J Community Health DOI 10.1007/s10900-014-9951-6
ORIGINAL PAPER
Decreasing Trend in Tobacco-Related Cancer Incidence, United States 2005–2009 J. Michael Underwood • Thomas B. Richards • S. Jane Henley • Behnoosh Momin • Keisha Houston Italia Rolle • Carissa Holmes • Sherri L. Stewart
•
Ó Springer Science+Business Media New York (outside the USA) 2014
Abstract More than 1 in 3 cancer-related deaths are associated with tobacco use; these include cancers of the lung and bronchus, oral cavity and pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder, and cervix, and acute myeloid leukemia. In order to characterize the current cancer burden due to tobacco use, this study provides recent trends in tobaccorelated cancer incidence across the US. We analyzed data from CDC’s National Program of Cancer Registries and NCI’s Surveillance, Epidemiology and End Results Program, covering 100 % of the US population during 2005–2009. Age-adjusted incidence rates, 95 % confidence intervals and annual percent change were calculated for each state, the District of Columbia, and the US. Tobaccorelated cancer incidence in the US decreased significantly from 152.9 (per 100,000 persons) in 2005 to 145.8 in 2009.
Men had higher incidence rates, but a greater decrease in tobacco-related cancers per year over the 5-year time period (-1.4 % in men, compared to -0.8 % in women). Incidence rates decreased the most per year for larynx (-2.4 %), lung and bronchus (-1.9 %) and stomach (-1.5 %) cancers during the study period. Tobacco-related cancer incidence trends varied by state. While tobaccorelated cancer incidence in the United States decreased overall from 2005 to 2009, tobacco continued to account for a large cancer burden. Our findings suggest that continued efforts in tobacco prevention and control are needed to further reduce tobacco-related cancer burden in general and among targeted sub-populations in the US. Keywords
Epidemiology Cancer Neoplasm Tobacco
Background
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. J. M. Underwood (&) T. B. Richards S. J. Henley B. Momin K. Houston S. L. Stewart Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, N.E., Atlanta, GA 30341, USA e-mail: [email protected] I. Rolle C. Holmes Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, N.E., Atlanta, GA 30341, USA
Two-Thousand and Thirteen marked the 15-year anniversary of the 1998 Master Settlement Agreement (MSA) between states and tobacco manufacturers, which compensates states for health care costs incurred from tobaccorelated illnesses and deaths [6]. In addition to providing compensation, the MSA was intended to promote smoking prevention and cessation by implementing various tobacco control measures [6]. Today more than 1 in 3 cancer-related deaths are associated with tobacco use [11]; these include cancers of the lung and bronchus, oral cavity and pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder, and cervix, and acute myeloid leukemia [20]. A 2008 report from the Centers for Disease Control and Prevention (CDC) on US tobacco-related cancer incidence revealed an age-adjusted incidence rate of 155.7 per
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Fig. 1 Aggregate 5-year age-adjusted incidence trend, rate, count and annual percent change (APC) for tobacco-related cancers, US 2005–2009. Sources: Centers for Disease Control and Prevention’s National Program of Cancer Registries and National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. 2005–2009 data from these population-based cancer registries represent 100 % of the US population. Tobacco-related cancers include cancers of the lung and bronchus, oral cavity and pharynx,
larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder (invasive and in situ cases), cervix, and acute myeloid leukemia. Five-year aggregate rates of tobacco-related cancer diagnosed per 100,000 persons, age adjusted to the 2000 US standard population. APC was used to quantify the change in incidence rates over time and was calculated using least squares regression. *APC is significant
100,000 persons from 1999 to 2004 [15]. The same report demonstrated a slight decrease in tobacco-related cancer burden during the study period, which was largely due to reductions in lung and bronchus cancer [7]. In order to update the previous CDC report, this study characterizes the current cancer burden due to tobacco use by reporting trends in tobacco-related cancer incidence across the US from 2005 to 2009.
