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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
• More than one in five (21%) British adults currently smokes
• Smoking causes 90% of lung cancers in men and 83% of cases in women in the UK
• 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 83% of female cases of lung cancer in the UK.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 Recently, a 50-year follow-up study of smoking and lung cancer in British doctors showed a similar 25-fold increase in lung cancer risk in men smoking 25 cigarettes a day or more, compared to lifelong non-smokers.27

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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 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.

Exposure to environmental tobacco smoke also causes lung cancer. The most recent meta-analyses show that exposure to ETS at work or in the home increases the risk of lung cancer among non-smokers by about a quarter, while heavy exposure at work doubles the risk.9,11 Exposure to ETS has also been linked to risk of bladder and laryngeal cancer.29-31 It has been estimated that exposure to ETS in the home causes around 11,000 deaths in the UK each year from lung cancer, stroke and heart disease combined.10.

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. The risk for cancers of the upper aerodigestive tract in ex-smokers becomes lower than that of a current smoker within five years, although risk is still higher than someone who has never smoked 20 or more years after stopping, and the risk for bladder cancer is also higher than in never-smokers 20 years after giving up15-16,28.

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Type of tobacco 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 male British smokers consuming self-rolled cigarettes increased to 35% in 2007 from 25% in 1998, and among women it increased from 8% to 17% 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, pancreatic and oesophageal cancer. Much of the evidence for such an association comes from South East Asia, where betel quid is widely used. A recent review summarising the evidence about cancer and smokeless tobacco to date gave risk ratios for oral cancer in smokeless tobacco users in India and other Asian countries of about five, and in Sudan of about seven. The risk ratio for oral cancer in smokeless tobacco users in the USA and Canada was 2.6. Risk estimates of 1.6 and 1.8 were given for oesophageal and pancreatic cancer in Northern European smokeless tobacco users.22 In India, 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.23.

While the use of smokeless tobacco is not widespread in the UK, it is relatively common among some South Asian communities (Figure 1.333). The prevalence of tobacco chewing increases with age, especially among Bangladeshi men and women. Betel quid with tobacco is the most commonly used product25.

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Smoking prevalence in the UK

More than one in five British adults currently smokes. Men are still more likely to smoke than women (22% and 20% respectively). The average consumption of cigarettes per smoker per day is 14 in men and 13 in women19.

The peak smoking prevalence is in men and women aged 25-34 (32% and 30%, respectively), after which prevalence falls. Only 12% of British people over 60 years old smoke cigarettes. Almost 40% of regular smokers began smoking regularly before the age of 16.19.Among non-manual workers, smoking prevalence is 16%, compared with 25% 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 24% of men and 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. Smoking prevalence continues to fall in Britain, possibly aided by the recent bans on smoking in public places introduced in Scotland and England and Wales (Figure 1.419).

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Currently in Britain, 28% of men and 21% of women are ex-smokers, and 66% of those who do smoke would like to quit19. Smoking cessation has been greatest among more affluent groups.

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References for tobacco and cancer risk

1. Peto, R., Smoking and death: the past 40 years and the next 40. BMJ, 1994. 309(6959): p. 937-9.
2. Peto, R., et al., Mortality from smoking in developed countries 1950-2000, second edition pg 498, June 2006.
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.
5. Rylander, R., et al., Lung cancer, smoking and diet among Swedish men. Lung Cancer, 1996. 14 Suppl 1: p. S75-83.
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.
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.
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.
9. Taylor, R., et al.Meta-analysis of studies of passive smoking and lung cancer: effects of study type and continent. Int J Epidemiol, 2007. 36(5): p. 1048-59.
10. Jamrozik, K., Estimate of deaths attributable to passive smoking among UK adults: database analysis. BMJ, 2005.
11. Stayner, L., et al., Lung cancer risk and workplace exposure to environmental tobacco smoke. Am J Public Health, 2007. 97(3): p. 545-51.
12. Scottish Executive Health Department, Cancer Scenarios: An aid to planning cancer services in Scotland in the next decade. 2001, The Scottish Executive: Edinburgh.
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.
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.
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.
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.
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.
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.
19. Office for National Statistics, Living in Britain: General Household Survey 2007. 2009, TSO: London.
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.
21. Hsing, A.W., et al., Cigarette smoking and liver cancer among US veterans. Cancer Causes Control, 1990. 1(3): p. 217-21.
22. Boffetta, P., et al., Smokeless tobacco and cancer Lancet Oncol, 2008. 9(7): p. 667-75.
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.
24. Critchley, J.A. and B. Unal, Health effects associated with smokeless tobacco: a systematic review. Thorax, 2003. 58(5): p. 435-43.
25. The Health Survey for England - The Health of Ethnic Minority Groups. 1999, Department of Health.
26. Cancer Research UK, CancerStats: Lung Cancer and Smoking - UK. 2004.
27. Doll, R. et al., Mortality from cancer in relation to smoking: 50 years observations on British doctors. Br J Cancer, 2005. 92(3): p. 426-9.
28. Bosetti, C. et al., Tobacco Smoking, Smoking Cessation, and Cumulative Risk of Upper Aerodigestive Tract Cancers. Am J Epidemiol, 2008. 167(4): p. 468-73.
29. Bosetti, C. et al., Tobacco Smoking, Smoking Cessation, and Cumulative Risk of Upper Aerodigestive Tract Cancers. Am J Epidemiol, 2008. 167(4): p. 468-73.
30. Bjerregaard, B.K. et al., Tobacco smoke and bladder cancer-in the European prospective investigation into cancer and nutrition. Int J Cancer, 2006. 119(10): p. 2412-6.
31. Jiang, X. et al., Environmental tobacco smoke and bladder cancer risk in never smokers of Los Angeles County. Cancer Res, 2007. 67(15): p. 7540-5.
32. Lee, Y.C. et al., Involuntary smoking and head and neck cancer risk: pooled analysis in the international head and neck cancer epidemiology consortium. Cancer Epidemiol Biomarkers Prev, 2008. 17(8): p. 1974-81.
33. Health Survey for England 2004: The Health of Minority Ethnic Groups - headline tables. 2005, NHS Health and Social Care Information Centre, Public Health Statistics.

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