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Mortality in relation to smoking: 50 years' observations on male British doctors
Open accessAbstract
OBJECTIVE: To compare the hazards of cigarette smoking in men who formed their habits at different periods, and the extent of the reduction in risk when cigarette smoking is stopped at different ages. DESIGN: Prospective study that has continued from 1951 to 2001. SETTING: United Kingdom. PARTICIPANTS: 34 439 male British doctors. Information about their smoking habits was obtained in 1951, and periodically thereafter; cause specific mortality was monitored for 50 years. MAIN OUTCOME MEASURES: Overall mortality by smoking habit, considering separately men born in different periods. RESULTS: The excess mortality associated with smoking chiefly involved vascular, neoplastic, and respiratory diseases that can be caused by smoking. Men born in 1900-1930 who smoked only cigarettes and continued smoking died on average about 10 years younger than lifelong non-smokers. Cessation at age 60, 50, 40, or 30 years gained, respectively, about 3, 6, 9, or 10 years of life expectancy. The excess mortality associated with cigarette smoking was less for men born in the 19th century and was greatest for men born in the 1920s. The cigarette smoker versus non-smoker probabilities of dying in middle age (35-69) were 42% nu 24% (a twofold death rate ratio) for those born in 1900-1909, but were 43% nu 15% (a threefold death rate ratio) for those born in the 1920s. At older ages, the cigarette smoker versus non-smoker probabilities of surviving from age 70 to 90 were 10% nu 12% at the death rates of the 1950s (that is, among men born around the 1870s) but were 7% nu 33% (again a threefold death rate ratio) at the death rates of the 1990s (that is, among men born around the 1910s). CONCLUSION: A substantial progressive decrease in the mortality rates among non-smokers over the past half century (due to prevention and improved treatment of disease) has been wholly outweighed, among cigarette smokers, by a progressive increase in the smoker nu non-smoker death rate ratio due to earlier and more intensive use of cigarettes. Among the men born around 1920, prolonged cigarette smoking from early adult life tripled age specific mortality rates, but cessation at age 50 halved the hazard, and cessation at age 30 avoided almost all of it.
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“we found in our meta-analyses of risk reduction among former smokers that cessation shifts smokers into a lower-risk category, with greater reduction in risk for longer durations since cessation.40, 41, 42”
From Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019 (2021) · cites this paper as [42]
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“Relative risks of all-cause mortality from long-running cohort studies in the UK41, 42 and the USA43 indicate that up to two-thirds of long-term smokers will eventually die of a disease attributable to smoking.”
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In the citing paper
“The frequency or amount of a given behavior or activity is a potential objective indicator of control problems (eg, frequency of alcohol consumption45-47).”
From Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective (2024) · cites this paper as [47]
Experimental — accuracy not yet measuredIn the citing paper
“Specifically, it has been observed that quitting smoking at the age of 50 years reduces the risk of smoking-related death two-fold, and that cessation at the age of 30 years avoids any risk. In addition, stopping smoking at the age of 60, 50, 40, or 30 years has led to gains of about three years, six years, nine years, and ten years of survival, respectively [70].”
From Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic (2021) · cites this paper as [70]
In the citing paper
“There is also evidence that former smokers reduce their risk to that of never-smokers over time [40].”
From The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors (2009) · cites this paper as [40]
In the citing paper
“After breaking the tobacco withdrawal cycle, through smoking cessation, these systems recover (Mamede et al., 2007), possibly in the same way that other systems damaged by smoking reverse after smoking cessation (Doll et al., 2004; Pirie et al., 2013).”
From An application of the stress-diathesis model: A review about the association between smoking tobacco, smoking cessation, and mental health (2023) · cites this paper as Doll et al., 2004
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Reitsma, M. B., Flor, L. S., Mullany, E. C., Gupta, V., Hay, S. I., & Gakidou, E. E. (2021) · The Lancet Public Health · doi:10.1016/s2468-2667(21)00102-x · Cited by 472
Polosa, R., Caponnetto, P., Morjaria, J. B., Papale, G. A., Campagna, D., & Russo, C. (2011) · BMC Public Health · doi:10.1186/1471-2458-11-786 · Cited by 431
“This is because cigarette smoke harms several organ systems of the human body, thus causing a broad range of diseases, many of which are fatal [2,3].”
