OL

TABLE 1.—Summary of longitudinal studies of overall mortality ratios relative to never smokers among male current and former
smokers according to duration of abstinence (when reported)

 

 

 

 

. Current Former smokers
Study smokers Duration of abstinence (yr)

Alt 1-4 5-9 10-15 >15
British Physicians" LB 1.5 1.5 1.3 Lt
(Doll and Peto 1976)
ACS CPS-IP 1-19 cig/day 1.72 1.44 134 1.01
(Hanmmmond 1966) 20-39 cig/day 1.92 1.96 1.48 1.31
U.S. Veterans‘ 10 20cig/day 1.82 1.87 1.24 1.47
(Kahn 1966) 21 34 cig/day 2.04 2.08 1.88 1.22
Swedish study 1-7 gfday" 1.21 1.08
(Carstensen, Pershagen, 8-15 g/day" 1.35
Eklund 1987) >15 phlay" 1.70

<S 25

Australian 1-19 cig/day 1.45 1.60 0.93
petrochemical 20-29 cig/day 2.09 1.55 0.90
workers® (Christie et al, 230 cigday 2.10 [58 0.92
1987)
Framingham" 147 0.84

(Gordon, Kannel,
McGee 1974)
LL

TABLE 1.—Continued

 

Former smokers
All durations

 

Current Temporary Persistent
Study smokers quitters quitters
California HMO! 1.82 LSI 113

(Friedman et al. 1981)

 

NOTE: All mortality ratios are relative to never smokers. ACS CPS-[=American Cancer Society Cancer Prevention Study 1; HMO=Health Maintenance Organization.
“Age-adjusted.

"Aged 50-74.

“Aged 54-64.

“Tabacco consumption in g/day.

“Former smokers are those with sustained abstinence.

"Persistent quitters are those with sustained abstinence.
mortality risk was still higher than that of never smokers even after 10 years of
abstinence.

The more recent ACS study. ACS CPS-II. is designed similarly to CPS-I. Re-
searchers enlisted 77,000 volunteers, who then solicited their friends. neighbors, and
relatives to participate in the study. Those enrolled completed a four-page confidential
questionnaire on medical history, health behaviors, medication use, and occupational
exposures (Stellman and Garfinkel 1986: Garfinkel and Stellman 1988). A total of
521,555 men and 658.748 women were enrolled: 4-year followup data (1982-86) on
the cohort were included in the 1989 Surgeon General's Report (US DHHS 1989).

In this Report, mortality rates for all causes of death from the ACS CPS-II were
calculated using updated data for the same 4-year followup period (Table 2). Rates
were calculated by gender in 5-year age groups for current and former smokers
according to level of cigarette consumption (1-20 cig/day, 221 cig/day for males; 1-19
cig/day, 220 cig/day for females). Rates for former smokers were further stratified by
years since smoking cessation (<1, 1-2, 3~5S, 6-10, 11-15, and 216). Slightly different
strata were used for men and women with respect to daily Cigarette consumption in
order to provide suitable distributions of subjects across categories of smokers and
ex-smokers.

TABLE 2.—Overall mortality ratios among current and former smokers,
relative to never smokers, by sex and duration of abstinence at date
of enrollment, ACS CPS-II

 

Former smokers
Duration of abstinence at enrollment (yr)

 

 

 

 

 

 

Current

smokers <l 1-2 3-5 6-10 11-15 216
Males
1-20 cig/day 2:22 2.49 2.38 2.03 1.43 1.38 1.06
221 cig/day 2.43 277 2.64 2.25 2.04 1.77 1.27
Females
1-19 cig/day 1.60 1.58 1.96 T41 me! 1.10 1.04
220 cig/day 2.10 3.39 2.58 2.03 1.60 1.38 LIS

Former smokers excluding those with cancer, heart disease. or stroke
and those “sick” at interview
Duration of abstinence at enrollment (yr)

Current

smokers <I 1-2 35 6-10 H-1S >16
Males
1-20 cig/day 2.34 2.06 2.05 1.89 L48 1,29 1.01
221 cig/day 2.73 1.85 2.18 1.90 1.77 1.65 LAg
Females
1-19 cig/day 1.82 0.76 1.26 1.42 1.01 1.09 1.00
220 cig/day 2.46 3.33 2.15 L444 1.46 1.18 0.95

 

NOTE: Mortality ratios are relative to those of never smokers. ACS CPS-H=Amencan Cancer Society Cancer
Prevention Study IL.
SOURCE: Unpublished tabulations, American Cancer Society

78
In this analysis, subjects who had quit smoking were assigned to the duration of
abstinence category appropriate for when they enrolled in the study. This method of
assignment tends to blunt the rate of decline of mortality risk according to duration of
abstinence when compared with never smokers because former smokers do not change
categories as duration of abstinence lengthens. No attempt was made in this study to
determine smoking status after enrollment, and persons who had quit at enrollment but
had resumed smoking were still considered former smokers. Likewise, persons who
smoked at enrollment but subsequently quit remain assigned to the current smoker
category. This probably leads to some degree of misclassification and affects relative
risk estimates (Chapter 2).

