CHEST Original Research

LUNG CANCER

The Association Between Smoking Quantity

and Lung Cancer in Men and Women
Helen A. Powell, BMBS; Barbara Iyen-Omofoman, MBBS, MPH; Richard B. Hubbard, DM;
David R. Baldwin, MD; and Laila J. Tata, PhD

Background: Studies have shown that for the same quantity of cigarettes smoked, women are
more likely to develop heart disease than men, but studies in lung cancer have produced conict-
ing results. We studied the association between smoking quantity and lung cancer in men and
women.
Methods: Using data from The Health Improvement Network (a UK medical research database),
we generated a data set comprising 12,121 incident cases of lung cancer and 48,216 age-, sex-,
and general practice-matched control subjects. We used conditional logistic regression to calculate
ORs for lung cancer according to highest-ever-quantity smoked in men and women separately.
Results: The odds of lung cancer in women who had ever smoked heavily compared with those
who had never smoked were increased 19-fold (OR, 19.10; 95% CI, 16.98-21.49), which was more
than for men smoking the same quantity (OR, 12.81; 95% CI, 11.52-14.24). There was strong
evidence of a difference in effect of quantity smoked on lung cancer between men and women
(interaction P , .0001), which remained after adjusting for height (a proxy marker for lung
volume).
Conclusions: Moderate and heavy smoking carry a higher risk of lung cancer in women than in
men, and this difference does not seem to be explained by lung volume. The ndings suggest that
extrapolating risk estimates for lung cancer in men to women will underestimate the adverse
impact of smoking in women. CHEST 2013; 143(1):123129

Abbreviations: THIN 5 The Health Improvement Network

Lung cancer kills more women than any other can-

cer, and deaths have exceeded those from breast
cancer for the past 20 years.1 Although lung cancer
occurs in nonsmokers, smoking is by far the most impor-
tant risk factor, with . 80% of all lung cancer attrib-
utable to smoking cigarettes.2,3 Smoking prevalence
Manuscript received April 25, 2012; revision accepted June 1,
2012.
Afliations: From the Nottingham Respiratory Research Unit
(Drs Powell and Hubbard) and Division of Epidemiology and
Public Health (Drs Powell, Iyen-Omofoman, Hubbard, and Tata),
University of Nottingham, and Nottingham University Hospitals
National Health Service Trust (Drs Hubbard and Baldwin),
Nottingham, England.
Some of these results have been previously reported in abstract
form (Powell H, Iyen-Omofoman B, Baldwin D, et al. 135 Smoking
and lung cancer in women. Lung Cancer. 2012;75[suppl 1]:S44).
Funding/Support: Dr Hubbard is the GlaxoSmithKline/British
Lung Foundation Professor of Respiratory Epidemiology.
Correspondence to: Helen A. Powell, BMBS, Division of
Epidemiology and Public Health, University of Nottingham, Clinical
Sciences Bldg, Nottingham City Hospital, Hucknall Rd, Nottingham,
NG5 1PB, England; e-mail: helen.powell@nottingham.ac.uk
in women has increased since the end of World War II
to a peak prevalence of about 40% in northern
Europe in the 1980s. Worldwide, at least 250 million
women smoke, and although in high-income coun-
tries the prevalence is generally decreasing, in some
European countries, smoking in women now exceeds
that in men.4
Most studies quantifying smoking-related cancer
risks are in men, and these have been extrapolated
to female populations,5,6 yet evidence from a recent
systematic review showed that women who smoke
have a 25% greater risk of coronary heart disease than
male smokers.7 This relationship has also been exam-
ined in lung cancer but with conicting results,8-13
which may be due to variation in smoking patterns
2013 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.12-1068

