A Comparison of Two Methods of Adjusted Attributable Fraction Estimation as Applied to the Four Major Smoking Related Causes of Death, in Canada, in 2005

The main objective of the thesis was to compare two methods of calculating adjusted attributable fractions and deaths as applied to smoking exposure and four health outcomes, lung cancer, ischaemic heart disease, chronic obstructive pulmonary disease, and cerebrovascular disease, for Canadians 30 years or older in the year 2005. An additional objective was to calculate variance estimates for the evaluation of precision. Such estimates have not been published for Canada to date. Attributable fractions were calculated using the fully adjusted method and the partial adjustment method. This method requires confounder strata specific (stratified) estimates of relative risk, along with accompanying estimates of variance. These estimates have not previously been published, and were derived from the Cancer Prevention Study II cohort. Estimates of the prevalence of smoking in Canada were obtained from the Canadian Community Health Survey 2005. Variance estimates were calculated using a Monte Carlo simulation. The fully adjusted method produced smaller attributable fractions in each of the eight disease-sex-specific categories than the partially adjusted method. This suggests an upwards bias when using the partial adjustment method in the attributable fraction for the relationship between cigarette smoking and cause-specific mortality in Canadian men and women. Summed across both sexes and the four smoking related causes of death, the number of deaths attributable to smoking was estimated to be 25,684 using the fully adjusted method and 28,466 using the partial adjustment method, an upward bias of over ten percent, or 2,782 deaths. It is desirable, theoretically, to use methods which can fully adjust for the effect of confounding and effect modification. Given the large datasets required and access to original data, using these methods may not be feasible for some who would wish to do so.Ph