Definition, epidemiology and natural history of COPD
Viegi, G., Pistelli, F., Sherrill, D. L., Maio, S., Baldacci, S., & Carrozzi, L. (2007) · European Respiratory Journal · doi:10.1183/09031936.00082507 · Cited by 434
Mealing, N. M., Banks, E., Jorm, L. R., Steel, D. G., Clements, M., & Rogers, K. D. (2010) · BMC Medical Research Methodology · doi:10.1186/1471-2288-10-26 · Cited by 414
“By their nature, cohort studies tend not to be directly representative of the general population, however over time, their results have usually been shown to be both reproducible and generalisable to the larger population [6,7].”
Kontis, V., Mathers, C. D., Rehm, J., Stevens, G. A., Shield, K. D., Bonita, R., Riley, L. M., Poznyak, V., Beaglehole, R., & Ezzati, M. (2014) · The Lancet · doi:10.1016/s0140-6736(14)60616-4 · Cited by 418
Health promotion: An effective tool for global health
Kumar, S., & Preetha, G. S. (2012) · Indian Journal of Community Medicine · doi:10.4103/0970-0218.94009 · Cited by 398
“The Framingham Heart Study has led to the identification of major CVD risk factors such and blood pressure, blood triglycerides and cholesterol level, age, gender and psychosocial issues (Framingham Heart Study).(18)”
Gibson, P. G., McDonald, V. M., & Marks, G. B. (2010) · The Lancet · doi:10.1016/s0140-6736(10)61087-2 · Cited by 400
Smoking and Smoking Cessation in Relation to Mortality in Women
Kenfield, S. A. (2008) · JAMA · doi:10.1001/jama.299.17.2037 · Cited by 395
“and coupled with improvements in treatment, an estimated two-thirds of those persistent smokers were likely to die from smoking.(21) We did not see differences in early cigarette exposure among women born between 1920 and 1929 compared with women born between 1930 and 1939, translating into similar hazards for total m…”
Correll, C. U., Robinson, D. G., Schooler, N. R., Brunette, M. F., Mueser, K. T., Rosenheck, R. A., Marcy, P., Addington, J., Estroff, S. E., Robinson, J., et al. (2014) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2014.1314 · Cited by 384
Mortality from cancer in relation to smoking: 50 years observations on British doctors
Doll, R., Peto, R., Boreham, J., & Sutherland, I. (2005) · British Journal of Cancer · doi:10.1038/sj.bjc.6602359 · Cited by 392
“A more detailed account of the population and the methods of follow-up and analysis are described elsewhere (Doll et al, 2004).”
Self-citationPolygenic basis and biomedical consequences of telomere length variation
Codd, V., Wang, Q., Allara, E., Musicha, C., Kaptoge, S. K., Stoma, S., Jiang, T., Hamby, S. E., Braund, P. S., Bountziouka, V., et al. (2021) · Nature Genetics · doi:10.1038/s41588-021-00944-6 · Cited by 381
Are sirtuins viable targets for improving healthspan and lifespan?
Baur, J. A., Ungvari, Z. I., Minor, R. K., Couteur, D. G. L., & de Cabo, R. (2012) · Nature Reviews Drug Discovery · doi:10.1038/nrd3738 · Cited by 393
Chen, Z., Peto, R., Zhou, M., Iona, A., Smith, M., Yang, L., Guo, Y., Chen, Y., Bian, Z., Lancaster, G., et al. (2015) · The Lancet · doi:10.1016/s0140-6736(15)00340-2 · Cited by 430
Self-citationSchaller, J., Keller, D. B., Poget, L., Pratte, P., Kaelin, E., McHugh, D., Cudazzo, G., Smart, D. J., Tricker, A. R., Gautier, L., et al. (2016) · Regulatory Toxicology and Pharmacology · doi:10.1016/j.yrtph.2016.10.001 · Cited by 374
“Although the causal relationship between smoking and several diseases is well established (Doll et al., 2004), there is still very little understanding of the underlying mechanisms by which smoking causes disease.”
