Risk attribution and tobacco-related deaths

The number of deaths that would not have occurred had an exposure or trait been absent is generally estimated by observing mortality rates in sample populations of exposed and nonexposed persons and applying them to the population of interest. Three methods used to estimate deaths due to tobacco use are evaluated. Each method requires estimates of certain absolute and relative risks, and the published estimates based on them assume that the absolute and relative risks observed in the two large American Cancer Society prospective studies can be applied to the US population or to populations in developed countries. Computations using large representative samples of US decedents and of the entire US population for these methods result in estimated numbers of deaths for the US population that are substantially lower than those based on Cancer Prevention Survey-I or Cancer Prevention Survey-II. Computations also showed that controlling for confounding from two smoking-related variables results in still lower estimates of the number of excess deaths. Consequently, published results that ignore confounding and are based on nonrepresentative data overstate the contribution of smoking. It is imperative that estimates of excess deaths be based on representative data and control for relevant confounders.