Comparison of Smoking History Patterns Among African American and White Cohorts in the United States Born 1890 to 1990

Cigarette Smoking and Symptom Burden: Baseline Results From Nine ECOG-ACRIN Cancer Clinical Trials

CONTEXT

Approximately 11% of cancer survivors smoke postdiagnosis.

OBJECTIVES

Understanding the relationship between smoking and perceived cancer-related symptoms may inform tobacco treatment interventions for this population.

METHODS

From 2017 to 2021, 740 adults in 9 ECOG-ACRIN trials provided baseline data. The effects of smoking status on symptoms were evaluated using logistic regression, adjusting for age, gender, race, performance status, treatment setting, and anxiety. Fisher's exact test was used to compare the prevalence of patients reporting that smoking helps/worsens each symptom by smoking status (current vs. former).

RESULTS

Among participants (mean age = 58.8, 93.9% white, 30.3% female, most common cancer types: leukemia [35.5%], lymphoma [19.1%], and prostate [17.7%]), smoking statuses were: 81 current (10.9%), 257 former (34.7%), and 402 (54.3%) never. Patients currently smoking were more likely to experience cough compared to those who formerly (OR = 3.25, P < .0001) or never (OR = 3.70, P < .0001) smoked. Current smoking was associated with greater severity of cough and pain and greater pain interference compared to former and never smoking (OR's > 2.26, P's < .005). Patients currently smoking were more likely to report that smoking helps with nausea (29.4% vs. 1.3%, P < .0001), insomnia (16.4% vs. 0.6%, P < .0001), and pain (16.1% vs. 2.8%, P = .002) compared to those who formerly smoked.

CONCLUSION

Patients currently smoking report greater severity of cancer-related symptoms (i.e., cough, pain) yet were also more likely to believe that smoking helps with nausea, insomnia, and pain. Symptom management should include tobacco cessation, education on smoking and its relationship to symptoms, and strategies to reduce reliance on smoking for symptom relief.

Modelling annual prevalence of tobacco consumption in Spain, 1991-2020

The aim of this study was to estimate the series of tobacco smoking prevalence year-by-year in Spain, by sex and age group, for the period 1991-2020. Based on smoking prevalence obtained from national surveys and smoking-related auxiliary information from public statistics, we fitted a multinomial logistic mixed model with random area and time effects. Joinpoint regression was used to identify changes in the prevalence series across the period. To analyse the precision of the model-based estimates, we calculated the coefficients of variation. Between 1991 and 2020, the prevalence of smoking in Spain decreased in both sexes. In the 15-24 age group, the prevalence of smokers showed no differences by sex until 2007, after which prevalence in men exceeded that of women. However, in women aged 55 and over prevalence of smoking has been rising since 1991. After applying the model, the precision of smoking prevalence estimates improved. The reconstruction of a detailed series of tobacco smoking prevalence provides insight into the evolution of the tobacco epidemic in Spain. A detailed analysis by sex and age shows different trends in the prevalence of smoking among women that should be considered when control measures are formulated.

Analysis of Lung Cancer Incidence in Non-Hispanic Black and White Americans using a Multistage Carcinogenesis Model

PURPOSE

There are complex and paradoxical patterns in lung cancer incidence by race/ethnicity and gender; compared to non-Hispanic White (NHW) males, non-Hispanic Black (NHB) males smoke fewer cigarettes per day and less frequently but have higher lung cancer rates. Similarly, NHB females are less likely to smoke but have comparable lung cancer rates to NHW females. We use a multistage carcinogenesis model to study the impact of smoking on lung cancer incidence in NHB and NHW individuals in the Multiethnic Cohort Study (MEC).

METHODS

The effects of smoking on the rates of lung tumor initiation, promotion, and malignant conversion, and the incidence of lung cancer in NHB versus NHW adults in the MEC were analyzed using the Two-Stage Clonal Expansion (TSCE) model. Maximum likelihood methods were used to estimate model parameters and assess differences by race/ethnicity, gender, and smoking history.

RESULTS

Smoking increased promotion and malignant conversion but did not affect tumor initiation. Non-smoking-related initiation, promotion, and malignant conversion and smoking-related promotion and malignant conversion differed by race/ethnicity and gender. Non-smoking-related initiation and malignant conversion were higher in NHB than NHW individuals, whereas promotion was lower in NHB individuals.

CONCLUSION

Findings suggest that while smoking plays an important role in lung cancer risk, background risk not dependent on smoking also plays a significant and under-recognized role in explaining race/ethnicity differences. Ultimately, the resulting TSCE model will inform race/ethnicity-specific lung cancer natural history models to assess the impact of preventive interventions on US lung cancer outcomes and disparities by race/ethnicity.

Smoking Intensity and Mortality Across Age, Sex, and Race/Ethnicity Subgroups in the USA

OBJECTIVE

To determine whether standardized mortality ratios (SMRs) for smoking vary with age, sex, and race/ethnicity differences in smoking intensity.

METHODS

SMRs for current smoking were computed based on data of adult participants in the National Health Interview Surveys 2000-2003 separately by sex-age and sex-race/ethnicity subgroups. Mortality follow-up was through 2018.

RESULTS

SMRs across sex-age subgroups were highest for men aged 50-59 years (SMR 3.22) and lowest for men aged 80 years or older (SMR 1.10). Variations in SMRs across sex-age subgroups were directly correlated with group differences in median daily cigarette use (Spearman r = 0.70). Across sex-race/ethnicity subgroups, the SMR was highest among White men (SMR 2.39) and lowest among Hispanic men (SMR 1.26) and was again directly correlated with median daily cigarette use (Spearman r = 0.79).

CONCLUSIONS

SMRs for smoking are not singular estimates but rather vary widely with demographic-related differences in smoking intensity. In resource-constrained settings, smoking reduction interventions that target subgroups with higher smoking intensity may be more efficient in reducing smoking-related mortality.

Correlates of nicotine patch adherence in daily life

BACKGROUND

African Americans who smoke are disproportionately affected by the health consequences of smoking. Nicotine replacement therapy (NRT) is effective for helping people successfully quit, yet there are well-documented issues with nicotine patch adherence. This study aimed to examine the real-time associations of risk factors for patch non-adherence [lapse, motivation, self-efficacy, urge, cigarette availability] with patch adherence in a sample of African Americans who smoke and are attempting to quit.

METHODS

Participants were 239 African American adults, 50 % female, and ages 18-74. Ecological momentary assessment was used to assess patch use and risk factors. Multilevel modeling for binary outcomes was used to test concurrent and lagged associations between risk factors and patch use.

RESULTS

Lapse at a previous assessment (OR=0.61, 95 % CI: 0.42, 0.88), and urge (OR=0.77, 95 % CI: 0.66, 0.89) and cigarette availability (OR=0.84, 95 % CI: 0.71, 0.99) at concurrent assessments were associated with lower likelihood of patch use. Concurrent motivation (OR=1.28, 95 % CI: 1.05, 1.55) and self-efficacy (OR=1.31, 95 % CI: 1.06, 1.62) were associated with greater likelihood of patch use. There were no significant lagged associations between motivation, self-efficacy, urge, or cigarette availability with patch use.

DISCUSSION

It is critical to examine correlates of non-adherence among African Americans who smoke because they are less likely to quit and are disproportionately impacted by the health consequences of tobacco use. The results suggest that interventions might focus on promoting patch adherence at certain times (e.g., when cigarettes are available) and/or leveraging the benefits of protective factors (e.g., motivation and self-efficacy).

Cigarette smoking, e-cigarette use, and sociodemographic correlates of mental health and tobacco-related disease risk in the All of Us Research Program

SIGNIFICANCE

Research on the conditions under which electronic cigarette (EC) use produces a net reduction in the population harm attributable to combusted cigarette (CC) use requires the triangulation of information from cohort(s) of smokers, non-smokers, EC users, and dual-users of all varieties.

MATERIALS AND METHODS

This project utilizes data from the All of Us Research Program to contrast a panel of wellness and disease-risk indicators across a range of self-reported tobacco-use profiles, including smokers, current, and former EC users. This article focuses on the tobacco use history and current tobacco use status among All of Us participants enrolled between May 2017 and February 2023 (Registered Controlled Tier Curated Data Repository [CDR] v7).