Like ACS CPS-I and other cohort studies, mortality ratios were substantially lower
among former smokers than continuing smokers for all durations of abstinence except
that of | to 3 years. With the exclusion of those subjects who had a history of cancer,
heart disease, or stroke and those who said they were “sick” at the time of recruitment,
mortality ratios were lower among former than continuing smokers for all durations of
abstinence, among males at all prior levels of cigarette consumption, and among
females who smoked fewer than 20 cigarettes per day before they quit.

The difference in the pattern of decline in overall mortality between all subjects and
the subset of subjects who were healthy at recruitment provides strong evidence that
recent quitters disproportionately include those who have quit because they are ill. In
contrast with ACS CPS-I, which was conducted in the early 1960s, mortality ratios
among both heavy and light smokers in ACS CPS-II remained substantially elevated
in comparison with those of never smokers 10 years after quitting. This increase was
evident in all subjects and in the subset of subjects who did not have a history of cancer,
heart disease, or stroke and who did not state that they were “sick” when recruited.
Sixteen years after quitting, the mortality risk among male former smokers of fewer
than 21 cigarettes reached that of never smokers but remained elevated among former
smokers of 21 cigarettes or more. Among female former smokers in both categories,
mortality was comparable with that of never smokers after 16 years of abstinence.

The results of ACS CPS-II are broadly in agreement with those of the British
Physicians Study (Doll and Peto 1976; Doll and Hill 1964a,b) and the U.S. Veterans
Study (Kahn 1966; Rogot and Murray 1980). In both, the overall mortality risk among
former smokers remained elevated in comparison with that of never smokers up to 15
years after quitting, although the risk was substantially less than among continuing
smokers.

An Australian study of petrochemical workers (Christie et al. 1987) appears to differ
from the other cohort studies in finding that overall mortality risk among former
smokers reached that of never smokers 5 years after quitting. This study is unique in
that subjects classified as former smokers were all persistent abstainers.

The differences among other studies in estimates of the duration of abstinence needed
for a former smoker to have the same overall mortality risk as a never smoker are likely
to be due to other smoking-related factors, such as age at smoking initiation, that differ
among study populations and over time (Chapter 2). Irrespective of the duration of
abstinence needed to reach the mortality risk of never smokers, former smokers have
substantially lower mortality when compared with continuing smokers.

79
For three representative age groups (50-54, 60-64, and 70-74 yr), Figure | shows
the relative risk of death among current and former smokers compared with never
smokers based on recent ACS CPS-II data for the subjects who did not have cancer,
heart disease, or stroke and were not “sick” at recruitment. Complete data from ACS
CPS-II on mortality in current, former. and never smokers aged 50-74 years are
presented in Table 7 of the Chapter Appendix. Data are not presented for those aged
less than 45 years and greater than 80 years because there were fewer than 10 deaths in
almost all of the categories of former smokers. In each of the age subgroups shown in
Figure 1, among both sexes and among former light and heavy smokers, mortality risk
relative to continuing smokers decreased with increasing duration of abstinence.

Using a method described by Kleinbaum, Kupper. and Morgenstern (1982). the data
from ACS CPS-II were also used to estimate the effects of quitting at various ages on
the cumulative risk of total mortality in a fixed interval after cessation. Several
assumptions have been made in conjunction with CPS-I] age-specific mortality data in
order to estimate as many as 16.5 years’ risk of death from all causes for individuals
who continue to smoke and those who stop smoking. The first assumption is that
age-specific mortality rates measured from 1982-86 CPS-II data remain constant for
the next 16.5 years, The first category of smoking cessation is 1~2 years: that is, the
individual gave up smoking | to 2 years ago. Itis assumed that. on average, respondents
in the 12-year category gave up smoking 1.5 years ago. Similarly, for the cessation
categories 3-5, 6-10, and 1 1—15 years, the average durations of abstinence are 4. 8. and
13 years, respectively. It is further assumed that respondents are exposed to the
age-specific mortality rates of the age interval in which quitting occurs for 1.5 years
and to each of the next three age intervals for 5 years each, making a total of 16.5 years,
For example. a quitter of the 40-44-year interval would be exposed to the age-specific
mortality rates of the 40-44-year-olds for 1.5 years. to those of 45—49-year-olds for 5
years, to those of S0-54-year-olds for 5 years. and to 55-59-year-olds for 5 years.

The results of this analysis. presented in Table 3 and in greater detail in Table 8 of
the Chapter Appendix, show that the benefits of cessation for total mortality extend to
quitting at older ages. For example. a healthy man aged 60-64 years who smokes 21
cigarettes or more per day is estimated to have a chance of dying in the next 16.5 years
of 56 percent if he continues to smoke and 51 percent if he quits. Quitting smoking at
younger ages confers even greater proportionate increases in survival (see Figure 2 of
the Chapter Appendix).

