Mortality Trends for Selected Smoking-Related Cancers and Breast Cancer -- United States, 1950-1990

During 1990, nearly 419,000 deaths (approximately 20% of all deaths) in the United States were attributed to smoking, including more than 150,000 deaths from neoplasms (1). Cigarette smoking remains the single most preventable cause of premature death in the United States (2). Based on current and past smoking patterns, the public health burden of smoking-related cancers is expected to continue during the next several decades. The death rate for smoking-related cancers varies by race; race reflects differing distributions of several risk factors for smoking-related cancers (e.g., high-risk behaviors) and is useful for identifying groups at greatest risk for smoking-related cancers. This report describes mortality trends for cancers (i.e., lung, oral cavity and pharynx, esophagus, and larynx) that are at least 70% attributable to smoking and other tobacco use (2) by race and sex. In addition, because lung cancer recently surpassed breast cancer as the leading cause of cancer deaths among women, death rates for lung cancer are compared with those for breast cancer.

Race- and sex-specific cancer deaths during 1950-1990 were determined using underlying cause-of-death data compiled by CDC's National Center for Health Statistics. Denominators for rates were derived from U.S. census population estimates for intercensal years and census enumerations for decennial years. Rates were standardized to the 1970 age distribution of the U.S. population and are presented for whites and blacks only because numbers for other racial/ethnic groups were too small for meaningful analysis.

From 1950 to 1990, the overall age-adjusted death rate for lung cancer increased from 13.0 to 50.3 per 100,000 population; for men and women, death rates increased approximately fourfold and sevenfold, respectively (Table_1). Death rates for men were consistently higher than those for women. The rate of increase in lung cancer mortality was higher for black men than for white men, and death rates for black men first surpassed those for white men in 1963. The rate of increase for men began to slow during the early 1980s, while the rate for women continued to increase sharply. The rate for lung cancer first surpassed that for breast cancer among white women in 1986 (27.5 versus 27.3, respectively) and among black women in 1990 (32.0 versus 31.7, respectively) (Figure_1).

From 1950 to 1990, the overall age-adjusted death rate for cancers of the oral cavity and pharynx decreased from 4.0 to 3.0 (Table_1). For white men, the rate decreased. However, for black men, the oral cancer death rate increased rapidly from 1950 through 1980 and subsequently decreased slightly; from 1980 through 1990, the rate was approximately twice as high as that for white men. Oral cancer death rates for women increased slightly over the 41-year period.

The overall age-adjusted death rate for cancer of the esophagus increased from 2.9 in 1950 to 3.5 in 1990 (Table_1). For white men, the rate increased 20%; for black men, the rate increased twofold during 1950- 1980, then decreased slightly in 1990. The rate for black men was approximately three times higher than that for white men from the mid-1960s through 1990. During 1950-1990, the esophageal cancer death rate remained stable for white women and doubled for black women.

The overall age-adjusted death rate for cancer of the larynx remained stable from 1950 through 1990. Death rates remained stable for whites; however, rates increased 260% for black men and approximately 233% for black women.

Mortality from lung cancer has a substantial impact on the overall cancer death rate in the United States. From 1950 to 1990, the age-adjusted death rate for all cancers increased 10.8%, from 157.0 to 174.0. If lung cancer deaths had been excluded, however, the cancer death rate would have declined 14%, from 144.0 in 1950 to 123.7 in 1990. Reported by: CC Boring, TS Squires, T Tong, CW Heath, MD, American Cancer Society. Div of Cancer Prevention and Control, and Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that, in the United States, the overall age-adjusted death rate for lung cancer increased nearly fourfold from 1950 to 1990; in contrast, the rates for three other smoking-related cancers (i.e., cancer of the oral cavity and pharynx, esophagus, and larynx) remained relatively stable. In addition, death rates for these three cancers were substantially lower than that for lung cancer.

The continued increase in lung cancer death rates primarily reflects patterns of cigarette smoking throughout this century (2-4). For white men born during 1911-1930, smoking prevalence peaked at approximately 67% in the 1940s and 1950s (4). Smoking prevalences for birth cohorts for later years peaked at lower levels, and overall prevalence among persons aged greater than or equal to 18 years decreased sharply after 1960, reaching 27.4% in 1991 (4,5). For black men, smoking prevalence, while declining to 35.0% in 1991, has been higher than that for white men since 1965 (5). For women, smoking prevalence peaked in the 1960s at approximately 44% for the 1931-1940 birth cohort and has declined since; in 1991, prevalence was 23.7% for white women and 24.4% for black women (4,5). The declines in smoking prevalences have resulted in a stabilization or decline in the lung cancer death rate for men aged less than 55 years and for women aged less than 45 years, respectively (6). Overall, the lung cancer death rate for men is expected to peak before the year 2000, then begin to decline (6); for women, the rate will probably continue to increase into the next century (6).

