The impact of smoking on expected lifetime with and without chronic disease among Palestinian men in the West Bank

The impact of smoking on expected lifetime with and without chronic disease among Palestinian men... Abstract Background The purpose of the study was to estimate life expectancy and the average lifetime with and without chronic disease among male never smokers, ex-smokers and smokers living in the West Bank of the occupied Palestinian territory. Methods The study used a life table for the West Bank male population and Danish relative risk estimates for death for smokers and ex-smokers vs. never smokers and utilized data from the Palestinian Family Survey 2010. Expected lifetime with and without chronic disease was estimated and the contributions from the mortality and the morbidity effect to smoking related difference in average lifetime with and without chronic disease were assessed by decomposition. Results In the West bank 40% of the male population are smokers. Life expectancy of 15-year-old Palestinian men who would never start smoking was 59.5 years, 41.1 of which were expected to be without chronic disease. Ex-smokers could expect 57.9 years of remaining lifetime, 37.7 years of which without disease. For lifelong heavy smokers (> 20 cigarettes per day), the expected lifetime was reduced to 52.6 years, of which 38.5 years were without chronic disease. Of the total loss of 6.9 years of life expectancy among heavy smokers, the mortality effect accounted for 2.5 years without and 4.4 years with disease, whereas the morbidity effect was negligible. Conclusions The high prevalence of smoking causes a considerable loss of life years and lifetime without chronic disease. We recommend the Palestinian health authorities to enforce the anti-smoking law. Introduction Smoking is a serious preventable killer and in spite of smokers’ shorter life, they live on average as many or more years in poor health as non-smokers do.1–9 In the occupied Palestinian territory, the prevalence of smoking is much higher in the West Bank than the Gaza Strip and (still) almost negligible among women. The anti-smoking law in Palestine (https://www.tobaccocontrollaws.org/legislation/country/palestine/laws), which bans smoking in public places, restricts advertising and sale, etc. might have had an impact and reduced tobacco use. Thus, smoking prevalence among men living in the West Bank has declined,10 but yet about 40% of male population are smokers (figure 1). Figure 1 View largeDownload slide Smoking prevalence among men, West Bank, 2010 Figure 1 View largeDownload slide Smoking prevalence among men, West Bank, 2010 Life expectancy for 20-year-old men in the West bank increased from 52.9 years in 2006 to 53.5 years in 2010, whereas average lifetime without chronic disease decreased from 37.6 to 36.0 years.11 Furthermore, no gain in disease-free life expectancy was observed for the most prevalent diseases. Thus, expected lifetime with hypertension, diabetes and heart diseases increased by 2.1, 1.3 and 0.8 years, respectively.11 The explanation of the observed expansion of morbidity might reflect improved notification of diseases, treatment and rehabilitation. However, as no expansion of morbidity was seen among women the increase for men was most likely due to a higher prevalence of chronic diseases. The high smoking prevalence and the fact that these diseases are associated with smoking are worrisome and challenge the Palestinian health authorities. The purpose of the present study was to estimate the impact of smoking on expected lifetime without and with chronic disease at age 15 among West Bank male never smokers, ex-smokers and smokers. Furthermore, the contributions from the mortality and morbidity effects to smoking related differences in expected lifetime without and with chronic disease were investigated. Due to low prevalence of smoking, the West Bank women and the Gaza Strip population were not included in the study. Methods Estimation of expected lifetime in different health states by smoking category requires life tables and health status data for each smoking category. To establish life tables by smoking category we needed relative risk for death due to smoking relative to never smoking. Because (to our knowledge) no relative risk estimates from a Middle East (male) population exists we used relative risk estimates from a Danish study (table 1).12 Furthermore, we needed prevalence of smoking by age group, which was extracted from The Palestinian Family Survey 2010.13 Table 1 Relative risk of death due to smoking by age and smoking category (estimates from a Danish study12) Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 Table 1 Relative risk of death due to smoking by age and smoking category (estimates from a Danish study12) Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 To construct life tables by smoking category, let P0 signify the prevalence of never smokers in a given age group, Pi that for smoking category i and RRi the relative risk (relative to never smokers, i = 0). Then, the death rate for the age group in question is given by D = ∑ Pi × RRi × D0, where RR0 = 1 (never smokers). From this equation the death rate for never smokers, D0, was calculated. The age-specific death rates for never smokers, D0, were multiplied by the relative risks, RRi, giving the age-specific death rates for each smoking category. Finally, life tables were constructed for each smoking category. The Palestinian Family Survey 2010 was representative for the Palestinian population of the occupied Palestinian territory (i.e. the Gaza Strip and the West Bank, including East Jerusalem). A two-stage random sample was drawn from lists of all Palestinian households. First, enumeration areas were selected from the Palestinian territories, and then a random sample of households was drawn from each enumeration area in the West Bank and the Gaza Strip. The surveys consisted of 15 355 households and the response rate was 89.4%. The present study included men aged 15 or above living in the West Bank (14 769 participants). Information on household members’ sociodemographic characteristics was provided by the head of household or another mature person. Data for all members were collected by self-reported responses or by proxy. Age was assessed by asking for the exact date of birth or any document with this information. Chronic disease was measured by answers to the question ‘Does (name) have any disease according to a medical diagnosis and receive treatment continuously?’ The interviewees were categorized as never smokers, ex-smokers, moderate smokers (1–20 cigarettes per day) and heavy smokers (> 20 cigarettes per day). Smokers of pipe or water pipe (Nargile) were excluded (664). Further details are available in the survey report.13 An abridged life table for men living in the West Bank was established by use of MortPak, the UN demographic measurement software package.14 For each smoking category disease-free life expectancy was calculated by Sullivan’s method15 combining life table figures and prevalence data of chronic disease status. The expected number of years lived in the age intervals 15–19, 20–24, …, 65–69, 70+ were multiplied by age-specific proportions of men without disease taken from the survey data. Expected lifetime without chronic disease for 15-year-olds was calculated by adding these years for all age groups and dividing the sum by the number of survivors at age 15. By relating this estimate of disease-free life expectancy to total life expectancy, a measure of the proportion of disease-free life expectancy was established. Statistical tests were carried out using a Z test and 95% confidence intervals were calculated from the formulae recommended by the International Network on Health Expectancy.16 The contributions from the mortality effect and the morbidity effect to smoking related differences in disease-free life expectancy were assessed by decomposing.17 A change in age-specific mortality will change life expectancy because a greater or lesser number of years lived affects not only the specific age group but also the years lived in future older ages. This change (the mortality effect) will increase or reduce expected lifetime with or without disease. A change in the proportion of people with or without disease represents the decomposition’s other component (the morbidity effect). Thus, the health gain of being a never smoker measured by disease-free life expectancy was divided into the components of the effects of mortality and morbidity. We declare that no ethical approval was required for this study based on secondary data. Results Life expectancy of 15-year-old Palestinian men in the West Bank who would never start smoking was 59.5 years (table 2). Ex-smokers could expect 57.9 years of remaining lifetime. The corresponding figures for lifelong moderate and heavy smoking men were 55.6 years and 52.6 years, respectively. Of the 59.5 years of their remaining life, never smokers could expect 41.1 (95% CI 40.3–41.9) years without chronic disease. Ex-smokers could expect 37.7 years (CI 35.9–39.4) to be spend without disease, which was statistically significantly (P = 0.01) shorter than expected disease-free lifetime for never smokers (table 2). The reduced average lifetime of 52.6 years for lifelong heavy smokers also reduced lifetime without chronic disease (P = 0.01) to 38.5 (CI 37.3–39.7) (table 2). Table 2 Life expectancy, expected lifetime with and without chronic disease and proportion of expected lifetime without chronic disease at age 15 for Palestinian men living in the West Bank, 2010, by smoking categories Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) Table 2 Life expectancy, expected lifetime with and without chronic disease and proportion of expected lifetime without chronic disease at age 15 for Palestinian men living in the West Bank, 2010, by smoking categories Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) The expected lifetime with chronic disease was 18.4 years (CI 17.6–19.2) for never smokers and 20.2 years (CI 18.4–22.0) for ex-smokers, but not significantly longer (P = 0.16). Thus, the proportion of expected lifetime without chronic disease was lower for ex-smokers than for never smokers, although not statistically significant. The never smokers’ 18.4 years of expected lifetime with chronic disease was statistically significantly longer than for smokers (P < 0.001), 14.4 years (CI 13.3–15.4) for moderate smokers and 14.1 years (CI 12.9–15.2) for heavy smokers. Unexpectedly, the proportion of the average lifetime without chronic disease was statistically significantly higher among smokers compared to never smokers (table 2). The mortality effect from the decomposition contributed by 2.5 years of expected lifetime without chronic disease and by 4.4 years with disease to the total loss of 6.9 years of life expectancy of heavy smokers compared to never smokers (table 3). The contribution from the morbidity component was negligible (0.1 years without disease). For moderate smokers the mortality effect contributed by 1.6 years without and 2.3 years with chronic disease, whereas the morbidity effect accounted for 1.7 years with chronic disease reflecting that the mortality effect of abstaining from smoking exceeds the gain in expected lifetime without disease by 1.7 years. Comparing ex-smokers with never smokers showed that the mortality effect contributes by 0.5 years without and 1.1 years with chronic disease and the morbidity effect contributed by 2.9 years without disease. Table 3 Differences between never smokers, smokers and ex-smokers in expected lifetime with and without chronic disease decomposed into the mortality and morbidity effects Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Note: Fifteen-year-old Palestinian men living in the West Bank, 2010. Table 3 Differences