new cases of cancer were those reported to NPCR as of January 31, 2012, and to SEER as of November 1, 2011. Invasive cancers included all cancers except in situ cancers (except in the urinary bladder) or basal and squamous cell skin cancers. Data were evaluated according to United States Cancer Statistics eligibility criteria [16]; data from all 50 states and the District of Columbia met these criteria for the years 2005–2009, representing 100 % of the US population. Tobacco-related cancer incidence is presented as the aggregate number of new cases over the 5-year period. Incidence rates were calculated using population estimates from the U.S. Census [17], were age-adjusted to the 2000 US standard population, and expressed per 100,000 persons. Annual percent change (APC) was used to quantify the change in incidence rates from 2005 to 2009
Methods Data available from population-based cancer registries affiliated with NPCR and SEER were used in this analysis;
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Fig. 2 Annual percent change for tobacco-related cancer incidence by state, US 2005–2009. Sources: Centers for Disease Control and Prevention’s National Program of Cancer Registries and National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. 2005–2009 data from these population-based cancer registries represent 100 % of the US population. Tobacco-related cancers include cancers of the lung and bronchus, oral cavity and
pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder (invasive and in situ cases), cervix, and acute myeloid leukemia. APC was used to quantify the change in incidence rates over time and was calculated using least squares regression. Stable rates did not increase/decrease significantly. All other incidence rates are significant
and was calculated using least squares regression. Tobacco-related cancers are those in which ‘‘the evidence is sufficient to infer a causal relationship’’ between smoking and disease onset, according to the 2004 Report of the Surgeon General on the Health Consequences of Smoking [20]. Adjustments to population data were made by the U.S. Census Bureau to account for the Gulf Coast population in Alabama, Mississippi, Louisiana, and Texas displaced by Hurricanes Katrina and Rita in 2005 [17].
highest for lung and bronchus cancer among men (83.1 per 100,000) and women (55.8 per 100,000). Incidence rates for the total US population significantly decreased nearly 1.1 % (APC) per year from 152.9 (per 100,000 persons) in 2005 to 145.8 (per 100,000 persons) in 2009; resulting in a 4.7 % decrease from 2005 to 2009 (Fig. 1). Tobacco-related cancer incidence rates decreased 1.4 % per year from 2005 to 2009 among men, but were stable among women. Among specific cancer sites, incidence rates from 2005 to 2009 decreased for cancers of the stomach, larynx, lung and urinary bladder among men, and cancers of the esophagus, stomach, larynx, lung, cervix and urinary bladder among women (Fig. 1). By state, tobacco-related cancer incidence rates declined C2 % per year from 2005 to 2009 in Missouri, South Carolina, Utah and the District of Columbia; declined 0.7–1.9 % per year in California, Florida, Maine, New Mexico, North Carolina, North Dakota, South Dakota, and Virginia; and were stable in all other states (Fig. 2).
Results During 2005–2009, a total of 2,316,827 tobacco-related cancer diagnoses (aggregate annual incidence: 150.2 per 100,000) were reported in the US. Tobacco-related cancer incidence rates were higher among men (200.8 per 100,000) than women (112.0 per 100,000). Incidence rates were
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Conclusions Our analysis of tobacco-related cancer incidence reveals an overall rate of 150.2 (per 100,000 persons) from 2005 to 2009; decreasing 4.7 % from 152.9 in 2005, to 145.8 in 2009. Men had higher incidence rates, but a greater rate decrease over the study period when compared to women. Tobacco-related cancer incidence rates varied widely by cancer type and US state, though lung and bronchus cancer account for nearly half of all diagnoses. This report shows improvement in a steady decrease of tobacco-related cancer burden in the US, which was reported to be at an overall rate of 155.7 in a 2008 CDC study [15]. Similar to our findings, the prior study also identified lung and bronchus cancer as the predominant cancer type, which implies overall tobacco-related cancer burden is largely influenced by patterns in lung cancer incidence [7]. The steady reduction in lung cancer, and tobacco-related cancer overall is due to decreased smoking and tobacco consumption, and reflects smoking patterns in the United States over the last several years [4, 19]. After a 7-year (1997–2004) decline in smoking among adults around the turn of the century, rates plateaued at 20 % in the late 2000s [14]. The most recent report on smoking prevalence reveals 18.1% of US adults were current smokers in 2012 [1]. Despite the overall decrease in tobacco-related cancer burden across the country, only 1 in 4 states report a decrease in tobacco-related cancer incidence. Research shows that tobacco control done effectively can reduce the disease burden due to smoking [19, 20]. For example, California led the country in tobacco control over the last 40 years [13], and in this report California shows the greatest lung cancer decline in the nation. According to our study, a majority of states report persistent tobacco-related cancer burden. This finding may