RESULTS

The present analytic sample included an unweighted total of N = 412 211 individuals with information on ever-use of both CC and EC. Among them, 155 901 individuals have a history of CC use, with 65 206 identified as current smokers. EC usage is reported by 64 002 individuals, with 16 619 being current users. Model predicted analyses identified distinct patterns in CC and EC usage across demographic and socioeconomic variables, with younger ages favoring ECs.

DISCUSSION

Age was observed to significantly affect EC usage, and gender differences reveal that males were significantly more likely to use CC and/or EC than females or African Americans of any gender. Higher educational achievement and income were associated with lower use of both CC and EC, while lower levels of mental health were observed to increase the likelihood of using CC and EC products.

CONCLUSION

Findings suggest the potential for the All of Us Research Program for investigation of causal factors driving both behavioral use transitions and cessation outcomes.

The Development and Performance of Alternative Criteria for Lung Cancer Screening

BACKGROUND

The recommendation for lung cancer screening (LCS) developed by the U.S. Preventive Services Task Force (USPSTF) may exclude some high-benefit people.

OBJECTIVE

To determine whether alternative criteria can identify these high-benefit people.

DESIGN

Model-based projections.

SETTING

United States.

PARTICIPANTS

People from the 1997-2014 National Health Interview Survey (NHIS) to develop alternative criteria using fast-and-frugal tree algorithms and from the 2014-2018 NHIS and the 2022 Behavioral Risk Factor Surveillance System for comparisons of USPSTF criteria versus alternative criteria.

MEASUREMENTS

Life-years gained from LCS were estimated using the life-years gained from screening computed tomography (LYFS-CT) model. "High-benefit" was defined as gaining an average of at least 16.2 days of life from 3 annual screenings, which reflects high lung cancer risk and substantial life gains if lung cancer is detected by screening.

RESULTS

The final alternative criteria were 1) people who smoked any amount each year for at least 40 years, or 2) people aged 60 to 80 years with at least 40 pack-years of smoking. The USPSTF and alternative criteria selected similar numbers of people for LCS. Compared with the USPSTF criteria, the alternative criteria had higher sensitivity (91% vs. 78%; P < 0.001) and specificity (86% vs. 84%; P < 0.001) for identifying high-benefit people. For racial and ethnic minorities, the alternative criteria provided greater gains in sensitivity than the USPSTF criteria (Black: 83% vs. 56% [P < 0.001]; Hispanic: 95% vs. 73% [P = 0.086]; Asian: 94% vs. 68% [P = 0.171]) at similar specificity. The alternative criteria identify high-risk, high-benefit groups excluded by the USPSTF criteria (those with a smoking duration of ≥40 years but <20 pack-years and a quit history of >15 years), many of whom are members of racial and ethnic minorities.

LIMITATION

The results were based on model projections.

CONCLUSION

These results suggest that simple alternative LCS criteria can identify substantially more high-benefit people, especially in some racial and ethnic groups.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs Lung Precision Oncology Program.

Birth-cohort patterns of e-cigarette and other tobacco use among adolescents in the US

BACKGROUND

E-cigarette use has increased considerably among US adolescents. While many studies have described cross-sectional prevalence trends of youth e-cigarette use, less is known about cohort or generational initiation and use patterns.

METHODS

We used data from the US National Youth Tobacco Survey (NYTS) from 2014 to 2022 and age-period-cohort models to analyze age-specific patterns of e-cigarette use initiation and prevalence by cohort and calendar. For comparison, we also examined initiation and prevalence for cigarettes, cigars, and smokeless tobacco, using NYTS data from 1999 to 2022.

RESULTS

Age-specific e-cigarette initiation and prevalence varied considerably by calendar year and birth cohort. There was a rapid increase in e-cigarette initiation and prevalence starting with the 1995 birth cohort, peaking with the 2005 birth cohort, and showing signs of decline with more recent cohorts. In contrast, there were substantial continuous reductions in cigarette, cigar, and smokeless use initiation and prevalence by birth cohort. While the reductions in cigarette smoking started with the 1980s birth cohorts, cigar and smokeless initiation and prevalence did not decrease until the 1990-1995 cohorts.

CONCLUSIONS

Despite their recent emergence, e-cigarette use has varied considerably across US adolescent cohorts. After early increases, e-cigarette use and initiation peaked with the 2005 birth cohort. These patterns are in contrast with the continuous decreases by cohort in cigarette, cigar, and smokeless use and initiation. As the tobacco product landscape continues to evolve, it will be essential to monitor patterns of use of adolescent and young adult cohorts as they age into adulthood.

Smoking patterns by birth cohort in Argentina: an age-period-cohort population-based modeling study

Background

Argentina's smoking rates remain high. We aim to estimate Argentina age-specific histories of smoking initiation, cessation, prevalence, and intensity by birth-cohort to inform policy interventions.

Methods

Modeling study. Data from three Argentinian nationally representative surveys conducted from 2004 to 2018 (n = 268,193) were used to generate smoking histories. The Cancer Intervention and Surveillance Modeling (CISNET) Network Lung Working Group age, period, and cohort modeling approach was used to calculate smoking initiation and cessation probabilities, ever and current smoking prevalence, and intensity (cigarettes per day, CPD) by age, sex, and birth cohort from 1950 to 2018.

Findings

Ever smoking prevalence increases with age up to 25 and decreases with birth cohorts after 1990. Smoking initiation peaks between 15 and 18 years of age. Among females, initiation probabilities increased until the 1955 cohort, reaching a second peak in 1980-85 cohorts and declining thereafter. Males have higher initiation probabilities than females. Among males, initiation has decreased since the 1950 birth cohort, with a slight increase around the 1985 cohort. Current smoking prevalence has been decreasing since the 1960 birth cohort, except for a peak in 1980-85 cohorts. Cessation increases with age. Mean CPD increases with age and peaks around age 40, appearing flat in females since the 1985 cohort.

Interpretation

Recent birth cohorts seem to be experiencing lower rates of initiation, stable rates of quitting and lower current and ever smoking prevalence. The stabilization of cessation probabilities and mean CPD indicate the need to strengthen existing tobacco control measures and advance new ones.

Funding

NIH/NCI U01CA253858 grant.

Cardiovascular Health, Race, and Decline in Cognitive Function in Midlife Women: The Study of Women's Health Across the Nation

BACKGROUND

Cognitive decline may progress for decades before dementia onset. Better cardiovascular health (CVH) has been related to less cognitive decline, but it is unclear whether this begins early, for all racial subgroups, and all domains of cognitive function. The purpose of this study was to determine the impact of CVH on decline in the 2 domains of cognition that decline first in White and Black women at midlife.

METHODS AND RESULTS

Subjects were 363 Black and 402 White women, similar in baseline age (mean±SD, 46.6±3.0 years) and education (15.7±2.0 years), from the Chicago site of the Study of Women's Health Across the Nation. Cognition, measured as processing speed and working memory, was assessed annually or biennially over a maximum of 20 years (mean±SD, 9.8±6.7 years). CVH was measured as Life's Essential 8 (blood pressure, body mass index, glucose, non-high-density lipoprotein cholesterol, smoking, physical activity, diet, sleep). Hierarchical linear mixed models identified predictors of cognitive decline with progressive levels of adjustment. There was a decline in processing speed that was explained by race, age, and the 3-way interaction of race, CVH, and time (F1,4308=8.8, P=0.003). CVH was unrelated to decline in White women but in Black women poorer CVH was associated with greater decline. Working memory did not decline in the total cohort, by race, or by CVH.

CONCLUSIONS

In midlife Black women, CVH promotion may be a target for preventing the beginnings of cognitive decline, thereby enhancing independent living with aging.

The potential impact of removing a ban on electronic nicotine delivery systems using the Mexico smoking and vaping model (SAVM)

Objective

To develop the Mexico Smoking and Vaping Model (Mexico SAVM) to estimate cigarette and electronic nicotine delivery systems (ENDS) prevalence and the public health impact of legalizing ENDS use.

Methods

SAVM, a cohort-based discrete-time simulation model, compares two scenarios. The ENDS-Restricted Scenario estimates smoking prevalence and associated mortality outcomes under the current policy of an ENDS ban, using Mexico-specific population projections, death rates, life expectancy, and smoking and e-cigarette prevalence. The ENDS-Unrestricted Scenario projects smoking and vaping prevalence under a hypothetical scenario where ENDS use is allowed. The impact of legalizing ENDS use is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the ENDS-Restricted and Unrestricted scenarios.

