Lung cancer statistics, 2023

Despite decades of declining mortality rates, lung cancer remains the leading cause of cancer death in the United States. This article examines lung cancer incidence, stage at diagnosis, survival, and mortality using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Over the past 5 years, declines in lung cancer mortality became considerably greater than declines in incidence among men (5.0% vs. 2.6% annually) and women (4.3% vs. 1.1% annually), reflecting absolute gains in 2-year relative survival of 1.4% annually. Improved outcomes likely reflect advances in treatment, increased access to care through the Patient Protection and Affordable Care Act, and earlier stage diagnosis; for example, compared with a 4.6% annual decrease for distant-stage disease incidence during 2013-2019, the rate for localized-stage disease rose by 3.6% annually. Localized disease incidence increased more steeply in states with the highest lung cancer screening prevalence (by 3%-5% annually) than in those with the lowest (by 1%-2% annually). Despite progress, disparities remain. For example, Native Americans have the highest incidence and the slowest decline (less than 1% annually among men and stagnant rates among women) of any group. In addition, mortality rates in Mississippi and Kentucky are two to three times higher than in most western states, largely because of elevated historic smoking prevalence that remains. Racial and geographic inequalities highlight longstanding opportunities for more concerted tobacco-control efforts targeted at high-risk populations, including improved access to smoking-cessation treatments and lung cancer screening, as well as state-of-the-art treatment.

Colorectal cancer screening test exposure patterns in US adults 45 to 49 years of age, 2019-2021

Several organizations now recommend that individuals at average risk for colorectal cancer (CRC) begin screening at 45 rather than 50 years of age. We present contemporary estimates of CRC screening in newly eligible adults aged 45 to 49 years between 2019 and 2021. Nationally representative prevalence estimates and population number screened were estimated based on the National Health Interview Survey. A logistic regression model assessed CRC screening prevalence differences by survey year and sociodemographic characteristics. In 2021, 19.7%-that is, fewer than 4 million of the eligible 19 million adults aged 45 to 49 years-were up-to-date on CRC screening. Screening was lowest in those who were uninsured (7.6%), had less than a high school diploma (15.4%), and Asian (13.1%). Additionally, fecal occult blood test and/or fecal immunochemical testing was underused, with only 2.4% (<460 000 people) reporting being up-to-date with screening using this modality in 2021. CRC screening in eligible young adults remains low. Concerted efforts to improve screening are warranted, particularly in underserved populations.

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

The association of initiating HPV vaccination at ages 9-10 years and up-to-date status among adolescents ages 13-17 years, 2016-2020

Recent guidelines from the American Cancer Society stress HPV vaccination series initiation at the youngest opportunity, i.e., age 9 years. There are limited data on the association between initiating HPV vaccination at ages 9-10 years and up-to-date (UTD) status. In this study, we compare nationally representative UTD HPV vaccination rates between adolescents who initiated the series younger (ages 9-10 years) vs. older (≥ age 11 years). Five years of pooled data (2016-2020) from National Immunization Survey-Teen were used to estimate the UTD HPV vaccination prevalence among younger vs. older initiating 13-17-year-olds. Adjusted logistic regression models estimated prevalence ratios (aPRs), differences (aDs), and difference in differences (aDDs) in prevalence of being UTD to assess the overall association of age at initiation with being UTD and differences in sociodemographic predictors of being UTD among younger vs. older initiators. UTD prevalence for younger initiators was 93% compared with 72% among older initiators (aPR: 1.27,95%CI: 1.24,1.31). Among older initiators, UTD prevalence was significantly different by sex, insurance status, and current age; no such differences were observed among younger initiators. Results indicate that younger initiation is associated with a 27% higher UTD prevalence, highlighting the importance of promoting younger initiation, particularly among those with health-care barriers.

Concept flavor e-cigarette unit sales in the U.S.: 2019-2022

Introduction

Concept flavor e-cigarettes, defined as products with vague/ambiguous flavor (tobacco flavor and non-tobacco flavor) names, may limit the intended impact and enforcement of flavored tobacco restrictions. This study assessed trends in unit sales of concept flavor e-cigarettes in the U.S. by volume, nicotine concentration levels (NCL), flavor and device type.

Methods

We analyzed NielsenIQ Retail Scanner point-of-sales data collected from 2182 Local Trade Areas in the contiguous 48 U.S. states and the District of Columbia aggregated weekly from August 10, 2019, through April 9, 2022. Concept flavors were categorized by: flavor type (tobacco, fruity, menthol, mint, and other); device type (pods/refillable cartridges, disposables, e-liquids, and other); and NCL (0 %-2.0 %, 2.1 %-4.0 %, > 4.1 %, unknown). Joinpoint regression was used to assess sales trends.

Results

Overall unit sales during the study period increased by 33.63 % from 1040.85 to 1390.88 thousand units per month (p = 0.006). Between August 2019 and September 2021, unit sales increased and peaked; between September 2021 and April 2022 sales decreased by 14.46 % (from 1626.02 to 1390.88 thousand units; p = 0.002). Sales of fruity, menthol and mint flavors concept flavor e-cigarettes increased by > 1000 %; disposable devices by 302.18 %; pods and refillable cartridges by 33.81 % overall; and products NCL > 4.0 % increased by 110.18 %. Tobacco flavor concept flavors (93.28 %), pods (94.63 %), and products with 2.1 %-4.0 % NCL (88.40 %) dominated unit share.

Conclusion

Sustaining the recent overall decline in the unit sales of concept flavor e-cigarettes and monitoring the sales of products with nicotine concentration greater than 2.0%, non-tobacco flavor, and pod products warrant prioritization in tobacco control efforts.

The Burden of Lung Cancer in Women Compared With Men in the US

This cross-sectional study examines the incidence rates of lung cancer in women compared with men from 2000 to 2019.

Cancer Screening in the United States During the Second Year of the COVID-19 Pandemic

PURPOSE

To examine whether cancer screening prevalence in the United States during 2021 has returned to prepandemic levels using nationally representative data.

METHODS

Information on receipt of age-eligible screening for breast (women age 50-74 years), cervical (women without a hysterectomy age 21-65 years), prostate (men age 55-69 years), and colorectal cancer (men and women age 50-75 years) according to the US Preventive Services Task Force recommendations was obtained from the 2019 and 2021 National Health Interview Survey. Past-year screening prevalence in 2019 and 2021 and adjusted prevalence ratios (aPRs), 2021 versus 2019, with their 95% CIs were calculated using complex survey logistic regression models.

RESULTS

Between 2019 and 2021, past-year screening in the United States decreased from 59.9% to 57.1% (aPR, 0.94; 95% CI, 0.91 to 0.97) for breast cancer, from 45.3% to 39.0% (aPR, 0.85; 95% CI, 0.82 to 0.89) for cervical cancer, and from 39.5% to 36.3% (aPR, 0.9; 95% CI, 0.84 to 0.97) for prostate cancer. Declines were most notable for non-Hispanic Asian persons. Colorectal cancer screening prevalence remained unchanged because an increase in past-year stool testing (from 7.0% to 10.3%; aPR, 1.44; 95% CI, 1.31 to 1.58) offset a decline in colonoscopy (from 15.5% to 13.8%; aPR, 0.88; 95% CI, 0.83 to 0.95). The increase in stool testing was most pronounced in non-Hispanic Black and Hispanic populations and in persons with low socioeconomic status.

CONCLUSION

Past-year screening prevalence for breast, cervical, and prostate cancer among age-eligible adults in the United States continued to be lower than prepandemic levels in the second year of the COVID-19 pandemic, reinforcing the importance of return to screening health system outreach and media campaigns. The large increase in stool testing emphasizes the role of home-based screening during health care system disruptions.

[Media: see text].

Changes in E-Cigarette Use Among U.S. Adults, 2019-2021

INTRODUCTION

E-cigarette use increased between 2014 and 2018 among younger U.S. adults who had never smoked combustible cigarettes, potentially increasing nicotine addiction risk and progression to combustible tobacco products. It is unknown how prevalence changed after the E-cigarette, or vaping, product use-associated lung injury epidemic (late 2019) and COVID-19 pandemic (March 2020) by age group and combustible cigarette smoking status.