reflect state-level differences in efforts to prevent and control tobacco use, through policy and regulation. For example, high tobacco prices have been shown to reduce tobacco consumption, especially among young people [3–5]. Additionally, the price of tobacco varies greatly by state and locality, primarily due to great variation in tobacco excise taxes. For example, these taxes currently range from as low as 17 cents per pack of cigarettes in Missouri to high as $4.35 per pack in New York [19]. State and federal appropriations for tobacco control totaled $8.1 billion in 2010; whereas CDC’s Best Practices recommended funding of at least $29.2 billion [9]. From 1998 to 2010, the ratio of state tobacco revenues to state and federal tobacco control appropriations was approximately 30–1 ($243.8 billion to $8.1 billion); in 2010, the ratio was approximately 37–1 ($23.96 billion to $0.64 billion). Finally, comprehensive smoke-free air laws protect nonsmokers from secondhand
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smoke exposure and shape social norms to decrease the social acceptability of smoking, especially among youth— thus reducing the number of youth that become addicted smokers [3]. Twenty-seven states currently have comprehensive smoke-free air laws in place (defined as 100 % smoke-free in three key locations: bars, restaurants, and all worksites), which translates to only 47 % of the US population protected by the strongest laws. In contrast, five states are smoke-free in two of these locations and five are smoke-free in one of these three public places. Fourteen states do not have 100 % smoke-free air laws in any of these locations, leaving their populations vulnerable to secondhand smoke and perpetuating the social acceptability of smoking [19].States may achieve larger and more rapid reductions in smoking and associated morbidity and mortality by implementing the evidence-based tobacco control strategies mentioned above, such as increasing the price of tobacco products, allocating funding for tobacco control at levels recommended by Best Practices and implementing smoke-free air policies [19]. The findings in this report are subject to at least six limitations. First, given the latency between smoking initiation and cancer onset as well as the latency between smoking cessation and subsequent declines in cancer risk [20], our analysis of tobacco-related trends likely reflect tobacco control efforts over the last several decades and not necessarily MSA impact. Continued surveillance of tobacco-related cancers over the next 10–20 years may reveal greater reductions in the tobacco-related cancer burden. Second, errors in 2005–2009 postcensal populations that were estimated from the 2000 Census might increase as time passes after the census, which may lead to underestimates or overestimates of incidence rates. Third, information about smoking status and other risk factors is not available in the cancer registry data and correlations to tobacco-related cancer incidence at the individual level cannot be made. Fourth, cancer development is influenced by a number of factors and exposures such as second-hand smoke, alcohol use, infectious agents or occupational hazards might also influence rates and trends. Fifth, trends in tobacco-related cancers may differ for characteristics not examined in this report. Finally, we base our definition of tobacco-related cancers on the 2004 Surgeon General’s report on the Health Consequences of Smoking. The list of tobacco-related cancers has recently been expanded to include liver and colorectal cancers, but was not included in our investigation, order to maintain consistency with prior studies [18]. Future analyses will include the recent additions to the Surgeon General’s list of tobacco-related cancers. In the 15 years since the MSA, state programs have implemented initiatives to support tobacco prevention and cessation, and the resultant tobacco control policies have
J Community Health
contributed to success in reducing illnesses related to tobacco, such as heart disease and lung cancer [2, 8, 10]. However, some states have not fully committed to funding tobacco control efforts as recommended in the settlement, thus decreasing its impact [12]. Tobacco-related cancers still account for more than 30 % of all cancer deaths, and these cancers are typically more deadly than other, nontobacco-related cancers [11]. Because of the substantial disease burden due to tobacco, ‘‘reducing tobacco use’’ had been identified by CDC as a public health winnable battle [5]. Strategies for this winnable battle include discouraging smoking initiation, providing resources for the 45 million adults who currently smoke to quit, and protecting nonsmokers from secondhand smoke exposure, with the ultimate goal of reducing the 443,000 premature deaths, including 161,000 from cancer, in the United States each year [5]. Continued effective implementation of tobacco control policy is recommended, including systems and environmental changes such as designating tobacco-free zones and increasing tobacco taxation to adequately fund tobacco prevention and cessation efforts. Acknowledgments The authors of this report would like to acknowledge the CDC’s Workgroup on Tobacco-Related Cancer for their contributions to this study, as well as state and regional cancer registry staff. This work was supported by the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control, and Office on Smoking and Health.
