TABLE I.--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)

All









I ox

  Former smoker\
Duration ot ah\tinencc (yr )

    s-9            IO-15           >I5



    I.5             I.3            I I



    1.34             I.01
    1.3X             I.31


    1.x7             I.24           I 47
    7.0x             1 .xx           I .72

I .hO
I.55
I .5x

0.x-l

0.93
0.90
0 91


TABLE I.-Continued

Former wwhers
All tlurarion\

Study

Current
smokerc

Pcr\i\lent
uuIUcr\

California HMO'
(Friedman et al. 1981)

I .x2                                 I Sl             I.13


mortality risk was still higher than that of never smokers even after IO 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
52 1,555 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 S-year age groups for current and former smokers
according to level of cigarette consumption ( l-20 cig/day, 22 I cig/day for males: I -I 9
cig/day, 220 cig/day for females). Rates for former smokers were further stratified by
years since smoking cessation (<I, 1-2.3-S. 6-10. I l-1.5, 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 \mohrr\
Duratwn of abstmsncr at enrollment or)

Current
smohrr\

<I       l-2      3-s      6-10     I l-15     216

Male\
l-20 cigldlcy
>I! I cig/day

Female\
I-IO q/da>
20 <if/da)

7 -.-- 73     2.4Y     2.3x     2.03      I .h3      I .3x      I .06
2.13     2.77     7.M     2.25     7.04      I .77      I.27



I .hO      I 5x      I .Yh     I .Jl      I.14      I.10      I .(I I
z IO     3.3Y     1.5X     7 03      I .hO      I .3x      I.15

Currcm
\mohw

<I      IL2      3-s     610     I l-l.5     >Ih

Male\
I-20 q/da\
22 I cig/da>

Female\
I-IY cigiday
X0 q/da!

2.31     2.Oh     2.M      I .x9      I .4x      1.2')      I .o I
7.73      I x5     2 IS      I .YO      1.77      I fl.5      1.1')



I .x7     0.76     I.26     I .J2      I .OI      I .09      I .Oo
Z.Jh     7.33     2.15      I .-II      I 46      I.IX      0 YS


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 misclassitication and affects relative
risk estimates (Chapter 2).
Like AC3 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 I 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 IO 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 2 I 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.


For three reprc\entative age groups (NJ--54.60-64, and 70-74 yr). Figure I 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 X0 years because there were fewer than IO deaths in
almost all of the categories of former smokers. In each of the age subgroups shown in
Figure I. 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-II 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 mtes measured from 1982-86 CPS-II data remain constant for
the next 16.5 years. The first category of smoking cessation is l-2 years: that is. the
individual gave up smoking I to 2 years ago. It is assumed that. on average. respondents
in the I-2-year category pave up smoking I .5 years ago. Similarly. for the cessation
categories 3-S. 6-l 0, and I l-l 5 years, the average durations of abstinence are 1. X. 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 I .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 -IO-&-year interval would be exposed to the age-specific
mortality rates of the 301-t-year-olds for I .S years. to those of 4539-year-old\ for 5
years, to those of SG%-year-old\ for 5 years. and to 5%59.year-olds for 5 years.

The results of thi5 analysis. presented in Table 3 and in greater detail in Table X of
the Chapter Appendix. \how that the benefits of cessation for total mortality extend to
quitting at older age<. For example. a healthy man aged 60-63 years who smokes 21
cigarettes or more per day is estimated to have a chance of dying in the next 16.5 \`ears
of 56 percent if he continues to smoke and 5 I percent if he quits.  Quitting smoking at
younger ages confers even greater proportionate increasej in survival (\ee Figure 7 of
the Chapter Appendix ).

Framingham investigator\ recentI!, analyred data from their cohort (D'Ago\tino et
al. 19X9) and aI\0 found that the benefit\ of quitting apply to those who quit at more
advanced age\. These researchers estimated that mean additional life expectancy for
those who quit at ages 35 to 39 wah 5. I years for males and 3.2 years for females. For
those who quit at ages AS to 69. additional life expectancy was estimated to be I .3 years
for males and I .O year for females.

