California anti-smoking program may have saved more than 30,000 lives from heart disease, UCSF study shows; cutbacks linked to 8300 excess deaths

December 13, 2000

An estimated 33,300 heart-disease deaths were prevented during the first nine years of the voter-approved anti-smoking program in California, according to a new report by researchers at UCSF. The report represents the first time that scientists have attributed savings in lives to a tobacco control program.

In addition, the researchers estimate that 8,300 excess deaths from heart disease can be attributed to budget cuts and changes made to focus the program primarily on youth - steps which they say weakened the effort in the mid-1990s.

The study published in the December 14 issue of The New England Journal of Medicine examined the relationship between the tobacco control program and death rates for heart disease because, unlike lung cancer, the harmful effects of smoking on the heart develop rapidly and resolve rapidly. Research has shown that when people quit smoking, their excess risk of a heart attack is cut in half in just one year.

In 1988 the voters of California approved Proposition 99, which increased the tax on cigarettes by 25 cents per package and allocated five cents of the new tax to an anti-tobacco education program, including an aggressive media campaign attacking the tobacco industry and programs promoting clean indoor air. It became the largest such program ever undertaken.

Previous studies by UCSF researchers and others have estimated that the California Tobacco Control Program accelerated a decline in the prevalence of smoking and in per capita cigarette consumption. In the new study, the researchers compared death rates from heart disease in California with the rest of the United States beginning in 1980 - nine years before the California Tobacco Control Program began - until 1997 (the last year for which statistics were available). As is customary in such studies, the comparison was age-adjusted - adjusted to take into account differences in age distributions between California and the U.S.

The study used the relationship between heart disease death rates outside and inside California to estimate the death rates that would have existed without the program. Comparing those figures to the actual pattern of deaths, the researchers were able to estimate the number of lives saved through implementation of the tobacco control program.

"Our results show that large-scale, aggressive tobacco control programs save lives," said Stanton Glantz, PhD, UCSF professor of medicine. "They also show that there is a real human price to be paid when the tobacco industry succeeds in convincing politicians to cut back and water down these programs."

Glantz is a member of the UCSF Cardiovascular Research Institute and the UCSF Institute for Health Policy Studies. Lead author on the paper is Caroline Fichtenberg, MS, a post-graduate researcher in the Institute for Health Policy Studies.

Glantz and Fichtenberg also compared per capita cigarette consumption in California with the rest of the country and found that the state's tobacco control program was associated with about 2.9 billion fewer packs of cigarettes being smoked (worth $4 billion in pre-tax sales to the tobacco industry) between 1989 and 1997.

The reduced effectiveness of the program due to cutbacks and program changes in the mid-1990s is associated with an extra one billion packs of cigarettes being consumed in the state between 1993 and 1997, they report.

The changes in heart disease death rates paralleled the changes in cigarette consumption in about the proportion that would be expected given the known risk of heart disease associated with smoking, they estimate.

Fichtenberg and Glantz conclude that well-designed, aggressive tobacco control programs are associated with major reductions in deaths from heart disease in a short period of time.

"Our study also shows that scaling back or weakening such programs by limiting them to children, as the tobacco industry and some representatives of the public health community advocate, is associated with an increase in death," they write.
The research was supported by the National Cancer Institute.

In the NEJM paper the researchers note that a simple calculation shows that the changes in the rate of death from heart disease were quantitatively consistent with the changes in cigarette consumption. "Values for the risk of death from coronary heart disease that is attributable to smoking range from 40 to 55 percent," they write. "In 1997, the rate of per capita cigarette consumption in California was 21 percent lower than the predicted rate had the pre-1989 relation between the rates in California and the rest of the United States been maintained. A 40 to 55 percent reduction of 21 percent is 8 to 12 percent, which is similar to the actual 13 percent difference between the actual rate of death from heart disease in California and the predicted rate had the pre-1989 trend been maintained."

University of California - San Francisco

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