Association of Cigarette Type With Lung Cancer Incidence and Mortality: Secondary Analysis of the National Lung Screening Trial | Lung Cancer | JAMA Internal Medicine | JAMA Network
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Table 1.  Demographics and Smoking History of Study Population
Demographics and Smoking History of Study Population
Table 2.  Cigarette Type Distribution and Adjusted Hazard Ratios (HR) by Outcome
Cigarette Type Distribution and Adjusted Hazard Ratios (HR) by Outcome
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    2 Comments for this article
    Not only cigarettes, but other forms of smopking like sheesha, midwah,hookah are more pernicious
    Rajeev Gupta, MBBS, MD, DM (Cardiology) | Mediclinic Al Jowhara Hospital, Al Ain, UAE
    I congratulate the authors for dispelling the common myth: filtered cigarettes are less harmful. That said, other forms of smoking, common in some countries and cultures like sheesha, midwakh (sometimes spelled medwakh and also known as dokha), beedis, and hookah are more harmful. As per one estimate, smoking 1 time midwakh is equivalent to smoking 4-5 cigarettes, and smoking sheesha for 30-minute is equivalent to smoking 20-cigarettes over 30 minutes. Some people think, these forms of smoking are less harmful. Education is required about the much more pernicious nature of these non-cigarettes smokes.
    Effect of Socioeconomic Class on Mortality
    John Clark, MD | ANMC
    My clinical experience is patients most likely to smoke unfiltered cigarettes are poor, more likely to have significant co-morbidities, and less likely to receive routine medical care. Was any attempt made to adjust this analysis for health and socio-economic status between groups? It may be true that smoking unfiltered cigarettes identifies a cohort of patients at higher risk for lung cancer. However, the statement that "unfiltered cigarettes are the most dangerous" cannot be supported unless the patients were matched for co-morbidities, access to health care, and socioeconomic status.
    Research Letter
    October 21, 2019

    Association of Cigarette Type With Lung Cancer Incidence and Mortality: Secondary Analysis of the National Lung Screening Trial

    Author Affiliations
    • 1Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Hospital, Charleston, South Carolina
    • 2Thoracic Oncology Research Group, Medical University of South Carolina, Charleston
    • 3Hollings Cancer Center, Medical University of South Carolina, Charleston
    • 4Department of Public Health Sciences, Medical University of South Carolina, Charleston
    JAMA Intern Med. 2019;179(12):1710-1712. doi:10.1001/jamainternmed.2019.3487

    In response to increasing evidence implicating cigarette smoking as a cause of lung cancer in the 1950s, tobacco manufacturers introduced filtered and “lower-tar” cigarettes to allay consumer concerns, knowing they did not actually reduce health risks. Puncturing ventilation holes of varying sizes and numbers into the filter to dilute inhaled smoke became the optimum way to reduce tar yield.1

    Despite these changes, smoking remains responsible for 80% to 90% of lung cancer diagnoses and 5-year survival is 18%, highlighting the importance of prevention.2 Lung cancer screening with low-dose computed tomography has been shown to improve mortality, and tobacco treatment is a required component of effective screening. We investigated the association of filter status, tar level, and menthol flavor with lung cancer outcomes in the National Lung Screening Trial.


    This is a secondary data analysis of 14 123 National Lung Screening Trial participants who completed detailed smoking questionnaires.3 We examined baseline cigarette tar level (regular, light, or ultralight), flavor (unflavored or menthol), and filter status (filtered or unfiltered) and their association with lung cancer diagnosis, mortality, and all-cause mortality. Cox regression models were used to study the influence of cigarette tar level, flavor, and filter on clinical outcomes, controlling for sex, age, race, pack years, nicotine dependence (as measured by the Fagerström Test for Nicotine Dependence), and treatment arm. This study was approved by the Medical University of South Carolina institutional review board. Patient consent was waived because deidentified data were used. Two-sided t testing was conducted as indicated with a P value less than .05 being considered significant.


