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Cigarette Smoking and Cigarette Smoking and Cancer RiskCancer Risk
Epidemiology 242:Epidemiology 242:
Cancer EpidemiologyCancer Epidemiology
20092009
Prevalence of Cigarette Prevalence of Cigarette SmokingSmoking
1880 to after World War 1, cigarette 1880 to after World War 1, cigarette represented a small proportion of overall represented a small proportion of overall tobacco consumption.tobacco consumption.
1920-1945, cigarettes rose dramatically 1920-1945, cigarettes rose dramatically and commercially produced cigarettes and commercially produced cigarettes became the dominant form of tobaccobecame the dominant form of tobacco
1945-1965, cigarette consumption 1945-1965, cigarette consumption leveled offleveled off
1965-1995, cigarette consumption 1965-1995, cigarette consumption declined dramaticallydeclined dramatically
Trends in Per Capita Consumption of Trends in Per Capita Consumption of Various Tobacco Products – United Various Tobacco Products – United
States, 1880-2001States, 1880-2001
Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. CensusNote: Among persons >18 years old.
Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.
0
2
4
6
8
10
12
14
16
1880
1885
1890
1895
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
YEAR
PO
UN
DS
Cigarettes Cigars Pipe/Roll your own Chewing Snuff
Adult Per Capita Cigarette Consumption and Adult Per Capita Cigarette Consumption and Major Smoking and Health Events – United States, Major Smoking and Health Events – United States,
1900-20011900-2001
0
1000
2000
3000
4000
5000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000YEAR
Nu
mb
er o
f C
igar
ette
s
Source: United States Department of Agriculture
End of WW II
1st Smoking-Cancer Concern
Fairness Doctrine Messages on TV
and Radio
Non-Smokers Rights Movement
Begins
Federal Cigarette Tax Doubles
Surgeon General’s Report on ETS
1st Surgeon General’s
Report
1st World Conference on Smoking and Health
Broadcast Ad Ban
1st Great American Smoke-out
OTC Nicotine Medications
Master Settlement Agreement
Great Depression
Decreased Cigarette Consumption in Decreased Cigarette Consumption in the US since 1965the US since 1965
Since 1950, scientific reports linking Since 1950, scientific reports linking cigarette smoking with cancers and other cigarette smoking with cancers and other chronic diseaseschronic diseases
Bans on TV and radio advertisingBans on TV and radio advertising The growth of the nonsmokers rights The growth of the nonsmokers rights
movementmovement A dramatic increase in federal and state A dramatic increase in federal and state
cigarette taxcigarette tax
MenMen
Women
0
10
20
30
40
50
60
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
YEAR
% C
UR
RE
NT
SM
OK
ER
STrends in cigarette smoking* among adults aged
>18 years, by sex - United States, 1955-2002
Source: 1955 Current Population Survey; 1965-2002 National Health Interview Survey; 2002 estimates for first quarter only
*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days.
24.5%
18.8%
Current Use Among U.S. Adults of Current Use Among U.S. Adults of Various Tobacco Products, by Sex – Various Tobacco Products, by Sex –
National Health Interview Survey, 2000National Health Interview Survey, 2000
0
5
10
15
20
25
30
35
Any Use Cigarettes Cigars Pipes Snuff ChewingTobacco
Bidis
PE
RC
EN
T
Males
Females
Note: Current users report using either every day or on some days Source: National Center for Health Statistics
31.3
21.3
25.7
21.0
4.5
0.2 1.0 0.1
2.5 0.1 0.1
2.50.10.2
0
5
10
15
20
25
30
35
40
45
50
5519
60
1964
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
YEAR
NU
MB
ER
OF
ST
AT
ES
ExtensiveModerateBasicNominal
Restrictiveness Of State Laws Restrictiveness Of State Laws Regulating Smoking Regulating Smoking
In Public Places – U.S., 1960-2001In Public Places – U.S., 1960-2001
Sources: 1989 Surgeon General’s Report, ALA’s SLATI, CDC’s STATE system, Roswell Park Cancer Institute. Note: Includes the District of Columbia; Alabama = only state with no restrictions on public smoking.
