Smoking-related Deaths Research Articles

Toxic metal and nicotine content of cigarettes sold in China, 2009 and 2012.

Metals of primary health concern can accumulate in the tobacco plant and contribute to smokers' exposures to carcinogens, a significant cause of the millions of smoking-related deaths in China each year. These exposures are due to the smoker's addiction to nicotine. This study sought to explore toxic heavy metal and nicotine concentrations in the tobacco of Chinese cigarette brands purchased in 2009 and 2012, as well as its regional variation. Cigarette packs for this study were purchased from seven Chinese cities in 2009 and 2012, and 91 pairs of cigarettes were matched based on UPC for comparison. Ten cigarette sticks were randomly selected from each pack and tested using polarised energy dispersive X-ray fluorescence (XRF) for arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni) and lead (Pb) concentrations. Nicotine analysis was conducted following Coresta's Recommended Method N°62. Data analysis was conducted using SPSS, encompassing descriptive statistics, correlations and generalised estimating equations to observe changes in brand varieties overtime. On average, from 2009 to 2012, As, Cd, Cr and Pb concentrations have decreased in Chinese tobacco. Of the seven cities where the cigarette brands were purchased, only four cities showed significant differences of the selected metals from 2009 to 2012. However, there was no significant change in the tobacco nicotine content from 2009 to 2012. Tobacco in Chinese cigarettes purchased in seven geographically disbursed cities contains consistently high levels of metals, including carcinogens like Cd. One source may be the improper use of fertilisers. These numbers should be monitored more carefully and regulated by health officials.

Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis

Objective To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with...

Smoking cessation reverses DNA double-strand breaks in human mononuclear cells.

ObjectiveCigarette smoking is a major risk factor for atherosclerotic cardiovascular disease, which is responsible for a significant proportion of smoking-related deaths. However, the precise mechanism whereby smoking induces this pathology has not been fully delineated. Based on observation of DNA double-strand breaks (DSBs), the most harmful type of DNA damage, in atherosclerotic lesions, we hypothesized that there is a direct association between smoking and DSBs. The goal of this study was to investigate whether smoking induces DSBs and smoking cessation reverses DSBs in vivo through examination of peripheral mononuclear cells (MNCs).Approach and ResultsImmunoreactivity of oxidative modification of DNA and DSBs were increased in human atherosclerotic lesions but not in the adjacent normal area. DSBs in human MNCs isolated from the blood of volunteers can be detected as cytologically visible “foci” using an antibody against the phosphorylated form of the histone H2AX (γ-H2AX). Young healthy active smokers (n = 15) showed increased γ-H2AX foci number when compared with non-smokers (n = 12) (foci number/cell: median, 0.37/cell; interquartile range [IQR], 0.31–0.58 vs. 4.36/cell; IQR, 3.09–7.39, p<0.0001). Smoking cessation for 1 month reduced the γ-H2AX foci number (median, 4.44/cell; IQR, 4.36–5.24 to 0.28/cell; IQR, 0.12–0.53, p<0.05). A positive correlation was noted between γ-H2AX foci number and exhaled carbon monoxide levels (r = 0.75, p<0.01).ConclusionsSmoking induces DSBs in human MNCs in vivo, and importantly, smoking cessation for 1 month resulted in a decrease in DSBs to a level comparable to that seen in non-smokers. These data reinforce the notion that the cigarette smoking induces DSBs and highlight the importance of smoking cessation.

Abstract 447: Acrolein-Modified HDL Impairs Cholesterol Transport and HDL Function

