RESEARCH Open Access Smoking-attributable Mortality In .
Tachfouti et al. Archives of Public Health 2014, 23RESEARCHARCHIVES OF PUBLIC HEALTHOpen AccessSmoking-attributable mortality in Morocco: resultsof a prevalence-based study in CasablancaNabil Tachfouti1,2*, Chantal Raherison2,3, Adil Najdi1, Majdouline Obtel4, Ahmed Rguig4, Amina Idrissi Azami5and Chakib Nejjari1AbstractBackground: Tobacco control measurements’ had little impact on smoking prevalence in Morocco. The aim of thisstudy is to provide first data on smoking attributable mortality in Morocco.Method: The Smoking-Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software was used toestimate the smoking attributable mortality (SAM) in Casablanca region in 2012. Smoking prevalence and mortalitydata of people aged 35 years or older were obtained from the national survey on tobacco “Marta” and from HealthMinistry Mortality System, respectively.Results: Of the 5261deaths of persons aged 35 years and older, 508 (9.7%) were attributable to cigarette smoking.This total represents 16.2% of all male deaths (n 448) and 2.0% (n 80) of all female deaths in this region. Theleading four causes of smoking attributable deaths were lung cancer (177), chronic airways obstruction (76),ischemic heart disease (39), and cerebrovascular disease (31).Conclusion: Tobacco use caused one out of six deaths in Casablanca in 2012. Four leading causes (lung cancer,ischemic heart disease, cerebrovascular disease and chronic airways obstruction,) accounted for 51.6% of SAM.Effective and comprehensive actions must be taken in order to slow this epidemic in Morocco.BackgroundScientific evidence of harm caused by smoking has beenaccumulating for over 200 years, at first in relation tocancers of the lip and mouth, and then in relation tovascular diseases and lung cancer [1]. Cigarette smokinghas been identified as the second leading risk factor fordeath from any cause worldwide [2,3]. In 2000, an estimated 4.83 million deaths were attributed to cigarettesmoking globally, with nearly half occurring in the developing world [4]. In people over age 30, smoking accountsfor one in every five deaths among men and one in every20 deaths among women globally [5]. The World HealthOrganization (WHO) has estimated that approximately5.4 million people died worldwide from tobacco-relatedillnesses in 2006 and says that “unless urgent action istaken, tobacco’s annual death toll will rise to more thaneight million” by the year 2030 [6]. Because many low* Correspondence: tachfoutinabil@yahoo.fr1Laboratory of Epidemiology, Clinical Research and Community Health,Faculty of Medicine, Fez 30000, Morocco2INSERM U897, ISPED, University Bordeaux Segalen, 33076 Bordeaux, FranceFull list of author information is available at the end of the articleand middle-income countries are still in early stages of thetobacco epidemic, the number of smoking-related deathsin these nations will probably increase during the nextdecades. It is estimated that in the period 2002/2030,tobacco-attributable deaths will decrease by 9% in developed countries, but increase by 100% (to 6.8 million) indeveloping countries [7].In contrast to deaths which are clearly attributable toa given factor, for example, accidental deaths, deaths dueto smoking are harder to identify. The number of deathscaused by tobacco use in a population (the smokingattributable mortality, SAM) can be estimated by differentmethodologies [8-10]. Peto’s ‘indirect’ method10 used lungcancer rates to retroactively estimate smoking prevalence[11]. Malarcher calculated attributable fractions adjustedfor age and other potential confounders [12]. Thun usedthe Cox proportional hazard model, incorporating a widearray of potential confounders [13]. McNulty used smoking status reports from death certificates [14].The population attributable risk (PAR) methodology isthe most commonly used [8]. PAR incorporates the prevalence of smoking and the relative risk (RR) associated with 2014 Tachfouti et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver ) applies to the data made available in this article,unless otherwise stated.