journal.publications.chestnet.org CHEST / 143 / 1 / JANUARY 2013 123

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 and prevalence among countries. To our knowledge,
no study has assessed the effect in a UK population.
We used national data from a large UK general
practice database to investigate whether the risk of
lung cancer differs between men and women with
the same recorded quantity of cigarettes smoked. We
also tested the hypothesis that if women are at higher
risk of the effects of cigarette smoke that this may be
because they have smaller lung volumes than men
and, hence, a higher dose per lung volume for the
same number of cigarettes smoked.
Materials and Methods
Study Population
We generated a case-control data set using patient records
from The Health Improvement Network (THIN) database, a
medical research database comprising data entered during con-
sultations within general practice and through communication
from secondary care. Cases comprised patients with a diagnosis
of lung cancer (excluding mesothelioma) rst recorded between
January 2000 and July 2009 and at least 12 months of prospec-
tively computerized data prior to this cancer diagnosis date.
Control subjects were patients with no evidence of current or past
lung cancer, and up to four were matched to each case on sex,
year of birth, and the general practice with which they were regis-
tered. Control subjects were excluded if they had , 12 months of
data before their index date, which was dened as the date of
lung cancer diagnosis in their matched case.
Denition of Exposure
We dened smoking habit as never, current, or ex and quan-
tity as light (1-9 cigarettes/d), moderate (10-19 cigarettes/d), or
heavy ( 20 cigarettes/d) using general practitioners coding or,
where available, number of cigarettes smoked. Where there was
more than one smoking record, we used the highest smoking
quantity recorded before the index date as being most repre-
sentative of lifetime smoking quantity. As a sensitivity analysis,
we repeated our analyses using the last recorded smoking quan-
tity prior to the index or cancer date, excluding the last 6 months
so as not to capture potential reductions in quantity smoked
because of suspicion of lung cancer.
Covariate Denitions
We used the tallest height ever recorded for each individual
as a surrogate for lung volume. Height was categorized accord-
ing to quintile, with 1 being the shortest and 5 being the tallest
category for the population overall (ie, men and women com-
bined). Records for most patients in THIN include a Townsend
deprivation quintile (1 being least deprived), which is derived
from the patients home postal code based on 2001 census data.
Statistical Methods
All statistical analyses were performed using Stata/MP, version 12
(StataCorp LP) software. For the population overall and for men
and women separately, we compared proportions of cases and
control subjects across 10-year age bands, Townsend quintiles,
smoking quantity, and height quintiles. We used a conditional logis-
tic regression model to calculate ORs for lung cancer by smoking
quantity in the data set overall and then used a multiplicative test
124
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for interaction to assess whether the effect of smoking quantity on
lung cancer differed between men and women. P , .01 was con-
sidered statistically signicant. To test the hypothesis that lung
volume (represented by height) explains any difference in effect
of smoking quantity on lung cancer risk, we reassessed whether
the interaction remained after adjusting for height and separately
assessed the relationship of height on lung cancer risk by using
the conditional logistic regression model to estimate ORs for
lung cancer by height quintile.
Results
We identied 12,121 incident cases of lung cancer
between January 2000 and July 2009. We matched
11,960 cases with four control subjects, 84 with three
control subjects, 47 with two control subjects, and
30 with one control subject. Fifty-nine patients (of
whom 49% were women) were aged , 40 years at diag-
nosis and were excluded, as were their 236 matched
control subjects, leaving a total of 60,042 patients
for analysis. Forty-one percent of case subjects were
women. Overall, patients had a median of 9.6 years
of data available. A larger proportion of women than
men had never smoked (41% vs 26%), and the pro-
portion of heavy smokers was higher in men than in
women (19% vs 15%) (Table 1). Fifty-eight percent
of case subjects with lung cancer were moderate or
heavy smokers; this was similar for men and women,
but a higher proportion of women than men who
developed lung cancer were recorded as never smok-
ers (13% vs 8%). Height distribution was as expected,
with the majority of women in quintiles 1 to 3 and
the majority of men in quintiles 3 to 5. There were
no differences in age at diagnosis between men and
women, and the distribution of socioeconomic depri-
vation was very similar.
The odds of lung cancer were much higher in sub-
jects who smoked than in those who never smoked,
with the odds increasing with quantity of cigarettes
smoked (overall OR, 15.13 for the heaviest smokers)
(Table 2). A multiplicative test for interaction showed
strong evidence of a difference in the effect of quan-
tity smoked on lung cancer between men and women
(likelihood ratio test P , .0001). Compared with men
within strata of smoking quantity, the ORs for lung
cancer in women were 1.02 (95% CI, 0.91-1.15) for
never smokers, 1.06 (95% CI, 0.92-1.23) for light
smokers, 1.32 (95% CI, 1.20-1.46) for moderate
smokers, 1.42 (95% CI, 1.31-1.54) for heavy smokers,
0.92 (95% CI, 0.84-1.02) for smokers with unknown
quantity, and 1.25 (95% CI, 1.04-1.50) for those with
missing smoking status. To investigate this relation-
ship further, we performed the same analysis using
the last smoking status recorded prior to the index
date; the results were very similar.
The mean height for the study population was
1.68 0.1 m; this was the same for case subjects and
Original Research
on 01/03/2013
 Table 1Demographics Overall and by Sex

