1. Racial Disparity in Smoking-Attributable Mortality, Years of Potential Life Lost: Case of Missouri 2000-
Noaman Kayani, PhD
Chronic Disease and Nutrition Epidemiology Team,
Office of Epidemiology,
Missouri Department of Health and Senior Services

2. Methods
Smoking-Attributable Mortality, Morbidity and Economic Cost (SAMMEC) software by CDC was used to calculate:
Smoking-Attributable Mortality (SAM)
Years of Potential Life Lost (YPLL)
Productivity Losses (PLoss)

3. Methods Continued RR1 : Relative risk for current vs. never smokers
Smoking-Attributable Mortality
= SAF * Number of Deaths
Smoking-Attributable Fraction (SAF)
=[(p0+p1(RR1)+p2(RR2)) -1] / [p0 +p1(RR1) + p2(RR2)],
where
P0 : Percentage of adult never smokers
p1 : Percentage of adult current smokers
p2 : Percentage of adult former smokers
RR1 : Relative risk for current vs. never smokers
RR2 : Relative risk for former vs. never smokers
Sex- and age-specific smoking-attributable deaths were calculated by multiplying the total number of deaths in each sex and age category for 19 adult and 4 infant diseases by smoking-attributable fractions (SAFs).
(i.e., persons who have smoked  100 cigarettes and now smoke every day or some days) in the study population, p2 is the prevalence of former smokers (i.e., persons who have smoked  100 cigarettes and do not currently smoke), RR1 is the relative risk for current smokers vs. never smokers, and RR2 is the relative risk for former smokers vs. never smokers. Adults, sex-specific RR1 and RR2 for each cause of death were estimated from the American Cancer Society’s Cancer Prevention Study-II (CPS-II)

4. Methods Continued
RR1 is the relative risk for current smokers vs. never smokers, and RR2 is the relative risk for former smokers vs. never smokers. Adults, sex-specific RR1 and RR2 for each cause of death were estimated from the American Cancer Society’s Cancer Prevention Study-II (CPS-II) with 6 years follow up

5. Data Elements to Input Smoking Prevalence
Mortality by Sex, Age-group, ICD (International Classification of Disease) Codes
Life Expectancy by Sex and Age Group
Population Estimates

6. Smoking Prevalence 2004 Smoking Prevalence Male Female Current Smoker
Male
Female
Current Smoker
Former Smoker
35-64 years old
29.1
27.4
26.2
20.9
65 years or older
12.7
55.8
10.2
24.2

7. Smoking Related Cancer Diseases with ICD codes
Malignant Neoplasm (Cancer)
Lip, Oral Cavity, Pharynx (C00-C14)
Esophagus (C15)
Stomach (C16)
Pancreas (C25)
Larynx (C32)
Trachea, Lung, Bronchus (C33-C34) 3,803
Cervix Uteri (C53)
Kidney and Renal Pelvis (C64-C65)
Urinary Bladder (C67)
Acute Myeloid Leukemia (C92.0)

8. Smoking Related Cardiovascular Diseases
Ischemic Heart Disease
(I20-I25)
Other Heart Disease
(I00-I09, I26-I51)
Cerebrovascular Disease
(I00-I69)
Atherosclerosis
(I70-I71)
Aortic Aneurysm
(I71)
Other Arterial Disease
(I72-I78)

9. Smoking Related Respiratory Diseases
Pneumonia, Influenza
(J10-J18)
Bronchitis, Emphysema
(J40-J42, J43)
Chronic Airway Obstruction
(J44)

