Skip directly to search Skip directly to A to Z list Skip directly to site content
CDC Home

State-Specific Trends in Lung Cancer Incidence and Smoking --- United States, 1999--2008

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer death in the United States (1). Most deaths from lung cancer are caused by cigarette smoking and exposure to secondhand smoke (2). Large variations in lung cancer (1,3), smoking behavior (4), and tobacco control programs and policies (5,6) have been observed among states. Effective tobacco control policies can decrease smoking prevalence, ultimately leading to decreases in lung cancer (7). To assess lung cancer incidence by state, CDC analyzed data from the National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for the period 1999--2008. To assess smoking behavior by state, data from the Behavioral Risk Factor Surveillance System (BRFSS) for the period 1994--2009 were analyzed. This report summarizes the results of these analyses. From 1999 to 2008, decreases in lung cancer incidence were observed among men in 35 states and among women in six states. Regionally, the lowest rates and most rapid rate of decline in lung cancer were concentrated among states in the West, correlating with low smoking prevalence and high ratios of former smokers to ever smokers. Further reductions in smoking prevalence are critical to continue the decline in lung cancer incidence.

Data on new cases of invasive lung cancer (International Classification of Diseases for Oncology, Third Edition: C34.0--C34.9) diagnosed during 1999--2008 were obtained from population-based cancer registries affiliated with the NPCR and SEER programs, which, combined, cover all of the U.S. population. Data were evaluated according to United States Cancer Statistics (USCS) data-quality criteria.* Annual incidence rates per 100,000 persons were age-adjusted by the direct method to the 2000 U.S. standard population (19 age groups).Adjustments to population data were made by the U.S. Census Bureau to account for the Gulf Coast population in Alabama, Mississippi, Louisiana, and Texas displaced by major population shifts resulting from hurricanes Katrina and Rita in 2005.§ Annual percentage change (APC) was used to quantify the change in incidence rates over time and was calculated using joinpoint regression, which involves fitting a series of joined straight lines on a logarithmic scale to the trends in the annual age-adjusted rates. Up to two joined straight lines were allowed for nationwide and region-specific rates; one straight line was used for state-specific rates. Data from all states and the District of Columbia (DC) met USCS data quality criteria for 2008, but data from only 44 states and three U.S. Census regions (covering 90% of the U.S. population) met these criteria for all years 1999--2008; for this report, APC was calculated only for these states and regions.

Smoking behavior was estimated using results from BRFSS, a state-based surveillance system that collects information on health-risk behaviors, including tobacco use. BRFSS is a random-digit--dialed landline telephone survey of noninstitutionalized civilian adults aged ≥18 years conducted annually in all 50 states, DC, Puerto Rico, Guam, and the U.S. Virgin Islands. Smoking status was determined by asking respondents "Have you smoked at least 100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days or not at all?" Ever smokers were defined as those who reported having smoked at least 100 cigarettes during their lifetime; of these, current smokers were those who reported currently smoking every day or some days and former smokers were those who reported not currently smoking. Quit ratios were calculated as the ratio of former smokers to ever smokers.

The Pearson correlation was used to evaluate the association between lung cancer incidence (1999--2008) and smoking prevalence and quit ratios 5 years prior (1994--2003). Lung cancer rates begin to decline as soon as 5 years after smoking rates decline (6,7). Analyses were weighted by the inverse variances of the age-adjusted rates. All tests of statistical significance were two sided (p<0.05).

Among men, lung cancer incidence continued to decrease nationwide (APC 1999--2005 = -1.4 and APC 2005--2008 = -2.9) (Figure 1). Since 1999, lung cancer incidence among men declined at a faster rate in the West (APC 1999--2006 = -2.3 and 2006--2008 = -3.9) than in other U.S. Census regions. From 1999 to 2008 lung cancer incidence among men decreased in 35 of the 44 states analyzed and remained stable in the other nine states (Figure 2). Many of the states with lowest lung cancer incidence, as well as smoking prevalence, were clustered in the West (Figure 2). The correlation between lung cancer incidence and smoking prevalence 5 years prior was 0.72 (p<0.001). Many of the states with high quit ratios were clustered in the West and Northeast (Figure 2). The correlation between lung cancer incidence and quit ratios 5 years prior was -0.55 (p<0.001).

Among women, lung cancer incidence decreased nationwide (APC 2006--2008 = -2.2) after increasing for years (APC 1999--2006 = 0.5). Lung cancer incidence among women decreased in the West (APC 1999--2006 = -0.5; APC 2006--2008 = -3.7) and stabilized in the Midwest, but was still increasing in the Northeast (APC 1999--2008 = 0.7) (not calculated for the South) (Figure 1). From 1999 to 2008, lung cancer incidence among women decreased in six states (California and Nevada [-1.5%], Washington [-1.0%], Florida and Oregon [-0.9%], and Texas [-0.7%]), remained stable in 24 states, and increased slightly in 14 states (not calculated for six states and DC) (Figure 3). Nearly half of states with higher smoking prevalence for women and more than a third of states with higher lung cancer incidence are in the South (Figure 3). The correlation between lung cancer incidence and smoking prevalence 5 years prior was 0.69 (p<0.0001). High quit ratios among women were clustered among states in the West and Northeast (Figure 3). The correlation between lung cancer incidence and quit ratios 5 years prior was -0.33 (p<0.001).

