Tobacco Documents Online

i i i i i i i i i i 1 I i I I I TOBACCO SMOKING TABLE 2.10. Proportions and numbers of cases of oesophageal cancer avoidable among men in countries 1980, 1990 and 2000 if tobacco srnokin~ were eliminated Country and year Annual no. Incidence PAR%• per 100,000 of new eases Nordic countries, I980 541 4.9 59 Denmark 111 4.4 62 . Finland 107 4.6 66 Iceland 4 3.5 64 Norway 83 4. I 58 Sweden 236 5.7 55 Nordic countries, 1990 672 5.9 57 Denmark 191 7.5 58 Finland 128 5.3 59 Iceland 10 7.8 61 Norway 114 5.4 57 Sweden 229 5.4 54 Nordic countries, 2000 693 5.9 55 Denmark 194 7.5 58 Finland 103 4.2 59 Iceland 6 4.3 60 Norway 96 4.4 57 Sweden ° 294 6.7 51 the Nordic Avoidable number 325 70 70 3 50 130 380 110 75 5 65 125 385 115 60 4 55 150 Population attributable risk percent TABLE 2.11. Proportions and numbers of eases of oesophageal cancer avoidable among women countries in 1980, 1990 and 2000 if tobacco srnokin~ were eliminated Country and year Annual no. Incidence PAR%" per 100,000 of new cases Nordic countries, 1980 305 2.7 38 Denmark 68 2.6 46 Finland ~. 121 4.9 37 Iceland 2 1.8 53 Norway 26 1.3 32 Sweden 88 2.1 34 Nordic countries, 1990 301 2.6 44 Denmark 74 2.8 49 Finland 88 3.4 37 Iceland 4 3.2 53 Norway 40 1.9 42 Sweden 95 2.2 47 Nordic countries, 2000 332 2.7 44 Denmark 75 2.8 52 Finland 108 4.1 37 Iceland 6 4.3 54 Norway 44 2.0 48 Sweden 99 2.2 43 in the Nordic Avoidable number 115 30 45 1 10 30 125 35 30 2 15 45 145 40 40 3 20 40 • Population attributable risk percent ly 500 eases among men and 350 eases among women in 1990 (34-44). Relationship with tobacco smoking Tobacco smoking and alcohol consumption are known to be important risk factors for these turnout types, particularly when practised in combination (77, 78). Chewing of tobacco pro- ducts is also a risk factor (11). The risk esti- mates from the available studies (Fig. 2.5; 56, 57, 77-82), show a rise with the number of ciga- rettes smoked with relative risks of 1.7, 2.3, 3.7 19

DREYER et al. Relative risk 40: 2o! ........................ ~---+ ...... t ,V' ,-" 5; • -{- - - ..--:'- ; -'- 0 10 20 30 40 No. of cigarettes/day and 6.3 associated with daily smoking of 5, 10, 20 and 40 or more cigarettes. This corresponds to an excess relative risk of 0.13 per cigarette smoked per day. Former smokers have a relative risk of 2.0 and smokers of pipes and cigars only one of 3.5 (Table 2.4). The epidemiological characteristics of can- cers of the oral cavity and tongue are given in Tables 2.14 (men) and 2.15 (women). As seen for cancer of the pharynx, the crude rate among men increases while that of women is almost un- changed. Particularly high rates were registered in Danish and Norwegian men and in Danish women. About 50% of cancers of the oral cavity and tongue in men and 40% in women are 20 Fig. 2.4. Case-control studies: cigarette smok- ing and pharyngeal can- cer, adjusted for alcohol consumption. caused by smoking, which corresponds to an ex- pected annual total of about 500 cases around the year 2000. Pancreatic cancer (ICD-7: 157) Pancreatic cancer is moderately frequent on a worldwide basis and in the Nordic countries (32). In 1990, about 1400 cases were seen in men and 1700 in women (34-44). Relationship with tobacco smoking Tobacco smoking is the only environmental factor that has been consistently associated with an increased risk (22), and the risk appears to rise linearly with the number of cigarettes ! i I I I I I I I I I I I I I I I

