Over 14 Million Major Medical Conditions in U.S. Adults Linked to Cigarette Smoking

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At least 14 million major medical conditions among U.S. adults aged 35 years and older were attributed to cigarette smoking by a study estimating the disease burden of cigarette smoking, which, according to the study’s authors, “remains immense.” Among current and former smokers, prevalence ratios were “particularly high for lung cancer,” reported Brian L. Roston, MD, MPH, and colleagues from the Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland, and the Centers for Disease Control and Prevention (CDC), Atlanta.

The study, published online in JAMA Internal Medicine, used U.S. Census Bureau population estimates from 2009, National Health Interview Survey data on smoking and smoking-related disease prevalence from 2006 through 2012, and National Health and Nutrition Examination Survey spirometry data obtained from medical examinations of surveyed adults from 2007 through 2010. The researchers centered “the estimates around 2009 to allow for sufficient data to make accurate estimates,” they explained.

“Estimated prevalence ratios were higher for current and former smokers for most conditions,” the researchers reported. Prevalence ratios for lung cancer ranged from 4.45 to 9.35. Prevalence rates for other types of cancer among current or former smokers ranged from 1.54 to 3.01 for bladder cancer, 1.94 to 3.65 for cervical cancer, 1.36 to 1.60 for colorectal cancer, 1.15 to 2.00 for kidney cancer, 2.02 to 3.40 for oral cancers, and 0.44 to 1.51 for stomach cancer.

Other medical conditions with high prevalence ratios for current or former smokers were chronic obstructive pulmonary disease (2.02–4.00), diabetes mellitus (1.17–1.30), heart attack (1.54–3.03), and stroke (1.17–2.43).

“Heart attack, stroke, chronic bronchitis, emphysema, and cancers of the bladder, cervix, esophagus, kidney, larynx, mouth and/or pharynx, and pancreas have been previously identified as smoking-related conditions and were included in the previous CDC analysis of smoking-attributable morbidity. Stomach cancer was identified as a smoking-attributable condition in the 2004 Report of the Surgeon General, and colorectal and liver cancer and diabetes were identified as smoking attributable conditions in the 2014 Report of the Surgeon General,” the authors noted.

“Cigarette smoking remains a leading cause of preventable disease in the United States, underscoring the need for continuing and vigorous smoking-prevention efforts,” the investigators concluded.

Additional Perspectives

Although the prevalence of smoking is declining, “that decline is excruciatingly slow, and there are still more than 40 million smokers in the United States,” Steven A. Schroeder, MD, of the University of California, San Francisco, pointed out in an accompanying editorial. He continued:

Funds that should be dedicated to prevention and cessation are casualties of state budget crises, and there is no citizen advocacy movement such as those that exist with conditions like breast cancer and human immunodeficiency virus and AIDS. Physician involvement has been inconsistent, even among the subspecialties that most encounter smokers with disease: cardiologists, oncologists, and pulmonologists. The data from Rostron et al should serve to keep tobacco control and its 2-fold aims of preventing initiation and helping smokers quit as the most important clinical and public health priorities for the foreseeable future.

Lung Cancer Screening

JAMA Internal Medicine online for October 13 also includes an editor’s note and two special communications about whether lung cancer screening with low-dose computed tomography should be covered under Medicare. “At issue is not only whether low-dose CT will be covered but, if it is covered, the specifics, such as the number and frequency of scans, the beneficiaries who would be eligible, and the procedures to assure that scans are of high quality and that false-positive results are minimized,” Robert Steinbrook, MD, wrote in the editor’s note.

Steven H. Woolf, MD, MPH, of Virginia Commonwealth University and colleagues argued that “implementation of national screening may be premature. The magnitude of benefit from routine screening is uncertain,” and “potential harms—which could affect a large population—include false-positive results, anxiety, radiation exposure, diagnostic workups, and the resulting complications.”

It is unclear whether routine screening would result in net benefit or net harm. Woolf et al also expressed concern that low-dose CT screening could “draw attention or resources away from the priority of tobacco control.

Douglas E. Wood, MD, of the University of Washington, Seattle, argued that “a “decision to add lung cancer screening with low-dose CT as a covered benefit for Medicare beneficiaries should be inevitable given the high level of evidence that screening can lead to early diagnosis and cure for thousands of patients each year in the United States. Professional societies,” he stated, “have great expertise and experience in screening and can help [the Centers for Medicare & Medicaid Services] responsibly implement a program that is patient-centered and minimizes unintended harms and costs.” ■

Rostron BL, et al: JAMA Intern Med. October 13, 2014 (early release online).

Schroeder SA: JAMA Intern Med. October 13, 2014 (early release online).

Wood DE: JAMA Intern Med. October 13, 2014 (early release online).

Woolf SH, et al: JAMA Intern Med. October 13, 2014 (early release online).