1. CGHR.ORG Twitter: CGHR_org 21 st century hazards of smoking and benefits of cessation in the United States Jha P, Ramasundarahettige C, Landsman V, Thun M, Rostron B, Mcgaffey T, Anderson RA, Peto R Centre for Global Health Research (CGHR) St. Michael’s Hospital and Dalla Lana School of Public Health, University of Toronto jhap@smh.ca NEJM, January 24, 2013 (NOTE STRICT EMBARGO)

2. CGHR.ORG Twitter: CGHR_org Conclusions 21 st century smoking risks for American women and men are comparable (death risks for smokers are ~3 fold higher than for never smokers) Death risks for women who smoke are 50% greater than estimated from the 1980s studies At least a decade of life lost by current smokers Never smokers are about twice as likely to reach age 80 than are current smokers Cessation before age 30 yields 10 years of life versus current smokers Cessation by age 40, 50 and 60 yields 9, 6 and 4 years of life versus current smokers

3. CGHR.ORG Twitter: CGHR_org How was the study done? 1997-2004 annual representative surveys (“NHIS”) that include 93% of Americans (excluding only those in institutions or on military duty) Studies those 25-79 years of age (“middle age”) 1.3 million person-years (over 7 years of follow up) –220,000 adults; 90,000 men,130,000 women –17,000 deaths, of which ~10,000 at 25-79 years Link survey participants to National Death Index to 31.12.2006 (>95% match)

4. CGHR.ORG Twitter: CGHR_org Study team Epidemiological experts from St. Michael’s Hospital, University of Toronto, University of Oxford, US Centres for Disease Control and Prevention, and American Cancer Society Funded by NIH, CIHR and Bill and Melinda Gates Foundation (but funders had no role in data analyses or writing the paper)

5. CGHR.ORG Twitter: CGHR_org What is new about this study? Nationally representative, meaning the results reflect the whole of the United States (earlier studies were in specific groups like nurses or volunteers) Women’s risks represent those who began smoking early in life and continued smoking through middle age (and those who quit seriously) Examines the health benefits of the recent increase in cessation

6. CGHR.ORG Twitter: CGHR_org Differences between smokers and never smokers Smokers were thinner, drank alcohol more often and were less educated than never smokers The smoker versus never smoker analyses adjusts for these differences (and other differences)

7. CGHR.ORG Twitter: CGHR_org Cessation more common in men than in women At ages 65 to 69, ratio of former to current smokers is 2:1 for women but 4:1 for men

8. CGHR.ORG Twitter: CGHR_org Disease WomenMen Never/ current smoker RR (99%CI) Never/ current smoker RR (99%CI) Lung cancer61/26717.8 ( 11.4-27.8) 44/34814.6 (9.1-23.4) All cancer605/5253.2 (2.6-3.9) 324/6653.8 (3.1-4.8) Vascular784/4763.2 (2.7-3.9) 500/6432.6 (2.1-3.2) Respiratory119/2068.5 (6.1-11.8) 45/1889.0 ( 5.6-14.4) All diseases2190/15793.0 (2.7-3.3) 1283/20302.8 (2.4-3.1) Hazard ratios* by disease for current vs. never smokers, United States 1997-2006, ages 25-79, by gender * Cox- proportional HR adjusted for age, education, alcohol, and adiposity (BMI) Source: Jha et al, NEJM, Jan 24, 2013

9. CGHR.ORG Twitter: CGHR_org FEMALES: Survival probabilities between ages 25 and 80 years, among current and never smokers in the US HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used Source: Jha et al, NEJM, Jan 24, 2013

10. CGHR.ORG Twitter: CGHR_org MALES: Survival probabilities between ages 25 and 80 years, among current and never smokers in the US HR adjusted for age, education, alcohol, adiposity (BMI), scaled to 2004 national rates, but comparable results if only actual cohort used Source: Jha et al, NEJM, Jan 24, 2013

11. CGHR.ORG Twitter: CGHR_org HRs for continuing smoking versus cessation at various ages, adults aged 25 to 79 years HR adjusted for age, education, alcohol, and adiposity (BMI) Source: Jha et al, NEJM, Jan 24, 2013

12. CGHR.ORG Twitter: CGHR_org Effect of quitting on survival: men/women combined Source: Jha et al, NEJM Jan 24, 2013

13. CGHR.ORG Twitter: CGHR_org Global implications US has about 40 million smokers, out of a worldwide total of 1.3 billion smokers Unlike in the US, quitting in low or middle income countries is uncommon (usually as a result of disease, rather than to avoid disease) These “mature” risks suggest that the worldwide estimates of 21 st century smoking deaths are BIG (perhaps bigger than thought just a few years ago)  Without widespread cessation, smoking will kill 1 Billion people in the 21 st century (mostly in low/middle income countries) versus “only” 100 Million deaths in the 20 th century

14. CGHR.ORG Twitter: CGHR_org What can be done? Higher tobacco taxes are the single most effective intervention to reduce smoking and smoking deaths worldwide US: 53 cent federal excise tax increase per pack of cigarettes adopted in 2009 will save lives Other countries need to adopt large increases in tobacco excise taxes Prominent warning labels, advertising restrictions and cessation support also raise cessation rates

15. CGHR.ORG Twitter: CGHR_org Conclusions 21 st century smoking risks for American women and men are comparable (death risks for smokers are ~3 fold higher than for never smokers) Death risks for women who smoke are 50% greater than estimated from the 1980s studies At least a decade of life lost by current smokers Never smokers are about twice as likely to reach age 80 than are current smokers Cessation before age 30 yields 10 years of life versus current smokers Cessation by age 40, 50 and 60 yields 9, 6 and 4 years of life versus current smokers

16. CGHR.ORG Twitter: CGHR_org More material www.cghr.org/tobacco 1. NEJM Paper and Webappendix 2. PowerPoint slides 3. Frequently asked questions 4. Press release and video interviews www.cghr.org/tobacco Source: Jha et al, NEJM, Jan 24, 2013