Reported by

S. Jane Henley, MSPH, Christie R. Eheman, PhD, Lisa C. Richardson, MD, Marcus Plescia, MD, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion; Kat J. Asman, MSPH, Shanta R. Dube, PhD, Ralph S. Caraballo, PhD, Timothy A. McAfee, MD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: S. Jane Henley, shenley@cdc.gov, 770-488-4157.

Editorial Comment

This report documents recent decreases in lung cancer incidence that closely parallel smoking behavior patterns across the United States. States vary substantially in their success at reducing smoking prevalence and lung cancer incidence (1,4). A previous analysis of lung cancer incidence reported that the lowest incidence was in the West and the highest in the South (3). The results of this subsequent analysis demonstrate that lung cancer incidence is decreasing at a faster rate in the West than in other regions of the United States, which corresponds with changes in smoking behavior (1,4).

Since 1999, CDC has recommended and supported state efforts to implement and sustain comprehensive tobacco control programs to discourage smoking initiation, encourage smoking cessation, and protect nonsmokers from secondhand smoke exposure. Decreases in lung cancer incidence and the correlation between lung cancer incidence and quit ratios provide compelling evidence of the value of these tobacco control efforts (1,6). State smoke-free laws continue to be implemented nation-wide, and tobacco excise taxes continue to increase in most, but not all, states (5,8).** In fiscal year 2011, states will collect $25.3 billion from tobacco excise taxes and the tobacco settlement, a 46% increase over the past decade (8). Yet, in the past 3 years, states have cut funding for tobacco control programs by 28% ($199.3 million), and this year states will invest less than 2% of tobacco revenues ($518 million) in tobacco control programs (8). States that invest more fully in these programs, such as California, have experienced decreases in youth and adult smoking prevalence (7--9), decreases in lung cancer (7), and significant health-care savings (8,9).

The findings in this report are subject to at least five limitations. First, not all states met USCS data quality criteria for this period; many of these states were in the South, one of the regions with the highest smoking prevalence. Second, cigarette smoking status is self-reported by BRFSS participants; however, these data have high validity (4). Third, smoking prevalence might be underestimated because BRFSS is a land-line survey and adults with wireless-only service are more likely to smoke cigarettes than the rest of the U.S. population.†† Fourth, BRFSS data are not generalizable to certain populations who are not included in the survey, such as institutionalized persons or persons in the military. Fifth, the majority of lung cancers are caused by cigarette smoking and secondhand smoke exposure; however, lung cancer from other causes, such as other forms of tobacco use or exposure to radon or occupational hazards, might influence geographic variations in lung cancer incidence.

Lung cancer incidence is beginning to decrease among women and is continuing to decrease among men in most states. Variations among states in lung cancer incidence are influenced by variations in smoking behavior. Tobacco control strategies to prevent initiation, accelerate declines in use, and promote cessation have decreased lung cancer incidence among men (1,7) and progress is now being observed among women (10), especially in the West. Lung cancer incidence among women is declining in states with long-running, comprehensive tobacco control programs (8). Tobacco use is an endemic problem and warrants a long-term solution (1,7). Research has shown that the longer and more heavily states invest in comprehensive tobacco control programs, the greater the reduction in smoking and the greater the subsequent savings from reduced smoking-related health costs (8). Research also has shown that any slackening of effort can jeopardize progress.§§ Although great strides in tobacco control and lung cancer incidence reduction have been made, further progress requires intensified efforts to reduce cigarette smoking and secondhand smoke exposure. These efforts depend on adequate funding of tobacco control programs.

Acknowledgment

State and regional cancer registry staffs and Behavioral Risk Factor Surveillance System state coordinators.