Overall (N 5 60,042)a Men (n 5 35,481)b Women (n 5 24,561)c

Case Subjects Control Subjects Case Subjects Control Subjects Case Subjects Control Subjects
Demographic (n 5 12,062) (n 5 47,980) Total, % (n 5 7,143) (n 5 28,338) Total, % (n 5 4,919) (n 5 19,642) Total, %
Median length of data

journal.publications.chestnet.org
collection, y 9.54 9.56 9.56 9.60 9.64 9.63 9.48 9.47 9.47
Smoking quantity
Never 1,213 (10.1) 17,976 (37.5) 32.0 577 (8.1) 8,655 (30.5) 26.0 636 (12.9) 9,321 (47.5) 40.5
Trivial/light 1,030 (8.5) 3,113 (6.5) 6.9 640 (9.0) 1,978 (7.0) 7.4 390 (7.9) 1,135 (5.8) 6.2
Moderate 2,465 (20.4) 4,859 (10.1) 12.2 1,303 (18.2) 2,904 (10.2) 11.9 1,162 (23.6) 1,955 (10.0) 12.7
Heavy/very heavy 4,547 (37.7) 6,051 (12.6) 17.7 2,712 (38.0) 4,102 (14.5) 19.2 1,835 (37.3) 1,949 (9.9) 15.4

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Smoker but unknown 2,285 (18.9) 10,732 (22.4) 21.7 1,607 (22.5) 7,364 (26.0) 25.3 678 (13.8) 3,368 (17.1) 16.5

For personal use only. No other

quantity

by uses
Missing smoking status 522 (4.3) 5,249 (10.9) 9.6 304 (4.3) 3,335 (11.8) 10.3 218 (4.4) 1,914 (9.7) 8.7

David
Height quintile

without
1.60 m 2,360 (19.6) 9,387 (19.6) 19.6 179 (2.5) 760 (2.7) 2.6 2,181 (44.3) 8,627 (43.9) 44.0
. 1.62 m, 1.66 m 1,826 (15.1) 7,108 (14.8) 14.9 563 (7.9) 2,319 (8.2) 8.1 1,263 (25.7) 4,789 (24.4) 24.6

Kinnison
. 1.66 m, 1.72 m 2,059 (17.1) 8,150 (17.0) 17.0 1,454 (20.4) 5,571 (19.7) 19.8 605 (12.3) 2,579 (13.1) 13.0
. 1.72 m, 1.78 m 2,485 (20.6) 9,623 (20.1) 20.2 2,288 (32.0) 8,827(31.1) 31.3 197 (4.0) 796 (4.1) 4.0

permission.
. 1.78 1,614 (13.4) 6,584 (13.7) 13.7 1,590 (22.3) 6,473 (22.8) 22.7 24 (0.5) 111 (0.6) 0.5
Missing 1,718 (14.2) 7,128(14.9) 14.7 1,069 (15.0) 4,388 (15.5) 15.4 649 (13.2) 2,740 (13.9) 13.8
Townsend quintile

on 01/03/2013
1 (least deprived) 2,064 (17.1) 10,779 (22.5) 21.4 1,289 (18.0) 6,615 (23.3) 22.3 775 (15.8) 4,164 (21.2) 20.1
2 2,233 (18.5) 10,262 (21.4) 20.8 1,366 (19.1) 6,060 (21.4) 20.9 867 (17.6) 4,202 (21.4) 20.6
3 2,420 (20.1) 9,482 (19.8) 19.8 1,452 (20.3) 5,579 (19.7) 19.8 968 (19.7) 3,903 (19.9) 19.8
4 2,638 (21.9) 8,755 (18.2) 19.0 1,530 (21.4) 5,061 (17.9) 18.6 1,108 (22.5) 3,694 (18.8) 19.6
5 (most deprived) 2,232 (18.5) 6,748 (14.1) 15.0 1,237 (17.3) 3,915 (13.8) 14.5 995 (20.2) 2,833 (14.4) 15.6
Missing 475 (3.9) 1,954 (4.1) 4.0 269 (3.8) 1,108 (3.9) 3.9 206 (4.2) 846 (4.3) 4.3
Age at diagnosis or index
date (matched)
40-49 y 315 (2.6) 1,260 (2.6) 2.6 168 (2.4) 672 (2.4) 2.4 147 (3.0) 588 (3.0) 3.0
50-59 y 1,367 (11.3) 5,467 (11.4) 11.4 793 (11.1) 3,172 (11.2) 11.2 574 (11.7) 2,295 (11.7) 11.7
60-69 y 3,236 (26.8) 12,934 (27.0) 26.9 1,951 (27.3) 7,797 (27.5) 27.5 1,285 (26.1) 5,137 (26.2) 26.1

Copyright 2017. Elsevier Inc. All rights reserved.

70-79 y 4,520 (37.5) 18,011 (37.5) 37.5 2,738 (38.3) 10,896 (38.5) 38.4 1,782 (36.2) 7,115 (36.2) 36.2
. 80 y 2,624 (21.8) 10,308 (21.5) 21.5 1,493 (20.9) 5,801 (20.5) 20.6 1,131 (23.0) 4,507 (22.9) 23.0
Data are presented as No. (%), unless otherwise indicated.
aProportions are of population overall.

bProportions are of men overall.