As discussed in detail in Chapter _ 7 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. 19x0: Haines. Imeson. Meade 19X0: McManus and Weeks 1982:
Billings and Moos 19X3: Gottlieb 19X3: Brod and Hall 19X-l: Seltzer and Oechsli 19X5:

X0


MALES

            Aged XL54

Current Smokers <l    l-2 3-5    6-10    11-15   216

Aged 60-64

Current Smokers ~1

l-2    3-5    610   11-15   216

Aged 70-74

Current Smokers <l    l-2 3-5     6-10   11-15    216

             Former Smokers
         Duration of Abstinence (yr)

* ??????????

Q 221 c&/day

FIGURE I.-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: Unpuhll\hed tabulalions, Anwrican Cancer Societ).

XI


FEMALES

                               I

w --  Current Smokers cl    l-2    3-5    610   11-15   216

Aged 60-64

Current Smokers <1




4.0

4.0 -

I-2    3-5    6-10   11-15   216



              Aged 70-74

Current Smokers ~1

l-2    3-5    610    11-15   216
  Former Smokers
Duration of Abstinence (yr)

I 1-19 c&/day      0 220 c ig/da y

F`I(;IRE 1. (Continued )--Compared u ith ne\er smoker\. relati\ e risk of
      mortalit! in current and former smokers aged 50-54.60-64. and
      70-71 at enrollment. b> amount smoked and duration of
        abstinence

x2


TABLE 3.-Estimated probability of dying in the next 16.5year interval for
     quitting at various ages compared with never smoking and
     continuing to smoke, by amount smoked and sex

Age at
quitting or
at 51art of
interv31

Female\

Age at
qutttmg or
at \tart of
interval

Never
\moher\

   x!o q/da\

Contmumg     Former
mohrr\     smoker\

1&`&l        0.03        0.06         0.03             (I ox        0.0-l
4519        0.04        0.0')         0.06             0.1 3        0.0
SO&S-l        0.07        0. l-l         0.07             0.14        (l.OY
55-s')        0.1 I        0.2 I         0. 12             0.27        (I. IS
60-64        0.1 x        0.30         0. I Y             (I.38        0.3'
65-6')        0.30        0.46        0.3Y             0.52        (I.32
70-7-1"        0.26        0.4 I         0.77             0.4S        (I.3 I

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 A. 7 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 smokin, 0 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

x3


former smokers and would need to be strong predictors of mortality. There is no
substantial evidence that thih is the tax.

SMOKING CESSATION AND OVERALL MORTALITY IN
        INTERVENTION STUDIES

Five studies. four of which were randombed triak evaluated overall mortality in
relation to interventions that included smoking cessation 3s a component. The results
of these studies are aummurired in Table 1.

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

Otil!~ one stud! cxaminccl wlohin g inter\ c'ntion alone t Rwc and Hamilton 197X:
Rose et al. 19X2). Of I .145 IIMIC` mwk~~. aged 10 to 59 and at hish ri\h of coronaq
heart diNe;Iw (CHDI or chrotttc hronchttis. 7 t-I \+erc randomt~ a\\iyed to a11 interLen-
tion group and 73 I to ;I norm;tl cat-c group. hlcn in the inter\ ention group wcrc fi\ en
individual ad\ ice to quit \mohing. and if intereaxi III quittins. up to four additional
vi5it4 over 12 month\.  AI the c)-!car follow up. 55 pcrccnt of responder5 in the
intervention reported abbtincnce compared I+ itli 1 I percent in the normal care group.
After IO !eat-\ of 1'~~llo~~ up. there \\crc 123 death\ III the inter\,ention group and 1% in
the normal care group. The proportionatt' diffcrcnce in total mort;rlit! hewecn the
intervention group anti normal cxc group I-2 percent) \\a not \t;iti4icall\ stgnitkxnt.
but the confidence inter\;tl \\;I\ u I& 1-12 percent to +23 percent). There \\t're XI

