From success to sustained action: Tobacco control must remain a priority

Abstract

In this issue, Islami and colleagues present remarkable data estimating that 3.9 million lung cancer deaths have been averted over the past 5 decades, along with a compelling analysis revealing 75 person-years of life gained from avoided premature lung cancer deaths—both of which can be attributed to a major public health victory in tobacco control.¹ The consequence of the estimated number of averted lung cancer deaths on overall cancer mortality reductions was also analyzed. Findings revealed that these prevented deaths accounted for more than one half (51%) of the estimated declines in overall cancer deaths. With the inclusion of person-years of life gained, these results extend prior research and further highlight the striking contributions of tobacco control in reducing the overall cancer burden.

The decline in lung cancer mortality rates parallels the reduction in smoking that began after the landmark US Surgeon General's report in 1964 that confirmed the health risks of smoking and, most importantly, the causal relationship between smoking and lung cancer.² Since then, the adult smoking prevalence has dropped from an all-time high of 52.0% among men and 34.1% among women to 13.1% and 10.1%, respectively.^{3, 4} Although the authors' analyses focused solely on reductions in smoking prevalence among adults, it is critical to acknowledge the profound implications of recent data on youth smoking trends and their potential to vastly reduce the future burden of lung cancer. One of most recent, greatest public health triumphs—which has received notably little attention—is the unprecedented shift in youth smoking to the lowest levels ever reported. In 1997, over one third of high school students were smoking, whereas, today, only 1.7% report smoking, making combustible cigarette use virtually nonexistent among youth.⁵ The long-term effect of this decline should result in further dramatic reductions in lung cancer mortality and increasing person-years of life saved.

Just as the decline in lung cancer deaths is attributed by the authors to a reduction in combustible cigarette smoking, the decrease in smoking prevalence can be attributed primarily to changes in tobacco-control policies and regulations.³ As noted by the authors, the most significant decline in smoking occurred because of cigarette price increases, taxation, and the implementation of clear indoor air laws. Other key factors that contribute to a comprehensive approach to tobacco control include mass media campaigns, restrictions on marketing and advertising, access to quitting resources (e.g., tobacco quitlines available in all states at no cost), and evidence-based interventions for quitting smoking, including counseling and US Food and Drug Administration (FDA)-approved medications.³

Beyond established tobacco-control policies, pending regulations, if implemented, could yield equal or even greater influence on smoking prevalence and, ultimately, on lung cancer burden. For instance, recently, the FDA proposed limiting the maximum level of nicotine permitted in tobacco filler to 0.70 mg per gram of tobacco.⁶ Although nicotine does not cause cancer, it is the primary addictive component in tobacco products. Therefore, a reduction in the nicotine is being proposed to make cigarettes minimally addictive or nonaddictive. The recommended reduction in nicotine could have population-level benefits by preventing those who begin using cigarettes from becoming addicted. Based on FDA modeling estimates, if this product standard were implemented, by the year 2100, 48 million individuals would not become addicted to cigarettes, resulting in greater than 4 million deaths averted by the end of the century.⁶ Despite potential public health gains, the inevitable tobacco industry challenges and the current environment make it unlikely that this rule will be implemented soon.⁷

According to the recent Surgeon General's report, Eliminating Tobacco-Related Disease and Death: Addressing Disparities, policies restricting the availability of menthol cigarettes are essential to reduce the smoking prevalence among Black populations, which have been targeted by the tobacco industry and suffer disproportionate adverse health outcomes.⁸ This potentially effective regulatory measure has received much attention since the FDA's stated intention to issue a product standard banning menthol (i.e., prohibiting menthol as a characterizing flavor in cigarettes) in 2021, with several subsequent missed deadlines for issuance of the final rule. Implementation of a menthol ban has the potential to address tobacco-related disparities because most Black smokers use menthol cigarettes, which are associated with greater difficulty in quitting and dependence. By using US and international (e.g., Canada, European Union) data, recent meta-analyses provide evidence that menthol bans promote smoking cessation.⁹ However, this FDA proposal has similarly stalled.

