1. Epidemiology and Global Health

The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries

  1. Prabhat Jha  Is a corresponding author
  1. Centre for Global Health Research, Dalla Lana School of Public Health and Unity Health, Toronto, University of Toronto, Canada
https://doi.org/10.7554/eLife.49979
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  1. Prabhat Jha
(2020)
The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries
eLife 9:e49979.
https://doi.org/10.7554/eLife.49979
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12 figures and 9 tables

Figures

Figure 1
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Trends in per capita consumption in Canada, US, UK in cigarettes per adult per year.

Note. Data from Forey et al. (2016), International smoking statistics.

Figure 2
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Prevalence (%) of adult males (right panel), and females (left panel), usually 15 to 18 years or older that smoke by sex in US, UK and Canada.

Note. Data from National Center for Health Statistics, 2008, 1965–2012 National Health Interview Survey (NHIS); Office for National Statistics, 2018, Adult Smoking habits in Great Britain; and Reid et al., 2017, Tobacco Use in Canada: Patterns and Trends, 2017 Edition.

Figure 3
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Survival by smoking among US insured adults.

© 1938, The American Association for the Advancement of Science, All Rights Reserved. Figure 3 is reproduced from Pearl (1938) with permission. It is not covered by the CC-BY 4.0 licence and further reproduction of this panel would need permission from the copyright holder.

Figure 4
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Trends in per capita cigarette consumption and age-standardized lung cancer death rates in the US.

Adapted from American Cancer Society (2013).

Figure 5
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Trends in age-specific lung cancer death rates among men and women at ages 35–39, 55–59 and 75–79 in selected countries.

Figures provided by Hangchao Pan and Richard Peto, University of Oxford, 2018.

Figure 6
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Lung cancer death rates by sex by study period.

Adapted from U.S. Department of Health and Human Services (2014).

Figure 7
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Number of cigarettes (from 1955 to 1985) per death with a 20 year lag in US, UK, and Canada (from 1975 to 2005).

Note. Author’s calculations.

Figure 8
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Survival differences between smokers and non-smokers, adjusting for various factors.

Adapted from Jha and Peto (2014), p. 62.

Figure 9
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USSGR 2014 estimation of anatomic sites and cancers linked to smoking.

Adapted from U.S. Department of Health and Human Services (2014).

Figure 10
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Former and current smoking prevalence, US (2017), UK (2017), and Canada (2014) by sex and age group.

Note. Data from National Center for Health Statistics, 2017, NHIS, Office for National Statistics, 2017, Adult Smoking habits in Great Britain; Statistics Canada, 2016, Canadian Community Health Survey.

Figure 11
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Relative risks for all-cause mortality and cancer of the lung, by age of quitting, among UK women.

Adapted from Pirie et al. (2013), p. 138.

Figure 12
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Life expectancy: loss of 3 years with moderate obesity and 10 years with smoking.

Note: 2 kg/m2 extra BMI (if overweight) or 10% smoking prevalence shortens life by ~1 year. Adapted from Peto et al. (2010), p. 856.

Tables

Table 1
Adult smoking prevalence (daily and non-daily) and daily cigarettes for US, UK, and Canada in 2000 and 2015.
Year20002015Change in %
Prevalence*
US23.115.2−34.2%
UK27.017.8−34.1%
Canada24.413.0−46.7%
Amount per day (among daily smokers)
US18.114.2−21.5%
UK*13.811.3−18.1%
Canada16.813.8−17.9%

  1. *Daily and non-daily smokers.

    Note. Data from National Centre for Health Statistics, NHIS; Office of National Statistics, Adult Smoking habits in Great Britain; Statistics Canada and Reid et al., 2017, Tobacco Use in Canada: Patterns and Trends, 2017 Edition –Defined as having smoked in the past 30 days and having smoked 100 cigarettes in a lifetime. Adult ages are 15+ in Canada and the UK and 18+ in the US.