References 1. Agaku, I. T., King, B. A., & Dube, S. R. (2014). Current cigarette smoking among adults—United States, 2005–2012. Morbidity and Mortality Weekly Report, 63(2), 29–34. 2. Barnoya, J., & Glantz, S. (2004). Association of the California tobacco control program with declines in lung cancer incidence. Cancer Causes and Control, 15(7), 689–695. doi:10.1023/B: CACO.0000036187.13805.30. 3. Centers for Disease Control and Prevention. (2014). State Tobacco Activities Tracking and Evaluation (STATE) System. http://www.cdc.gov/tobacco/statesystem. 4. Centers for Disease Control and Prevention. (2014). Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2011. http://www.cdc.gov/tobacco/ data_statistics/tables/trends/cig_smoking/. 5. Centers for Disease Control and Prevention. (2014). Winnable battles. http://www.cdc.gov/winnablebattles/tobacco/index.html. 6. Clark, T. T., Sparks, M. J., McDonald, T. M., & Dickerson, J. D. (2011). Post-tobacco master settlement agreement: policy and practice implications for social workers. Health and Social Work, 36(US Department of Health and Human Services, 2004), 217–224. doi 10.1093/hsw/36.3.217. 7. Henley S.J., Eheman C. R., Richardson L. C., Plescia M., Asman K. J., Dube S. R., Caraballo R. S., McAfee T. A. (2011) State-Specific Trends in Lung Cancer Incidence and Smoking—United States, 1999–2008. Morbidity and Mortality Weekly Report 60(36), 1243–1247. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60 36a3.htm.
8. Jemal, A., Thun, M. J., Ries, L. A., Howe, H. L., Weir, H. K., Center, M. M., et al. (2008). Annual report to the nation on the status of cancer, 1975–2005, featuring trends in lung cancer, tobacco use, and tobacco control. Journal of the National Cancer Institute, 100(23), 1672–1694. doi:10.1093/jnci/djn389. 9. Kaufmann R., Francis J., Tynan M. A., Pechacek T. (2012). State tobacco revenues compared with tobacco control appropriations– United States, 1998–2010. Morbidity and Mortality Weekly Report, 61(20), 370–374. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6120a3.htm. 10. Moolgavkar, S. H., Holford, T. R., Levy, D. T., Kong, C. Y., Foy, M., Clarke, L., et al. (2012). Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975–2000. Journal of the National Cancer Institute, 104(7), 541–548. doi:10.1093/jnci/djs136. 11. National Cancer Institute. (2014). Surveillance epidemiology and end results cancer stat fact sheets. http://seer.cancer.gov/statfacts/. 12. Niemeyer, D., Miner, K. R., Carlson, L. M., Baer, K., & Shorty, L. (2004). The 1998 master settlement agreement: A public health opportunity realized—Or lost? Health Promotion Practice, 5(3 Suppl), 21S–32S. doi:10.1177/1524839904264588. 13. Pierce, J. P., Messer, K., White, M. M., Kealey, S., & Cowling, D. W. (2010). Forty years of faster decline in cigarette smoking in California explains current lower lung cancer rates. Cancer Epidemiology, Biomarkers and Prevention, 19(11), 2801–2810. doi:10.1158/1055-9965.EPI-10-0563. 14. Rock, V. J., Malarcher, A., Kahende, J. W., Asman, K., Husten, C., Caraballo, R. (2007). Cigarette smoking among adults—United States, 2006. Morbidity and Mortality Weekly Report, 56(44), 1157–1161. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm56 44a2.htm. 15. Stewart, S. L., Cardinez, C. J., Richardson, L. C., Norman, L., Kaufmann, R., Pechacek, T. F., Sabatino, S. A. (2008). Surveillance for cancers associated with tobacco use—United States, 1999–2004. Morbidity and Mortality Weekly Report. Surveillance summaries (Washington, DC: 2002), 57(US Department of Health and Human Services, 2012), 1. http://www.cdc.gov/ mmwr/preview/mmwrhtml/ss5708a1.htm. 16. United States Cancer Statistics. (2014). Cancer data eligibility criteria. http://www.cdc.gov/uscs. 17. U.S. Census Methodology. (2014). http://www.census.gov/popest/ topics/methodology. 18. US Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 17. 19. US Department of Health and Human Services. (2012). Preventing tobacco use among youth and young adults: A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrievable from http://www.surgeongeneral.gov/library/reports/preventing-youthtobacco-use/index.html. 20. US Department of Health and Human Services. (2004). The health consequences of smoking: a report of the Surgeon General. Washington, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrievable from http://www.surgeongen eral.gov/library/reports/smokingconsequences/index.html.
