Cigarette tar yields in relation to mortality from lung cancer in the cancer prevention study II prospective cohort, 1982-8
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《英国医生杂志》
1 Department of Economics, Massachusetts Institute of Technology, Cambridge MA 02139, USA, 2 Epidemiology and Surveillance Research, American Cancer Society, 1599 Clifton Road NE, Atlanta GA 30329, USA
Correspondence to: J E Harris Internal Medicine Associates, Massachusetts General Hospital, Boston MA 02114 USA jeharris@partners.org
Abstract
During the past 50 years, changes in the design and manufacture of cigarettes have markedly reduced their machine measured "tar" yields.1 2 The introduction of cellulose acetate filters in the 1950s, and subsequently more porous cigarette papers, reduced the average tar rating per cigarette in the United States from about 37 mg in 1950 to 22 mg in 1967.1 The introduction of air ventilation holes in the filter tip in the late 1960s and expanded tobacco in the 1970s permitted manufacturers to market low tar (generally in the range of 8-14 mg per cigarette) and very low tar cigarettes ( 7 mg per cigarette). Concomitantly, the US average tar level per cigarette, as rated by the US Federal Trade Commission (FTC), declined to about 13 mg by 1990.1 Similar trends in standardised tar yields have been reported in the United Kingdom3 4 and other countries.
While many case-control and cohort studies have examined risk of lung cancer in relation to type of cigarette smoked,5-53 nearly all have compared the risks of smoking high tar non-filter brands with smoking medium tar filter brands,5 14-44 or to the corresponding ranges of tar yield.6-13 45-53 The three case-control studies that have included participants who smoked low tar brands11-13 yielded negative or equivocal results, but the observation periods for these studies ended in 1980-1, when the combined market share of low tar and very low tar cigarettes in the United States had exceeded 10% for only five or six years.54 In most epidemiological studies,7 8 10-13 14-29 34 45-50 52 the observation period ended before 1986, when the market share in the United States had exceeded 10% for only a decade.54 Thus no large, long term prospective study has specifically compared the risk of lung cancer in smokers of medium tar filter cigarettes with that in smokers of low tar and very low tar filter cigarettes.
We analysed the relation between the tar rating of the brand of cigarette smoked in 1982 and mortality from lung cancer over six years among men and women in the cancer prevention study II (CPS-II), a nationwide prospective cohort of over one million US adults aged 30 years or older. We specifically compared the risk of lung cancer among smokers of very low tar ( 7 mg) filter, low tar (8-14 mg) filter, or high tar ( 22 mg) non-filter brands with the risk among those who smoke conventional medium tar (15-21 mg) filter brands.
Methods
Tables 1 and 2 show descriptive characteristics of the cohorts of 100 868 men and 124 270 women who were current smokers at enrolment. Tables 3 and 4 show the corresponding data for the cohorts of 263 371 men and 452 265 women who never smoked or who had quit smoking at enrolment. Smokers of brands with medium or high tar ratings were more likely to be African American; more likely to have attained no more than a high school education; more likely to have a recent blue collar job or a history of potential occupational asbestos exposure; and less likely to report use of vitamins A, C, and E than participants who smoked lower tar brands, who never smoked, or who quit smoking before age 35 years. Current smokers of very low tar cigarettes (especially men) tended to smoke more cigarettes a day. Moreover, among the subset of current smokers who were re-enrolled in the CPS-II nutrition cohort, those men and women who had smoked very low tar and low tar cigarettes in 1982 were more likely to have quit smoking by 1992.