Tachfouti et al. Archives of Public Health 2014, 23various amounts of smoking [8-10]. Adult SmokingAttributable Mortality, Morbidity and Economic Costs(SAMMEC), an online application developed by theCenters for Disease Control and Prevention (CDC), useattributable risk formulas to estimate the number ofdeaths from cancer, cardiovascular and respiratory diseases associated with cigarette smoking [15]. SAMMEChas been applied in United States and other countriessuch as Australia [16], Canada [17], Spain [18] Brazil [19],Israel [20], and Italy [21]. Counting and establishing thecauses of deaths is a matter of concern for the publichealth community. Information on deaths is crucial to theplanning, implementation and evaluation of public healthprograms at local, national and international levels. In developed countries, data on major health risk factors areregularly obtained from population surveys and morbidityspecific registers such as those for cancer. Many developing countries have reasonably reliable data on mortality by cause, but lack population data on the prevalenceof risk factors, such as smoking, which are essential toestablish public health policy priorities. Attempts toproduce indirect estimates are needed, because an important share of the global tobacco burden falls on developing countries, where 84% of the 1.3 billion currentsmokers reside [20].The Kingdom of Morocco has a surface area of 710850 km2 and is situated in the north west of Africa witha population of 29.8 million (Census 2004), with an average per capita monthly income of 1200. Tobacco controlmeasurements’ and antismoking legislation had little impact on the prevalence of smoking. A study on cardiovascular risk factors conducted in 2000 found smoking ratesof 17.2% (31.5% for men and 0.6% for women) [22]. In2006, nationwide smoking-specific studies have been performed looking at prevalence and determinants. The overall prevalence of current smoking was 18.5% (31.5% formales and 3.1% for females) [23]. Among daily smokers,the proportion of household income spent on tobaccowas around 30% [24]. Moreover, no data is available aboutmortality attributable to smoking.In 2006, a large population-based survey was conductedin seven Moroccan administrative regions to assess prevalence, knowledge and attitude towards tobacco amongMoroccan adult population [22-24]. The results of the survey allowed, along with other information, to estimate forthe first time the number of smoking attributable deaths inCasablanca, the biggest city and economic capital ofMorocco. Greater Casablanca is the largest economical region representing 12% of total population whose 91.6% areurban and whose population is homogenous. There are 1.7million men and 63% of the population are less than35 years old (mean age 25 years). Life Expectancy at birthis 67.1 years for men and 70.7 for women (MoroccanHealth Ministry, 2003).Page 2 of 8MethodsModelizationAfter considering all the methods that could be used toestimate smoking attributable fraction (SAF) in Morocco,we decided to use the population attributable risk (PAR)method. Direct estimates of mortality cannot be madebecause there is a lack of longitudinal studies on thedifferential mortality of smokers, former smokers andnon-smokers, necessary to provide RR estimates forsmoking-related diseases and mortality. The smokingimpact ratio (SIR) method proposed by Peto [11] requires lung cancer mortality rates in never smokers,which are not available in Morocco. SAMMEC methodwas used to calculate age-adjusted SAM rates for persons aged 35 years and older, using age, sex and causespecific mortality rates, current smoking prevalence byage group and sex (which is available for Morocco), andthe American Cancer Society’s Cancer Prevention StudyII (CPS-II) relative risks [25].SAM is calculated for each cause of mortality usingthe following formula: SAM OM PAF; where OM isthe observed (absolute) mortality, and PAF the populationattributable fraction. The following equations were usedto calculate the PAF:PAF ¼ ððp0 þ p1 RR1 þ p2 RR2Þ 1Þ ðp0 þ p1 RR1 þ p2 RR2Þ;where p0, p1 and p2 represent the prevalence of nonsmokers, smokers and ex-smokers, respectively. RR1 andRR2 refer to the risk of dying for smoking related pathologies of smokers and ex-smokers respectively compared to a baseline population of non-smokers.Data sourcesMortality dataThe 2012 mortality data for 19 adult smoking-relateddiseases were drawn from the Mortality declaration registries in eight prefectures (administrative department) inCasablanca. Deaths were categorized by cause, sex andage group. Diseases were coded according to InternationalDisease Classifications ICD 10 as shown in, Table 1 [26].Data on deaths from burns or second hand smoke werenot included in the present study. Causes of death weredistributed into three groups: Group I: malignant tumors (lung-trachea-bronchus,lip-oral cavity-throat, esophagus, larynx, cervix,bladder and urinary tract, kidney and pancreas); Group II: cardiovascular diseases (ischemic heartdisease and cerebrovascular disease in groups aged35–64 years and 64 years); Group III: respiratory diseases (chronic bronchitisand emphysema).