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ORIGINAL PAPER
Decreasing Trend in Tobacco-Related Cancer Incidence, United States 2005–2009 J. Michael Underwood • Thomas B. Richards • S. Jane Henley • Behnoosh Momin • Keisha Houston Italia Rolle • Carissa Holmes • Sherri L. Stewart
•
Ó Springer Science+Business Media New York (outside the USA) 2014
Abstract More than 1 in 3 cancer-related deaths are associated with tobacco use; these include cancers of the lung and bronchus, oral cavity and pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder, and cervix, and acute myeloid leukemia. In order to characterize the current cancer burden due to tobacco use, this study provides recent trends in tobaccorelated cancer incidence across the US. We analyzed data from CDC’s National Program of Cancer Registries and NCI’s Surveillance, Epidemiology and End Results Program, covering 100 % of the US population during 2005–2009. Age-adjusted incidence rates, 95 % confidence intervals and annual percent change were calculated for each state, the District of Columbia, and the US. Tobaccorelated cancer incidence in the US decreased significantly from 152.9 (per 100,000 persons) in 2005 to 145.8 in 2009.
Men had higher incidence rates, but a greater decrease in tobacco-related cancers per year over the 5-year time period (-1.4 % in men, compared to -0.8 % in women). Incidence rates decreased the most per year for larynx (-2.4 %), lung and bronchus (-1.9 %) and stomach (-1.5 %) cancers during the study period. Tobacco-related cancer incidence trends varied by state. While tobaccorelated cancer incidence in the United States decreased overall from 2005 to 2009, tobacco continued to account for a large cancer burden. Our findings suggest that continued efforts in tobacco prevention and control are needed to further reduce tobacco-related cancer burden in general and among targeted sub-populations in the US. Keywords
Epidemiology Cancer Neoplasm Tobacco
Background
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. J. M. Underwood (&) T. B. Richards S. J. Henley B. Momin K. Houston S. L. Stewart Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, N.E., Atlanta, GA 30341, USA e-mail: [email protected] I. Rolle C. Holmes Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, N.E., Atlanta, GA 30341, USA
Two-Thousand and Thirteen marked the 15-year anniversary of the 1998 Master Settlement Agreement (MSA) between states and tobacco manufacturers, which compensates states for health care costs incurred from tobaccorelated illnesses and deaths [6]. In addition to providing compensation, the MSA was intended to promote smoking prevention and cessation by implementing various tobacco control measures [6]. Today more than 1 in 3 cancer-related deaths are associated with tobacco use [11]; these include cancers of the lung and bronchus, oral cavity and pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder, and cervix, and acute myeloid leukemia [20]. A 2008 report from the Centers for Disease Control and Prevention (CDC) on US tobacco-related cancer incidence revealed an age-adjusted incidence rate of 155.7 per
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Fig. 1 Aggregate 5-year age-adjusted incidence trend, rate, count and annual percent change (APC) for tobacco-related cancers, US 2005–2009. Sources: Centers for Disease Control and Prevention’s National Program of Cancer Registries and National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. 2005–2009 data from these population-based cancer registries represent 100 % of the US population. Tobacco-related cancers include cancers of the lung and bronchus, oral cavity and pharynx,
larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder (invasive and in situ cases), cervix, and acute myeloid leukemia. Five-year aggregate rates of tobacco-related cancer diagnosed per 100,000 persons, age adjusted to the 2000 US standard population. APC was used to quantify the change in incidence rates over time and was calculated using least squares regression. *APC is significant
100,000 persons from 1999 to 2004 [15]. The same report demonstrated a slight decrease in tobacco-related cancer burden during the study period, which was largely due to reductions in lung and bronchus cancer [7]. In order to update the previous CDC report, this study characterizes the current cancer burden due to tobacco use by reporting trends in tobacco-related cancer incidence across the US from 2005 to 2009.