    Of 14 123 participants, 7056 (50%) were current smokers, 13 038 (92%) were white, and had a history of smoking an average of 60 pack of cigarettes per year (Table 1). Most individuals (12 488 [88%]) smoked filtered cigarettes, and nearly half smoked light (4660 [33.0%]) or ultralight (1562 [11.1%]) cigarettes. After adjustment, unfiltered cigarette smokers were nearly 40% (hazard ratio, 1.37; 95% CI, 1.10-1.17) more likely to develop lung cancer and nearly twice (hazard ratio, 1.96; 95% CI, 1.46-2.64) as likely to die of lung cancer compared with those who smoked filtered cigarettes. Additionally, all-cause mortality was nearly 30% (hazard ratio, 1.28; 95% CI, 1.09-1.50) higher (Table 2). There was no difference in mortality outcomes between light/ultralight or flavored vs regular cigarette smokers.


    This study evaluated mortality in the setting of lung cancer screening based on the type of cigarette smoked and found that smoking unfiltered cigarettes is associated with significantly higher lung cancer incidence and death. There was no difference in lung cancer outcomes when comparing light/ultralight or menthol smokers with regular cigarette smokers.

    This study confirms that smoking filtered and unfiltered cigarettes is associated with increased risk of lung cancer incidence and mortality and is consistent with other studies in the literature.4 Identifying individuals who smoke unfiltered cigarettes is important as they stand to benefit greatly from aggressive tobacco treatment. Although filtered cigarettes fared better than unfiltered cigarettes, this study demonstrated lung cancer mortality in filtered cigarette smokers to be 1600 per 100 000 persons compared with a never-smoking cohort with just 34 lung cancer deaths per 100 000 persons.5 The difference in outcomes in those smoking filtered and unfiltered cigarettes observed in this study and others likely reflects filtered cigarette design features including the amount, density, and blends of tobacco in the column, additives, and filter paper porosity.5,6 Further, evidence suggests that despite adoption of new cigarette designs, cigarette smoking continues to pose enormous health risk.1,5

    Light/ultralight cigarette smokers had similar mortality rates compared with those smoking regular cigarettes. This outcome may be explained by the concept of compensatory smoking in which smokers achieve higher nicotine levels by changing smoking behaviors.6 Tobacco companies marketed low-tar cigarettes to consumers as an alternative to quitting, suggesting that this improved health risks. Unfortunately, most smokers believe light/ultralight cigarettes reduce risk, and this misconception may dissuade them from quitting.7

    This study confirms that smoking any type of cigarette conveys serious health risks. Within the context of this study, unfiltered cigarettes are the most dangerous, and individuals who smoke them should be targeted for aggressive tobacco treatment interventions. Some smokers may switch to light or ultralight cigarettes believing they are safer; however, this is not the case. Lung cancer screening is considered a teachable moment, and the findings here should lead to the design of personalized tobacco treatment interventions within this context. Importantly, this study adds to the overwhelming evidence showing the risk of developing and dying of lung cancer caused by smoking both filtered and unfiltered cigarettes.

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    Article Information

    Accepted for Publication: June 21, 2019.

    Corresponding Author: Nichole T. Tanner, MD, MSCR, Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Hospital, 109 Bee St, Charleston, SC 29425 (

    Published Online: October 21, 2019. doi:10.1001/jamainternmed.2019.3487

    Author Contributions: Dr Tanner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Tanner, Thomas, Rojewski, Toll, Silvestri.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Tanner, Thomas, Ward, Rojewski, Gebregziabher, Silvestri.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Ward, Gebregziabher, Silvestri.

    Obtained funding: Toll.

    Supervision: Toll, Silvestri.

    Conflict of Interest Disclosures: Dr Tanner reports grants from the American Cancer Institute during the conduct of the study; grants from Cook Medical, Exact Sciences, Olympus America, and Veracyte outside the submitted work; and consulting from Cook Medical, Exact Sciences, Biodesix, and Olympus America outside the submitted work. Dr Rojewski reports grants from the National Cancer Institute during the conduct of the study. Dr Toll reported personal fees from Pfizer and has consulted on an advisory board regarding e-cigarettes and has offered testimony on behalf of plaintiffs who filed litigation against tobacco companies. No other disclosures were reported.

    Funding/Support: This study was supported in part by research funding from the Hollings Cancer Center at the Medical University of South Carolina.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank K. Michael Cummings, PhD, MPH (Medical University of South Carolina), for his thoughtful review and comments on this paper. He received no compensation for his assistance.

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