Framingham investigators recently analyzed data from their cohort (D'Agostino et
al. 1989) and also found that the benefits of quitting apply to those who quit at more
advanced ages. These researchers estimated that mean additional life expectancy for
those who quit at ages 35 to 39 was 5.1 years for males and 3.2 years for females, For
those who quit at ages 65 to 69. additional lite expectancy was estimated to be 1.3 years
for males and 1.0 year for females,

As discussed in detail in Chapter 2 and other chapters. smokers differ from non-
smokers in a variety of social, behavioral. and psychological characteristics. and
successful quitters differ from those who continue to smoke (Rode, Ross. Shephard
1972; Blair et al. 1980: Haines, Imeson. Meade 1980: McManus and Weeks 198):
Billings and Moos 1983; Gottlieb 1983; Brod and Hall 1984; Seltzer and Oechsli 1985:

80
MALES

 

   

 

RELATIVE RISK
c

 

 

Aged 50-54

 

 

216

 

 

 

 

 

 

RELATIVE RISK

Aged 60-64

 

 

 

 

Current Smokers <1

 

 

   

 

 

Ms
:
BR
<
a
4
Current Smokers <] 1-2 3-5 6-10
Former Smokers
Duration of Abstinence (yr)
1-20 cig/day 221 cig/day

Aged 70-74

 

 

 

 

11-15 216

FIGURE 1.—Compared with never smokers, relative risk of mortality in
current and former smokers aged 50-54, 60-64, and 70-74 at
enrollment, by amount smoked and duration of abstinence

SOURCE: Unpubhshed tabulations, American Cancer Society.

8]
FEMALES

 

 

  

 

 

 

 

  

 

 

   

 

—
Aged 50-54
Mw
<2)
x |
2
E |
< ;
4
fz
Current Smokers <1 3-5 6-10 11-15 216
as
20 Aged 60-64
Mas
4
% 20
B 18
FE 10
<
— Os
33 : =
MK oo ae SS
Current Smokers <1 1-2 3-5 6-10 11-15 >16
Aged 70-74
Mw
4
~
E
<
a
a
oe

 

 

 

 

~ Current Smokers <1 1-2 3-5 6-10 11-15) 316
Former Smokers
Duration of Abstinence (yr)

@ 1-19 cig/day () >20 cig/day

FIGURE 1. (Continued) —Compared with never smokers, relative risk of
mortality in current and former smokers aged 50-54, 60-64, and
70-74 at enrollment, by amount smoked and duration of

abstinence
SOURCE: Unpublished tabulations, American Cancer Society.
TABLE 3.—Estimated probability of dying in the next 16.5-year interval for
quitting at various ages compared with never smoking and
continuing to smoke, by amount smoked and sex

 

 

 

 

 

Males
Age at 1-20 ciz/day 221 cig/day
quitting or —
at start of Never Continuing Former Continuing Former
interval smokers smokers smokers smokers smokers
40-44 0.05 0.11 0.05 O14 0.07
45-49 0.07 O18 0.10 0.22 Ol
50-54 0.11 0.27 0.17 0.31 0.21
55-59 0.18 0.39 0.28 0.46 0.33
60-64 0.30 0.54 0.46 0.56 0.5]
65-69 0.46 0.68 0.59 0.67 0.64
70-74" 0.40 0.61 0.58 0.58 0.52

Females
Age at 1-19 cig/day 220 cig/day
quitting or .
at start of Never Continuing Former Continuing Former
interval smokers smokers ~ smokers smokers smokers
40-44 0.03 0.06 0.03 0.08 0.04
45-49 0.04 0.09 0.06 0.13 0.05
§0-54 0.07 O.14 0.07 0.19 G.09
§5-59 0.11 0.21 0.12 0.27 QS
60-64 0.18 0.30 0.19 0.38 0.32
65-69 0.30 0.46 0.39 0.52 0.32
70-74" 0.26 O41 0.27 0.45 0.31

 

NOTE: Based on American Cancer Society Cancer Prevention Study H data for persons without a history of cancer.
heart disease, or stroke who were not “sick” at enrollment.
Estimates for quitting at this age are estimates of the probability of dying im the next 12.5-yr interval.

SOURCE: Unpublished tabulations, American Cancer Society.

Kaprio and Koskenvuo 1988). These differences may exist among adolescents prior
to initiation of smoking (Seltzer and Oechsli 1985). For these reasons, interpretations
of studies comparing these self-selected groups (never smokers, smokers, and quitters)
must consider the problem of confounding (Chapter 2). Misclassification, which is
discussed in detail in Chapter 2. also must be considered. However, studies of smoking
cessation predominantly misclassify persons who are still smoking cigarettes as former
smokers, and this would tend to obscure the benefits of cessation in comparison with
continued smoking. Further, although the possibility of uncontrolled confounding
needs to be considered in epidemiologic studies of smoking cessation and mortality.
the totality of data must be interpreted with consideration of its consistency. To account
for the evidence of a benefit of quitting that derives from nonexperimental cohort
studies, confounders would need to be distributed quite differently among current and

83
former smokers and would need to be strong predictors of mortality. There is no
substantial evidence that this is the case.

SMOKING CESSATION AND OVERALL MORTALITY IN
INTERVENTION STUDIES

Five studies, four of which were randomized trials. evaluated overall mortality in
relation to interventions that included smoking cessation as a component. The results
of these studies are summarized in Table 4.