Tachfouti et al. Archives of Public Health 2014, 23Page 3 of 8Table 1 ICD 10 codes for smoking related diseases [26]Relative risk of mortalityDisease categorySAMMEC application uses the American Cancer Society’sCancer Prevention Study II (CPS-II) relative risks [24].The CPS-II is an ongoing prospective study of 1,185,106residents in United States, aged 30 years or over, for thosewho, in 1982, had never smoked regularly, and for thosewho were then current cigarette smokers [31]. US Centerfor Disease Control and Prevention (CDC) estimates forsmokers and exsmokers are given in Table 2. It shows thatdespite smoking cessation leading to substantial reducerelative risk of mortality, ex smokers are still at a higherrisk than never-smokers. The relative risk ratio of smokersversus ex-smokers ranges from one unit to 3.2 for thepathologies in question. Even if the relative risk is reducedwith the passing of time since smoking cessation andICD 10Malignant cancersTrachea, lungs, arynxLips, oral cavity, pharynxNeck of the uterusKidney and renal pelvisUrinary bladderAcute myeloid lar diseasesIschemic heart diseaseI20-I25Cerebrovascular disease 35I60–I69AtherosclerosisAortic aneurysmTable 2 Relative risk of death for smokers and exsmokers comparing to nonsmokersMalesI 70I71Other arterial diseaseI72-I78Other cardiaq diseasesI25Respiratory diseasesBronchitis, EmphysemaJ40-J43Chronic airway obstructionJ44–J46Pneumonia, InfluenzaJ10-J18Smoking dataSmoking prevalence rates for adults aged 35 years or olderwere obtained from MARTA survey data [23,27-30]. It is anational cross-sectional study of a random sample of9,195 individuals aged 15–90 years conducted in 2006.The sampling was performed with stratification by region,socioeconomic level, age and sex, taking into consideration the urban-to-rural ratios in each region. The countrywas divided into seven regions: central north region (Fezand surroundings), occidental region (Casablanca and surroundings), northwest region (Tangier and surroundings),eastern region (Oujda and surroundings). In each region, aprefecture (administrative division) was randomly chosenaccording to the size of the population. Smoking habit wasdefined according to the International Union Against Tuberculosis and Lung Diseases guide (Slama 1998). Respondents were classified as smokers if they had smoked atleast 100 cigarettes until the date of the interview (dailysmokers if they daily smoked and occasional smokers ifthey smoked on some days), ex smokers if they hadsmoked but had quit (for 3 months), and nonsmokers ifthey had never smoked or had smoked fewer than 100 cigarettes until the date of the interview. We extracted smoking data in Casablanca region according to gender foradult population aged 35 years.Disease kerFormersmoker10.893.405.082.29Malignant neoplasmsLip, Oral cavity, .16Trachea, lung, bronchus23.268.7012.694.53Cervix Uteri0.000.001.591.14Kidney and renal pelvis2.721.731.291.05Urinary bladder3.272.092.221.89Acute myeloid leukemia1.861.331.131.38Persons aged 35–642.801.643.081.32Persons aged 65 1.511.211.601.20Other heart lar diseasesIschemic heart diseaseCerebrovascular diseasePersons aged 35–64Persons aged 65 tic aneurysm6.213.077.072.07Other arterial disease2.071.012.171.12Pneumonia, influenza1.751.362.171.10Bronchitis, Emphysema17.1015.6412.0411.77Chronic airway obstruction10.586.8013.086.78Respiratory diseasesSource: Centers for Disease Control and Prevention, Project “Smoking-AttributableMortality, Morbidity, and Economic Costs (SAMMEC)”, https://apps.nccd.cdc.gov/sammec/show risk data.asp.
Tachfouti et al. Archives of Public Health 2014, 23Page 4 of 8Table 3 Repartition of number of observed deaths due tosmoking related disease according to sex in Casablanca(2012)Disease categoryObserved mortalityMalesFemalesMalignant cancers309148Total457Cardiovascular diseases5766021178Respiratory disease10844152Total9937941787even if it can match that of never-smokers, on averagethis population has a greater aggregated risk than thatof never-smokers. Table 2 shows mortality relative riskfor smokers and ex-smokers versus nonsmokers according to sex and diseases.ResultsIn 2013, a total of 5261 deaths of individuals aged 35years and older (2767 males; 2494 females) were reportedin Casablanca. From this total, missing information aboutcause of death accounted for 933 of death certificates,1787 deaths were linked to smoking related diseases (993men and 794 female) and were taking into account for theestimation of SAM. Cardiovascular disease caused 1178deaths, cancer was responsible for 457 deaths, and respiratory disease for 152 deaths. Table 3 shows number of observed deaths according to mortality cause and sex. Theprevalence of current and former smoking by sex and twoage groups (35–64 years and 65 years) are shown inTable 4. Prevalence’s of smokers and ex-smokers are muchhigher among men, with the latter category being generally higher than the former one, especially among olderadults. Moreover, there are no smokers among womenaged 65 and older. Concerning amount of smoking, 15.6%of smokers do not smoke daily, and most of the remaining(75%) smoke more than ten cigarettes per day.Mortality attributable fraction (MAF) in men varied from0.1 for cerebrovascular disease (person aged 65 years andolder) to 