Soft tissue sarcoma and tobacco use: data from a prospective cohort study of United States veterans

Trends in Overall Survival among Patients Treated for Sarcoma at a Large Tertiary Cancer Center between 1986 and 2014

Sarcomas are relatively rare malignancies accounting for about 1% of all cancer diagnoses. Studies on sarcomas comprising large cohorts covering extended time periods are lacking. Therefore, this study aimed to evaluate the impact of demographic, behavioral, and clinical characteristics on overall survival (OS) among individuals diagnosed with soft tissue sarcoma (STS) or bone sarcoma at the Moffitt Cancer Center between 1986 and 2014. Unadjusted and multivariable Cox proportional hazard regression (CPHR) models were constructed to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to evaluate associations between a range of demographic, behavioral, and clinical characteristics, and OS. Additionally, Kaplan-Meier survival curves, associated log-rank statistics, and adjusted CPHR models were generated by time periods based on the year of first contact (1986-1994, 1995-1999, 2000-2005, 2006-2010, 2011-2014) to evaluate for temporal differences in OS. Of the 2570 patients, 2037 were diagnosed with STS, whereas 533 were diagnosed with bone sarcoma. At the time of analysis, 50% of the population were alive. In multivariable analyses, we observed poorer survival for patients ≥ 40 years of age (HR = 1.54, 95% CI = 1.34-1.78), current smokers (HR = 1.18, 95% CI = 1.01-1.37), patients with metastasis (HR = 2.19, 95% CI = 1.95-2.47), and patients not receiving first-line surgery treatment (HR = 2.11, 95% CI = 1.82-2.45). We discovered limited improvements in OS over time among individuals diagnosed with STS or bone sarcomas with the exception of gastrointestinal stromal tumors (GIST), which showed a significant improvement in OS across time periods (p = 0.0034). Overall, we identified well-established characteristics associated with OS (e.g., metastasis) in addition to factors (e.g., smoking status) not previously reported to impact OS. Improvements in survival over time have been relatively modest, suggesting the need for improved therapeutic options, especially for those diagnosed with less frequent sarcomas.

Family cancer history and smoking habit associated with sarcoma in a Japanese population study

Sarcoma is a rare cancer, and little is known about the etiology, lifestyle epidemiology, and actual circumstances of treatment in hospitals in Japan. Understanding these issues is essential for the effective prevention and treatment of sarcoma. We therefore investigated the incidence of a personal and family cancer history in a total of 1320 sarcoma patients at the National Cancer Center Hospital. In addition, obesity, hypertension, dyslipidemia, diabetes mellitus, drinking, smoking, age and sex were compared in a descriptive study of 1159 of these sarcoma patients who were ≥ 20 years of age, and 7738 controls derived from the National Health and Nutrition Examination Survey in Japan. A total of 8% of sarcoma patients had a personal history of another cancer, and 30% of soft tissue sarcoma patients had a family cancer history in a first-degree relative (malignant peripheral nerve sheath tumor, 52%; leiomyosarcoma, 46%). A smoking habit was associated with the development of sarcoma (odds ratio [OR], 2.05; 95% confidence interval, 1.78-2.37; p < 0.01). According to the histology, the ORs for undifferentiated pleomorphic sarcoma (UPS) of bone, UPS of soft tissue, and liposarcoma were 5.71, 3.04, and 2.92, respectively. A family cancer history may be associated with certain soft tissue sarcomas, and a smoking habit was significantly associated with the development of sarcomas; however, further studies are necessary.

Descriptive epidemiology of soft tissue and bone sarcomas in Lebanon

OBJECTIVES

Most epidemiologic studies on soft tissue sarcomas (STS) and bone sarcomas (BS) are performed in western countries, with few in the Middle East and North Africa region. We describe the epidemiology of sarcomas in Lebanon using the medical records database at the American University of Beirut Medical Center (AUBMC).

METHODS

This single-center retrospective cohort study included patients with sarcomas registered in the database between 2015 and 2019. Their charts were reviewed for baseline characteristics, tumor biology and location, treatment modalities, recurrence, metastasis, and death.