The interaction between scavenger receptor BI (SR-BI) and HDL reduces the risk for cardiovascular disease (CVD) by playing key roles in the reverse cholesterol transport pathway (RCT). In the beginning of RCT, SR-BI stimulates release of free cholesterol (FC) from peripheral macrophages to HDL, whereas in the final step of RCT, HDL binds to hepatic SR-BI for delivery of excess cholesteryl esters (CE) into the liver for excretion via bile. While “functioning” HDL is crucial in protection against CVD, environmental factors such as acrolein, a highly reactive aldehyde found in tobacco smoke, can induce oxidative stress that promotes HDL modifications and renders the particle “dysfunctional”. Although there is a strong correlation between cigarette smoking and CVD risk, much less is known about the effects of smoking on RCT. We hypothesized that acrolein modifications to HDL (acro-HDL) generate a dysfunctional particle by: (i) impairing SR-BI-mediated selective uptake of HDL-CE and efflux of FC and (ii) upregulating inflammatory pathways in macrophages that promote atherogenesis. To test this hypothesis, human HDL was modified with 250μM acrolein and acrolein adducts on HDL were confirmed by immunoblot analysis and mass spectrometry. To evaluate acro-HDL’s functionality at the beginning of RCT, SR-BI-mediated FC release to native- or acro-HDL was measured in SR-BI-transfected COS-7 cells. Our data revealed that there was 30% less efflux of FC in the presence of acro-HDL as compared to native HDL. To assess acro-HDL functionality at the end of RCT, HDL binding and HDL-CE uptake assays were performed and acro-HDL (0-50μg/mL) was 10-25% less efficient at delivering CE to cells via SR-BI. Finally, to determine whether acro-HDL was rendered atherogenic, we used qRT-PCR to demonstrate that acro-HDL, but not native HDL, paralleled the effects of oxidized LDL by upregulating mRNA scavenger receptor expression (CD36 and LOX-1) and inflammatory marker expression (MCP-1, IL-6, ICAM-1) in THP-1 macrophages. Altogether, our data reveal that acrolein modification produces a dysfunctional HDL particle that upregulates inflammatory pathways. More detailed investigations into the impact of acrolein adducts on HDL function may help prevent smoking-related CVD deaths.

Control del tabaco y reducción de la mortalidad prematura relacionada con el tabaco en Estados Unidos 1964-2012

En este ano 2014, se cumple el 50 aniversario del primer informe tabaco y salud. Este documento original fue realizado por organizaciones gubernamentales, no gubernamentales y el sector privado con el objetivo de reducir la mortalidad derivada del consumo del tabaco intentando disminuir el inicio del habito del tabaco y promover el cese del habito del tabaco. Se publica ahora en JAMA un manuscrito que valora la reduccion de la mortalidad asociada al tabaco desde 1964 hasta 2012. Las variables estudiadas fueron el numero de muertes prematuras evitadas y los anos de vida ganados. Los cambios en la esperanza de vida asociados con el cambio en la exposicion al tabaco era otra de las variables estudiadas. Resultados: Desde 1964 a 2012 se estimo que 17,7 millones de muertes estaban relacionadas con el tabaco y se estimo que 8 millones de muertes (IC 7,4-8,3 millones) prematuras fueron evitadas por el control del tabaco, de ellas 5,3 millones (IC 4,8-5,5 millones) en hombres y 2,7 millones (IC 2,5-2,7 millones) en mujeres. Por otra parte, se estimo en 157 millones de anos (IC 139-165 millones) los ganados por el control del tabaco de ellos 111 (IC 97-117) en hombres y 46 (IC 42-48) en mujeres, con una media de 19,6 anos por beneficiario. Durante este tiempo, se estimo que el incremento en la esperanza de vida fue de 7,8 anos para hombres y 5,4 anos para las mujeres de los que estan asociados con el control del tabaco 2,3 anos (IC 1,8-2,5 anos) en los hombres y 1,6 anos (IC 1,4-1,7 anos) en las mujeres, lo que supone que un 30% (IC 23-33) del incremento en la esperanza de vida en los hombres y un 29% (IC 25-32) del incremento de la esperanza de vida es las mujeres esta relacionado con el control del tabaco. Conclusiones: El control del tabaco se estima que esta asociado con evitar 8 millones de muertes prematuras y con un aumento en la vida media de 19-20 anos. Aunque el control del tabaco es un logro importante de salud publica alcanzado, los esfuerzos deben continuar para reducir la mortalidad relacionada con el tabaco.

Burden of total and cause-specific mortality related to tobacco smoking among adults aged ≥ 45 years in Asia: a pooled analysis of 21 cohorts.

