Tuesday, June 5, 2012

Health Costs of Smoking and Prop 29

Smoking causes 5-6 million avoidable deaths annually worldwide.  One in 5 men and 1 in 20 women who die after age 30 die of smoking-related causes.  

These distressing numbers should be enough to galvanize the California voters who will decide to accept or reject the California Cancer Research Act, commonly called Proposition 29 (or Prop 29).  If Prop 29 passes, the money raised through new taxes on cigarettes will support research into smoking-related diseases.

However, the "Big Tobacco" and their proxies have fought back, and have overspent the supporters of Prop 29 by 8 times.  While we wait for the saner voices to prevail, here let's take one more look at the hard numbers and an urgent need to reduce smoking behavior.

Deaths from smoking

While lung cancer hogs much of the headlines, smoking-related deaths include cardiovascular (heart attack and stroke), respiratory diseases (eg, chronic obstructive pulmonary disease; COPD), other cancers types (esophageal, head and neck, stomach, and pancreatic cancers), and tuberculosis. 

Smoking cause 4 times more deaths due to non-cancer related causes than lung cancer.  In India, 40% of all deaths due to tuberculosis are because of smoking's effect on virulence of TB bacterium and/or effect on immunity of an individual.  In the United States, 50% of heart attacks are attributed to smoking.  Similarly 50% of COPD have a smoking gun involved.

There are 7000 chemicals in tobacco and tobacco smoke, and FDA has listed 93 of these compounds as harmful and potentially harmful constituents (HPHCs). 

Chemicals in smoking makes infections worse and increase the risk of death.  Tuberculosis is a classic example.  So is the rising rates of liver cancer due to hepatitis viruses, and cervical cancers.

Big numbers
  • Smoking is the direct cause 5-6 million deaths annually worldwide.  And, if no action is taken now, this number will be around 10 million by 2030.
  • One in 5 men and 1 in 20 women (>30 year old) die from smoking related causes.
  • Smoking is responsible for 31% of all cancer deaths in men and 6% in women.
Some good news:  quitting smoking before middle age (which scientist define as 30s and not 40s or 50s) will decrease the deaths due to smoking related causes by 90%.

Can high taxes work? Yes!

In France, high cigarette taxes have helped reduce smoking behavior and resulting death rates.  The estimates are that if price of a cigarette is raised by 70% (ie, increase the current tax rate by 2-3 times), we can save roughly 115 million deaths over the next 2-3 decades. 

"115 million" 
That's all the people living today in the South from Texas to Virginias, or twice the number of people living in Maine to Pennsylvania and New Jersey.  That's a lot of lives which can be saved.  And, this number accounts for just one-fourth of all tobacco-related deaths.

What happens if nothing is done?

Deaths from smoking-induced lung cancer lag by 30-50 years.  At the current rate, just taking into account current smokers, there will be 450 million deaths by 2050 from smoking-related causes.  By the end of the 21st century there would be a billion lives lost.  By contrast, consider the 2oth century which is just 12 years in the rear-view mirror: in the 20th century, there were 100 million smoking-related deaths, 70% of which were in US and Europe among men, mostly, who smoked in the 1930s to 1950s when it was cool to do so.

On average smokers die 10 years earlier than non-smokers and lose 2 decade of life due to various complications.  For example, in UK the peak smoking times were 1920s-1940s and mostly men smoked at that time.  By 1975, smoking-related deaths among men were at the peak, and 50% of all cancer deaths among UK males during this period were smoking-related.

Unfortunately, at present smoking rates are increasing in low income places like China, India and Indonesia.  Therefore, these countries are yet to see the worse outcome.  The tobacco companies heavily promote smoking lifestyle in countries outside US and EU where regulation is lax and public health institutions are chronically underfunded.

Just ten countries account for 60% of all the smokers in the world: China, India (mostly in the form of "bidi" smoking), Bangladesh, Indonesia, Russia, Turkey, Germany, US and Brazil.  Yes, US is still in the list.  Thus, initiatives, such as, Prop 29 have added significance.

In the last century, it was the men who smoked and bore the brunt of lung cancer from 1970s-1990s.  But, today in the Western world almost 21% of women (versus 37% men) light a cigarette.  Therefore, these women will make up an increasing share of lung cancer patients 30 years from now.  In the developing world, the numbers look like a repeat of 20th century America and Europe.  In low income countries, 49% of men and 8% of women over age 25 are smokers.