new cases of cancer were those reported to NPCR as of January 31, 2012, and to SEER as of November 1, 2011. Invasive cancers included all cancers except in situ cancers (except in the urinary bladder) or basal and squamous cell skin cancers. Data were evaluated according to United States Cancer Statistics eligibility criteria [16]; data from all 50 states and the District of Columbia met these criteria for the years 2005–2009, representing 100 % of the US population. Tobacco-related cancer incidence is presented as the aggregate number of new cases over the 5-year period. Incidence rates were calculated using population estimates from the U.S. Census [17], were age-adjusted to the 2000 US standard population, and expressed per 100,000 persons. Annual percent change (APC) was used to quantify the change in incidence rates from 2005 to 2009
Methods Data available from population-based cancer registries affiliated with NPCR and SEER were used in this analysis;
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Fig. 2 Annual percent change for tobacco-related cancer incidence by state, US 2005–2009. Sources: Centers for Disease Control and Prevention’s National Program of Cancer Registries and National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. 2005–2009 data from these population-based cancer registries represent 100 % of the US population. Tobacco-related cancers include cancers of the lung and bronchus, oral cavity and
pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder (invasive and in situ cases), cervix, and acute myeloid leukemia. APC was used to quantify the change in incidence rates over time and was calculated using least squares regression. Stable rates did not increase/decrease significantly. All other incidence rates are significant
and was calculated using least squares regression. Tobacco-related cancers are those in which ‘‘the evidence is sufficient to infer a causal relationship’’ between smoking and disease onset, according to the 2004 Report of the Surgeon General on the Health Consequences of Smoking [20]. Adjustments to population data were made by the U.S. Census Bureau to account for the Gulf Coast population in Alabama, Mississippi, Louisiana, and Texas displaced by Hurricanes Katrina and Rita in 2005 [17].
highest for lung and bronchus cancer among men (83.1 per 100,000) and women (55.8 per 100,000). Incidence rates for the total US population significantly decreased nearly 1.1 % (APC) per year from 152.9 (per 100,000 persons) in 2005 to 145.8 (per 100,000 persons) in 2009; resulting in a 4.7 % decrease from 2005 to 2009 (Fig. 1). Tobacco-related cancer incidence rates decreased 1.4 % per year from 2005 to 2009 among men, but were stable among women. Among specific cancer sites, incidence rates from 2005 to 2009 decreased for cancers of the stomach, larynx, lung and urinary bladder among men, and cancers of the esophagus, stomach, larynx, lung, cervix and urinary bladder among women (Fig. 1). By state, tobacco-related cancer incidence rates declined C2 % per year from 2005 to 2009 in Missouri, South Carolina, Utah and the District of Columbia; declined 0.7–1.9 % per year in California, Florida, Maine, New Mexico, North Carolina, North Dakota, South Dakota, and Virginia; and were stable in all other states (Fig. 2).
Results During 2005–2009, a total of 2,316,827 tobacco-related cancer diagnoses (aggregate annual incidence: 150.2 per 100,000) were reported in the US. Tobacco-related cancer incidence rates were higher among men (200.8 per 100,000) than women (112.0 per 100,000). Incidence rates were
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Conclusions Our analysis of tobacco-related cancer incidence reveals an overall rate of 150.2 (per 100,000 persons) from 2005 to 2009; decreasing 4.7 % from 152.9 in 2005, to 145.8 in 2009. Men had higher incidence rates, but a greater rate decrease over the study period when compared to women. Tobacco-related cancer incidence rates varied widely by cancer type and US state, though lung and bronchus cancer account for nearly half of all diagnoses. This report shows improvement in a steady decrease of tobacco-related cancer burden in the US, which was reported to be at an overall rate of 155.7 in a 2008 CDC study [15]. Similar to our findings, the prior study also identified lung and bronchus cancer as the predominant cancer type, which implies overall tobacco-related cancer burden is largely influenced by patterns in lung cancer incidence [7]. The steady reduction in lung cancer, and tobacco-related cancer overall is due to decreased smoking and tobacco consumption, and reflects smoking patterns in the United States over the last several years [4, 19]. After a 7-year (1997–2004) decline in smoking among adults around the turn of the century, rates plateaued at 20 % in the late 2000s [14]. The most recent report on smoking prevalence reveals 18.1% of US adults were current smokers in 2012 [1]. Despite the overall decrease in tobacco-related cancer burden across the country, only 1 in 4 states report a decrease in tobacco-related cancer incidence. Research shows that tobacco control done effectively can reduce the disease burden due to smoking [19, 20]. For example, California led the country in tobacco control over the last 40 years [13], and in this report California shows the greatest lung cancer decline in the nation. According to our study, a majority of states report persistent tobacco-related cancer burden. This finding may