between never smokers, smokers and ex-smokers in expected lifetime with and without chronic disease decomposed into the mortality and morbidity effects Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Note: Fifteen-year-old Palestinian men living in the West Bank, 2010. Discussion The life-years lost due to smoking in our study were almost 7 and 4 years among heavy and moderate male smokers, respectively. As expected the results are consistent with the Danish estimates as the life tables by smoking category were constructed based on the overall life table for men living in the West Bank and Danish relative risk estimates for death due to smoking. However, life-years lost for Danish men was longer (life expectancy at age 25 reduced by 8.7 and 5.1 years among heavy and moderate male smokers, respectively)4 due to the overall longer life expectancy in Denmark compared with the occupied Palestinian territory. The use of Danish relative risk estimates for death was due to lack of known estimates from a Middle East male population. A meta-analysis of the impact of smoking on mortality suggests that the relative risks are fairly robust and not varying significantly between study populations.18 Thus, we assumed that the impact of smoking on death is ‘universal’ and does not differ between Palestinian and Danish men. However, because the classification of moderate and heavy smoking in the present study differed from that of the Danish study (1–14 cigarettes per day for moderate smoking, and ≥ 15 cigarettes per day for heavy smoking), the relative risks is assumed to be at a minimum and the results of the impact of smoking among Palestinian men to be underestimated. In our study, the loss of years without chronic disease was substantial among heavy smokers and in particular among ex-smokers, probably because ex-smokers stopped smoking due to chronic diseases. The prevalence of self-reported chronic disease differs from the prevalence based on for instance hospital discharge data, because some diseases seldom lead to a medical practitioner visit or a hospital contact, whereas other diseases will usually be diagnosed by a doctor or at a hospital. The Israeli occupation might affect the prevalence data on chronic diseases because the persistent tightening of closure systems, checkpoints, intensified difficulties in obtaining permits to travel and other restrictions on freedom of movement obstruct access to health care on the West Bank.19–21 Thus, restricted access to health care might result in undiagnosed diseases such as diabetes and chronic obstructive pulmonary disease. Due to the association between smoking and these and other diseases,22,23 prevalence of chronic diseases among smokers might be underestimated and therefore bias the results in the direction of more disease-free life expectancy among smokers. Furthermore, the unexpected higher proportion of disease-free life expectancy among smokers than never smokers might also partly be explained by general poor health among older Palestinian men or a healthy selection mechanism which might occur if healthy and robust (young) men are more prone to start smoking. Another reason for the high proportion of disease-free life expectancy among smokers can be premature mortality among smokers. Self-reported data on smoking habits might tend to result in underestimated smoking prevalence.24,25 This potential misclassification could lead to an underestimated difference in expected lifetime without chronic disease between smoking categories. The impact of smoking on disease-free life expectancy have been estimated in only a few studies.3–5 Expanding to the broader concept of health expectancy including expected lifetime in self-rated good health and disability-free life expectancy (typically investigated for middle-aged and older subpopulations) adds more studies.2,6–9 It is, however, not possible to compare the results from these studies and the present study because of differences in the choice of health expectancy indicators, age groups and smoking categories. Nevertheless, all studies conclude that smoking is the most serious preventable lifestyle risk factor for health-damaging effect–also when measured by loss of years in good health. The Palestinians living in the occupied territories are constantly exposed to the Israeli strategy of straining the population by military presence, violation and assaults from Israeli soldiers and Zionist settlers, land confiscation, house demolitions, injustice etc.20,26 These stressors, the abnormal living circumstances, economic hardship, unemployment and hopeless future prospects lead to increasing tobacco addiction, particularly among adolescents and young adults.27 Thus, in addition to be training ground for the Israeli military and arms industry the Palestinians are victims of aggressive marketing from the tobacco industry.28 This put an extra burden on The Palestinian National Authority: Besides the threats on the existence of the Palestine society, the health threat of tobacco is a great concern for the health authorities and call for effective, comprehensive and pervasive prevention policy against smoking by implementation and strengthen the regulations of the anti-smoking law. Supportive smoking cessation programmes to help smokers to quit should be recommended, but considering the age distribution of the population with one third being below 15 years of age, the main goal must be to protect children and adolescent from smoking.29,30 In particular, the low smoking prevalence among women should be maintained by make safe that girls abstain from start smoking. The most effective intervention is to raise taxes on tobacco.31 We strongly recommend to straighten out the lack of attention of the health impact of smoking on the Palestinian population and to follow-up activities to enforce the anti-smoking law. Funding The study did not receive any funding. Conflicts of interest: We