RESULTS

The cohort included 234 patients with STS and 99 patients with BS. Most tumors were <10 cm in size. The most common subtypes were liposarcoma for STS and osteosarcoma for BS. The most common location of STS was the thigh. The most frequent sites of STS metastasis were the lungs. Histological subtype, smoking status, and tumor size and grade were significant for progression-free survival (PFS) in patients with STS. By multivariable analysis, smoking was significantly associated with poorer PFS in STS. For BS, only tumor grade was significant for PFS.

CONCLUSION

The epidemiology of sarcomas at AUBMC is similar to that previously reported. Smoking history was associated with poorer survival in patients with STS.

Risk Factors for Occurrence and Relapse of Soft Tissue Sarcoma

The diagnosis and prognostic outcome of STS pose a therapeutic challenge in an interdisciplinary setting. The treatment protocols are still discussed controversially. This systematic meta-analysis aimed to determine prognostic factors leading to the development and recurrence of STS. Eligible studies that investigated potential risk factors such as smoking, genetic dispositions, toxins, chronic inflammation as well as prognostic relapse factors including radiation, chemotherapy and margins of resection were identified. Data from 24 studies published between 1993 and 2019 that comprised 6452 patients were pooled. A statistically significant effect developing STS was found in overall studies stating a causality between risk factors and the development of STS (p < 0.01). Although subgroup analysis did not meet statistical significances, it revealed a greater magnitude with smoking (p = 0.23), genetic predisposition (p = 0.13) chronic inflammation, (p = 0.20), and toxins (p = 0.14). Secondly, pooled analyses demonstrated a higher risk of relapse for margin of resection (p = 0.78), chemotherapy (p = 0.20) and radiation (p = 0.16); after 3 years of follow-up. Therefore, we were able to identify risk and relapse prognostic factors for STS, helping to diagnose and treat this low incidental cancer properly.

Cigarette, cigar, and pipe smoking and the risk of head and neck cancers: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium

Cigar and pipe smoking are considered risk factors for head and neck cancers, but the magnitude of effect estimates for these products has been imprecisely estimated. By using pooled data from the International Head and Neck Cancer Epidemiology (INHANCE) Consortium (comprising 13,935 cases and 18,691 controls in 19 studies from 1981 to 2007), we applied hierarchical logistic regression to more precisely estimate odds ratios and 95% confidence intervals for cigarette, cigar, and pipe smoking separately, compared with reference groups of those who had never smoked each single product. Odds ratios for cigar and pipe smoking were stratified by ever cigarette smoking. We also considered effect estimates of smoking a single product exclusively versus never having smoked any product (reference group). Among never cigarette smokers, the odds ratio for ever cigar smoking was 2.54 (95% confidence interval (CI): 1.93, 3.34), and the odds ratio for ever pipe smoking was 2.08 (95% CI: 1.55, 2.81). These odds ratios increased with increasing frequency and duration of smoking (Ptrend ≤ 0.0001). Odds ratios for cigar and pipe smoking were not elevated among ever cigarette smokers. Head and neck cancer risk was elevated for those who reported exclusive cigar smoking (odds ratio = 3.49, 95% CI: 2.58, 4.73) or exclusive pipe smoking (odds ratio = 3.71, 95% CI: 2.59, 5.33). These results suggest that cigar and pipe smoking are independently associated with increased risk of head and neck cancers.

Soft-tissue sarcoma and pesticides exposure in men: results of a Canadian case-control study

OBJECTIVES

The objective was to investigate the putative associations of specific pesticides with soft-tissue sarcoma (STS).

METHODS

A Canadian population-based case-control study conducted in six provinces was used in this analysis. The study design consisted of two stages: a self-administered postal questionnaire and a telephone interview for those reporting pesticides exposure of 10 hours per year or more; and a 15% random sample of the remainder. Conditional logistic regression was used to fit the statistical models.

RESULTS

A positive history of cancer among first-degree relatives and exposure to aldrin and diazinon were statistically significant independent predictors of an increased risk for STS, whereas diagnosis of whopping cough lowered the risk of STS.

CONCLUSIONS

The incidence of STS was associated with specific insecticides after adjustment for other independent predictors.