METHODS

Data from cross-sectional, nationally representative National Health Interview Surveys in 2019, 2020, and 2021 (analyzed in 2022) were used to estimate current E-cigarette use prevalence, adjusted prevalence difference between survey years, and population counts, by age group (younger, 18-29 years, n=11,700; middle age, 30-44 years, n=21,300, 45-59 years, n=21,308; older, ≥60 years, n=36,224) and cigarette smoking status (current, former, and never).

RESULTS

E-cigarette use prevalence increased among younger adults between 2019 and 2021 (8.8%-10.2%, adjusted prevalence difference=1.7% points, 95% CI=0.1, 3.3), primarily owing to an increase among those who never smoked cigarettes (4.9%-6.4%, adjusted prevalence difference=1.7% points, 95% CI=0.3, 3.1). People who never smoked cigarettes constituted 53% (2.68 million) of younger adults who used E-cigarettes in 2021, increasing by 0.71 million from 2019. Conversely, among middle age and older adults, the prevalence was similar in 2019 and 2021 irrespective of cigarette smoking status, and those who formerly smoked cigarettes constituted the largest proportion of people who used E-cigarettes in 2021 (age 30-44 years: 51.8%, 1.8 million; age 45-59 years: 51.6%, 0.85 million; age ≥60 years: 47.5%, 0.45 million).

CONCLUSIONS

Efforts must address the rise in E-cigarette use among younger adults who never smoked cigarettes. At the same time, assistance is needed to help those who switched to E-cigarettes to stop smoking to transition to non-use of all products.

Association between cigarette sales in the USA and FDA's announcement of its intention to prohibit menthol as a characterising flavour in cigarettes

INTRODUCTION

On 29 April 2021, the US Food and Drug Administration (FDA) announced its intention to prohibit menthol as a characterising flavour in cigarettes.

METHODS

We assessed the changes in cigarette sales associated with the FDA's announcement using interrupted time series analysis based on monthly retail point-of-sale data on cigarettes from the NielsenIQ Local Trade Area (LTA) data from September 2019 to April 2022. Main outcome variables included LTA-level monthly menthol and non-menthol cigarette sales per 1000-persons.

RESULTS

Monthly cigarette sales were declining before the FDA's announcement (menthol vs non-menthol: -1.68 (95% CI -1.92, -1.45) vs -3.14 (95% CI -3.33, -2.96) packs per 1000-persons). Monthly menthol cigarette sales increased immediately in May 2021 after the FDA's announcement by 6.44 packs per 1000-persons (95% CI 3.83, 9.05). Analysis stratified by LTA-level racial/ethnic compositions showed that LTAs with a relatively higher proportion of non-Hispanic Black population (>8.94%) experienced higher spike in menthol cigarette sales in May 2021 immediately after the announcement and higher post-announcement 12-month menthol cigarette sales than expected.

CONCLUSIONS

Areas with a relatively higher proportion of non-Hispanic Black population are potentially at risk of experiencing increased burden of menthol cigarette consumption. Targeted community level cessation support in non-Hispanic Black majority areas may help mitigate the growing burden of menthol cigarette smoking and improve health equity. The findings of this study also suggest that FDA's prompt finalisation and enforcement of such ban may help avoid extending the increased burden of menthol cigarette consumptions in non-Hispanic Black majority areas.

Declining trend in cigarette smoking among U.S. adults over 2008-2018: A decomposition analysis

The United States (U.S.) witnessed considerable reduction in cigarette smoking prevalence in the recent past. While the correlates of smoking prevalence and related disparities among U.S. adults are well documented, there is limited information on how this success was shared among different population sub-groups. Based on data from the National Health Interview Surveys, 2008 and 2018, representative of non-institutionalized U.S. adults (18 years and above), we applied the threefold Kitawaga-Oaxaca-Blinder linear decomposition analysis. We decomposed the trends in cigarette smoking prevalence, smoking initiation, and successful cessation into changes in population characteristics holding smoking propensities constant (compositional change), changes in smoking propensities by population characteristics holding population composition constant (structural change), and the unmeasured macro-level changes affecting smoking behavior in different population sub-groups at differential rates (residual change) to quantify the shares of population sub-groups by sex, age, race/ethnicity, education, marital status, employment status, health insurance coverage, family income, and region of residence in the overall change in smoking rates. The analysis shows that decreases in smoking propensities regardless of the changes in population composition accounted for 66.4% of the reduction in smoking prevalence and 88.7% of the reduction in smoking initiation. The major reductions in smoking propensity were among Medicaid recipients and young adults (ages 18-24 years). The 25-44-year-olds experienced moderate increase in successful smoking cessation, while the overall successful smoking cessation rate remained steady. Taken together, consistent reduction in smoking among U.S. adults by all major population characteristics, accompanied by disproportionately larger reduction in smoking propensities among the population sub-groups with initially higher smoking propensity compared to the national average, characterized the decline in overall cigarette smoking. Strengthening proven tobacco control measures with targeted interventions to reduce smoking propensities among underserved populations is key to continued success in reducing smoking overall and remedying inequities in smoking and population health.

Association of nicotine replacement therapy product sales with menthol cigarette sales restriction in Massachusetts

BACKGROUND

Massachusetts was the first to implement a state-wide menthol cigarette sales restriction in the USA. Following its implementation in June 2020, evidence showed declines in cigarette sales in Massachusetts; however, changes in nicotine replacement therapy (NRT) product sales are unknown.

METHODS

This cohort study analysed NRT products sold by US-based retailers available in 26 states from the Nielsen Retail Scanner Data. Outcomes were state-level 4-week aggregate sales of gum, lozenge and patch NRT products converted into pieces per 1000 adults (aged ≥18 years) who smoke cigarettes based on smoking rates from the Behavioral Risk Factor Surveillance System and corresponding population from the US Census Bureau. We used a difference-in-differences method to compare changes in NRT product sales in Massachusetts before (1 January 2017 to 13 June 2020) and after (14 June 2020 to 4 December 2021) the policy with sales in 25 states.

RESULTS

The analysis included 1664 observations for each NRT product, with 1170 from before and 494 from after the policy change. The 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states increased for gums by 643.11 (95% CI 365.33 to 920.89; p<0.001) pieces or 12.9% and for lozenges by 436.97 (95% CI 292.88 to 581.06; p<0.001) pieces or 17.9% but no statistically significant change in patches after implementing the policy.

CONCLUSION

The increases in sales of gum and lozenge NRT products in Massachusetts after implementing the policy suggest that a nationwide ban on menthol cigarettes can increase NRT product use; therefore, interventions are needed to strengthen cessation support for adults who smoke cigarettes but intend to quit.

Updated Review of Major Cancer Risk Factors and Screening Test Use in the United States, with a Focus on Changes During the COVID-19 Pandemic

We present national and state representative prevalence estimates of modifiable cancer risk factors, preventive behaviors and services, and screening, with a focus on changes during the COVID-19 pandemic. Between 2019 and 2021, current smoking, physical inactivity, and heavy alcohol consumption declined, and human papillomavirus vaccination and stool testing for colorectal cancer screening uptake increased. In contrast, obesity prevalence increased, while fruit consumption and cervical cancer screening declined during the same timeframe. Favorable and unfavorable trends were evident during the 2nd year of the COVID-19 pandemic that must be monitored as more years of consistent data are collected. Yet disparities by racial/ethnic and socioeconomic status persisted, highlighting the continued need for interventions to address suboptimal levels among these population subgroups.

Changes in State-Level Cigarette Sales During the COVID-19 Pandemic

This cohort study estimates state-level changes in cigarette sales in the US during the COVID-19 pandemic.

Nicotine Pouch Sales Trends in the US by Volume and Nicotine Concentration Levels From 2019 to 2022

This cross-sectional study examines the sale of 4 nicotine pouch brands in the contiguous 48 states and Washington, DC.

Spatial Analysis of Changes in Cigarette Sales in Massachusetts and Bordering States Following the Massachusetts Menthol Flavor Ban

This cohort study examines changes in cigarette sales in Massachusetts and its bordering states following a comprehensive ban on menthol flavor in Massachusetts in 2020.

The first year of the COVID-19 pandemic and health among cancer survivors in the United States

Background

Cancer survivors represent a population with high health care needs. If and how cancer survivors were affected by the first year of the coronavirus disease 2019 (COVID‐19) pandemic are largely unknown.