BackgroundDare, S., Mackay, D., & Pell, J. P. (2015) · PLoS ONE · doi:10.1371/journal.pone.0123579 · Cited by 386
“Smoking increases the risk of cancer, respiratory and cardiovascular diseases, and is the leading preventable cause of death in developed countries [1].”
BackgroundScreening for and early detection of chronic obstructive pulmonary disease
Soriano, J. B., Zielinski, J., & Price, D. B. (2009) · The Lancet · doi:10.1016/s0140-6736(09)61290-3 · Cited by 383
Impact of graphic and text warnings on cigarette packs: findings from four countries over five years
Borland, R., Wilson, N., Fong, G. T., Hammond, D. G., Cummings, K. M., Yong, H.-H., Hosking, W., Hastings, G., Thrasher, J. F., & McNeill, A. D. (2009) · Tobacco Control · doi:10.1136/tc.2008.028043 · Cited by 350
“Tobacco is a very unusual consumer product, given that it is highly addictive and kills around half of its long-term users.”
BackgroundToking, Vaping, and Eating for Health or Fun
Schauer, G. L., King, B. A., Bunnell, R. E., Promoff, G. R., & McAfee, T. A. (2015) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2015.05.027 · Cited by 344
Smoking and All-Cause Mortality in Older People
Gellert, C., Schöttker, B., & Brenner, H. (2012) · Archives of Internal Medicine · doi:10.1001/archinternmed.2012.1397 · Cited by 354
Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis.
Groenman, A. P., Janssen, T. W. P., & Oosterlaan, J. (2017) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2017.05.004 · Cited by 335
Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis
O’Keeffe, L. M., Taylor, G. M. J., Huxley, R., Mitchell, P., Woodward, M., & Peters, S. A. E. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-021611 · Cited by 360
“The sevenfold higher RRs of lung cancer associated with smoking found in the present meta-analysis are considerably smaller than the 20-fold increased risks reported in the Million Women’s Study 13 and the British Doctors Study.(14) Both of these studies had the advantage of capturing smoking-related risks in populati…”
ResultProspective Study of One Million Deaths in India: Rationale, Design, and Validation Results
Jha, P., Gajalakshmi, V., Gupta, P. C., Kumar, R., Mony, P., Dhingra, N., Peto, R., & Collaborators, R.-C. P. S. (2005) · PLoS Medicine · doi:10.1371/journal.pmed.0030018 · Cited by 323
Self-citationImpact of Tobacco Control Policies and Mass Media Campaigns on Monthly Adult Smoking Prevalence
Wakefield, M. A., Durkin, S. J., Spittal, M. J., Siahpush, M., Scollo, M., Simpson, J. A., Chapman, S. F., WHITE, V. M., & Hill, D. (2008) · American Journal of Public Health · doi:10.2105/ajph.2007.128991 · Cited by 328
Pinkhasov, R. M., Wong, J., Kashanian, J. A., Lee, M., Samadi, D. B., Pinkhasov, M. M., & Shabsigh, R. (2010) · International Journal of Clinical Practice · doi:10.1111/j.1742-1241.2009.02290.x · Cited by 343
Byberg, L., Melhus, H., Gedeborg, R., Sundström, J., Ahlbom, A., Zethelius, B., Berglund, L., Wolk, A., & Michaëlsson, K. (2009) · BMJ · doi:10.1136/bmj.b688 · Cited by 331
“and smoking is probably the most well established modifiable behavioural risk factor for premature death.”
BackgroundBanks, E., Joshy, G., Korda, R., Stavreski, B., Kay, S., Egger, S. J., Day, C., Clarke, N. E., Lewington, S., & López, A. D. (2019) · BMC Medicine · doi:10.1186/s12916-019-1351-4 · Cited by 350
Time perspective, personality and smoking, body mass, and physical activity: An empirical study
Adams, J. M., & Nettle, D. (2008) · British Journal of Health Psychology · doi:10.1348/135910708x299664 · Cited by 329
Clustering of risk behaviors with cigarette consumption: A population-based survey
Chiolero, A., Wietlisbach, V., Ruffieux, C., Paccaud, F., & Cornuz, J. (2006) · Preventive Medicine · doi:10.1016/j.ypmed.2006.01.011 · Cited by 310
“health risk increases sharply with daily cigarette consumption (Doll et al., 2004).”
