Cigarettes Linked to More Deaths Than Previously Thought

FP Expert Says Focus Needs to Be on Helping Patients Quit

February 25, 2015 02:13 pm Chris Crawford

The U.S. surgeon general estimates that cigarette smoking kills about 480,000 people in the United States each year. But a new study led by American Cancer Society researchers found smoking may kill tens of thousands more from diseases that are not currently included in that official estimate.

[Close-up of man smoking a cigarette]

Published online Feb. 12 in the New England Journal of Medicine, the study( found that about 17 percent of excess deaths in smokers were caused by diseases that at least doubled the risk of death from renal failure, intestinal ischemia, hypertensive heart disease, infections and various respiratory diseases other than chronic obstructive pulmonary disease.

"The number of additional deaths potentially linked to cigarette smoking is substantial," said Eric Jacobs, Ph.D., co-author of the study, in a news release.( "We believe there is strong evidence that many of these deaths may have been caused by smoking. If the same is true nationwide, then cigarette smoking may be killing about 60,000 more Americans each year than previously estimated, a number greater than the total number who die each year of influenza or liver disease.”

Researchers also linked smoking to smaller increases in risk of death from other cancers not formally recognized as being caused by smoking, including breast cancer, prostate cancer and cancers of unknown site.

Story highlights
  • A study published online Feb. 12 in the New England Journal of Medicine found that about 17 percent of excess deaths in smokers were caused by diseases not previously linked to smoking cigarettes.
  • AAFP member Adam Goldstein, M.D., M.P.H., told AAFP News that the focus should now be less on new conditions linked to smoking and more on helping people quit.
  • Another study, published online Feb. 15 in the Journal of the National Cancer Institute, associated cigar smoking in males with a fivefold increased risk of death from lung cancer.

The team analyzed data from more than 950,000 men and women in the United States who were 55 or older and enrolled in one of five cohort studies (American Cancer Society's Cancer Prevention Study-II, Health Professionals Follow-up Study, NIH-AARP Diet and Health Study, Nurses' Health Study and Women's Health Initiative).

During the approximately 10 years the cohorts were followed, more than 180,000 deaths occurred, according to the news release. Researchers also found that current smokers, as expected, had death rates nearly three times higher than nonsmokers.

Family Physician Expert's Perspective

AAFP member Adam Goldstein, M.D., M.P.H., is a professor in the family medicine department at the University of North Carolina in Chapel Hill and an expert on smoking cessation.

He told AAFP News it's common knowledge that smoking cigarettes and using other forms of tobacco are the primary preventable causes of premature death and disease, with almost a third of cancers causally linked to tobacco use.

But Goldstein said the focus should now be less about new conditions linked to smoking and more about helping people quit.

"For instance, 14 percent of Alzheimer's cases worldwide may be linked to smoking," he said. "That knowledge alone doesn't get people to quit. Family physicians must instead have honest conversations with their patients who smoke, and offer them advice, counseling, medications and referrals to tobacco treatment specialists when appropriate."

Goldstein said it's not enough for physicians to check off a box showing that they counseled a patient.

In an article( published Feb. 5 in the online-only journal Preventing Chronic Disease, Goldstein was among a group of doctors who conducted focus groups with smokers in their practices.

"We found that our patients who smoke expect us to ask in a nonjudgmental way about their smoking and advise them to quit at every office visit," he said. "They also want us to show them respect; to recognize that for many, this is a serious addiction; that they need help and encouragement with quitting; and that the trusted relationship between us and patients is a sacred space for having such conversations."

On April 16 at 2 p.m. EDT, Goldstein will present a webinar titled "Tobacco Control and the Patient-centered Medical Home"( that is co-sponsored by the AAFP and the American Academy of Pediatrics Julius B. Richmond Center of Excellence. In it, he will discuss how tobacco prevention and control in the practice setting complements and fits easily into the patient-centered medical home.

"Today, the practicing physician can take advantage of tools and opportunities to help more tobacco users quit their addiction than ever before," he said. "For instance, we get reimbursed for counseling tobacco users to quit -- the more time we spend, the better the outcomes for patients -- and our reimbursement also goes up. If we refer patients to 1-800-QUITNOW smoking cessation quitlines, their quit rates increase. And if we prescribe one of the seven FDA-approved smoking cessation pharmacotherapies, quit rates can double."

Cigar Study Expands Cancer Connection

In another study published online on Feb. 15 in the Journal of the National Cancer Institute, researchers from the American Cancer Society and CDC associated cigar smoking in males with a fivefold increased risk of death from lung cancer, according to a news release.(

That risk increased further among men who reported smoking three or more cigars a day (7.8 times the risk of nonsmoking men) and men who inhale their cigar smoke (11.3 times the risk of nonsmoking men).

"We have actually seen large increases in little cigar and cigarillo use in the U.S. in the last decade," Goldstein said. "This increase in use is driven by industry marketing practices that use enticing marketing combined with flavors that appeal to young people.

"The message we must give to patients is unequivocal: Whether it is cigar use or hookah exposure, combustible tobacco products are poisonous. Who would inhale asbestos or formaldehyde purposefully? Are people OK with jumping off the third floor of the building instead of the eighth floor?"