declare that we have no conflicts of interest. We had no support from any organization for the submitted work and no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work. Key points In spite of a high prevalence of smoking (40 %) among men in the West Bank of the occupied Palestinian territory the impact of smoking on life expectancy and average lifetime in good health has never been examined among Palestinians. Heavy and moderate male smokers in the West Bank lose on average 7 and 4 years of life respectively compared with their never smoking counterparts. In addition, smoking causes a considerable loss of lifetime without chronic disease. The results must be of great concern for the Palestinian health authorities and emphasize the importance of enforcement of the anti-smoking law. The longterm strategy is first of all to protect children, adolescent and women to start smoking. References 1 Jha P , Peto R . Global effects of smoking, of quitting, and of taxing tobacco . N Engl J Med 2014 ; 370 : 60 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Nusselder WJ , Looman CWN , Marang-van de Mheen PJ , et al. Smoking and the compression of morbidity . J Epidemiol Community Health 2000 ; 54 : 566 – 74 . Google Scholar CrossRef Search ADS PubMed 3 Brønnum-Hansen H , Juel K . Abstention from smoking extends life and compresses morbidity: a population based study of health expectancy among smokers and never smokers in Denmark . Tob Control 2001 ; 10 : 273 – 8 . Google Scholar CrossRef Search ADS PubMed 4 Brønnum-Hansen H , Juel K , Davidsen M , Sørensen J . Impact of selected risk factors on expected lifetime without long-standing illness in Denmark . Prev Med 2007 ; 45 : 49 – 53 . 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Impact of selected risk factors on quality-adjusted life expectancy in Denmark . Scand J Pub Health 2007 ; 35 : 510 – 5 . Google Scholar CrossRef Search ADS 13 Palestinian Family Survey, 2010, Main Report, Ramallah , 2011 . Available at: http://www.pcbs.gov.ps/Portals/_PCBS/Downloads/book1821.pdf (4 September 2017, date last accessed). 14 MORTPAK for Windows . The United Nations Software Package for Demographic Measurement. Developed by the United Nations Population Division Department of Economic and Social Affairs. Available at: http://www.un.org/esa/population/publications/mortpak/MORTPAKwebpage.pdf (4 September 2017, date last accessed). 15 Sullivan DF . A single index of mortality and morbidity . Health Services and Mental Health Administration (HSMHA) Health Rep 1971 ; 86 : 347 – 54 . 16 Jagger C , Van Oyen H , Robine JM . Health expectancy calculation by the Sullivan method: A practical guide, 4rd Edition. EHLEIS. 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Barriers to the access to health services in the occupied Palestinian territory: a cohort study . Lancet 2012 ; 380 :Special Issue, S18 – 9 . Google Scholar CrossRef Search ADS 22 Willi C , Bodenmann P , Ghali WA , et al. Active smoking and the risk of type 2 diabetes. A systematic review and meta-analysis . JAMA 2007 ; 298 : 2655 – 64 . Google Scholar CrossRef Search ADS 23 Forey BA , Thornton AJ , Lee PN . Systematic review with meta-analysis of the epidemiological evidence relating smoking to COPD, chronic bronchitis and emphysema . BMC Pulmonary Med 2011 ; 11 : 36 . Google Scholar CrossRef Search ADS 24 Patrick DL , Cheadle A , Thompson DC , et al. The validity of self-reported smoking: a review and meta-analysis . Am J Public Health 1994 ; 84 : 1086 – 93 . Google Scholar CrossRef Search ADS PubMed 25 Vartiainen E , Seppala T , Lillsunde P , Puska P . Validation of self reported smoking by serum cotinine measurement in a community-based study . 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Patterns of global tobacco use in young people and implications for future chronic disease burden in adults . Lancet 2006 ; 367 : 749 – 53 . Google Scholar CrossRef Search ADS PubMed 30 Khader A , Shaheen Y , Turki Y , et al. Tobacco use among Palestinian refugee students (UNRWA) aged 13-15 . Prev Med 2009 ; 49 : 224 – 8 . Google Scholar CrossRef Search ADS PubMed 31 World Health Organization. WHO Report on the Global Tobacco Epidemic, 2015: Raising Taxes on Tobacco . Geneva : World Health Organization , 2015 . © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

The impact of smoking on expected lifetime with and without chronic disease among Palestinian men in the West Bank

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Oxford University Press
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1101-1262
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Abstract

Abstract Background The purpose of the study was to estimate life expectancy and the average lifetime with and without chronic disease among male never smokers, ex-smokers and smokers living in the West Bank of the occupied Palestinian territory. Methods The study used a life table for the West Bank male population and Danish relative risk estimates for death for smokers and ex-smokers vs. never smokers and utilized data from the Palestinian Family Survey 2010. Expected lifetime with and without chronic disease was estimated and the contributions from the mortality and the morbidity effect to smoking related difference in average lifetime with and without chronic disease were assessed by decomposition. Results In the West bank 40% of the male population are smokers. Life expectancy of 15-year-old Palestinian men who would never start smoking was 59.5 years, 41.1 of which were expected to be without chronic disease. Ex-smokers could expect 57.9 years of remaining lifetime, 37.7 years of which without disease. For lifelong heavy smokers (> 20 cigarettes per day), the expected lifetime was reduced to 52.6 years, of which 38.5 years were without chronic disease. Of the total loss of 6.9 years of life expectancy among heavy smokers, the mortality effect accounted for 2.5 years without and 4.4 years