Table 2
Trends in smoking-attributable deaths from 1955 to 2015, (with projections to 2020) by sex in US, UK, and Canada (in thousands).
YearUSUKCanada
Smoking-attributableTotalSmoking-attributableTotalSmoking-attributableTotal
Males
1955139882903038.875
19652351 0361263241787
19753051 0631423372696
19853351 09212532531100
19953411 1639530833111
20053021 1996727929116
20152861 3255526428129
1960–2020*18 04068 7606 10018 3701 6406 390
Females
19551.466312285054
196519795243070.761
197579858433314.270
1985169983593311180
19952721 135693322099
20053021 2296630626113
20133021 2886027730126
1960–2020*11 43062 8803 21018 8409195 490
Both sexes 1960–2020*29 470131 6409 31037 2102 55911 880

  1. * 1960-2020* 1960–2020 totals by taking totals for 1965, 1975, 1986, 1995, 2005 and 2015 totals multiplied by 10. Note. Author’s calculations based on Peto et al. (2018).

    Cumulatively, from 1960 to 2020, smoking killed about 29.5 million Americans, 9.3 million UK residents, and 2.6 million Canadians, or a total of 41.3 million adults (Table 2).

Table 3
Proportion of deaths by cause among current smokers that would be avoided at non-smoking death rates, by sex and age
Among smokers, % avoided at non-smoking death rates
Disease/sexMalesFemales
Age groups35–5455–6465–74≥7535–5455–6465–74≥75
Lung cancer93%95%96%96%92%95%96%96%
Other cancers43%46%57%54%22%52%51%48%
Coronary heart disease74%67%64%49%80%69%70%56%
Cerebrovascular disease54%32%56%41%
Aortic aneurysm, other arterial and atherosclerosis86%80%85%83%
Diabetes mellitus33%9%35%9%
All vascular at ages 35–6458%60%59%49%
Influenza, pneumonia, tuberculosis61%38%43%51%
Chronic obstructive pulmonary disease97%96%97%95%
All respiratory at ages 35–6478%93%84%89%
All causes61%66%67%58%44%62%65%60%

  1. Notes: Author calculations. The avoidable proportion for each condition and sex is calculated as (RRc-1)/RRc, where RRc refers to the smoker: non-smoker relative risks (RR) for current smoking in the U.S. Department of Health and Human Services (2014) (Appendix 1).

Table 4
Relative risks for fatal and non-fatal ischemic heart disease by age for men.
STUDYAGE (years)Relative risk
Fatal ischemic heart disease
US35–692.5
CHINA35–691.2
INDIA30–691.6
Non-fatal ischemic heart disease
UK30–39
40–49
50–59
60–69
70–79		6.3
4.7
3.1
2.5
1.9
INDIACurrent
Ever
Former		4.7
3.9
2.6
SEVERAL COUNTRIESCurrent
Former		3.0
1.9

  1. Note. Author’s calculations based on an earlier review (Jha et al., 2010).

Table 5
Relative reduction in excess risk among former smokers as compared to excess risk among current smokers, by sex and age
Reduction in excess risk
Disease/sexMalesFemales
Age groups35–5455–6465–74≥7535–5455–6465–74≥75
Lung cancer74%80%75%75%87%78%74%76%
Other cancers51%64%64%61%14%74%75%71%
Coronary heart disease71%74%67%67%69%91%76%66%
Cerebrovascular disease80%75%81%86%
Aortic aneurysm, other arterial and atherosclerosis81%82%78%79%
Diabetes mellitus40%46%40%
All vascular at ages 35–6495%66%100%90%
Influenza, pneumonia, tuberculosis61%32%63%80%
Chronic obstructive pulmonary disease75%75%61%70%
All respiratory at ages 35–6465%79%84%52%
All causes79%76%72%71%72%79%72%71%

  1. Notes: Author calculations. The reduction in excess risk for each condition and sex is calculated as (1- [RRf-1)/ [RRc-1]), where RRf and RRc refer to the smoker: non-smoker relative risks (RR) for former and current smoking, respectively in the U.S. Department of Health and Human Services, 2014 (Appendix 1).