Results

Compared to a national ENDS ban, The Mexico SAVM projects that legalizing ENDS use could decrease smoking prevalence by 40.1% in males and 30.9% in females by 2049 compared to continuing the national ENDS ban. This reduction in prevalence would save 2.9 (2.5 males and 0.4 females) million life-years and avert almost 106 (91.0 males and 15.5 females) thousand deaths between 2025 and 2049. Public health gains decline by 43% to 59,748 SVADs averted when the switching rate is reduced by half and by 24.3% (92,806 SVADs averted) with a 25% ENDS risk level from that of cigarettes but increased by 24.3% (121,375 SVADs averted) with the 5% ENDS risk.

Conclusions

Mexico SAVM suggests that greater access to ENDS and a more permissive ENDS regulation, simultaneous with strong cigarette policies, would reduce smoking prevalence and decrease smoking-related mortality. The unanticipated effects of an ENDS ban merit closer scrutiny, with further consideration of how specific ENDS restrictions may maximize public health benefits.

Does the revised LDCT lung cancer screening guideline bridge the racial disparities gap: Results from the health and retirement study

PURPOSE

This study examined racial/ethnic disparities in lung cancer screening eligibility rates using 2013 US Preventive Services Task Force (USPSTF) guidelines for lung cancer with low-dose computed tomography (LDCT) and the revised 2021 guidelines.

METHODS

The study utilized a retrospective and cross-sectional research design by analyzing data from the Health and Retirement Study (HRS). N = 2,823 respondents aged 50-80 who self-reported current smoking were included in the analyses. Binary logistic regression analysis was conducted to examine the changed status of LDCT screening eligibility based on the revised 2021 guidelines by race/ethnicity after adjusting for respondent demographics.

RESULTS

Our study found substantial increases in screening eligibility rates across racial and ethnic groups when comparing the original and revised guidelines. The largest increase was observed among Black people (174%), Hispanics (152%), those in the other category (118%), and Whites who smoke (80.8%). When comparing original screening guidelines to revised guidelines, Whites who smoke had the highest percentage of changes from "not eligible" to "eligible" (28.3%), followed by individuals in the "other" category (28.1%), Black people (23.2%) and Hispanics who smoke (18.3%) (p < 0.001). Binary logistic regression results further showed that Black people who smoke (OR = 0.71, p = 0.001), as well as Hispanics who smoke (OR=0.54, p < 0.001), were less likely to change from not eligible to eligible for screening compared to Whites who smoke after adopting the revised screening guidelines. Based on the absolute differences in screening eligibility rates between Whites and other racial/ethnic groups, the disparities may have widened under the new guidelines, particularly with larger absolute differences observed between Whites, Black people, and Hispanics.

CONCLUSIONS

Our study highlights racial/ethnic disparities in LDCT screening eligibility among people who currently smoke. While the revised USPSTF guidelines increased screening eligibility for racial and ethnic minorities, they did not eliminate these disparities and may have widened under the new guidelines. Targeted interventions and policies are necessary to address barriers faced by underrepresented populations and promote equitable access to lung cancer screening.

Sex and Racial/Ethnic Patterns of Tobacco Product Use Among Students at a U.S. University in 2021-2023

Background: Although the prevalence of conventional tobacco product use among U.S. college students has declined, an increasing number of students use various novel tobacco products. Objectives: This study aims to examine up-to-date sex and racial/ethnic patterns of tobacco use among students at a U.S. university in 2021-2023. Methods: Data of 2,732 students at an urban university in the Southeast of the U.S. were collected in 2021-2023 as part of the National College Health Assessment of the American College Health Association. Self-reported past 3-month use of five tobacco products (cigarette, electronic vapor products, water pipe/hookah, smokeless tobacco, and cigars) was dichotomized. We conducted multinomial logistic regression analysis to examine sex (male or female) and racial/ethnic (non-Hispanic White, non-Hispanic Black, Hispanic, or non-Hispanic Other) differences in single and dual/poly (con-current use of two or more tobacco products) tobacco use compared to nonuse, adjusting for age, student status, parent education level, obese status, psychological distress level, and survey year. Results: Male students had higher odds of being dual/poly tobacco user than female students, adjusting for covariates (adjusted odds ratio [AOR] = 2.00, 95% confidence interval [CI] = 1.42, 2.82). Non-Hispanic Black students had lower odds of being single (AOR = 0.43, 95% CI = 0.26, 0.69) and dual/poly (AOR = 0.09, 95% CI = 0.02, 0.37) tobacco user compared to non-Hispanic White students, adjusting for covariates. Conclusions: Considering higher health risk of con-current use of multiple tobacco products, dual/poly tobacco use prevention strategies targeting male and non-Hispanic White students may be considered.

Dual and polytobacco use disparities at the intersection of age, sex, race and ethnicity, and income among US adults. Results from the 2018-2019 TUS-CPS

Aim

We aim to describe disparities in dual and polytobacco use at the intersection of age, sex, race and ethnicity, and income.

Methods

We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey to estimate the prevalence of combinations of dual (two products) and polytobacco (three or more products) use for cigarettes, e-cigarettes, cigars, and smokeless tobacco (n = 135,268). We created five mutually exclusive categories: 1) cigarettes and e-cigarettes, 2) cigarettes and cigars, 3) cigarettes and smokeless tobacco, 4) dual/polyuse without cigarettes, and 5) polyuse with cigarettes. We estimated the dual/polyuse prevalence at the intersection of age (18-34, 35-54, 55+ years), sex (male, female), race and ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, and Non-Hispanic Other), and annual household income (<$50,000, $50,000-$99,999, ≥$100,000), resulting in 72 sociodemographic categories. We used a visualization tool that allowed for detailed characterization and identification of dual and polytobacco use disparities.

Results

Females were in three of the top four groups with the highest cigarette and e-cigarette dual use. Cigarette and cigar dual use was disproportionately high among low-income Non-Hispanic Black male adults aged 35-54 and 18-34. The highest prevalence of both polyuse with cigarettes and dual/polyuse without cigarettes was among low-income, Non-Hispanic White male adults aged 18-34 years.

Conclusion

We identified the population groups disproportionately using two or more tobacco products. This information is helpful for surveillance and for the implementation of tobacco control policies aimed at decreasing disparities in tobacco use.

Public health impact of a US menthol cigarette ban on the non-Hispanic black population: a simulation study

INTRODUCTION

With the US Food and Drug Administration recently proposing to implement a ban on menthol cigarettes, it is critical to estimate the potential public health effects of such a ban. With high rates of menthol cigarette use and important smoking-related health disparity implications, the impact of the ban on the non-Hispanic black (NHB) population merits strong consideration.

METHODS

We apply the previously developed Menthol Smoking and Vaping Model to the NHB population. A status quo scenario is developed using NHB-specific population, smoking and vaping initiation, cessation and death rates. Estimates from a recent expert elicitation on behavioural impacts of a menthol cigarette ban on the NHB population are used to develop a menthol ban scenario implemented in 2021. The public health impacts of the menthol ban are estimated as the difference between smoking and vaping attributable deaths (SVADs) and life years lost (LYLs) in the status quo and the menthol ban scenarios from 2021 to 2060.

RESULTS

Under the menthol ban scenario, overall smoking is projected to decline by 35.7% in 2026 and by 25.3% in 2060 relative to the status quo scenario. With these reductions, SVADs are estimated to fall by about 18.5% and LYLs by 22.1%, translating to 255 895 premature deaths averted, and 4.0 million life years gained over a 40-year period.

CONCLUSIONS

A menthol cigarette ban will substantially reduce the smoking-associated health impact on the NHB population, thereby reducing health disparities.

Black Race Remains Associated with Lower Eligibility for Screening Using 2021 US Preventive Services Task Force Recommendations Among Lung Cancer Patients at an Urban Safety Net Hospital

OBJECTIVE

To evaluate whether the revised US Preventive Services Task Force (USPSTF) criteria reduced inequities in lung cancer screening (LCS) eligibility among a racially diverse sample of patients with lung cancer.

METHODS

This is a retrospective analysis of adults diagnosed with primary lung malignancies at an urban safety net hospital. For all patients and exclusively ever-smokers, χ2 tests were used to evaluate differences in LCS eligibility among socio-demographic variables using the 2013 and 2021 USPSTF criteria. Patients who were ineligible for LCS were categorized by reason for exclusion.