BackgroundLin, H.-H., Murray, M. B., Cohen, T., Colijn, C., & Ezzati, M. (2008) · The Lancet · doi:10.1016/s0140-6736(08)61345-8 · Cited by 303
Mouse models for human lung cancerPreprint
Meuwissen, R. L. J., & Berns, A. J. M. (2005) · Genes & Development · doi:10.1101/gad.1284505 · Cited by 307
“Although smoking cessation before the age of 30 does substantially reduce the risk of lung cancer, this is significantly less for those who stop smoking at 50 or 60 yr (Peto et al. 2000; Doll et al. 2004).”
Campbell, S. C., Moffatt, R. J., & STAMFORD, B. A. (2008) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2008.04.046 · Cited by 298
Talmud, P. J., Hingorani, A. D., Cooper, J. A., Marmot, M. G., Brunner, E. J., Meena Kumari, B., Mika Kivimaki, B., & Humphries, S. E. (2010) · BMJ · doi:10.1136/bmj.b4838 · Cited by 297
“As a technology, however, genotype based tests have several inherent advantages over non-genetic tests. Genotype based assays are cheap, have high fidelity, and can be multiplexed, in contrast to multiple phenotypic risk factors and biomarkers, many of which require different methods for their measurement, and which a…”
BackgroundDecramer, M., Rennard, S. I., Troosters, T., Mapel, D. W., Giardino, N. D., Mannino, D. M., Wouters, E. F. �., Sethi, S., & Cooper, C. B. (2008) · COPD Journal of Chronic Obstructive Pulmonary Disease · doi:10.1080/15412550802237531 · Cited by 296
“People who stop smoking, even in middle age, have a survival benefit (180).”
BackgroundÜnal, B., Critchley, J., & Capewell, S. (2005) · BMJ · doi:10.1136/bmj.38561.633345.8f · Cited by 292
Kotz, D., Brown, J., & West, R. (2014) · Addiction · doi:10.1111/add.12429 · Cited by 283
“Every year that someone continues to smoke after early middle age loses them 3 months of life expectancy [2].”
BackgroundCigarette smoking: An undertreated risk factor for cardiovascular disease
Erhardt, L. (2009) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2009.01.007 · Cited by 284
Roberts, E. T., Haan, M. N., Dowd, J. B., & Aiello, A. E. (2010) · American Journal of Epidemiology · doi:10.1093/aje/kwq177 · Cited by 281
“Smoking status, hypertension, low density lipoprotein cholesterol, and high density lipoprotein cholesterol were assessed as covariates because they are associated with death (22, 23) and CMV infection.”
Background
Metadata
- Authors
- Doll, R., Peto, R., Boreham, J., & Sutherland, I.
- Affiliations
- University of Oxford (GB)
- Corresponding author
- Doll, Richard
- ORCID
- Peto, Richard
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2004-06-22
- Volume
- 328
- Issue
- 7455
- Pages
- 1519
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC437139
- OpenAlex
- W4292672078
- Cited by
- 2,920
- References
- 39
- Citations by year
- 2026: 81 · 2025: 79 · 2024: 125 · 2023: 135 · 2022: 127 · 2021: 134 · 2020: 159 · 2019: 135 · 2018: 158 · 2017: 134 · 2016: 153 · 2015: 165 · 2014: 146 · 2013: 182 · 2012: 162
- FWCI
- 59.98
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- BMJ (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Funders
- Cancer Research UK
- British Heart Foundation
- University of Oxford
- Medical Research Council
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
- Health Sciences › Medicine › Oncology › Global Cancer Incidence and Screening
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
- Keywords
- cigarette smoking, mortality, smoking cessation, life expectancy, birth cohort differences, vascular disease, neoplasms, respiratory diseases, smoking intensity, cardiovascular disease, lung cancer, chronic obstructive pulmonary disease, alcohol consumption, tobacco control, smoking cessation counseling, smoking cessation interventions
- MeSH terms
- Adult, Aged, Aged, 80 and over, Cause of Death, Epidemiologic Methods, United Kingdom, Humans, Lung Neoplasms, Male, Middle Aged, Mortality, Neoplasms, Physicians, Prospective Studies, Smoking, Smoking Cessation, Age Distribution
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