with disease, whereas the morbidity effect was negligible. Conclusions The high prevalence of smoking causes a considerable loss of life years and lifetime without chronic disease. We recommend the Palestinian health authorities to enforce the anti-smoking law. Introduction Smoking is a serious preventable killer and in spite of smokers’ shorter life, they live on average as many or more years in poor health as non-smokers do.1–9 In the occupied Palestinian territory, the prevalence of smoking is much higher in the West Bank than the Gaza Strip and (still) almost negligible among women. The anti-smoking law in Palestine (https://www.tobaccocontrollaws.org/legislation/country/palestine/laws), which bans smoking in public places, restricts advertising and sale, etc. might have had an impact and reduced tobacco use. Thus, smoking prevalence among men living in the West Bank has declined,10 but yet about 40% of male population are smokers (figure 1). Figure 1 View largeDownload slide Smoking prevalence among men, West Bank, 2010 Figure 1 View largeDownload slide Smoking prevalence among men, West Bank, 2010 Life expectancy for 20-year-old men in the West bank increased from 52.9 years in 2006 to 53.5 years in 2010, whereas average lifetime without chronic disease decreased from 37.6 to 36.0 years.11 Furthermore, no gain in disease-free life expectancy was observed for the most prevalent diseases. Thus, expected lifetime with hypertension, diabetes and heart diseases increased by 2.1, 1.3 and 0.8 years, respectively.11 The explanation of the observed expansion of morbidity might reflect improved notification of diseases, treatment and rehabilitation. However, as no expansion of morbidity was seen among women the increase for men was most likely due to a higher prevalence of chronic diseases. The high smoking prevalence and the fact that these diseases are associated with smoking are worrisome and challenge the Palestinian health authorities. The purpose of the present study was to estimate the impact of smoking on expected lifetime without and with chronic disease at age 15 among West Bank male never smokers, ex-smokers and smokers. Furthermore, the contributions from the mortality and morbidity effects to smoking related differences in expected lifetime without and with chronic disease were investigated. Due to low prevalence of smoking, the West Bank women and the Gaza Strip population were not included in the study. Methods Estimation of expected lifetime in different health states by smoking category requires life tables and health status data for each smoking category. To establish life tables by smoking category we needed relative risk for death due to smoking relative to never smoking. Because (to our knowledge) no relative risk estimates from a Middle East (male) population exists we used relative risk estimates from a Danish study (table 1).12 Furthermore, we needed prevalence of smoking by age group, which was extracted from The Palestinian Family Survey 2010.13 Table 1 Relative risk of death due to smoking by age and smoking category (estimates from a Danish study12) Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 Table 1 Relative risk of death due to smoking by age and smoking category (estimates from a Danish study12) Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 Smoking category Age group 15–34 35–64 65–74 75+ Never smoker 1 1 1 1 Ex-smoker 1 1.4 1.2 1.2 Moderate smoker (1–20 cigarettes per day) 1 2.1 1.6 1.2 Heavy smoker (> 20 cigarettes per day) 1 3.2 2.1 1.3 To construct life tables by smoking category, let P0 signify the prevalence of never smokers in a given age group, Pi that for smoking category i and RRi the relative risk (relative to never smokers, i = 0). Then, the death rate for the age group in question is given by D = ∑ Pi × RRi × D0, where RR0 = 1 (never smokers). From this equation the death rate for never smokers, D0, was calculated. The age-specific death rates for never smokers, D0, were multiplied by the relative risks, RRi, giving the age-specific death rates for each smoking category. Finally, life tables were constructed for each smoking category. The Palestinian Family Survey 2010 was representative for the Palestinian population of the occupied Palestinian territory (i.e. the Gaza Strip and the West Bank, including East Jerusalem). A two-stage random sample was drawn from lists of all Palestinian households. First, enumeration areas were selected from the Palestinian territories, and then a random sample of households was drawn from each enumeration area in the West Bank and the Gaza Strip. The surveys consisted of 15 355 households and the response rate was 89.4%. The present study included men aged 15 or above living in the West Bank (14 769 participants). Information on household members’ sociodemographic characteristics was provided by the head of household or another mature person. Data for all members were collected by self-reported responses or by proxy. Age was assessed by asking for the exact date of birth or any document with this information. Chronic disease was measured by answers to the question ‘Does (name) have any disease according to a medical diagnosis and receive treatment continuously?’ The interviewees were categorized as never smokers, ex-smokers, moderate smokers (1–20 cigarettes per day) and heavy smokers (> 20 cigarettes per day). Smokers of pipe or water pipe (Nargile) were excluded (664). Further details are available in the survey report.13 An abridged life table for men living in the West Bank was established by use of MortPak, the UN demographic measurement software package.14 For each smoking category disease-free life expectancy was calculated by Sullivan’s method15 combining life table figures and prevalence data of chronic disease status. The expected number of years lived in the age intervals 15–19, 20–24, …, 65–69, 70+ were multiplied by age-specific proportions of men without disease taken from the survey data. Expected lifetime without chronic disease for 15-year-olds was calculated by adding these years for all age groups and dividing the sum by the number of survivors at age 15. By relating this estimate of disease-free life expectancy to total life expectancy, a measure of the proportion of disease-free life expectancy was established. Statistical tests were carried out using a Z test and 95% confidence intervals were calculated from the formulae recommended by the International Network on Health Expectancy.16 The contributions from the mortality effect and the morbidity effect to smoking related differences in disease-free life expectancy were assessed by decomposing.17 A change in age-specific mortality will change life expectancy because a greater or lesser number of years lived affects not only the specific age group but also the years lived in future older ages. This change (the mortality effect) will increase or reduce expected lifetime with or without disease. A change in the proportion of people with or without disease represents the decomposition’s other component (the morbidity effect). Thus, the health gain of being a never smoker measured by disease-free life expectancy was divided into the components of the effects of mortality and morbidity. We declare that no ethical approval was required for this study based on secondary data. Results Life expectancy of 15-year-old Palestinian men in the West Bank who would never start smoking was 59.5 years (table 2). Ex-smokers could expect 57.9 years of remaining lifetime. The corresponding figures for lifelong moderate and heavy smoking men were 55.6 years and 52.6 years, respectively. Of the 59.5 years of their remaining life, never smokers could expect 41.1 (95% CI 40.3–41.9) years without chronic disease. Ex-smokers could expect 37.7 years (CI 35.9–39.4) to be spend without disease, which was statistically significantly (P = 0.01) shorter than expected disease-free lifetime for never smokers (table 2). The reduced average lifetime of 52.6 years for lifelong heavy smokers also reduced lifetime without chronic disease (P = 0.01) to 38.5 (CI 37.3–39.7) (table 2). Table 2 Life expectancy, expected lifetime with and without chronic disease and proportion of expected lifetime without chronic disease at age 15 for Palestinian men living in the West Bank, 2010, by smoking categories Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) Table 2 Life expectancy, expected lifetime with and without chronic disease and proportion of expected lifetime without chronic disease at age 15 for Palestinian men living in the West Bank, 2010, by smoking categories Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease Proportion of expected lifetime without chronic disease Years Years (95% CI) Years (95% CI) % (95% CI) Never smoker 59.5 41.1 (40.3–41.9) 18.4 (17.6–19.2) 69.1 (67.7–70.5) Ex-smoker 57.9 37.7 (35.9–39.4) 20.2 (18.4–22.0) 65.1 (62.0–68.1) Moderate smoker 55.6 41.2 (40.1–42.3) 14.4 (13.3–15.4) 74.1 (72.2–76.0) Heavy smoker 52.6 38.5 (37.3–39.7) 14.1 (12.9–15.2) 73.3 (71.0–75.5) All men 58.3 40.8 (40.3–41.4) 17.4 (16.9–18.0) 70.1 (69.2–71.0) The expected lifetime with chronic disease was 18.4 years (CI 17.6–19.2) for never smokers and 20.2 years (CI 18.4–22.0) for ex-smokers, but not significantly longer (P = 0.16). Thus, the proportion of expected lifetime without chronic disease was lower for ex-smokers than for never smokers, although not statistically significant. The never smokers’ 18.4 years of expected lifetime with chronic disease was statistically significantly longer than for smokers (P < 0.001), 14.4 years (CI 13.3–15.4) for moderate smokers and 14.1 years (CI 12.9–15.2) for heavy smokers. Unexpectedly, the proportion of the average lifetime without chronic disease was statistically significantly higher among smokers compared to never smokers (table 2). The mortality effect from the decomposition contributed by 2.5 years of expected lifetime without chronic disease and by 4.4 years with disease to the total loss of 6.9 years of life expectancy of heavy smokers compared to never smokers (table 3). The contribution from the morbidity component was negligible (0.1 years without disease). For moderate smokers the mortality effect contributed by 1.6 years without and 2.3 years with chronic disease, whereas the morbidity effect accounted for 1.7 years with chronic disease reflecting that the mortality effect of abstaining from smoking exceeds the gain in expected lifetime without disease by 1.7 years. Comparing ex-smokers with never smokers showed that the mortality effect contributes by 0.5 years without and 1.1 years with chronic disease and the morbidity effect contributed by 2.9 years without disease. Table 3 Differences between never smokers, smokers and ex-smokers in expected lifetime with and without chronic disease decomposed into the mortality and morbidity effects Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Note: Fifteen-year-old Palestinian men living in the West Bank, 2010. Table 3 Differences between never smokers, smokers and ex-smokers in expected lifetime with and without chronic disease decomposed into the mortality and morbidity effects Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Smoking category Life expectancy Expected lifetime without chronic disease Expected lifetime with chronic disease years years years Never smokers 59.5 41.1 18.4 Heavy smokers 52.6 38.5 14.1 Difference 6.9 2.6 4.3     Mortality effect 6.9 2.5 4.4     Morbidity effect 0.1 –0.1 Never smokers 59.5 41.1 18.4 Moderate smokers 55.6 41.2 14.4 Difference 3.9 –0.1 4.0     Mortality effect 3.9 1.6 2.3     Morbidity effect –1.7 1.7 Never smokers 59.5 41.1 18.4 Ex-smokers 57.9 37.7 20.2 Difference 1.6 3.4 –1.8     Mortality effect 1.6 0.5 1.1     Morbidity effect 2.9 –2.9 Note: Fifteen-year-old Palestinian men living in the West Bank, 2010. Discussion The life-years lost due to