Burden of cancer deaths from smoking heaviest in U.S. south

(Reuters Health) - Of all cancer deaths in the U.S., the share that’s related to smoking varies considerably by region, with southern states bearing the heaviest burden, according to a new study.

With up to 40 percent of cancer deaths attributable to smoking in some areas and just 8 percent in others, the disparities may come down largely to how aggressively states pursue tobacco control, researchers write in JAMA Internal Medicine, October 24th.

“Declines in smoking prevalence have accelerated over the past seven to eight years,” lead author Joannie Lortet-Tieulent of Surveillance and Health Services Research at the American Cancer Society in Atlanta, told Reuters Health by email.

“However, the decline could have been accelerated much faster with full implementation of known tobacco interventions throughout the country such as increased excise tax, banning smoking in all public places, and reducing nicotine in cigarettes to non-addictive level,” she said.

The study estimates that at least 28.6 percent of U.S. cancer deaths in 2014 among people over age 35 were linked to smoking, which translates to 167,133 lives that might have been saved.

For the new study, the researchers estimated what proportion of cancer deaths in each state could be attributed to smoking by basing their calculations on past research showing a smoking-associated increased risk for 12 cancers: acute myeloid leukemia; cancers of the oral cavity and pharynx; esophagus; stomach; colorectum; liver; pancreas; larynx; trachea, lung, and bronchus; cervix uteri; kidney and renal pelvis; and urinary bladder.

Combining that with state-specific smoking prevalence data, they found that the portion of smoking-related cancer deaths among men in 2014 ranged from a high of 39.5 percent in Arkansas to a low of 21.8 percent in Utah. With the exception of Utah, the proportion was at least 30 percent for men in all states.

Among women, 11 percent of cancer deaths in Utah were attributable to cigarette smoking, compared to 29 percent in Kentucky, and the proportion was at least 20 percent in every state except Utah, California and Hawaii.

“We knew that some states have higher tobacco control and higher funding for anti-smoking programs than others, but we did not anticipate that would be a doubling between the state with the lowest fraction and the highest fraction of smoking-attributable cancer death,” Lortet-Tieulent said.

More than half of the top-10 ranked states for smoking-related cancer deaths among both men and women were located in the South. For men, the top five states were Arkansas, Louisiana, Tennessee, West Virginia and Kentucky. For women, Kentucky, Arkansas and Tennessee were also in the top five, along with Alaska and Nevada.

Southern states generally have more current and former smokers and weaker tobacco control policies, such as lower excise taxes and less comprehensive smoke-free policies, Lortet-Tieulent said. In addition, for middle aged people, current and former smoking is more common for men than women.

“Many of the stalled states are in the southeastern United States, where tobacco has traditionally been grown and manufactured, and others are in areas with historically little investment for public health or tobacco control,” Kurt M. Ribisl of the University of North Carolina at Chapel Hill and colleagues write in a related commentary.

After New York City raised the cigarette excise tax from $0.08 to $1.50, banned smoking in bars and restaurants, and offered free nicotine replacement patches in 2002 through 2003, smoking decreased by about 11 percent in the City, equivalent to about 140,000 fewer smokers, they write.

About three-quarters of smoking-related cancer deaths are due to lung cancer, Lortet-Tieulent noted.

“The risk of lung cancer death gradually reduces after smoking cessation but does not reach to the level among never smokers,” she said. “Nearly all the excess risk of death from lung cancer can be avoided if a smoker quits smoking before the age of 40 years.”

“Increasing tobacco control funding, implementing innovative new strategies, and strengthening tobacco control policies and programs all contribute to increase smoking cessation and avoiding smoking initiation,” she said. “For example, California, Hawaii and 145 smaller localities have increased the tobacco sales age to 21 years. Likewise, communities across the U.S. have passed laws that limit or prohibit smoking in multifamily housing.”


JAMA Intern Med 2016.