X-l


smoking-related deaths in the intervention group and Y2 in the normal care group. The
proportionate difference in smohing-related deaths has -Y percent. Again the con-
fidence interval was wide (-31 percent to +20 percent). Twenty percent of the men in
the intervention group who quit smohing cigarettes tooh up pipe or cigar smohing
compared with 3 percent of the men in the normal care group. and to the extent that
pipe and cigar smoking are mortalit) rish factors. any benefit of cessation of cigarette
smohing 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 uas
further compromised by the relatively poor compliance of the subjects with the
intervention: the net reduction in mean cigarette consumption over the IO years of the
followup among the intervention group compared ti ith the normal care group was onI\
7.6 cigarettes per day.

Other intervention studies that allow assessment of the relation ofsmohing 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. 19X6) and was
aimed at modifying smohing. cholesterol levels. and blood pressure. The rest of Finland
was used for comparison. In the IO years after initiation of an aggressive risk reduction
program. there was a 35percent decrease in smohing in North Karelia compared with
a I-percent reduction in the rest of Finland (Salonen et al. IYXY). Blood pressure and
cholesterol levels did not change significantly in the intervention area compared u ith
the rest of Finland. Total mortality in the intervention area in the IO 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 Karelis study is 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 mortalit\, in the stud)
area with that of Finland. During the study period. overall mortalit) 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. 19X9). Second. the study was
not designed to investigate smoking cessation alone. Because of the mixing of inter-
ventions for three CHD rish factors, it was difficult to isolate the impact of the smoking
cessation component.

The Oslo study (Hjermann 19X0: Hjermann et al. 1981; Holme 1982) involved 1.237
normotensive men at high risk for CHD because of their smoking behavior and
cholesterol levels. The men were randomly assigned either to recei\,e 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 I3 percent in serum cholesterol between the
intervention and control groups over 5 years (Hjermann et al. IYX I ). The stud!, was
small. and it was not designed toexamine total mortality endpoints; only 42 deaths were

X5


observed. Nevertheless. the mortality rate in the intervention group was one-third lower
than in the control group (one-sided p value=O. 13). 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 perday in the intervention factories was X.9 percent (WHO
European Collaborative Group 1983). At 6 years. overall mortality in the intervention
factories was 3.04 percent: in the control factories. it was 4. IS. 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 1981). Men in the special intervention group received an intensive
intervention aimed at reducing hlood 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. q-l.3 percent of special intervention smokers and 3.X percent of the usual
care smokers reported cessation. In the 7-year followup data reported in IYXZ. there
was no difference in total mortality between the special intervention and usual care
groups (MRFIT Research Group lYX3). However. in the 10.5-year follow up 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=O. IO: YO-percent
confidence interval (Cl). -16.6 to +7.3) (MRFIT Research Group IYYO).
A subgroup of MRFIT special intervention participants. who were hypertensive. had
resting electrocurdiograrll abnormalities. and comprised 31 percent of the special
intervention group. may have suffered excess mortality as a result of an unanticipated
adv,erse effect of one of the antihy~pertcnsive drugs (Cutler. MacMahon. Furberg 19X9).
This has recently been sugested as an explanation for the absence of an overall
difference in mortality~ between the special intervention and usual care groups at the
7-year follow LIP (MRFIT Research Group. submitted for publication I. Furthermore.
Ockene and coworhers ( 1900) recently reported that at IO.5 years. MRFIT participants
who quit smohing had significantI\ lower death rates than those who continued to
smohe in both special inter\ cntion and usual care groups. Mo5t important. like the other
multifactor intervention trials. it is difficult to infer a benefit or a lath of benefit ot
smoking cessation for total mortality from this study.
In summary. studies in\,ol\ in? smohing cessation interventions include a randomized
trial in which smohing cessation was the sole interventton and three intervention studies
in M hich it was ;I component. The small six of the former and the mixing of a smohing
intervention with other interventions in the latter mahe it impossible to reach con-
clusions about the benefits of smohing cessation from these studies alone: however.


nonintervention (i.e.. cohort) studies described in the previous Section clearI! indicate
a benefit of smoking cessation on overall mortalit!,.