RESULTS

Among 678 lung cancer patients (46% female, mean age 66 ± 10 years), 51% were White, and 39% were Black. Using the 2013 guidelines, White patients (57%) would have been more likely to be eligible than Black (37%) and other-race patients (35%) (P < 0.0001) at time of cancer diagnosis. Under the 2021 guidelines, White patients (68%) remained more likely to be eligible for LCS than Black (54%) and other-race patients (48%) (P = 0.0002). Among exclusively ever-smoking patients, we did not observe a significant difference in eligibility by race under the 2021 USPSTF guidelines (White [73%], Black [65%], and other-race [65%]; [P = 0.48]). Sex, ethnicity, education level, and insurance type were not associated with differential screening eligibility under either the 2013 or 2021 guidelines.

CONCLUSION

The revised 2021 USPSTF LCS guidelines may not be sufficient to eliminate racial inequities in LCS eligibility among patients who go on to be diagnosed with primary lung cancer. Differential rates of lung cancer among never-smokers may contribute to this inequity.

The smoking and vaping model, A user-friendly model for examining the country-specific impact of nicotine VAPING product use: application to Germany

BACKGROUND

Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs.

METHODS

SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM's adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data.

RESULTS

Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period.

CONCLUSIONS

SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.

Contribution of smoking, disease history, and survival to lung cancer disparities in Black individuals

BACKGROUND

Lung cancer is the leading cause of cancer deaths and disproportionately affects self-identified Black or African American ("Black") people, especially considering their relatively low self-reported smoking intensity rates. This study aimed to determine the relative impact of smoking history and lung cancer incidence risk, histology, stage, and survival on these disparities.

METHODS

We used 2 lung cancer models (MichiganLung-All Races and MichiganLung-Black) to understand why Black people have higher rates of lung cancer deaths. We studied how different factors, such as smoking behaviors, cancer development, histology, stage at diagnosis, and lung cancer survival, contribute to these differences.

RESULTS

Adjusted for smoking history, approximately 90% of the difference in lung cancer deaths between the overall and Black populations (born in 1960) was the result of differences in the risk of getting lung cancer. Differences in the histology and stage of lung cancer and survival had a small impact (4% to 6% for each). Similar results were observed for the 1950 and 1970 birth cohorts, regardless of their differences in smoking patterns from the 1960 cohort.

CONCLUSIONS

After taking smoking into account, the higher rate of lung cancer deaths in Black people can mostly be explained by differences in the risk of developing lung cancer. As lung cancer treatments and detection improve, however, other factors may become more important in determining differences in lung cancer mortality between the Black and overall populations. To prevent current disparities from becoming worse, it is important to make sure that these improvements are available to everyone in an equitable way.

Trends and Demographic Differences in the Incidence and Mean Age of Starting to Smoke Cigarettes Regularly, National Health Interview Survey, 1997-2018

OBJECTIVES

Surveillance of cigarette smoking behavior provides evidence for evaluating the impact of current tobacco control measures. We examined temporal changes and demographic differences in the incidence and mean age of starting to smoke cigarettes regularly in the United States.

METHODS

We conducted retrospective birth-cohort and cross-sectional analyses using self-reported data from the 1997-2018 National Health Interview Survey to evaluate trends and demographic differences in the incidence and mean age of starting to smoke cigarettes regularly among participants aged 18-84 years. We estimated the incidence and mean age of starting to smoke cigarettes regularly by using Poisson and linear regression.

RESULTS

Among adults born during 1950-1999, the incidence of starting to smoke cigarettes regularly before age 35 years decreased by 18.8% (95% CI, 17.0%-20.7%) per 10 years, with a peak incidence at age about age 18 years. Male, non-Hispanic White, and US-born people had a higher incidence of starting to smoke cigarettes regularly than female, other racial and ethnic, and non-US-born people, respectively (P < .001 for all). From 1997 to 2018, the mean age of starting to smoke cigarettes regularly decreased by 0.4% (95% CI, 0.2%-0.6%) per 10 years among adults who ever smoked.

CONCLUSION

The incidence of starting to smoke cigarettes regularly decreased dramatically at all ages during the study period, which suggests a positive impact of current tobacco control measures. For evaluating trends in starting to smoke cigarettes regularly, incidence can be a more sensitive indicator of temporal change than mean age. Differences in smoking incidence by demographic subgroup suggest that additional opportunities exist to further reduce the incidence of starting to smoke cigarettes regularly.

Tobacco Use and Tobacco Dependence Management

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

Human Capital Development Factors and Black Adolescent Tobacco and Cannabis Use

INTRODUCTION

This study examined the association of four domains of human capital development (cognitive development, social and emotional development, physical health, and mental health) and exclusive and concurrent tobacco and cannabis use (TCU) among black youth.

AIMS AND METHODS

Nationally representative annual cross-sectional data for black adolescents (12-17 years; N = 9017) in the National Survey on Drug Use and Health 2015-2019 were analyzed. Analyses examined the influence of human capital factors (cognitive development, social and emotional development, physical health, and mental health) on exclusive and concurrent TCU.

RESULTS

In total, 50.4% were males; prevalence of 12-month tobacco use fluctuated insignificantly between 5.6% and 7.6% across survey years. Similarly, prevalence of 12-month cannabis use remained relatively stable around 13%, with no significant linear change. Prevalence of concurrent TCU also fluctuated insignificantly between 3.5% and 5.3%. Investment in cognitive development decreased the odds of tobacco (aOR = 0.58, p < .001), cannabis (aOR = 0.64, p < .001), and concurrent tobacco and cannabis (aOR = 0.58, p < .001) use. Similarly, investment in social and emotional development reduced the odds of tobacco (aOR = 086, p < .001), cannabis (aOR = 0.83, p < .001), and concurrent tobacco and cannabis (aOR = 0.81, p < .001) use. Good physical health reduced the odds of tobacco (aOR = 0.52, p < .1), cannabis (aOR = 0.63, p < .05), and concurrent TCU (aOR = 0.54, p < .05). Major depressive episodes increased the likelihood of cannabis use (aOR = 1.62, p < .001).

CONCLUSIONS

Investment in cognitive, social, and emotional aspects of human capital development, and physical health among black youth is protective against TCU. Efforts to sustain human capital development among black adolescents may contribute to reducing TCU disparities.

IMPLICATIONS

This is one of few studies to examine human capital development factors and their associations with TCU among black youth. Efforts to eliminate tobacco/cannabis-related disparities among black youth should also invest in social, emotional, cognitive, and physical health development opportunities.

Sources of Tobacco Smoke Exposure and Their Associations With Serum Cotinine Levels Among US Children and Adolescents

INTRODUCTION

We assessed tobacco smoke exposure (TSE) levels based on private and public locations of TSE according to race and ethnicity among US school-aged children ages 6-11 years and adolescents ages 12-17 years.

AIMS AND METHODS

Data were from 5296 children and adolescents who participated in the National Health and Nutrition Examination Survey (NHANES) 2013-2018. Racial and ethnic groups were non-Hispanic white, black, other or multiracial, and Hispanic. NHANES assessed serum cotinine and the following TSE locations: homes and whether smokers did not smoke indoors (home thirdhand smoke [THS] exposure proxy) or smoked indoors (secondhand [SHS] and THS exposure proxy), cars, in other homes, restaurants, or any other indoor area. We used stratified weighted linear regression models by racial and ethnic groups and assessed the variance in cotinine levels explained by each location within each age group.

RESULTS

Among 6-11-year-olds, exposure to home THS only and home SHS + THS predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic white children exposed to car TSE had higher log-cotinine (β = 1.64, 95% confidence interval [CI] = 0.91% to 2.37%) compared to those unexposed. Non-Hispanic other/multiracial children exposed to restaurant TSE had higher log-cotinine (β = 1.13, 95% CI = 0.23% to 2.03%) compared to those unexposed. Among 12-17-year-olds, home SHS + THS exposure predicted higher log-cotinine among all racial and ethnic groups, except for non-Hispanic black adolescents. Car TSE predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic black adolescents with TSE in another indoor area had higher log-cotinine (β = 2.84, 95% CI = 0.85% to 4.83%) compared to those unexposed.

