The smoking epidemic and lung cancer in the EU Carlo La Vecchia

Lung cancer trends in the EU Male lung cancer mortality rates have peaked in 1988 in the European Union (EU).

Trends in mortality from major cancer sites in the EU, men, 1980-2004. 3

Male lung cancer in the EU Male lung cancer: appreciable fall (over 20%) from the peak rate (55.4/100,000) in 1988 to 43.1 in 2004.

Male lung cancer in the EU 35-64 All ages

Trends in mortality from major cancer sites in the EU, women, 1980-2004. 6

Female lung cancer in the EU 20-44 35-64 All ages (Bosetti et al., 2005)

Male/female lung cancer sex ratios in the EU

Female lung cancer in the EU Lung is now the second leading cause of cancer mortality in women after breast and before colorectum. Female lung cancer rates are however still 50% lower than breast cancer ones, and 70% lower than US female lung cancer mortality.

Female lung cancer in the EU In most EU countries, the lower extent of recent increases compared with those of the past, and the more favorable trends in young women, suggest that female lung cancer mortality rates will not reach the high levels observed in the USA. Effective interventions to control and reduce tobacco smoking in women should be implemented to avoid a major lung cancer epidemic in European women.

Lung cancer in women 20-44 years

LUNG CANCER IN YOUNG WOMEN Since recent trends in the young give relevant information to the likely future trends in middle age, the female lung cancer epidemic is likely to expand in southern Europe from the current rates of 5.0/100,000 in Spain and 7.7 in France to approach 20/100,000 within the next two to three decades. Urgent interventions for smoking cessation in women are therefore required.

Doll, Peto et al British Med J. 2004; 328: 1519 Smoking & death in male British doctors: 50-year results 50-year prospective study – ask in 1951, & periodically thereafter (1957, 1966,1971, 1978, 1991,2001), what men smoked. Monitor for 50 years (1951-2001) the mortality of never-smokers & of continuing cigarette smokers (&, after they quit, ex-cigarette smokers). Doll, Peto et al British Med J. 2004; 328: 1519

Cumulative risk at UK male 1990 rates BMJ 2000; 321:323−9

Three main messages for the individual smoker: Risk is BIG: half are killed 1/6 die of lung cancer 1/4 are killed in MIDDLE age (35-69), losing many years STOPPING smoking works

Effects of cessation at various ages On average, for men born 1900-1930, cigarette smokers lost about 10 years. But, cessation at ages 60, 50, 40 or 30 gained about 3, 6, 9 or the full 10 years

Effects of cessation at various ages On average, for men born 1900-1930, cigarette smokers lost about 10 years. But, cessation at ages 60, 50, 40 or 30 gained about 3, 6, 9 or the full 10 years

UK, 1950-2000: mortality trends in middle age (35-69)

UK cancer mortality trends in middle age (35-69), from 1950 to 2000

France, age 40-44: Concordance between trends in cumulative cigarette consumption and in lung cancer (source: Catherine Hill, INSERM)

DELAY of tobacco hazards Nationwide delay of several decades between main increase in cigarette smoking by young adults and main increase in tobacco deaths: Main hazards are from cigarette smoking that starts in early adult life, and does not stop Age at risk of death from tobacco Delay (since young adults started) until main hazard at this age 35-39 ~20 y 55-59 ~40 y 75-79 ~60 y

Example of long delay: USA Main increase before 1950 in cigarette use by young adults (male, then female) Main increase after 1950 in tobacco deaths (male, then female) % of all US deaths at ages 35-69 attributed to tobacco 1950 12% 1990 33%

Chinese cigarette increase 40 years after US increase US adults,1910-1950 China (men),1950-1990 Year Cigarettes per day 1910 1 1952 1930 4 1972 1950 10 1992 Delayed hazard: proportion of all deaths at ages 35-69 due to tobacco US: all adults China (men only) 12% 1990 33% 2030 ~33%

Chinese cigarette increase 40 years after US increase China (men),1950-1990 Year Cigarettes per day 1910 1 1952 1930 4 1972 1950 10 1992 Delayed hazard: proportion of all deaths at ages 35-69 due to tobacco US: all adults China: men women 12% 1990 3% 33% 2030 ~33% 1%

World tobacco deaths, if current smoking patterns continue 2000-2025 ~150M 2025-2050 ~300M 2050-2100 >500M TOTAL for the 21st century ~1000M (1 billion) Compare with 20th century total ~100M (0.1 billion)

Prevention of a substantial proportion of the 450 million tobacco deaths before 2050 requires adult cessation Continuing to reduce the % children starting smoking prevents many deaths, but its main effect will be on mortality in ~2050 & later