Methods

Using data from the nationwide, population‐based Behavioral Risk Factor Surveillance System (2017–2020), the authors investigated changes in health‐related measures during the COVID‐19 pandemic among cancer survivors and compared them with changes among adults without a cancer history in the United States. Sociodemographic and health‐related measures such as insurance coverage, employment status, health behaviors, and health status were self‐reported. Adjusted prevalence ratios of health‐related measures in 2020 versus 2017–2019 were calculated with multivariable logistic regressions and stratified by age group (18–64 vs. ≥65 years).

Results

Among adults aged 18–64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history. Notably, declines in smoking were larger among cancer survivors than nonelderly adults without a cancer history. Few changes were observed for adults aged ≥65 years.

Conclusions

Further research is needed to confirm the observed positive health behavior and health changes and to investigate the role of potential mechanisms, such as the national and regional policy responses to the pandemic regarding insurance coverage, unemployment benefits, and financial assistance. As polices related to the public health emergency expire, ongoing monitoring of longer term effects of the pandemic on cancer survivorship is warranted.

Among cancer survivors aged 18–64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history.

Person-years of life lost and lost earnings from cigarette smoking-attributable cancer deaths, United States, 2019

State-specific information on lost earnings due to smoking-attributable cancer deaths to inform and advocate for tobacco control policies is lacking. We estimated person-years of life lost (PYLL) and lost earnings due to cigarette smoking-attributable cancer deaths in the United States nationally and by state. Proportions and numbers of cigarette smoking-attributable cancer deaths and associated PYLL among individuals aged 25 to 79 years in 2019 were calculated and combined with annual median earnings to estimate lost earnings attributable to cigarette smoking. In 2019, estimated total PYLL and lost earnings associated with cigarette smoking-attributable cancer deaths in ages 25 to 79 years in the United States were 2 188 195 (95% CI, 2 148 707-2 231 538) PYLL and $20.9 billion ($20.0 billion-$21.7 billion), respectively. States with the highest overall age-standardized PYLL and lost earning rates generally were in the South and Midwest. The estimated rate per 100 000 population ranged from 352 (339-366) in Utah to 1337 (1310-1367) in West Virginia for PYLL and from $4.3 million ($3.5 million-$5.2 million) in Idaho to $14.8 million ($10.6 million-$20.7 million) in Missouri for lost earnings. If age-specific PYLL and lost earning rates in Utah had been achieved by all states, 58.2% (57.0%-59.5%) of the estimated total PYLL (1 274 178; 1 242 218-1 306 685 PYLL) and 50.5% (34.2%-62.4%) of lost earnings ($10.5 billion; $7.1 billion-$13.1 billion) in 2019 nationally would have been avoided. Lost earnings due to smoking-attributable cancer deaths are substantial in the United States and are highest in states with weaker tobacco control policies.

Changes in Smoking Cessation-Related Behaviors Among US Adults During the COVID-19 Pandemic

IMPORTANCE

Smoking cessation is an urgent public health priority given that smoking is associated with increased risk of severe COVID-19 outcomes and other diseases. It is unknown how smoking cessation changed nationally during the COVID-19 pandemic.

OBJECTIVE

To investigate changes in smoking cessation-related behaviors in the US during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using 2011 to 2020 data on 788 008 individuals who had smoked in the past year from the nationally representative Behavioral Risk Factor Surveillance System (BRFSS) survey. Representative retail scanner sales data between January 2017 and July 2021 for 1004 unique nicotine replacement therapy (NRT) universal product codes in 31 US states from NielsenIQ were also used.

EXPOSURES

Calendar year and 4-week sales periods.

MAIN OUTCOMES AND MEASURES

Changes in annual self-reported prevalence of past-year quit attempts and recent successful cessation before (ie, 2011-2019) and during (ie, 2020) the COVID-19 pandemic and changes in sales volumes in millions of pieces of nicotine gum, lozenge, and patch brands before (1271 four-week sales periods between January 2017 and February 2020) and during (558 four-week sales periods between March 2020 and July 2021) the COVID-19 pandemic were calculated.

RESULTS

The 2011 to 2020 pooled BRFSS sample (response rate range, 45.2%-49.9%) included 788 008 respondents (243 061 individuals ages 25-44 years [weighted percentage, 42.5%]; 374 519 men [weighted percentage, 55.7%]). For the first time since 2011, annual past-year quit attempt prevalence decreased between 2019 and 2020, from 65.2% (95% CI, 64.5% to 65.9%) to 63.2% (95% CI, 62.3% to 64.0%), with the largest relative decreases among individuals ages 45 to 64 years (61.4% [95% CI, 60.3% to 62.5%] vs 57.7% [95% CI, 56.3% to 59.2%]), those with 2 or more comorbidities (67.1% [95% CI, 66.0% to 68.2%] to 63.0% [95% CI, 61.6% to 64.4%]), and Black individuals (72.5% [95% CI, 70.3 to 74.6] vs 68.4% [95% CI, 65.3% to 71.3%]). Recent successful cessation remained unchanged during 2019 to 2020. Observed mean (SD) 4-week NRT sales volume in the prepandemic period was 105.6 (66.2) million gum pieces, 51.9 (31.6) million lozenges, and 2.0 (1.1) million patches. Compared with expected sales, observed sales during the COVID-19 pandemic were lower by 13.0% (95% CI, -13.7% to -12.3%) for lozenges, 6.4% (95% CI, -7.3% to -5.5%) for patches, and 1.2% (95% CI, -1.7% to -0.7%) for gum.

CONCLUSIONS AND RELEVANCE

This study found that serious smoking cessation activity among US adults decreased immediately and remained depressed for more than a year during the COVID-19 pandemic. These findings suggest that smokers experiencing disproportionately negative outcomes during the pandemic should be reengaged and assisted in quit attempts.

Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018-2020

INTRODUCTION

It is unknown how U.S. adults' relative harm perceptions of E-cigarettes versus cigarettes and associated behaviors changed during the E-cigarette or vaping product use‒associated lung injury epidemic (late 2019) and COVID-19 pandemic (since early 2020).

METHODS

Data from cross-sectional nationally representative Health Information National Trends Survey collected in 2018 (n=3,360), 2019 (n=3,217), and 2020 (n=3,677) (analyzed in 2021) were used to estimate changes in relative harm perceptions of E-cigarettes versus cigarettes (less harmful, as harmful, more harmful, don't know as a measure of uncertainty). In addition, changes in exclusive cigarette smoking, exclusive E-cigarette use, and dual use were estimated for each relative harm perception level.

RESULTS

Perceptions of E-cigarettes as more harmful than cigarettes doubled year on year, increasing most between 2019 and 2020 (2018: 6.8%, 2019: 12.8%, 2020: 28.3%), whereas uncertainty in relative harm declined (2018: 38.2%, 2019: 34.2%, 2020: 24.7%). Less harmful relative perceptions declined (2018:17.6%, 2019:15.3%, 2020:11.4%), whereas as harmful perceptions remained steady (2018: 37.4%, 2019: 37.7%, 2020: 35.6%). Exclusive cigarette smoking increased between 2019 and 2020 among those who perceived E-cigarettes as relatively more harmful (2018: 18.5%; 2019: 8.4%; 2020: 16.3%), exclusive E-cigarette use increased linearly among those who perceived them as relatively less harmful (7.9%, 15.3%, 26.7%), and dual use increased linearly in those who perceived them relatively as harmful (0.1%, 1.4%, 2.9%).

CONCLUSIONS

Perceptions of E-cigarettes as more harmful than cigarettes increased sharply between 2019 and 2020. Increases in tobacco product use were potentially guided by product-specific relative harm perceptions because changes occurred primarily in individuals who perceived their preferred product as relatively less harmful, suggesting the need for accurate messaging of relative and absolute product risks.

Changes in Cancer Screening in the US During the COVID-19 Pandemic

IMPORTANCE

Health care was disrupted in the US during the first quarter of 2020 with the emergence of the COVID-19 pandemic. Early reports in selected samples suggested that cancer screening services decreased greatly, but population-based estimates of cancer screening prevalence during 2020 have not yet been reported.