Lung cancer is the principal cause of cancer deaths for both sexes (6), and smoking accounts for approximately 87% of lung cancer deaths (2). Although the annual incidence of breast cancer exceeds lung cancer among both black and white women, the 5-year survival rate for lung cancer (13.0%) is substantially lower than for breast cancer (78.0%), accounting for the higher death rate for lung cancer (6).

Tobacco and alcohol use are the major determinants of cancers of the oral cavity and pharynx, esophagus, and larynx (3,7,8). For these cancers, incidence and death rates for smokers are lower than those for lung cancer. These variations may be at least partially explained by differential sites of deposit of carcinogens in tobacco smoke: up to 90% of aerosol particles in inhaled tobacco smoke are deposited in the lung (9). Differences in cancer rates by sex and by race can be at least partially attributed to variations in tobacco and alcohol use and differences in consumption of fruits and vegetables (3,7,8).

Cigar or pipe use increases the risk for cancers of the lung, oral cavity and pharynx, esophagus, and larynx (2). However, the prevalence of cigar and pipe smoking among both white and black men has decreased substantially since 1970 (CDC, unpublished data). Similarly, snuff and chewing tobacco use among men aged greater than or equal to 50 years declined during 1970-1985 (10). Although the prevalence of snuff and chewing tobacco use has increased among younger males, this trend is too recent to have any demonstrated effect on oral cancer rates (10).

In this analysis, the relation between socioeconomic status and race was not examined. Therefore, the extent to which the associations between race and death rates for smoking-related cancers reflect differences in distribution of socioeconomic status among the racial groups could not be determined.

Primary prevention activities that discourage tobacco-use initiation and encourage cessation can assist in preventing a substantial number of cancer deaths (2,4,10). Because many factors influence both smoking initiation and smoking cessation, multiple approaches are necessary (2), including 1) increasing comprehensive school-based health education, 2) reducing minors' access to tobacco products, 3) more extensive counseling by health-care providers about smoking cessation, 4) developing and enacting strong clean indoor-air policies and laws, 5) restricting and eliminating advertising aimed at persons aged less than 18 years, and 6) increasing tobacco excise taxes. In addition, reduction of alcohol use and increased consumption of fruits and vegetables can contribute to a substantial reduction in preventable cancer deaths (3).

References

1. CDC. Cigarette smoking-attributable mortality and years of potential

life lost -- United States, 1990. MMWR 1993;42:645-9.

2. CDC. Reducing the health consequences of smoking: 25 years of progress- -a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989; DHHS publication no. (CDC)89-8411.

3. Schottenfeld D, Fraumeni JF. Cancer epidemiology and prevention. Philadelphia: WB Saunders, 1982.

4. National Cancer Institute. Strategies to control tobacco use in the United States: a blueprint for public health action in the 1990s. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1991; DHHS publication no. (NIH)92-3316.

5. NCHS. Health, United States, 1992. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993; DHHS publication no. (PHS)93-1232.

6. Miller BA, Gloeckler-Ries LA, Hankey BF, Kosary CL, Edwards BK, eds. Cancer statistics review, 1973-1989. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1992; DHHS publication no. (NIH)92-2789.

7. Day GL, Blot WJ, Austin DF, et al. Racial differences in risk of oral and pharyngeal cancer: alcohol, tobacco, and other determinants. J Natl Cancer Inst 1993;85:465-73.

8. Yu MC, Garabrant DH, Peters JM, Mack TM. Tobacco, alcohol, diet, occupation, and carcinoma of the esophagus. Cancer Res 1988;48:3843-8.

