Smoke Alarm: Ill Effects of Tobacco are Worse than We Thought

ACCEL | Driving change with MPOWER

Worldwide, tobacco use causes more than 5 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030. In the United States, cigarette smoking is responsible for more than 480,000 deaths per year, including an estimated 41,000 deaths resulting from secondhand smoke exposure. Smokers die, on average, more than a decade before nonsmokers.

Some real advancement has been made in the U.S. in recent years. In analyses of the fall in coronary heart disease (CHD) mortality from 1980 to 2000, half (51%) of the improvement is due to improvements in risk factors, such as a 12% drop in smoking.1

That's the good news; the bad news is that smoking remains a big problem among people with lung obstruction of some kind, such as asthma or chronic obstructive pulmonary disease (COPD). In January 2015, the National Center for Health Statistics reported that from 2007 to 2012, approximately 46% of adults aged 40–79 years with any lung obstruction were current cigarette smokers.2 That's more than double the percentage of current smokers without lung obstruction (19.8%). Among adults with mild lung obstruction, 41.2% were current cigarette smokers, and among those with moderate or worse lung obstruction, more than one-half (55.0%) were current smokers. Overall, in 2012, 18.1% of all U.S. adults (42.1 million people) were current smokers, including 20.1% of males and 14.5% of females.


More bad news: smoking's toll on health is even worse than we've previously thought. In February 2015, an analysis of nearly 1 million people found that a substantial portion of the excess mortality among current smokers between 2000 and 2011 was due to associations with diseases that have not been formally established as caused by smoking.3

These included associations between current smoking and deaths from renal failure (relative risk [RR], 2.0; 95% confidence interval [CI], 1.7-2.3), intestinal ischemia (RR, 6.0; 95% CI, 4.5-8.1), hypertensive heart disease (RR, 2.4; 95% CI, 1.9-3.0), infections (RR, 2.3; 95% CI, 2.0-2.7), various respiratory diseases (RR, 2.0; 95% CI, 1.6-2.4), breast cancer (RR, 1.3; 95% CI, 1.2-1.5), and prostate cancer (RR, 1.4; 95% CI, 1.2-1.7). Importantly, among former smokers, the relative risk for each of these outcomes declined as the number of years since quitting increased.

What can be done? The World Health Organization introduced the MPOWER measures intended to promote tobacco cessation. MPOWER stands for:

  • Monitoring tobacco use and prevention policies
  • Protecting people from tobacco smoke
  • Offering help to smokers who want to quit
  • Warning about the dangers of smoking
  • Enforcing bans on advertising, promotion and sponsorship
  • Raising tobacco taxes

Each approach has been demonstrated to help reduce smoking and some are now broadly used. For example, more than 1 billion people live in countries, such as the United States, where large graphic warnings are used to discourage smoking.

According to Martin O'Flaherty, MD, PhD, benefits relating to cardiovascular disease are seen in relatively short order upon smoking cessation, whereas benefits relating to cancer and COPD occur later. Using data from Europe, a 5% to 15% weighted reduction in smoking by 2030 would conservatively produce CHD mortality reductions of roughly 4%. More likely, he said at ESC.14, there would be a reduction in CHD mortality of 6% to 8% and possibly, according to modeling, the reduction could be as high as 10%.

He noted that modeling studies can be very helpful, not only to map the potential gains associated with changes in specific risk factors, but also to warn of the rapid deterioration of hard-won gains should efforts to reduce risk falter. More importantly, he added, the lessons of smoking cessation strategies can now be applied to other problems that remain largely out-of-hand across the world, such as diet, which continues to be a key driver in the increases in noncommunicable diseases.


  • While efforts to reduce tobacco smoking have paid dividends in reducing coronary heart disease (CHD) mortality, about 18% of adults in the United States continue to smoke.
  • New data suggest smoking's toll on health is even worse than previously thought, with a substantial portion of the excess mortality among current smokers associated with diseases that have not been previously thought to be caused by smoking.
  • We know what works in terms of population-wide efforts to reduce smoking; now, some of these same lessons should be applied to other risk factors that continue to drive CHD mortality, namely diet.


  1. Ford ES, Ajani UA, Croft JB, et al. N Engl J Med. 2007;356:2388-98.
  2. Paulose-Ram R, Tilert T, Dillon CF, Brody DJ. NCHS data brief, no 181. Hyattsville, MD: National Center for Health Statistics. 2015.
  3. Carter BD, Abnet CC, Feskanich D, et al. N Engl J Med. 2015;372:631-40.

Keywords: ACC Publications, CardioSource WorldNews

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