reflect state-level differences in efforts to prevent and control tobacco use, through policy and regulation. For example, high tobacco prices have been shown to reduce tobacco consumption, especially among young people [3–5]. Additionally, the price of tobacco varies greatly by state and locality, primarily due to great variation in tobacco excise taxes. For example, these taxes currently range from as low as 17 cents per pack of cigarettes in Missouri to high as $4.35 per pack in New York [19]. State and federal appropriations for tobacco control totaled $8.1 billion in 2010; whereas CDC’s Best Practices recommended funding of at least $29.2 billion [9]. From 1998 to 2010, the ratio of state tobacco revenues to state and federal tobacco control appropriations was approximately 30–1 ($243.8 billion to $8.1 billion); in 2010, the ratio was approximately 37–1 ($23.96 billion to $0.64 billion). Finally, comprehensive smoke-free air laws protect nonsmokers from secondhand
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smoke exposure and shape social norms to decrease the social acceptability of smoking, especially among youth— thus reducing the number of youth that become addicted smokers [3]. Twenty-seven states currently have comprehensive smoke-free air laws in place (defined as 100 % smoke-free in three key locations: bars, restaurants, and all worksites), which translates to only 47 % of the US population protected by the strongest laws. In contrast, five states are smoke-free in two of these locations and five are smoke-free in one of these three public places. Fourteen states do not have 100 % smoke-free air laws in any of these locations, leaving their populations vulnerable to secondhand smoke and perpetuating the social acceptability of smoking [19].States may achieve larger and more rapid reductions in smoking and associated morbidity and mortality by implementing the evidence-based tobacco control strategies mentioned above, such as increasing the price of tobacco products, allocating funding for tobacco control at levels recommended by Best Practices and implementing smoke-free air policies [19]. The findings in this report are subject to at least six limitations. First, given the latency between smoking initiation and cancer onset as well as the latency between smoking cessation and subsequent declines in cancer risk [20], our analysis of tobacco-related trends likely reflect tobacco control efforts over the last several decades and not necessarily MSA impact. Continued surveillance of tobacco-related cancers over the next 10–20 years may reveal greater reductions in the tobacco-related cancer burden. Second, errors in 2005–2009 postcensal populations that were estimated from the 2000 Census might increase as time passes after the census, which may lead to underestimates or overestimates of incidence rates. Third, information about smoking status and other risk factors is not available in the cancer registry data and correlations to tobacco-related cancer incidence at the individual level cannot be made. Fourth, cancer development is influenced by a number of factors and exposures such as second-hand smoke, alcohol use, infectious agents or occupational hazards might also influence rates and trends. Fifth, trends in tobacco-related cancers may differ for characteristics not examined in this report. Finally, we base our definition of tobacco-related cancers on the 2004 Surgeon General’s report on the Health Consequences of Smoking. The list of tobacco-related cancers has recently been expanded to include liver and colorectal cancers, but was not included in our investigation, order to maintain consistency with prior studies [18]. Future analyses will include the recent additions to the Surgeon General’s list of tobacco-related cancers. In the 15 years since the MSA, state programs have implemented initiatives to support tobacco prevention and cessation, and the resultant tobacco control policies have
J Community Health
contributed to success in reducing illnesses related to tobacco, such as heart disease and lung cancer [2, 8, 10]. However, some states have not fully committed to funding tobacco control efforts as recommended in the settlement, thus decreasing its impact [12]. Tobacco-related cancers still account for more than 30 % of all cancer deaths, and these cancers are typically more deadly than other, nontobacco-related cancers [11]. Because of the substantial disease burden due to tobacco, ‘‘reducing tobacco use’’ had been identified by CDC as a public health winnable battle [5]. Strategies for this winnable battle include discouraging smoking initiation, providing resources for the 45 million adults who currently smoke to quit, and protecting nonsmokers from secondhand smoke exposure, with the ultimate goal of reducing the 443,000 premature deaths, including 161,000 from cancer, in the United States each year [5]. Continued effective implementation of tobacco control policy is recommended, including systems and environmental changes such as designating tobacco-free zones and increasing tobacco taxation to adequately fund tobacco prevention and cessation efforts. Acknowledgments The authors of this report would like to acknowledge the CDC’s Workgroup on Tobacco-Related Cancer for their contributions to this study, as well as state and regional cancer registry staff. This work was supported by the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control, and Office on Smoking and Health.