9. Van Lancker JL. Smoking and disease. In: Jarvik ME, Cullen JW, Gritz ER, Vogt TM, West LJ, eds. Research on smoking behavior. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, 1979; DHEW publication no. (ADM)79-581. (NIDA research monograph no. 17). 10. National Cancer Institute. Smokeless tobacco or health: an international perspective. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1992; DHHS publication no. (NIH)92-3461.
Table_1
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TABLE 1. Age-adjusted death rates * for selected smoking-related cancers, by sex and
race + -- United States, selected years, 1950-1990
================================================================================================
Type of cancer             1950  1955  1960  1965  1970  1975  1980  1985   1990
---------------------------------------------------------------------------------
LUNG &
  Male
    White                  21.9  30.4  38.2  47.3  57.7  64.8  70.4  71.8    73.6
    Black                  15.7  24.3  37.9  47.8  66.1  80.6  93.3  97.9   107.7
    Total @                21.6  30.0  38.2  47.4  58.2  65.8  71.9  73.4    75.6
  Female
    White                   4.9   5.1   5.6   7.5  11.1  15.5  21.1  26.8    32.1
    Black                   3.8   5.2   5.6   7.2  11.7  15.4  21.6  25.7    32.0
    Total @                 4.8   5.1   5.6   7.5  11.1  15.4  21.0  26.4    31.8
Total @                    13.0  17.1  21.0  25.8  32.1  37.4  42.7  46.4    50.3

ORAL CAVITY AND PHARYNX **
  Male
    White                   6.6   6.2   6.0   5.7   6.0   5.6   5.1   4.5     4.2
    Black                   4.8   4.7   7.4   6.4   7.6   8.7  11.0   9.4     9.8
    Total @                 6.5   6.1   5.9   5.8   6.1   5.9   5.6   4.9     4.7
  Female
    White                   1.5   1.5   1.6   1.5   1.8   1.9   1.9   1.7     1.6
    Black                   1.9   1.6   1.4   1.9   2.2   2.2   2.4   2.2     2.2
    Total @                 1.6   1.5   1.6   1.6   1.9   2.0   1.9   1.8     1.7

Total @                     4.0   3.7   3.7   3.5   3.7   3.7   3.5   3.2     3.0

ESOPHAGUS ++
  Male
    White                   4.4   4.5   4.3   4.4   4.2   4.5   4.6   4.7     5.3
    Black                   7.6   7.9  10.0  11.9  12.6  15.0  16.1  15.1    14.4
    Total @                 4.7   4.7   4.8   5.0   4.9   5.4   5.6   5.6     6.0
  Female
    White                   1.2   1.1   1.1   1.1   1.2   1.2   1.2   1.2     1.2
    Black                   1.9   2.0   2.6   2.9   3.1   3.7   4.4   3.7     3.9
    Total @                 1.2   1.2   1.2   1.3   1.3   1.4   1.5   1.4     1.5

Total @                     2.9   2.9   2.9   3.0   2.9   3.2   3.3   3.3     3.5

LARYNX &&
  Male
    White                   2.6   2.7   2.7   2.7   2.9   2.7   2.5   2.3     2.3
    Black                   1.9   2.4   3.2   3.3   3.8   4.4   5.0   4.9     5.0
    Total @                 2.6   2.7   2.8   2.7   2.9   2.8   2.7   2.5     2.5
  Female
    White                   0.3   0.2   0.2   0.3   0.3   0.4   0.4   0.4     0.4
    Black                   0.3   0.3   0.4   0.4   0.5   0.7   0.8   0.8     1.0
    Total @                 0.3   0.2   0.2   0.3   0.3   0.4   0.5   0.5     0.5

Total @                     1.4   1.4   1.4   1.4   1.5   1.5   1.4   1.3     1.3
---------------------------------------------------------------------------------
 * Per 100,000 population, standardized to the 1970 age distribution of the U.S. population.
 + Estimates are presented for whites and blacks only because numbers for other racial/ethnic
   groups were too small for meaningful analysis.
 & Includes malignancies of the lung, trachea, and broncus. International Classification of
   Diseases, Sixth Revision (ICD-6; 1950-1957), codes 162, 163; Seventh Revision (ICD-7;
   1958-1967), codes 162, 163; Eighth Revision, Adapted for Use in the United States (ICDA-8;
   1968-1978), code 162; Ninth Revision (ICD-9; 1979-1990), code 162.
 @ Includes races other than black and white.
** Includes malignancies of the lip, oral cavity, and pharynx (ICD-6 and ICD-7, codes 140-148;
   ICDA-8 and ICD-9, codes 140-149).
++ ICD-6, ICD-7, ICDA-8, and ICD-9, code 150.
&& ICD-6, ICD-7, ICDA-8, and ICD-9, code 161.
================================================================================================

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