A novel indicator of life-course smoking prevalence in the United States combining popularity, duration, quantity, and quality of smoking

Objectives. To develop a smoking indicator that combines the popularity and duration of smoking and the quantity and quality of consumed cigarettes, factors that vary dramatically over time and across generations. Methods. We used retrospective reports on smoking behavior and a time series of cigarette tar yields to standardize nationally representative life-course smoking prevalence rates of 11 generations of US men and women, spanning 120 years. For each generation and gender, we related the standardized data with the corresponding rates of smoking-attributable mortality. Results. Our indicator suggests that US cigarette consumption spread, peaked, and contracted faster than commonly perceived; predicts a significantly stronger smoking- mortality correlation than unadjusted smoking prevalence; and reveals the emergence of a delay (by up to 8 years) in premature death from smoking that is consistent with increasing population access to effective treatments. In fact, we show that, among recent cohorts, smoking health-risk exposure is at a historic low and will account for less than 5% of deaths. Conclusions. Relative to unstandardized measures, our novel, standardized indicator of smoking prevalence describes a different history of smoking diffusion in the United States, and more strongly predicts later-life mortality.