In a first-of-its-kind examination of death in the United States, government researchers report today that while heart disease and cancer may be listed as the nation's leading killers, the biggest underlying cause of death is tobacco use.
The authors came to the startling conclusion that nearly half of the 2.148 million deaths in 1990 could have been prevented through behavioral changes, among them stopping smoking, eating healthier food, exercising more, shunning alcohol and practicing safe sex.
But the research, published in today's Journal of the American Medical Association, singled out tobacco as the No. 1 culprit in causing death. It found that smoking contributed to the deaths of 400,000 people in 1990 -- more than the deaths caused by drug use, guns, irresponsible sexual behavior and automobile accidents combined.
"People may not realize the extent to which deaths among Americans are preventable," said Dr. J. Michael McGinnis, who heads the Office of Disease Prevention at the U.S. Department of Health and Human Services and is the study's lead author.
The JAMA article, which is the first study to rank the "root causes" of death, comes at a time when the Clinton administration is pushing health care reform as a way to cut medical costs. But the study suggests that simply giving all people access to care will not be enough to reduce the nation's medical bill.
"When you come up with half the total number of deaths in this country are preventable, that people can do something about, the implications are enormous from an economic point of view," said Dorothy Rice, a medical economist at the University of California, San Francisco. "We still have a host of public health problems that simply will not be solved by comprehensive universal health care."
The government estimates that the nation will spend $900 billion on health care this year -- an average of about $14,000 per year for a family of four. But only 5 percent of that money is devoted to prevention.
"There are two messages here, one is to the individual and one is to society," said Dr. McGinnis. "To the individual, the message is, 'You can do a great deal to control your own health destiny.' To society, the message is, 'If we want to get serious about controlling premature and unnecessary and costly death and illness, we need to . . . invest heavily in health promotion and disease prevention.' "
Dr. McGinnis and his co-author, Dr. William H. Foege of the Carter Presidential Center in Atlanta, examined the major external factors -- those that are not genetic but are instead a product of environment -- that contribute to death. In examining death certificates from 1990, the researchers looked beyond the diseases and illnesses listed as cause of death to the reasons people may have gotten sick in the first place. They found that smoking contributed to 19 percent of all deaths in the nation, including those from a wide variety of cancers, heart disease, stroke, low birth weight and burns.
Not surprisingly, this finding drew criticism from a spokesman for the Tobacco Institute, who said the study's findings about smoking were "not reliable."
Next to tobacco, the study ranked poor diet and lack of exercise as the leading cause of death. These habits accounted for 300,000 lost lives, the study said, by increasing the incidence of such illnesses as stroke, diabetes and colon cancer.
Leading causes of deaths in U.S. in 1990, according to a study published today:
* Tobacco 400,000
* Diet, inactivity 300,000
* Alcohol 100,000
* Infectious diseases other than AIDS 90,000
* Toxic pollutants and contaminants 60,000
* Firearms 35,000
* Sexual behavior 30,000
* Motor vehicles 25,000
* Illegal drugs 20,000