Social inequalities, tobacco chewing, and cancer mortality in south India: a case-control analysis of 2,580 cancer deaths among non-smoking non-drinkers

OBJECTIVE

The objective of this work was to describe the relationships between educational level, tobacco chewing, and cancer mortality in south India, among middle-aged adults who never smoked tobacco or drank alcohol, to eliminate confounding by those habits.

METHODS

This case-control study was conducted in two areas of Tamil Nadu state. The cases studied were 2,580 lifelong non-smoking non-drinkers who died at age 35-69 years during 1995-1998, with interviews in 1998-2000 of a spouse, neighbour, or close associate, who retrospectively provided information on the education and chewing/other habits of the deceased. Underlying neoplastic cause of death was determined by verbal autopsy. The controls were 429,306 lifelong non-smoking non-drinkers aged 35-69 from these two study areas, interviewed during 1998-2001.

RESULTS

Among the controls, prevalence of current tobacco chewing was much higher in those with less education, irrespective of sex, urban/rural residence, or birth year. Compared with never chewers, ever chewers had fivefold higher mortality from mouth cancer (odds ratio 4.9, 95% confidence interval 3.5-6.8), and 1.5 to twofold higher mortality from cancers of the pharynx/larynx/oesophagus combined, stomach, and cervix. Each of these cancers had a strong, independent, inverse association with educational level.

CONCLUSION

This study supports a substantial body of evidence that tobacco chewing can cause mouth cancer, and adds to evidence that chewing may increase the risk of cancer at other sites. The analysis suggests a possible link with cervical cancer, but this could have been because of residual confounding by social factors. Avoidance of tobacco chewing would avert many cancer deaths in south India, especially for people who have received relatively little formal education.

Cigarette smoking as a cause of cancers other than lung cancer: an exploratory study using the Surveillance, Epidemiology, and End Results Program

BACKGROUND

Cigarette smoking is causally related to several cancers, particularly lung cancer, yet for some cancers there are inconsistent associations. This study investigates the association of smoking with other cancers by correlating them with the regional incidence rates for lung cancer, which was used as a proxy for cigarette smoking. This ecologic approach relating cigarette smoking to cancer using a large database avoids the limitations and bias present in case-control and cohort studies.

METHODS

Based on the assumption that regions with a high rate of lung cancer also have a high rate of cigarette smoking, our original hypothesis is that these high-intensity regions will also have high rates of other cancers if they are associated with cigarette smoking. Linear regression and correlation analysis of regional incidence rates for lung cancer, obtained from the Surveillance, Epidemiology, and End Results (SEER) Program, were plotted with incidence rates of other cancers to determine the association between lung cancer and the other cancers.

RESULTS

Cancers that have a strong correlation with cigarette smoking in the literature also demonstrate a strong correlation with lung cancer. These cancers included urinary bladder, laryngeal, esophageal, colorectal, and kidney cancer. A number of cancers showed a weak association with cigarette smoking, such as pancreatic and liver cancer. Other cancers showed no correlation, such as ovarian and prostate cancer.

CONCLUSIONS

Cancers that respectively showed a strong or absent correlation with lung cancer in the SEER Program were similarly strongly or weakly correlated with cigarette smoking in the literature. Cancers with borderline correlations show ambiguous results or confounding variables in the literature.

Systematic review of the relation between smokeless tobacco and cancer in Europe and North America

BACKGROUND

Interest is rising in smokeless tobacco as a safer alternative to smoking, but published reviews on smokeless tobacco and cancer are limited. We review North American and European studies and compare effects of smokeless tobacco and smoking.

METHODS

We obtained papers from MEDLINE searches, published reviews and secondary references describing epidemiological cohort and case-control studies relating any form of cancer to smokeless tobacco use. For each study, details were abstracted on design, smokeless tobacco exposure, cancers studied, analysis methods and adjustment for smoking and other factors. For each cancer, relative risks or odds ratios with 95% confidence intervals were tabulated. Overall, and also for USA and Scandinavia separately, meta-analyses were conducted using all available estimates, smoking-adjusted estimates, or estimates for never smokers. For seven cancers, smoking-attributable deaths in US men in 2005 were compared with deaths attributable to introducing smokeless tobacco into a population of never-smoking men.

