Cigarette%20Smoking%20and%20Cancer%20Risk

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Cigarette Smoking and Cancer Risk

• Epidemiology 242
• Cancer Epidemiology
• 2009

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Prevalence of Cigarette Smoking

• 1880 to after World War 1, cigarette represented
  a small proportion of overall tobacco
  consumption.
• 1920-1945, cigarettes rose dramatically and
  commercially produced cigarettes became the
  dominant form of tobacco
• 1945-1965, cigarette consumption leveled off
• 1965-1995, cigarette consumption declined
  dramatically

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• Trends in Per Capita Consumption of Various
  Tobacco Products United States, 1880-2001

Source Tobacco Situation and Outlook Report,
U.S. Department of Agriculture, U.S.
Census Note Among persons gt18 years old.
Beginning in 1982, fine-cut chewing tobacco was
reclassified as snuff.
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Adult Per Capita Cigarette Consumption and Major
Smoking and Health Events United States,
1900-2001
1st World Conference on Smoking and Health
Broadcast Ad Ban
1st Surgeon Generals Report
1st Great American Smoke-out
End of WW II
OTC Nicotine Medications
Master Settlement Agreement
Fairness Doctrine Messages on TV and Radio
1st Smoking-Cancer Concern
Non-Smokers Rights Movement Begins
Surgeon Generals Report on ETS
Federal Cigarette Tax Doubles
Great Depression
Source United States Department of Agriculture
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Decreased Cigarette Consumption in the US since
1965

• Since 1950, scientific reports linking cigarette
  smoking with cancers and other chronic diseases
• Bans on TV and radio advertising
• The growth of the nonsmokers rights movement
• A dramatic increase in federal and state
  cigarette tax

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• Men

Women
24.5
18.8
Source 1955 Current Population Survey 1965-2002
National Health Interview Survey 2002 estimates
for first quarter only
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Current Use Among U.S. Adults of Various Tobacco
Products, by Sex National Health Interview
Survey, 2000
31.3
25.7
21.3
21.0
4.5
2.5
0.1
2.5
1.0
0.2
0.1
0.1
0.1
0.2
Note Current users report using either every
day or on some days

Source National Center for Health
Statistics
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Restrictiveness Of State Laws Regulating Smoking
In Public Places U.S., 1960-2001
Sources 1989 Surgeon Generals Report, ALAs
SLATI, CDCs STATE system, Roswell Park Cancer
Institute. Note Includes the District of
Columbia Alabama only state with no
restrictions on public smoking.
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Number of U.S. States including D.C., with
Legislation Restricting the Purchase of
Cigarettes to Persons aged gt18 years, 1988-2001
District of Columbia Source State Legislated
Actions On Tobacco Issues, 1988-2001, CDCs
STATE system, Roswell Park Cancer Institute.
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Smoking in Young People

• 3 million young people under age 18 smoke half a
  billion cigarettes each year and that more than
  one-half of them consider themselves dependent
  upon cigarettes.
• The decision to use tobacco is nearly always made
  in the teen years, and about one-half of young
  people usually continue to use tobacco products
  as adults.

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Age at Initiation of Smoking

• The initiation of daily smoking most often occurs
  in grades six through nine among children between
  the ages of 11 and 14. About half (51.3) of
  high-school seniors who smoke daily began smoking
  by age 15.
• About 80 of regular smokers started smoking
  before the age of 18.

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Stages of Initiation (Flay)
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• Cumulative Age of Initiation of Cigarette
  Smoking Among Persons Aged 30 39 YearsUnited
  States, 1996-1998

Age First Tried a Cigarette
Age Began Smoking Daily
Among persons 30-39 years old who have ever
smoked daily Source National Household Survey
on Drug Abuse, 1996-1998 public use data tapes
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• Incidence of Initiation of Cigarette Smoking,
• by 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.
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Cigarette Smoking among youth and adults in 24
states and the District of Columbia, 1997
KY
SD
r2 0.552 ß 0.940 P lt 0.001 N 25
NV
DC
UT
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 gt 20 days during the previous 30
days Adult current smoking smoking every day
or on some days
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• Men