Number of U.S. States including D.C.*, with Number of U.S. States including D.C.*, with Legislation Restricting the Purchase of Cigarettes to Legislation Restricting the Purchase of Cigarettes to
Persons aged Persons aged >>18 years, 1988-200118 years, 1988-2001
1014 14
1821
24 26 27 2932 33
36 36 37
0
10
20
30
40
50
Year
# of
Sta
tes
*District of Columbia
Source: “State Legislated Actions On Tobacco Issues”, 1988-2001, CDC’s STATE system, Roswell Park Cancer Institute.
Smoking in Young PeopleSmoking in Young People
3 million young people under age 18 smoke 3 million young people under age 18 smoke half a billion cigarettes each year and that half a billion cigarettes each year and that more than one-half of them consider more than one-half of them consider themselves dependent upon cigarettes. themselves dependent upon cigarettes.
The decision to use tobacco is nearly The decision to use tobacco is nearly always made in the teen years, and about always made in the teen years, and about one-half of young people usually continue to one-half of young people usually continue to use tobacco products as adults.use tobacco products as adults.
Age at Initiation of SmokingAge at Initiation of Smoking
The initiation of daily smoking most often The initiation of daily smoking most often occurs in grades six through nine among occurs in grades six through nine among children between the ages of 11 and 14. children between the ages of 11 and 14. About half (51.3%) of high-school seniors About half (51.3%) of high-school seniors who smoke daily began smoking by age 15.who smoke daily began smoking by age 15.
About 80% of regular smokers started About 80% of regular smokers started smoking before the age of 18. smoking before the age of 18.
Stages of Initiation (Flay)Stages of Initiation (Flay)
Preparatory stage
Trying stage
Experimental stage
Regular use
Addiction/Dependent smoker
Never smokes
No longer smokes
Quits smoking
No longer smokes
Cumulative Age of Initiation of Cigarette Cumulative Age of Initiation of Cigarette SmokingSmoking** Among Persons Aged 30 – 39 Among Persons Aged 30 – 39
Years—United States, 1996-1998Years—United States, 1996-1998
0
10
20
30
40
50
60
70
80
90
100
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38Age
Per
cen
t
* Among persons 30-39 years old who have ever smoked dailySource: National Household Survey on Drug Abuse, 1996-1998 public use data tapes
Age First Tried a Cigarette
Age Began Smoking Daily
Incidence of Initiation of Cigarette Smoking*,Incidence of Initiation of Cigarette Smoking*,by Age -- United States, 1994/1995by Age -- United States, 1994/1995
Source: National Household Survey on Drug Abuse, 1994-B and 1995 public use data tapes.*Among persons 12-39 years old.
0
5
10
15
20
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
Age (years)
Init
iate
s pe
r 10
0 pe
rson
s
Incidence of first use Incidence of first daily use
12th Grade 30 Day Smoking Prevalence and Price
$1.25
$1.50
$1.75
$2.00
$2.25
$2.50
$2.75
$3.00
$3.25
1981 1986 1991 1996
Year
Real
Pric
e Pe
r Pac
k
27
29
31
33
35
37
39
Smok
ing
Prev
alen
ce
Cigarette Price 30 Day Smoking Prevalence
Cigarette Smoking among youth and adults in 24 states and the District of Columbia, 1997
0
5
10
15
20
25
30
10 15 20 25 30 35
Percent Current Smokers (Adults)
Per
cent
Fre
quen
t Sm
oker
s (A
dole
scen
ts)
Sources: 1997 Youth Risk Behavior Survey (14-18 year old public school students)
1997 Behavioral Risk Factor Survey (adults 18+ years old)
Note: Frequent Smoking among youth = smoking on > 20 days during the previous 30 days
Adult current smoking = smoking every day or on some days
r2 = 0.552
ß = 0.940
P < 0.001
N = 25UT
DC
NV
KY
SD
MenMen
Women
0
10
20
30
40
50
60
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
YEAR
% C
UR
RE
NT
SM
OK
ER
STrends in cigarette smoking* among adults aged
>18 years, by sex - United States, 1955-2002
Source: 1955 Current Population Survey; 1965-2002 National Health Interview Survey; 2002 estimates for first quarter only
*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day day or some days.