RESULTS

Eighty-nine studies were identified; 62 US and 18 Scandinavian. Forty-six (52%) controlled for smoking. Random-effects meta-analysis estimates for most sites showed little association. Smoking-adjusted estimates were only significant for oropharyngeal cancer (1.36, CI 1.04-1.77, n = 19) and prostate cancer (1.29, 1.07-1.55, n = 4). The oropharyngeal association disappeared for estimates published since 1990 (1.00, 0.83-1.20, n = 14), for Scandinavia (0.97, 0.68-1.37, n = 7), and for alcohol-adjusted estimates (1.07, 0.84-1.37, n = 10). Any effect of current US products or Scandinavian snuff seems very limited. The prostate cancer data are inadequate for a clear conclusion.Some meta-analyses suggest a possible effect for oesophagus, pancreas, larynx and kidney cancer, but other cancers show no effect of smokeless tobacco. Any possible effects are not evident in Scandinavia. Of 142,205 smoking-related male US cancer deaths in 2005, 104,737 are smoking-attributable. Smokeless tobacco-attributable deaths would be 1,102 (1.1%) if as many used smokeless tobacco as had smoked, and 2,081 (2.0%) if everyone used smokeless tobacco.

CONCLUSION

An increased risk of oropharyngeal cancer is evident most clearly for past smokeless tobacco use in the USA, but not for Scandinavian snuff. Effects of smokeless tobacco use on other cancers are not clearly demonstrated. Risk from modern products is much less than for smoking.

Meta-analysis of the relation between European and American smokeless tobacco and oral cancer

BACKGROUND

Smokeless tobacco is often referred to as a major contributor to oral cancer. In some regions, especially Southeast Asia, the risk is difficult to quantify due to the variety of products, compositions (including non-tobacco ingredients) and usage practices involved. In Western populations, the evidence of an increased risk in smokeless tobacco users seems unclear, previous reviews having reached somewhat differing conclusions. We report a detailed quantitative review of the evidence in American and European smokeless tobacco users, and compare our findings with previous reviews and meta-analyses.

METHODS

Following literature review a meta-analysis was conducted of 32 epidemiological studies published between 1920 and 2005 including tests for homogeneity and publication bias.

RESULTS

Based on 38 heterogeneous study-specific estimates of the odds ratio or relative risk for smokeless tobacco use, the random-effects estimate was 1.87 (95% confidence interval 1.40-2.48). The increase was mainly evident in studies conducted before 1980. No increase was seen in studies in Scandinavia. Restricting attention to the seven estimates adjusted for smoking and alcohol eliminated both heterogeneity and excess risk (1.02; 0.82-1.28). Estimates also varied by sex (higher in females) and by study design (higher in case-control studies with hospital controls) but more clearly in studies where estimates were unadjusted, even for age. The pattern of estimates suggests some publication bias. Based on limited data specific to never smokers, the random-effects estimate was 1.94 (0.88-4.28), the eight individual estimates being heterogeneous and based on few exposed cases.

CONCLUSION

Smokeless tobacco, as used in America or Europe, carries at most a minor increased risk of oral cancer. However, elevated risks in specific populations or from specific products cannot definitely be excluded.

Evaluation of Carcinogen Exposure in People Who Used "Reduced Exposure" Tobacco Products

BACKGROUND

Although tobacco products with reportedly reduced carcinogen content are being marketed, carcinogen uptake in people who use these products has not been assessed systematically.

METHODS

Between June 2001 and November 2002, 54 users of smokeless tobacco and 51 cigarette smokers were randomly assigned to one of two groups. One used test products (Swedish snus for users of smokeless tobacco or OMNI cigarettes for smokers), while the other quit and used medicinal nicotine (the nicotine patch). All participants were assessed for urinary levels of total NNAL [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronide], metabolites of the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone. Smokers were also assessed for levels of 1-hydroxypyrene (1-HOP), a biomarker of polycyclic aromatic hydrocarbon uptake. Assessments were made weekly during 2 weeks of baseline normal tobacco use and 4 weeks of treatment. Statistical tests were two-sided.