TOBACCO SMOKING i I TABLE 2.12. Proportions and numbers of cases of pharyngeal cancer avoidable among men in the Nordic coun- tries in 1980, 1990 and 2000 if tobacco smokinf, were eliminated Country and year Annual no. Incidence PAR%• Avoidable of new cases per I00,000 number Nordic countries, 1980 270 2.4 57 150 Denmark 61 2.4 61 35 Finland 39 1".7 61 25 Iceland 3 2.6 63 2 Norway 35 1.7 56 20 Sweden 132 3.2 54 70 Nordic countries, 1990 347 3.0 54 190 Denmark 99 3.9 57 55 Finland 51 2.1 55 30 Iceland 1 0.8 61 1 Norway 53 2.5 55 30 Sweden 143 3.4 51 75 Nordic countries, 2000 456 3.9 52 235 Denmark 129 5.0 55 70 Finland 54 2.2 55 30 Iceland 1 0.7 57 1 Norway 83 3.8 54 45 Sweden ° 189 4.3 47 90 Population attributable risk percent TABLE 2.13. Proportions and numbers of eases of pharyngeal cancer avoidable among women in the Nordic countries in 1980, 1990 and 2000 i/tobacco smokin~ were eliminated Country and year Annual no. Incidence PAR%a of new cases per 100,000 Nordic countries, 1980 132 1.2 34 45 Denmark • 34 1.3 43 15 Finland 30 1.2 32 10 Iceland 2 1.8 49 1 Norway 21 1.0 28 5 Sweden 45 I.I 31 15 Nordic countries, 1990 124 1.1 40 50 Denmark 34 1.3 46 15 Finland 27 1.1 33 10 Iceland 0 0.0 - - Norway 16 0.7 38 5 Sweden 47 1.1 42 20 Nordic countries, 2000 121 1.0 41 50 Denmark 42 1.6 47 20 Finland 17 0.6 33 5 Iceland I 0.7 49 0 Norway 22 1.0 44 I0 Sweden 39 0.9 38 15 Avoidable number I I • Population attributablerisk percent smoked per day (Fig. 2.6; 2, 45, 46, 51, 83--91). Thus, by increasing the number of eighrettes smoked daily to 5, 10, 20 and 40 or more, the risk increases by 1.2-, 1.4-, 1.8- and 2.5-fold, re- speetively, over that of "never-smokers". This corresponds to an excess relative risk of 0.04 per cigarette smoked per day. Former smokers (2, 83) and smokers of pipes and cigars only (91, 92) do not have a detectable increase in risk (Table 2.4). 21

DREYER et al. • Fig. 2.5. Case-con- Relative risk trol studies: ciga- 40 r---'--------- ~ ~ rctte smoking and ~ | cancers of the oral ~ / cavity and tongue, [ | adjusted for alcohol :35 t ................................. ....[ consumption. 0 1 0 20 :30 40 No. of cigarettes/day Tables 2.16 (men) and 2.17 (women) give Cancers of the lower urinary tract (ICD-7: 181, the key figures for pancreatic cancer in the 180 partly) Nordic countries. The crude rate for women The,,. term "cancers of the lower urinary" increases between 1980 to 2000, but no clear tract includes both cancers and bemgn papil- trend is sccn for men. As the association with lomas of the urinary bladder, renal pelvis, cigarette smoking is weaker than that for ureter and urethra. Cancer of the bladder is cancers of the respiratory trac~, the PAR% for pancreatic cancer is about 17% in men and 10-12% in women, corresponding to an annual, expected number of 550 pancreatic cancers in men and women around the y~ar 2000. 22 relatively common, ranking eleventh on a glo- bal basis (32). Cancers of the lower urinary tract arc particularly common in the Nordic countries, with approximately 4150 new cases in men and 1550 in women in 1990 (34- I I