smoking in our study were almost 7 and 4 years among heavy and moderate male smokers, respectively. As expected the results are consistent with the Danish estimates as the life tables by smoking category were constructed based on the overall life table for men living in the West Bank and Danish relative risk estimates for death due to smoking. However, life-years lost for Danish men was longer (life expectancy at age 25 reduced by 8.7 and 5.1 years among heavy and moderate male smokers, respectively)4 due to the overall longer life expectancy in Denmark compared with the occupied Palestinian territory. The use of Danish relative risk estimates for death was due to lack of known estimates from a Middle East male population. A meta-analysis of the impact of smoking on mortality suggests that the relative risks are fairly robust and not varying significantly between study populations.18 Thus, we assumed that the impact of smoking on death is ‘universal’ and does not differ between Palestinian and Danish men. However, because the classification of moderate and heavy smoking in the present study differed from that of the Danish study (1–14 cigarettes per day for moderate smoking, and ≥ 15 cigarettes per day for heavy smoking), the relative risks is assumed to be at a minimum and the results of the impact of smoking among Palestinian men to be underestimated. In our study, the loss of years without chronic disease was substantial among heavy smokers and in particular among ex-smokers, probably because ex-smokers stopped smoking due to chronic diseases. The prevalence of self-reported chronic disease differs from the prevalence based on for instance hospital discharge data, because some diseases seldom lead to a medical practitioner visit or a hospital contact, whereas other diseases will usually be diagnosed by a doctor or at a hospital. The Israeli occupation might affect the prevalence data on chronic diseases because the persistent tightening of closure systems, checkpoints, intensified difficulties in obtaining permits to travel and other restrictions on freedom of movement obstruct access to health care on the West Bank.19–21 Thus, restricted access to health care might result in undiagnosed diseases such as diabetes and chronic obstructive pulmonary disease. Due to the association between smoking and these and other diseases,22,23 prevalence of chronic diseases among smokers might be underestimated and therefore bias the results in the direction of more disease-free life expectancy among smokers. Furthermore, the unexpected higher proportion of disease-free life expectancy among smokers than never smokers might also partly be explained by general poor health among older Palestinian men or a healthy selection mechanism which might occur if healthy and robust (young) men are more prone to start smoking. Another reason for the high proportion of disease-free life expectancy among smokers can be premature mortality among smokers. Self-reported data on smoking habits might tend to result in underestimated smoking prevalence.24,25 This potential misclassification could lead to an underestimated difference in expected lifetime without chronic disease between smoking categories. The impact of smoking on disease-free life expectancy have been estimated in only a few studies.3–5 Expanding to the broader concept of health expectancy including expected lifetime in self-rated good health and disability-free life expectancy (typically investigated for middle-aged and older subpopulations) adds more studies.2,6–9 It is, however, not possible to compare the results from these studies and the present study because of differences in the choice of health expectancy indicators, age groups and smoking categories. Nevertheless, all studies conclude that smoking is the most serious preventable lifestyle risk factor for health-damaging effect–also when measured by loss of years in good health. The Palestinians living in the occupied territories are constantly exposed to the Israeli strategy of straining the population by military presence, violation and assaults from Israeli soldiers and Zionist settlers, land confiscation, house demolitions, injustice etc.20,26 These stressors, the abnormal living circumstances, economic hardship, unemployment and hopeless future prospects lead to increasing tobacco addiction, particularly among adolescents and young adults.27 Thus, in addition to be training ground for the Israeli military and arms industry the Palestinians are victims of aggressive marketing from the tobacco industry.28 This put an extra burden on The Palestinian National Authority: Besides the threats on the existence of the Palestine society, the health threat of tobacco is a great concern for the health authorities and call for effective, comprehensive and pervasive prevention policy against smoking by implementation and strengthen the regulations of the anti-smoking law. Supportive smoking cessation programmes to help smokers to quit should be recommended, but considering the age distribution of the population with one third being below 15 years of age, the main goal must be to protect children and adolescent from smoking.29,30 In particular, the low smoking prevalence among women should be maintained by make safe that girls abstain from start smoking. The most effective intervention is to raise taxes on tobacco.31 We strongly recommend to straighten out the lack of attention of the health impact of smoking on the Palestinian population and to follow-up activities to enforce the anti-smoking law. Funding The study did not receive any funding. Conflicts of interest: We declare that we have no conflicts of interest. We had no support from any organization for the submitted work and no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work. Key points In spite of a high prevalence of smoking (40 %) among men in the West Bank of the occupied Palestinian territory the impact of