SMOKING CESSATION AND MEDICAL CARE L'TILIZATIO\

Population Projections

The relationship between smohinf cessation and medical care utilization is acomplcx
issue.  Data on differential disease and mortalit!, rates comparing smohers and
abstainers are abundant. and man\ in\,ectigators have used these data to pro,ject the
savings in dollars attributable to smohing cessation (Weinham. Roscnbaum. Sterling
IYX7: Leu and Schaub 1'3x3; Lute and Schweit/el- 197X: O\ter. Coldit/. Kelly IYXIJ.
Cenerall\~. these projections produce results that depend on the man> assumption\ ot
the models that create them. For example. Lute and Schweitzer ( I Y~XJ projected that
the total 1976 dollar cost of smohing in the United State\ was about 527.5 billion and
that excess medical care costs accounted for about SX.2 billion of tho\r costs.
Weinkam. Rosenbaum. and Sterling ( lYX7) and Leu and Schaub ( IYX3). both using
population simulation approaches. concluded that mohin, (7 does not. o\er a lifetime.
lead to increased medical care utilization. Thi\ is because the short-term higher levels
of utilization of smokers are approximateI\, balanced b) shorter longevity and the
resulting reduced need for medical care.

Oster. Coldity. and Kelly ( 19X-I) used population prcjjcctions to estimate the medical
care costs of smoking and the proportion of those costs that are potentialI> recoverable
depending on the age at which smokin g is riven up and the level of smohing prior to
                               c
quitting. Male light smokers (<I pack/dab) who quit between ages 35 and 39 uere
estimated to recover about 59 percent of their lifetime excess medical care costs. Even
if quitting ua\ delayed until age\ 7.5 to 79. Ii@ smohers were estimated to recover
one-third of the costs.  For heavy smokers, quittin, ~7 earlier was estimated to ha\c
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 ser\,ices b)
current smokers. former smokers. and never smokers. These studies suggest that
smoking is associated with higher utilization of hospital services and that former
smokersexperienced a brief period of increased utilization of hospital {ervicesjust 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 IYXX; Vogt and Schueit;ler
19X5; Oakes et al. 1973).

SMOKING CESSATION AND HEALTH STATUS

Table 6 summarizes studies of smohing 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 smoher< is
available. Because some smohers quit due to illness and because most studies fail to

x7


TABLE S.--Summary of studies of medical care utilization among smokers and
       former smokers

R~fW3lCY

Re\uk\

Ashford      75.500 re\ldent\ of
(1973)       Exeter

Oahe\ et al.
(1974)

2.557 HMO memher~
m California

Phqwinn
visit\.
ho\pitali/alion

No consiwznt difference\ in any
mearure ot uIiII7aImn between former
smoker\ and current \moker\.

Male former \moher\ have more
phywtan viGts than current smoker\:
female former \moher\ have more
physician visit\ than currenr smoker\.
Male former smohrr\ are less likelq than
current smoher\ to be hospitalized:
ho\pituliratlon among female former
smoker\ compared with currenr \moher\
varle\ uith age.

Phkhician
\,`isits"     Da)\
     hospilali/ed"

Non\moher\
Smoher\
~0.5 ppd
I PPd
2 I .5 ppd

2.41      0.6-i


2.37     0.x7
2.Sh     0.6X
3.16     0.44

identit`y the reawn~ for quittin y. the relation betMew quitting and health status may be
obwured in \tudirs that clasGt) prrwn\ ah t'ornw and current mohers (Chapter 2). A
few \tudie\ differentiate bet\vetm short-term abstainer\ (-c I 1 r) and long-term abstainer\
(>I yr). and thtw htudiek are highlIghted.