TABLE 4.—Summary of overall mortality ratios in intervention studies in
which smoking cessation was a component

 

 

. Ditference Mortality
Study Intervention Subjects (age) in smoking ratio
Whitehall Civil Servants’ — Smoking Males (40-59) 14g" 0.98
(Rose et al. 1982)
North Karelia Smoking. BP, Both sexes (35-64) Males 4¢<° 1.00" (males)
(Tuomilehto et al. 1986) diet Females —3¢%" 0.94 (females)
Oslo" (Hjermann et al. Smoking. BP. Males (40-59) -4 cig/day? 0.68"
1981) diet
WHO" Smoking. BP. Males (40-59) -K.9% 0.97"
(WHO European diet
Collaborative Group 1983)
MRFIT" Smoking. BP. Males (35-57) =13G° 1.02" (Fyn
(MRFIT Research Group diet 0.92 (iOS sr

1982. 1990)

 

NOTE: BP=blood pressure: WHO=W orld Health Organization: MREIT= Multiple Risk Factor Intervention Trial
“Randomized trial

"Intervention minus control

“Change i mortality in rest of Finland/change in mortality in North Karelia

“Mortality Inintervention/mortality i contrat,

Only one study examined smoking intervention alone (Rose and Hamilton 1978:
Rose et al. 1982). Of 1.445 male smokers, aged 40 to 59 and at high risk of coronan
heart disease (CHD) or chronic bronchitis. 714 were randomly assigned to an interven-
tion group and 731 to anormal care group. Men in the intervention group were given
individual advice to quit smoking. and if interested in quitting. up to four additional
visits over 12 months. At the 9-year followup. SS percent of responders in the
intervention reported abstinence compared with 41 percent in the normal care group.
After 10 years of follow up. there were 123 deaths in the intervention group and [28 in
the normal care group. The proportionate difference in total mortality between the
intervention group and normal care group {-2 percent) wits not statistically significant.
but the confidence interval was wide (-22 percent to +23 percent). There were 81

84
smoking-related deaths in the intervention group and 92 in the normal care group. The
proportionate difference tn smoking-related deaths was —9 percent. Again the con-
fidence interval was wide (—31 percent to +20 percent). Twenty percent of the men in
the intervention group who quit smoking cigarettes took up pipe or cigar smoking
compared with 3 percent of the men in the normal care group, and to the extent that
pipe and cigar smoking are mortality risk factors. any benefit of cessation of cigarette
smoking is obscured.

This trial is largely uninformative as to the benefit or lack of benefit of smoking
cessation for total mortality because of the small number of subjects. The trial was
turther compromised by the relatively poor compliance of the subjects with the
intervention: the net reduction in mean cigarette consumption over the 10 years of the
followup among the intervention group compared with the normal care group was only
7.6 Cigarettes per day.

Other intervention studies that allow assessment of the relation of smoking cessation
to overall mortality have involved multiple interventions aimed at reducing several
different factors for CHD. The ability to draw conclusions about the effect of smoking
cessation on overall mortality from these studies is quite limited for this reason.

The North Karelia study targeted a region of Finland that had the world’s highest
CHD death rate at the time of the study's initiation (Tuomilehto et al. 1986) and was
aimed at modifying smoking, cholesterol levels, and blood pressure. The rest of Finland
was used for comparison. In the 10 years after initiation of an aggressive risk reduction
program, there was a 35-percent decrease in smoking in North Karelia compared with
a 2-percent reduction in the rest of Finland (Salonen et al. 1989). Blood pressure and
cholesterol levels did not change significantly in the intervention area compared with
the rest of Finland. Total mortality in the intervention area in the !0 years after the start
of the study declined more rapidly than in the rest of Finland, although the difference
in the rate of decline in overall mortality was not statistically significant.

For at least two reasons, interpretation of the North Karelia study 1s problematic with
respect to the effect of smoking cessation on overall mortality. First. the study was
nonexperimental, with conclusions based on a comparison of total mortality in the study
area with that of Finland. During the study period. overall mortality also declined in
the rest of Finland, perhaps because of secular changes in other factors related to
mortality and to changes in medical care (Salonen et al. 1989), Second. the study was
not designed to investigate smoking cessation alone. Because of the mixing of inter-
ventions for three CHD risk factors, it was difficult to isolate the impact of the smoking
cessation component.

The Oslo study (Hjermann 1980: Hjermann etal. 1981; Holme 1982) involved 1,232
normotensive men at high risk for CHD because of their smoking behavior and
cholesterol levels. The men were randomly assigned either to receive interventions
aimed at reducing both CHD risk factors or to a control group. Tobacco consumption.
including pipe and cigar smoking, fell 45 percent more in the intervention group than
in the control group.

There was also a mean difference of 13 percent in serum cholesterol between the
intervention and control groups over 5 years (Hjermann et al. 1981). The study was
small. and it was not designed to examine total mortality endpoints: only 42 deaths were

8S
observed. Nevertheless, the mortality rate in the intervention group was one-third lower
than in the control group (one-sided p value=0.12). Because there were changes in both
smoking and cholesterol levels, the difference in mortality cannot be attributed entirely
to smoking cessation.

The World Health Organization (WHO) European Collaborative Group conducted
an intervention study in factories in four European countries (WHO European Col-
laborative Group 1983). The study involved random allocation of 66 factories that
employed 49,781 men aged 40 to 59 to an intervention program targeting smoking.
cholesterol level. and blood pressure or to a control group. After 4 years, the net
reduction in mean cigarettes per day in the intervention factories was 8.9 percent (WHO
European Collaborative Group 1983). At 6 years, overall mortality in the intervention
factories was 4.04 percent: in the control factories. it was 4.15. The difference was not
statistically significant.

