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Tobacco and cancer risk

Smoking is the single greatest avoidable risk factor for cancer; in the UK, it is the cause of more than a quarter (29%) of all deaths from cancer and has killed an estimated 6 million people over the last 50 years.

Worldwide, tobacco consumption caused an estimated 100 million deaths in the last century and if current trends continue it will kill 1,000 million in the 21st century. Around half of all regular smokers will die from the habit, half of these in middle age1.

This page includes information on lung cancer and other cancers related to smoking. It looks at risk associated with different types of tobacco and has a summary of smoking prevalence in the UK

Smoking and cancer summary

• More than a quarter (29%) of all UK cancer deaths are caused by smoking
• One in four British adults currently smoke
• Smoking causes 90% of lung cancers in men and up to 86% of cases in women in developed countries
• Smoking prevalence (any tobacco product) in British men was 30% in 2002 compared with 82% in 1948

Table 1.1 shows the strength of evidence for an increased risk of cancer due to tobacco consumption.

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Lung cancer and smoking

Table 1.2 shows the proportion of cancer deaths in the UK attributable to smoking. Smoking causes around 90% of male and between 57 and 86% of female cases of lung cancer in the developed world.2 The link between lung cancer and cigarette smoking was first established in 1950, with a study showing a 26-fold increased risk of lung cancer among smokers of 15-24 cigarettes a day, compared with non-smokers.3

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Lung cancer risk increases with both duration and intensity of smoking4. (Figure 1.15)

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The effect of stopping smoking at any age on the excess risk of lung cancer is striking. Figure 1.2 1-4 shows the cumulative risk of lung cancer among men in the UK at age 75 according to age at which they stopped smoking6.

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The interaction between smoking and other harmful exposures can result in a much greater risk in people exposed to both. The risks of smoking and exposure to radon interact multiplicatively, and reanalysis of data from European case-control studies shows that most of the additional cases of lung cancer in people exposed to radon in the home are in smokers.7

Studies have shown that exposure to asbestos increases the risk of lung cancer by around ten-fold in non-smokers, while in smokers exposed to asbestos, there is a 100-fold increase in risk8.

Passive smoking also causes lung cancer. Meta-analyses show a 25% increased risk of lung cancer in adult never-smokers who are exposed to second hand smoke in the home, and it is estimated that exposure to domestic second hand smoke causes more than 10,000 deaths in the UK each year from lung cancer, stroke and heart disease combined9-10. A recent European nested case-control study reported a more than doubled risk of lung cancer in non-smokers and former smokers exposed to second hand smoke at their occupation11.

Male lung cancer incidence rates peaked in the early 1970s, reflecting the peak in smoking prevalence 20-30 years earlier. Rates in women have stabilised, after increasing throughout the 1970s and 1980s. Forecasting suggests that female lung cancer mortality rates will reach current male levels within the next ten years and then fall, while deaths will continue to fall in men12.

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Other smoking related cancers

While deaths from lung cancer account for around a quarter of smoking related cancer deaths in the UK smoking is also an established risk factor for cancers of the oesophagus, larynx, pharynx, oral cavity, pancreas, bladder, nasal cavity and sinuses, stomach, liver, kidney, cervix and myeloid leukaemia4.

Also, alcohol consumption in combination with smoking greatly increases the risk of upper aerodigestive tract cancers (see section on alcohol)13. Studies report a 40 to 60% increased risk of bowel cancer in men who smoke and a 60 to 100% increase in women14.

Smoking cessation reduces the risk for most of these cancers but the extent of risk reduction varies. For example, the excess risk for oral and laryngeal cancer almost disappears within ten years, while the excess risk for bladder cancer is still higher than in never-smokers twenty years after giving up13,15-16.

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Type of tobacco smoked and cancer risk

Most UK evidence on tobacco and cancer risk is based on smokers of manufactured filtered cigarettes. Risk is generally higher among smokers of filterless cigarettes, high tar cigarettes, and black tobacco. Hand-rolled cigarettes have a stronger effect than manufactured cigarettes on risk of cancer of the oral cavity and pharynx17,18. The proportion of British smokers consuming self-rolled cigarettes increased to 33% in 2002 from 18% in 1990, and among women it increased from 2% to 13% over the same period19.

Pipe and cigar smokers have an increased risk of lung and upper aerodigestive tract cancer compared with non-smokers4. A cohort study reported a seven-fold increase in risk of liver cancer in current cigar smokers and another study reported a three-fold increase in risk for current cigar or pipe smokers20,21. Heavy pipe or cigar smoking also increases risk of bladder,bowel, stomach and pancreas cancers4. The proportion of all men in Britain smoking cigars in 2002 was 5%, compared with 16% in 1978, and the proportion of men smoking a pipe in 2002 was 1%. The proportion of British women smoking cigars or pipes is very small19.

Long-term users of smokeless (chewing) tobacco have an increased risk for oral, pharyngeal and oesophageal cancer. Much of the evidence for such an association comes from South East Asia, where betel quid is widely used. The risk of oral cancer is greatest in chewers of mixtures containing tobacco, but the risk in chewers of betel quid without tobacco is higher than non-users. Unusually, risk associated with chewing is higher in women than in men: one study reported an odds ratio (OR) for women chewing betel quid at least 10 times a day of more than 100, while the corresponding OR for men was 822,23. Case-control studies have reported up to a 48-fold increased risk of oral cancer among people who have used oral snuff for 50 years or more24.

While the use of smokeless tobacco is not widespread in the UK, it is relatively common among some South Asian communities (Figure 1.325). The prevalence of tobacco chewing increases with age, especially among women. Betel quid with tobacco is the most commonly used product25.