Table 6
Estimated probability of death (%) from any cause between ages 35 and 69 in the US population, by combination of alcohol drinking and smoking, in 1990.
Sex and alcohol drinking statusSmokersNon-smokers
MEN
Drinkers4322
Non-drinkers4626
WOMEN
Drinkers2814
Non-drinkers3017

  1. Adapted from Alcohol consumption and mortality among middle-aged and elderly US adults, by Thun et al. (1997), New England Journal of Medicine, 337(24), p. 1712.

Table 7
Proportions of cancer deaths in the United States in the 1970s attributed to various different factors, as defined by Doll and Peto (1981).
Factor or class of factorsPercent of all cancer deaths
Best estimateRange of acceptable estimates
Tobacco3025–40
Alcohol32–4
Food additives<1−5–2
Reproductive and sexual behaviour71–13
Occupation42–8
Pollution2<1–5
Industrial products<1<1–2
Medicines and medical procedures10.5–3
Geophysical factors (mostly Ultraviolet light)32–4
Infection10?1-?
Diet3510–70
Unknown??

  1. Adapted from The causes of cancer: Quantitative estimates of avoidable risks of cancer in the United States today, Doll and Peto (1981), Journal of the National Cancer Institute, 66(6), p. 1192–1308.

Appendix 1—table 1
Relative risks for various diseases by smoking status, adults 35 or older in the United States.
Current smokers (years of age)Former smokers (years of age)
35-5455-6465-74≥7535-5455-6465-74≥75
MALES
Lung Cancer14.3319.0328.2922.514.44.577.796.46
Other Cancers1.741.862.352.181.361.311.491.46
Coronary heart disease3.882.992.761.981.831.521.581.32
Other heart disease2.221.661.321.15
Cerebrovascular disease2.171.481.231.12
Other vascular diseases7.254.932.21.72
Diabetes mellitus1.511.531.06
Other cardiovascular diseases2.42.511.071.51
Influenza, pneumonia, tuberculosis2.581.621.621.42
Chronic obstructive pulmonary disease29.6923.018.136.55
Influenza, pneumonia, tuberculosis, chronic obstructive pulmonary disease4.4715.172.223.98
All Causes2.552.973.022.41.331.471.571.41
FEMALES
Lung Cancer13.318.9523.6523.082.6456.86.38
Other Cancers1.282.082.061.931.241.281.261.27
Coronary heart disease4.983.253.292.252.231.211.561.42
Other heart disease1.851.751.291.32
Cerebrovascular disease2.271.71.241.1
Other vascular diseases6.815.772.262.02
Diabetes mellitus1.541.11.291.06
Other cardiovascular diseases2.441.9811.1
Influenza, pneumonia, tuberculosis1.752.061.281.21
Chronic obstructive pulmonary disease38.8920.9615.727.06
Influenza, pneumonia, tuberculosis, chronic obstructive pulmonary disease6.4391.854.84
All Causes1.792.632.872.471.221.341.531.43

  1. Source: USSGR Report, 2014. Analyses of Cancer Prevention Study II (CPS-II) and updated analyses of the pooled contemporary cohort population described in Thun et al. (2013) provided to the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. See Table 12.3 of the USSGR Report for important details on each condition.