10. Mortality Data by Sex, Age and ICD Codes
Frequency
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Ca_oral 4 2 16 12 15 10 11 5
Ca_esoph 6 22 36 30 40 37 18
Ca_stomach 9 13 20 21
Ca_panc 1 3 17 19 29 46 41 53 34
Ca_larynx 7
Ca_lung_etc 81
113
171
276
370
460
422
274
164
Ca_cervix
Ca_kidney 28 26
Ca_uriblad 14 32 42 38
Ca_: AcMyLeuk 8
Otherheart 31 57
102
116
135
192
279
285
486
Ischemic 47 89
283
328
414
491
600
804
871
1210
Stroke 43 63
112
139
205
266
371
Athero 60
Aortic_an 33
Oth_arter
Pneu_influ 52 73
119
245
Bronch_emph
COPD 80
124
167
253
215
217

11. Life Expectancy Table by Sex and Age Groups
Male
Female
35–39
38.5
42.9
40–44
34.0
38.2
45–49
29.6
33.5
50–54
25.3
29.0
55–59
21.3
24.7
60–64
17.5
20.7
65–69
14.1
17.0
70–74
11.0
13.4
75–79
8.4
10.3
80–84
6.1
7.5
85+
5.1
6.2

12. Population Estimates 2004 Age Group Male Female 35–39 193,924 195,604
2004
Age Group
Male
Female
35–39
193,924
195,604
40–44
225,923
229,791
45–49
216,788
223,820
50–54
187,574
198,202
55–59
158,708
170,180
60–64
125,208
138,280
65–69
97,473
110,225
70–74
81,614
102,462
75–79
65,862
91,006
80–84
44,619
72,052
85+
28,894
71,485

13. Missouri SAM Due to Cancer, 2000-2004
Cause of Death (ICD-10 Code) Deaths SAM YPLL PLoss*
Malignant Neoplasm
Lip, Oral Cavity, Pharynx (C00-C14) , $37,312
Esophagus (C15) , $58,044
Stomach (C16) $12,467
Pancreas (C25) , $45,692
Larynx (C32) $21,179
Trachea, Lung, Bronchus (C33-C34) 3,803 3, ,197 $903,844
Cervix Uteri (C53) $6,915
Kidney and Renal Pelvis (C64-C65) , $25,739
Urinary Bladder (C67) , $19,698
Acute Myeloid Leukemia (C92.0) $7,905
Total ,884 3, ,433 $1,138,797
10 diseases
* Productivity Losses due to smoking-attributable mortality

14. Missouri SAM Due to Cardiovascular Diseases, 2000-2004
Cause of Death (ICD-10 Code) Deaths SAM YPLL PLoss*
Cardiovascular Diseases
Ischemic Heart Disease ,397 2, ,094 $604,179
(I20-I25)
Other Heart Disease 4, ,010 $121,499
(I00-I09, I26-I51)
Cerebrovascular Disease 3, ,086 $127,219
(I00-I69)
Atherosclerosis $3,429
(I70-I71)
Aortic Aneurysm , $35,417
(I71)
Other Arterial Disease $7,567
(I72-I78)
Total ,314 3,256 45,225 $899,309
6 diseases
* Productivity Losses due to smoking-attributable mortality

15. Missouri SAM Due to Respiratory Diseases, 2000-2004
Cause of Death (ICD-10 Code) Deaths SAM YPLL PLoss*
Respiratory Diseases
Pneumonia, Influenza 1, , $32,943
(J10-J18)
Bronchitis, Emphysema , $55,884
(J40-J42, J43)
Chronic Airway Obstruction 2,395 1,884 21,046 $292,379
(J44)
Total 4,264 2,453 27,254 $381,206
3 diseases
* Productivity losses due to smoking-attributable mortality

16. Burden of Smoking It was estimated that every year during 2000-04:
9,578 Missouri adults age 35 and older died prematurely due to smoking-related diseases
29 Infants died prematurely due to smoking-related diseases
More than one death per hour
About one in every five adult deaths (18.3%)

17. 9607 Deaths are an Under-Estimation of SAM in Missouri
It does not include deaths due to:
Second-hand smoke ( * deaths)
It is based on current smoking prevalence that is lower than the past. The deaths are the result of smoking in the past
Use of other tobacco products
Cigar, Bidi, Kretik, Pipe and Smokeless tobacco
* Campaign for Tobacco Free Kids, 2007