TOBACCO SMOKING TABLE 2.14. Proportions and numbers in the Nordic countries in Country and year Annual no. of new cases of cases of cancer of the oral cavity and tongue avoidable among men 1980, 1990 and 2000 if tobacco smoking were elimi hated Incidence PAR%~ • Avoidable per 100,000 number Nordic countries, 1980 388 3.5 57 220 Denmark 86 3.4 61 55 Finland 52 2.3 61 30 Iceland 3 2.6 63 2 Norway 83 4.1 56 45 Sweden 164 4.0 54 90 Nordic countries, 1990 449 3.9 54 245 Denmark 139 5.5 57 80 Finland 65 2.7 55 35 Iceland 6 4.7 61 4 Norway 86 4.1 55 45 Sweden 153 3.6 51 80 Nordic countries, 2000 611 5.2 52 315 Denmark 191 7.4 55 105 Finland 74 3.0 55 40 Iceland 4 2.8 57 2 Norway 130 5.9 54 70 Sweden ° 212 4.8 47 100 • Population attributable risk percent TABLE 2.15. Proportions and numbers of cases of cancer of the oral cavity and tongue avoidable among women in the Nordic countries in 1980, 1990 and 2000 if tobacco smokin$ were eliminated Country and year Annual no. Incidence PAR%• Avoidable of new cases per 100,000 number Nordic countries, 1980 268 2.3 34 90 Denmark • 70 2.7 43 30 Finland 48 1.9 32 15 Iceland 0 0.0 - - Norway 54 2.6 28 15 Sweden 96 2.3 31 30 Nordic countries, 1990 341 2.9 40 140 Denmark 85 3.3 46 40 Finland 72 2.8 33 25 Iceland 1 0.8 49 0 Norway 51 2.4 38 20 Sweden 132 3.0 42 55 Nordic countries, 2000 363 3.0 41 145 Denmark 108 4.1 47 50 Finland 50 1.9 33 15 Iceland 5 3.6 49 2 Norway 77 3.4 44 35 Sweden 123 2.7 38 45 • Population attributable risk percent Relationship with tobacco smoking The predominant risk factor for these can- cars is cigarette smoking, but industrial ex- posures also play an important role in de- veloped countries. In Africa and the Eastern Mediterranean, schistosomal infection is of particular importance (32). There is some vari- ation in the magnitude of the reported risk for moderate smokers in particular, as illustrated in Fig. 2.7 (2, 45, 46, 50-52, 93-101). AI- 23

DREYER et al. Relative risk 40~ Bouohardy et al (83) Car=lenten et =! (45) C, uzlck at al (~4) Doll et al {2) Engholm et al (46) Falk ~ at (85) F=rrow ~ al (86) MacMzhon ¢ zl (88) McLlughltn mal (51) Sl~e~m~ ¢ ~1 (82) ~Wynder = 11 (~) +Zheng = =L 1~3 (91) ~Our estimate Fig. 2.6. Cohort and case-control studies: cigarette smoking and pan- erratic cancer. 0 10 2O 3O 4O NO. of cigarrets/day though most of the studies cited do not in- clude papillomas of the lower urinary tract, the smoking habits of patients with these neo- plasms appear to be similar to those of pa- tients with invasive bladder tumours (102, 103). For equal levels of tobacco smoking, the relative risks are generally higher for cancers of the renal pelvis and ureter than for those of the urinary bladder (11). Overall, by increasing the number of cigarettes smoked per day to 5, lO, 20 and 40 or more, the risk for cancers in the lower urinary tract increases by 1.5-, two, thr~e and fivefold, respectively, over that of "never-smokers", corresponding to an excess 24 relative risk of 0.10 per cigarette smoked per day. Smoking of pipes and cigars only also in- creases the relative risk for bladder cancer (45, 103-104), but at lower levels, most likely around 1.5 (Table 2.4). The group of former smokers was allocated an average relative risk for cancers of the lower urinary tract of 1.5 (Table 2.4). The rates of cancers of the urinary tract have and will increase during the last decades of this century (Tables 2.18 and 2.19). Denmark has remarkably high incidence rates in both men and women, that in men are pre- dicted to exceed 50 new cases per 100,000 per ( [ I i I ! I I ! 0 0~, ! I I I I I