References

  1. Jemal A, Thun MJ, Ries LAG, et al. Annual report to the nation on the status of cancer, 1975--2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst 2008;100:1672--94.
  2. CDC. Smoking-attributable mortality, years of potential life lost, and productivity losses---United States, 2000--2004. MMWR 2008;57:1226--8.
  3. CDC. Racial/ethnic disparities and geographic differences in lung cancer incidence---38 states and the District of Columbia, 1998--2006. MMWR 2010;59:1433--8.
  4. CDC. Vital Signs: current cigarette smoking among adults aged ≥18 years---United States, 2005--2010. MMWR 2011;60:1207--12.
  5. Cokkinides VE, Prandi P, McMahon C, et al. Tobacco control in the United States: recent progress and opportunities. CA Cancer J Clin 2009;59:353--65.
  6. Jemal A, Cokkinides VE, Shafey O, Thun MJ. Lung cancer trends in young adults: an early indicator of progress in tobacco control (United States). Cancer Causes Control 2003;14:579--85.
  7. Pierce JP, Messer K, White MM, Kealey S, Cowling DW. Forty years of faster decline in cigarette smoking in California explains current lower lung cancer rates. Cancer Epidemiol Biomarkers Prev 2010;19:2801--10.
  8. Campaign for Tobacco-Free Kids. A broken promise to our children: the 1998 state tobacco settlement 12 years later. Washington, DC: Campaign for Tobacco-Free Kids; 2010. Available at http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement. Accessed September 9, 2011.
  9. Lightwood J, Glantz S. Effect of the Arizona tobacco control program on cigarette consumption and healthcare expenditures. Soc Sci Med 2011;72:166--72.
  10. Kohler BA, Ward E, McCarthy BJ, et al. Annual report to the nation on the status of cancer, 1975--2007, featuring tumors of the brain and other nervous system. J Natl Cancer Inst 2011;103:714--36.

* CDC and the National Cancer Institute, in collaboration with the North American Association of Central Cancer Registries, maintain the USCS dataset, which contains the official federal statistics on cancer incidence. Cancer registries demonstrated that cancer incidence data were of high quality by meeting six USCS publication criteria: 1) case ascertainment is ≥90% complete, 2) ≤5% of cases are ascertained solely on the basis of a death certificate, 3) ≤3% of cases are missing information on sex, 4) ≤3% of cases are missing information on age, 5) ≤5% of cases are missing information on race, and 6) ≥97% of the registry's records passed a set of single-field and inter-field computerized edits that test the validity and logic of data components. Additional information is available at http://www.cdc.gov/uscs and http://www.cdc.gov/cancer/npcr/uscs/2007/technical_notes/stat_methods/suppression.htm.

Additional information is available at http://seer.cancer.gov/popdata/index.html.

§ Additional information is available at http://www.census.gov/popest/topics/methodology.

Pertinent CDC recommendations are available at http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm.

** Additional information is available at http://apps.nccd.cdc.gov/statesystem/default/default.aspx.

†† Additional information is available at http://www.cdc.gov/nchs/data/nhsr/nhsr039.pdf.

§§ Additional information is available at http://www.iom.edu/reports/2007/ending-the-tobacco-problem-a-blueprint-for-the-nation.aspx.


What is already known on this topic?

Cigarette smoking causes lung cancer in men and women. Wide variations in state tobacco control efforts, smoking prevalence, and lung cancer incidence have been observed in the United States. Lung cancer incidence has been decreasing for the past several decades among men but not among women.

What is added by this report?

Lung cancer incidence is beginning to decrease among women and is continuing to decrease among men in most states. Lung cancer rates are declining more rapidly in the West, which corresponds with smoking behavior; states with low smoking prevalence and high quit ratios are concentrated in this region.

What are the implications for public health practice?

Decreases in lung cancer incidence provide compelling evidence for state tobacco control policies, such as increasing tobacco excise taxes, enacting smoke-free laws, and funding policies to assist smokers in quitting. To continue these decreases in lung cancer incidence, current tobacco control funding for states needs to be increased to implement and sustain successful programs to reduce cigarette smoking and secondhand smoke exposure.


FIGURE 1. Lung cancer incidence per 100,000 persons, by sex and U.S. Census region --- United States, 1999--2008*

The figure shows lung cancer incidence, per 100,000 persons, by sex and U.S. Census region from 1999-2008. Among men, lung cancer incidence continued to decrease nationwide (annual percentage change [APC] 1999-2005 = -1.4 and APC 2005-2008 = -2.9).

* Based on data from the National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology, and End Results program that met United States Cancer Statistics data quality criteria for each year 1999--2008 (covering 90% of the U.S. population). Rates for 1999--2008 per 100,000 persons were calculated for U.S. census regions that met criteria for inclusion (http://www.cdc.gov/cancer/npcr/uscs/2007/technical_notes/stat_methods/suppression.htm) and age-adjusted to the 2000 U.S. standard population. Rates for the South census region did not meet inclusion criteria; instead rates were calculated for southern states that met data quality criteria for all years of 1999--2008 (Alabama, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Oklahoma, South Carolina, Texas, and West Virginia); these might not be representative of the entire South census region. Trends were measured with annual percentage change (APC) in age-adjusted rates estimated by joinpoint regression which allowed different slopes for two periods; the year at which slopes changed could vary by region. All trends were significant with p<0.05. Trends were not calculated for southern states.

