Tobacco has been ingrained into Virginia’s fabric since English settlers planted the first seeds along the banks of the James River in 1612.

While states like North Carolina and Kentucky produce more tobacco than Virginia, Richmond arguably remains the capital of America’s tobacco industry, with the headquarters of the nation’s largest tobacco conglomerate, Altria Group, located on West Broad Street in Henrico County. About half of all the cigarettes produced in the U.S. are manufactured at Altria subsidiary Philip Morris USA’s cigarette plant in South Richmond off Interstate 95.

Given that history, it is unsurprising that many of the top causes of death in the Richmond area are often linked to tobacco use, according to data from the Centers for Disease Control and Prevention analyzed by the Richmond Times-Dispatch.

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The CDC’s cause-of-death database shows that lung cancer is responsible for more than 11,000 deaths in the Richmond area — the “Big 4” of Richmond, Chesterfield, Hanover and Henrico, plus neighboring cities Petersburg and Hopewell — from 1999 to 2020, over 6% of all deaths in that time period. But lung cancer, which has killed more than 3 million nationwide since 1999, is only the second-most common cause of death around Richmond.

Topping the list is atherosclerotic heart disease, caused by the blockage of arteries due to buildup of fats and other substances. The disease has killed just over 12,500 people in the region since 1999, or 58 deaths per 100,000 residents during that time period.

Other top causes of death include acute myocardial infarctions, better known as heart attacks; various forms of dementia, including those caused by Alzheimer’s disease; chronic obstructive pulmonary disease; and strokes.

Those causes are largely in line with the top causes of death nationwide — pneumonia is the only one of the top 10 national causes of death that is not also in the top 10 in the Richmond area — but there are some notable differences in the death rates; 25% fewer people die of heart disease or heart attacks in the Richmond area than the nationwide rate.

But HIV, the virus that causes AIDS, kills nearly four times as many people per capita in the city of Richmond than in the rest of the country.

Elaine Martin, deputy director of the Virginia Department of Health’s disease prevention division, told The Times-Dispatch that social health determinants like poverty and access to health care are factors in the city’s high incidence of HIV deaths.

Richmond’s poverty rate is more than twice as high as its immediate neighboring counties, and its median household income in 2020 was just over $51,000 — $25,000 below the statewide median. Virginia’s Central health region, which includes the Richmond metropolitan area, has slightly lower rates of insured residents than other parts of the state, Martin said.

Accidental overdoses are approximately twice as likely to kill in the Richmond area than the rest of the nation, and more than three times as likely within the city of Richmond. Overdose deaths in the region increased by 764% from 1999 to 2020, per the CDC data, driven largely by the increasing prevalence of the synthetic opioid fentanyl, which is present in three-fourths of overdose deaths in Virginia, according to the state’s top forensic epidemiologist.

The Richmond region also outpaces the rest of the country in gun-related deaths. More than 3,200 people in the area were killed by firearms from 1999 to 2020. Of those gun deaths, 45% were categorized as acts of intentional self-harm. Over 60% of firearm suicides in the Richmond area since 1999 have occurred in Chesterfield and Henrico counties.

More than half of the 1,763 gun homicides in the area took place in the city of Richmond, where per capita gun homicides increased 43% from 2019 to 2020, according to a review the CDC published in May. The May report linked poverty and gun deaths, finding that localities with high levels of poverty had firearm homicide rates 4.5 times as high as in localities with the lowest poverty levels.

While heart disease and lung cancer were the most common causes of death across the full 1999-2020 window, nothing was as deadly in 2020 as COVID-19, which accounted for nearly 8% of all deaths in the Richmond area — 730, according to the CDC data, nearly 100 more than heart disease.

In 2012, Frances Givens of Bon Air began to feel dizzy while coming out of a department store. She didn’t pass out or fall down. There were no headaches or chest pain. But she’d never felt anything like it before.

Soon after, she went to her primary care physician. After she underwent a stress test and cardiac catheterization, they found blockage in her arteries.

She had atherosclerosis, and a stent was put in to treat it.

Givens, now 80, said she sees her cardiologist every six months and is glad she didn’t ignore the symptoms.