CONCLUSIONS

TSE location was uniquely associated with cotinine levels by race and ethnicity. Smoke-free home and car legislation are needed to reduce TSE among children and adolescents of all racial and ethnic backgrounds.

IMPLICATIONS

Racial and ethnic disparities in TSE trends have remained stable among US children and adolescents over time. This study's results indicate that TSE locations differentially contribute to biochemically measured TSE within racial and ethnic groups. Home TSE significantly contributed to cotinine levels among school-aged children 6-11 years old, and car TSE significantly contributed to cotinine levels among adolescents 12-17 years old. Racial and ethnic differences in locations of TSE were observed among each age group. Study findings provide unique insight into TSE sources, and indicate that home and car smoke-free legislation have great potential to reduce TSE among youth of all racial and ethnic backgrounds.

Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S

INTRODUCTION

Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics.

METHODS

Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966-2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th-11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020-2021.

RESULTS

Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th-11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group.

CONCLUSIONS

Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education

INTRODUCTION

The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking.

METHODS

Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022.

RESULTS

All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender.

CONCLUSIONS

Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

Patterns of Birth Cohort‒Specific Smoking Histories in Brazil

INTRODUCTION

Smoking prevalence has decreased considerably in Brazil from 34.8% in 1989 to 12.6% in 2019 owing to the implementation of strong tobacco control policies. However, recent data show that the downward trend may be stagnating. Detailed analyses of historical smoking patterns by birth cohort could guide tobacco control decision making in Brazil.

METHODS

Using the 2008 Global Adult Tobacco Survey and the 2013 and 2019 National Health Surveys, historical smoking patterns in Brazil were estimated, supplemented with data from the 2006‒2019 Surveillance System of Risk Factors for Chronic Diseases by Telephone Interviews. Age‒period‒cohort models with constrained natural splines were applied to estimate the annual probabilities of smoking initiation and cessation, current smoker prevalence, and mean cigarettes smoked per day by age, gender, and birth cohort. Analysis was conducted in 2021‒2022.

RESULTS

Current smoker prevalence has declined considerably since the 1950 and 1955 birth cohorts for males and females, respectively, reflecting decreased smoking initiation and increased smoking-cessation probabilities over time. Among female cohorts born on or after 2000, smoking initiation may be increasing even as their smoking cessation has increased considerably. Mean cigarettes smoked per day has remained relatively constant across period and cohorts, showing only a minor decrease among males.

CONCLUSIONS

These detailed cohort-specific smoking parameters can be used to inform models that evaluate the impact of tobacco use and policies on long-term health outcomes and guide public health decision making in Brazil. Stagnant mean cigarettes smoked per day, increasing female smoking initiation, and limited improvement in male cessation among recent cohorts present challenges to tobacco control.

Using the Past to Understand the Future of U.S. and Global Smoking Disparities: A Birth Cohort Perspective

U.S. smoking-related disparities persist, but data evaluating how smoking patterns across diverse populations have changed by birth cohort are lacking. Worldwide, smoking continues to exact harm, especially to low- and middle-income nations with less historical data for smoking analyses. The Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group previously generated smoking histories for the whole U.S. population using an age, period, and birth cohort (APC) methodological framework. These inputs have been used in numerous models to simulate future patterns of smoking and to evaluate the potential impact of policies. However, the absence of detailed model-ready inputs on smoking behaviors for diverse U.S. populations has been a barrier to research evaluating future trends in smoking-related disparities or the projected impacts of policies across sociodemographic groups. This supplement issue provides new estimates of smoking behaviors with detailed historical data by race/ethnicity, educational attainment, family income, and for each of the 50 U.S. states and Washington, DC. All-cause mortality relative risks associated with smoking by race/ethnicity and educational attainment are also available for the first time. Finally, the supplement issue presents comprehensive smoking histories for Brazil, demonstrating the application of this methodology to resource-limited settings. Collectively, these data aim to offer insight into future U.S. and global smoking disparities and accelerate research on tobacco control policies that advance health equity. This effort will allow tobacco simulation models to account comprehensively for population diversity, thereby enabling researchers to develop more sophisticated analyses of tobacco use and control interventions.

Patterns of Birth Cohort‒Specific Smoking Histories by Race and Ethnicity in the U.S

INTRODUCTION

U.S. smoking prevalence varies greatly by race/ethnicity. However, little is known about how smoking initiation, cessation, and intensity vary by birth cohort and race/ethnicity.

METHODS

Adult smoking data were obtained from the 1978-2018 National Health Interview Surveys. Age‒period‒cohort models with constrained natural splines were developed to estimate historical smoking patterns among non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, and non-Hispanic American Indian and Alaskan Native individuals. Annual smoking prevalence and probabilities of smoking initiation, cessation, and intensity by age, year, gender, and race/ethnicity were estimated for the 1900 to 2000 birth cohorts. Analysis was conducted in 2020-2021.

RESULTS

Smoking initiation probabilities were highest for the American Indian and Alaskan Native population, second highest among the non-Hispanic White population, and lowest among Asian and Pacific Islander and Hispanic populations across birth cohorts. Historically, initiation probabilities among non-Hispanic Black populations were comparable with those among non-Hispanic White populations but have decreased since the 1970 birth cohort. Cessation probabilities were lowest among American Indian and Alaskan Native and non-Hispanic Black populations and highest among non-Hispanic White and Asian and Pacific Islander populations across cohorts and ages. Initiation and cessation probabilities produce observed patterns of smoking where prevalence among American Indian and Alaskan Native populations is highest across all ages and cohorts. Across cohorts, smoking prevalence among non-Hispanic Black populations, particularly males, is lower than among non-Hispanic White populations at younger ages but higher at older ages.

CONCLUSIONS

There are important and persistent racial/ethnic differences in smoking prevalence, initiation, cessation, and intensity across U.S. birth cohorts. Targeted interventions should address widening smoking disparities by race/ethnicity, particularly for American Indian and Alaskan Native and non-Hispanic Black populations.

Birth Cohort‒Specific Smoking Patterns by Family Income in the U.S

INTRODUCTION

In the U.S., low-income individuals generally smoke more than high-income individuals. However, detailed information about how smoking patterns differ by income, especially differences by birth cohort, is lacking.

METHODS

Using the National Health Interview Survey 1983-2018 data, individual family income was calculated as a ratio of the federal poverty level. Missing income data from 1983 to 1996 were imputed using sequential regression multivariate imputation. Age‒period‒cohort models with constrained natural splines were used to estimate annual probabilities of smoking initiation and cessation and smoking prevalence and intensity by gender and birth cohort (1900-2000) for 5 income groups: <100%, 100%-199%, 200%-299%, 300%-399%, and ≥400% of the federal poverty level. Analysis was conducted in 2020-2021.

RESULTS

Across all income groups, smoking prevalence and initiation probabilities are decreasing by birth cohort, whereas cessation probabilities are increasing. However, relative differences between low- and high-income groups are increasing markedly, such that there were greater declines in prevalence among those in high-income groups in more recent cohorts. Smoking initiation probabilities are lowest in the ≥400% federal poverty level group for males across birth cohorts, whereas for females, this income group has the highest initiation probabilities in older cohorts but the lowest in recent cohorts. People living below the federal poverty level have the lowest cessation probabilities across cohorts.

CONCLUSIONS

Smoking prevalence has been decreasing in all income groups; however, disparities in smoking by family income are widening in recent birth cohorts. Future studies evaluating smoking disparities should account for cohort differences. Intervention strategies should focus on reducing initiation and improving quit success among low-income groups.

Smoking Histories by State in the U.S

INTRODUCTION

Smoking rates across U.S. states have declined at different rates over time because some states have progressive tobacco control policies, whereas others have yet to adopt them. Therefore, each state has its own unique historical experience of smoking initiation, cessation, and prevalence. This study characterizes smoking histories for each U.S. state by birth cohort.

METHODS

Using 1965-2018 National Health Interview Survey and 1992-2019 Tobacco Use Supplement to the Current Population Survey data, statistical methods applied an age‒period‒cohort modeling framework to reconstruct population-level smoking histories for each state. Smoking initiation, cessation, and intensity by age, gender, and cohort were estimated for each state. These were used to construct state-specific trends in the prevalence of current, former, and never smoking as well as the mean smoking duration and pack years. Analysis was conducted from 2017 to 2022.