The Multiple Risk Factor Intervention Trial (MRFIT) was a randomized study of
more than 12,000 American men, aged 35 to 57 at entry, who were at high risk for CHD
on the basis of their smoking behavior, blood pressure. and cholesterol levels (MRFIT
Research Group 1982). Men in the special intervention group received an intensive
intervention aimed at reducing blood pressure and cholesterol and encouraging smok-
ing cessation. Men in the usual care group were referred to their physicians and
examined annually. The interventions continued over the entire course of the study.
At 6 years, 44.4 percent of special intervention smokers and 25.8 percent of the usual
care smokers reported cessation. In the 7-year followup data reported in 1982. there
was no difference in total mortality between the special intervention and usual care
groups (MRFIT Research Group 1982). However, in the 10.5-year followup data of
MRFIT participants, overall mortality for the special intervention participants was 7.7
percent lower than for the usual care group (one-sided p value=0.10: 90-percent
contidence interval (CI). —16.6 to +2.3) (MRFIT Research Group 1990).

A subgroup of MRFIT special intervention participants, who were hypertensive, had
resting electrocardiogram abnormalities. and comprised 31 percent of the special
intervention group. may have suffered excess mortality as a result of an unanticipated
adverse effect of one of the antihypertensive drugs (Cutler. MacMahon. Furberg 1989).
This has recently been suggested as an explanation for the absence of an overall
difference in mortality between the special intervention and usual care groups at the
7-year followup (MRFIT Research Group, submitted for publication). Furthermore,
Ockene and coworkers (1990) recently reported that at 10.5 vears. MRFIT participants
who quit smoking had significantly lower death rates than those who continued to
smoke in both special intervention and usual care groups. Most important, like the other
multifactor intervention trials. it is difficult to infer a benefit or a lack of benefit of
smoking cessation for total mortality from this study.

In summary. studies involving smoking cessation interventions include a randomized
trial in which smoking cessation was the sole intervention and three intervention studies
in which it was a component. The small size of the former and the mixing of a smoking
intervention with other interventions in the latter make it impossible to reach con-
clusions about the benefits of smoking cessation from these studies alone: however.

86
nonintervention (i.e., cohort) studies described in the previous Section clearly indicate
a benefit of smoking cessation on overall mortality.

SMOKING CESSATION AND MEDICAL CARE UTILIZATION

Population Projections

The relationship between smoking cessation and medical care utilization is a complex
issue. Data on differential disease and mortality rates comparing smokers and
abstainers are abundant. and many investigators have used these data to project the
savings in dollars attributable to smoking cessation (Weinkam. Rosenbaum. Sterling
1987, Leu and Schaub 1983; Luce and Schweitzer 1978: Oster. Colditz. Kelly 1984).
Generally, these projections produce results that depend on the many assumptions of
the models that create them. For example. Luce and Schweitzer (1978) projected that
the total 1976 dollar cost of smoking in the United States was about $27.5 billion and
that excess medical care costs accounted for about $8.2 billion of those costs.
Weinkam. Rosenbaum, and Sterling (1987) and Leu and Schaub (1983), both using
population simulation approaches. concluded that smoking does not, over a lifetime.
lead to increased medical care utilization. This is because the short-term higher levels
of utilization of smokers are approximately balanced by shorter longevity and the
resulting reduced need for medical cure.

Oster. Colditz, and Kelly (1984) used population projections to estimate the medical
care costs of smoking and the proportion of those costs that are potentially recoverable
depending on the age at which smoking is given up and the level of smoking prior to
quitting. Male light smokers (<1 pack/day) who quit between ages 35 and 39 were
estimated to recover about 59 percent of their lifetime excess medical care costs. Even
if quitting was delayed until ages 75 to 79. light smokers were estimated to recover
one-third of the costs. For heavy smokers. quitting earlier was estimated to have
somewhat more benefit. For both sexes and all levels of smoking. medical care cost
savings from smoking cessation were estimated to be substantial,

Observational Studies

Table 5 summarizes studies that directly measured utilization of medical services by
current smokers. former smokers. and never smokers. These studies suggest that
smoking is associated with higher utilization of hospital services and that former
smokers experienced a brief period of increased utilization of hospital services just after
quitting followed by declines in utilization to levels of never smokers. Modest increases
in outpatient utilization by smokers are to some degree offset by a decreased propensity
to use preventive care services (Marsden. Bray. Herbold 1988: Vogt and Schweitzer
1985, Oakes et al. 1974).

SMOKING CESSATION AND HEALTH STATUS

Table 6 summarizes studies of smoking cessation and health status. The variety of
measures used makes direct comparison across studies problematic, Furthermore, in
most Cases, only a comparison of measures for never. current. and former smokers is
available. Because some smokers quit due to illness und because most studies fail to

87
TABLE 5.—Summary of studies of medical care utilization among smokers and

former smokers

 

Measure of
medical care

 

Reference Population utilization Results
Ashford 75,500 residents of Physician No consistent differences in any
(1973) Exeter visits, home measure of utilization between former

Oakes et al.
(1974)

Marsden, Bray.
Herbold (198%)

Vogt and
Schweitzer
(1985)

Newcamb and

Bentler (1987)

Freeborn et al.
(990)

2.557 HMO members
in California

1985 worldwide
survey of alcohol
and drug use by
military personnel

2.582 HMO
members in Oregon

654 adults aged 21-24.

in Los Angeles

312 adults aged 265 in
an HMO in Oregon

Visits,
hospitalization

Physician
Visits.
hospitalization

Physician
visits, days
hospitalized

Days
hospitalized.
physician visits

Nights
hospitalized.
physician visits

Ambulatory

care use

smokers and current smokers.