“You know your body better than anybody else,” Givens said. “And one needs to listen and pay attention to things that are not normal or routine. I think, too often, folks ignore things that they might ought to get a professional to look at.”

Atherosclerosis is caused by an accumulation of fats, cholesterol and other substances obstructing blood flow through the arteries. When plaque buildups occur in the arteries of your heart, said Dr. Hem Bhardwaj, a cardiologist with VCU Health, they can rupture and cause heart attacks. But often, there are no definitive symptoms until blood flow is severely decreased. A buildup of plaque can cause chest pain, shortness of breath and fatigue, but those symptoms are nonspecific, Bhardwaj said.

“Could it be because you have asthma? Could it just be that you could have fatigue because you’re just not sleeping well at night?” she asked. “The key thing is if there’s any symptom changes, or you have any symptoms or any changes in how you’re feeling, go to your primary care doctor or go see your cardiologist to discuss the symptoms.”

At least 495 people in the Richmond region have died from atherosclerosis each year since 1999, with an additional 250 or more succumbing to heart attacks annually. Someone in the U.S. has a heart attack every 40 seconds, according to CDC data.

When heart attacks do happen, Dr. Michael Kontos, a cardiologist at VCU Medical Center, said the biggest factor between life and death is time. At VCU Medical Center, the average time it takes from first medical contact to get a patient into treatment is 78 minutes. The goal is under 90 minutes.

Kontos, who has worked in Richmond his whole career, said the main risk factors for heart attacks are blood pressure, nutrition and tobacco use — but that tobacco use is the risk factor more likely to be seen in younger heart attack patients.

“I think we have seen significant decreases over the last 20 to 30 years as there has been increased recognition of the adverse effect [smoking] has,” he said. “But still, many patients continue to smoke and it’s probably one of the most important risk factors for those that come in with early heart attacks, those in their 30s and 40s.”

One reason that tobacco use is such a prominent risk factor is nicotine’s impact on blood pressure. Robin Gahan, vice president of health for the Richmond American Heart Association, said monitoring blood pressure is a top priority for the organization in its outreach programs.

“We launched in May with Feed More and a number of food pantries across Richmond,” Gahan said, “to include blood pressure screening as a part of monthly food pantry services.”

And in the fall, the AHA partnered with St. Paul’s Baptist Church in Richmond and Henrico to add blood pressure monitors to nurses’ stations and at other events the church hosts.

‘A failure of a system’

Tobacco use is also a key risk factor for lung cancer, the disease most commonly associated with smoking. According to the CDC, cigarette smoking is linked to as many as 90% of all lung cancer deaths, and small cell lung cancer is almost always caused by smoking.

According to data from the CDC collected between 2018 and 2020, Virginia’s smoking rate — 14.9% of adults — is higher than the national rate of 12.5%, but lower than that of many of its southern neighbors. In West Virginia, 25.5% of adults identified as smokers, the highest rate in the U.S., and more than 20% of adults smoked in Tennessee, Kentucky, Mississippi and Louisiana.

One of the main differentiators between smoking and non-smoking is income. The CDC found that just over 20% of adults with an annual household income below $35,000 smoke, while only 6% of adults with household income above $100,000 are smokers.

Dr. Robert Winn, director of the Massey Cancer Center at VCU, says lung cancer screening and treatment techniques have improved significantly in the last decade, but there’s still a messaging issue that makes the disease deadlier than it needs to be. Screenings are recommended for Black smokers beginning at age 45 and for other smokers at age 50.

“I think it’s a failure of a system to appropriately educate folks, like we have in breast cancer, that lung cancer can be prevented and if you get it, it is not a death sentence,” Winn said. “Lung cancer doesn’t have to be the number one cancer in the state if we just get people screened and make sure that everyone can get access to the latest and most cutting-edge treatments.”

Dr. Renato Martins, chair of hematology, oncology and palliative care at the Massey Center, came to Richmond in March from the University of Washington in Seattle, where he helped develop new therapies and treatments that are improving outcomes for lung cancer patients.

To Winn and Martins, two things are effective in curbing smoking: restrictions that make smoking a “hassle,” like banning indoor smoking or prohibiting the use of menthol as a flavoring agent in cigarettes, and taxation. Virginia currently taxes cigarettes at 60 cents per pack, one of the lowest rates in the country, according to a January analysis by the Federation of Tax Administrators.

