European Journal of Epidemiology

, Volume 22, Issue 5, pp 301–309 | Cite as

Mortality risks among heavy-smokers with special reference to women: a long-term follow-up of an urban population

  • M. Ekberg-Aronsson
  • P. M. Nilsson
  • J.-Å. Nilsson
  • C.-G. Löfdahl
  • K. Löfdahl


Increased mortality risks associated with smoking are well established among men. There are very few population-based studies comprising a sufficient number of heavily smoking women, measuring the direct effect of smoking on mortality risks. Between 1974 and 1992, 8,499 women and 13,888 men attended a health screening programme including reporting of smoking habits. Individuals were followed for total mortality until 2005. All-cause, cancer, cardiovascular, lung cancer and respiratory mortality were calculated in smoking categories <10 g per day, 10–19 g per day, and ≥20 g per day with never-smokers as a reference group and with adjustments for co-morbidities, socio-economic and marital status. For respiratory mortality and lung cancer adjustments for FEV1, socio-economic and marital status were performed. Smoking was associated with a two to almost threefold increased mortality risk among women and men. The relative risk (RR) with 95% confidence interval, (CI) for women who smoked 10–19 g per day was 2.44 (2.07–2.87), and for those who smoked 20 g per day or more the RR (95% CI) was 2.42 (2.00–2.92). Smoking was a strong risk factor for cardiovascular mortality among women, the RR (95% CI) for women who smoked 10–19 g per day was 4.52 (3.07–6.64). Ex-smoking women showed increased risks of all-cause mortality; RR (95% CI) 1.26 (1.04–1.52) cancer (excluding lung cancer); RR (95% CI) 1.42 (1.07–1.88) and lung cancer RR (95% CI) 2.71 (1.02–7.23) mortality. However, the cardiovascular; RR (95% CI) 1.18 (0.69–2.00) and respiratory; RR (95% CI) 0.79 (0.16–3.84) mortality risks were not statistically significant. This study confirms that as for men, middle-aged heavily smoking women have a two to threefold increased mortality risk. Adjustments for co-morbidity, socio-economic and marital status did not change these results.


Epidemiology Men Mortality Smoking Tobacco Women 



This study was supported by grants from the Swedish Heart and Lung Foundation. Ethical approval When MPP was started in 1974 no Ethical Committee was available to approve of the baseline screening examination. The screening was at that time regarded as an integrated part of routine health care. All participating subjects agreed to have follow-up of clinical events and register follow-up. This has been confirmed by approval of the Swedish Data register authorities (“Data-inspektionen” in decision 1997-06-24; Dnr 2403-97). A new application to the Ethical committee of the Medical Faculty, University of Lund, was approved in August 2002 (LU 244-02), and for genetic analyses (Lund protocol 2004/3, Dnr. 154/2004).