24.5%
18.8%
0
5
10
15
20
25
30
35
40
1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Per
cent
Heavy Cigarette Smoking* Among Adults Aged 18+ by Gender – United States, 1974 -2000
Source: NHS, 1974-2000 *Smoking 25+ cigarettes per day
Men
Women
0
10
20
30
40
50
6019
65
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
Year
Per
cent
Percentage of Ever Smokers* Who Have Quit, Adults Aged > 18 Years, by Sex-United States,
1965 - 2002
Source: National Health Interview Surveys, 1965-2002; 2002 estimate is for first quarter ony Centers for Disease Control and Prevention: National Center for Health Statistics and Office on Smoking and Health. *Ever-smoked >100 cigarettes, Also known as the quit ratio. Note: estimates since 1992 incorporate same-day smoking
Men
Women
Percent of Current Smokers Who Want to Percent of Current Smokers Who Want to Quit by Age and Number of Previous Quit Quit by Age and Number of Previous Quit
Attempts – United States, 2000Attempts – United States, 2000
0
1020
30
4050
60
7080
90
100
0 tries 1-2 tries 3-6 tries 7+ tries
18-24
25-44
45-64
65+
Source: National Center for Health Statistics, NHIS 2000 (with NCI Cancer Supplement)
Annual use of pharmacologic aids to Annual use of pharmacologic aids to smoking cessation— United States, smoking cessation— United States,
1984-19981984-1998
Est
imat
ed A
ssis
ted
Qui
t A
ttem
pts
(in
th
ousa
nds)
Gum (2mg)2/84
Patches1/92
Gum (4mg)3/93
Vaporinhaler3/98
Zyban5/97Gum OTC
4/96
2 patches OTC8/96
Nasal spray8/96
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998Year
Zyban
Inhaler
Nasal Spray
Patch
Gum
Source: CDC. MMWR 2000;665-668.
Tobacco Control Model of Nicotine Addiction
Agent
VectorHost
Tobacco Products
Tobacco Industry; Other Users
Smoker/Chewer/UserIncidental Host
EnvironmentFamilial, Social,
Cultural, Political, Economic, Media,
Historical
Involuntary Smoker
Adapted from: Orleans & Slade, 1993
Paradigm for Tobacco Control
Cessation activities Prevention activities Clean indoor air Regulation/Liability Price/Economic
Minor’s access Advertising
Society
TobaccoAddiction
Individual
Tobacco and AddictionTobacco and Addiction
Cigarettes and other forms of tobacco are Cigarettes and other forms of tobacco are addictive. Nicotine is the drug in tobacco addictive. Nicotine is the drug in tobacco that causes addiction. that causes addiction.
The pharmacologic and behavioral The pharmacologic and behavioral processes that determine tobacco addiction processes that determine tobacco addiction are similar to those that determine addiction are similar to those that determine addiction to drugs such as heroin and cocaine. to drugs such as heroin and cocaine.
Tobacco AddictionTobacco Addiction
Nicotine is found in substantial amounts in Nicotine is found in substantial amounts in tobaccotobacco
It is absorbed readily from tobacco smoke in It is absorbed readily from tobacco smoke in the lungs and from smokeless tobacco in the lungs and from smokeless tobacco in the mouth or nose and is rapidly distributed the mouth or nose and is rapidly distributed throughout the body. throughout the body.
SGR: Preventing Youth SGR: Preventing Youth Tobacco UseTobacco Use
Criteria for Drug DependenceCriteria for Drug Dependence
Primary CriteriaPrimary CriteriaHighly controlled or compulsive useHighly controlled or compulsive usePsychoactive effectsPsychoactive effectsDrug-reinforced behaviorDrug-reinforced behavior
Additional criteriaAdditional criteriaStereotypic patterns of useStereotypic patterns of useUse despite harmful effectsUse despite harmful effectsRelapse following abstinenceRelapse following abstinenceRecurrent drug cravingsRecurrent drug cravings
Dependence-producing drugs often manifest the following:Dependence-producing drugs often manifest the following:ToleranceTolerancePhysical dependencePhysical dependencePleasant (euphoric) effectPleasant (euphoric) effect
Source: Adapted from USDHHS (1988)Source: Adapted from USDHHS (1988)
Nicotine is A PoisonNicotine is A Poison
An injection of one drop of nicotine in its An injection of one drop of nicotine in its purest form (70 mg) will kill an average-purest form (70 mg) will kill an average-sized man.sized man.
Cigarettes contain a very small amount of Cigarettes contain a very small amount of nicotine (between .1 and 2.2 mg). This nicotine (between .1 and 2.2 mg). This amount will not kill you, but will make your amount will not kill you, but will make your heart beat faster and can make your hands heart beat faster and can make your hands shake. shake.
