Although rates of smoking have been declining in the United States, smoking is still contributing substantially to the cancer burden, accounting for nearly 4 in 10 cancer deaths in some areas.
The finding comes from a study that looked at geographical variations across the US, and found that the highest proportions of deaths attributable to smoking were in the South and Appalachia.
“This largely reflects historically weaker state- and local-level tobacco control policies and programs in those areas, including low taxes on cigarettes and weak comprehensive smoke-free laws and tobacco cessation programs,” commented study author Farhad Islami, MD, PhD, scientific director, Cancer Disparity Research, American Cancer Society, Atlanta, Georgia
The study was published online January 26 in Cancer Causes & Control.
Regional Variation
For their study, Islami and colleagues examined the proportion of cancer deaths attributable to cigarette smoking from 2013 to 2017 in 152 metropolitan and micropolitan statistical areas (MMSAs) across the US.
The proportion of cancer deaths caused by cigarette smoking ranged from 8.8% in Logan (Utah-Idaho) to 35.7% in Lexington-Fayette (Kentucky). But even with this large variation, at least 20% of all cancer deaths were attributable to cigarette smoking in 147 out of 152 MMSAs.
The smoking-related proportion of cancer deaths attributable to smoking (or population attributable fraction [PAF]) varied not only across the US but within regions and individual states. For example, in the Northeast, the PAF ranged from 24.2% to 33.7%; and within the same state of Texas, the PAF in Wichita Falls was 1.5 times higher than the PAF in El Paso.
Data show the proportion of cancer deaths attributable to cigarette smoking was greater in men than in women in all evaluated MMSAs. Among men, the PAF ranged from 11.7% in Provo-Orem, Utah to 43% in Florence, South Carolina. For women, it ranged from 5.2% in Logan (Utah-Idaho) to 31.7% in Panama City, Florida.
Although the article did not address the reasons for the variations seen across the country, one factor is the unequal implementation of cigarette tax rates and other tobacco control initiatives, the authors suggest. For example, the high total excise tax in New York City ($1.50 per pack in addition to the New York state tax of $4.35 per pack) may contribute to the lower proportion of smoking-related cancer deaths in the New York-Jersey City-White Plains metropolitan division compared with other areas of New York state and the Northeast.
“Increasing the price of tobacco products through excise taxes is the single most effective intervention for reducing smoking prevalence,” said Islami. Although the state cigarette tax rate is $4.00 per pack or higher in Washington DC, Rhode Island, New York, and Connecticut, it is still less than $1.50 per pack in 23 states, 19 of which are in the South and Midwest.
Islami added that the disparate high proportion of low-income individuals — in whom smoking is more prevalent — may also, in part, contribute to higher cancer mortality rates in some areas. “However, previous studies have shown that for the same socioeconomic group, state-level smoking prevalence is substantially lower in the Northeast and West, which have historically stronger tobacco control policies.”
Other interventions such as smoke-free laws, bans on tobacco product advertisements and promotions, media campaigns against tobacco use, and counseling and treatment for tobacco dependence are also proven to reduce smoking, he explained.
“It should be noted that only a relatively small proportion of current smokers receive tobacco counseling or pharmacotherapy,” he said. “Increasing health insurance coverage, including through Medicaid expansion, and comprehensive inclusion of these preventive care measures in health plans could increase successful smoking cessation.”
Islami also pointed out that although this study did not consider the influence of the tobacco industry on smoking-related cancers, previous studies have shown that, historically, there has been strong political resistance to tobacco control policies in tobacco-growing states largely because of the industry’s influence.
The study was supported by the Intramural Research Department of the American Cancer Society. Islami is an employee of the American Cancer Society and has no other disclosures.
Cancer Causes & Control. Published online January 26, 2021. Abstract
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