OBJECTIVE: To evaluate the impact of combinations of lifestyle factors on 
mortality in middle aged women.
DESIGN: Prospective cohort study.
SETTING: Nurses' health study, United States.
PARTICIPANTS: 77 782 women aged 34 to 59 years and free from cardiovascular 
disease and cancer in 1980.
MAIN OUTCOME MEASURE: Relative risk of mortality during 24 years of follow-up in 
relation to five lifestyle factors (cigarette smoking, being overweight, taking 
little moderate to vigorous physical activity, no light to moderate alcohol 
intake, and low diet quality score).
RESULTS: 8882 deaths were documented, including 1790 from cardiovascular disease 
and 4527 from cancer. Each lifestyle factor independently and significantly 
predicted mortality. Relative risks for five compared with zero lifestyle risk 
factors were 3.26 (95% confidence interval 2.45 to 4.34) for cancer mortality, 
8.17 (4.96 to 13.47) for cardiovascular mortality, and 4.31 (3.51 to 5.31) for 
all cause mortality. A total of 28% (25% to 31%) of deaths during follow-up 
could be attributed to smoking and 55% (47% to 62%) to the combination of 
smoking, being overweight, lack of physical activity, and a low diet quality. 
Additionally considering alcohol intake did not substantially change this 
estimate.
CONCLUSIONS: These results indicate that adherence to lifestyle guidelines is 
associated with markedly lower mortality in middle aged women. Both efforts to 
eradicate cigarette smoking and those to stimulate regular physical activity and 
a healthy diet should be intensified.