An investigation by a team of epidemiologists from the American Cancer Society has provided a sobering look into who, exactly, is dying of cancer because of their addiction to cigarettes.
Published Monday, the paper provided a state-by-state breakdown of smoking-related cancer deaths in the U.S., an analysis that highlighted both the influence of Big Tobacco and societal health disparities.
All told, cigarette smoking was directly responsible for nearly 30 percent of all cancer deaths in the U.S. in 2014, killing just over 167,000 men and women. And that number is low, researchers said, since they only looked at 12 cancers (there are more tied to tobacco use) and didn’t fold in cancer deaths caused by secondhand smoke, pipes, cigars, smokeless tobacco or nicotine products like e-cigs. Cancers examined included acute myeloid leukemia as well as cancers of the lung, liver, pancreas, colon, esophagus and six other body sites.
Men were much more likely to die than women, researchers found, particularly those from Southern states where people tend to smoke more, have less education and anti-smoking policies and programs are weaker thanks to Big Tobacco’s influence (95 percent of the U.S. tobacco crop is grown in the South).
“The proportion of cancer deaths attributable to cigarette smoking varies substantially across states [but] is highest in the South, where up to 40 percent of cancer deaths in men are caused by smoking,” wrote lead author and senior epidemiologist Joannie Lortet-Tieulent of the ACS’s Surveillance and Health Services Research Program in Atlanta, Georgia.
Dr. Jaimee Heffner, a public health researcher with the Tobacco and Health Behavior Science Research Group at Fred Hutchinson Cancer Research Center, said the report was the first of its kind to look at smoking’s impact by state.
“Previously, there have been national-level data but this was the first study to look at deaths on a state-by-state basis,” she said. “I think this will be useful for the tobacco-control efforts taking place in each state. They’ll be able to say, ‘This is yet another indicator how much tobacco is affecting the health of our population.’”
Although enlightening, Heffner said the report’s findings weren’t all that surprising.
“It maps onto the prevalence of smoking in each state,” she said. “It makes sense. The states with the highest smoking prevalence should have the higher mortality from smoking-related cancer.”
Kentucky, where tobacco farming was the No. 1 crop for most of the 20th century, had the highest proportion of cigarette-related cancer deaths in the nation: 38.2 percent of the men and 29 percent of the women who died of cancer in that state died because of cigarettes. In addition to Kentucky, others among the “top 10” states for cigarette-related cancer deaths were, from top down, Arkansas, Tennessee, West Virginia, Louisiana, Alaska, Missouri, Alabama, Oklahoma and Nevada.
Utah, which has a high number of Mormons (adherents don’t smoke or drink), had the lowest proportion of cigarette-related cancer deaths: 21.8 of men and a mere 11.1 percent of women had cancer deaths linked to cigarette smoking. In addition to Utah, the “bottom 10” states where fewer people die of smoking-related cancers were, from bottom up, California, Colorado, Hawaii, New York, Idaho, Minnesota, New Jersey, Texas and North Dakota. Washington state weighed in at No. 36, just a smidge better than Oregon.
On average, about 30 percent of men’s cancer deaths and about 20 percent of women’s were due to smoking cigarettes.
Heffner, whose research focuses on smoking cessation, particularly among vulnerable populations, said the report definitely highlighted “the bigger issue of disparities.”
“Certain people have a greater exposure to tobacco because of where they live or who they are,” she said. “The state you live in and the tobacco-control policies in that state influence the rates of smoking. We have specific populations — people with a low socioeconomic status, people in certain racial groups, people with psychiatric disorders — who have a higher prevalence of smoking. And in those groups, you see higher rates of tobacco-related disease and deaths, including death from cancer.”
Southern states have higher smoking-related cancer deaths than, say, states like Utah or Connecticut because black men tend to smoke more than white men and Southern states have more black residents. But timely and affordable access to screening and high-quality health care also come into play. Black people are more likely to be diagnosed later, when treatments are more limited and less effective, and their five-year survival rates are lower.
Likewise, people with a low level of education (high school graduate or less) tend to smoke more than college graduates. So in states like Kentucky, where only 50 percent of adults go on to college, you’re going to find more smokers and more cancer-related smoking deaths.
It’s not that these people don’t know cigarettes can cause cancer, said Heffner, it’s just that the health disparities deck is stacked against them. (More on health disparities research at Fred Hutch.)
“I have yet to meet a smoker, regardless of educational level, who didn’t understand that smoking carried health risks,” she said. “[But] people of low socioeconomic status (including low education and income as indicators) have less access to resources to help them quit, live in areas with higher concentrations of tobacco outlets, have greater exposure to other smokers and, consequently, [have] more social influence to smoke.”
The ACS report also showed how public policy impacts public health, for better or worse.
“Policy initiatives are heavily influenced by the tobacco industry in all states, especially those in the South,” wrote study author Lortet-Tieulent. “Public smoking restrictions and high cigarette prices (through excise taxes, price promotion restrictions, and minimum price laws) are among the most effective tobacco control policies, and both are primarily legislated by states.”
Not surprisingly, the least restrictive public smoking policies and the most affordable cigarettes are found in the South.
In major tobacco states, for instance, the mean cigarette excise tax is 49 cents compared with $1.80 in other states, the report said. Virginia charges 30 cents extra per pack, North Carolina charges 45 cents and Kentucky charges 60 cents. New York, on the other hand, taxes each pack an additional $4.35; New York ranks fifth in the least amount of cancer-related smoking deaths.
What can we do? The study authors called for increased tobacco-control funding and stronger tobacco-control policies and programs to help mitigate the “burden of smoking-related cancers,” which they felt were too high in all states, “regardless of ranking.”
Heffner agreed that broader tobacco-control strategies were key, but said it was also important to work together to help friends and loved ones kick a very addictive habit.
“On average, nationally, we know that one-third of cancer deaths are caused by tobacco use,” she said. “We all need to work together on this issue to bring everyone along. Stopping smoking is, by far, the best thing someone can do to prevent cancer.”
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Diane Mapes is a staff writer at Fred Hutch. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at firstname.lastname@example.org.