RESULTS

Primary data analyses were conducted on 41 users of smokeless tobacco and 38 cigarette smokers who met the inclusion criteria. Total NNAL levels were statistically significantly lower in users of smokeless tobacco after they switched to snus or to nicotine patch (P<.001 for both groups) than they were before the switch, although the overall mean total NNAL level among subjects who used the nicotine patch was statistically significantly lower than that among those who used snus (mean = 1.2 and 2.0 pmol of NNAL/mg of creatinine, respectively; mean difference = 0.9 pmol of NNAL/mg of creatinine, 95% confidence interval [CI] = 0.2 to 1.5; P =.008). Compared with baseline levels, total NNAL levels (P =.003), but not 1-HOP levels, were statistically significantly reduced in cigarette smokers who switched to the OMNI cigarette, although both total NNAL levels and 1-HOP levels were statistically significantly reduced in smokers who switched to the nicotine patch (P<.001 for both). The overall mean total NNAL levels among smokers who used the nicotine patch was statistically significantly lower than that among smokers who used the OMNI cigarette (mean = 1.2 and 1.9 pmol of NNAL/mg of creatinine, respectively; mean difference = 0.6 pmol of NNAL/mg of creatinine, 95% CI = 0.1 to 1.1; P =.022).

CONCLUSION

Switching to reduced-exposure tobacco products or medicinal nicotine can decrease levels of tobacco-associated carcinogens, with greater reductions being observed with medicinal nicotine. Medicinal nicotine is a safer alternative than modified tobacco products.

Smokeless tobacco use: harm reduction or induction approach?

BACKGROUND

Smokeless tobacco (ST) substitution for cigarettes as a method to reduce harm has been actively debated. Use of ST as a smoking cessation method or as a means to reduce cigarettes has been proposed. The impact of using ST in these ways is relatively unknown.

METHODS

A review of the different issues and studies related to using smokeless tobacco as a method to reduce tobacco toxin exposure and harm is presented.

RESULTS

The toxicity of the product itself varies by brand of ST and across countries. Of the existing studies, comparisons of consequences between cigarettes and ST show that cigarette smoking produces more negative health effects, is likely to have a higher addiction potential and more severe withdrawal, and leads to a higher rate of relapse than ST use. On the other hand, ST use facilitates the use of cigarettes, which is a deadly tobacco product. Additionally, ST is not a harmless product, and a less harmful product, medicinal nicotine, is available as an effective treatment approach. Furthermore, ST products are not under the same regulatory scrutiny as medicinal nicotine products.

CONCLUSIONS

Considerably more research and product regulation is necessary prior to considering smokeless tobacco as a harm reduction method.

Disparities between public health educational materials and the scientific evidence that smokeless tobacco use causes cancer

BACKGROUND AND METHODS

We reviewed 4 dozen health education brochures on the dangers of smokeless tobacco (ST) use, printed between 1981 and 2001 and available to the public in 2002. Collectively, these brochures state that ST use causes oral leukoplakia, other oral conditions, and cancers of the oral cavity, larynx, pharynx, esophagus, stomach, pancreas, lung, breast, prostate, bladder, and kidney. We then reviewed the scientific literature to determine whether these claims were substantiated.

RESULTS

Only for oral leukoplakia and several oral conditions is the evidence persuasive for causation by ST. The evidence that ST causes oral cancer is very suggestive, whereas the evidence for causation of other cancers is either absent or contradictory.

CONCLUSIONS

Communication of the health risks of using ST must be done accurately and should be data based. Broadening the message to include additional diseases for which the evidence is inadequate could cause the message about true risks, as well as the messenger, to be discounted.