Tobacco smoking is a major risk factor for many diseases. We sought to quantify the burden of tobacco-smoking-related deaths in Asia, in parts of which men's smoking prevalence is among the world's highest. We performed pooled analyses of data from 1,049,929 participants in 21 cohorts in Asia to quantify the risks of total and cause-specific mortality associated with tobacco smoking using adjusted hazard ratios and their 95% confidence intervals. We then estimated smoking-related deaths among adults aged ≥45 y in 2004 in Bangladesh, India, mainland China, Japan, Republic of Korea, Singapore, and Taiwan-accounting for ∼71% of Asia's total population. An approximately 1.44-fold (95% CI = 1.37-1.51) and 1.48-fold (1.38-1.58) elevated risk of death from any cause was found in male and female ever-smokers, respectively. In 2004, active tobacco smoking accounted for approximately 15.8% (95% CI = 14.3%-17.2%) and 3.3% (2.6%-4.0%) of deaths, respectively, in men and women aged ≥45 y in the seven countries/regions combined, with a total number of estimated deaths of ∼1,575,500 (95% CI = 1,398,000-1,744,700). Among men, approximately 11.4%, 30.5%, and 19.8% of deaths due to cardiovascular diseases, cancer, and respiratory diseases, respectively, were attributable to tobacco smoking. Corresponding proportions for East Asian women were 3.7%, 4.6%, and 1.7%, respectively. The strongest association with tobacco smoking was found for lung cancer: a 3- to 4-fold elevated risk, accounting for 60.5% and 16.7% of lung cancer deaths, respectively, in Asian men and East Asian women aged ≥45 y. Tobacco smoking is associated with a substantially elevated risk of mortality, accounting for approximately 2 million deaths in adults aged ≥45 y throughout Asia in 2004. It is likely that smoking-related deaths in Asia will continue to rise over the next few decades if no effective smoking control programs are implemented. Please see later in the article for the Editors' Summary.

Diffuse Smoking-Related Lung Disease: Emphysema and Interstitial Lung Disease

Themaincauses of smoking-related deaths are lung cancer, chronicobstructive pulmonary disease (COPD), and ischemic heartdisease.Smokinghasalsobeenstronglyassociatedwithseveralinterstitiallungdiseases(ILDs),namelypulmonaryLangerhanscell histiocytosis (PLCH), respiratory bronchiolitis (RB), RB-associated ILD (RB-ILD), and desquamative interstitialpneumonia (DIP).This article reviews the major diffuse pulmonary diseasesaffectingsmokers,includingemphysemaandsmoking-relatedILDs. We describe the histologic and radiologic features of thedifferent forms of emphysema (centrilobular, panlobular, andparaseptal). Finally, we then discuss the clinical, histopatho-logic, and radiologic characteristics of smoking-related ILDs,including PLCH, RB, RB-ILD, and DIP. Bronchogenic carci-noma is not covered in this article.

Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012

Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012

Losing Ground - Swedish Life Expectancy in a Comparative Perspective

BackgroundIn the beginning of the 1970s, Sweden was the country where both women and men enjoyed the world's longest life expectancy. While life expectancy continues to be high and increasing, Sweden has been losing ground in relation to other leading countries.MethodsWe look at life expectancy over the years 1970–2008 for men and women. To assess the relative contributions of age, causes of death, and smoking we decompose differences in life expectancy between Sweden and two leading countries, Japan and France. This study is the first to use this decomposition method to observe how smoking related deaths contribute to life expectancy differences between countries.ResultsSweden has maintained very low mortality at young and working ages for both men and women compared to France and Japan. However, mortality at ages above 65 has become considerably higher in Sweden than in the other leading countries because the decrease has been faster in those countries. Different trends for circulatory diseases were the largest contributor to this development in both sexes but for women also cancer played a role. Mortality from neoplasms has been considerably low for Swedish men. Smoking attributable mortality plays a modest role for women, whereas it is substantially lower in Swedish men than in French and Japanese men.ConclusionsSweden is losing ground in relation to other leading countries with respect to life expectancy because mortality at high ages improves more slowly than in the leading countries, especially due to trends in cardiovascular disease mortality. Trends in smoking rates may provide a partial explanation for the trends in women; however, it is not possible to isolate one single explanatory factor for why Sweden is losing ground.

Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964-2012.