XX


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 (I 989) 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 1 year reported good health with about
the same frequency as persons who smoked only I 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 1 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 5 1 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.

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

Sell-rcpofl ol ~llne\\ and   (`hronic ilIne\\
ph!\lcian VI\I~\        Acure illW\\
            Outpatient vl\n
            PhyGcian
                conwlliition

I.0-r' 1.31" 1.76"
I .03   I .OY   I.29
I .46   I .46   I .43
I.12   I .0x   I .OY

Gig/day
<IO   210

0.X2h
0.79
0.Y I

I .Olh
0.97
I .os


032'

o.X6h
0.7Y
I .oU

0.7Yh
O.Xh
0.66


0.49'

Quit   Quir
>I yr  <I yr
- -
I .43"  I.?h"
I.1 I    I 4x
I .40    I.75
I.10    I .47

I .(I"
I A)"
I .o"
I .o"

Y.6    I I.6
9.0    Y.6

IO.2
6.X

9.0
7.3


TABLE 6.-Continued

Reference

Population

Health status
measure

           Re\Ult\

Current smoker\       Former smoker\        Never smokers

   Gig/da!         CJUll   Quit

Ii-15 21-3  >??I      51 yr  >I yr
                  --

Segovia,
Bartlett.
Edwards
(IYXY)

Telephone survey of
representative sample
us adults

Self-report of "good health"            4. IX< 1.00" I .a'      3.42'   5.13"          6.13"

Gallop
(19X9)

Workers in the
pulp/paper industry

Work absence\

I.3'           I .OY'            I .otf


CONCLUSIONS

1. 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.

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

3. Among former smokers, the decline in risk of death compared with continuing
smokers begins shortly after quitting and continues for at least IO to 15 years. After
IO to I5 years of abstinence, risk of all-cause mortality returns nearly to that of
persons who never smoked.

4. 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.

92


CHAPTER 3 APPENDIX


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

4s 1')

so s4

55- SY

hOM4

hS-hY

70-73

75-74

I Xh.0        42Y.2

25.5.6        702.7

44x.9       1.131.4

733.7       I .YX I. I

I.1 IY.4       3,(H)3.0
2.070.5       3.6Yl.S

3.675.3       7.340.6

Current

Former wwher\ (22 I cie/d;tv)


TABLE 7.-Continued

Females



Age

Never
\mokrr\

<I

l-2

Former smokers (l-19 ctg/day)

Duration ofabtinence (yr)

  3-s         b-10

4SAY

so-s-l

55-w

6044

hS-hY

70-7-l

7s-7')

Females

Age

125.7        225.6

177.3        353.x

244.X        s42.x

3Y7.7        x5x.0

hY2. I       I .4Y6.2

l.lhO.0       2.0x4.x

7.070.x       2.3IY.5

Former smokers (Z20 cidciav)

Duration ofabstinence (yr)

<I           l-2           3-5         h-10          I I-IS         Zlh

4s -4')                    `77.Y           266.7         IO?.7          17X.6         224.7         142.1         I3X.X

SC& s4                    5 17.`)           13x.7         -%6.X          270. I         190.2         116.X         x3.0

55-s')                    x23.s           473.6         hO?.O          361 .o        4.543         412.2         1x2.1

6044                  I ,302.Y          I.1 14.x        X62.1          6YY.h        541.7         373. I        356.4

654,`)                  I .Y34.Y          2.219 h       I ,250.o        I ,hXX.O        X2X.7         7Yl.Y        SXI 3

70-74                  2.x77.0         4,635.X       2517.2        I ,6X7.2       2.X4X.7        I .62 I .?       I.ih3.4