Table 1 Characteristics of men who currently smoked, according to tar level of cigarettes smoked in 1982
Table 2 Characteristics of women who currently smoked, according to tar level of cigarettes smoked in 1982
Table 3 Characteristics of men who had never smoked or were former smokers, according to age when they quit smoking
Table 4 Characteristics of women who had never smoked or were former smokers, according to age when they quit smoking
Figures 1 and 2 show multivariate adjusted hazard ratios and 95% confidence intervals for never smokers, for former smokers who had quit at various ages, and for current smokers of brands with various tar ratings, relative to current smokers of brands with 15-21 mg tar. Men and women who smoked very low tar ( 7 mg) and low tar (8-14 mg) brands had risks of lung cancer indistinguishable from those who smoked medium tar (15-21 mg) brands (Wald test for homogeneity of strata62 P = 0.27 for men, P = 0.80 for women). The risk was higher in those who smoked non-filter cigarettes and substantially lower in men (fig 1) and women (fig 2) who quit smoking. People who quit smoking before age 35 years had risks of lung cancer approaching those of people who had never smoked. Further adjustment for age when people started to smoke and number of cigarettes smoked a day showed nearly identical patterns in current and former smokers to those shown in figures 1 and 2. For men the adjusted figures were 0.06 (0.04 to 0.09) for those who quit aged 35 years, 0.23 (0.20 to 0.27) for those who quit aged 35-54, and 0.63 (0.55 to 0.71) for those who quit aged 55. For women the corresponding figures were 0.09 (0.05 to 0.14), 0.26 (0.21 to 0.32), and 0.47 (0.38 to 0.59).
Fig 1 Hazard ratios for lung cancer in men, 1982-8, by smoking status and tar yield of brand smoked, relative to current smokers of brands with tar ratings 15-21 mg
Fig 2 Hazard ratios for lung cancer in women, 1982-8, by smoking status and tar yield of brand smoked, relative to current smokers of brands with tar ratings 15-21 mg
Among men who never smoked, 93 died from lung cancer. Among men who quit smoking, 23 who quit aged 35 years, 344 who quit aged 35-54 years, and 540 who quit aged 55 years died from lung cancer. Among women who never smoked, 211 died from lung cancer. Among women who quit smoking, 16 who quit aged 35 years, 122 who quit aged 35-54 years, and 131 who quit aged 55 years died from lung cancer.
Tables 5 and 6 show multivariate sensitivity analyses in current smokers that examine whether varying the exclusion criteria or the boundaries of the very low tar and low tar categories materially alter the results. In both men and women, the findings were essentially unchanged when people with emphysema and other diseases attributable to smoking were excluded, when the analyses were restricted to people who had smoked their current brand for a minimum of 5 or 10 years, or when the boundaries of the very low or low tar categories were altered slightly.
Table 5 Multivariate analyses of mortality from lung cancer of men who were current smokers, according to tar level of cigarette smoked in 1982*
Table 6 Multivariate analyses of mortality from lung cancer of women who were current smokers, according to tar level of cigarette smoked in 1982*
Discussion
Hoffmann D, Djordjevic M, Brunnemann K. Changes in cigarette design and composition over time and how they influence the yields of smoke constituents. In: Shopland D, ed. The FTC cigarette test method for determining tar, nicotine, and carbon monoxide yields of US cigarettes: report of the NCI expert committee. NCI smoking and tobacco control monograph No 7. Bethesda MD: US National Institutes of Health, National Cancer Institute, 1996: 15-37. (NIH Publication No 96-4028.)
Kozlowski LT, O'Connor RJ, Sweeney CT. Cigarette design. Risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. Bethesda, MD: US National Institutes of Health, National Cancer Institute, NCI Smoking and Tobacco Control, 2001: 13-37. (Monograph No 13.)
Wald N, Doll R, Copeland G. Trends in tar, nicotine, and carbon monoxide yields of UK cigarettes manufactured since 1934. BMJ 1981;282: 763-5.
Kiryluk S, Wald N. Trends in cigarette smoking habits in the United Kingdom, 1905-1985. In: Wald N, Froggatt P, eds. Nicotine, smoking and the low tar programme. Oxford: Oxford University Press, 1989.
Thun MJ, Lally CA, Flannery JT, Calle EE, Flanders WD, Heath CW Jr. Cigarette smoking and changes in the histopathology of lung cancer. J Natl Cancer Inst 1997;89: 1580-6.
Garfinkel L, Stellman SD. Smoking and lung cancer in women: findings in a prospective study. Cancer Res 1988;48: 6951-5.