“Just like any principle of capitalism, if you increase prices, you decrease demand,” he said.

Dr. Rashelle Hayes, an associate professor of psychiatry at VCU and a certified tobacco treatment provider, says quitting smoking is even more difficult than you might think.

“About 70% of people who smoke say they want to quit each year, and about half will try to quit each year, but even fewer than this will successfully quit,” Hayes said. Fewer than 1 in 10 adult smokers successfully quit each year, according to the CDC.

Altria Group spokesman David Sutton says the conglomerate, which made more than 80% of its $20.8 billion in revenue in 2020 from the sale of conventional cigarettes, is trying to “fundamentally change the landscape” and become smoke-free by 2030. A 2020 report by the Office of the Surgeon General found that annual U.S. health care spending related to smoking is more than $170 billion.

“We are moving from a tobacco company to a tobacco harm reduction company,” Sutton told The Times-Dispatch.

The company’s “Moving Beyond Smoking” strategy includes the production of e-cigarettes and other smokeless products, though it is unclear what impact the Food and Drug Administration’s June order to pull all Juul products from the market — which has been put on hold pending further review — will have on that strategy. Altria owns a 35% stake in Juul Labs.

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, said in a June statement that “Juul, more than any other product or company, has been responsible for creating and fueling the youth e-cigarette epidemic.”

Martins, of the Massey Cancer Center, said vapes have “less chemicals” and “theoretically they should be less dangerous,” but there is not enough research yet to fully determine the effect e-cigarettes have on people’s lungs and whether they cause lung cancer like tobacco does.

Leslie Jones is the executive director of Anthology of Midlothian, a facility in North Chesterfield that offers assisted living and memory care for people with many types of dementia. She started volunteering in nursing homes when she was 14 and developed a passion for caring for people with dementia after seeing it affect her aunt and grandmother.

“Dementia, I think, is one of the worst diagnoses because it’s a slow death,” Jones said. “You lose a piece of that person every day, and I personally am very passionate about the dignity and care in the life of someone with dementia.”

More than 450 people in the Richmond area — including 70 from the city — died of dementia in 2020, up from just 102 in 1999.

The fourth-leading cause of death in the Richmond region, dementia is defined by the CDC as a general term for impaired ability to remember, think or make decisions. It encompasses a group of conditions and disorders characterized by the impairment of numerous brain functions, like memory loss and judgment.

A state commission found that Black and Hispanic people are as much as twice as likely to have dementia than white people, and that more than 60% of all people ages 65 and up living with dementia are women.

When specifically diagnosed, Alzheimer’s disease, the most common cause of dementia, is by itself the seventh-leading cause of death in the country, according to the CDC’s database.

Anthology resident Lorraine Tracy said she was likely having symptoms long before she realized it.

“My kids would always tell me, ‘Mom, we told you that yesterday,’ or something would happen and they would remind me they already told me that,” she said.

Matthew Barrett, a neurologist with VCU Health, described Tracy’s experience as a common phenomenon.

“Individuals experiencing the cognitive changes are often unaware of it, and this is especially the case for Alzheimer’s disease,” Barrett said. “And so in that situation, it’s really the family members or other people close to the individual that recognize the changes and pursue medical evaluations.”

And even when people may recognize some of the warning signs, there’s a stigma around dementia that makes some unwilling to talk about it, said Kevin Jameson, founder of the Dementia Society of America.

“In many cases, they don’t want to talk about it,” he said. “And so they don’t get the care they need, don’t get the workup they need to determine a diagnosis, and many doctors are not prepared for how to deal with their patients that may have it — especially primary care physicians. So we’re really all about changing the dialogue and the message around dementia.”

Dementia often changes the lives of a person’s family members, too, Jameson said. Since the diseases causing dementia are progressive, what is normal one week becomes the exception the next week.

Tracy noticed it. Her handwriting used to be nice, but now it’s not very nice anymore. But she still looks for different ways to try to remember and keep moving forward.

And if you’re having symptoms of dementia, she said, “go see a doctor — it doesn’t take that long.”