Sarcomas of the head and neck

With the exception of pediatric RMS, soft tissue sarcomas only rarely arise in the head and neck region. Soft tissue sarcomas include a diverse array of histologic types because of the variety of mesenchymal tissues from which they originate. The combination of infrequent occurrence, varied pathologic features, and the many potential sites of presentation makes these tumors a challenge for the head and neck oncologist and underscore the need for review by a pathologist experienced with soft tissue tumors. Classification schemes that group sarcomas according to grade have been helpful in providing prognostic information. Although local control of the primary tumor is critical to successful treatment of both high- and low-grade lesions, the high rate of distant metastases in high-grade tumors supports the role of combined modality therapy. Compared with other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumors arising in sites not amenable to resection. Exceptions to this principle include RMSs of the orbit, paranasal sinuses, and masticator space in children; these are usually treated with radiotherapy and combined multiagent chemotherapy, thereby avoiding the functional and cosmetic impact of surgery. Also, extensive angiosarcomas of the scalp should be treated with multimodality therapy combining surgery and wide-field radiation therapy in an attempt to achieve local control. Adjuvant radiotherapy is generally recommended for high-grade sarcomas, large tumors, close or positive surgical margins, and certain histologic variants. Systemic chemotherapy is recommended for those tumors with a significant risk of distant metastases. Increasingly, neoadjuvant chemotherapy is being used to determine responsiveness to chemotherapy, which can help physicians select patients who may benefit from systemic postoperative therapy. Traditional predictors of treatment failure for soft tissue sarcomas include larger tumor size, high-grade histology, and positive surgical margins. The advent of more advanced reconstructive techniques, including free tissue transfer, has made more aggressive surgical resection of these tumors possible. Nevertheless, a considerable number of ancillary support staff are critical to the patient's postoperative rehabilitation and eventual return to a satisfactory level of function and quality of life. In the future, the discovery of the molecular pathogenesis of specific tumor types, such as the cytogenetic findings in synovial sarcoma, will improve physicians' prognostic abilities and selection of patients who are most likely to benefit from emerging adjuvant therapies.

Tobacco use and cancer causation: association by tumour type

In the second part of our review we describe the association between tobacco use and risk of specific cancer types. There is evidence for an established association of tobacco use with cancer of the lung and larynx, head and neck, bladder, oesophagus, pancreas, stomach and kidney. In contrast, endometrial cancer is less common in women who smoke cigarettes. There are some data suggesting that tobacco use increases the risk for myeloid leukaemia, squamous cell sinonasal cancer, liver cancer, cervical cancer, colorectal cancer after an extended latency, childhood cancers and cancer of the gall bladder, adrenal gland and small intestine. Other forms of cancer, including breast, ovarian and prostate cancer, are unlikely to be linked to tobacco use.

Smokeless tobacco use and cancer of the upper respiratory tract

The most recent epidemiologic review of the cancer risks associated with smokeless tobacco use appeared in 1986, when 10 studies were available. This review describes 21 published studies, 20 of which are of the case-control type. We characterize each study according to the specific anatomic sites and according to the type of smokeless tobacco products for which it provides relative risks of cancer. The use of moist snuff and chewing tobacco imposes minimal risks for cancers of the oral cavity and other upper respiratory sites, with relative risks ranging from 0.6 to 1.7. The use of dry snuff imposes higher risks, ranging from 4 to 13, and the risks from smokeless tobacco, unspecified as to type, are intermediate, from 1.5 to 2.8. The strengths and limitations of the studies and implications for future research are discussed.

Cancer, cigarette smoking and premature death in Europe: a review including the Recommendations of European Cancer Experts Consensus Meeting, Helsinki, October 1996