Cost to public health

Smoking directly taxes shrinking national health budgets.  In UK, direct cost in 2005-2006 was estimated to be around 5.2 Billion Pounds.  This was 5.5% of total NHS budget.



  1. Jha P (2009). Avoidable global cancer deaths and total deaths from smoking. Nature reviews. Cancer, 9 (9), 655-64 PMID: 19693096 
  2. Kenfield SA, Wei EK, Rosner BA, Glynn RJ, Stampfer MJ, & Colditz GA (2010). Burden of smoking on cause-specific mortality: application to the Nurses' Health Study. Tobacco control, 19 (3), 248-54 PMID: 20501499 
  3. Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, Sinha DN, Dikshit RP, Parida DK, Kamadod R, Boreham J, Peto R, & RGI-CGHR Investigators (2008). A nationally representative case-control study of smoking and death in India. The New England journal of medicine, 358 (11), 1137-47 PMID: 18272886 
  4. Allender S, Balakrishnan R, Scarborough P, Webster P, & Rayner M (2009). The burden of smoking-related ill health in the UK. Tobacco control, 18 (4), 262-7 PMID: 19509003 
  5. Jemal A, Ward E, & Thun M (2010). Declining death rates reflect progress against cancer. PloS one, 5 (3) PMID: 20231893

Also read:

Lung Cancer related posts on this blog:


  1. Early polling results look good :-)

    Tobacco tax takes slim lead; term limits changes passing by landslide

    By Steven Harmon and Tracey Kaplan Staff Writers
    Posted: 06/05/2012 08:35:58 PM PDT
    Updated: 06/05/2012 09:04:50 PM PDT

    SACRAMENTO -- Voters were passing the tobacco tax by a slight margin in the first results posted tonight by the California Secretary of State's office.

    With 10.3 percent of the votes in, 51.3 percent had voted for Proposition 29, and 48.7 percent voting against the ballot measure, which would boost tobacco taxes by $1 a pack, on top of the 87-cent tax already in place.

    The yes side has picked up 873,330 votes, compared with 828,767 votes for the no side, with 2,257 of 21,993 precincts reporting.
    Northern California counties, including Santa Clara, Contra Costa, and San Mateo, were carrying the yes vote, while Los Angeles County was siding against the ballot measure in the early voting.

  2. Few more factoids:

    The cost of lung cancer to US health care was 12 Billion in 2010
    Lung Cancer from thoracic.org

    1. ...The economic costs associated with those lost years of life are substantial. One study estimated that those costs in 2000 in the
      United States were $289.4 billion (4). Direct medical costs related to treatment for lung cancer are also staggering. In 2004, the National Cancer Institute estimated lung cancer treatment expenditures at $9.6 billion (3) Lung Cancer Educational materials from American Thoracic Society

  3. Cigarette Tax Proposal Gets Smoked SF Weekly, June 26, 2012.

    [...]Technically, as of the weekend, there were still some 100,000 uncounted ballots. But an Associated Press analysis concluded that the contest was already decided, and on Friday the "Yes on 29" campaign conceded defeat.

    For tobacco companies, it was $47 million well spent. To put that amount in perspective, the San Jose Mercury News notes that "Jerry Brown spent about $36 million in his successful 2010 bid to become governor of California. Wisconsin Gov. Scott Walker and his allies spent $47 million to beat back his recall challenge on June 5."

    [...]The "Yes on 29" campaign raised $11 million, including contributions from Lance Armstrong and NYC mayor Michael Bloomberg. "No on 29" raised $47 million , including more than $20 million from Philip Morris and more than $10 million from R.J. Reynolds.

    Letters: The defeat of Prop. 29 - L.A Times, June 26, 2012,

    [...]The cigarette industry bombarded voters with propaganda that the tax would not be used to create jobs and might be used out of the state. Gullible voters failed to see that this was a distraction from the real issue: The tax money was to be used for cancer research. Now how could Californians be so gullible as to fail to see the deception of the cigarette industry? How could they not distinguish between the benefits of cancer research and the cozenage of not creating jobs.