Smoking and HealthSmoking and Health
An estimated 47 million adults in the U.S. An estimated 47 million adults in the U.S. smoke cigarettes, which will result in death smoke cigarettes, which will result in death or disability for half of all regular usersor disability for half of all regular users
Over 46 million Americans have quit Over 46 million Americans have quit smoking but 3,000 adolescents try their first smoking but 3,000 adolescents try their first cigarette every day.cigarette every day.
Chronic Disease and Related FactorsChronic Disease and Related Factors
0 5 10 15 20
Percentage (of all deaths)
TobaccoPoor diet/ lack
of exerciseAlcohol
Infectious agents
Pollutants/ toxics
Firearms
Sexual Behaviors
Motor vehicles
Illicit drug use
Actual causes of death, United States, 1990†Leading caues of death, United States, 1999*
0 10 20 30 40
percentage (of all deaths)*NHCS National Vital Statistics, Vol. 49 Sept. 2001 †McGinnis JM, Foege WH. Actual causes of
death in the United States. JAMA 1992; 270:2207-12
Diseases Caused by Tobacco UseDiseases Caused by Tobacco Use
Cigarette smoking increases the risk of:Cigarette smoking increases the risk of: Coronary heart diseaseCoronary heart disease
Atherosclerotic peripheral vascular diseaseAtherosclerotic peripheral vascular disease
Cerebrovascular diseaseCerebrovascular disease
Cancers of the lung, larynx, mouth, esophagus, bladder, Cancers of the lung, larynx, mouth, esophagus, bladder, pancreas,pancreas,
kidney, and cervixkidney, and cervix
Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease
Intrauterine growth retardation, premature rupture of membranesIntrauterine growth retardation, premature rupture of membranes
Low-birthweight babies, perinatal mortalityLow-birthweight babies, perinatal mortality
Cataract, macular degeneration; hip fractureCataract, macular degeneration; hip fracture
Peptic ulcer diseasePeptic ulcer disease
Possibly liver, stomach, and colorectal cancers and acute Possibly liver, stomach, and colorectal cancers and acute myelocytic leukemiamyelocytic leukemia
Disease Caused by Tobacco UseDisease Caused by Tobacco Use
Involuntary smoking (environmental tobacco smoke) is a Involuntary smoking (environmental tobacco smoke) is a cause of:cause of:
Lung cancer and coronary heart disease in Lung cancer and coronary heart disease in nonsmokersnonsmokers
Respiratory infections and symptoms in the children ofRespiratory infections and symptoms in the children of parents who smokeparents who smoke
Smokeless tobacco causes:Smokeless tobacco causes: Oral Cancer Oral Cancer Oral leukoplakia Oral leukoplakia Dental caries (possibly) Dental caries (possibly)
Cigars causeCigars cause:: Cancers of the mouth, larynx, and lung Cancers of the mouth, larynx, and lung Coronary heart diseaseCoronary heart disease COPDCOPD
Domestic Market Share of Cigarettes by Tar Domestic Market Share of Cigarettes by Tar Yield, Filter Status, Length, and Menthol Yield, Filter Status, Length, and Menthol
Status: United States, 1963 - 2000Status: United States, 1963 - 2000
0
10
20
30
40
50
60
70
80
90
100
1945 1965 1985
Year
Per
cen
t
Source: United States Department of Agriculture, 1962; Federal Trade Commission, 2001
Filter
<15 mg. tar yield
> 94 mm.
Menthol
Smoking and HealthSmoking and Health
It is estimated that every cigarette a person It is estimated that every cigarette a person smokes takes about 12 minutes off his or smokes takes about 12 minutes off his or her life. her life.
Smoking increases your risk of getting many Smoking increases your risk of getting many serious diseases including cancer, heart serious diseases including cancer, heart disease, emphysema and bronchitisdisease, emphysema and bronchitis. .
