Southern Discomfort: Top for Smoking-Related Cancer Deaths

Kristin Jenkins

October 24, 2016

Despite a drop of more than 50% in the prevalence of cigarette smoking in the last five decades, 40 million Americans are still lighting up — but more so in the South, where over 95% of US tobacco is grown, than elsewhere across the nation.

A previous study has shown that at least 28.6% of all cancer deaths in adults older than 35 years in the United States were attributable to cigarette smoking, with 62% occurring in men and 38% occurring in women.

Now, a unique state-by-state analysis shows that proportionally, smoking-related cancer deaths were highest in adult smokers living in the southern states, accounting for almost 40% of cancer deaths in men and nearly 26% of cancer deaths in women.

"In most states, approximately one-third of cancer deaths in men and one-quarter in women were explained by cigarette smoking," say Joannie Lortet-Tieulent, MSc, from the American Cancer Society, Atlanta, Georgia, and colleagues, in a report published on October 24 in JAMA Internal Medicine.

"However, consistent with smoking-attributable all-cause mortality, cancer deaths were associated with cigarette smoking less often in Western states and more often in the South, particularly among men."

The study showed that across all 50 states, as well as in the District of Columbia, the estimated proportion of smoking-attributable cancer deaths in men was highest in 5 southern states: Arkansas (39.5%), Tennessee and Louisiana (both 38.5%), and Kentucky and West Virginia (both 38.2%).

In women, 3 of the 5 states with the highest proportion of smoking-attributable cancer deaths were Kentucky (29%) and Arkansas and Tennessee (both 26.3%). Smoking-attributable cancer deaths in women were also high in Alaska (27.5%) and Nevada (27.1%).

Historically, there have been more smokers in the South, and this has driven higher smoking-attributed cancer mortality, the researchers point out. Disproportionately high levels of poverty, weaker tobacco control, nonexistent public smoking policies, and lower cigarette taxes in southern states have also contributed.

"The human costs of cigarette smoking are high in all states, regardless of ranking," Lortet-Tieulent and colleagues emphasized. "Increasing tobacco control funding, implementing innovative new strategies, and strengthening tobacco control policies and programs, federally and in all states and localities, might further increase smoking cessation, decrease initiation, and reduce the future burden of smoking-related cancers."

Analysis of Smoking-Related Cancers

For their study, the researchers used data from large US prospective studies and state-specific smoking prevalence data from the Behavioral Risk Factor Surveillance System to calculate relative risks for 12 smoking-related cancers.

These included acute myeloid leukemia and 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.

The results were mapped and states were ranked by number, with 1 indicating the highest smoking-attributable cancer mortality.

Racial and even religious differences in smoking prevalence may account for some state-to-state variation in the cancer mortality caused by smoking, the researchers noted.

In the past, non-Hispanic black men, who account for up to 30% of the population in Louisiana and Mississippi but only 5% in Utah and Connecticut, have tended to have a higher smoking prevalence than non-Hispanic white men.

On the other hand, cancer death rates caused by smoking are lower in Hispanic men, who disproportionately populate states such as California and Texas.

In Utah, cancer mortality due to smoking is also low (16.6% for men; 11.1% for women), reflecting Mormon beliefs about the practice.

However, the study showed that for non-Hispanic white men, state-specific rankings for cancer mortality caused by smoking were generally similar to those for all races/ethnicities combined (P < .001). The exception was in Washington, DC, where the cancer mortality was 18.5% for well-educated non-Hispanic white men who smoked compared with 33.3% for male smokers overall.

This finding indicates that "variation in racial composition is unlikely to be the driving factor for state differences in SAMC [smoking-attributable cancer mortality]," the researchers conclude.

Instead, the disparity in smoking-attributable cancer mortality in different US states appears to be driven more by uneven, suboptimal tobacco control policies and programs than by demographic differences, they emphasize.

The "Big Stall" on Tobacco Control Policies

The study showed that as of 2016, two thirds of states did not have 100% smoke-free laws in public places. In addition, no states had a tax on cigarettes that equaled 75% of the retail price, as recommended by the World Health Organization. The only tobacco control programs funded at the level recommended by the Centers for Disease Control and Prevention (CDC) were in North Dakota.

This state-level stagnation regarding implementation of tobacco control policies has been called the "Big Stall," said Kurt M. Ribisl, MD, from the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill, and colleagues in an accompanying commentary.

The phrase the "Big Stall" was coined by inspectors for the CDC, they note.

"Given the lag between reduction in smoking prevalence and smoking-attributable cancer mortality, the Big Stall raises concerns that the disparities among states will worsen before they improve," the editorialists write, adding that, to "unstick" the Big Stall, evidence-based policy changes are needed.

The editorialists conducted a comparison study and confirmed that states with the highest cancer mortality rates due to smoking also had the weakest tobacco control programs and policies.

Cigarette excise taxes were "substantially lower" in Kentucky, Arkansas, Tennessee, West Virginia, Louisiana, Alaska, Missouri, Alabama, Oklahoma, and Nevada, they found.

In addition, comprehensive smoke-free policies were nonexistent, the rate of preemption of tobacco control policies was three times the rate in other states, and spending for state tobacco control programs was modest in these states.

"The 10 states with these highest rates could be considered a priority population, akin to other vulnerable or high-risk groups that are defined by age, income, race, sexual orientation, or geography," Dr Ribisl and colleagues suggest.

Policy innovation at the local level can provide a partial remedy, they say, citing a recent example. "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, the city observed an 11% relative decrease in smoking prevalence, equivalent to approximately 140,000 fewer smokers."

To reverse the contribution of Big Tobacco to the Big Stall, more resources and investment are needed to monitor the industry, stimulate "message-framing" research, and mine social media and other data for lessons learned, they said.

In stalled states, the CDC could also play a role by redirecting funding and offering incentives to states making the greatest inroads into reducing disparities, the editorialists suggest. Alternatively, the CDC could compel states to strengthen tobacco policies by withholding funding, much as the federal government compelled states to raise the legal drinking age to 21 years.

"Under the current Synar program," Dr Ribisl and colleagues point out, "the federal government may withhold millions in substance abuse block grant funding from states that do not reduce their rate of illegal tobacco sales to minors to less than 20%."

"Quit Smoking" Message From Health Professionals

In clinical practice, more health professionals need to counsel more patients to quit smoking, Lortet-Tieulent said in an interview.

Only about 52% of individuals diagnosed with cancer who are active smokers report being counseled to quit smoking by a health professional within the previous 12 months, she told Medscape Medical News.

"Clinicians should ask all patients whether they smoke cigarettes or other forms of tobacco in order to counsel and assist those who smoke to quit according to the US Public Health Service Clinical Practice Guideline," she said.

Even after a cancer diagnosis, quitting smoking increases the chance of survival, she pointed out. "This can also be communicated to cancer patients."

Research shows that patients listen when a clinician advises them to quit smoking. Brief advice that gets repeated increases quit rates, said Lortet-Tieulent. Smokers who go cold turkey should be offered treatment proven to increase their chances of success.

The lower cancer mortality burden in female smokers compared with male smokers is changing, she warned, noting that in younger cohorts, smoking histories and subsequent mortality risks are already similar. In South Dakota, Montana, and Arkansas, the number of female smokers has already surpassed that of men.

This study was supported by the Intramural Research Department of the American Cancer Society, which employs all the study authors. Funding for the tobacco control policy comparison study (Ribisl et al) was provided by the National Cancer Institute's State and Community Tobacco Control Initiative. No other conflicts of interest were disclosed.

JAMA Intern Med. Published online October 24, 2016. Study full text, Editorial extract

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