  1. 1.
    Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr., Doll R. Mortality from smoking world-wide. Br Med Bull 1996;52(1):12–21.PubMedGoogle Scholar
  2. 2.
    Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. Bmj 2004;328(7455):1519.PubMedCrossRefGoogle Scholar
  3. 3.
    Jacobs DR Jr., Adachi H, Mulder I, Kromhout D, Menotti A, Nissinen A, et al. Cigarette smoking and mortality risk: twenty-five-year follow-up of the Seven Countries Study. Arch Intern Med 1999;159(7):733–40.PubMedCrossRefGoogle Scholar
  4. 4.
    Qiao Q, Tervahauta M, Nissinen A, Tuomilehto J. Mortality from all causes and from coronary heart disease related to smoking and changes in smoking during a 35-year follow-up of middle-aged Finnish men. Eur Heart J 2000;21(19):1621–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Vollset SE, Tverdal A, Gjessing HK. Smoking and deaths between 40 and 70 years of age in women and men. Ann Intern Med 2006;144(6):381–9.PubMedGoogle Scholar
  6. 6.
    Prescott E, Osler M, Andersen PK, Hein HO, Borch-Johnsen K, Lange P, et al. Mortality in women and men in relation to smoking. Int J Epidemiol 1998;27(1):27–32.PubMedCrossRefGoogle Scholar
  7. 7.
    Nordlund LA. Trends in smoking habits and lung cancer in Sweden. Eur J Cancer Prev 1998;7(2):109–16.PubMedGoogle Scholar
  8. 8.
    Graham H. Smoking prevalence among women in the European community 1950–1990. Soc Sci Med 1996;43(2):243–54.PubMedCrossRefGoogle Scholar
  9. 9.
    The Health Consequences of Smoking for women. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2001.Google Scholar
  10. 10.
    The Swedish National board of Health and Welfare. Public Health Report 2005. Stockholm 2005. Available at Scholar
  11. 11.
    The Health Consequences of Smoking for women. A Report of the Surgeon General. US Department of Health and Human Services, Public Health service, office for the assistant secretary for health, Office on smoking and health, Rockville, Maryland, 1980. Google Scholar
  12. 12.
    Barbeau EM, Leavy-Sperounis A, Balbach ED. Smoking, social class, and gender: what can public health learn from the tobacco industry about disparities in smoking? Tob Control 2004;13(2):115–20.PubMedCrossRefGoogle Scholar
  13. 13.
    Kunst AE, Groenhof F, Mackenbach JP. Mortality by occupational class among men 30–64 years in 11 European countries. EU Working Group on Socioeconomic Inequalities in Health. Soc Sci Med 1998;46(11):1459–76.PubMedCrossRefGoogle Scholar
  14. 14.
    Boffett P, Ye W, Boman G, Nyren O. Lung cancer risk in a population-based cohort of patients hospitalized for asthma in Sweden. Eur Respir J 2002;19(1):127–33.PubMedCrossRefGoogle Scholar
  15. 15.
    Trell E. Community-based preventive medical department for individual risk factor assessment and intervention in an urban population. Prev Med 1983;12(3):397–402.PubMedCrossRefGoogle Scholar
  16. 16.
    Berglund G, Eriksson KF, Israelsson B, Kjellstrom T, Lindgarde F, Mattiasson I, et al. Cardiovascular risk groups and mortality in an urban Swedish male population: the Malmö Preventive Project. J Intern Med 1996;239(6):489–97.PubMedCrossRefGoogle Scholar
  17. 17.
    Berglund G, Nilsson P, Eriksson KF, Nilsson JA, Hedblad B, Kristenson H, et al. Long-term outcome of the Malmö preventive project: mortality and cardiovascular morbidity. J Intern Med 2000;247(1):19–29.PubMedCrossRefGoogle Scholar
  18. 18.
    Janzon L, Lindell SE, Trell E, Larme P. Smoking habits and carboxyhaemoglobin. A cross-sectional study of an urban population of middle-aged men. J Epidemiol Community Health 1981;35(4):271–3.PubMedGoogle Scholar
  19. 19.
    Ekberg-Aronsson M, Nilsson PM, Nilsson JA, Pehrsson K, Lofdahl CG. Socio-economic status and lung cancer risk including histologic subtyping—a longitudinal study. Lung Cancer 2006;51(1):21–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Statistics, Sweden. A memo on socio-economic classification (SEI). Stockholm: Statistics Sweden; 1982.Google Scholar
  21. 21.
    Engstrom G, Hedblad B, Nilsson P, Wollmer P, Berglund G, Janzon L. Lung function, insulin resistance and incidence of cardiovascular disease: a longitudinal cohort study. J Intern Med 2003;253(5):574–81.PubMedCrossRefGoogle Scholar
  22. 22.
    Ekberg-Aronsson M, Pehrsson K, Nilsson JA, Nilsson PM, Lofdahl CG. Mortality in GOLD stages of COPD and its dependence on symptoms of chronic bronchitis. Respir Res 2005;6:98.PubMedCrossRefGoogle Scholar
  23. 23.
    The Health Consequences of Smoking: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.Google Scholar
  24. 24.
    LaCroix AZ, Lang J, Scherr P, Wallace RB, Cornoni-Huntley J, Berkman L, et al. Smoking and mortality among older men and women in three communities. N Engl J Med 1991;324(23):1619–25.PubMedCrossRefGoogle Scholar
  25. 25.
    Nilsson S, Carstensen JM, Pershagen G. Mortality among male and female smokers in Sweden: a 33 year follow up. J Epidemiol Community Health 2001;55(11):825–30.PubMedCrossRefGoogle Scholar
  26. 26.
    Doll R, Gray R, Hafner B, Peto R. Mortality in relation to smoking: 22 years’ observations on female British doctors. Br Med J 1980;280(6219):967–71.PubMedGoogle Scholar
  27. 27.
    Kawachi I, Colditz GA, Stampfer MJ, Willett WC, Manson JE, Rosner B, et al. Smoking cessation in relation to total mortality rates in women. A prospective cohort study. Ann Intern Med 1993;119(10):992–1000.PubMedGoogle Scholar
  28. 28.
    Ebbert JO, Yang P, Vachon CM, Vierkant RA, Cerhan JR, Folsom AR, et al. Lung cancer risk reduction after smoking cessation: observations from a prospective cohort of women. J Clin Oncol 2003;21(5):921–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Vagero D, Persson G. Occurrence of cancer in socio-economic groups in Sweden. An analysis based on the Swedish Cancer Environment Registry. Scand J Soc Med 1986;14(3):151–60.PubMedGoogle Scholar
  30. 30.
    Manjer J, Berglund G, Bondesson L, Garne JP, Janzon L, Malina J. Breast cancer incidence in relation to smoking cessation. Breast Cancer Res Treat 2000;61(2):121–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Al-Delaimy WK, Cho E, Chen WY, Colditz G, Willet WC. A prospective study of smoking and risk of breast cancer in young adult women. Cancer Epidemiol Biomarkers Prev 2004;13(3):398–404.PubMedGoogle Scholar
  32. 32.
    Tillgren P, Haglund BJ, Lundberg M, Romelsjo A. The sociodemographic pattern of tobacco cessation in the 1980s: results from a panel study of living condition surveys in Sweden. J Epidemiol Community Health 1996;50(6):625–30.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2007

Authors and Affiliations

  • M. Ekberg-Aronsson
    • 1
  • P. M. Nilsson
    • 2
  • J.-Å. Nilsson
    • 2
  • C.-G. Löfdahl
    • 1
  • K. Löfdahl
    • 1
  1. 1.Department of Respiratory Medicine and Allergology, Lund University HospitalUniversity of LundLundSweden
  2. 2.Department of Clinical Sciences, Malmö University HospitalUniversity of LundMalmoSweden

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