Year of Potential Life Lost (YPLL)Year of Potential Life Lost (YPLL)
65 – age at death form smoking related 65 – age at death form smoking related disease: 1,152,635 YPLLdisease: 1,152,635 YPLL
Current gender-specific life expectancy – Current gender-specific life expectancy – age at death from smoking related diseases: age at death from smoking related diseases: 5,048,740 YPLL5,048,740 YPLL
Smoking and HealthSmoking and Health
Direct medical care cost from smoking Direct medical care cost from smoking related diseases were estimated to be $50 related diseases were estimated to be $50 billion in 1993billion in 1993
Another $50 billion in indirect costs, such as Another $50 billion in indirect costs, such as time lost from work, housekeeping time lost from work, housekeeping expenses, and lost income, etc.expenses, and lost income, etc.
Tobacco SmokingTobacco Smoking
Tobacco smoke contains over 4,000 Tobacco smoke contains over 4,000 chemical compoundschemical compounds
includes at least 60 different includes at least 60 different carcinogenic substances. carcinogenic substances.
Group 1: Carcinogenic to Group 1: Carcinogenic to HumansHumans
Tobacco SmokingTobacco Smoking Tobacco Products, SmokelessTobacco Products, Smokeless 4-Aminobiphenyl (4-ABP)4-Aminobiphenyl (4-ABP) BenzeneBenzene CarmiumCarmium ChromiumChromium 2-Naphthylamine (2-NA)2-Naphthylamine (2-NA) NickelNickel Polonium-210 (Radon)Polonium-210 (Radon) Vinyl ChlorideVinyl Chloride
Group 2A: Probably Group 2A: Probably Carcinogenic to HumansCarcinogenic to Humans
AcrylonitrileAcrylonitrile Benzo[a]pyreneBenzo[a]pyrene Benzo[a]anthraceneBenzo[a]anthracene 1,3-Butadiene1,3-Butadiene Dibenz(a,h)anthraceneDibenz(a,h)anthracene FormaldehydeFormaldehyde N-NitrosodiethylamineN-Nitrosodiethylamine N-NitrosodimethylamineN-Nitrosodimethylamine
Tobacco Smoking and Lung Tobacco Smoking and Lung CancerCancer
Smoking and Lung CancerSmoking and Lung Cancer
Smoking accounts for more than 85% of all Smoking accounts for more than 85% of all lung cancer deaths. lung cancer deaths.
The risk of developing lung cancer is The risk of developing lung cancer is affected by the number and type of affected by the number and type of cigarettes smoked and the numbers of cigarettes smoked and the numbers of years a person has been smoking.years a person has been smoking.
Lung Cancer: DistributionsLung Cancer: Distributions
The commonest cancer in the world (1.2 million The commonest cancer in the world (1.2 million new cases in 2000, 12.3% of all new cases)new cases in 2000, 12.3% of all new cases)
52% in the developed countries and 48% in the 52% in the developed countries and 48% in the developing countriesdeveloping countries
More common in men (75%) than in womenMore common in men (75%) than in women Areas with highest incidence include Europe Areas with highest incidence include Europe
(Eastern Europe), North America, Australia /New (Eastern Europe), North America, Australia /New Zealand, and Southern America.Zealand, and Southern America.
The rates in China, Japan, and Southeast Asia are The rates in China, Japan, and Southeast Asia are moderately high. moderately high.
Lung Cancer: DistributionsLung Cancer: Distributions
For US blacks, New Zealand Maoris men, For US blacks, New Zealand Maoris men, about 13% chance of developing a lung about 13% chance of developing a lung cancer before the age of 75 years.cancer before the age of 75 years.
In developing countries, the highest rate are In developing countries, the highest rate are seen where the tobacco smoking habit has seen where the tobacco smoking habit has been longest established – the Middle East, been longest established – the Middle East, China, the Caribbean, South Africa, China, the Caribbean, South Africa, Zimbabwe, and the Pacific.Zimbabwe, and the Pacific.
Lung Cancer: DistributionsLung Cancer: Distributions
In women, the highest rates are observed in In women, the highest rates are observed in North America and North West Europe (UK, North America and North West Europe (UK, Iceland, Denmark) with moderate incidence Iceland, Denmark) with moderate incidence rates in Australia and New Zealand and rates in Australia and New Zealand and China. China.
Lung Cancer: Cigarette SmokingLung Cancer: Cigarette Smoking
Overall, 86% of cases in men and 49% in Overall, 86% of cases in men and 49% in women are due to smoking.women are due to smoking.