Male former smokers have more
physician visits than current smokers:
female former smokers have more
physician visits than current smokers.
Male former smokers are less likely than
current smokers to be hospitalized:
hospitalization among female former
smokers compared with current smokers
varies with age.

Physician Days
visits’ hospitalized"
Nonsmokers 2.41 0.64
Smokers
<0.5 ppd 2.37 0.82
| ppd 2.56 0.68
21.5 ppd 3.16 0.99

Former smokers have lower mean
number of hospital days than current
smokers after adjustment for age. sex.
duration of membership, and alcohol

use. Total physician visits are higher
among former smokers than current
smokers after adjustment for age. sex,
duration of membership. and alcohol use.

Adolescent smoking is related to
spending more nights in the hospital and
having more physician vinits for iflness
during early adulthood.

Smokers consistently are more often in
upper tertile of care utilization.

 

NOTE: ppd=packs/das: HMO=Health Miuntenanee Organization,

“Mean

identify the reasons for quitting, the relation between quitting and health status may be
obscured in studies that classify persons as former and current smokers (Chapter 2). A
few studies differentiate between short-term abstainers (<1 yr} and long-term abstainers
(>I yr). and these studies are highlighted.

88
Data from the National Center for Health Statistics (US DHHS 1980) suggest that
former smokers have fewer illness days than continuing smokers, particularly among
younger women. Gallop (1989) found that former smokers have absentee rates between
those of current smokers and never smokers.

Segovia, Bartlett, and Edwards (1989) conducted a telephone survey of 3,300 adults
and found a strong relation between smoking status and the reporting of good health.
Persons who had quit smoking for more than | year reported good health with about
the same frequency as persons who smoked only { to 5 cigarettes per day, whereas those
who had quit for less than 1 year reported good health at a frequency comparable with
smokers of 16 to 20 cigarettes per day. Balarajan, Yuen, and Bewley (1985) examined
the associations among various levels of smoking, recent and former cessation, and
presence of acute and chronic illness, medical office visits, and doctor consultations.
Current smokers had a higher prevalence of acute and chronic illness, and rates varied
in relation to the amount smoked. Former smokers who had quit in the year prior to
the survey had higher rates of illness compared with continuing smokers, and former
smokers who quit more than | year prior to the survey had rates between those of never
smokers and smokers of 20 cigarettes or more per day.

Reed (1983) found no difference in general physical health status between current,
former, and never smokers, not otherwise defined. Seidell and colleagues (1986)
examined the number of reported health complaints, out of an inventory of 51 possible
complaints, by smoking status and found that male, but not female, former smokers
reported fewer health complaints than smokers.

Astrand and Isacsson (1988) found that male employees of a pulp and paper plant
who smoked retired at an earlier age than nonsmokers. Data from the 1979 National
Health Interview Survey indicate that smokers have more restricted activity days, more
bed disability days, more hospital days, more physician visits, and an increased
probability of being unable to work or keep house, than nonsmokers (Rice, Hodgson,
Sinsheimer 1986). Analyses of data for the 1976-80 Health Interview Surveys showed
that smokers have a 55 to 75 percent excess in days with respiratory conditions
associated with reduced activity (Ostro 1989). Smokers experience more school
absences (Charlton and Blair 1989; Alexander and Klassen 1988) and work absenteeism
(Andersson and Malmgren 1986; Coughlin 1987; Hendrix and Taylor 1987: Gallop
1989) than do never smokers. None of these studies reported information on former
smokers.

These studies are extremely heterogeneous, with some methodologic shortcomings
(Chapter 2). Furthermore, smoking is associated with other behaviors that may affect
health (Pearson et al. 1987; Stephens 1986), and the studies do not adjust for changes
in other risk variables, such as increased exercise, that might be associated with smoking
cessation. Taken together, however, the studies are consistent with the hypothesis that
smoking cessation produces improvements in health status. This conclusion is evident
particularly when considering that smoking-related morbidity is a powerful motivation
to quit smoking and that recent quitters are likely to be sicker than continuing smokers.