Ockene JK, Kuller LH, Svendsen KH, Meilahn E. The relationship of smoking cessation to coronary heart disease and lung cancer in the multiple risk factor intervention trial (MRFIT). Am J Public Health 1990;80: 954-8.
Kuller LH, Ockene JK, Meilahn E, Wentworth DN, Svendsen KH, Neaton JD. Cigarette smoking and mortality. MRFIT research group. Prev Med 1991;20: 638-54.
Zang EA, Wynder EL. Cumulative tar exposure. A new index for estimating lung cancer risk among cigarette smokers. Cancer 1992;70: 69-76.
Tang JL, Morris JK, Wald NJ, Hole D, Shipley M, Tunstall-Pedoe H. Mortality in relation to tar yield of cigarettes: a prospective study of four cohorts. BMJ 1995;311: 1530-3.
Vutuc C, Kunze M. Lung cancer risk in women in relation to tar yields of cigarettes. Prev Med 1982;11: 713-6.
Vutuc C, Kunze M. Tar yields of cigarettes and male lung cancer risk. J Natl Cancer Inst 1983;71: 435-7.
Wilcox HB, Schoenberg JB, Mason TJ, Bill JS, Stemhagen A. Smoking and lung cancer: risk as a function of cigarette tar content. Prev Med 1988;17: 263-72.
Bross ID, Gibson R. Risks of lung cancer in smokers who switch to filter cigarettes. Am J Public Health Nations Health 1968;58: 1396-403.
Wynder EL, Mabuchi K, Beattie EJ Jr. The epidemiology of lung cancer. Recent trends. JAMA 1970;213: 2221-8.
Hawthorne VM, Fry JS. Smoking and health: the association between smoking behaviour, total mortality, and cardiorespiratory disease in west central Scotland. J Epidemiol Community Health 1978;32: 260-6.
Todd GF, Hunt BM, Lambert PM. Four cardiorespiratory symptoms as predictors of mortality. J Epidemiol Community Health 1978;32: 267-74.
Wynder EL, Stellman SD. Impact of long-term filter cigarette usage on lung and larynx cancer risk: a case-control study. J Natl Cancer Inst 1979;62: 471-7.
Lee PN, Garfinkel L. Mortality and type of cigarette smoked. J Epidemiol Community Health 1981;35: 16-22.
Rimington J. The effect of filters on the incidence of lung cancer in cigarette smokers. Environ Res 1981;24: 162-6.
Lubin JH, Blot WJ, Berrino F, Flamant R, Gillis CR, Kunze M, et al. Modifying risk of developing lung cancer by changing habits of cigarette smoking. BMJ 1984;288: 1953-6.
Buffler PA, Pickle LW, Mason TP, Contant C. The causes of lung cancer in Texas. In: Mizell M, Correa P, eds. Lung cancer causes and prevention: New York, NY: Verlag Cheim Int, 1984: 83-99.
Benhamou S, Benhamou E, Tirmarche M, Flamant R. Lung cancer and use of cigarettes: a French case-control study. J Natl Cancer Inst 1985;74: 1169-75.
Alderson MR, Lee PN, Wang R. Risks of lung cancer, chronic bronchitis, ischaemic heart disease, and stroke in relation to type of cigarette smoked. J Epidemiol Community Health 1985;39: 286-93.
Pathak DR, Samet JM, Humble CG, Skipper BJ. Determinants of lung cancer risk in cigarette smokers in New Mexico. J Natl Cancer Inst 1986;76: 597-604.
Benhamou E, Benhamou S, Flamant R. Lung cancer and women: results of a French case-control study. Br J Cancer 1987;55: 91-5.
Wynder EL, Kabat GC. The effect of low-yield cigarette smoking on lung cancer risk. Cancer 1988;62: 1223-30.
Benhamou E, Benhamou S, Auquier A, Flamant R. Changes in patterns of cigarette smoking and lung cancer risk: results of a case-control study. Br J Cancer 1989;60: 601-4.