January 2014 marks the 50th anniversary of the first surgeon general's report on smoking and health. This seminal document inspired efforts by governments, nongovernmental organizations, and the private sector to reduce the toll of cigarette smoking through reduced initiation and increased cessation. To model reductions in smoking-related mortality associated with implementation of tobacco control since 1964. Smoking histories for individual birth cohorts that actually occurred and under likely scenarios had tobacco control never emerged were estimated. National mortality rates and mortality rate ratio estimates from analytical studies of the effect of smoking on mortality yielded death rates by smoking status. Actual smoking-related mortality from 1964 through 2012 was compared with estimated mortality under no tobacco control that included a likely scenario (primary counterfactual) and upper and lower bounds that would capture plausible alternatives. National Health Interview Surveys yielded cigarette smoking histories for the US adult population in 1964-2012. Number of premature deaths avoided and years of life saved were primary outcomes. Change in life expectancy at age 40 years associated with change in cigarette smoking exposure constituted another measure of overall health outcomes. In 1964-2012, an estimated 17.7 million deaths were related to smoking, an estimated 8.0 million (credible range [CR], 7.4-8.3 million, for the lower and upper tobacco control counterfactuals, respectively) fewer premature smoking-related deaths than what would have occurred under the alternatives and thus associated with tobacco control (5.3 million [CR, 4.8-5.5 million] men and 2.7 million [CR, 2.5-2.7 million] women). This resulted in an estimated 157 million years (CR, 139-165 million) of life saved, a mean of 19.6 years for each beneficiary (111 million [CR, 97-117 million] for men, 46 million [CR, 42-48 million] for women). During this time, estimated life expectancy at age 40 years increased 7.8 years for men and 5.4 years for women, of which tobacco control is associated with 2.3 years (CR, 1.8-2.5) (30% [CR, 23%-32%]) of the increase for men and 1.6 years (CR, 1.4-1.7) (29% [CR, 25%-32%]) for women. Tobacco control was estimated to be associated with avoidance of 8 million premature deaths and an estimated extended mean life span of 19 to 20 years. Although tobacco control represents an important public health achievement, efforts must continue to reduce the effect of smoking on the nation's death toll.

Effective Smoking-Cessation Strategies in Primary Care Setting

Smoking leads to nicotine addiction and serious health problems and smoking cessation can reduce the risk of developing smoking-related diseases and premature death. Smoking is a chronic disease that requires repeated interventions, including counseling and pharmacotherapy. These are both effective for smoking cessation, but combined intervention is more effective than using either alone. Several first-line medications are effective and recommended for use, such as nicotine-replacement therapy (patch, gum, inhaler, lozenge, and nasal spray), bupropion SR, and varenicline. Special populations such as adolescent smokers, pregnant women, and smokers with mental illness can be treated with both counselling and medication. Physicians should recommend effective counselling and pharmacotherapy strategies to all smokers at every clinic visit. Insurance coverage for counselling and medications for quitting smoking are essential to reduce the smoking rate, especially in a primary care setting. (Korean J Med 2014;87:296-301)

Assessing Public Awareness about the Health Effects of Nicotine and Cigarettes Using Negative Binomial Regression

Both the public and private sectors have acted responsibly to help decrease smoking-related deaths by putting health warnings on all cigarette packages. This study investigated the social or demographic factors associated with public awareness of health warnings on the harmful effects of environmental tobacco smoke based on baseline data collected by the health bureau of Amhara Region (in Ethiopia). Respondents in the survey were asked to recall the number of anti-smoking messages which appeared as warning messages on cigarette advertisements. The number of anti-smoking messages recalled ranged from 0 to 7 with a mean of 2.90 (variance of 3.11) and a median of 3.00. Because the variance (3.11) was different from mean (2.9), the negative binomial regression model provided an improved fit to the data and accounted better for over dispersion than the Poisson regression model, which assumed that the mean and variance are the same. The level of education was found to be the most significant factors. Moreover, the lower income socio-economic class nonsmokers’ anti-smoking messages recalling rate was 2.5 times that of the lower socio-economic class smokers. Unlike men, women’s anti-smoking message response rate increased with income.