&9
06

TABLE 6.—Relation of smoking cessation to various measures of general health status

 

Reference

Population

Health status
measure

Results

 

Current smokers

Former smokers

Never smokers

 

US DHHS
(1985)

Reed
(1983)

Balarajan,

Yuen, Bewley

C19KS)

Seidell etal.
C1986)

Representative sample of
US population

450 employees offered
subscription to. an HMO

Household survey of
residents of Great Britain

1.245 persons ina
morbidity registry

Days of work lost
due to iliness

General physical
health status

Self-report of iflness and
physician visits

Number of health
complaints

Females
220 yr
20-44 yr
45-64 yr
Males
220 yr
20-44 yr
45-04 yr

Chronic illness
Acute illness
Outpatient visit
Physician
consultation

Females
Mules

 

1.00" 0.82
1.00" 0.79
1.00" 0.91
1.00" 1.03"
1.008 0.92
1.00" 1.05
0.50° 0.5%
Cig/day Quit Quit
1-9 10-19 220 2lyr 9 <lyr
1.07 art 176" 1.43" 1.26"
1.03. £09 1.29 htt 1.48
146 146 1.43 1.40 1.25
1.12 1.08 4.09 119 1.47
Cig/day
<l10 210
96 116 10.2
9.0 96 6.8

0.86"
0.79
1.00

0.79"
0.86
0.66

0.49

1.0"
1.0"
oo
1.0"

9.0
7.3
lo

TABLE 6.—Continued

 

 

 

 

 

Results
. Health status
Reference Population measure Current smokers Former smokers Never smokers
Cig/day Quit Quit

T1-15 21-25) >3) <lyr oo >lyr
Segovia, Telephone survey of Self-report of “good health” 4.18 2.00 146° an 6.14"
Bartlett, representative sample
Edwards US adults
(1989)
Gallop Workers in the Work absences 1.25! 1.09! 1.00°
(1989) pulp/paper industry

“"Referrent.

bps
"Ratio compared with current smokers,
“Mean ridit score adjusted for age and sex.

d, : . . ao . .
“Odds ratio compared with never smokers and adjusted for age, sex, and socioeconomic status.

“Log odds of self-report of good health.
‘Ratio of absences compared with never smokers.
92

CONCLUSIONS

. Former smokers live longer than continuing smokers, and the benefits of quitting

extend to those who quit at older ages. For example, persons who quit smoking
before age 50 have one-half the risk of dying in the next 15 years compared with
continuing smokers.

. Smoking cessation at all ages reduces the risk of premature death.

Among former smokers, the decline in risk of death compared with continuing
smokers begins shortly after quitting and continues for at least 10 to 15 years. After
10 to 15 years of abstinence, risk of all-cause mortality returns nearly to that of
persons who never smoked.

Former smokers have better health status than current smokers as measured in a
variety of ways, including days of illness, number of health complaints, and
self-reported health status.
CHAPTER 3 APPENDIX

93
TABLE 7.—Age- and sex-specific mortality rates among never smokers, continuing smokers, and former smokers by amount
smoked and duration of abstinence at time of enrollment for subjects in ACS CPS-II study who did not have a history
of cancer, heart disease, or stroke and were not sick at enrollment

 

Males Former smokers (1-20 cig/day)

 

Duration of abstinence (yr)

 

 

 

 

 

Never Current

Age smokers smokers <] 1-2 3-§ 6-10 11-15 216

45-49 186.0 439.2 234.4 365.8 159.6 216.9 167.4 159.5
50-54 255.6 702.7 544.7 431.0 454.8 349.7 214.0 250.4
55-59 444.9 1132.4 945.2 728.8 729.4 590.2 447.3 436.6
60-64 733.7 1981.1 1,177.7 1,589.2 1,316.5 1,266.9 875.6 703.0
65-69 L194 3,003.0 2,244.9 3,380.3 2,374.9 1.820,2 1.669. | 1,159.2
70-74 2,070.5 4.697.5 4,255.3 5.083.0 4,485.0 3,888.7 3,184.3 2,194.9
75-19 3,675.3 7,340.6 S.882.4 6,597.2 7,707.5 4,945.1 5,618.0 4,128.9
Males Former smokers (221 cig/day)

Duration of abstinence (yr)
Current

Age smokers <| 1-2 3-5 6-10 11-15 216
4519 610.0 4975 251.7 47S 127.6 198.3 193.4
S0--S4 915.6 482.8 500.7 A8KY9 402.9 393.9 454.3
55 SY 1391.0 1,757.1 953.5 1,025.8 744.0 668.5 537.8
60 64 2,393.4 LS78 4 1.847.2 1.790. 1 1.220.7 1,100.0 993.3
45 69 3,497.9 2301.8 3,776.6 2,081.0 2,766.4 2,268.1 1,230.7
70 74 5861.3 3,174.6 2,974.0 3.7129 3,988.8 3,268.6 2,468.9

75 79 6.250.0 4,000.0 4424.8 7,329.8 6,383.0 7,666.1 5.0481
96

 

 

 

 

 

 

 