I l i l l l i I I I TOBACCO SMO~LINO TABLE 2.16. Proportions and numbers of cases of pancreatic cancer avoidable among men in the Nordic countries in 1980, 1990 and 2000 if tobacco smokin8 were eliminated Country and year Annual no. Incidence PAR%= Avoidable of new cases Per lO0,O00 number Nordic countries, 1980 1588 14.3 18 280 Denmark 407 16.1 17 70 Finland • 254 11.0 28 70 Iceland 15 13.0 19 3 Norway 268 13.2 17 45 Sweden 644 15.6 14 90 Nordic countries, 1990 1389 12.2 17 230 Denmark 311 12.3 16 50 Finland 280 11.6 20 55 Iceland 18 14.1 15 3 Norway 246 11.7 16 40 Sweden 534 12.6 15 80 Nordic countries, 2000 1814 15.4 17 315 Denmark 376 14.5 20 75 Finland 423 17.1 22 90 Iceland 18 12.8 20 4 Norway 307 14.0 17 50 Sweden ° 690 15.6 14 95 Population attributable risk percent TABLE 2.17. Proportions and numbers of cases of pancreatic cancer avoidable among women in countries in 1980, 1990 and 2000 if tobacco smoking were eliminated Country and year Annual no. Incidence PAR%= per 100,000 of new eases Nordic countries, 1980 1489 13.0 9 Denmark , 389 15.0 12 Finland 287 11.6 I0 Iceland 14 12.4 18 Norway 220 10.7 8 Sweden 579 13.8 7 Nordic countries, 1990 1670 14.2 13 Denmark 359 13.8 14 Finland 404 15.8 10 Iceland 13 10.2 16 Norway 267 12.5 12 Sweden 627 14.5 15 Nordic countries, 2000 2030 16.7 12 Denmark 417 15.7 18 Finland 464 17.7 9 Iceland 16 11.5 18 Norway 340 15.2 14 Sweden 793 17.5 10 the Nordic Avoidable number 135 45 30 3 15 40 215 50 40 2 30 95 245 75 40 3 45 80 Population" attributable risk p~rcent year before the year 2000. The low incidence rate in Finland may well re, fleet less reporting of benign and borderline papillomas of the bladder. In 1990, about 41% of the male cases and 32% of the female cases were attributed to tobacco smoking, corresponding to more than 2000 cancers of the lower urinary tract in the Nordic countries combined. More than 2,500 25

Relative risk 40! No. of cigarettes/day cases are expected to occur in 2000 due to smoking in these populations. Renal cancer (ICD-7:180 partly) Cancers of the renal parenchyma, mainly re- hal-cell carcinomas, show moderate geographic variation, but the incidence rates in Eskimo populations and in the Scandinavian countries are among the highest in the world (32). In the Nordic countries in 1990, about 1500 cases were recorded in men and 1000 in women (34-44). Relationship with tobacco smoking Tobacco smoking is a risk factor for renal can- cer, but occupational exposures may also play a 26 Fig. 2. 7. Cohort and case-control studies: cigarette smoking and lower urinary tract cancer. role (32). The previously reported dose- response curves for cigarette smoking and cancer of the kidney (2, 45, 46, 51, 52, 105-112; Fig. 2.8) all show a modest increase, with overall relative risks of 1.2, 1.3, 1.6 and 2.2 for smokers of 5, 10, 20 and 40 or more cigarettes per day, respectively, when compared with the rates in neversmokers. This corresponds to an excess relative risk of 0.03 per cigarette smoked per day. Smokers of pipes and cigars only and former smokers have no measurable increase in risk (Table 2.4). The crude rates of renal cancer in the Nordic countrics have increased slightly since 1980 and will apparently continue to increase in the years to come (Tables 2.20 and 2.21). The recorded rates [ ! ! [ 1 ! I [