0.91 for lung cancer and bronchitis and emphysema. In women, it was very lower especially for cardiovascular diseases; the highest SAF for women’s was around0,44 fir lung and larynx cancers as shown in Table 5.Of total 5261 deaths recorded in Casablanca in 2012among person aged 35 years and older, 508 were attributed to smoking in the three groups of selected causes;448 men’s and 60 women’s. Smoking accounted for 9.7%of all deaths; 16.2% of deaths in men, and 2.0% in women.Cancer was the most frequent cause, responsible for 247of all smoking attributable deaths, followed by Cardiovascular diseases (160 deaths) and respiratory diseases (101deaths).The four leading specific causes of adult smoking attributable deaths were lung cancer (177 deaths: 159 men’s and18 women’s), chronic airways obstruction (76 deaths; 62men’s and 14 women’s), ischemic heart disease (39 deaths:37 men’s and two women’s), cerebrovascular disease (31deaths: 28 men’s and three women’s). Combined, thesefour conditions were responsible for 63.6% of all SAM(323/861); 64.0% among men and 61.6% among women’s.Table 6 presents the number of smoking-attributabledeaths by sex grouped into three broad categories: cancer,cardiovascular and respiratory diseases.Males and females differed slightly in the ranking ofthe four leading causes of smoking attributable deaths.Among males they were: lung cancer (159 deaths),chronic airways obstruction (62 deaths), ischemic heartdisease (IHD) (37 deaths), and cerebrovascular disease(31 deaths). Among females they were lung cancer (18death), chronic airways obstruction (14 deaths), atherosclerosis (38 deaths), cerebrovascular disease (three deaths).Table 6 shows Observed mortality (OM) and smoking attributable mortality (SAM) according to sex and relatedsmoking cause of death.DiscussionTo our knowledge, this is the first study to estimateSAM in Morocco; cigarette smoking was responsible for9.7% of all adult deaths (16.2% in men’s and 2.0% inwomen’s) and 28.4% of smoking related disease deaths(45.1% among men’s and 7.6% among women’s) in thestudied population. The current SAM reported in thispaper shows clearly how hazardous and costly in livessmoking are to a society. Combining the four leadingcauses of smoking attributable deaths in Casablanca cities in 2012; lung cancer, ischemic heart disease, cerebrovascular disease and chronic airways obstruction; accountfor 63.6% of the SAM. These diseases are among the mostTable 4 Proportion of current, former and nonsmokers according to gender and age groups in Casablanca (2006)MalesFemalesAge categoryNon smoker %(35% CI)Current smoker %(35% CI)Ex smokers %(35% CI)Non smoker %(35% CI)Current smoker %(35% CI)Ex smokers %(35% CI)35 - 6432.7 (28.8 – 37.6)36.3 (31.6 – 41.2)31.0 (26.5 – 35.8)89.4 (85.4 – 92.6)5.5 ( 3.3 – 8.8)5.2 ( 3.1 – 8.4) 65 years32.5 (18.6 – 49.1)15.0 (5.7 – 29.8)52.5 (36.1 – 68.5)100.0 (100.0 – 100.0)0.0 (0.0 – 13.2)0.0 (0.0 – 13.2) 35 years32.6 (28.4 – 37.4)34.2 (29.9 – 39.0)33.2 (28.6 – 37.6)90.2 (86.6 – 93.1)5.1 (3.1 – 8.1)4. 7 (2.8 – 7.8)
Tachfouti et al. Archives of Public Health 2014, 23Page 5 of 8Table 5 Smoking attributable fraction according to sexand diseasesDisease categoryCID 10Malignant C320.870.44Trachea, lungs, bronchiLips, Oral cavity, PharynxC00–C140.810.21Neck of the uterusC53xxxx0.05Kidney, renal 250.460.120.1600.460.150.100Urinary bladderAcute myeloid leukaemiaCardiovascular diseasesIschemCI heart disease 35 35Cerebrovascular disease 35I60–I69 35AtherosclerosisI 700.380.05AortCI aneurysmI710.710.27Other arterial diseaseI72-I780.270.07Other cardiaq diseasesI250.260.04Bronchitis. EmphysemaJ40-J430.910.53ChronCI airway obstructionJ44–J460.840.487Pneumonia, InfluenzaJ10-J180.280.07Respiratory diseasesimportant causes of death in the country. In 2010, according to Health Ministry statistics, cardiovascular diseases,cancer and respiratory diseases together were responsiblefor 45.8% of all adult deaths in Morocco. Concerning cancer deaths, our results are in concordance with Casablancacancer registry data (2005–2007) [32]. Incidence datashow that among men lung localization represents 22.7%of all cancer localization, neck of uterus represents 13.3%of total female cancer localization. Thus, these resultssuggest that a la
method. Direct estimates of mortality cannot be made because there is a lack of longitudinal studies on the differential mortality of smokers, former smokers and non-smokers, necessary to provide RR estimates for smoking-related diseases and mortality.
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the prevalence and burden of periodontal disease, the prevalence of smoking and number of cigarettes smoked per smoker, and the association between smoking and periodontal disease. As a result, the smoking-attributable burden of periodontal disease on population level was estimated for 186 countries in three age groups, separated for sex, in 2015
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Chart I is a quick reference to the major provisions of local smoking ordinances in the United States. It lists significant city and county smoking ordinances with the population, date of enactment, and whether the law limits smoking in the work- place, restaurants, and retail stores. There are 543 smoking ordinances included herein.