OBJECTIVE

To examine changes in breast cancer (BC), cervical cancer (CC), and colorectal cancer (CRC) screening prevalence with contemporary national, population-based Behavioral Risk Factor Surveillance System (BRFSS) data.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included respondents from the 2014, 2016, 2018, and 2020 BRFSS surveys who were eligible for BC (women aged 50-74 years), CC (women aged 25-64 years), and CRC (women and men aged 50-75 years) screening. Data analysis was performed from September 2021 to February 2022.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Self-reported receipt of a recent (defined as in the past year) BC, CC, and CRC screening test. Adjusted prevalence ratios (aPRs) comparing 2020 vs 2018 prevalence and 95% CIs were computed.

RESULTS

In total, 479 248 individuals were included in the analyses of BC screening, 301 453 individuals were included in CC screening, and 854 210 individuals were included in CRC screening, In 2020, among respondents aged 50 to 75 years, 14 815 (11.4%) were Black, 12 081 (12.6%) were Hispanic, 156 198 (67.3%) were White, and 79 234 (29.9%) graduated from college (all percentages are weighted). After 4 years (2014-2018) of nearly steady prevalence, past-year BC screening decreased by 6% between 2018 and 2020 (from 61.6% in 2018 to 57.8% in 2020; aPR, 0.94; 95% CI, 0.92-0.96), and CC screening decreased by 11% (from 58.3% in 2018 to 51.9% in 2020; aPR, 0.89; 95% CI, 0.87-0.91). The magnitude of these decreases was greater in people with lower educational attainment and Hispanic persons. CRC screening prevalence remained steady; past-year stool testing increased by 7% (aPR, 1.07; 95% CI, 1.02-1.12), offsetting a 16% decrease in colonoscopy (aPR, 0.84; 95% CI, 0.82-0.88) between 2018 and 2020.

CONCLUSIONS AND RELEVANCE

In this survey study, stool testing increased and counterbalanced a decrease in colonoscopy during 2020, and BC and CC screening modestly decreased. How these findings might be associated with outcomes is not yet known, but they will be important to monitor, especially in populations with lower socioeconomic status, who experienced greater screening decreases during the COVID-19 pandemic.

COVID-19 and Tweets About Quitting Cigarette Smoking: Topic Model Analysis of Twitter Posts 2018-2020

Background

The risk of infection and severity of illness by SARS-CoV-2 infection is elevated for people who smoke cigarettes and may motivate quitting. Organic public conversations on Twitter about quitting smoking could provide insight into quitting motivations or behaviors associated with the pandemic.

Objective

This study explored key topics of conversation about quitting cigarette smoking and examined their trajectory during 2018-2020.

Methods

Topic model analysis with latent Dirichlet allocation (LDA) identified themes in US tweets with the term “quit smoking.” The model was trained on posts from 2018 and was then applied to tweets posted in 2019 and 2020. Analysis of variance and follow-up pairwise tests were used to compare the daily frequency of tweets within and across years by quarter.

Results

The mean numbers of daily tweets on quitting smoking in 2018, 2019, and 2020 were 133 (SD 36.2), 145 (SD 69.4), and 127 (SD 32.6), respectively. Six topics were extracted: (1) need to quit, (2) personal experiences, (3) electronic cigarettes (e-cigarettes), (4) advice/success, (5) quitting as a component of general health behavior change, and (6) clinics/services. Overall, the pandemic was not associated with changes in posts about quitting; instead, New Year’s resolutions and the 2019 e-cigarette or vaping use–associated lung injury (EVALI) epidemic were more plausible explanations for observed changes within and across years. Fewer second-quarter posts in 2020 for the topic e-cigarettes may reflect lower pandemic-related quitting interest, whereas fourth-quarter increases in 2020 for other topics pointed to a late-year upswing.

Conclusions

Twitter posts suggest that the pandemic did not generate greater interest in quitting smoking, but possibly a decrease in motivation when the rate of infections was increasing in the second quarter of 2020. Public health authorities may wish to craft messages for specific Twitter audiences (eg, using hashtags) to motivate quitting during pandemics.

Association of Cigarette Sales With Comprehensive Menthol Flavor Ban in Massachusetts

This cohort study examines whether cigarette sales changed after Massachusetts banned menthol-flavored tobacco products.

Abstract PR-01: Association of Affordable Care Act Medicaid expansions with healthcare access and utilization among people who smoke

Background: People who smoke have a higher risk of developing cancer and disproportionately lower incomes which worsens healthcare access and health outcomes. The Affordable Care Act expanded Medicaid eligibility to adults with income up to 138% of the federal poverty line. It is unknown if and how Medicaid expansions changed healthcare access, preventive service use, and health behaviors. Also, it is unknown whether expansions impacted income or racial/ethnic disparities in these measures, given historically lower healthcare access and utilization in lower income people and people of color. Methods: Data were from the nationally representative Behavioral Risk Factor Surveillance System surveys between 2011-2019 of adults ages 18-64 years who currently smoked cigarettes and former smokers who had quit in the past year (n=580,858). Generalized difference-in-differences (DID) analyses using logistic regression models examined the association of Medicaid expansions (staggered time-varying exposure, 34 states expanded as of December 2019) with healthcare access (insurance coverage, care affordability, usual source of care), preventive service use (routine checkup, flu shot, HIV test, breast and colorectal cancer screening, cholesterol check, dentist visit), and health/risk behaviors (heavy alcohol drinking, obesity), including cessation behaviors (past-year quit attempt, successful cessation for &gt;3 months). Income and race/ethnicity differences were also tested. Results: Among people who smoke, Medicaid expansions were associated with healthcare access and preventive care utilization improvements, but not health behaviors, including cessation. Expansions resulted in narrowing of disparities in several measures across income levels and Black vs. White people in expansion states. For example, expansion associated gains in insurance coverage were significantly larger in low-income (expansion: 74.6% vs. nonexpansion: 60.8%; DID: 13.8% 95% CI: 12.8, 14.8%) than high-income (insurance: 87.5% vs. 93.7%, DID: -6.2% points 95% CI: -7.2, -5.2%); and in Black people (82.6% vs. 74.6%, DID: 7.9% points 95% CI: 6.3, 9.5%) than White people (79.5% vs. 75.7%; DID: 3.8%, 95% CI: 3, 4.6%). Medicaid expansions gains were also larger among lower than higher income people for all in preventive care utilization measures studied; and uptake of flu shots, mammograms, and HIV tests were larger in Black than White people. Significant gains in multiple measures were also observed for Hispanic and American Indian/Alaska Native people who smoke, but changes were generally no different than White people. Conclusions: Among people who smoke, Medicaid expansions improved healthcare access and preventive services use. Expansions were also associated with a reduction, but not elimination, of income and Black-White disparities in healthcare access and utilization. Despite insurance and preventive service gains, expansions were not associated with cessation behaviors, signaling the need for improving comprehensive cessation treatments in Medicaid expansion programs.

Citation Format: Priti Bandi, Samuel Asare, J. Lee Westmaas, Nigar Nargis, Robin Yabroff, Ahmedin Jemal, Xuesong Han, Stacey Fedewa. Association of Affordable Care Act Medicaid expansions with healthcare access and utilization among people who smoke [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR-01.

Unemployment and cancer screening: Baseline estimates to inform health care delivery in the context of COVID-19 economic distress

Background

During the coronavirus disease 2019 pandemic, US unemployment rates rose to historic highs, and they remain nearly double those of prepandemic levels. Employers are the most common source of health insurance among nonelderly adults. Thus, job loss may lead to a loss of health insurance and reduce access to cancer screening. This study examined associations between unemployment, health insurance, and cancer screening to inform the pandemic's potential impacts on early cancer detection.

Methods

Up‐to‐date and past‐year breast, cervical, colorectal, and prostate cancer screening prevalences were computed for nonelderly respondents (aged <65 years) with 2000‐2018 National Health Interview Survey data. Multivariable logistic regression models with marginal probabilities were used to estimate unemployed‐versus‐employed unadjusted and adjusted prevalence ratios.

Results

Unemployed adults (2000‐2018) were 4 times more likely to lack insurance than employed adults (41.4% vs 10.0%; P < .001). Unemployed adults had a significantly lower up‐to‐date prevalence of screening for cervical cancer (78.5% vs 86.2%; P < .001), breast cancer (67.8% vs 77.5%; P < .001), colorectal cancer (41.9 vs 48.5%; P < .001), and prostate cancer (25.4% vs 36.4%; P < .001). These differences were eliminated after accounting for health insurance coverage.