For regions with longest history of smoking, For regions with longest history of smoking, 90% cases in men. The proportions are 90% cases in men. The proportions are more variable in women from 0% to 80% more variable in women from 0% to 80% (UK)(UK)
Lung Cancer: Cigarette SmokingLung Cancer: Cigarette Smoking
The most important cause of lung cancerThe most important cause of lung cancer A clear dose-response relationship between lung A clear dose-response relationship between lung
cancer risk and the number of cigarettes smoked cancer risk and the number of cigarettes smoked per day, degree of inhalation and age at initiationper day, degree of inhalation and age at initiation
A life-time smoker has a risk 20-30 times that of a A life-time smoker has a risk 20-30 times that of a non-smoker.non-smoker.
The risk is diminished in smokers of filter and low The risk is diminished in smokers of filter and low tar cigarettes and increasing use of these has tar cigarettes and increasing use of these has contributed to declines in risk in recent contributed to declines in risk in recent generations of smokers (as well as the declining generations of smokers (as well as the declining prevalence of smoking) prevalence of smoking)
Lung Cancer: Other TobaccoLung Cancer: Other Tobacco
The early observation that pipe-smokers The early observation that pipe-smokers and smokers of cigars had a lower risk of and smokers of cigars had a lower risk of lung cancer than cigarette smokers is due to lung cancer than cigarette smokers is due to the lesser amount of tobacco smoked and to the lesser amount of tobacco smoked and to the lower degree of inhalation.the lower degree of inhalation.
Smokers of other types of tobacco (e.g. Smokers of other types of tobacco (e.g. bidis in India) are at similar risk to smokers bidis in India) are at similar risk to smokers of cigarette.of cigarette.
Lung Cancer: Histological Types Lung Cancer: Histological Types and Smokingand Smoking
Smoking is related to all histological types of lung Smoking is related to all histological types of lung cancercancer
The relative risk is greater for squamous-cell and The relative risk is greater for squamous-cell and small-cell carcinomas than for adenocarcinomas.small-cell carcinomas than for adenocarcinomas.
Adenocarcinoma is more common in women than Adenocarcinoma is more common in women than men in both smokers and non-smokers.men in both smokers and non-smokers.
Risk of lung cancer between men and women at Risk of lung cancer between men and women at equivalent levels of exposure is similar. equivalent levels of exposure is similar.
Lung Cancer: Other Risk FactorsLung Cancer: Other Risk Factors
Passive smoking may increase 30-50% of riskPassive smoking may increase 30-50% of risk Family history of lung cancer may also related to Family history of lung cancer may also related to
lung cancer risk, which is probably because of lung cancer risk, which is probably because of polymorphisms of genetic metabolic genes.polymorphisms of genetic metabolic genes.
Chinese female non-smokers have a high risk of Chinese female non-smokers have a high risk of adenocarcinoma, which may be related to adenocarcinoma, which may be related to exposure to cooking fumes, indoor smoky coal exposure to cooking fumes, indoor smoky coal emission, or air pollution. emission, or air pollution.
Lung Cancer: Other Risk FactorsLung Cancer: Other Risk Factors
Occupational exposures to asbestos, some Occupational exposures to asbestos, some metals (nickel, arsenic and cadmium), radon metals (nickel, arsenic and cadmium), radon (among miners) and ionizing radiation.(among miners) and ionizing radiation.
Diet high in vegetables and fruits can protect Diet high in vegetables and fruits can protect against lung cancer. Although intakes of against lung cancer. Although intakes of carotenoids is associated with decreased carotenoids is associated with decreased risk, beta-carotene does not prevent lung risk, beta-carotene does not prevent lung cancer, in 3 intervention trials.cancer, in 3 intervention trials.
Lung Cancer: Time TrendsLung Cancer: Time Trends
Trends in lung cancer incidence and mortality Trends in lung cancer incidence and mortality reflect the maturity of the smoking epidemic in reflect the maturity of the smoking epidemic in different countries.different countries.
Study of time trends in lung cancer incidence or Study of time trends in lung cancer incidence or mortality by age group shows that the level of risk mortality by age group shows that the level of risk is closely related to the birth cohort, or the cohort is closely related to the birth cohort, or the cohort specific incidence is related to the smoking habit specific incidence is related to the smoking habit of the same generation.of the same generation.
