Racial Disparity in Smoking-Attributable Mortality, Years of Potential Life Lost: Case of Missouri 2000- Noaman Kayani, PhD Chronic Disease and Nutrition Epidemiology Team, Office of Epidemiology, Missouri Department of Health and Senior Services

Methods Smoking-Attributable Mortality, Morbidity and Economic Cost (SAMMEC) software by CDC was used to calculate: Smoking-Attributable Mortality (SAM) Years of Potential Life Lost (YPLL) Productivity Losses (PLoss)

Methods Continued RR1 : Relative risk for current vs. never smokers Smoking-Attributable Mortality = SAF * Number of Deaths Smoking-Attributable Fraction (SAF) =[(p0+p1(RR1)+p2(RR2)) -1] / [p0 +p1(RR1) + p2(RR2)], where P0 : Percentage of adult never smokers p1 : Percentage of adult current smokers p2 : Percentage of adult former smokers RR1 : Relative risk for current vs. never smokers RR2 : Relative risk for former vs. never smokers Sex- and age-specific smoking-attributable deaths were calculated by multiplying the total number of deaths in each sex and age category for 19 adult and 4 infant diseases by smoking-attributable fractions (SAFs). (i.e., persons who have smoked  100 cigarettes and now smoke every day or some days) in the study population, p2 is the prevalence of former smokers (i.e., persons who have smoked  100 cigarettes and do not currently smoke), RR1 is the relative risk for current smokers vs. never smokers, and RR2 is the relative risk for former smokers vs. never smokers. Adults, sex-specific RR1 and RR2 for each cause of death were estimated from the American Cancer Society’s Cancer Prevention Study-II (CPS-II)

Methods Continued RR1 is the relative risk for current smokers vs. never smokers, and RR2 is the relative risk for former smokers vs. never smokers. Adults, sex-specific RR1 and RR2 for each cause of death were estimated from the American Cancer Society’s Cancer Prevention Study-II (CPS-II) with 6 years follow up

Data Elements to Input Smoking Prevalence Mortality by Sex, Age-group, ICD (International Classification of Disease) Codes Life Expectancy by Sex and Age Group Population Estimates

Smoking Prevalence 2004 Smoking Prevalence Male Female Current Smoker   Male Female Current Smoker Former Smoker 35-64 years old 29.1 27.4 26.2 20.9 65 years or older 12.7 55.8 10.2 24.2

Smoking Related Cancer Diseases with ICD codes Malignant Neoplasm (Cancer) Lip, Oral Cavity, Pharynx (C00-C14) Esophagus (C15) Stomach (C16) Pancreas (C25) Larynx (C32) Trachea, Lung, Bronchus (C33-C34) 3,803 Cervix Uteri (C53) Kidney and Renal Pelvis (C64-C65) Urinary Bladder (C67) Acute Myeloid Leukemia (C92.0)

Smoking Related Cardiovascular Diseases Ischemic Heart Disease (I20-I25) Other Heart Disease (I00-I09, I26-I51) Cerebrovascular Disease (I00-I69) Atherosclerosis (I70-I71) Aortic Aneurysm (I71) Other Arterial Disease (I72-I78)

Smoking Related Respiratory Diseases Pneumonia, Influenza (J10-J18) Bronchitis, Emphysema (J40-J42, J43) Chronic Airway Obstruction (J44)

Mortality Data by Sex, Age and ICD Codes Frequency 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Ca_oral 4 2 16 12 15 10 11 5 Ca_esoph 6 22 36 30 40 37 18 Ca_stomach 9 13 20 21 Ca_panc 1 3 17 19 29 46 41 53 34 Ca_larynx 7 Ca_lung_etc 81 113 171 276 370 460 422 274 164 Ca_cervix Ca_kidney 28 26 Ca_uriblad 14 32 42 38 Ca_: AcMyLeuk 8 Otherheart 31 57 102 116 135 192 279 285 486 Ischemic 47 89 283 328 414 491 600 804 871 1210 Stroke 43 63 112 139 205 266 371 Athero 60 Aortic_an 33 Oth_arter Pneu_influ 52 73 119 245 Bronch_emph COPD 80 124 167 253 215 217

Life Expectancy Table by Sex and Age Groups Male Female 35–39 38.5 42.9 40–44 34.0 38.2 45–49 29.6 33.5 50–54 25.3 29.0 55–59 21.3 24.7 60–64 17.5 20.7 65–69 14.1 17.0 70–74 11.0 13.4 75–79 8.4 10.3 80–84 6.1 7.5 85+ 5.1 6.2

Population Estimates 2004 Age Group Male Female 35–39 193,924 195,604   2004 Age Group Male Female 35–39 193,924 195,604 40–44 225,923 229,791 45–49 216,788 223,820 50–54 187,574 198,202 55–59 158,708 170,180 60–64 125,208 138,280 65–69 97,473 110,225 70–74 81,614 102,462 75–79 65,862 91,006 80–84 44,619 72,052 85+ 28,894 71,485

Missouri SAM Due to Cancer, 2000-2004 Cause of Death (ICD-10 Code) Deaths SAM YPLL PLoss* Malignant Neoplasm Lip, Oral Cavity, Pharynx (C00-C14) 144 95 1,611 $37,312 Esophagus (C15) 257 179 2,709 $58,044 Stomach (C16) 202 45 623 $12,467 Pancreas (C25) 636 153 2,300 $45,692 Larynx (C32) 77 62 974 $21,179 Trachea, Lung, Bronchus (C33-C34) 3,803 3,117 46,197 $903,844 Cervix Uteri (C53) 77 11 272 $6,915 Kidney and Renal Pelvis (C64-C65) 286 77 1,168 $25,739 Urinary Bladder (C67) 241 102 1,181 $19,698 Acute Myeloid Leukemia (C92.0) 161 28 397 $7,905 Total 5,884 3,870 57,433 $1,138,797 10 diseases * Productivity Losses due to smoking-attributable mortality

