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Original Investigation
December 2016

State-Level Cancer Mortality Attributable to Cigarette Smoking in the United States

Author Affiliations
  • 1Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
  • 2Epidemiology Research Program, American Cancer Society, Atlanta, Georgia
JAMA Intern Med. 2016;176(12):1792-1798. doi:10.1001/jamainternmed.2016.6530
Key Points

Question  What proportion of cancer deaths are attributable to cigarette smoking in each US state?

Findings  In this study of population-attributed fraction of cancer deaths due to cigarette smoking, cigarette smoking explained a high proportion of cancer deaths in all states, but this proportion was highest in several Southern states, notably Kentucky, Arkansas, Tennessee, West Virginia, and Louisiana.

Meaning  Strengthened tobacco control is needed to reduce the burden of cancer death in all states.

Abstract

Importance  State-specific information about the health burden of smoking is valuable because state-level initiatives are at the forefront of tobacco control. Smoking-attributable cancer mortality estimates are currently available nationally and by cancer, but not by state.

Objective  To calculate the proportion of cancer deaths among adults 35 years and older that were attributable to cigarette smoking in 2014 in each state and the District of Columbia.

Design, Setting, and Participants  The population-attributable fraction (PAF) of cancer deaths due to cigarette smoking was computed using relative risks for 12 smoking-related cancers (acute myeloid leukemia and cancers of the oral cavity and pharynx; esophagus; stomach; colorectum; liver; pancreas; larynx; trachea, lung, and bronchus; cervix uteri; kidney and renal pelvis; and urinary bladder) from large US prospective studies and state-specific smoking prevalence data from the Behavioral Risk Factor Surveillance System.

Main Outcomes and Measures  The PAF of cancer deaths due to cigarette smoking in each US state and the District of Columbia.

Results  We estimate that at least 167 133 cancer deaths in the United States in 2014 (28.6% of all cancer deaths; 95% CI, 28.2%-28.8%) were attributable to cigarette smoking. Among men, the proportion of cancer deaths attributable to smoking ranged from a low of 21.8% in Utah (95% CI, 19.9%-23.5%) to a high of 39.5% in Arkansas (95% CI, 36.9%-41.7%), but was at least 30% in every state except Utah. Among women, the proportion ranged from 11.1% in Utah (95% CI, 9.6%-12.3%) to 29.0% in Kentucky (95% CI, 27.2%-30.7%) and was at least 20% in all states except Utah, California, and Hawaii. Nine of the top 10 ranked states for men and 6 of the top 10 ranked states for women were located in the South. In men, smoking explained nearly 40% of cancer deaths in the top 5 ranked states (Arkansas, Louisiana, Tennessee, West Virginia, and Kentucky). In women, smoking explained more than 26% of all cancer deaths in the top 5 ranked states, which included 3 Southern states (Kentucky, Arkansas, and Tennessee), and 2 Western states (Alaska and Nevada).

Conclusions and Relevance  The proportion of cancer deaths attributable to cigarette smoking varies substantially across states and is highest in the South, where up to 40% of cancer deaths in men are caused by smoking. Increasing tobacco control funding, implementing innovative new strategies, and strengthening tobacco control policies and programs, federally and in all states and localities, might further increase smoking cessation, decrease initiation, and reduce the future burden of morbidity and mortality associated with smoking-related cancers.

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