References 1. Agaku, I. T., King, B. A., & Dube, S. R. (2014). Current cigarette smoking among adults—United States, 2005–2012. Morbidity and Mortality Weekly Report, 63(2), 29–34. 2. Barnoya, J., & Glantz, S. (2004). Association of the California tobacco control program with declines in lung cancer incidence. Cancer Causes and Control, 15(7), 689–695. doi:10.1023/B: CACO.0000036187.13805.30. 3. Centers for Disease Control and Prevention. (2014). State Tobacco Activities Tracking and Evaluation (STATE) System. http://www.cdc.gov/tobacco/statesystem. 4. Centers for Disease Control and Prevention. (2014). Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2011. http://www.cdc.gov/tobacco/ data_statistics/tables/trends/cig_smoking/. 5. Centers for Disease Control and Prevention. (2014). Winnable battles. http://www.cdc.gov/winnablebattles/tobacco/index.html. 6. Clark, T. T., Sparks, M. J., McDonald, T. M., & Dickerson, J. D. (2011). Post-tobacco master settlement agreement: policy and practice implications for social workers. Health and Social Work, 36(US Department of Health and Human Services, 2004), 217–224. doi 10.1093/hsw/36.3.217. 7. Henley S.J., Eheman C. R., Richardson L. C., Plescia M., Asman K. J., Dube S. R., Caraballo R. S., McAfee T. A. (2011) State-Specific Trends in Lung Cancer Incidence and Smoking—United States, 1999–2008. Morbidity and Mortality Weekly Report 60(36), 1243–1247. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60 36a3.htm.
8. Jemal, A., Thun, M. J., Ries, L. A., Howe, H. L., Weir, H. K., Center, M. M., et al. (2008). Annual report to the nation on the status of cancer, 1975–2005, featuring trends in lung cancer, tobacco use, and tobacco control. Journal of the National Cancer Institute, 100(23), 1672–1694. doi:10.1093/jnci/djn389. 9. Kaufmann R., Francis J., Tynan M. A., Pechacek T. (2012). State tobacco revenues compared with tobacco control appropriations– United States, 1998–2010. Morbidity and Mortality Weekly Report, 61(20), 370–374. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6120a3.htm. 10. Moolgavkar, S. H., Holford, T. R., Levy, D. T., Kong, C. Y., Foy, M., Clarke, L., et al. (2012). Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975–2000. Journal of the National Cancer Institute, 104(7), 541–548. doi:10.1093/jnci/djs136. 11. National Cancer Institute. (2014). Surveillance epidemiology and end results cancer stat fact sheets. http://seer.cancer.gov/statfacts/. 12. Niemeyer, D., Miner, K. R., Carlson, L. M., Baer, K., & Shorty, L. (2004). The 1998 master settlement agreement: A public health opportunity realized—Or lost? Health Promotion Practice, 5(3 Suppl), 21S–32S. doi:10.1177/1524839904264588. 13. Pierce, J. P., Messer, K., White, M. M., Kealey, S., & Cowling, D. W. (2010). Forty years of faster decline in cigarette smoking in California explains current lower lung cancer rates. Cancer Epidemiology, Biomarkers and Prevention, 19(11), 2801–2810. doi:10.1158/1055-9965.EPI-10-0563. 14. Rock, V. J., Malarcher, A., Kahende, J. W., Asman, K., Husten, C., Caraballo, R. (2007). Cigarette smoking among adults—United States, 2006. Morbidity and Mortality Weekly Report, 56(44), 1157–1161. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm56 44a2.htm. 15. Stewart, S. L., Cardinez, C. J., Richardson, L. C., Norman, L., Kaufmann, R., Pechacek, T. F., Sabatino, S. A. (2008). Surveillance for cancers associated with tobacco use—United States, 1999–2004. Morbidity and Mortality Weekly Report. Surveillance summaries (Washington, DC: 2002), 57(US Department of Health and Human Services, 2012), 1. http://www.cdc.gov/ mmwr/preview/mmwrhtml/ss5708a1.htm. 16. United States Cancer Statistics. (2014). Cancer data eligibility criteria. http://www.cdc.gov/uscs. 17. U.S. Census Methodology. (2014). http://www.census.gov/popest/ topics/methodology. 18. US Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 17. 19. US Department of Health and Human Services. (2012). Preventing tobacco use among youth and young adults: A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrievable from http://www.surgeongeneral.gov/library/reports/preventing-youthtobacco-use/index.html. 20. US Department of Health and Human Services. (2004). The health consequences of smoking: a report of the Surgeon General. Washington, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrievable from http://www.surgeongen eral.gov/library/reports/smokingconsequences/index.html.
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