Appendix 1—table 2
Estimates of smoking-attributable deaths in US, UK, and Canada from 1950 to 2015.
USUKCanada
YearNo of cigarettes sold nationallyDeaths from smoking at all agesCigs/death no lagCigs/death 20 year lagNo of cigarettes sold nationallyDeaths from smoking at all agesCigs/death no lagCigs/death 20 year lagNo of cigarettes sold nationallyDeaths from smoking at all agesCigs/death no lagCigs/death 20 year lag
19503,60,19,90,00,00082,35043,74,00185,14,50,00,00078,00010,91,60317,17,20,00,0004,35039,47,586
19513,79,72,50,00,00093,66040,54,29289,33,50,00,00082,80010,78,92515,67,20,00,0005,24029,90,840
19523,94,10,90,00,0001,04,97037,54,49290,40,00,00,00087,60010,31,96317,84,40,00,0006,13029,10,930
19533,86,82,60,00,0001,16,28033,26,67792,69,50,00,00092,40010,03,19321,00,00,00,0007,02029,91,453
19543,68,72,50,00,0001,27,59028,89,92195,23,00,00,00097,2009,79,73322,11,60,00,0007,91027,95,954
19553,82,06,10,00,0001,38,90027,50,61998,67,00,00,0001,02,0009,67,35324,57,60,00,0008,80027,92,727
19563,93,15,40,00,0001,50,21026,17,36299,56,00,00,0001,06,8009,32,21027,00,00,00,0009,69027,86,378
19574,09,43,60,00,0001,61,52025,34,8941,02,25,00,00,0001,11,6009,16,21930,14,40,00,00010,58028,49,149
19584,36,35,40,00,0001,72,83025,24,7581,04,02,00,00,0001,16,4008,93,64332,40,40,00,00011,47028,25,109
19594,53,68,10,00,0001,84,14024,63,7831,06,60,00,00,0001,21,2008,79,53833,82,20,00,00012,36027,36,408
19604,70,13,60,00,0001,95,45024,05,4031,10,90,00,00,0001,26,0008,80,15934,28,90,00,00013,25025,87,849
19614,88,11,90,00,0002,06,76023,60,8001,13,40,00,00,0001,30,8008,66,97236,69,90,00,00014,14025,95,403
19624,94,46,30,00,0002,18,07022,67,4511,09,90,00,00,0001,35,6008,10,47238,68,30,00,00015,03025,73,719
19635,09,58,80,00,0002,29,38022,21,5891,15,20,00,00,0001,40,4008,20,51339,87,70,00,00015,92025,04,837
19644,97,44,70,00,0002,40,69020,66,7541,14,40,00,00,0001,45,2007,87,87940,63,90,00,00016,81024,17,549
19655,11,46,40,00,0002,52,00020,29,6191,12,00,00,00,0001,50,0007,46,66743,01,30,00,00017,70024,30,113
19665,22,53,30,00,0002,64,80019,73,3121,17,60,00,00,0001,53,5007,66,12446,27,60,00,00018,95024,42,005
19675,27,80,00,00,0002,77,60019,01,2971,19,10,00,00,0001,57,0007,58,59946,86,40,00,00020,20023,20,000
19685,23,00,80,00,0002,90,40018,00,9921,21,80,00,00,0001,60,5007,58,87946,26,90,00,00021,45021,57,063
19695,10,53,10,00,0003,03,20016,83,8091,24,90,00,00,0001,64,0007,61,58546,58,20,00,00022,70020,52,070
19705,32,76,90,00,0003,16,00016,85,9781,27,90,00,00,0001,67,5007,63,58249,82,30,00,00023,95020,80,292
19715,28,85,80,00,0003,28,80016,08,4491,22,40,00,00,0001,71,0007,15,78950,86,40,00,00025,20020,18,413
19725,51,01,70,00,0003,41,60016,13,0471,30,50,00,00,0001,74,5007,47,85153,29,10,00,00026,45020,14,783
19735,90,30,00,00,0003,54,40016,65,6321,37,40,00,00,0001,78,0007,71,91054,86,30,00,00027,70019,80,614
19745,99,00,00,00,0003,67,20016,31,2641,37,00,00,00,0001,81,5007,54,82157,12,28,01,00028,95019,73,154