Conclusions

Unemployment was adversely associated with up‐to‐date cancer screening, and this was fully explained by a lack of health insurance. Ensuring the continuation of health insurance coverage after job loss may mitigate the pandemic's economic distress and future economic downturns' impact on cancer screening.

Unemployment is adversely associated with up‐to‐date cancer screening, and this is fully explained by a lack of health insurance.

Cancer statistics for the US Hispanic/Latino population, 2021

The Hispanic/Latino population is the second largest racial/ethnic group in the continental United States and Hawaii, accounting for 18% (60.6 million) of the total population. An additional 3 million Hispanic Americans live in Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanic individuals in the United States using the most recent population-based data. An estimated 176,600 new cancer cases and 46,500 cancer deaths will occur among Hispanic individuals in the continental United States and Hawaii in 2021. Compared to non-Hispanic Whites (NHWs), Hispanic men and women had 25%-30% lower incidence (2014-2018) and mortality (2015-2019) rates for all cancers combined and lower rates for the most common cancers, although this gap is diminishing. For example, the colorectal cancer (CRC) incidence rate ratio for Hispanic compared with NHW individuals narrowed from 0.75 (95% CI, 0.73-0.78) in 1995 to 0.91 (95% CI, 0.89-0.93) in 2018, reflecting delayed declines in CRC rates among Hispanic individuals in part because of slower uptake of screening. In contrast, Hispanic individuals have higher rates of infection-related cancers, including approximately two-fold higher incidence of liver and stomach cancer. Cervical cancer incidence is 32% higher among Hispanic women in the continental US and Hawaii and 78% higher among women in Puerto Rico compared to NHW women, yet is largely preventable through screening. Less access to care may be similarly reflected in the low prevalence of localized-stage breast cancer among Hispanic women, 59% versus 67% among NHW women. Evidence-based strategies for decreasing the cancer burden among the Hispanic population include the use of culturally appropriate lay health advisors and patient navigators and targeted, community-based intervention programs to facilitate access to screening and promote healthy behaviors. In addition, the impact of the COVID-19 pandemic on cancer trends and disparities in the Hispanic population should be closely monitored.

State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States

BACKGROUND

Annual lung cancer screening (LCS) with low-dose chest computed tomography in older current and former smokers (ie, eligible adults) has been recommended since 2013. Uptake has been slow and variable across the United States. We estimated the LCS rate and growth at the national and state level between 2016 and 2018.

METHODS

The American College of Radiology's Lung Cancer Screening Registry was used to capture screening events. Population-based surveys, the US Census, and cancer registry data were used to estimate the number of eligible adults and lung cancer mortality (ie, burden). Lung cancer screening rates (SRs) in eligible adults and screening rate ratios with 95% confidence intervals (CI) were used to measure changes by state and year.

RESULTS

Nationally, the SR was steady between 2016 (3.3%, 95% CI = 3.3% to 3.7%) and 2017 (3.4%, 95% CI = 3.4% to 3.9%), increasing to 5.0% (95% CI = 5.0% to 5.7%) in 2018 (2018 vs 2016 SR ratio = 1.52, 95% CI = 1.51 to 1.62). In 2018, several southern states with a high lung-cancer burden (eg, Mississippi, West Virginia, and Arkansas) had relatively low SRs (<4%) among eligible adults, whereas several northeastern states with lower lung cancer burden (eg, Massachusetts, Vermont, and New Hampshire) had the highest SRs (12.8%-15.2%). The exception was Kentucky, which had the nation's highest lung cancer mortality rate and one of the highest SRs (13.7%).

CONCLUSIONS

Fewer than 1 in 20 eligible adults received LCS nationally, and uptake varied widely across states. LCS rates were not aligned with lung cancer burden across states, except for Kentucky, which has supported comprehensive efforts to implement LCS.

Updated Review of Major Cancer Risk Factors and Screening Test Use in the United States in 2018 and 2019, with a Focus on Smoking Cessation

Cancer prevention and early detection efforts are central to reducing cancer burden. Herein, we present estimates of cancer risk factors and screening tests in 2018 and 2019 among US adults, with a focus on smoking cessation. Cigarette smoking reached a historic low in 2019 (14.2%) partly because 61.7% (54.9 million) of all persons who had ever smoked had quit. Yet, the quit ratio was <45% among lower-income, uninsured, and Medicaid-insured persons, and was <55% among Black, American Indian/Alaska Native, lower-educated, lesbian, gay or bisexual, and recent immigrant persons, and in 12 of 17 Southern states. Obesity levels remain high (2017-2018: 42.4%) and were disproportionately higher among Black (56.9%) and Hispanic (43.7%) women. HPV vaccination in adolescents 13 to 17 years remains underutilized and over 40% were not up-to-date in 2019. Cancer screening prevalence was suboptimal in 2018 (colorectal cancer ≥50 years: 65.6%; breast ≥45 years: 63.2%; cervical 21-65 years: 83.7%), especially among uninsured adults (colorectal: 29.8%; breast: 31.1%). This snapshot of cancer prevention and early detection measures was mixed, and substantial racial/ethnic and socioeconomic disparities persisted. However, gains could be accelerated with targeted interventions to increase smoking cessation in under-resourced populations, stem the obesity epidemic, and improve screening and HPV vaccination coverage.

Trends in E-Cigarette Use by Age Group and Combustible Cigarette Smoking Histories, U.S. Adults, 2014-2018

INTRODUCTION

The trends in e-cigarette prevalence and population count of users according to cigarette smoking histories are unknown. These data are needed to inform public health actions against a rapidly changing U.S. e-cigarette market.

METHODS

Data collected between 2014 and 2018 (analyzed in 2020) from cross-sectional, nationally representative National Health Interview Surveys were used to estimate current e-cigarette prevalence, adjusted prevalence differences (percentage points), and population counts of users. Analyses were stratified by age group (younger, 18-29 years, n=25,445; middle age, 30-49 years, n=47,745; older, ≥50 years, n=79,517) and cigarette smoking histories (current smokers, recent quitters [quit <1 year ago], near-term quitters [quit 1-8 years ago], long-term quitters [quit >8 years ago], never smokers).

RESULTS

Among younger adults, e-cigarette use increased in all groups of smokers, with notable increases between 2014 and 2018 among never smokers (1.3%-3.3%, adjusted prevalence difference=2%, p<0.001) and near-term quitters (9.1%-19.2%, adjusted prevalence difference=8.8%, p=0.024). Conversely, the only substantial increase in e-cigarette use between 2014 and 2018 among middle-aged (5.8%-14.4%, adjusted prevalence difference=8.2%, p<0.001) and older (6.3%-9.5%, adjusted prevalence difference=3.3%, p=0.045) adults was among near-term quitters. The largest absolute population increase in e-cigarette users between 2014 and 2018 was among younger-adult never smokers (0.49-1.35 million), followed by near-term quitters among middle-aged (0.36-0.95 million), younger (0.23-0.57 million), and older (0.35-0.50 million) adults.

CONCLUSIONS

The continuous increase among younger-adult never smokers suggests a rise in primary nicotine initiation with e-cigarettes. The concomitant increase among near-term quitters of all age groups suggests continuing e-cigarette use among smokers who may have switched from cigarettes previously.

Proportion of cancer cases and deaths attributable to alcohol consumption by US state, 2013-2016

BACKGROUND

Alcohol consumption is an established risk factor for several cancer types, but there are no contemporary published estimates of the state-level burden of cancer attributed to alcoholic beverage consumption. Such estimates are needed to inform public policy and cancer control efforts. We estimated the proportion and number of incident cancer cases and cancer deaths attributable to alcohol consumption by sex in adults aged ≥30 years in all 50 states and the District of Columbia in 2013-2016.

METHODS

Age-, sex-, and state-specific cancer incidence and mortality data (2013-2016) were obtained from the US Cancer Statistics database. State-level, self-reported age and sex stratified alcohol consumption prevalence was estimated using the 2003-2006 Behavioral Risk Factor Surveillance System surveys and adjusted with state sales data.