Augustine A, Harris RE, Wynder EL. Compensation as a risk factor for lung cancer in smokers who switch from nonfilter to filter cigarettes. Am J Public Health 1989;79: 188-91.
Lange P, Nyboe J, Appleyard M, Jensen G, Schnohr P. Relationship of the type of tobacco and inhalation pattern to pulmonary and total mortality. Eur Respir J 1992;5: 1111-7.
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Correspondence to: J E Harris Internal Medicine Associates, Massachusetts General Hospital, Boston MA 02114 USA jeharris@partners.org
Abstract
During the past 50 years, changes in the design and manufacture of cigarettes have markedly reduced their machine measured "tar" yields.1 2 The introduction of cellulose acetate filters in the 1950s, and subsequently more porous cigarette papers, reduced the average tar rating per cigarette in the United States from about 37 mg in 1950 to 22 mg in 1967.1 The introduction of air ventilation holes in the filter tip in the late 1960s and expanded tobacco in the 1970s permitted manufacturers to market low tar (generally in the range of 8-14 mg per cigarette) and very low tar cigarettes ( 7 mg per cigarette). Concomitantly, the US average tar level per cigarette, as rated by the US Federal Trade Commission (FTC), declined to about 13 mg by 1990.1 Similar trends in standardised tar yields have been reported in the United Kingdom3 4 and other countries.
While many case-control and cohort studies have examined risk of lung cancer in relation to type of cigarette smoked,5-53 nearly all have compared the risks of smoking high tar non-filter brands with smoking medium tar filter brands,5 14-44 or to the corresponding ranges of tar yield.6-13 45-53 The three case-control studies that have included participants who smoked low tar brands11-13 yielded negative or equivocal results, but the observation periods for these studies ended in 1980-1, when the combined market share of low tar and very low tar cigarettes in the United States had exceeded 10% for only five or six years.54 In most epidemiological studies,7 8 10-13 14-29 34 45-50 52 the observation period ended before 1986, when the market share in the United States had exceeded 10% for only a decade.54 Thus no large, long term prospective study has specifically compared the risk of lung cancer in smokers of medium tar filter cigarettes with that in smokers of low tar and very low tar filter cigarettes.
We analysed the relation between the tar rating of the brand of cigarette smoked in 1982 and mortality from lung cancer over six years among men and women in the cancer prevention study II (CPS-II), a nationwide prospective cohort of over one million US adults aged 30 years or older. We specifically compared the risk of lung cancer among smokers of very low tar ( 7 mg) filter, low tar (8-14 mg) filter, or high tar ( 22 mg) non-filter brands with the risk among those who smoke conventional medium tar (15-21 mg) filter brands.
Methods
Tables 1 and 2 show descriptive characteristics of the cohorts of 100 868 men and 124 270 women who were current smokers at enrolment. Tables 3 and 4 show the corresponding data for the cohorts of 263 371 men and 452 265 women who never smoked or who had quit smoking at enrolment. Smokers of brands with medium or high tar ratings were more likely to be African American; more likely to have attained no more than a high school education; more likely to have a recent blue collar job or a history of potential occupational asbestos exposure; and less likely to report use of vitamins A, C, and E than participants who smoked lower tar brands, who never smoked, or who quit smoking before age 35 years. Current smokers of very low tar cigarettes (especially men) tended to smoke more cigarettes a day. Moreover, among the subset of current smokers who were re-enrolled in the CPS-II nutrition cohort, those men and women who had smoked very low tar and low tar cigarettes in 1982 were more likely to have quit smoking by 1992.