Missouri SAM Due to Cardiovascular Diseases, 2000-2004 Cause of Death (ICD-10 Code) Deaths SAM YPLL PLoss* Cardiovascular Diseases Ischemic Heart Disease 11,397 2,000 29,094 $604,179 (I20-I25) Other Heart Disease 4,371 588 7,010 $121,499 (I00-I09, I26-I51) Cerebrovascular Disease 3,690 396 6,086 $127,219 (I00-I69) Atherosclerosis 292 44 365 $3,429 (I70-I71) Aortic Aneurysm 319 190 2,215 $35,417 (I71) Other Arterial Disease 245 37 455 $7,567 (I72-I78) Total 20,314 3,256 45,225 $899,309 6 diseases * Productivity Losses due to smoking-attributable mortality

Missouri SAM Due to Respiratory Diseases, 2000-2004 Cause of Death (ICD-10 Code) Deaths SAM YPLL PLoss* Respiratory Diseases Pneumonia, Influenza 1,529 273 2,632 $32,943 (J10-J18) Bronchitis, Emphysema 340 295 3,576 $55,884 (J40-J42, J43) Chronic Airway Obstruction 2,395 1,884 21,046 $292,379 (J44) Total 4,264 2,453 27,254 $381,206 3 diseases * Productivity losses due to smoking-attributable mortality

Burden of Smoking It was estimated that every year during 2000-04: 9,578 Missouri adults age 35 and older died prematurely due to smoking-related diseases 29 Infants died prematurely due to smoking-related diseases More than one death per hour About one in every five adult deaths (18.3%)

9607 Deaths are an Under-Estimation of SAM in Missouri It does not include deaths due to: Second-hand smoke (830-1470* deaths) It is based on current smoking prevalence that is lower than the past. The deaths are the result of smoking in the past Use of other tobacco products Cigar, Bidi, Kretik, Pipe and Smokeless tobacco * Campaign for Tobacco Free Kids, 2007

Missouri SAM Breakup 2000-2004 (Annual Average) Total Adult 9,578 deaths 18.3% of all adult deaths Men 5,800 deaths 22.1% of all deaths in men Women 3,778 deaths 13.3% of all deaths in women

Missouri Adult SAM by Disease Category, 2000-2004 (Annual Average) % of Total SAM Cancer (Malignant Neoplasm) 3,870 40.4% Cardiovascular Diseases 3,256 34.0% Respiratory Diseases 2,453 25.6% 19 adult and 4 MCH disease categories.

Three Leading Diseases for Missouri SAM, 2000-2004 (Annual Average) % of Total SAM Lung, Trachea and Bronchus Cancer 3,117 32.5% Ischemic Heart Diseases 2,000 20.9% Chronic Airway Obstruction 1,884 19.7% Total of 3 Diseases 7,001 73.0%

Indirect Cost of Smoking, 2000-2004 Annually, Smoking Caused 132,103 Years of Potential Life Lost (YPLL) in Missouri 78,686 YPLL in men 53,417 YPLL in women

Economic Cost of Smoking (Average Annual 2000-2004) Total monetary cost = $4.6 billion Smoking-attributable medical expenditures in Missouri = $2.2 billion (in 2004 dollars) Productivity losses due to SAM = $2.4 billion Smoking-attributable Medicaid cost = $512 million ($91 paid for by each Missouri resident)

Racial Disparity in Smoking-Related Mortality

Racial Disparity in Smoking-Related Mortality Cause of Death (ICD-10 Code) Smoking-Attributable Mortality Rates (per 100,000 population) Relative Disparity (%) White Black Male Female Total Total Adult 451 205 306 616 217 368 37* 6* 20* Malignant Neoplasms 189 76 124 273 90 161 44* 18* 30* Trachea, Lung, Bronchus (C33-C34) 148 65 100 204 74 38* 14* 24* Cardiovascular Diseases 152 101 248 89 150 63* 49* Ischemic Heart Disease (I20-I25) 95 38 63 143 54 88 51* 42* 40* Respiratory Diseases 110 64 81 37 57 -14* -42* -30* Chronic Airway Obstruction (J44) 84 51 67 28 42 -20* -45* -33* * The difference in the SAM/YPLL rates of Blacks and Whites is statistically significant at (p <= 0.05) level for the three categories and major diseases

Disparity Index Relative Disparity =[(SAMRTBlacks–SAMRTWhites)/ SAMRTWhites] *100

Assumption and Possible Reasons for Disparity (Needs Further Research) It was assumed that both races have the same relative risks Some studies found the difference in socio- economic status to be the major cause of Black and White disparity They may smoke different types of cigarettes Difference in per capita cigarette consumptions

Results The SAM rate for Blacks in Missouri was 20% higher than for Whites Racial disparity was larger in men (37%) than in women (6%) SAM rates for Blacks were higher than for Whites for malignant neoplasms (30%) and cardiovascular diseases (49%) but lower for respiratory diseases (-30%)

Conclusions – Racial Disparity in SAM Significant racial disparities in smoking- attributable mortality exist in Missouri with 62 per 100,000 more Black adults dying each year from cigarette smoking than White adults Blacks die at a higher rate due to smoking- related cardiovascular and cancer diseases Whites die at a higher rate due to smoking- related respiratory diseases

Shukriya, Merci, Gracias Noaman Kayani Noaman.kayani@health.mo.gov Thank You Shukriya, Merci, Gracias Noaman Kayani Noaman.kayani@health.mo.gov