TOBACCO SMOKING TABLE 2.18. Proportions and numbers of cases of lower urinary tract cancer avoidable among men countries in 1980, 1990 and 2000 if tobacco smokinf, were eliminated Country and year Annual no. Incidence PAR%• per 100,000 in the Nordic Avoidabl~ of now cases number Nordic countries, 1980 3329 30.0 42 1410 Denmark 1054 41.7 43 455 Finland 364 15.8 53 195 Iceland 27 23.5 46 15 Norway 637 31.5 42 270 Sweden 1247 30.3 38 475 Nordic countries, 1990' 4146 36.4 41 1695 Denmark 1204 47.5 41 490 Finland 576 23.9 45 260 Iceland 36 28.1 43 15 Norway 794 37.9 41 330 Sweden 1536 36.3 39 600 Nordic countries, 2000 5067 42.9 41 2060 Denmark 1409 54.5 43 610 Finland 735 29.7 46 340 Iceland 49 34.9 45 20 Norway 980 44.7 41 405 Sweden " 1894 42.9 36 685 • Population attributable ri/s, k percent TABLE 2.19. Proportions and numbers of cases of lower urinary tract cancer avoidable among women in the Nordic countries in 1980, 1990 and 2000 if tobacco smoking were eliminated Country and year Annual no. Incidence PAR%= Avoidable of nvw eases per 100,000 number Nordic countries, 1980 Denmark Finland Iceland Norway Sweden Nordic countries, 1990 1238 10.8 26 315 389 15.0 31 120 146 5.9 25 35 13 11.5 41 5 211 10.2 22 45 479 11.4 22 110 1534 13.0 32 495 451 17.3 34 155 232 9.1 25 60 10 7.9 39 4 258 12.0 29 75 583 13.5 34 200 1867 15.3 32 600 554 20.8 38 210 264 10.1 25 65 17 12.2 41 5 333 14.9 34 I 15 699 15.5 30 205 Denmark Finland Iceland Norway Sweden Nordic countries, 2000 Denmark Finland Iceland Norway Sweden Population attributable risk p~rc~nt are highest in Sweden. The PAR% for renal cancer and smoking is about 14% in men and 10% in women, which reflects the moderate relationship seen between cigarette smoking and this type of cancer. Owing to the relatively high incidence of renal cancer in the Nordic countries, however, an- nually almost 400 cases per year can be attributed to the current smoking habits of the popula- tions. For all the cancer sites described above the 27

DR.EYER et el, Relative risk 40~ 0 10 20 30 40 No. of cigarettes/day Benhamou et al (I05) Brownson et al (106) Carstensen et =I (45) Doll et ad (2) Engholm et all (48) Hlatt et =I (107) "~'McLaughlin et al McLaughlin et al (109) Musoat et =I (110) Weir et el (52) "'Wynder et el (111) et =1 (112) ~"Yu "I~" °ur Fig. 2.& Cohort and. case-contro] studies: cigarette smoking and renal cancer. ! I I I I I ! i ! I I ! i cause-effect relationship with tobacco smoking has been confirmed; however, for the following sites a causal relationship has only been suspected. Lip cancer (ICD-7: 140) Lip cancers are not common in most popula- tions, although high rates are seen in Canada and in latitudes near the equator. High risks are also observed among persons living in rural areas and those with outdoor occupations (32). In 1990, about 500 cases were registered among men in the Nordic countries and 100 among women (34-44). 28 Relationship with tobacco smoking Data from epidemiological studies are con- sistent in demonstrating a causal relationship between exposure to sunlight and cancers of the lip (32). The effect of tobacco smoking on the risk for lip cancer has been investigated in only one cohort study; no association was found (50). Most case-control studies (ll, ll3), how- ever, have reported an increased risk for lip can- cer among pipe smokers, while the association between cigarette smoking and lip cancer has been less consistent (1 l, 56, 114). In this review, the risk for lip cancer has been I I