Table 1 Characteristics of men who currently smoked, according to tar level of cigarettes smoked in 1982
Table 2 Characteristics of women who currently smoked, according to tar level of cigarettes smoked in 1982
Table 3 Characteristics of men who had never smoked or were former smokers, according to age when they quit smoking
Table 4 Characteristics of women who had never smoked or were former smokers, according to age when they quit smoking
Figures 1 and 2 show multivariate adjusted hazard ratios and 95% confidence intervals for never smokers, for former smokers who had quit at various ages, and for current smokers of brands with various tar ratings, relative to current smokers of brands with 15-21 mg tar. Men and women who smoked very low tar ( 7 mg) and low tar (8-14 mg) brands had risks of lung cancer indistinguishable from those who smoked medium tar (15-21 mg) brands (Wald test for homogeneity of strata62 P = 0.27 for men, P = 0.80 for women). The risk was higher in those who smoked non-filter cigarettes and substantially lower in men (fig 1) and women (fig 2) who quit smoking. People who quit smoking before age 35 years had risks of lung cancer approaching those of people who had never smoked. Further adjustment for age when people started to smoke and number of cigarettes smoked a day showed nearly identical patterns in current and former smokers to those shown in figures 1 and 2. For men the adjusted figures were 0.06 (0.04 to 0.09) for those who quit aged 35 years, 0.23 (0.20 to 0.27) for those who quit aged 35-54, and 0.63 (0.55 to 0.71) for those who quit aged 55. For women the corresponding figures were 0.09 (0.05 to 0.14), 0.26 (0.21 to 0.32), and 0.47 (0.38 to 0.59).
Fig 1 Hazard ratios for lung cancer in men, 1982-8, by smoking status and tar yield of brand smoked, relative to current smokers of brands with tar ratings 15-21 mg
Fig 2 Hazard ratios for lung cancer in women, 1982-8, by smoking status and tar yield of brand smoked, relative to current smokers of brands with tar ratings 15-21 mg
Among men who never smoked, 93 died from lung cancer. Among men who quit smoking, 23 who quit aged 35 years, 344 who quit aged 35-54 years, and 540 who quit aged 55 years died from lung cancer. Among women who never smoked, 211 died from lung cancer. Among women who quit smoking, 16 who quit aged 35 years, 122 who quit aged 35-54 years, and 131 who quit aged 55 years died from lung cancer.
Tables 5 and 6 show multivariate sensitivity analyses in current smokers that examine whether varying the exclusion criteria or the boundaries of the very low tar and low tar categories materially alter the results. In both men and women, the findings were essentially unchanged when people with emphysema and other diseases attributable to smoking were excluded, when the analyses were restricted to people who had smoked their current brand for a minimum of 5 or 10 years, or when the boundaries of the very low or low tar categories were altered slightly.
Table 5 Multivariate analyses of mortality from lung cancer of men who were current smokers, according to tar level of cigarette smoked in 1982*
Table 6 Multivariate analyses of mortality from lung cancer of women who were current smokers, according to tar level of cigarette smoked in 1982*
Discussion
Hoffmann D, Djordjevic M, Brunnemann K. Changes in cigarette design and composition over time and how they influence the yields of smoke constituents. In: Shopland D, ed. The FTC cigarette test method for determining tar, nicotine, and carbon monoxide yields of US cigarettes: report of the NCI expert committee. NCI smoking and tobacco control monograph No 7. Bethesda MD: US National Institutes of Health, National Cancer Institute, 1996: 15-37. (NIH Publication No 96-4028.)
Kozlowski LT, O'Connor RJ, Sweeney CT. Cigarette design. Risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. Bethesda, MD: US National Institutes of Health, National Cancer Institute, NCI Smoking and Tobacco Control, 2001: 13-37. (Monograph No 13.)
Wald N, Doll R, Copeland G. Trends in tar, nicotine, and carbon monoxide yields of UK cigarettes manufactured since 1934. BMJ 1981;282: 763-5.
Kiryluk S, Wald N. Trends in cigarette smoking habits in the United Kingdom, 1905-1985. In: Wald N, Froggatt P, eds. Nicotine, smoking and the low tar programme. Oxford: Oxford University Press, 1989.
Thun MJ, Lally CA, Flannery JT, Calle EE, Flanders WD, Heath CW Jr. Cigarette smoking and changes in the histopathology of lung cancer. J Natl Cancer Inst 1997;89: 1580-6.
Garfinkel L, Stellman SD. Smoking and lung cancer in women: findings in a prospective study. Cancer Res 1988;48: 6951-5.