19756,07,20,00,00,0003,80,00015,97,89510,05,4241,32,60,00,00,0001,85,0007,16,7575,33,35157,75,57,95,00030,20019,12,4448,13,775
19766,13,50,00,00,0003,92,40015,63,45610,01,9221,30,60,00,00,0001,84,9007,06,3285,38,45360,74,48,85,00031,38019,35,7838,60,421
19776,17,00,00,00,0004,04,80015,24,20910,11,4531,25,90,00,00,0001,84,8006,81,2775,53,30161,78,65,71,00032,56018,97,6229,25,799
19786,16,00,00,00,0004,17,20014,76,51010,45,9111,25,20,00,00,0001,84,7006,77,8565,63,18461,61,00,13,00033,74018,26,0239,60,403
19796,21,50,00,00,0004,29,60014,46,69510,56,0541,24,30,00,00,0001,84,6006,73,3485,77,46563,86,56,38,00034,92018,28,9139,68,557
19806,31,50,00,00,0004,42,00014,28,73310,63,6561,21,50,00,00,0001,84,5006,58,5376,01,08464,34,33,00,00036,10017,82,3639,49,834
19816,40,00,00,00,0004,54,40014,08,45110,74,2061,10,30,00,00,0001,84,4005,98,1566,14,96766,37,56,00,00037,28017,80,4619,84,415
19826,34,00,00,00,0004,66,80013,58,18310,59,2611,02,00,00,00,0001,84,3005,53,4455,96,31066,15,74,00,00038,46017,20,16110,05,798
19836,00,00,00,00,0004,79,20012,52,08710,63,4141,01,60,00,00,0001,84,2005,51,5746,25,40762,78,51,03,50039,64015,83,88310,05,979
19846,00,40,00,00,0004,91,60012,21,31810,11,89499,00,00,00,0001,84,1005,37,7516,21,40162,13,39,14,50040,82015,22,1449,95,566
19855,94,00,00,00,0005,04,00011,78,57110,14,81097,75,00,00,0001,84,0005,31,2506,08,69659,30,44,61,10542,00014,12,01110,24,119
19865,83,80,00,00,0005,14,90011,33,81210,14,82495,00,00,00,0001,82,0005,21,9786,46,15455,76,23,21,86043,10012,93,78910,73,689
19875,75,00,00,00,0005,25,80010,93,57210,03,80496,00,00,00,0001,80,0005,33,3336,61,66752,87,70,31,89044,20011,96,31310,60,271
19885,62,50,00,00,0005,36,70010,48,0729,74,48997,00,00,00,0001,78,0005,44,9446,84,27051,33,89,17,80045,30011,33,30910,21,391
19895,40,00,00,00,0005,47,6009,86,1219,32,30698,00,00,00,0001,76,0005,56,8187,09,65947,76,46,41,60046,40010,29,41010,03,922
19905,25,00,00,00,0005,58,5009,40,0189,53,9281,02,50,00,00,0001,74,0005,89,0807,35,05746,44,08,01,08047,5009,77,70110,48,905
19915,10,00,00,00,0005,69,4008,95,6809,28,79997,90,00,00,0001,72,0005,69,1867,11,62839,13,45,12,00048,6008,05,23710,46,584
19925,00,00,00,00,0005,80,3008,61,6239,49,53892,80,00,00,0001,70,0005,45,8827,67,64735,20,01,50,36549,7007,08,25310,72,254
19934,85,00,00,00,0005,91,2008,20,3659,98,47888,90,00,00,0001,68,0005,29,1678,17,85730,34,98,69,58050,8005,97,43810,79,980
19944,86,00,00,00,0006,02,1008,07,1759,94,85188,30,00,00,0001,66,0005,31,9288,25,30145,93,47,44,88551,9008,85,06311,00,632
19954,87,00,00,00,0006,13,0007,94,4549,90,53888,00,00,00,0001,64,0005,36,5858,08,53745,70,99,99,54053,0008,62,45310,89,732
19964,87,00,00,00,0006,12,4007,95,23210,01,79687,20,00,00,0001,60,7005,42,6268,12,69447,33,83,59,35053,2008,89,81911,41,821
19974,80,00,00,00,0006,11,8007,84,57010,08,50084,00,00,00,0001,57,4005,33,6727,99,87345,64,03,20,71053,4008,54,68811,57,052