Emotional graphic cigarette warning labels reduce the electrophysiological brain response to smoking cues

There is an ongoing public debate about the new graphic warning labels (GWLs) that the Food and Drug Administration (FDA) proposes to place on cigarette packs. Tobacco companies argued that the strongly emotional images FDA proposed to include in the GWLs encroached on their constitutional rights. The court ruled that FDA did not provide sufficient scientific evidence of compelling public interest in such encroachment. This study's objectives were to examine the effects of the GWLs on the electrophysiological and behavioral correlates of smoking addiction and to determine whether labels rated higher on the emotional reaction (ER) scale are associated with greater effects. We studied 25 non-treatment-seeking smokers. Event-related potentials (ERPs) were recorded while participants viewed a random sequence of paired images, in which visual smoking (Cues) or non-smoking (non-Cues) images were preceded by GWLs or neutral images. Participants reported their cigarette craving after viewing each pair. Dependent variables were magnitude of P300 ERPs and self-reported cigarette craving in response to Cues. We found that subjective craving response to Cues was significantly reduced by preceding GWLs, whereas the P300 amplitude response to Cues was reduced only by preceding GWLs rated high on the ER scale. In conclusion, our study provides experimental neuroscience evidence that weighs in on the ongoing public and legal debate about how to balance the constitutional and public health aspects of the FDA-proposed GWLs. The high toll of smoking-related illness and death adds urgency to the debate and prompts consideration of our findings while longitudinal studies of GWLs are underway.

Smoking-related deaths averted due to three years of policy progress.

To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010. Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models. In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700,000), cessation treatments (380,000), and bans on tobacco marketing (306,000). From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.

Reductions in Cardiovascular, Cerebrovascular, and Respiratory Mortality following the National Irish Smoking Ban: Interrupted Time-Series Analysis

BackgroundPrevious studies have shown decreases in cardiovascular mortality following the implementation of comprehensive smoking bans. It is not known whether cerebrovascular or respiratory mortality decreases post-ban. On March 29, 2004, the Republic of Ireland became the first country in the world to implement a national workplace smoking ban. The aim of this study was to assess the effect of this policy on all-cause and cause-specific, non-trauma mortality.MethodsA time-series epidemiologic assessment was conducted, utilizing Poisson regression to examine weekly age and gender-standardized rates for 215,878 non-trauma deaths in the Irish population, ages ≥35 years. The study period was from January 1, 2000, to December 31, 2007, with a post-ban follow-up of 3.75 years. All models were adjusted for time trend, season, influenza, and smoking prevalence.ResultsFollowing ban implementation, an immediate 13% decrease in all-cause mortality (RR: 0.87; 95% CI: 0.76–0.99), a 26% reduction in ischemic heart disease (IHD) (RR: 0.74; 95% CI: 0.63–0.88), a 32% reduction in stroke (RR: 0.68; 95% CI: 0.54–0.85), and a 38% reduction in chronic obstructive pulmonary disease (COPD) (RR: 0.62; 95% CI: 0.46–0.83) mortality was observed. Post-ban reductions in IHD, stroke, and COPD mortalities were seen in ages ≥65 years, but not in ages 35–64 years. COPD mortality reductions were found only in females (RR: 0.47; 95% CI: 0.32–0.70). Post-ban annual trend reductions were not detected for any smoking-related causes of death. Unadjusted estimates indicate that 3,726 (95% CI: 2,305–4,629) smoking-related deaths were likely prevented post-ban. Mortality decreases were primarily due to reductions in passive smoking.ConclusionsThe national Irish smoking ban was associated with immediate reductions in early mortality. Importantly, post-ban risk differences did not change with a longer follow-up period. This study corroborates previous evidence for cardiovascular causes, and is the first to demonstrate reductions in cerebrovascular and respiratory causes.

Faut-il arrêter le tabac quand on est âgé ? Oui ! Le sevrage tabagique est bénéfique à tout âge

Smoking prevalence remains high among the elderly. Mortality of older smokers is multiplied by 2 to 3 compared to subjects who had never smoked and 70 % of smoking-related deaths occur beyond 60 years. Smoking is a risk factor for premature death, including among older subjects, with a loss of at least 10 years of life expectancy compared to non-smokers. Smoking cessation increases life expectancy even in patients over 60 years, with a relative reduction in the risk of death of about 20 to 30 %, including beyond 80 years. The fastest and most important benefit is cardiovascular, particularly in the context of secondary prevention. This benefit increases with time since smoking cessation, hence the importance of the earliest possible withdrawal. Smoking cessation is not more difficult than in young subjects and the different therapeutic approaches have the same efficacy as in younger. It is essential to stop smoking as soon as possible, but there is no age beyond which it is totally unnecessary.