Among men, the APC nationwide was -1.4 for 1999--2005 and -2.9 for 2005--2008; in the Northeast, the APC was -1.5 for 1999--2008; in the Midwest, the APC was -0.9 for 1999--2006 and -3.9 for 2006--2008; and in the West, the APC was -2.3 for 1999--2006 and -3.9 for 2006--2008.

§ Among women, the nationwide APC nationwide was 0.5 for 1999--2006 and -2.2 for 2006--2008; in the Northeast, the APC was 0.7 for 1999--2008; in the Midwest, the APC was 1.3 for 1999--2006 and was stable for 2006--2008; and in the West, the APC was -0.5 for 1999--2006 and -3.7 for 2006--2008.

Alternate Text: The figure above shows lung cancer incidence, per 100,000 persons, by sex and U.S. Census region from 1999-2008. Among men, lung cancer incidence continued to decrease nationwide (annual percentage change [APC] 1999-2005 = -1.4 and APC 2005-2008 = -2.9).


FIGURE 2. Lung cancer incidence and trends, and smoking behavior among men --- United States

The figure includes four maps of the United States that show lung cancer incidence and trends, and smoking behavior among men, by state. From1999 to 2008 lung cancer incidence among men decreased in 35 of the 44 states analyzed and remained stable in the other nine states. Many of the states with lowest lung cancer incidence, as well as smoking prevalence, were clustered in the West.

* Rates for 2008, per 100,000 persons, based on data from the National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results program, and age-adjusted to the 2000 U.S. standard population. Categories are based on quintiles.

Linear increase or decrease in age-adjusted rates was measured with annual percentage change (APC) for the period 1999--2008. Rates were considered to increase or decrease if the APC was signficant (p<0.05); rates were considered stable if the APC was not significant. APC was not calculated for states that did not meet data quality criteria for all years 1999--2008.

§ Percentage of men aged ≥18 years who were current smokers (reported smoking at least 100 cigarettes during their lifetimes and who, at the time of interview, reported smoking every day or some days), based on Behavioral Risk Factor Surveillance System 2009 data. Categories are based on quintiles.

Quit ratios were calculated as the ratio of former smokers (persons who reported smoking at least 100 cigarettes during their lifetime but currently did not smoke) to ever smokers and is a measure of cessation over time, based on Behavioral Risk Factor Surveillance System 2009 data. Categories are based on quintiles.

Alternate Text: The figure above includes four maps of the United States that show lung cancer incidence and trends, and smoking behavior among men, by state. From1999 to 2008 lung cancer incidence among men decreased in 35 of the 44 states analyzed and remained stable in the other nine states. Many of the states with lowest lung cancer incidence, as well as smoking prevalence, were clustered in the West.


Figure 3. Lung cancer incidence and trends, and smoking behavior among women --- United States

The figure includes four maps of the United States that show lung cancer incidence and trends, and smoking behavior among women, by state. From 1999 to 2008, lung cancer incidence among women decreased in six states (California and Nevada [-1.5%], Washington [-1.0%], Florida and Oregon [-0.9%], and Texas [-0.7%]), remained stable in 24 states, and increased slightly in 14 states (not calculated for six states and the District of Columbia). Nearly half of states with higher smoking prevalence for women and more than a third of states with higher lung cancer incidence are in the South.

* Rates for 2008, per 100,000 persons, based on data from the National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results program, and age-adjusted to the 2000 U.S. standard population. Categories are based on quintiles.

Linear increase or decrease in age-adjusted rates was measured with annual percentage change (APC) for the period 1999--2008. Rates were considered to increase or decrease if the APC was signficant (p<0.05); rates were considered stable if the APC was not significant. APC was not calculated for states that did not meet data quality criteria for all years 1999--2008.

§ Percentage of women aged ≥18 years who were current smokers (reported smoking at least 100 cigarettes during their lifetimes and who, at the time of interview, reported smoking every day or some days), based on Behavioral Risk Factor Surveillance System 2009 data. Categories are based on quintiles.

Quit ratios were calculated as the ratio of former smokers (persons who reported smoking at least 100 cigarettes during their lifetime but currently did not smoke) to ever smokers and is a measure of cessation over time, based on Behavioral Risk Factor Surveillance System 2009 data. Categories are based on quintiles.

Alternate Text: The figure above includes four maps of the United States that show lung cancer incidence and trends, and smoking behavior among women, by state. From 1999 to 2008, lung cancer incidence among women decreased in six states (California and Nevada [-1.5%], Washington [-1.0%], Florida and Oregon [-0.9%], and Texas [-0.7%]), remained stable in 24 states, and increased slightly in 14 states (not calculated for six states and the District of Columbia). Nearly half of states with higher smoking prevalence for women and more than a third of states with higher lung cancer incidence are in the South.



Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.


All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

 
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Road Atlanta, GA 30329-4027, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
A-Z Index
  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
  27. #