RESULTS

California and Kentucky, respectively, are exemplar states of more and less aggressive tobacco control. Initiation probabilities were consistently lower in California than in Kentucky, and cessation probabilities were higher. Hence, the smoking prevalence derived from these parameters is higher in Kentucky. The intensity of cigarette smoking was higher in Kentucky than in California, yielding considerably higher estimated pack years when used with the other parameters. Summaries of smoking trends are given for all states.

CONCLUSIONS

Smoking initiation, cessation, and intensity trends vary substantially across states, resulting in major differences in estimated smoking prevalence, duration, and pack years. Some states show improvements in smoking metrics over time with more recent birth cohorts, but others have shown very little.

Public health impact of a US ban on menthol in cigarettes and cigars: a simulation study

INTRODUCTION

The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs).

METHODS

After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060.

RESULTS

As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications.

CONCLUSIONS AND RELEVANCE

Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.

Policy Recommendations for Reducing Tobacco Exposure for Youth and Adults in Wilmington, Delaware

Objective

To highlight and recommend policies that can be projected to reduce disproportionate tobacco exposure for youth and adults in Wilmington, Delaware's densest and most disadvantaged neighborhoods. Four policy options were drawn from the literature: pharmacy tobacco bans, zoning-based tobacco retailer reductions, residential density caps, and buffers around K-12 schools.

Method

Changes in tobacco retailer density and resident-to-retailer distance in Wilmington's medium- and high- density residentially zoned neighborhoods were projected using GIS analysis of current conditions and projections for each of the four policies.

Results

Banning tobacco sales in pharmacies was found to be least effective, while 500-meter buffers around K-12 schools was projected to have the greatest impact on both retailer density and resident-to-retailer distance.

Policy Implications

As a result of these findings, the authors recommend a ban of tobacco sales with a 500-meter radius of all K-12 schools in the City of Wilmington.

National Cancer Institute Smoking Cessation at Lung Examination Trials Brief Report: Baseline Characteristics and Comparison With the U.S. General Population of Lung Cancer Screening-Eligible Patients

Introduction

The National Cancer Institute Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight clinical trials testing smoking cessation interventions delivered with lung cancer screening (LCS). This investigation compared pooled participant baseline demographic and smoking characteristics of seven SCALE trials to LCS-eligible smokers in three U.S. nationally representative surveys.

Methods

Baseline variables (age, sex, race, ethnicity, education, income, cigarettes per day, and time to the first cigarette) from 3614 smokers enrolled in SCALE trials as of September 2020 were compared with pooled data from the Tobacco Use Supplement-Current Population Survey (2018-2019), National Health Interview Survey (2017-2018), and Population Assessment of Tobacco and Health (wave 4, 2016-2017) using the U.S. Preventive Services Task Force 2013 (N = 4803) and 2021 (N = 8604) LCS eligibility criteria.

Results

SCALE participants have similar average age as the U.S. LCS-eligible smokers using the 2013 criteria but are 2.8 years older using the 2021 criteria (p < 0.001). SCALE has a lower proportion of men, a higher proportion of Blacks, and slightly higher education and income levels than national surveys (p < 0.001). SCALE participants smoke an average of 17.9 cigarettes per day (SD 9.2) compared with 22.4 (SD 9.3) using the 2013 criteria and 19.6 (SD 9.7) using the 2021 criteria (p < 0.001). The distribution of time to the first cigarette differs between SCALE and the national surveys (p < 0.001), but both indicate high levels of nicotine dependence.

Conclusions

SCALE participants smoke slightly less than the LCS-eligible smokers in the general population, perhaps related to socioeconomic status or race. Other demographic variables reveal small but statistically significant differences, likely of limited clinical relevance with respect to tobacco treatment outcomes. SCALE trial results should be applicable to LCS-eligible smokers from the U.S. population.

Associations of lung cancer risk with biomarkers of Helicobacter pylori infection

Helicobacter pylori infection has been suggested to be associated with lung cancer risk. However, information is lacking on whether the association differs by H. pylori antigen. We conducted a nested case-control study within the Southern Community Cohort Study, including 295 incident lung cancer cases and 295 controls. Helicobacter pylori multiplex serology assay was performed to detect antibodies to 15 H. pylori proteins. Conditional logistic regression was used to estimate odds ratios (ORs) and confidence intervals (95% CIs) after adjustment for covariates. Overall H. pylori+ was associated with a non-statistically significant increased risk of lung cancer (OR: 1.29; 95% CI: 0.85-1.95). Significant associations, however, were observed for H. pylori+ VacA+ (OR: 1.64; 95% CI: 1.02-2.62) and H. pylori+ Catalase+ (OR: 1.75; 95% CI: 1.11-2.77). The positive association of H. pylori+ Catalase+ with lung cancer risk was predominantly seen among African Americans (OR: 2.09; 95% CI: 1.11-3.95) but not European Americans (OR: 1.20; 95% CI: 0.56-2.54). Among participants who smoked ≥ 30 pack-years, overall H. pylori+ (OR: 1.85; 95% CI: 1.02-3.35), H. pylori+ CagA+ (OR: 2.77; 95% CI: 1.35-5.70), H. pylori+ VacA+ (OR: 2.53; 95% CI: 1.25-5.13) and H. pylori+ HP1564+ (OR: 2.01; 95% CI: 1.07-3.77) were associated with increased risk of lung cancer. Our study provides novel evidence that associations of H. pylori infection with lung cancer risk differ by H. pylori biomarker, may be more evident among African Americans and may be modified by smoking habits. Furthermore, studies are warranted to confirm our findings.

Understanding long-term trends in smoking in England, 1972-2019: an age-period-cohort approach

BACKGROUND AND AIMS

Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour.

DESIGN

APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys.

SETTING

England (1972-2019).

PARTICIPANTS

Individuals aged 18-90 years.

MEASUREMENTS

We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years.

FINDINGS

Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25.

CONCLUSIONS

Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25.

Profiles of substance use related protective and risk factors and their associations with alcohol and tobacco use initiation among black adolescents

Insufficient attention to protective and risk factors of particular salience for Black youth (e.g., racial identity and racial discrimination) in population-based substance use studies has left gaps in our understanding of alcohol and tobacco use development in Black adolescents. The current study aimed to capture the clustering of such understudied factors and their collective influence on alcohol and tobacco use initiation among Black adolescents. Data were drawn from The National Survey of American Life (n = 1,170; age range = 13-17; 6.9% Afro Caribbean, 93.1% African American; 50.0% female). Latent profile analysis applied to 11 indicators representing family, community, and individual level protective and risk factors revealed (1) High Vulnerability (high risk, low protective factors; 17.5%), (2) Moderate Vulnerability (moderate on both; 63.2%), and (3) Low Vulnerability (high protective, low risk factors; 19.3%) classes. Classes differed significantly by religious community support, school bonding, quality of relationship with mother, religious involvement, and interpersonal trauma. Relative to Class 2, Class 1 had higher odds of alcohol (OR = 1.518, CI:1.092-2.109) and tobacco use (OR = 1.998, CI:1.401-2.848); Class 3 had lower odds of alcohol (OR = 0.659, CI:0.449-0.968) but not tobacco use (OR = 0.965, CI:0.611-1.523). Findings suggest that alcohol and tobacco use initiation among Black adolescents is shaped by the collective influence of community and family level support, with commonly experienced risk factors such as non-interpersonal trauma distinguishing liability to a lesser degree. The equally modest prevalence of tobacco use among low and moderate vulnerability classes further indicates that fostering these connections may be especially effective in reducing tobacco use risk.

Individual Health Determinants that Predict Low Risk of Transitioning to Tobacco Use During Young Adulthood: An in-Depth Examination of Race and Ethnicity

Introduction

The present study examines the contributions of individual-level health determinants on young adult tobacco use initiation to improve understanding of racial and ethnic distinctions and to inform effective tobacco prevention strategies.

Methods

Using time-to-event analyses, the 10–wave (2011–2016) Truth Initiative Young Adult Cohort, a probability-based, nationally representative sample of the US young adults aged 18–34 years (N = 7 665), provides data to examine differences in variables that influence tobacco uptake, by race and ethnicity.