TABLE 7.—Continued
Females Former smokers (1-19 cig/day)
Duration of abstinence (yr)
Never Current
Age smokers smokers <l 1-2 3-5 6-10 11-15 216
45-49 125.7 225.6 0 433.9 212.0 107.2 135.9 91.0
50-54 177.3 353.8 116.8 92.1 289.5 200.9 121.3 172.1
55-59 244.8 542.8 287.4 259.5 375.9 165.8 202.2 247.2
60-64 397.7 858.0 1,016.3 365.0 650.9 470.8 570.6 319.7
65-69 692.1 1496.2 1,108.0 1,348.5 1,263.2 864.8 586.6 618.0
70-74 1,160.0 2,084.8 645.2 1,483.1 1,250.0 1,126.3 1,070.5 1.272.)
75-79 2,070.8 3,319.5 0 2,580.6 2,590.7 3,960.4 1,666.7 L.861.5
Females Former smokers (220 cig/day)
. Duration of abstinence (yr)
Current
Age smokers <| 1-2 3-5 6-10 11-15 216
45-49 277.9 266.7 102.7 178.6 224.7 142.1 138.8
50-54 S179 138.7 466.8 270.1 190.2 116.8 83.0
55-59 823.5 473.6 602.0 361.0 454.5 412.2 182.1
60-64 1,302.9 11148 862.1 699.6 541.7 373.1 356.4
65-69 1,934.9 2,319.6 1,250.0 1,688.0 828.7 797.9 581.5
70-74 2,827.0 4,635.8 2,517.2 1,687.3 2,848.7 1,621.2 1,363.4
75-79 4,273.1 2,409.6 5,769.2 3,125.0 2.978.7 2,803.7 2,195.4

 

NOTE: Mortality rates are per 100,000 persons. ACS CPS-ll=American Cancer Society Cancer Prevention Study IL
SOURCE: Unpublished tabulations. American Cancer Society.
TABLE 8.—Estimated probability of dying in the next 16.5-year interval
(95% CI) for quitting at various ages compared with
never smoking and continuing to smoke, by amount smoked and sex

 

 

 

 

 

 

 

Males
Age al 1-20 cig/day 221 cig/day
quitting
or at start Never Continuing Former Continuing Former
of interval smokers smokers smokers smokers smokers
40-44 0.05 01) 0.05 0.14 0.07
(0.04-0.05) (0.10-0.12) (0.04—-0.06) (0.13-0.15) (0.06-0.09)
45-49 0.07 0.18 0.10 0.22 0.11
(0.07-0.08) (0.17-0.19) (0.08-0.1 1) (0.21-0.23) (0.10-0.13)
50-54 O11 0.27 0.17 0.31 0.21
(0.11-0.12) (0.260).28) (0.15-0.19) (0.30-0,33) (0.18-0.23)
55-59 0.18 0.39 0.28 0.46 0.33
(0.17-0.19) (0.38-0.41) (0.25.31) (0.43—-0.48) (0.30—0.37)
60-64 0.30 0.54 0.46 0.56 0.51
(0.28-0.31) (0.52-0.57) (0.42-0.50) (0.51-0.61) (0,480.57)
65-69 0.46 0.68 0.59 0.67 0.64
(0.43-0.48) (0.64—0.72) (0.51-0.67) (0.57-0.78) (0.51-0.77)
70-74" 0.40 0.61 0.55 0.58 0.51
(0,380.43) (0.56-0.65) (0.45--0.64) (0.44-0.71) {0.32--0.72)
Females
Age at o/day ; ,
quitting 1-19 cig/day 220 cig/day
or at start Never Continuing Former Continuing Former
of interval smokers smokers smokers smokers smokers
40-44 0.03 0.06 0.03 0.08 0.04
(0.03-0.03) (0.0S—0.06) (0.02-0.04) {0.08-0.09) (0.03-0.05)
45-49 0.04 0.09 0.06 0.13 0.05
(0.04-0.04} (0.08-0.09) (0.04-0.07) (0.12-0.13) (0.04-0.07)
50-54 0.07 0.14 0.07 0.19 0.09
(0.06-0.07) (0.13-0.15) (0.05—0.09) (0.18-0.20) (0.07-0.11}
55-59 0.1] 0.21 0.13 0.27 0.15
(0.11-0.11) (0.19-0.22) (0.09-0. 16) (0.25-0.29) (0.12-0.19)
60-64 0.18 0.30 0.19 0.38 0.32
(0.18-0.19) (0.27-0.33) (0.13-0.25) (0.34-0.41} (0.24-0.39)
65-69 0.30 0.46 0.39 0.52 0.32
(0.29-0.31) (0.41-0.52) (0.26-0.52) (0.45-0.59) (0.17-0.47)
70-74" 0.26 0.41 0.27 0.45 0.31
(0.25-0.27) (0.35-0.47) (0.09-0.46) (0.37-0.53) (0.13-0.50)

 

NOTE: Based on American Cancer Society Cancer Prevention Study II data for persons without a history of cancer.

heart disease. or stroke who were not “sick” at enrollment. Cl=confidence interval.

“Estimates for quitting at this age are estimates of the probability of dying in the next 12.5-yr interval.

SOURCE: Unpublished tabulations, American Cancer Society.

97
86

50

 

40

30

20

 

 

 

 

PERCENTAGE
°

Oo

 

Continuing smokers

Former smokers

[| Never smokers

 

 

 

 

 

 

MEN

 

 

WOMEN

FIGURE 2.—Estimated probability of dying in the next 16.5-yr interval for
quitting at ages 55-59 compared with never smoking and

continuing to smoke, by sex

NOTE: Continuing and former smokers include only those smoking 221 (men) or 220 (women)
cig/day. Vertical bars represent 95% C1; the interval for female never smokers is not shown because it is
extremely narrow (11-11%). Based on American Cancer Society Cancer Prevention Study I data for
persons without a history of cancer, heart disease. or stroke who were not “sick” at enrollment.

SOURCE: Unpublished tabulations, American Cancer Society, (see Table 8).
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