18. Missouri SAM Breakup 2000-2004 (Annual Average)
Total Adult 9,578 deaths
18.3% of all adult deaths
Men 5,800 deaths
22.1% of all deaths in men
Women 3,778 deaths
13.3% of all deaths in women

19. Missouri Adult SAM by Disease Category, 2000-2004
(Annual Average)
% of Total SAM
Cancer
(Malignant Neoplasm)
3,870
40.4%
Cardiovascular Diseases
3,256
34.0%
Respiratory Diseases
2,453
25.6%
19 adult and 4 MCH disease categories.

20. Three Leading Diseases for Missouri SAM, 2000-2004
(Annual Average)
% of Total SAM
Lung, Trachea and Bronchus Cancer
3,117
32.5%
Ischemic Heart Diseases
2,000
20.9%
Chronic Airway Obstruction
1,884
19.7%
Total of 3 Diseases
7,001
73.0%

21. Indirect Cost of Smoking, 2000-2004
Annually, Smoking Caused
132,103 Years of Potential Life Lost (YPLL) in Missouri
78,686 YPLL in men
53,417 YPLL in women

22. Economic Cost of Smoking (Average Annual 2000-2004)
Total monetary cost = $4.6 billion
Smoking-attributable medical expenditures in Missouri = $2.2 billion (in 2004 dollars)
Productivity losses due to SAM = $2.4 billion
Smoking-attributable Medicaid cost = $512 million ($91 paid for by each Missouri resident)

23. Racial Disparity in Smoking-Related Mortality

24. Racial Disparity in Smoking-Related Mortality
Cause of Death
(ICD-10 Code)
Smoking-Attributable Mortality Rates
(per 100,000 population)
Relative Disparity (%)
White
Black
Male
Female
Total
Total Adult
451
205
306
616
217
368
37* 6*
20*
Malignant Neoplasms
189 76
124
273 90
161
44*
18*
30*
Trachea, Lung, Bronchus
(C33-C34)
148 65
100
204 74
38*
14*
24*
Cardiovascular Diseases
152
101
248 89
150
63*
49*
Ischemic Heart Disease
(I20-I25) 95 38 63
143 54 88
51*
42*
40*
Respiratory Diseases
110 64 81 37 57
-14*
-42*
-30*
Chronic Airway Obstruction (J44) 84 51 67 28 42
-20*
-45*
-33*
* The difference in the SAM/YPLL rates of Blacks and Whites is statistically significant at (p <= 0.05) level for the three categories and major diseases

25. Disparity Index Relative Disparity
=[(SAMRTBlacks–SAMRTWhites)/ SAMRTWhites] *100

26. Assumption and Possible Reasons for Disparity (Needs Further Research)
It was assumed that both races have the same relative risks
Some studies found the difference in socio- economic status to be the major cause of Black and White disparity
They may smoke different types of cigarettes
Difference in per capita cigarette consumptions

27. Results
The SAM rate for Blacks in Missouri was 20% higher than for Whites
Racial disparity was larger in men (37%) than in women (6%)
SAM rates for Blacks were higher than for Whites for malignant neoplasms (30%) and cardiovascular diseases (49%) but lower for respiratory diseases (-30%)

28. Conclusions – Racial Disparity in SAM
Significant racial disparities in smoking- attributable mortality exist in Missouri with 62 per 100,000 more Black adults dying each year from cigarette smoking than White adults
Blacks die at a higher rate due to smoking- related cardiovascular and cancer diseases
Whites die at a higher rate due to smoking- related respiratory diseases

29. Shukriya, Merci, Gracias Noaman Kayani Noaman.kayani@health.mo.gov
Thank You
Shukriya, Merci, Gracias
Noaman Kayani