Women
24.5
18.8
Source 1955 Current Population Survey 1965-2002
National Health Interview Survey 2002 estimates
for first quarter only
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Men
Women
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Men
Women
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Percent of Current Smokers Who Want to Quit by
Age and Number of Previous Quit Attempts United
States, 2000
Source National Center for Health Statistics,
NHIS 2000 (with NCI Cancer Supplement)
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Annual use of pharmacologic aids to smoking
cessation United States, 1984-1998
Vapor inhaler 3/98
Zyban 5/97
Gum OTC4/96 2 patches OTC8/96 Nasal spray8/96
Patches 1/92
Estimated Assisted Quit Attempts(in thousands)
Gum (4mg) 3/93
Gum (2mg) 2/84
Source CDC. MMWR 2000665-668.
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Tobacco Control Model of Nicotine Addiction
Tobacco Products
Agent
Environment
Familial, Social, Cultural, Political, Economic,
Media, Historical
Host
Vector
Smoker/Chewer/User
Tobacco Industry Other Users
Incidental Host
Involuntary Smoker
Adapted from Orleans Slade, 1993
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Paradigm for Tobacco Control

• Cessation activities
• Prevention activities
• Clean indoor air
• Regulation/Liability
• Price/Economic

• Minors access
• Advertising

Individual
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Tobacco and Addiction

• Cigarettes and other forms of tobacco are
  addictive. Nicotine is the drug in tobacco that
  causes addiction.
• The pharmacologic and behavioral processes that
  determine tobacco addiction are similar to those
  that determine addiction to drugs such as heroin
  and cocaine.

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Tobacco Addiction

• Nicotine is found in substantial amounts in
  tobacco
• It is absorbed readily from tobacco smoke in the
  lungs and from smokeless tobacco in the mouth or
  nose and is rapidly distributed throughout the
  body.

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SGR Preventing Youth Tobacco Use
Criteria for Drug Dependence Primary
Criteria Highly controlled or compulsive
use Psychoactive effects Drug-reinforced
behavior Additional criteria Stereotypic
patterns of use Use despite harmful
effects Relapse following abstinence Recurrent
drug cravings Dependence-producing drugs often
manifest the following Tolerance Physical
dependence Pleasant (euphoric) effect
Source Adapted from USDHHS (1988)
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Nicotine is A Poison

• An injection of one drop of nicotine in its
  purest form (70 mg) will kill an average-sized
  man.
• Cigarettes contain a very small amount of
  nicotine (between .1 and 2.2 mg). This amount
  will not kill you, but will make your heart beat
  faster and can make your hands shake.

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Smoking and Health

• An estimated 47 million adults in the U.S. smoke
  cigarettes, which will result in death or
  disability for half of all regular users
• Over 46 million Americans have quit smoking but
  3,000 adolescents try their first cigarette every
  day.

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Chronic Disease and Related Factors
NHCS National Vital Statistics, Vol. 49 Sept.
2001 McGinnis JM, Foege WH. Actual causes of
death in the United States. JAMA 1992
2702207-12
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Diseases Caused by Tobacco Use

• Cigarette smoking increases the risk of
• ? Coronary heart disease
• ? Atherosclerotic peripheral vascular disease
• ? Cerebrovascular disease
• ? Cancers of the lung, larynx, mouth, esophagus,
  bladder, pancreas,
• kidney, and cervix
• ? Chronic obstructive pulmonary disease
• ? Intrauterine growth retardation, premature
  rupture of membranes
• ? Low-birthweight babies, perinatal mortality
• ? Cataract, macular degeneration hip fracture
• ? Peptic ulcer disease
• ? Possibly liver, stomach, and colorectal
  cancers and acute myelocytic leukemia

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Disease Caused by Tobacco Use

• Involuntary smoking (environmental tobacco
  smoke) is a cause of
• ? Lung cancer and coronary heart disease in
  nonsmokers
• ? Respiratory infections and symptoms in the
  children of
• parents who smoke
• Smokeless tobacco causes
• ? Oral Cancer
• ? Oral leukoplakia
• ? Dental caries (possibly)
• Cigars cause
• ? Cancers of the mouth, larynx, and lung
• ? Coronary heart disease
• ? COPD

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Domestic Market Share of Cigarettes by Tar Yield,
Filter Status, Length, and Menthol Status
United States, 1963 - 2000
Filter
lt15 mg. tar yield
gt 94 mm.
Menthol
Source United States Department of
Agriculture, 1962 Federal Trade Commission, 2001
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Smoking and Health

• It is estimated that every cigarette a person
  smokes takes about 12 minutes off his or her
  life.
• Smoking increases your risk of getting many
  serious diseases including cancer, heart disease,
  emphysema and bronchitis.

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Year of Potential Life Lost (YPLL)

• 65 age at death form smoking related disease
  1,152,635 YPLL
• Current gender-specific life expectancy age at
  death from smoking related diseases 5,048,740
  YPLL

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Smoking and Health

• Direct medical care cost from smoking related
  diseases were estimated to be 50 billion in 1993
• Another 50 billion in indirect costs, such as
  time lost from work, housekeeping expenses, and
  lost income, etc.