smoking on life expectancy and average lifetime in good health has never been examined among Palestinians. Heavy and moderate male smokers in the West Bank lose on average 7 and 4 years of life respectively compared with their never smoking counterparts. In addition, smoking causes a considerable loss of lifetime without chronic disease. The results must be of great concern for the Palestinian health authorities and emphasize the importance of enforcement of the anti-smoking law. The longterm strategy is first of all to protect children, adolescent and women to start smoking. References 1 Jha P , Peto R . Global effects of smoking, of quitting, and of taxing tobacco . N Engl J Med 2014 ; 370 : 60 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Nusselder WJ , Looman CWN , Marang-van de Mheen PJ , et al. Smoking and the compression of morbidity . J Epidemiol Community Health 2000 ; 54 : 566 – 74 . Google Scholar CrossRef Search ADS PubMed 3 Brønnum-Hansen H , Juel K . Abstention from smoking extends life and compresses morbidity: a population based study of health expectancy among smokers and never smokers in Denmark . Tob Control 2001 ; 10 : 273 – 8 . Google Scholar CrossRef Search ADS PubMed 4 Brønnum-Hansen H , Juel K , Davidsen M , Sørensen J . Impact of selected risk factors on expected lifetime without long-standing illness in Denmark . Prev Med 2007 ; 45 : 49 – 53 . 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Impact of selected risk factors on quality-adjusted life expectancy in Denmark . Scand J Pub Health 2007 ; 35 : 510 – 5 . Google Scholar CrossRef Search ADS 13 Palestinian Family Survey, 2010, Main Report, Ramallah , 2011 . Available at: http://www.pcbs.gov.ps/Portals/_PCBS/Downloads/book1821.pdf (4 September 2017, date last accessed). 14 MORTPAK for Windows . The United Nations Software Package for Demographic Measurement. Developed by the United Nations Population Division Department of Economic and Social Affairs. Available at: http://www.un.org/esa/population/publications/mortpak/MORTPAKwebpage.pdf (4 September 2017, date last accessed). 15 Sullivan DF . A single index of mortality and morbidity . Health Services and Mental Health Administration (HSMHA) Health Rep 1971 ; 86 : 347 – 54 . 16 Jagger C , Van Oyen H , Robine JM . Health expectancy calculation by the Sullivan method: A practical guide, 4rd Edition. EHLEIS. Available at: http://reves.site.ined.fr/fichier/s_rubrique/20182/sullivan.guide.pre.final.oct2014.en.pdf (4 September 2017, date last accessed). 17 Nusselder WJ , Looman CW . Decomposition of differences in health expectancy by cause . Demography 2004 ; 41 : 315 – 34 . Google Scholar CrossRef Search ADS PubMed 18 Shavelle RM , Paculdo DR , Strauss DJ , Kush J . Smoking habits and mortality: a meta-analysis . J Insur Med 2008 ; 40 : 170 – 8 . Google Scholar PubMed 19 Rytter MJH , Kjældgaard A-L , Brønnum-Hansen H , Helweg LK . Effects of armed conflict on access to emergency health care in Palestine West Bank: systematic collection of data in emergency departments . BMJ 2006 ; 332 : 1122 – 4 . Google Scholar CrossRef Search ADS PubMed 20 Batniji R , Rabaia Y , Nguyen-Gillham V , et al. Health as human security in the occupied Palestinian territory . Lancet 2009 ; 373 : 1133 – 43 . Google Scholar CrossRef Search ADS PubMed 21 Vitullo A , Soboh A , Oskarsson J , et al. Barriers to the access to health services in the occupied Palestinian territory: a cohort study . Lancet 2012 ; 380 :Special Issue, S18 – 9 . Google Scholar CrossRef Search ADS 22 Willi C , Bodenmann P , Ghali WA , et al. Active smoking and the risk of type 2 diabetes. A systematic review and meta-analysis . JAMA 2007 ; 298 : 2655 – 64 . Google Scholar CrossRef Search ADS 23 Forey BA , Thornton AJ , Lee PN . Systematic review with meta-analysis of the epidemiological evidence relating smoking to COPD, chronic bronchitis and emphysema . BMC Pulmonary Med 2011 ; 11 : 36 . Google Scholar CrossRef Search ADS 24 Patrick DL , Cheadle A , Thompson DC , et al. The validity of self-reported smoking: a review and meta-analysis . Am J Public Health 1994 ; 84 : 1086 – 93 . Google Scholar CrossRef Search ADS PubMed 25 Vartiainen E , Seppala T , Lillsunde P , Puska P . Validation of self reported smoking by serum cotinine measurement in a community-based study . J Epidemiol Commun Health 2002 ; 56 : 167 – 70 . Google Scholar CrossRef Search ADS 26 Giacaman R , Khatib R , Shabaneh L , et al. Health status and health services in the occupied Palestinian territory . Lancet 2009 ; 373 : 837 – 49 . Google Scholar CrossRef Search ADS 27 Abu-Rmeileh NME , Alderete E , Duque LF , et al. Smoking among adolescents and teenagers living under conflict: cross-sectional surveys in three settings. TheLancet.com. Published online July 5, 2011. Available at: http://www.thelancet.com/health-in-the-occupied-palestinian-territory-2011 (4 September 2017, date last accessed). 28 Eriksen M , Mackay J , Schluger NW , et al. The tobacco atlas. The American Cancer Society and World Lung Foundation, 2015. Available at: http://www.tobaccoatlas.org (4 September 2017, date last accessed). 29 Warren CW , Jones NR , Eriksen MP , Asma S . for the Global Tobacco Surveillance System (GTSS) collaborative group . Patterns of global tobacco use in young people and implications for future chronic disease burden in adults . Lancet 2006 ; 367 : 749 – 53 . Google Scholar CrossRef Search ADS PubMed 30 Khader A , Shaheen Y , Turki Y , et al. Tobacco use among Palestinian refugee students (UNRWA) aged 13-15 . Prev Med 2009 ; 49 : 224 – 8 . Google Scholar CrossRef Search ADS PubMed 31 World Health Organization. WHO Report on the Global Tobacco Epidemic, 2015: Raising Taxes on Tobacco . Geneva : World Health Organization , 2015 . © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The European Journal of Public HealthOxford University Press

Published: Oct 31, 2017

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