75-79                  4,273. I          2.4OY.6       5.76Y.2         3.125.0       2.Y7X.7       2.x03.7       2.lYS.4


TABLE %-Estimated probability of dying in the next 16.5year interval
     (95% CI) for quitting at various ages compared with
     never smoking and continuing to smoke, by amount smoked and sex

Age at
quittlng
or at start
of interval

Never
smokers

          Males

    I-30 q/day
Continumf       Former
smokers        smokers

   22 I cig/dq

Contmuinf       Former
smohers       smoker\

4&44       0.01,
       (0.04&0.05)
4549       0.07
       ~0.07-0.08)
5&53       0.1 I
       (0.1 l4t.12)
F-59       0. I X
       (O.l7~.lY)
h&64       0.30
       (0.28-0.3 1 )
65-69       0.46
       (0.43~.4X)
7G-74"       0.40
       (0.384l.43,

  0.11
(0.10~).12)
  O.IX
to. 174.19)
  0.27
lo.zbwx)
  0.39
(0.7X%0.41 )
  I)..54
(0.52Kt.57)
  0.68
(0.64-0.72)
  0.61
lO.SfFo.65)

  0.05
(0.oGo.06)
  0. IO
(0.080. I I )
  0.17
to.ls~).lY)
  0.2X
to.`s4if)
  0.46
(0.4-0.50,
  0.5')
(0.5 14.67)
  0.55
(0.4S-o.64)

Female\

  0. I4
(0.13~).15)
  0.22
10.21LO.23,
  0.3 I
(0.3%0.33)
  0.46
(0.434.4n)
  056
(0.S 1~1.61 1
  0.67
(0.57-0.78~
  0.58
(0.444.7 I 1

  0.07
(O.OM.09)
  0.1 I
(0.10-0.13)
  0.2 1
tO.lX4.23)
  0.33
(O.xLO.37)
  0.51
(0.48<)..57)
  0.64
(0.5 I-0.77)
  0.5 I
10.32-0.72)

Age at
outtting

1-l') clg/day             ~20 ctg/day

1 L
or at start     Never     Continumg      Former      Continuing       Former
of interval    smoker\       smokers       smokers        smokers       smokers

4tx44       0.03
       (0.03-0.03)
4.549       0.04
       (0.04-0.04)
50-54       0.07
       (O.O&O.O7)
55-59       0.1 I
       (0.11-0.11)
6cM4       0.18
       (0.1%0.19)
65-69       0.30
       (0.29xI.3 I )
70-74"      0.26
      (0.25-0.27)

  0.06
(0.054.06)
  0.09
K~.O%O.O9)
  0.14
(0.13415)
  0.2 I
(0.I9-0.22)
0.30
(0.27wI.33)
  0.46
(0.41Hl.52)
  0.4 1
(0.35-0.47)

  0.03
(0.02-0.04)
  0.06
(0.o;co.07)
  0.07
(0.05-0.09)
  0.13
(0.0%0.16)
  0.19
iO.13-0.25)
  0.39
(0.26-0.52)
  0.27
(0.094.46)

97


30





2a

I-







l-






l-






b-





I-

Continuing smokers

:;:::
cl
;:;i;; Former smokers
.
0 Never smokers

WOMEN

FIGURE 2.--Estimated probability of dying in the next 16.5yr interval for
     quitting at ages 55-59 compared with never smoking and
      continuing to smoke, by sex
NOTE: Continuing and former \mokzrs include only thaw wlohing 2 I (men) or 210 (women)
c&c/day. Vertical bar\ represent 05% CI: the interval fur female never xmokw ih not shown hecauw it is
extremely narrtrw I I I-I I'% j. Bawd on Amwcan Cancer Society Cancer Prrvrntion Study II data fur
perwn, wthout a hl\tory of cancer, heart dlwaw. or stroke wjho were not "\ick"nt rnrollment.
SOUKCE: I!npuhlished tahulatwns. American Cancer Swiety, (we Table Xl.


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