Cigarette smoking has been clearly and unambiguously identified as a direct cause of cancers of the oral cavity, oesophagus, stomach, pancreas, larynx, lung, bladder, kidney and leukaemia, especially acute myeloid leukaemia. Additionally, cigarette smoking is a direct cause of ischaemic heart disease (the commonest cause of death in western countries), respiratory heart disease, aortic aneurysm, chronic obstructive lung disease, stroke, pneumonia and cirrhosis and cancer of the liver. Cigarette smoking can kill in 24 different ways and, although smoking protects against several fatal and non-fatal conditions, the adverse effect of smoking on health is largely negative. In developed countries as a whole, tobacco is responsible for 24% of all male deaths and 7% of all female deaths: these figures rise to over 40% in men in some countries of central and eastern Europe and to 17% in women in the United States. The average loss of life of smokers is 8 years. Among United Kingdom doctors followed for 40 years, overall death rates in middle age were about three times higher among doctors who smoked cigarettes as among doctors who had never smoked regularly. About half of all regular cigarette smokers will eventually be killed by their habit. The important information is that it is never too late to stop smoking: among United Kingdom doctors who stopped smoking, even in middle age, there was a substantial improvement in life expectancy. World-wide, smoking is killing three million people each year and this figure is increasing. In most countries the worst is yet to come, since by the time the young smokers of today reach middle or old age there will be about 10 million deaths/year from tobacco. Approximately 500 million individuals alive today can expect to be killed by tobacco, 250 million of these deaths will occur in middle age. Tobacco is already the biggest cause of adult death in developed countries. Over the next few decades tobacco could well become the biggest cause of adult death in the world. For men in developed countries, the full effects of smoking can already be seen. Tobacco now causes one-third of all male deaths in middle age (plus one fifth in old age). Tobacco is a cause of about half of all male cancer deaths in middle age (plus one-third in old age). Of those who start smoking in their teenage years and keep on smoking, about half will be killed by tobacco. Half of these deaths will be in middle age (35-69) and each will lose an average of 20-25 years of non-smoker life expectancy. In non-smokers in many countries, cancer mortality is decreasing slowly and total mortality rapidly. The war against cancer is being won slowly: the effects of cigarette smoking are holding back this victory. Lung cancer now kills more women in the United States each year than breast cancer. For women in developed countries, the peak of the tobacco epidemic has not yet arrived. Tobacco now causes almost one-third of all deaths in women in middle age in the United States. Although it has only 5% of the world's female population, the United States has 50% of the world's deaths from smoking in women. Tobacco smoking is a major cause of premature death. Throughout Europe, in 1990 tobacco smoking caused three quarters of a million deaths in middle age (between 35 and 69). In the Member States of the European Union in 1990 there were over one quarter of a million deaths in middle age directly caused by tobacco smoking: there were 219700 in men and 31900 in women. There were many more deaths caused by tobacco at older ages. In countries of central and eastern Europe, including the former USSR, there were 441200 deaths in middle age in men and 42100 deaths in women. There is a need for urgent action to help contain this important and unnecessary loss of life. In formulating Recommendations, the European Cancer Experts Consensus Committee recognised that Tobacco Control depends on various parts of society and not only on the individual.

Sarcomas and other malignancies of soft tissue, retroperitoneum, peritoneum, pleura, heart, mediastinum, and spleen

BACKGROUND

Malignant neoplasms of the structural tissues, consisting mostly of soft tissue sarcomas, are morphologically diverse and rarely treated for epidemiologic purposes as individual entities. Our understanding to date of the pattern of occurrence of sarcomas is based largely on reports of limited individual clinic experience or case-control studies, each driven by a single hypothesis, and there have been virtually no descriptions according to specific morphologic type.

METHODS

The accumulated coverage of the SEER populations offers an opportunity to correct this deficit. Each of the diagnoses has been reported and coded using a single set of rules and described in relation to the population at risk in terms of age, sex, race, calendar period, anatomic location, and outcome. In addition, each morphologic type has been compared with each of the others with respect to the pattern of occurrence and survival.

RESULTS

For most of the individual morphologic entities, the pattern of occurrence is specific and unlike other patterns. Differences according to anatomic site, age, sex, race, and period-specific survival were found. Partly because of changes in diagnostic criteria over the years, differences in secular trend, other than that for Kaposi's sarcoma, could not be verified. Although some types of sarcoma may have important genetic determinants, there is evidence of environmental causation in others; for some varieties both genetic and environmental factors may operate. There is no evidence of improvements in survival.

CONCLUSIONS

The most likely basis for the observed patterns are morphology-specific differences in etiology and growth phase. Each of the entities should be considered etiologically distinct and should be studied individually whenever possible.

Planning a spit tobacco cessation intervention: identification of beliefs associated with addiction

We examine the relationship between beliefs regarding spit tobacco (ST) use and addiction among 473 male college athletes who currently use ST. Beliefs were assessed using methods prescribed by the Theory of Reasoned Action. Independent associations between beliefs and addiction, defined by self-reported amount of ST used per week, were found via multivariate polychotomous regression modeling. We found that with increasing addiction level, athletes were significantly more likely to believe that "ST helps me relax," "ST keeps me alert," "ST tastes good," and "ST is addicting." All athletes believed that clinicians, parents, and girlfriends do not approve of their ST use, but that male peers, coaches, and professional athletes are fairly indifferent about it. To increase quit rates, highly addicted ST users may require an intensive cessation program including nicotine replacement to overcome symptoms of withdrawal, oral substitutes for the enjoyable taste of ST, and the support of male peers and athletes who influence their social norms.