Decreased life expectancy may occur after remote peptic ulcer surgery, but the cause of shortened survival is unclear. A 50-year follow-up study of an Amsterdam cohort of postgastrectomy patients who underwent ulcer surgery between 1931 and 1960 showed a statistically significant decrease in survival after a postoperative interval of 12 years or more compared with the general population. The shortened life expectancy mainly reflected decreased survival in men. In women, no significant difference in survival compared with the general population was observed. The excess mortality in men was predominantly due to a statistically significant increase in cancer-related deaths. Carcinoma of the lung accounted for the majority of excess mortality. No time relationship between lung cancer death and interval since surgery was observed. Thus, smoking, primarily in men who had undergone surgery for gastric ulcers, seems an important factor contributing to excess mortality and shortened life expectancy. Excess mortality due to tobacco use has also been observed in postmarketing surveillance of H2-receptor antagonists. Therefore, smoking cessation may provide the greatest improvement in the long-term prognosis of peptic ulcer patients, regardless of the treatment.