RESULTS

The proportion of alcohol-attributable incident cancer cases ranged from 2.9 % (95 % confidence interval: 2.7 %-3.1 %) in Utah to 6.7 % (6.4 %-7.0 %) in Delaware among men and women combined, from 2.7 % (2.5 %-3.0 %) in Utah to 6.3 % (5.9 %-6.7 %) in Hawaii among men, and from 2.7 % (2.4 %-3.0 %) in Utah to 7.7 % (7.2 %-8.3 %) in Delaware among women. The proportion of alcohol-attributable cancer deaths also varied considerably across states: from 1.9 % to 4.5 % among men and women combined, from 2.1% to 5.0% among men, and from 1.4 % to 4.4 % among women. Nationally, alcohol consumption accounted for 75,199 cancer cases and 18,947 cancer deaths annually.

CONCLUSION

Alcohol consumption accounts for a considerable proportion of cancer incidence and mortality in all states. Implementing state-level policies and cancer control efforts to reduce alcohol consumption could reduce this cancer burden.

Association of teleworking and smoking behavior of U.S. wage and salary workers

INTRODUCTION

The COVID-19 pandemic has led to a major shift in workspace from office to home. This report examined how telecommuting is related to smoking behavior of wage and salary workers.

METHODS

Self-reported smoking behavior of 1,390 U.S. wage and salary workers aged 16-64 years from the Tobacco Use Supplement of the Current Population Survey 2018/19 were linked to the 2018 American Time Use Survey. Weighted multivariate logistic regression predicting smoking probability and generalized linear regression predicting smoking intensity were used for analysis.

RESULTS

Almost a fifth (19%) of wage and salary workers reported working from home and over a half (52%) reported working in telecommuting amenable occupations. Nearly 12% were current smokers, smoking 14.7 cigarettes daily on average. Compared to their counterparts, smoking prevalence (percentage points) was lower among those employed in telecommuting amenable occupations (-0.52, p < .001 for all; 0.01, p = .862 for men; -2.40, p < .001 for women) and who worked more frequently from home (-0.21, p < .001 for all; -0.76, p < .001 for men; -0.03, p = .045 for women). Smoking intensity (cigarettes per day) was lower among those employed in telecommuting amenable occupations (-3.39, p = .03 for all; -0.36, p = .90 for men; -4.30, p = .21 for women). We found no statistically significant association between smoking intensity and telecommuting frequency.

CONCLUSIONS

The lower likelihood of smoking and lower level of smoking intensity among telecommuting wage and salary workers suggests the need for proactive efforts to address the potential exacerbation in occupation-related smoking disparities between occupations that are and are not amenable to telecommuting.

Abstract S09-04: Unemployment and cancer screening: Baseline estimates to inform health care provision in the context of COVID-19 economic distress

Introduction: During the COVID-19 pandemic, the unemployment rate has sharply risen from 3.5% in February 2020 to 13.3% in May 2020, a level not seen since the Great Depression. There are an estimated 21.0 million unemployed adults in the United States. Employers are the most common source of health insurance among working-aged adults and their families. Thus, job loss may lead to loss of insurance and reduce access to cancer screening, which can detect cancer at earlier, more treatable stages, and reduce cancer mortality. In this study, we examined sequential associations between unemployment, health insurance, and cancer screening to inform COVID’s potential longer-lasting impacts on early cancer detection.

Methods: Up-to-date (UTD) and recent (past-year) breast (BC) and colorectal cancer (CRC) screening prevalence were computed among respondents aged 50-64 years in 2000-2018 National Health Interview Survey data. Respondents were grouped as unemployed (not working but looking BC n=852; CRC n=1,747) and employed (currently working BC n=19,013; CRC n= 36,566). A series of logistic regression models with predicted marginal probabilities were used to estimate unemployed vs. employed unadjusted (PR) and adjusted prevalence ratios (aPR) and corresponding 95% Confidence Intervals (CI).

Results: Unemployed adults were four times as likely to be uninsured as employed adults (41.4% v 10.0%, p-value &lt;0.001). Unemployment was associated with lower UTD breast (67.8% vs 77.5%, p-value&lt;0.001, PR=0.82, 95%CI 0.77,0.87) and colorectal (49.4% and 60.1%, p-value&lt;0.001, PR=0.86, 95%CI 0.80, 0.92) cancer screening prevalence. These differences remained after adjusting for race/ethnicity, age, and sex, but were eliminated after accounting for health insurance. Patterns and magnitudes of PR and aPRs were similar for past-year CRC and BC screening prevalence.

Conclusion: Unemployment was adversely associated with guideline-recommended and potentially life-saving breast and colorectal cancer screening. Compared to the employed, the unemployed disproportionately lacked health insurance, which accounted for their lower cancer screening utilization. Expanding and ensuring health insurance coverage after job loss may mitigate COVID-19’s economic impacts on cancer screening.

Citation Format: Stacey A. Fedewa, K. Robin Yabroff, Zhiyuan Zheng, Priti Bandi, Ann Goding Sauer, Robert A. Smith, Nigar Nargis, Jeffrey Drope, Ahmedin Jemal. Unemployment and cancer screening: Baseline estimates to inform health care provision in the context of COVID-19 economic distress [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S09-04.

Changes in Black-White Difference in Lung Cancer Incidence among Young Adults

Background

We previously reported that lung cancer incidence between Blacks and Whites younger than 40 years of age converged in women and approached convergence in men. Whether this pattern has continued in contemporary young birth cohorts is unclear.

Methods

We examined 5-year age-specific lung cancer incidence in Blacks and Whites younger than 55 years of age by sex and calculated the Black-to-White incidence rate ratios (IRRs) and smoking prevalence ratios by birth cohort using nationwide incidence data from 1997 to 2016 and smoking data from 1970 to 2016 from the National Health Interview Survey.

Results

Five-year age-specific incidence decreased in successive Black and White men born since circa 1947 and women born since circa 1957, with the declines steeper in Blacks than Whites. Consequently, the Black-to-White IRRs became unity in men born 1967-1972 and reversed in women born since circa 1967. For example, the Black-to-White IRRs in ages 40-44 years born between 1957 and 1972 declined from 1.92 (95% confidence interval [CI] = 1.82 to 2.03) to 1.03 (95% CI = 0.93 to 1.13) in men and from 1.32 (95% CI = 1.24 to 1.40) to 0.71 (95% CI = 0.64 to 0.78) in women. Similarly, the historically higher sex-specific smoking prevalence in Blacks than Whites disappeared in men and reversed in women born since circa 1965. The exception to these patterns is that the incidence became higher in Black men than White men born circa 1977-1982.

Conclusions

The historically higher lung cancer incidence in young Blacks than young Whites in the United States has disappeared in men and reversed in women, coinciding with smoking patterns, though incidence again became higher in Black men than White men born circa 1977-1982.

Geographic and sociodemographic differences in cervical cancer screening modalities

Cervical cancer screening recommendations for women aged 30-65 years include co-testing (high-risk human papillomavirus [hrHPV] with Pap testing) every five years or Pap testing alone every three years. Geographic variations of these different screening modalities across the United States have not been examined. We selected 82,426 non-pregnant women aged 30-65 years from the 2016 Behavioral Risk Factor Surveillance System with data on sociodemographics, hysterectomy, and cervical cancer screening, representing 42 states and the District of Columbia. Logistic regression models with predicted marginal probabilities were used to calculate state-level prevalence estimates of recent cervical cancer screening and uptake of co-testing, Pap testing, and hrHPV testing among those who were recently screened. Analysis was conducted in 2018-2019. Recent screening prevalence ranged from 80.0% (Idaho) to 92.2% (Massachusetts), with more state-level geographic variability in co-testing than Pap testing alone. Uptake of co-testing ranged from 27.5% (Utah) to 49.9% (District of Columbia); compared to the national estimate, co-testing was lower in 12 states and higher in six states. Overall, Midwestern and Southern states had the lowest uptake of co-testing whereas Northeastern states had the highest. Sociodemographic, healthcare, and behavioral factors accounted for some but not all state-level variation in co-testing. There was substantial state-level variability in co-testing prevalence, which was lowest in Midwestern and Southern states; the variation was not entirely explained by individual sociodemographic, healthcare, and behavioral factors. Future studies should monitor the impact of geographic variations in screening modalities on state-level differences in cervical cancer incidence, survival, and mortality.

