Life
MIRA Risk Review
Smoking – Deeper insights into risk factors
Smoking is the single most
important preventable risk
factor for a variety of common
diseases and kills 10% of all
adults worldwide. Special
attention is called for when
applications of smokers for
products are calculated on
an aggregate smoker/non-
smoker basis.
After doing without smoking for one
year, about 70% remain abstinent for
the long term.
Smokers who quit before the age of
35 can gain the same life expectancy
as those who have never smoked.
Unlike other risk factors, smoking is priced by actuarial calculation for all life
products. As a result, there is no need to rate smoking as a substandard risk. In
cases involving additional impairments, relative risks for diseased smokers
compared to diseased non-smokers are generally comparable to – or lower
than – for their healthy counterparts. Additional ratings for smoking-related
impairments are thus only required for aggregate smoker/non-smoker prod-
ucts as opposed to products already priced for smoking.
Understanding the condition
Tobacco smoking is one of the most common forms of recreational drug use.
There are 1.2 billion smokers worldwide, most of them in developing countries.
Rates of smoking are tending to decline in the developed world1, 2, while rising
steadily in the developing world. The World Health Organization (WHO) states
that much of the disease burden and premature mortality attributable to
tobacco use disproportionately affects the poor3 .
For life-threatening diseases such as cancer, myocardial infarction, stroke and
obstructive pulmonary disease, smoking is the most significant preventable
single risk factor. On a global scale, tobacco-related diseases kill one in ten
adults.4 Depending on the number of cigarettes smoked, the mortality risk of
smokers is two to three times higher on average than for non-smokers. 5, 6, 7
Smokers also face a significantly increased risk of occupational disability8 and
early retirement9.
Not surprisingly, the prognosis is considerably better after cessation. However,
not all ex-smokers remain abstinent: after one smoke-free year, the majority
will continue not to smoke in the future. In sum, about 25% will relapse in the
second or third year. Later the relapse rate drops to less than 5% per year (see
Fig. 1).10
A British study on more than 34,000 male doctors with 50 years of observa-
tion showed that if smokers quit before the age of 35, they gain the same life
expectancy as those who have never smoked. If cessation occurs later in life,
ex-smokers will not reach the lifespan of those who have never smoked. Never-
theless, giving up smoking at any age improves prognosis significantly.11
Munich Re
MIRA RISK REVIEW
Smoking
After three years, the relapse rate drops to
less than 5% per year.
Source: Hughes JR et al., 2008, see
footnote 12
Pipe and cigar smokers often smoke
cigarettes as well.
Smoking is an exceptional impair-
ment because its risk is already
accounted for by actuarial pricing
of basic premiums.
In the case of smoker products,
­substandard ratings already cover
the aspect of smoking, as they are
applied in smoker tables.
Source: Munich Re
Page 2/4
Fig. 1: Relapse rate after cessation of smoking
Per cent abstinent
100
80
60
40
20
0
0 2 4 6 8 10 12 Year after stopping smoking
Pipe and cigar smokers also have a considerably increased risk for all smok-
ing-related diseases and premature death, though slightly lower than cigarette
smokers.13, 14 However, this group is difficult to distinguish, as a big proportion
of pipe and cigar smokers consume cigarettes as well.15
Smoking is exceptional among risk factors like elevated cholesterol or
blood pressure, because it is the only medical parameter taken into account by
actuarial pricing of all standard life insurance products. Products are either
tailored for smokers/non-smokers or based on an aggregate calculation pre-
suming a certain percentage of smokers. So in both cases, the risk of smoking
is already taken into account and there is thus no need for substandard ratings.
These calculations also include a certain proportion of heavy smokers, yet they
need not be rated as substandard provided overrepresentation – e.g. due to
negative selection – can be ruled out. In addition, the reliability of disclosures
on the amount smoked is questionable and is often not even asked for.
The additional risk from interaction between smoking and an underlying
impairment depends on the type of impairment and the severity of related
findings. In general, impairments are only involved where smoking either
increases risks due to a pre-existing disease or boosts sequels together with
other pre-existing risk factors. Impairments in this respect are cardiovascular
diseases including causative risk factors, smoking-related cancers and lung
disease. Examples of relative risks for some diseases are given in Table 1.
Table 1: Examples of relative risks of death for diseased smokers compared
to non-smokers with same disease
Disease name Relative risk Source (examples)
Hypertension 1.8 16
Diabetes mellitus 1.8 17
Chronic obstructive pulmonary disease 1.8 18
Coronary artery disease 2.0 19
Non-small-cell lung cancer 2.9 20
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MIRA RISK REVIEW
Smoking

With few exceptions, the relative risks of smokers with a pre-existing disease
compared to diseased non-smokers are not higher than the relative risks of
healthy smokers compared to healthy non-smokers. As the latter is the basis
of actuarial pricing, this means for the medical underwriting of a smoker prod-
uct that substandard rates for the disease automatically cover the extra risk of
smoking in the case of a pre-existing disease because the multiplicative factor
embedded in smoker tables multiplies again with the substandard ratings (see
Fig. 2). Exceptions exist where relative risks for diseased smokers are higher
than for healthy smokers or where flat extras are applied without adjustment
to smoker tables. This is found, for example, in smoking-related cancers like
bronchial carcinoma, where smoker products as well as a different substand-
ard rating are necessary.