Lung Cancer: Time TrendsLung Cancer: Time Trends
Decreased smoking prevalence leads to a Decreased smoking prevalence leads to a decreased risk of lung cancer in several countries decreased risk of lung cancer in several countries such as U.K., Finland, Australia, the Netherlands, such as U.K., Finland, Australia, the Netherlands, New Zealand, the USA, Singapore, and more New Zealand, the USA, Singapore, and more recently Denmark, Germany, Italy, and Sweden.recently Denmark, Germany, Italy, and Sweden.
In most other countries, there is a continuing rise In most other countries, there is a continuing rise in rates, and this is most dramatic in the countries in rates, and this is most dramatic in the countries of Eastern Europe.of Eastern Europe.
In women, with increase smoking prevalence, the In women, with increase smoking prevalence, the risk of lung cancer increase.risk of lung cancer increase.
Ecological Observation of Smoking Ecological Observation of Smoking
Prevalence and Lung Cancer IncidencePrevalence and Lung Cancer Incidence Male lung cancer incidence started to decrease in Male lung cancer incidence started to decrease in
1980’s and early 1990’s, which is the direct result 1980’s and early 1990’s, which is the direct result of the dramatic decrease in smoking prevalence of the dramatic decrease in smoking prevalence during 1960s and 1970sduring 1960s and 1970s
The rise in lung cancer incidence rates among The rise in lung cancer incidence rates among women during 1970s and early 1980s and ended women during 1970s and early 1980s and ended in the early 1990s is also the direct result of in the early 1990s is also the direct result of increase prevalence of smoking several decades increase prevalence of smoking several decades ago. ago.
The Consistency of the The Consistency of the AssociationAssociation
In 1984 surgeon general’s report, 29 retrospective In 1984 surgeon general’s report, 29 retrospective and 7 prospective studies have all demonstrated and 7 prospective studies have all demonstrated an association between cigarette smoking and an association between cigarette smoking and lung cancerlung cancer
Similar findings had thus reported from a large Similar findings had thus reported from a large number of studies by different investigators, using number of studies by different investigators, using different methodological approaches, and in different methodological approaches, and in different populationsdifferent populations
First Two Case-Control StudiesFirst Two Case-Control Studies
A case-control study included 1045 lung A case-control study included 1045 lung cancer cases and 605 controls at Roswell cancer cases and 605 controls at Roswell Park Memorial Institute at Buffalo by Levin Park Memorial Institute at Buffalo by Levin et al. (1950)et al. (1950)
A case-control study included 684 lung A case-control study included 684 lung cancer cases and 780 controls by Wynder cancer cases and 780 controls by Wynder et al. (1950) et al. (1950)
The Strength of the AssociationThe Strength of the Association
In men, the relative risk ranged from 3.8 to In men, the relative risk ranged from 3.8 to 14.214.2
In women, the relative risk ranged from 2 to In women, the relative risk ranged from 2 to 55
Men and women who smoked one of more Men and women who smoked one of more packs per day experienced a 25 to 30-fold packs per day experienced a 25 to 30-fold increased risk of dying from lung cancer increased risk of dying from lung cancer when compared with non-smokerswhen compared with non-smokers
RR of lung cancer for current smoking of cigarette only. IARC, 1986
0
2
4
6
8
10
12
14
16
ACS-9 ACS-25 Br Doc Norway
RR
Canada Sweden US Vets
9.9
14.9
9.2
7.0
1412.1
9.5
Dose-Response RelationshipDose-Response Relationship
The existence of a dose-response The existence of a dose-response relationship between smoking and lung relationship between smoking and lung cancer constitutes further evidence of a cancer constitutes further evidence of a causal relationship.causal relationship.
Many studies have demonstrated a dose-Many studies have demonstrated a dose-response relationship between cigarette response relationship between cigarette smoked per day, years of smoking and smoked per day, years of smoking and pack-years of smoking and lung cancer. pack-years of smoking and lung cancer.
Specificity of the AssociationSpecificity of the Association
The degree of specificity between lung cancer and The degree of specificity between lung cancer and smoking is measured by the attributable risk.smoking is measured by the attributable risk.
It is estimated that 85% to 90% of lung cancer It is estimated that 85% to 90% of lung cancer deaths in men is due to cigarette smokingdeaths in men is due to cigarette smoking
The observation that all smokers do not develop The observation that all smokers do not develop lung cancer indicate the genetic susceptibility, lung cancer indicate the genetic susceptibility, competing causes of death. competing causes of death.