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Smoking prevalence in the UK

Around one in four British adults currently smoke. Men are still more likely to smoke than women (27% and 25% respectively). The average consumption of cigarettes per smoker per day is 15 in men and 13 in women19.

Smoking prevalence increases in young adults up to the age of about 25, after which prevalence falls. Only 15% of British people over 60 years old smoke cigarettes, compared with 38% of 20-24 year olds. About one-fifth of British 15 year olds are regular smokers, and, among 16-19 year olds, women are more likely to smoke than men19.One in five non-manual workers smoke, compared with 31% of manual workers19. Geographical variations in smoking prevalence within the UK largely reflect these socioeconomic differences. Smoking rates in Scotland are higher than elsewhere in the UK with 29% of men and 28% of women smoking19.

The prevalence of smoking peaked in the late 1940s for British males at 82% and the 1970s for British females at 44%26. The epidemic of smoking related cancers in the UK has peaked and recent years have seen record falls in death rates for smoking related diseases. Over the last 10-15 years the fall in smoking prevalence among British men and women has slowed considerably (Figure 1.419). The consequence of this will be a slowing and eventual stop to the decrease in smoking related mortality.

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Currently in Britain, 28% of men and 21% of women are ex-smokers, and almost 70% of those who do smoke would like to quit19. Smoking cessation has been greatest among more affluent groups.

Many of the 13 million smokers in the UK are resistant to anti-smoking messages. Therefore the current focus of public health campaigns is on getting ‘hard core’ smokers to quit and preventing young people taking up smoking.

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References

1. Peto, R., Smoking and death: the past 40 years and the next 40. BMJ, 1994. 309(6959): p. 937-9.PubMed
2. Boyle, P., et al., European Code Against Cancer and scientific justification: third version (2003). Ann Oncol, 2003. 14(7): p. 973-1005.PubMed
3. Doll, R. and A.B. Hill, Smoking and carcinoma of the lung. Preliminary report. British Medical Journal, 1950: p. ii:739-48.
4. International Agency for Research on Cancer, Tobacco smoking, in IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. 1986, IARC: Lyon. p. 127-35.Link
5. Rylander, R., et al., Lung cancer, smoking and diet among Swedish men. Lung Cancer, 1996. 14 Suppl 1: p. S75-83.PubMed
6. Crispo, A., et al., The cumulative risk of lung cancer among current, ex- and never-smokers in European men. Br J Cancer, 2004. 91(7): p. 1280-6.PubMed
7. Darby, S., et al., Radon in homes and risk of lung cancer: collaborative analysis of individual data from 13 European case-control studies. BMJ, 2005. 330(7485): p. 223.PubMed
8. Lee, P.N., Relation between exposure to asbestos and smoking jointly and the risk of lung cancer. Occup Environ Med, 2001. 58(3): p. 145-53.PubMed
9. Boffetta, P., Involuntary smoking and lung cancer. Scand J Work Environ Health, 2002. 28 Suppl 2: p. 30-40.PubMed
10. Jamrozik, K., Estimate of deaths attributable to passive smoking among UK adults: database analysis. BMJ, 2005.PubMed
11. Vineis, P., et al., Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study. BMJ, 2005. 330(7486): p. 277.PubMed
12. Scottish Executive Health Department, Cancer Scenarios: An aid to planning cancer services in Scotland in the next decade. 2001, The Scottish Executive: Edinburgh.Link
13. International Agency for Research on Cancer, IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Tobacco smoke and involuntary smoking. Volume83 ed. Vol. 83. 2004, Lyon: IARC Press.Link
14. Giovannucci, E., An updated review of the epidemiological evidence that cigarette smoking increases risk of colorectal cancer. Cancer Epidemiol Biomarkers Prev, 2001. 10: p. 752-731.PubMed
15. Brennan, P., et al., Cigarette smoking and bladder cancer in men: a pooled analysis of 11 case-control studies. Int J Cancer, 2000. 86(2): p. 289-94.PubMed
16. Brennan, P., et al., The contribution of cigarette smoking to bladder cancer in women (pooled European data). Cancer Causes Control, 2001. 12(5): p. 411-7.PubMed
17. De Stefani, E., et al., Smoking patterns and cancer of the oral cavity and pharynx: a case-control study in Uruguay. Oral Oncol, 1998. 34(5): p. 340-6.PubMed
18. De Stefani, E., et al., Hand-rolled cigarette smoking and risk of cancer of the mouth, pharynx, and larynx. Cancer, 1992. 70(3): p. 679-82.PubMed
19. Office for National Statistics, Living in Britain: Results from the 2002 General Household Survey. 2004, TSO: London.Link
20. Carstensen, J.M., G. Pershagen, and G. Eklund, Mortality in relation to cigarette and pipe smoking: 16 years' observation of 25,000 Swedish men. J Epidemiol Community Health, 1987. 41(2): p. 166-72.PubMed
21. Hsing, A.W., et al., Cigarette smoking and liver cancer among US veterans. Cancer Causes Control, 1990. 1(3): p. 217-21.PubMed
22. Lee, C.H., et al., The precancer risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral submucous fibrosis in southern Taiwan. Br J Cancer, 2003. 88(3): p. 366-72.PubMed
23. Balaram, P., et al., Oral cancer in southern India: the influence of smoking, drinking, paan-chewing and oral hygiene. Int J Cancer, 2002. 98(3): p. 440-5.PubMed
24. Critchley, J.A. and B. Unal, Health effects associated with smokeless tobacco: a systematic review. Thorax, 2003. 58(5): p. 435-43.PubMed
25. The Health Survey for England - The Health of Ethnic Minority Groups. 1999, Department of Health.Link
26. Cancer Research UK, CancerStats: Lung Cancer and Smoking - UK. 2004.PubMed

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