Call for papers—respiratory medicine

According to the Global Burden of Disease study, chronic obstructive pulmonary disease, lower respiratory infections, and lung cancer were the third, fourth, and fifth most substantial causes of death, respectively, in 2010.1 Deaths from chronic respiratory diseases are estimated to have totalled 3·78 million in 2010; trachea, bronchus, and lung cancer deaths are estimated to have increased from 1·04 million in 1990 to 1·53 million in 2010, reflecting, among other factors, a substantial rise in smoking-related deaths in developing countries.

An Antinicotine Vaccine

Roughly 500,000 Americans die from smoking-related deaths annually, and approved “stop smoking” methods work at most 30% of the time. Alternative

Impact of reduced ignition propensity cigarette regulation on consumer smoking behavior and quit intentions: evidence from 6 waves (2004–11) of the ITC Four Country Survey

BackgroundAlthough on the decline, smoking-related fires remain a leading cause of fire death in the United States and United Kingdom and account for over 10% of fire-related deaths worldwide. This has prompted lawmakers to enact legislation requiring manufacturers to implement reduced ignition propensity (RIP) safety standards for cigarettes. The current research evaluates how implementation of RIP safety standards in different countries influenced smokers’ perceptions of cigarette self-extinguishment, frequency of extinguishment, and the impact on consumer smoking behaviors, including cigarettes smoked per day and planning to quit.MethodsParticipants for this research come from Waves 3 through 8 of the International Tobacco Control (ITC) Four Country Survey conducted longitudinally from 2004 through 2011 in the United States, United Kingdom, Australia, and Canada.ResultsPerceptions of cigarette self-extinguishment and frequency of extinguishment increased concurrently with an increase in the prevalence of RIP safety standards for cigarettes. Presence of RIP safety standards was also associated with a greater intention to quit smoking, but was not associated with the number of cigarettes smoked per day. Intention to quit was higher among those who were more likely to report that their cigarettes self-extinguish sometimes and often, but we found no evidence of an interaction between frequency of extinguishment and RIP safety standards on quit intentions.ConclusionsOverall, because these standards largely do not influence consumer smoking behavior, RIP implementation may significantly reduce the number of cigarette-related fires and the associated death and damages. Further research should assess how implementation of RIP safety standards has influenced smoking-related fire incidence, deaths, and other costs associated with smoking-related fires.

Valuation of Tobacco Control Policies by the Public in North Carolina: Comparing Perceived Benefit With Projected Cost of Implementation

After 40 years of continuous decline, smoking rates in the United States have stabilized signaling a challenge for tobacco control. Renewed decline may be guided by public opinion where support for tobacco control is strong. This study sought the public's preferences about tobacco control strategies. This contingent valuation study investigated whether the public's valuations of 2 tobacco control policies outweighed their implementation costs. In a hypothetical referendum, a representative sample of North Carolinians aged 45-64 years (n = 644) was asked to indicate whether they would prefer a policy that would halve the youth smoking rate or one that would reduce smoking-related deaths by 10%, and to indicate how much additional tax they would be willing to pay to implement their preferred policy. This willingness-to-pay value formed the perceived "benefit" component in a cost-benefit analysis. Costs to halve youth smoking were calculated from evidence about the resources required to increase the state tobacco excise tax. Costs to reduce tobacco-related deaths were based on evidence about the resources required for a counseling quitline offering free nicotine replacement therapy. The majority (85%) of respondents voted to halve the youth smoking rate. The mean maximum amount per person that voters were willing to pay in 1 year to do that was $14.90 (95% CI, $10.10-$19.60), and the maximum amount per person they were willing to pay in 1 year to reduce smoking-related deaths was $13.70 (95% CI, $2.10-$25.40). When aggregated to the North Carolina population aged 45-64 years (N = 2,400,144), the perceived benefit of halving youth smoking was $35.8 million. Implementation of a program to achieve this outcome would cost $109.8 million. Aggregating to the same population, the perceived benefit of a 10% reduction in tobacco-related deaths was $32.9 million, an amount that exceeds the $12.8 million estimated cost of achieving the outcome. A counseling quitline with free nicotine replacement therapy would achieve a positive net benefit.