Fig. 2: Comparison of smoker and non-smoker tables with either standard

rates or 100% extramortality (standard non-smoker = 1).
Relative risk

4.5
4.0
3.5
3.0
  Non-smoker
2.5
  Smoker
2.0
Risk relation of smoker and non-smoker 1.5
tables automatically multiplies with sub-
1.0
standard ratings.
0.5
Source: Munich Re 0

Standard 100% EM

In the case of products with aggregate smoker/non-smoker rates, the extra

premiums only partially cover the additional risk due to smoking in substand-
ard applicants with a smoking-related disease. To close this gap, additional
ratings are necessary if a pre-existing disease is related to smoking. The ad-
ditional premium for smoking is based on the type of disease and possible
additional prognostic factors.
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MIRA RISK REVIEW
Smoking

Evidence-based underwriting

MIRA is dedicated to efficient, evidence-based risk assessment in a changing

world. For this reason, Munich Re continuously revises and updates the online
tool to reflect the latest scientific findings and risk trends. MIRA thus provides
maximum legal security regarding underwriting decisions. At the same time,
it serves as a solid basis for writing new business and optimising risk manage-
ment. The MIRA Risk Review series gives clients a clear overview of each revi-
sion and its scientific background.

Benefits
For pure smoker products, with few exceptions, the risk is completely covered
by the substandard ratings for the factor. Extra ratings for smokers are only
necessary in the presence of other risk-relevant diseases and then only for
aggregate smoker/non-smoker products. This means easier underwriting for
substandard smokers and, in many cases, a reduction of extra premiums.

CONTACT
Dr. Jürgen Becher
Senior Medical Consultant
Centre of Competence for Medical Risks
Research, Underwriting & Claims
Tel.: +49 89 38 91-99 88
Fax: +49 89 38 91-7 99 88
jbecher@munichre.com
Literature
1,3,4 WHO fact sheet smoking statistics.
http://www.wpro.who.int/media_centre/fact_
sheets/fs_20020528.htm
2 UK Office for national statistics. Cigarette
smoking. http://www.statistics.gov.uk/cci/nug-
get.asp?id=866
5 Kenfield SA. Smoking and smoking cessation in
relation to mortality in women. JAMA, 2008;
299: 2037–2047
6, 11 Doll
R et al. Mortality in relation to smoking:
50 years’ observation on male British doctors.
BMJ, 2004; 328: 1519–27
7 Shavelle RM et al. Smoking habit and mortality:
a meta-analysis. Journal of Insurance Medicine,
2008; 40: 170–178
8 Claessen H et al. Smoking habits and occu­
pational disability: a cohort study of 14,483
­construction workers. Occup Environ Med,
2010; 67: 84–90
9 Husemoen LN et al. Smoking and subsequent
risk of early retirement due to permanent disabil-
ity. European Journal of Public Health, 2004; 14:
86–92
10, 12 Hughes JR et al. Relapse to Smoking After
1 Year of Abstinence: A Meta-analysis.
Addict Behav., 2008; 33 (12): 1516–1520
14 Henley SJ et al. Association between exclusive
pipe smoking and mortality from cancer and
other diseases. Journal of the National Cancer
Institute, 2004; 96: 853–861
15 Rodriguez J et al. The association of pipe and
cigar use with cotinine levels, lung function,
and airflow obstruction: a cross-sectional study.
Ann Intern Med, 2010; 152: 201–210
16 Fagard RH. Smoking amplifies cardiovascular
risk on patients with hypertension and diabetes.
Diabetes Care, 2009; 32 (Supplement 2):
S429–S431
17 Al-Delaimy WK et al. Smoking and mortality
among women with type 2 diabetes. Diabetes
Care, 2001; 24: 2043–2048
18 Anthonisen NR et al. The effects of a smoking
cessation intervention on 14.5-year mortality.
Ann Intern Med, 2005; 142: 233–239
19 Critchley J, Capewell S. Smoking cessation for
the secondary prevention of coronary heart
­disease. Cochrance Database Syst Rev, 2004;
1: CD003041
20 Parsons A et al. Influence of smoking cessation
after diagnosis of early stage lung cancer on
prognosis: systematic review of observational
studies with meta-analysis. BMJ, 2010; 340:
b5569

13 Shaper AG et al. Pipe and cigar smoking and

major cardiovascular events, cancer incidence
and all-cause mortality in middle-aged British
men. International Journal of Epidemiology,
2003; 32: 802–806

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