24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of Brazil

Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25-69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines among females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities in female smoking widened mainly until 2003 (SII: 15.8). Conversely, among males, declines were steeper in higher-educated groups only in relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute equalities in male smoking were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities in smoking vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1979-1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.

Age-Related Differences in Antihypertensive Medication Adherence in Hispanics: A Cross-Sectional Community-Based Survey in New York City, 2011-2012

Introduction

US Hispanics, particularly younger adults in this population, have a higher prevalence of uncontrolled hypertension than do people of other racial/ethnic groups. Little is known about the prevalence and predictors of antihypertensive medication adherence, a major determinant of hypertension control and cardiovascular disease, and differences between age groups in this fast-growing population.

Methods

The cross-sectional study included 1,043 community-dwelling Hispanic adults with hypertension living in 3 northern Manhattan neighborhoods from 2011 through 2012. Age-stratified analyses assessed the prevalence and predictors of high medication adherence (score of 8 on the Morisky Medication Adherence Scale [MMAS-8]) among younger (<60 y) and older (≥60 y) Hispanic adults.

Results

Prevalence of high adherence was significantly lower in younger versus older adults (24.5% vs 34.0%, P = .001). In younger adults, heavy alcohol consumption, a longer duration of hypertension, and recent poor physical health were negatively associated with high adherence, but poor self-rated general health was positively associated with high adherence. In older adults, advancing age, higher education level, high knowledge of hypertension control, and private insurance or Medicare versus Medicaid were positively associated with high adherence, whereas recent poor physical health and health-related activity limitations were negatively associated with high adherence.

Conclusion

Equitable achievement of national hypertension control goals will require attention to suboptimal antihypertensive medication adherence found in this study and other samples of US Hispanics, particularly in younger adults. Age differences in predictors of high adherence highlight the need to tailor efforts to the life stage of people with hypertension.

Temporal trends in motor vehicle fatalities in the United States, 1968 to 2010 - a joinpoint regression analysis

Background

In the past 40 years, a variety of factors might have impacted motor vehicle (MV) fatality trends in the US, including public health policies, engineering innovations, trauma care improvements, etc. These factors varied in their timing across states/localities, and many were targeted at particular population subgroups. In order to identify and quantify differential rates of change over time and differences in trend patterns between population subgroups, this study employed a novel analytic method to assess temporal trends in MV fatalities between 1968 and 2010, by age group and sex.

Methods

Cause-specific MV fatality data from traffic injuries between 1968 and 2010, based on death certificates filed in the 50 states, and DC were obtained from Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). Long-term (1968 to 2010) and short-term (log-linear piecewise segments) trends in fatality rates were compared for males and females overall and in four separate age groups using joinpoint regression.

Results

MV fatalities declined on average by 2.4% per year in males and 2.2% per year in females between 1968 and 2010, with significant declines observed in all age groups and in both sexes. In males overall and those 25 to 64 years, sharp declines between 1968 and mid-to-late 1990s were followed by a stalling until the mid-2000s, but rates in females experienced a long-term steady decline of a lesser magnitude than males during this time. Trends in those aged <1 to 14 years and 15 to 24 years were mostly steady over time, but males had a larger decline than females in the latter age group between 1968 and the mid-2000s. In ages 65+, short-term trends were similar between sexes.

Conclusions

Despite significant long-term declines in MV fatalities, the application of Joinpoint Regression found that progress in young adult and middle-aged adult males stalled in recent decades and rates in males declined relatively more than in females in certain age groups. Future research is needed to establish the causes of these observed trends, including the potential role of contemporaneous MV-related policies and their repeal. Such research is needed in order to better inform the design and evaluation of future population interventions addressing MV fatalities nationally.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-015-0035-6) contains supplementary material, which is available to authorized users.

Cigarette affordability in the United States

INTRODUCTION

Cigarette excise tax and price increases reduce smoking consumption and prevalence. Studies have previously defined cigarette affordability internationally and have discussed its relevance as a tobacco control policy measure. This study provides the first estimates on cigarette affordability in the United States.

METHODS

Cigarette affordability was defined as cigarette price in relation to individuals' income level. Three measures of cigarette affordability were estimated for U.S. states and nationally between 1970 and 2010.

RESULTS

In 2010, on average, it took 1.62% of an individual's annual personal disposable income to purchase 100 packs of cigarettes in a U.S. state (relative income price). An individual who earned the equivalent of the hourly median wage in a U.S. state needed to work 21.4min in an hour to purchase a pack of cigarettes (minutes of labor, MoL50), whereas a relatively poorer individual earning the hourly 25th percentile wage needed to work 32.7min (MoL25). Cigarettes were most affordable in parts of the South and West and were least affordable in Northeastern states. While cigarette prices increased significantly between 1970 and 2008, affordability remained unchanged during this time and cigarettes may have become more affordable since the early 2000s in many states.

CONCLUSIONS

Cigarette affordability in 2010 varied widely across U.S. states, a result of cigarette price increases not keeping pace with income increases in some parts of the United States, especially in Southern and Western states. In order to maximize the public health gains from cigarette tax increases, state taxation policies may consider affordability in benchmarking excise tax increases.

Annual Report to the Nation on the Status of Cancer, 1975-2009, featuring the burden and trends in human papillomavirus(HPV)-associated cancers and HPV vaccination coverage levels

Background

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updates on cancer incidence and death rates and trends in these outcomes for the United States. This year’s report includes incidence trends for human papillomavirus (HPV)–associated cancers and HPV vaccination (recommended for adolescents aged 11–12 years).

Methods

Data on cancer incidence were obtained from the CDC, NCI, and NAACCR, and data on mortality were obtained from the CDC. Long- (1975/1992–2009) and short-term (2000–2009) trends in age-standardized incidence and death rates for all cancers combined and for the leading cancers among men and among women were examined by joinpoint analysis. Prevalence of HPV vaccination coverage during 2008 and 2010 and of Papanicolaou (Pap) testing during 2010 were obtained from national surveys.

Results

Death rates continued to decline for all cancers combined for men and women of all major racial and ethnic groups and for most major cancer sites; rates for both sexes combined decreased by 1.5% per year from 2000 to 2009. Overall incidence rates decreased in men but stabilized in women. Incidence rates increased for two HPV-associated cancers (oropharynx, anus) and some cancers not associated with HPV (eg, liver, kidney, thyroid). Nationally, 32.0% (95% confidence interval [CI] = 30.3% to 33.6%) of girls aged 13 to 17 years in 2010 had received three doses of the HPV vaccine, and coverage was statistically significantly lower among the uninsured (14.1%, 95% CI = 9.4% to 20.6%) and in some Southern states (eg, 20.0% in Alabama [95% CI = 13.9% to 27.9%] and Mississippi [95% CI = 13.8% to 28.2%]), where cervical cancer rates were highest and recent Pap testing prevalence was the lowest.

Conclusions

The overall trends in declining cancer death rates continue. However, increases in incidence rates for some HPV-associated cancers and low vaccination coverage among adolescents underscore the need for additional prevention efforts for HPV-associated cancers, including efforts to increase vaccination coverage.

Cancer-related risk factors and preventive measures in US Hispanics/Latinos

In this article, we provide prevalence data on major cancer-related risk factors, early detection testing, and vaccination among Hispanics using nationally representative surveys. Compared with non-Hispanic whites, Hispanic adults are less likely to be current smokers (13% vs 22%) or frequent alcohol drinkers, but they are more likely to be obese (32% vs 26%) and to have lower levels of mammography use within the past year (46% vs 51%), colorectal screening as per recommended intervals (47% vs 61%), and Papanicolaou (Pap) test use within the past 3 years (74% vs 79%). Within the Hispanic population, the prevalence of these risk factors and early detection methods substantially vary by country of origin. For example, Cuban men (20.7%) and Puerto Rican men (19%) had the highest levels of current smoking than any other Hispanic subgroups, while Mexican women had the lowest levels of mammogram use (44%) and Pap test use (71%). Hispanic migrants have a higher prevalence of hepatitis B virus and Helicobacter pylori, which cause liver and stomach cancer, respectively. Among Hispanic adolescents, tobacco use (eg, 20.8% use of any tobacco products), alcohol use (42.9%), and obesity (23.2%) remain highly prevalent risk factors. Although 56% of Hispanic adolescents initiate human papillomavirus vaccination, only 56% of them completed the 3-dose series. Differences in risk factors and early detection testing among Hispanic groups should be considered in clinical settings and for cancer control planning.

