will remain high.

FDA has issued regulations to restrict youth access to tobacco and to reduce the appeal of cigarette advertising among youths and has issued a proposal to require a program to educate youths about the health consequences associated with tobacco use (1). Because smoking-related deaths are preventable (1,9), public health efforts should emphasize both prevention of smoking initiation in the youngest birth cohorts (2) and cessation as early as possible among youth who already have started smoking (6,7).

References

1. Kessler DA, Witt AM, Barnett PS, et al. The Food and Drug Administration's regulation of tobacco products. N Engl J Med 1996;335:988-94.

2. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

3. Johnston L, Bachman J, O'Malley P. Cigarette smoking among American teens rises again in 1995. Ann Arbor, Michigan: University of Michigan News and Information Service, December 11, 1995.

4. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1992.

5. Bureau of the Census. Population estimates and population distribution branches. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1995.

6. Peto R, Lopez AD, Boreham J, et al. Mortality from smoking in developed countries, 1950-2000: indirect estimates from national vital statistics. New York: Oxford University Press, 1994.

7. Mattson ME, Pollack ES, Cullen JW. What are the odds that smoking will kill you? Am J Public Health 1987;77:425-31.

8. Thun MJ, Day-Lally CA, Calle EE, Flanders WD, Heath CW. Excess mortality among cigarette smokers: changes in a 20-year interval. Am J Public Health 1995;85:1223-30.

9. US Department of Health and Human Services. For a healthy nation: returns on investment in public health. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

10. CDC. Cigarette smoking-attributable mortality in years of potential life lost -- United States, 1990. MMWR 1993;42:645-9.

TABLE 1. Prevalence of current smoking among adults aged 18-30 years * and projected number of persons aged 0-17 years who will become smokers + and die
prematurely as adults because of a smoking-related illness, by state -- United States, 1995
============================================================================================================================================================