Notably, given racial differences in smoking patterns, Islami and colleagues' analyses comparing Black and White populations provide important insights. Their results demonstrated a difference in the absolute estimated number of averted lung cancer deaths between White and Black populations (3.2 million vs. 527,000) as well as the proportion of all averted cancer deaths (53.6% vs. 40.0%, respectively). Lacking in their analysis because of limitations in the available cancer mortality data were comparisons across other racial and ethnic groups, such as Hispanics and American Indians/Alaskan Natives, who also exhibit different patterns of smoking. This is particularly critical because racial and ethnic disparities are clearly evident for lung cancer, with Black and Latino individuals 15% and 17% less likely to be diagnosed early with localized lung cancer, respectively.¹⁰ Black individuals are also less likely to undergo surgery for lung cancer and less likely to survive for 5 years compared with non-White Hispanic individuals.¹⁰ Thus efforts to reduce inequities in lung cancer burden must also consider early detection strategies.

As noted by Islami et al., lung cancer screening (LCS) remains markedly underused; thus we have not yet been able to realize a measurable decrease in lung cancer mortality that can be attributed to early detection.¹ Data from the American Lung Association's, State of Lung Cancer 2024 report demonstrates only a modest national increase in survival rates over the past 5 years of 2.4% (from 26% to 28.4%).¹⁰ It is striking that, despite the 2021 expansion of eligibility criteria by the US Preventative Services Task Force, which greatly expanded the number of LCS-eligible individuals by lowering the number of pack-years and the eligibility age, only 16.0% of eligible individuals were screened, with rates varying across states (from 8.6% to 28.6%).¹¹ In 2024, Kratzner and colleagues reported a higher incidence of localized disease among states with the highest LCS rates.¹² Ideally, as noted in the recent American Cancer Society guideline update, to achieve maximum impact, smoking-cessation interventions must be combined with LCS using low-dose computed tomography.^{13, 14} Multiple studies have been undertaken to evaluate LCS as a teachable moment for delivering various smoking-cessation interventions.¹⁵ Recent research has demonstrated short-term cessation efficacy with a comprehensive standard of care comprising intensive telephone counseling and nicotine replacement within the context of LCS; however, no intervention effect was revealed for the tested gain-framed intervention approach, highlighting the need for strategies for sustaining long-term abstinence.¹⁶ Future analyses will be essential to evaluate greater earlier stage lung cancer diagnosis with the expectation of increased LCS uptake and joint LCS and efficacious cessation interventions.

Another noteworthy consideration for future analyses is the rapidly changing tobacco landscape. As nicotine consumption transitions from combustible to noncombustible delivery systems, the effect of this shift on lung cancer deaths must be monitored. Noncombustible nicotine products include electronic nicotine delivery systems (electronic cigarettes; e-cigarettes) as well as smokeless tobacco and nicotine products, such as snus and nicotine pouches. Although the use of nicotine is not without risks, and the very long-term health consequences are not fully known, e-cigarettes are significantly less harmful than traditional cigarettes because of the lack of combustion and reduced exposure to toxicants.¹⁷ For this reason, multiple leaders in the tobacco field have called for a careful examination of e-cigarettes that balances risks for youth and benefits for adult smokers.¹⁸

In addition to examining lung cancer mortality, it is imperative to address morbidity by examining methods for improving overall health and quality of life among individuals already diagnosed with cancer. Continued smoking among patients with cancer leads to increased risk of cancer-specific mortality, reduced treatment efficacy, increased risk of second primary cancers, and cancer recurrence.¹⁹ Thus efforts are also needed to support smoking cessation among patients with cancer to reduce cancer morbidity and mortality. Future research is needed into the potential benefits of completely transitioning to noncombustible tobacco products like e-cigarettes for those unable to quit with FDA-approved medications, particularly given their superior efficacy over nicotine-replacement therapy.²⁰

Despite substantial gains in averted lung cancer deaths because of reductions in smoking, which certainly are worthy of celebration, smoking remains the chief preventable cause of cancer. Importantly, future research will need to keep pace with and evaluate the outcomes of changes occurring in multiple areas, such as tobacco policy and regulations, emerging tobacco products, changing patterns of tobacco product use among both youth and adults, and improvements in early detection through LCS on lung cancer rates. There is also a critical need to examine the potential for differential effects of these changes on vulnerable populations. Future progress will require a steadfast commitment to tobacco control, including equal access to evidence-based smoking-cessation interventions, to continue to reduce cancer burden.