Lung Cancer Death Rates in Younger Women Have Increased in Southern States

Young women in Southern and Midwestern states have seen death rates from lung cancer decline more slowly than elsewhere in the country, or even increase, over the last several decades, according to a new study. The research was sponsored by the American Cancer Society (ACS) and the National Cancer Institute (NCI) and is published in the Journal of Clinical Oncology.

“I was not surprised by the results,” said lead author Ahmedin Jemal, DVM, PhD, of the ACS in Atlanta, in an email. Previous work has shown an overall pattern of lung cancer deaths in the United States, with a continuous decrease beginning with men and women born in the 1920s and 1930s. The decrease slowed briefly with women born in the 1950s, but Dr. Jemal and colleagues guessed that widely varying socioeconomic factors and public policies regarding tobacco use could mean big differences between states in terms of lung cancer death rates. Previous studies have shown people with a lower socioeconomic status are less likely to quit smoking compared to those with a higher socioeconomic status.

Lung cancer causes approximately 28% of all cancer deaths, accounting for more deaths than from colon, breast, and prostate cancers combined. Smoking is the main cause of both small-cell and non–small-cell lung cancer-accounting for 80% and 90% of lung cancer deaths in both sexes.

To test this theory, they gathered data on lung and bronchus cancer death rates from 1973 through 2007 in the NCI’s Surveillance, Epidemiology, and End Results (SEER) mortality database. They examined rates among white women aged 35 to 84 years in 23 states with sufficient data. Overall, the analysis included 1,076,613 lung cancer deaths and almost 1.5 billion woman-years of follow-up.

Not surprisingly given its leading policies on tobacco use, California saw age-specific lung cancer death rates continue to decrease in all age groups younger than 75 years beginning in the 1990s. The death rate rose 3.6-fold from 1893 until the referent year, 1933, after which it fell by a similar amount through later decades. New York saw similar declines after 1933, though not as steeply as in California. Alabama, meanwhile, had a similar rise between 1893 and 1933, but beginning around 1950 there was a sharp increase in death rates, up to a rate ratio of more than 2.5 times the referent year of 1933.

Though California-and New York and several other states, to a lesser extent-saw declines in death rates across age groups, the increase in rates in Alabama, Kentucky, South Carolina, and other states were particularly striking among younger women born in the 1950s or 1960s. In Alabama, lung cancer death rates declined in the 1990s for those women aged 60 to 64, for example, while the rates increased dramatically among women aged 35 to 39 and 40 to 44. In all, data from 23 states were analyzed.

Tobacco Policies

The overall decline in lung cancer deaths in the United States has been attributed to a better knowledge of the hazards of smoking, due to public health campaigns and individual state policies, including cigarette taxes and smoking bans. The goal of these measures is to discourage people to smoke. The authors did note that other factors such as occupational and environmental exposures could contribute to the differences in lung cancer death rates, but that these were likely modest or minimal in importance compared to smoking patterns.

The geographic differences in the rates reported in this study are likely due in part to differences in smoking cessation, wrote the authors.

California has among the lowest smoking rates and has spearheaded antismoking programs, including becoming the first state to have a statewide tobacco-control program through tobacco tax hikes and increased prices starting in 1988. It was also the first state to have smoke-free work offices as early as the 1970s. Successful smoking cessation in the 1990s in people between the ages of 35 and 49 were much higher in California than in other regions.

The authors cite the weaker policies to reduce smoking rates in states with a history of tobacco growing as a main reason for the continued upward trend. “Southern states have low taxes on cigarettes and lack policies on banning smoking in public places,” said Jemal.

One study in 2001 and 2002 found that half the smokers had quit by the age of 44 in California, compared with 47 years in New York and New Jersey; in tobacco-growing states in the South, however, half had quit smoking only by age 54. California smokers also showed the largest decline in per capita cigarette consumption since the 1960s.

Compared to the seven-cent excise tax on cigarettes in South Carolina, the tax in New York was as high as a dollar in the 2000s, according to a 2008 study.

“The findings underscore the need for concerted efforts to implement proven tobacco control policies,” Dr. Jemal said in an email. These policies include “increases in price of cigarettes and banning smoking in public places in order to promote smoking cessation in all parts of the country, especially in most Southern states where such policies are weak or nonexistent.”

The authors also pointed out that clinicians have a major opportunity to increase the rate of people who stop smoking. According to a national survey from 2005, only 60% of smokers reported being advised to stop smoking by their physicians.