Cigarette smoking, lung cancer - NCBI

3. Tobacco companies target teens. Smok Health Rev 1984; 14: 3 4. BJARTVEIT K: Legislation and political activity. Presented at the 5th World Conference on Smoking and Health, Winnipeg, July 12, 1983

5. COLLISHAW NE, ROGERS B: Tobacco in Canada. Can Pharm J 1984; 117: 147-150 6. Canadian Tobacco Manufacturers' Council: Cigarette and Cigarette Tobacco Advertising and Promotion Code, Montreal, 1984

Cigarette smoking, lung cancer and Canadian women KRISTAN A. L'ABBt JOHN R. HOEY, MD

The overall mortality rate for Canadian women declined by 16.5% between 1970 and 1979.' However, in this group the rate of death from lung cancer will double between 1976 and 1987, when it will exceed that of breast cancer and when lung cancer will be the leading cause of death from cancer in women'"2 (Fig. 1). Most lung cancers are attributable to cigarette smoking. Estimates of the proportions of cases of lung cancer in women attributable to smoking were 41% in Sweden,3 67% in the United States4 and 71% in England and Wales.5 In Alberta the proportion has been estimated to be 52%.6 The life expectancy for men and women who do not smoke is approximately the same.7 Among those who do smoke, the men have a lower life expectancy than the women since the former started smoking earlier and in greater numbers. However, in recent years increments in life expectancy have been greater for men than for women, which perhaps can be accounted for by the increasing use of cigarettes among women. Over the past 30 years, as the prevalence of cigarette smoking among women has approached that of men, so has the rate of death from lung cancer.8'9 The 1978-79 Canada Health Survey revealed that 43.8% of men and 35.8% of women were "regular" smokers (data were collected for those 15 years of age or older),'` whereas the 1981 Labour Force Survey reported a decline between 1966 and 1981 in the proportions of regular smokers, from 54% to 37% among men and from 32% to 29% among women." The self-administered questionnaires used by the Canada Health Survey probably provided more accurate estimates of the prevalence of tobacco use than the interviews used by the Labour Force Survey. Over the 15-year period covered in the second report, however, the absolute number of male smokers declined by an estimated 9%, while the absolute number of female smokers increased by 29%." The patterns in Quebec have been similar, although this province has had the

highest proportions of regular smokers: 48% for men and 38% for women.'` According to the Canada Health Survey 36.0% of women aged 15 to 19 years and 46.5% aged 20 to 24 years were regular smokers in 1978-79.` The Labour Force Survey showed an increase between 1966 and 1981 in the proportions of regular smokers among women aged 15 to 19 years (20.0% to 23.4%), 25 to 44 years (31.4% to 33.4%) and 65 years or more (8.3% to 10.8%)." It is striking that the proportions of men and women aged 15 to 19 years who were regular smokers had become equal, the proportion of male teenage smokers having decreased while that of female teenage smokers increased.'0" Of the female smokers less than 25 years of age over half had started to smoke before they were 16. This is in marked contrast to even their older sisters: fewer of them smoked, and of those who did, most had begun smoking after they were 21."' Several public policy changes have been suggested in the hope of at least abating the increase in the prevalence of cigarette smoking. These include antismoking campaigns, education on the dangers of smoking, aid for quitters, restriction of smoking in public places, reductions in the concentrations of hazardous substances in cigarettes, subsidies for growing food instead of tobacco, and the phasing-out of cigarette production. Recently, a ban on tobacco advertising has been recommended.'2'3 Since the voluntary ban on cigarette 605040 0

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From the department of community health, Montreal General Hospital

Reprint requests to: Dr. John R. Hoey, Department of community health, Montreal General Hospital, 1597 Pine Ave. W, Montreal, PQ H3G 1B3

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Fig. 1-Age-standardized rates of death from breast cancer (solid line) and lung cancer (dotted line) in Canadian women aged 25 to 74 years. (Adapted, with permission, from reference 2.) CAN MED ASSOC J, VOL. 130, JUNE 15, 1984