Association of insurance status and age with cervical cancer stage at diagnosis: National Cancer Database, 2000-2007

OBJECTIVES

We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years.

METHODS

We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

The proportion of late-stage disease increased with age: from 16.53% (21-34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients.

CONCLUSIONS

Screening should be encouraged for women at high risk for advanced-stage disease.

Trends in colorectal cancer screening with home-based fecal occult blood tests in adults ages 50 to 64 years, 2000-2008

BACKGROUND

National surveys have reported declines in rates of home-based fecal occult blood test (FOBT) screening for colorectal cancer (CRC) in the last decade. However, socioeconomic status (SES) and racial/ethnic differences in FOBT trends and their changes relative to endoscopic CRC screening have not been evaluated.

METHODS

Data on adults ages 50 to 64 years from the 2000, 2005, and 2008 National Health Interview Surveys were used. Weighted analyses and multivariate logistic regression were used to study trends in the use of FOBT and endoscopic CRC screening during this period.

RESULTS

Between 2000 and 2008, significant declines in FOBT prevalence occurred in higher SES groups, but not in lower SES groups (uninsured and publicly insured, those without a usual source of care, lower educated, lower income, and immigrants to the United States) or Hispanics. Endoscopic CRC screening during the period studied consistently increased in all higher SES subgroups. In contrast, few lower SES subgroups (publicly insured, lower educated, near poor individuals, long-term immigrants) and Hispanics experienced increases in CRC endoscopic screening, and these increases were smaller than those observed in higher SES subgroups.

CONCLUSIONS

Socially and economically disadvantaged groups experienced little or no change in FOBT prevalence, and few of these groups experienced contemporaneous increases in CRC endoscopic screening. These trends suggest the continued availability and acceptance of FOBT in these groups. If national CRC screening goals are to be achieved in populations with lower access to colonoscopy, then annual high-sensitivity FOBT should be promoted as an immediately accessible and viable alternative.

Breast cancer statistics, 2011

In this article, the American Cancer Society provides an overview of female breast cancer statistics in the United States, including trends in incidence, mortality, survival, and screening. Approximately 230,480 new cases of invasive breast cancer and 39,520 breast cancer deaths are expected to occur among US women in 2011. Breast cancer incidence rates were stable among all racial/ethnic groups from 2004 to 2008. Breast cancer death rates have been declining since the early 1990s for all women except American Indians/Alaska Natives, among whom rates have remained stable. Disparities in breast cancer death rates are evident by state, socioeconomic status, and race/ethnicity. While significant declines in mortality rates were observed for 36 states and the District of Columbia over the past 10 years, rates for 14 states remained level. Analyses by county-level poverty rates showed that the decrease in mortality rates began later and was slower among women residing in poor areas. As a result, the highest breast cancer death rates shifted from the affluent areas to the poor areas in the early 1990s. Screening rates continue to be lower in poor women compared with non-poor women, despite much progress in increasing mammography utilization. In 2008, 51.4% of poor women had undergone a screening mammogram in the past 2 years compared with 72.8% of non-poor women. Encouraging patients aged 40 years and older to have annual mammography and a clinical breast examination is the single most important step that clinicians can take to reduce suffering and death from breast cancer. Clinicians should also ensure that patients at high risk of breast cancer are identified and offered appropriate screening and follow-up. Continued progress in the control of breast cancer will require sustained and increased efforts to provide high-quality screening, diagnosis, and treatment to all segments of the population.

Abstract B75: Association of insurance status and age with stage at diagnosis among cervical cancer patients, National Cancer Database 2000–2007

Introduction: Late stage cervical cancer at diagnosis is associated with greater morbidity and mortality and higher treatment costs. Few studies have examined the association between insurance status and cervical cancer stage at diagnosis. Existing studies have been either state-specific or limited to elderly Medicare recipients. This study aims to examine the relationship between patient characteristics, with a particular focus on age at diagnosis and insurance status, and stage in a large number of cervical cancer patients aged 21–85 in the National Cancer Database (NCDB).

Methods: Women diagnosed with their first primary invasive cervical cancer between 2000 and 2007 were selected from the NCDB. We evaluated the association between late stage (stage III/IV) and insurance and age while adjusting for race/ethnicity and other socio-demographic and clinical factors. Multivariate log binomial models were used to estimate risk ratios (RR) and 95% confidence intervals (CIs), respectively.

Results: Among the 69,739 evaluable patients, the rate of late stage disease increased from 16.53% in 21–34 year olds to 42.44% in women ≥70. The adjusted risk of advanced stage of disease among women 50 years and older was 2.2 to 2.5 times that of patients aged 21–34. Uninsured (RR=1.44, 95% CI 1.40–1.49), Medicaid (RR=1.37, 95% CI 1.34–1.41), Younger Medicare (RR=1.12, 95% CI 1.06–1.19), and Older Medicare (RR=1.20, 95% CI 1.15–1.26) patients had a higher risk of late stage disease compared to privately insured patients. African Americans (RR=1.05, 95%CI 1.02–1.08) had slightly higher risks of advanced stage disease while Hispanics (RR=0.86, 95%CI 0.83–0.89) and other race/ethnicities (RR=0.88, 95%CI 0.84–0.92) had a lower risks compared to whites.

Conclusion: In a large national sample of women diagnosed with cervical cancer, the strongest predictor of late stage at diagnosis was age. Patients without private insurance were also more likely to be diagnosed at later stages, particularly uninsured and Medicaid insured patients. Screening should be encouraged for those women for whom it is recommended, especially those at higher risk of advanced stage disease. Consideration of these findings in developing future guidelines for cervical cancer screening among older women is recommended.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B75.

Abstract B96: Trends in colorectal cancer screening with home-based fecal occult blood test (FOBT) in adults aged 50–64 years, 2000–2008

Introduction: Screening for colorectal cancer (CRC) in asymptomatic average risk populations reduces CRC incidence and mortality. Annual home-based fecal occult blood testing (FOBT) has been recommended as a CRC screening modality in average-risk adults aged 50 and older. National surveys have reported declines in FOBT screening rates in the last decade, but it is unknown whether these declines have extended across all socioeconomic status (SES) and racial/ethnic groups, and the changes relative to endoscopic screening have not been evaluated.

Methods: Data on respondents aged 50–64 years were from the Cancer Control Module administered to sampled adults National Health Interview Surveys in 2000, 2005, and 2008. Weighted analyses and multivariate logistic regression were used to study trends in the use of home FOBT testing in the past year and endoscopic test in the past 10 years.

Results: Overall, the prevalence of home FOBT in the past year declined 5.9% points (95% CI: 4.5%, 7.3%) between 2000 and 2008. SES differences in trends were observed wherein significant declines were restricted to higher-SES groups (those with private and military insurance, those with a usual source of care, those with a high school degree or higher, those classified as not poor, those born in the US), whereas lower-SES (uninsured and the publicly-insured, those without a usual source of care, those with less than a high school education, the poor and the near poor, and immigrants to the US) did not experience significant changes in FOBT prevalence during this time period. FOBT rates in Hispanics did not change significantly during this time, whereas non-Hispanic whites and non-Hispanic blacks experienced significant declines. Coincident with declines in FOBT prevalence during this time, endoscopic screening prevalence increased consistently in higher-SES groups. Fewer lower-SES groups experienced increases in endoscopic screening prevalence, with most increases being of a lower magnitude than in the higher-SES subgroups.

Conclusions: Socially and economically disadvantaged groups experienced little or no change in FOBT rates from 2000 to 2008. There has been a significant shift from FOBT to endoscopic screening in higher-SES and a few lower-SES groups, but the extent of this shift in lower-SES groups appeared to be smaller than in higher-SES groups. Programs promoting annual screening with high-sensitivity guaiac-based or immunochemical FOBT represent an appropriate and low cost alternative to colonosopy screening, provided that these programs consider patient- and physician attitudes, knowledge and preferences, and systems-issues related to referral, adherence, test quality assurance, and adequate follow-up of positive test results.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B96.