19984,65,00,00,00,0006,11,2007,60,79810,07,85384,00,00,00,0001,54,1005,45,1018,12,45945,55,66,36,42053,6008,49,93711,49,441
19994,35,00,00,00,0006,10,6007,12,41410,17,85184,00,00,00,0001,50,8005,57,0298,24,27144,87,29,65,60053,8008,34,07011,87,094
20004,30,00,00,00,0006,10,0007,04,91810,35,24681,50,00,00,0001,47,5005,52,5428,23,72943,36,81,94,70054,0008,03,11511,91,543
20014,25,00,00,00,0006,09,4006,97,40710,50,21379,00,00,00,0001,44,2005,47,8507,64,91042,08,73,29,21054,2007,76,51912,24,642
20024,15,00,00,00,0006,08,8006,81,66910,41,39376,00,00,00,0001,40,9005,39,3907,23,91837,62,74,91,46054,4006,91,68212,16,129
20034,00,00,00,00,0006,08,2006,57,6789,86,51874,00,00,00,0001,37,6005,37,7917,38,37235,81,79,32,59954,6006,56,00611,49,910
20043,88,00,00,00,0006,07,6006,38,5789,88,15072,00,00,00,0001,34,3005,36,1137,37,15634,57,89,18,60654,8006,31,00211,33,831
20053,76,00,00,00,0006,07,0006,19,4409,78,58370,00,00,00,0001,31,0005,34,3517,46,18332,97,06,21,64355,0005,99,46610,78,263
20063,80,72,63,50,5216,01,8006,32,6469,70,09067,50,00,00,0001,41,7004,76,3596,70,43030,21,71,91,19455,3005,46,42310,08,360
20073,61,66,52,82,8825,96,6006,06,2119,63,79564,50,00,00,0001,39,4004,62,6976,88,66628,70,47,13,38255,4005,18,1369,54,459
20083,46,41,92,70,7545,91,4005,85,7619,51,13361,50,00,00,0001,37,1004,48,5787,07,51327,55,93,82,15355,5004,96,5659,25,026
20093,18,02,91,35,7705,86,2005,42,5279,21,18758,50,00,00,0001,34,8004,33,9767,27,00328,62,75,07,22555,6005,14,8838,59,076
20103,00,48,93,90,4435,81,0005,17,1939,03,61452,50,00,00,0001,32,5003,96,2267,73,58531,65,36,15,88455,7005,68,2888,33,767
20112,92,76,91,35,5605,75,8005,08,4568,85,72450,30,00,00,0001,30,2003,86,3297,51,92031,17,80,12,11655,8005,58,7467,01,335
20122,87,48,65,11,3825,70,6005,03,8328,76,27146,00,00,00,0001,27,9003,59,6567,25,56731,34,74,37,10555,9005,60,7776,29,699
20132,73,78,73,72,1535,65,4004,84,2378,57,80041,60,00,00,0001,25,6003,31,2107,07,80331,46,78,96,96756,0005,61,9275,41,962
20142,62,68,12,73,1035,60,2004,68,9068,67,54739,70,00,00,0001,23,3003,21,9797,16,13929,47,82,34,31556,0005,26,3978,20,263
20152,62,68,12,73,1035,55,0004,73,3008,77,47739,70,00,00,0001,21,0003,28,0997,27,27329,47,82,34,31556,0005,26,3978,16,250
USUKCANADA
TOTALS since 19503,12,38,43,79,95,6712,79,01,30063,06,95,50,00,00098,63,00027,73,85,14,67,65923,67,750
Average cigarettes per death with no lag12,95,4036,23,23814,72,021
Average cigarettes per death with 20 year lag9,83,9107,01,9729,95,413

  1. Note. Author’s calculations. Tobacco sales to deaths are shown in the column entitled ‘Deaths from smoking at all ages’. For particular years, some data were missing. In this case, I interpolated these data or did forward projections based on earlier years. These more uncertain numbers are shown in italics.

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  1. Prabhat Jha
(2020)
The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries
eLife 9:e49979.
https://doi.org/10.7554/eLife.49979