In the United States, smoking-related illnesses accounted for an estimated 480,000 deaths each year.[1,2] (Also available online.) On average, these deaths occur 12 years earlier than would be expected, so the aggregate annual loss exceeds 5 million life-years. These deaths are primarily due to smoking’s role as a major cause of cancer, cardiovascular diseases, and chronic lung diseases. The known adverse health effects also include other respiratory diseases and symptoms, nuclear cataract, hip fractures, reduced female fertility, and diminished health status. Maternal smoking during pregnancy is associated with fetal growth restriction, low birth weight, and complications of pregnancy. It has been estimated that about 30% of cancer deaths and 20% of all premature deaths in the United States are attributable to smoking.
Tobacco products are the single, major avoidable cause of cancer, causing more than 155,000 deaths among smokers in the United States annually due to various cancers. The majority of cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, nasal cavity, and esophagus are attributable to tobacco products, particularly cigarettes. Smoking is also causally associated with cancers of the pancreas, kidney, bladder, stomach, and cervix and with myeloid leukemia.[4,6]
Smoking also has substantial effects on the health of nonsmokers. Environmental or secondhand tobacco smoke is implicated in causing lung cancer and coronary heart disease. Among children, secondhand smoke exposure is causally associated with sudden infant death syndrome, lower respiratory tract illnesses, otitis media, middle ear effusion, exacerbated asthma, and respiratory effects such as cough, wheeze, and dyspnea.
Environmental tobacco smoke has the same components as inhaled mainstream smoke, although in lower absolute concentrations, between 1% and 10%, depending on the constituent. Carcinogenic compounds in tobacco smoke include the polycyclic aromatic hydrocarbons (PAHs), including the carcinogen benzo[a]pyrene (BaP) and the nicotine-derived tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). Elevated biomarkers of tobacco exposure, including urinary cotinine, tobacco-related carcinogen metabolites, and carcinogen-protein adducts, are seen in passive or secondhand smokers.[7,9-11]
In 2013, 20.5% of adult men and 15.3% of adult women in the United States were current smokers. (Also available online.) Cigarette smoking is particularly common among American Indians and Alaska Natives. The prevalence of smoking also varies inversely with education, and was highest among adults who had earned a General Educational Development diploma (41.4%) and generally decreased with increasing years of education. (Also available online.) From 2000 to 2011, significant declines occurred in the use of cigarettes among middle school (10.7% to 4.3 %) and high school (27.9% to 15.8%) students. (Also available online.) Cigarette smoking prevalence among male and female high school students increased substantially during the early 1990s in all ethnic groups but appears to have been declining since approximately 1996.[13,14] (Also available online.)
The effect of tobacco use on population-level health outcomes is illustrated by the example of lung cancer mortality trends. Smoking by women increased between 1940 and the early 1960s, resulting in a greater than 600% increase in female lung cancer mortality since 1950. Lung cancer is now the leading cause of cancer death in women.[13,15] In the last 30 years, prevalence of current cigarette use has generally decreased, though far more rapidly in males. Lung cancer mortality in men peaked in the 1980s, and has been declining since then; this decrease has occurred predominantly in squamous cell and small cell carcinomas, the histologic types most strongly associated with smoking. Variations in lung cancer mortality rates by state also more or less parallel long-standing state-specific differences in tobacco use. Among men, the average annual age-adjusted lung cancer death rates from 2001 to 2005 were highest in Kentucky (111.5 per 100,000), where 29.1% of men were current smokers in 1997, and lowest in Utah (33.7 per 100,000), where only 10.4% of men smoked. Among women, lung cancer death rates were highest in Kentucky (55.9 per 100,000), where 28.0% of women were current smokers, and lowest in Utah (16.9 per 100,000), where only 9.3% of women smoked.
- American Cancer Society: Cancer Facts and Figures 2015. Atlanta, Ga: American Cancer Society, 2015. Available online. Last accessed January 7, 2015.
- Jamal A, Agaku IT, O'Connor E, et al.: Current cigarette smoking among adults--United States, 2005-2013. MMWR Morb Mortal Wkly Rep 63 (47): 1108-12, 2014. [PUBMED Abstract]
- Nelson DE, Kirkendall RS, Lawton RL, et al.: Surveillance for smoking-attributable mortality and years of potential life lost, by state--United States, 1990. Mor Mortal Wkly Rep CDC Surveill Summ 43 (1): 1-8, 1994. [PUBMED Abstract]
- U.S. Department of Health and Human Services: The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available online. Last accessed January 30, 2015.
- Centers for Disease Control and Prevention: Targeting Tobacco Use: The Nation's Leading Cause of Death 2005. Atlanta, Ga: CDC, 2005.
- Ontario Task Force on the Primary Prevention of Cancer: Recommendations for the Primary Prevention of Cancer. Toronto, Canada: Queen's Printer for Ontario, 1995.
- U.S. Department of Health and Human Services: The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Also available online. Last accessed January 30, 2015.
- Cinciripini PM, Hecht SS, Henningfield JE, et al.: Tobacco addiction: implications for treatment and cancer prevention. J Natl Cancer Inst 89 (24): 1852-67, 1997. [PUBMED Abstract]
- Finette BA, O'Neill JP, Vacek PM, et al.: Gene mutations with characteristic deletions in cord blood T lymphocytes associated with passive maternal exposure to tobacco smoke. Nat Med 4 (10): 1144-51, 1998. [PUBMED Abstract]
- Benowitz NL: Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 18 (2): 188-204, 1996. [PUBMED Abstract]
- Hecht SS: Human urinary carcinogen metabolites: biomarkers for investigating tobacco and cancer. Carcinogenesis 23 (6): 907-22, 2002. [PUBMED Abstract]
- Centers for Disease Control and Prevention (CDC): Current tobacco use among middle and high school students--United States, 2011. MMWR Morb Mortal Wkly Rep 61 (31): 581-5, 2012. [PUBMED Abstract]
- Jemal A, Thun MJ, Ries LA, et al.: Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst 100 (23): 1672-94, 2008. [PUBMED Abstract]
- Johnston LD, O'Malley PM, Bachman JG: Monitoring the Future: National Survey Results on Drug Use, 1975-2001. Volume I: Secondary School Students. Bethesda, Md: National Institute on Drug Abuse, 2002. NIH Pub. No. 02-5106. Also available online. Last accessed February 9, 2015.
- U.S. Preventive Services Task Force: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, Md: Williams & Wilkins, 1996.