Results

Among Non–Hispanic White young adults, having fewer peers who smoke cigarettes is protective against any tobacco initiation, whereas hazard of tobacco initiation increases for males, having low confidence to resist smoking, and having higher proclivity for sensation seeking. Depressive and anxiety symptoms increase uptake hazard most in the Non–Hispanic All Other Races group and least among Non–Hispanic Black individuals. Among Hispanic young adults, being female and perceiving tobacco as harmful are notably protective while being male is a notable uptake hazard. Unlike other groups, higher income levels do not lower hazards among Hispanic individuals. Cannabis use and overestimating the smoking rate among peers increase hazard least among Hispanic individuals. In the Non–Hispanic All Other Races group, aging is least protective; hazard increases notably if individuals engage in regular alcohol or cannabis use.

Conclusions

Tobacco prevention efforts are critical during young adulthood. Specific tobacco uptake hazard and protective factors exist by race and ethnicity and should be considered when developing selective young adult prevention, particularly among groups with the highest risk for tobacco initiation during this life stage.

Implications

Rising rates of tobacco initiation among the US young adults necessitate expanded efforts to prevent tobacco use initiation and progression beyond youth. Results highlight nuanced and differential tobacco uptake hazards by race and ethnicity for late initiation and sustained non–tobacco use among young adults. The study confirms existing evidence on tobacco use patterns and contributes to new knowledge on risk and protective factors. Tobacco prevention and control interventions, including policies, tailored in more meaningful ways could reduce tobacco use disparities among those most disproportionately affected.

Racial Disparities in Cigarette Smoking Behaviors and Differences Stratified by Metropolitan Area of Residence

Background: Black cigarette smokers experience a disproportionate burden of non-small cell lung cancer (NSCLC) compared to other racial and ethnic groups, despite starting to smoke later in life, smoking less frequently, and smoking fewer cigarettes per day compared with White smokers. Research has shown that these disparities in NSCLC are wider in rural areas. Objective: To examine differences in smoking behaviors between Black and White individuals living in non-metropolitan areas and metropolitan areas. Methods: Using harmonized data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) years 2010–2011, 2014–2015, and 2018–2019, we compared smoking behaviors between Black and White current and former smokers by metropolitan status (i.e., whether an individual lives in a densely populated area or not) and by both metropolitan status and sex. Results: Smoking prevalence was higher among White participants living in non-metropolitan versus Black participants. Further, in non-metropolitan areas, Black individuals reported smoking fewer cigarettes per day, fewer years of smoking, and a later age of initiation compared to White individuals. Additionally, Black individuals, especially men, were more likely than White individuals to be current non-daily smokers. Conclusions: Our findings show that Black individuals living in non-metropolitan areas do not, in aggregate, have more cigarette smoking exposure relative to White individuals. Additional research is needed to further understand smoking-related exposures and other factors that may contribute to lung cancer disparities, especially in non-metropolitan areas.

Lung cancer screening use and implications of varying eligibility criteria by race and ethnicity: 2019 Behavioral Risk Factor Surveillance System data

BACKGROUND

In 2021, the US Preventive Services Task Force (USPSTF) expanded the eligibility criteria for low-dose computed tomographic lung cancer screening (LCS) to reduce racial disparities that resulted from the 2013 USPSTF criteria. The annual LCS rate has risen slowly since the 2013 USPSTF screening recommendations. Using the 2019 Behavioral Risk Factor Surveillance System (BRFSS), this study 1) describes LCS use in 2019, 2) compares the percent eligible for LCS using the 2013 versus 2021 USPSTF criteria, and 3) determines the percent eligible using the more detailed PLCOm2012_Race3L risk-prediction model.

METHODS

The analysis included 41,544 individuals with a smoking history from states participating in the BRFSS LCS module who were ≥50 years old.

RESULTS

Using the 2013 USPSTF criteria, 20.7% (95% confidence interval [CI], 19.0-22.4) of eligible individuals underwent LCS in 2019. The 2013 USPSTF criteria was compared to the 2021 USPSTF criteria, and the overall proportion eligible increased from 21.0% (95% CI, 20.2-21.8) to 34.7% (95 CI, 33.8-35.6). Applying the 2021 criteria, the proportion eligible by race was 35.8% (95% CI, 34.8-36.7) among Whites, 28.5% (95% CI, 25.2-31.9) among Blacks, and 18.0% (95% CI, 12.4-23.7) among Hispanics. Using the 1.0% 6-year threshold that is comparable to the 2021 USPSTF criteria, the PLCOm2012_Race3L model selected more individuals overall and by race.

CONCLUSIONS

Using data from 20 states and using multiple imputation, higher LCS rates have been reported compared to prior BRFSS data. The 2021 expanded criteria will result in a greater number of screen-eligible individuals. However, risk-based screening that uses additional risk factors may be more inclusive overall and across subgroups.

LAY SUMMARY

In 2013, lung cancer screening (lung screening) was recommended for high risk individuals. The annual rate of lung screening has risen slowly, particularly among Black individuals. In part, this racial disparity resulted in expanded 2021 criteria. Survey data was used to: 1) describe the number of people screened in 2019, 2) compare the percent eligible for lung screening using the 2013 versus 2021 guidelines, and 3) determine the percent eligible using more detailed criteria. Lung screening rates increased in 2019, and the 2021 criteria will result in more individuals eligible for screening. Using additional criteria may identify more individuals eligible for lung screening.

Longitudinal Associations Between Changes in Cigarette Smoking and Alcohol Use, Eating Behavior, Perceived Stress, and Self-Rated Health in a Cohort of Low-Income Black Adults

BACKGROUND

Black adults in the U.S. experience significant health disparities related to tobacco use and obesity. Conducting observational studies of the associations between smoking and other health behaviors and indicators among Black adults may contribute to the development of tailored interventions.

PURPOSE

We examined associations between change in cigarette smoking and alcohol use, body mass index, eating behavior, perceived stress, and self-rated health in a cohort of Black adults who resided in low-income urban neighborhoods and participated in an ongoing longitudinal study.

METHODS

Interviews were conducted in 2011, 2014, and 2018; participants (N = 904) provided at least two waves of data. We fit linear and logistic mixed-effects models to evaluate how changes in smoking status from the previous wave to the subsequent wave were related to each outcome at that subsequent wave.

RESULTS

Compared to repeated smoking (smoking at previous and subsequent wave), repeated nonsmoking (nonsmoking at previous and subsequent wave) was associated with greater likelihood of recent dieting (OR = 1.59, 95% CI [1.13, 2.23], p = .007) and future intention (OR = 2.19, 95% CI [1.61, 2.98], p < .001) and self-efficacy (OR = 1.64, 95% CI [1.21, 2.23], p = .002) to eat low calorie foods, and greater odds of excellent or very good self-rated health (OR = 2.47, 95% CI [1.53, 3.99], p < .001). Transitioning from smoking to nonsmoking was associated with greater self-efficacy to eat low calorie foods (OR = 1.89, 95% CI [1.1, 3.26], p = .021), and lower perceived stress (β = -0.69, 95% CI [-1.34, -0.05], p = .036).

CONCLUSIONS

We found significant longitudinal associations between smoking behavior and eating behavior, perceived stress, and self-rated health. These findings have implications for the development of multiple behavior change programs and community-level interventions and policies.

Examining Menthol Preference as a Correlate of Change in Cigarette Smoking Behavior over a One-Year Period

Menthol cigarette use has been shown to be a contributing factor in the changes in smoking over time among youth. The current study aim was to use prospective survey data to identify if menthol cigarette use was associated with changes in smoking among adults. A representative cohort from the 2010 U.S. Tobacco Use Supplement to the Current Population Survey was interviewed at two time points one year apart. Respondents were past-30-day cigarette smokers at Wave 1 or Wave 2 categorized by menthol vs. non-menthol flavor preference (n = 3668). Trajectories were categorized as maintained, increased, or decreased smoking behavior between Waves. Multinomial logistic regressions examined if menthol cigarette use was associated with an increase/decrease in smoking behavior, adjusting for age, race/ethnicity, and sex. Menthol cigarette use was not associated with change over time in cigarette smoking in adult smokers. Age, race/ethnicity and sex were associated with changes in cigarette smoking. Young (vs. older) adults were more likely to increase smoking. Black and Hispanic smokers (vs. white smokers) were more likely to report any change in smoking. Males were less likely than females to change smoking behavior. Menthol status was not associated with changes in smoking among adults; however, young age, race/ethnicity, and sex were, suggesting populations to target for intervention.