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Tobacco Smoking

• Tobacco smoke contains over 4,000 chemical
  compounds
• includes at least 60 different carcinogenic
  substances.

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Group 1 Carcinogenic to Humans

• Tobacco Smoking
• Tobacco Products, Smokeless
• 4-Aminobiphenyl (4-ABP)
• Benzene
• Carmium
• Chromium
• 2-Naphthylamine (2-NA)
• Nickel
• Polonium-210 (Radon)
• Vinyl Chloride

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Group 2A Probably Carcinogenic to Humans

• Acrylonitrile
• Benzoapyrene
• Benzoaanthracene
• 1,3-Butadiene
• Dibenz(a,h)anthracene
• Formaldehyde
• N-Nitrosodiethylamine
• N-Nitrosodimethylamine

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Tobacco Smoking and Lung Cancer
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Smoking and Lung Cancer

• Smoking accounts for more than 85 of all lung
  cancer deaths.
• The risk of developing lung cancer is affected by
  the number and type of cigarettes smoked and the
  numbers of years a person has been smoking.

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Lung Cancer Distributions

• The commonest cancer in the world (1.2 million
  new cases in 2000, 12.3 of all new cases)
• 52 in the developed countries and 48 in the
  developing countries
• More common in men (75) than in women
• Areas with highest incidence include Europe
  (Eastern Europe), North America, Australia /New
  Zealand, and Southern America.
• The rates in China, Japan, and Southeast Asia are
  moderately high.

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Lung Cancer Distributions

• For US blacks, New Zealand Maoris men, about 13
  chance of developing a lung cancer before the age
  of 75 years.
• In developing countries, the highest rate are
  seen where the tobacco smoking habit has been
  longest established the Middle East, China, the
  Caribbean, South Africa, Zimbabwe, and the
  Pacific.

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Lung Cancer Distributions

• In women, the highest rates are observed in North
  America and North West Europe (UK, Iceland,
  Denmark) with moderate incidence rates in
  Australia and New Zealand and China.

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Lung Cancer Cigarette Smoking

• Overall, 86 of cases in men and 49 in women are
  due to smoking.
• For regions with longest history of smoking, 90
  cases in men. The proportions are more variable
  in women from 0 to 80 (UK)

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Lung Cancer Cigarette Smoking

• The most important cause of lung cancer
• A clear dose-response relationship between lung
  cancer risk and the number of cigarettes smoked
  per day, degree of inhalation and age at
  initiation
• A life-time smoker has a risk 20-30 times that of
  a non-smoker.
• The risk is diminished in smokers of filter and
  low tar cigarettes and increasing use of these
  has contributed to declines in risk in recent
  generations of smokers (as well as the declining
  prevalence of smoking)

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Lung Cancer Other Tobacco

• The early observation that pipe-smokers and
  smokers of cigars had a lower risk of lung cancer
  than cigarette smokers is due to the lesser
  amount of tobacco smoked and to the lower degree
  of inhalation.
• Smokers of other types of tobacco (e.g. bidis in
  India) are at similar risk to smokers of
  cigarette.

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Lung Cancer Histological Types and Smoking

• Smoking is related to all histological types of
  lung cancer
• The relative risk is greater for squamous-cell
  and small-cell carcinomas than for
  adenocarcinomas.
• Adenocarcinoma is more common in women than men
  in both smokers and non-smokers.
• Risk of lung cancer between men and women at
  equivalent levels of exposure is similar.

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Lung Cancer Other Risk Factors

• Passive smoking may increase 30-50 of risk
• Family history of lung cancer may also related to
  lung cancer risk, which is probably because of
  polymorphisms of genetic metabolic genes.
• Chinese female non-smokers have a high risk of
  adenocarcinoma, which may be related to exposure
  to cooking fumes, indoor smoky coal emission, or
  air pollution.

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Lung Cancer Other Risk Factors

• Occupational exposures to asbestos, some metals
  (nickel, arsenic and cadmium), radon (among
  miners) and ionizing radiation.
• Diet high in vegetables and fruits can protect
  against lung cancer. Although intakes of
  carotenoids is associated with decreased risk,
  beta-carotene does not prevent lung cancer, in 3
  intervention trials.

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Lung Cancer Time Trends

• Trends in lung cancer incidence and mortality
  reflect the maturity of the smoking epidemic in
  different countries.
• Study of time trends in lung cancer incidence or
  mortality by age group shows that the level of
  risk is closely related to the birth cohort, or
  the cohort specific incidence is related to the
  smoking habit of the same generation.