Temporal Relationship Temporal Relationship
Temporal relationship is approved by Temporal relationship is approved by several prospective cohort studies when several prospective cohort studies when exposure to cigarette smoking was obtained exposure to cigarette smoking was obtained before the occurrence of lung cancerbefore the occurrence of lung cancer
The latent period between first exposure The latent period between first exposure and the onset of the disease is about 20-30 and the onset of the disease is about 20-30 yearsyears
Coherence of the AssociationCoherence of the Association Distribution of the disease and of the cigarette Distribution of the disease and of the cigarette
smoking are similar with regards to person, smoking are similar with regards to person, place, and time.place, and time.
Rapid rise in cigarette consumption resulted in Rapid rise in cigarette consumption resulted in the rapid rise of lung cancer after a period of the rapid rise of lung cancer after a period of latency.latency.
The distribution of cigarette smoking among The distribution of cigarette smoking among sexes, among rural and urban residents, and sexes, among rural and urban residents, and among different socioeconomic classes was among different socioeconomic classes was similar to the distribution of lung cancer among similar to the distribution of lung cancer among these groups.these groups.
These who quit smoking had a decreased risk.These who quit smoking had a decreased risk.
Biological CredibilityBiological Credibility
Over 60 carcinogens in cigarette smokingOver 60 carcinogens in cigarette smoking Carcinogens may cause DNA damageCarcinogens may cause DNA damage Mutation of Tumor suppresser genes are Mutation of Tumor suppresser genes are
linked to cigarette smokinglinked to cigarette smoking Animal studies also support the relationship Animal studies also support the relationship
between cigarette smoking and lung cancer. between cigarette smoking and lung cancer.
Prospects for Prevention Prospects for Prevention
Smoking cessation among smokersSmoking cessation among smokers Reinforcing social pressure to make Reinforcing social pressure to make
smoking unattractive and difficult for smoking unattractive and difficult for adolescents to start smokingadolescents to start smoking
Early detection of early lesions, by x-ray or Early detection of early lesions, by x-ray or other means other means
Smoking and Other CancersSmoking and Other Cancers
Head and neck cancers (oral, laryngeal and Head and neck cancers (oral, laryngeal and pharyngeal cancers)pharyngeal cancers)
Esophageal cancerEsophageal cancer Stomach cancerStomach cancer Pancreatic CancerPancreatic Cancer Bladder cancerBladder cancer Cervical cancerCervical cancer Liver cancerLiver cancer
Environmental Tobacco SmokeEnvironmental Tobacco Smoke
3,000 nonsmoking Americans die of lung 3,000 nonsmoking Americans die of lung cancercancer
300,000 children suffer from lower 300,000 children suffer from lower respiratory tract infections.respiratory tract infections.
Major Sources of Data on Major Sources of Data on Tobacco Use in the United Tobacco Use in the United
StatesStatesSurveys of Young People
• Teenage Tobacco Surveys
• Monitoring the Future Surveys (MTFS)
• National Household Survey on Drug Abuse (NHSDA)
• National Health and Nutrition Examination Survey (NHANES)
• Youth Risk Behavior Surveillance System (YRBSS)
• National Youth Tobacco Survey (NYTS)
• Youth Tobacco Survey (YTS)
• Global Youth Tobacco Survey (GYTS)
• Legacy Media Tacking Surveys
Major Sources of Data on Major Sources of Data on Tobacco Use in the United Tobacco Use in the United
StatesStatesSurveys of Adults
• Current Population Surveys (CPS)
• Adult Use of Tobacco Surveys (AUTS); Adult Tobacco Surveys (ATS)
• National Health Interview Survey (NHIS)
• National Household Survey on Drug Abuse (NHSDA)
• National Health and Nutrition Examination Survey (NHANES)
• Behavioral Risk Factor Surveillance System (BRFSS)
• American Smoking and Health Survey (ASHES)
A bidi is a small, flavored, filterless cigarette made in A bidi is a small, flavored, filterless cigarette made in India. A bidi is a dried tendu leaf rolled around India. A bidi is a dried tendu leaf rolled around tobacco, usually tied with a red string. They come tobacco, usually tied with a red string. They come in a variety of flavors, including vanilla, cherry, in a variety of flavors, including vanilla, cherry, menthol, and chocolate etc. menthol, and chocolate etc.