Disparities in Surgical Oncology: Management of Advanced Cancer

Significant variations in the patterns of care, incidence, and mortality rates of several common cancers have been noted. These disparities have been attributed to a complex interplay of factors, including genetic, environmental, and healthcare-related components. Within this review, primarily focusing on commonly occurring cancers (breast, lung, colorectal), we initially summarize the burden of these disparities with regard to incidence and screening patterns. We then explore the interaction between several proven genetic, epigenetic, and environmental influences that are known to contribute to these disparities.

Social class discrimination as a predictor of first cigarette use and transition to nicotine use disorder in Black and White youth

PURPOSE

To characterize the association of social class discrimination with the timing of first cigarette use and progression to DSM-IV nicotine dependence (ND) in Black and White youth, examining variation by race, parent vs. youth experiences of discrimination, socioeconomic status (SES), and stage of smoking.

METHODS

Data were drawn from 1461 youth (55.2% Black, 44.8% White; 50.2% female) and mothers in a high-risk family study of alcohol use disorder and related conditions. Cox proportional hazard regression analyses were conducted, using youth's and mother's social class discrimination to predict first cigarette use and progression to ND, stratifying by race. Interactions between discrimination and SES indicators (parental education and household income) were tested. Adjusted models included psychiatric covariates.

RESULTS

In the adjusted first cigarette use models, neither youth's nor mother's social class discrimination was a significant predictor among Black youth, but mother's discrimination was associated with increased risk [HR = 1.53 (1.18-1.99)] among White youth. In the adjusted ND models, mother's discrimination was associated with reduced ND risk for Black youth in middle-income families [HR = 0.29 (CI 0.13-0.63)], but neither youth's nor mother's discrimination predicted transition to ND among White youth.

CONCLUSIONS

The observed race and smoking stage-specific effects suggest that social class discrimination is more impactful on early stages of smoking for White youth and later stages for Black youth. The robustness of links with mother's discrimination experiences further suggests the importance of considering family-level effects and the need to explore possible mechanisms, such as socialization processes.

Birth-cohort estimates of smoking initiation and prevalence in 20th century Australia: Synthesis of data from 33 surveys and 385,810 participants

The aim of our study was to quantify sex-specific patterns of smoking prevalence and initiation in 10-year birth cohorts from 1910 to 1989 in Australia. We combined individual data of 385,810 participants from 33 cross-sectional surveys conducted between 1962 and 2018. We found that age-specific smoking prevalence varied considerably between men and women within birth cohorts born before 1960. The largest difference was observed in the earliest cohort (1910-1919), with up to 37.7% point greater proportion of current smokers in men than in women. In subsequent cohorts, the proportion decreased among men, but increased among women, until there was no more than 7.4% point difference in the 1960-69 birth cohort. In the 1970-79 and 1980-89 cohorts, smoking among men marginally increased, but the proportion was at most ~11.0% points higher than women. Our analysis of initiation indicated that many women born before the 1930s who smoked commenced smoking after age 25 years (e.g., ~27% born in 1910-19); compared to at most 8% of men in any birth cohort. The earliest birth cohort (1910-1919) had the greatest difference in age at initiation between sexes; 26.6 years in women versus 19.0 in men. In later cohorts, male and female smokers initiated increasingly earlier, converging in the 1960-69 cohort (17.6 and 17.8 years, respectively). While 22.9% of men and 8.4% of women initiated smoking aged < = 15 in the 1910-1919 cohort, in the latest cohort (1980-89) the reverse was true (21.4% and 28.8% for men and women, respectively). Marked differences in smoking prevalence and age at initiation existed between birth cohorts of Australian men and women born before 1960; after this, sex-specific trends in prevalence and initiation were similar. Understanding these patterns may inform the evaluation of tobacco control policies and the targeting of potential interventions for exposed populations such as lung cancer screening.

Disparities of National Lung Cancer Screening Guidelines in the US Population

BACKGROUND

Current US Preventive Services Task Force (USPSTF) lung cancer screening guidelines are based on smoking history and age (55-80 years). These guidelines may miss those at higher risk, even at lower exposures of smoking or younger ages, because of other risk factors such as race, family history, or comorbidity. In this study, we characterized the demographic and clinical profiles of those selected by risk-based screening criteria but were missed by USPSTF guidelines in younger (50-54 years) and older (71-80 years) age groups.

METHODS

We used data from the National Health Interview Survey, the CISNET Smoking History Generator, and results of logistic prediction models to simulate lifetime lung cancer risk-factor data for 100 000 individuals in the 1950-1960 birth cohorts. We calculated age-specific 6-year lung cancer risk for each individual from ages 50 to 90 years using the PLCOm2012 model and evaluated age-specific screening eligibility by USPSTF guidelines and by risk-based criteria (varying thresholds between 1.3% and 2.5%).

RESULTS

In the 1950 birth cohort, 5.4% would have been ineligible for screening by USPSTF criteria in their younger ages but eligible based on risk-based criteria. Similarly, 10.4% of the cohort would be ineligible for screening by USPSTF in older ages. Notably, high proportions of blacks were ineligible for screening by USPSTF criteria at younger (15.6%) and older (14.2%) ages, which were statistically significantly greater than those of whites (4.8% and 10.8%, respectively; P < .001). Similar results were observed with other risk thresholds and for the 1960 cohort.

CONCLUSIONS

Further consideration is needed to incorporate comprehensive risk factors, including race and ethnicity, into lung cancer screening to reduce potential racial disparities.

Modeling historic incidence trends implies early field cancerization in esophageal squamous cell carcinoma

Patterns of cancer incidence, viewed over extended time periods, reveal important aspects of multistage carcinogenesis. Here we show how a multistage clonal expansion (MSCE) model for cancer can be harnessed to identify biological processes that shape the surprisingly dynamic and disparate incidence patterns of esophageal squamous cell carcinoma (ESCC) in the US population. While the dramatic rise in esophageal adenocarcinoma (EAC) in the US has been largely attributed to reflux related increases in the prevalence of Barrett’s esophagus (BE), the premalignant field in which most EAC are thought to arise, only scant evidence exists for field cancerization contributing to ESCC. Our analyses of incidence patterns suggest that ESCC is associated with a premalignant field that may develop very early in life. Although the risk of ESCC, which is substantially higher in Blacks than Whites, is generally assumed to be associated with late-childhood and adult exposures to carcinogens, such as from tobacco smoking, alcohol consumption and various industrial exposures, the temporal trends we identify for ESCC suggest an onset distribution of field-defects before age 10, most strongly among Blacks. These trends differ significantly in shape and strength from field-defect trends that we estimate for US Whites. Moreover, the rates of ESCC-predisposing field-defects predicted by the model for cohorts of black children are decreasing for more recent birth cohorts (for Blacks born after 1940). These results point to a potential etiologic role of factors acting early in life, perhaps related to nutritional deficiencies, in the development of ESCC and its predisposing field-defect. Such factors may explain some of the striking racial differences seen in ESCC incidence patterns over time in the US.

We used a cell-level carcinogenesis model to analyze incidence patterns of esophageal squamous cell carcinoma (ESCC) in the US. We found an important role of an esophageal field-defect that is predicted to occur predominantly in childhood and predisposes to ESCC in adult life. Age-specific ESCC incidence patterns are also known to differ considerably between Blacks and Whites, and between males and females in the US, but the model consistently predicts early-childhood field-defects in all four groups. The estimated historical field-defect trends appear consistent with possible early childhood nutritional deficiencies.

Public health implications of vaping in the USA: the smoking and vaping simulation model

Background

Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA.

Methods

SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses.

Results

The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters.

Discussion

Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data.

Conclusion

The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00250-7.

Disparities in Lung Cancer Screening: A Review

Lung cancer is the leading cause of cancer mortality in the United States. Certain groups are at increased risk of developing lung cancer and experience greater morbidity and mortality than the general population. Lung cancer screening provides an opportunity to detect lung cancer at an early stage when surgical intervention can be curative; however, current screening guidelines may overlook vulnerable populations with disproportionate lung cancer burden. This review aims to characterize disparities in lung cancer screening eligibility, as well as access to lung cancer screening, focusing on underrepresented racial/ethnic minorities and high-risk populations, such as individuals with human immunodeficiency virus. We also explore potential system- and patient-level barriers that may influence smoking patterns and healthcare access. Improving access to high-quality health care with a focus on smoking cessation is essential to reduce the burden of lung cancer experienced by vulnerable populations.