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advertising on television and radio in 1971, tobacco manufacturers in Canada have limited their overall expenditures on advertising, with only inflationary increases, to the 1971 levels.'4 This freed up a vast sum of money for relatively less expensive advertising through other media, primarily magazines and newspapers, which profited highly from this enforced shift of emphasis. In Canada it is estimated (on the basis of 1977 data adjusted for inflation) that in 1983 $100 million was spent by tobacco companies on cigarette advertising.'5 This type of expenditure pays off; in 1982, for example, 66.3 billion domestically produced and 820 million imported cigarettes were sold, and the retail value of all tobacco products was about $4.4 billion, more than 1.2% of the Canadian gross national product.'6 In addition, between 1981 and 1982 the sale of domestically produced tobacco for "roll-your-own" cigarettes increased by 16.5%, to 5.5 million kg.'7 While domestic sales of manufactured cigarettes increased by 43.8% between 1968 and 1981, the per-capita use of cigarettes by Canadians 15 years of age and older rose from 3703 to 3872; the largest relative increase (64.3%) was recorded for women who smoked more than 25 cigarettes per day." This is in contrast to the relative decrease (28.5%) recorded for women who smoked 1 to 10 cigarettes a day." Since more young women are smoking and are using more cigarettes per day, and since cigarette advertisements are apparently effective in promoting the sale of cigarettes, a ban on. all forms of tobacco advertising may help prevent young women from starting to smoke. For example, a ban on cigarette advertisements in women's magazines may be one means of "separating the vector from the host"'3 since more than 8 of every 10 women read women's magazines.'8 Many women's magazines depend on revenues from tobacco advertisements; hence, they contain few articles on the health effects of smoking. For example, magazines that accept cigarette advertisements, such as Cosmopolitan, Harper's Bazaar, Mademoiselle, McCall's and Redbook, have each had fewer than five articles on smoking in the past 16 years, and the Ladies' Home Journal and Ms. have had none.'9'20 Only Good Housekeeping, Seventeen and Teen do not accept cigarette advertisements; since 1979 these magazines have substantially increased their coverage of the hazards of smoking.20 A ban on cigarette advertisements would allow magazine editors to consider publishing articles on smoking and health independent of this source of revenue. At present the scanty coverage of this important public health issue is a major gap in the health education of female teenagers. The increase in the prevalence of cigarette smoking and in the incidence of lung cancer in women can be stopped. A dual strategy, aimed at the individual and the community, will be most effective. The community should make programs like that in Toronto2' widely available to help young people to avoid starting or to quit smoking. A national long-range antismoking policy could coordinate prevention at all levels and promote proposals for legislative changes, the most urgent of which is the banning of all tobacco advertisements and promotion. Physicians can contribute by participating in 1540

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these activities and may be especially effective in encouraging local government to restrict smoking in hospitals and in public and municipal buildings. We thank Drs. Don Wigle and Neil Collishaw, from the Department of National Health and Welfare, for their helpful comments. This study was supported in part by the national health research and development program of that department, through a national health fellowship grant to Kristan L'Abbe, and in part by the Ministry of Social Affairs of Quebec.

References 1. MAO Y, SMITH MH, SIMPSON H: Recent mortality trends of leading causes of death in Canada. Chronic Dis Can 1982; 3: 1922 2. MAO Y, SMITH MH: The lung cancer epidemic among Canadian women. Chronic Dis Can 1983; 4: 33-35 3. CEDERLOF R, FRIBERG L, HUBEC Z, LORRICH U: The Relationship of Smoking and Some Social Covariables to Mortality and Cancer Morbidity. A Ten-year Follow-up in a Probability Sample of 55,000 Swedish Subjects Aged 18 to 69. Parts 1 and 2, Karolinska Institute, Stockholm, 1975 4. WYNDER EL, STELLMAN SD: Comparative epidemiology of tobacco-related cancers. Cancer Res 1977; 37: 4608-4622 5. TOWNSEND JL: Smoking and lung cancer: a cohort study of men and women in England and Wales: 1935-1970. J R Stat Soc [Ser A] 1978; 141 (pt 1): 95-107 6. WIGLE DT, MAO Y, GRACE M: Relative importance of smoking as a risk factor for selected cancers. Can J Public Health 1980; 71: 269-275 7. MILLER GH, GERSTEIN DR: The life expectancy of nonsmoking men and women. Public Health Rep 1983; 98: 343-349 8. MILLER AB: Recent trends in lung cancer mortality in Canada. Can Med Assoc J 1977; 116: 28-30 9. LEWIS CE, LEWIS MA: The potential impact of sexual equality on health. N Engl J Med 1977; 297: 863-869 10. The Health of Canadians: Report of the Canada Health Survey (cat no 82-538-E), Dept of National Health and Welfare and Statistics Canada, Ottawa, 1981: 47-65 11. MILLAR WJ: Smoking Behaviour of Canadians (cat no H-39-66/1983 E), health promotion directorate, Dept of National Health and Welfare, Ottawa, 1981: 1-74 12. BRESLOW L: Control of cigarette smoking from a public policy perspective. Annu Rev Public Health 1982; 3: 129-151 13. STOLLEY PD: Lung cancer in women - five years later, situation worse. N Engl J Med 1983; 309: 428-429 14. Cigarette and Cigarette Tobacco Advertising and Promotion Code of the Canadian Tobacco Manufacturers' Council, Can Tobacco Manufacturers' Council, Montreal, 1976 15. Economic Impact of the Tobacco Industry in Canada 1979, Can Tobacco Manufacturers' Council, Montreal, 1979 16. Economic Impact of the Tobacco Industry in Canada 1982, Can Tobacco Manufacturers' Council, Montreal, 1983 17. Tobacco in Canada 1982, Can Tobacco Manufacturers' Council, Montreal, 1983 18. JACOBSON B: The Ladykillers. Why Women Smoke, Eden Pr, Montreal, 1983: 57 19. WHELAN EM, SHERIDEN MJ, MEISTER KA, MOSHER BA: Analysis of coverage of tobacco hazards in women's magazines. J Public Health Pol 1981; 2: 28-35 20. MARRA JM (ed): Readers' Guide to Periodical Literature: an Author and Subject Index, Bienniel Cumulation, vols 39-42, Wilson, New York, 1979-83 21. MORGAN PP: Toronto Department of Public Health plans community-wide "breakaway" from smoking. Can Med Assoc J 1984; 130: 358-359 For prescribing information see page

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