                                                        Prevalence
                                                    of current smoking                              Persons aged 0-17 years
                                                      among persons               --------------------------------------------------------------------------
                                                     aged 18-30 years                                  Projected smokers            Projected no.
                                                 ------------------------                           -----------------------            deaths
State                                                    %  (95% CI &)               No. @              No.    (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama                                               24.1  (+/-3.4%)             1,080,145          260,639  (+/- 36,465)             83,404
Alaska                                                29.7  (+/-4.8%)               189,253           56,246  (+/-  9,006)             17,999
Arizona                                               25.8  (+/-4.6%)             1,193,270          307,864  (+/- 54,337)             98,516
Arkansas                                              24.0  (+/-3.5%)               649,521          155,690  (+/- 22,994)             49,821
California                                            16.5  (+/-2.0%)             8,793,616        1,446,550  (+/-176,420)            462,896
Colorado                                              27.7  (+/-3.6%)               981,200          271,694  (+/- 35,093)             86,942
Connecticut                                           22.0  (+/-3.5%)               797,733          175,501  (+/- 27,690)             56,160
Delaware                                              29.0  (+/-3.3%)               178,826           51,806  (+/-  5,968)             16,578
District of                                           13.4  (+/-4.3%)               114,652           15,398  (+/-  4,887)              4,927
Columbia
Florida                                               27.5  (+/-2.8%)             3,371,328          928,464  (+/- 93,582)            297,108
Georgia                                               21.3  (+/-3.0%)             1,923,594          409,726  (+/- 57,900)            131,112
Hawaii                                                20.9  (+/-3.0%)               309,262           64,574  (+/-  9,353)             20,664
Idaho                                                 21.9  (+/-3.0%)               347,924           76,230  (+/- 10,517)             24,394
Illinois                                              26.0  (+/-3.2%)             3,125,894          813,670  (+/- 99,723)            260,374
Indiana                                               30.0  (+/-3.1%)             1,487,359          439,515  (+/- 46,329)            140,645
Iowa                                                  23.1  (+/-2.7%)               724,511          167,507  (+/- 19,326)             53,602
Kansas                                                22.2  (+/-3.5%)               692,761          153,862  (+/- 23,936)             49,236
Kentucky                                              28.2  (+/-3.3%)               972,708          274,693  (+/- 32,116)             87,902
Louisiana                                             26.7  (+/-3.5%)             1,239,214          331,366  (+/- 43,742)            106,037
Maine                                                 32.0  (+/-4.9%)               304,895           97,536  (+/- 14,792)             31,211
Maryland                                              21.1  (+/-2.0%)             1,271,966          267,876  (+/- 25,759)             85,720
Massachusetts                                         23.1  (+/-3.4%)             1,431,854          330,186  (+/- 48,366)            105,659
Michigan                                              28.6  (+/-3.1%)             2,519,455          721,572  (+/- 78,357)            230,903
Minnesota                                             24.3  (+/-2.2%)             1,245,492          303,153  (+/- 27,294)             97,009
Mississippi                                           20.0  (+/-3.5%)               761,909          152,610  (+/- 26,343)             48,835
Missouri                                              26.9  (+/-4.3%)             1,381,552          372,052  (+/- 59,197)            119,057
Montana                                               19.9  (+/-4.3%)               236,134           47,014  (+/- 10,151)             15,045
Nebraska                                              25.0  (+/-3.6%)               443,297          110,913  (+/- 15,842)             35,492
Nevada                                                24.8  (+/-3.4%)               398,586           98,770  (+/- 13,716)             31,606
New Hampshire                                         25.2  (+/-4.0%)               294,969           74,303  (+/- 11,886)             23,777
New Jersey                                            21.6  (+/-3.8%)             1,963,523          423,728  (+/- 74,663)            135,593
New Mexico                                            20.9  (+/-4.1%)               500,099          104,271  (+/- 20,422)             33,367
New York                                              26.0  (+/-3.1%)             4,536,862        1,179,584  (+/-141,545)            377,467
North Carolina                                        28.8  (+/-3.0%)             1,799,119          517,786  (+/- 53,965)            165,692
North Dakota                                          22.5  (+/-3.2%)               170,445           38,350  (+/-  5,367)             12,272
Ohio                                                  31.2  (+/-4.6%)             2,859,848          891,129  (+/-131,262)            285,161
Oklahoma                                              22.7  (+/-5.2%)               878,039          199,490  (+/- 45,586)             63,837
Oregon                                                24.1  (+/-2.9%)               797,040          191,688  (+/- 23,220)             61,340
Pennsylvania                                          29.5  (+/-2.9%)             2,909,302          857,371  (+/- 84,342)            274,359
Rhode Island                                          30.9  (+/-5.9%)               237,611           73,446  (+/- 13,931)             23,503
South Carolina                                        22.0  (+/-3.0%)               944,384          208,142  (+/- 28,621)             66,606
South Dakota                                          22.1  (+/-3.3%)               206,436           45,705  (+/-  6,715)             14,626
Tennessee                                             25.1  (+/-2.9%)             1,310,297          329,147  (+/- 38,256)            105,327
Texas                                                 21.5  (+/-3.6%)             5,400,417        1,158,389  (+/-192,545)            370,685
Utah                                                  16.1  (+/-2.5%)               674,618          108,883  (+/- 16,797)             34,843
Vermont                                               26.3  (+/-3.4%)               146,760           38,613  (+/-  4,914)             12,356
Virginia                                              26.3  (+/-3.5%)             1,612,527          423,288  (+/- 56,079)            135,452
Washington                                            23.8  (+/-2.5%)             1,418,404          336,871  (+/- 34,770)            107,799
West Virginia                                         28.6  (+/-3.3%)               421,868          120,443  (+/- 13,970)             38,542
Wisconsin                                             27.0  (+/-3.8%)             1,353,205          365,907  (+/- 51,333)            117,090
Wyoming                                               23.2  (+/-4.3%)               136,268           31,669  (+/-  5,812)             10,134
Total                                                   NA         NA            68,739,952       16,620,878  (+/-219,091)          5,318,681
------------------------------------------------------------------------------------------------------------------------------------------------------------
* Obtained  from Behavioral Risk Factor Surveillance System data for 1994 and 1995, except for Rhode Island for 1995 and the District of Columbia for 1994.
+ Based on 1995 population data and the prevalence of current smoking among adults aged 18-30 years.
& Confidence interval.
@ Obtained from 1995 census data.
============================================================================================================================================================

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