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Lung Cancer Time Trends

• Decreased smoking prevalence leads to a decreased
  risk of lung cancer in several countries such as
  U.K., Finland, Australia, the Netherlands, New
  Zealand, the USA, Singapore, and more recently
  Denmark, Germany, Italy, and Sweden.
• In most other countries, there is a continuing
  rise in rates, and this is most dramatic in the
  countries of Eastern Europe.
• In women, with increase smoking prevalence, the
  risk of lung cancer increase.

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Ecological Observation of Smoking Prevalence and
Lung Cancer Incidence

• Male lung cancer incidence started to decrease in
  1980s and early 1990s, which is the direct
  result of the dramatic decrease in smoking
  prevalence during 1960s and 1970s
• The rise in lung cancer incidence rates among
  women during 1970s and early 1980s and ended in
  the early 1990s is also the direct result of
  increase prevalence of smoking several decades
  ago.

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The Consistency of the Association

• In 1984 surgeon generals report, 29
  retrospective and 7 prospective studies have all
  demonstrated an association between cigarette
  smoking and lung cancer
• Similar findings had thus reported from a large
  number of studies by different investigators,
  using different methodological approaches, and in
  different populations

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First Two Case-Control Studies

• A case-control study included 1045 lung cancer
  cases and 605 controls at Roswell Park Memorial
  Institute at Buffalo by Levin et al. (1950)
• A case-control study included 684 lung cancer
  cases and 780 controls by Wynder et al. (1950)

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The Strength of the Association

• In men, the relative risk ranged from 3.8 to 14.2
• In women, the relative risk ranged from 2 to 5
• Men and women who smoked one of more packs per
  day experienced a 25 to 30-fold increased risk of
  dying from lung cancer when compared with
  non-smokers

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RR of lung cancer for current smoking of
cigarette only. IARC, 1986
14.9
14
12.1
9.9
9.2
9.5
7.0
Canada
Sweden
US Vets
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Dose-Response Relationship

• The existence of a dose-response relationship
  between smoking and lung cancer constitutes
  further evidence of a causal relationship.
• Many studies have demonstrated a dose-response
  relationship between cigarette smoked per day,
  years of smoking and pack-years of smoking and
  lung cancer.

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Specificity of the Association

• The degree of specificity between lung cancer and
  smoking is measured by the attributable risk.
• It is estimated that 85 to 90 of lung cancer
  deaths in men is due to cigarette smoking
• The observation that all smokers do not develop
  lung cancer indicate the genetic susceptibility,
  competing causes of death.

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Temporal Relationship

• Temporal relationship is approved by several
  prospective cohort studies when exposure to
  cigarette smoking was obtained before the
  occurrence of lung cancer
• The latent period between first exposure and the
  onset of the disease is about 20-30 years

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Coherence of the Association

• Distribution of the disease and of the cigarette
  smoking are similar with regards to person,
  place, and time.
• Rapid rise in cigarette consumption resulted in
  the rapid rise of lung cancer after a period of
  latency.
• The distribution of cigarette smoking among
  sexes, among rural and urban residents, and among
  different socioeconomic classes was similar to
  the distribution of lung cancer among these
  groups.
• These who quit smoking had a decreased risk.

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Biological Credibility

• Over 60 carcinogens in cigarette smoking
• Carcinogens may cause DNA damage
• Mutation of Tumor suppresser genes are linked to
  cigarette smoking
• Animal studies also support the relationship
  between cigarette smoking and lung cancer.

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Prospects for Prevention

• Smoking cessation among smokers
• Reinforcing social pressure to make smoking
  unattractive and difficult for adolescents to
  start smoking
• Early detection of early lesions, by x-ray or
  other means

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Smoking and Other Cancers

• Head and neck cancers (oral, laryngeal and
  pharyngeal cancers)
• Esophageal cancer
• Stomach cancer
• Pancreatic Cancer
• Bladder cancer
• Cervical cancer
• Liver cancer

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Environmental Tobacco Smoke

• 3,000 nonsmoking Americans die of lung cancer
• 300,000 children suffer from lower respiratory
  tract infections.

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Major Sources of Data on Tobacco Use in the
United States

• Surveys 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

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Major Sources of Data on Tobacco Use in the
United States

• Surveys 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)

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• A bidi is a small, flavored, filterless cigarette
  made in India. A bidi is a dried tendu leaf
  rolled around tobacco, usually tied with a red
  string. They come in a variety of flavors,
  including vanilla, cherry, menthol, and chocolate
  etc.

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