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Can we smoke?

President Nixon called for a “national commitment to fighting cancer” when he signed the National Cancer Act of 1971, which embodied his plan for the war on cancer. In 2016, then-Vice President Joe Biden launched the Cancer Moon Shot to accelerate progress against cancer. On February 2 of this year, the White House announced that incumbent President Joe Biden was relaunching the Cancer Moon Shot “to reduce cancer mortality by at least 50% over the next 25 years and … to end cancer as we know it today. .” Both presidents’ initiatives focus on research and development of new treatments, but also cancer prevention and screening and improved patient care.

Neither Nixon in 1971 nor Biden in 2016 mentioned reducing smoking, the leading cause of cancer death in both men and women. However, the February 2 moon landing statement did acknowledge progress against smoking. (Longstandingly the leading cause of cancer death in men, lung cancer surpassed breast cancer as the leading cause of cancer death in women in 1987. Even decades later, two-thirds of women still consider breast cancer to be the leading cause.)

Most recently, on June 21st, the Biden administration announced a plan that may be the most effective smoking reduction measure ever: requiring the reduction of nicotine in burnt tobacco products to non-addictive levels . It may also be the single most effective measure to reduce future cancer mortality.

If implemented seriously, this controversial regulation will spark a storm of opposition from the tobacco industry, tobacco product retailers, philosophical opponents and, of course, many smokers. This objection means that implementation will not happen for many years, if ever. (Interestingly, if unsure, a large percentage of current smokers support reducing nicotine to non-addictive levels.)

Impact of very low nicotine regulations on cancer mortality How big is it? Looking back, we can learn the answers, asking how the war on cancer has progressed so far, and how the decades-long fight against smoking has shaped that progress.

While advances in the fight against cancer have impacted cancer diagnosis rates, incidence rates, and 5-year survival rates, I’ll focus on arguably the most important metric: cancer mortality. Smoking causes countless cancers, including cancer of the mouth, throat, bladder, kidney, liver, stomach, pancreas, colon and rectum, and cervix. However, I will only examine lung cancer, which is the single largest source of cancer mortality from smoking and the most important cancer “marker” of smoking. Other cancer sites have several causes (some unknown), while 80-90% of lung cancers are related to smoking and secondhand smoke.

Adult smoking rates have fallen since Nixon declared war on cancer, rising from 37% in 1971 to 12.5% ​​in 2020. Today, smoking is banned by law and regulation, banned in many workplaces and public places, and cigarettes are getting more expensive due to rising wholesale prices from manufacturers and government excise taxes. In addition to reducing smoking rates, these factors also significantly reduced the proportion of current smokers who smoked per day, and the number of cigarettes consumed by smokers per day. The decline in the percentage of smokers and the number of cigarettes they smoke has led to a sharp decline in a measure of combined smoking prevalence and daily cigarette consumption: Annual Adult Per Capita Cigarette Consumption (APCCC). Defined as the total annual national consumption of cigarettes divided by the number of adults aged 18 and over, the APCCC has risen sharply since the early 2000s century, when man-made cigarettes first became popular, by 1963, the year before the first report by surgeons on smoking and health. Smoking rates declined thereafter, again significantly (see Figure 1). The apparent rise and fall of smoking prompted Harvard historian Alan Brandt to label the 1900s the cigarette century .


Since the development of lung cancer was decades after the start of smoking, lung cancer was basically in the early 20s Unknown onth century. Likewise, there was a lag between the decline in smoking rates and the subsequent decline in lung cancer. Thus, while adult smoking rates began to decline in 1964, lung cancer mortality peaked in 1993, nearly three years later.

What is the effect of the transition to smoking on overall cancer mortality? How is this rate independent of a reduction in smoking? Figure 2 below shows a very encouraging age-adjusted map of all-bit cancer mortality.


The overall increase in cancer mortality throughout the 1980s. For both sexes, cancer mortality peaked in 1991. Death rates for women also peaked that year. For men, the rate peaked a year ago. From the peak incidence rate to 2019, cancer death rates for all sites combined decreased by 32.1% in both sexes: 28.2% in women and 38.2% in men. This is a remarkable achievement by any measure.

Figure 3 shows the changes in lung cancer mortality over the same period. Mortality rates for men rose in 1990, the same year that all-male cancer mortality peaked. In contrast, the incidence of lung cancer in women has been rising in 2002. The 12-year gap between the highest incidence rates in both sexes (lower highest incidence in women) reflects that women started smoking later than men, never reaching the higher prevalence of smoking in men, and also later on. Start to exit. Smoking rates among men peaked in the 1950s, with more than half of all men smoking, and remained fairly stable through the early 1960s. Smoking rates among women continued to rise until the Surgeon General’s report in 1964 interrupted the upward trend. The smoking rate among women is just over one-third. Lung cancer death rates for both men and women peaked in 1993. By 2019, the lung cancer death rate for men and women fell by 43.5%. For women, the percentage dropped by 32.5%. For men, it plummeted by 55.7%.


Check all-site cancer mortality With the exception of lung cancer , since 1991, when all-bit mortality rates peaked, there has been a 27% decrease in both men and women combined, 19.7% in women and 29.8% in men.

What is a take-home message? First, with the increase in all-site age-adjusted cancer mortality rates in 1991, President Nixon died in 1994, barely alive to see his war on cancer come to an end. But it did turn the tide, with cancer death rates down by a third by 2019. Importantly, the increase and decrease in cancer mortality almost coincided with the increase and decrease in lung cancer mortality, especially in men. The decline in smoking rates—and thus lung cancer—has contributed significantly to the dramatic decline in overall cancer mortality. Most strikingly, the decline in lung cancer mortality in men accounted for almost half (47%) of the decline in all cancer deaths in men. Of course, not all lung cancer deaths are caused by smoking—as many as 20% are not—but offsetting this consideration is that a reduction in smoking also leads to a reduction in cancers in multiple other sites.

Second important message: Independent of progress in smoking, we have made substantial progress in reducing cancer mortality, reflecting other forms of prevention, better screening and earlier diagnosis and better treatment.

Third message: President Biden’s ambitious cancer mortality goals are possible. Halving cancer mortality over the next 25 years will require greater success than the decline over the past 25 years. This will depend on continued improvements in early cancer diagnosis and treatment. It may depend on the ability of President Biden’s administration (and possibly his successor) to withstand significant political and legal pressure as it tries to implement very low nicotine regulations. If the stars align, we might be able to photograph the moon.

Dr. Kenneth E. Warner, Avedis Donabedian Distinguished University Professor Emeritus and Dean Emeritus of the University of Michigan School of Public Health. image




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