Ockene JK, Kuller LH, Svendsen KH, Meilahn E. The relationship of smoking cessation to coronary heart disease and lung cancer in the multiple risk factor intervention trial (MRFIT). Am J Public Health 1990;80: 954-8.
Kuller LH, Ockene JK, Meilahn E, Wentworth DN, Svendsen KH, Neaton JD. Cigarette smoking and mortality. MRFIT research group. Prev Med 1991;20: 638-54.
Zang EA, Wynder EL. Cumulative tar exposure. A new index for estimating lung cancer risk among cigarette smokers. Cancer 1992;70: 69-76.
Tang JL, Morris JK, Wald NJ, Hole D, Shipley M, Tunstall-Pedoe H. Mortality in relation to tar yield of cigarettes: a prospective study of four cohorts. BMJ 1995;311: 1530-3.
Vutuc C, Kunze M. Lung cancer risk in women in relation to tar yields of cigarettes. Prev Med 1982;11: 713-6.
Vutuc C, Kunze M. Tar yields of cigarettes and male lung cancer risk. J Natl Cancer Inst 1983;71: 435-7.
Wilcox HB, Schoenberg JB, Mason TJ, Bill JS, Stemhagen A. Smoking and lung cancer: risk as a function of cigarette tar content. Prev Med 1988;17: 263-72.
Bross ID, Gibson R. Risks of lung cancer in smokers who switch to filter cigarettes. Am J Public Health Nations Health 1968;58: 1396-403.
Wynder EL, Mabuchi K, Beattie EJ Jr. The epidemiology of lung cancer. Recent trends. JAMA 1970;213: 2221-8.
Hawthorne VM, Fry JS. Smoking and health: the association between smoking behaviour, total mortality, and cardiorespiratory disease in west central Scotland. J Epidemiol Community Health 1978;32: 260-6.
Todd GF, Hunt BM, Lambert PM. Four cardiorespiratory symptoms as predictors of mortality. J Epidemiol Community Health 1978;32: 267-74.
Wynder EL, Stellman SD. Impact of long-term filter cigarette usage on lung and larynx cancer risk: a case-control study. J Natl Cancer Inst 1979;62: 471-7.
Lee PN, Garfinkel L. Mortality and type of cigarette smoked. J Epidemiol Community Health 1981;35: 16-22.
Rimington J. The effect of filters on the incidence of lung cancer in cigarette smokers. Environ Res 1981;24: 162-6.
Lubin JH, Blot WJ, Berrino F, Flamant R, Gillis CR, Kunze M, et al. Modifying risk of developing lung cancer by changing habits of cigarette smoking. BMJ 1984;288: 1953-6.
Buffler PA, Pickle LW, Mason TP, Contant C. The causes of lung cancer in Texas. In: Mizell M, Correa P, eds. Lung cancer causes and prevention: New York, NY: Verlag Cheim Int, 1984: 83-99.
Benhamou S, Benhamou E, Tirmarche M, Flamant R. Lung cancer and use of cigarettes: a French case-control study. J Natl Cancer Inst 1985;74: 1169-75.
Alderson MR, Lee PN, Wang R. Risks of lung cancer, chronic bronchitis, ischaemic heart disease, and stroke in relation to type of cigarette smoked. J Epidemiol Community Health 1985;39: 286-93.
Pathak DR, Samet JM, Humble CG, Skipper BJ. Determinants of lung cancer risk in cigarette smokers in New Mexico. J Natl Cancer Inst 1986;76: 597-604.
Benhamou E, Benhamou S, Flamant R. Lung cancer and women: results of a French case-control study. Br J Cancer 1987;55: 91-5.
Wynder EL, Kabat GC. The effect of low-yield cigarette smoking on lung cancer risk. Cancer 1988;62: 1223-30.
Benhamou E, Benhamou S, Auquier A, Flamant R. Changes in patterns of cigarette smoking and lung cancer risk: results of a case-control study. Br J Cancer 1989;60: 601-4.
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