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cProportions are of women overall.

CHEST / 143 / 1 / JANUARY 2013

125
 126
Table 2Odds for Lung Cancer

Overall (N 5 60,042) Men (n 5 35,481) Women (n 5 24,561)

Variable OR (95% CI) Adjusted OR (95% CI) a OR (95% CI) Adjusted OR (95% CI) a OR (95% CI) Adjusted OR (95% CI)a
Smoking quantity
Highest reported
Never 1.00 1.00 1.00 1.00 1.00 1.00
Trivial/light 5.79 (5.26-6.38) 5.83 (5.30-6.42) 5.61 (4.94-6.38) 5.67 (4.99-6.44) 5.75 (4.95-6.68) 5.78 (4.97-6.71)

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Moderate 9.37 (8.63-10.17) 9.43 (8.69-10.24) 8.24 (7.36-9.24) 8.34 (7.44-9.34) 10.78 (9.57-12.15) 10.82 (9.61-12.19)

For personal use only. No other

Heavy/very heavy 15.13 (14.00-16.3) 15.30 (14.15-16.54) 12.81 (11.52-14.24) 13.04 (11.73-14.50) 19.10 (16.98-21.49) 19.19 (17.06-21.29)

by uses
Smoker but unknown quantity 3.61 (3.34-3.91) 3.65 (3.37-3.95) 3.60 (3.23-3.99) 3.64 (3.28-4.05) 3.32 (2.93-3.75) 3.34 (2.95-3.78)

David
Missing smoking status 1.29 (1.15-1.45) 0.99 (0.88-1.12) 1.21 (1.04-1.41) 0.90 (0.76-1.05) 1.34 (1.13-1.60) 1.12 (0.92-1.35)
Smoking (quintiles)

without
Latest reportedb
Never 1.00 1.00 1.00 1.00 1.00 1.00

Kinnison
Ex light 7.01 (6.29-7.82) 7.19 (6.45-8.02) 6.58 (5.68-7.61) 6.79 (5.86-7.85) 7.43 (6.30-8.77) 7.57 (6.42-8.93)

permission.
Ex moderate 8.76 (7.92-9.70) 9.00 (8.12-9.96) 7.77 (6.78-8.91) 8.06 (7.02-9.24) 10.07 (8.62-1.76) 10.22 (8.75-11.93)
Ex heavy 10.77 (9.73-11.92) 11.03(9.96-12.21) 9.27 (8.14-10.56) 9.58 (8.41-10.92) 13.84 (11.68-16.41) 13.99 (11.80-16.58)
Current light 9.32 (8.48-10.25) 9.38 (8.53-10.31) 8.35 (7.35-9.48) 8.42 (7.41-9.56) 10.60 (9.18-12.24) 10.64 (9.21-12.30)

on 01/03/2013
Current moderate 11.78 (10.79-12.87) 11.77 (10.77-12.86) 10.41 (9.21-11.77) 10.44 (9.23-11.81) 13.49 (11.87-15.34) 13.47 (11.85-15.32)
Current heavy 15.02 (13.69-16.48) 14.97 (13.64-16.43) 12.73 (11.24-14.41) 12.72 (11.23-14.41) 18.74 (16.26-21.60) 18.67 (16.20-21.52)
Ex or current smoker unknown quantity 3.91 (3.62-4.23) 3.94 (3.65-4.26) 3.90 (3.52-4.33) 3.95 (3.56-4.38) 3.59 (3.18-4.01) 3.60 (3.19-4.06)
Missing smoking status 1.30 (1.16-1.46) 1.01 (0.90-1.15) 1.22 (1.05-1.43) 0.92 (0.78-1.08) 1.36 (1.14-1.62) 1.14 (0.94-1.37)
Height quintile
1.60 m 1.00 1.00 1.00 1.00 1.00 1.00
. 1.62 m, 1.66 m 1.02 (0.95-1.09) 1.00 (0.92-1.08) 1.03 (0.86-1.24) 0.99 (0.81-1.21) 1.05 (0.97-1.13) 1.04 (0.95-1.14)
. 1.66 m, 1.72 m 1.00 (0.93-1.08) 0.96 (0.88-1.04) 1.11 (0.94-1.32) 1.07 (0.89-1.29) 0.93 (0.84-1.03) 0.91 (0.81-1.02)
. 1.72 m, 1.78 m 1.02 (0.94-1.10) 1.00 (0.92-1.09) 1.11 (0.94-1.32) 1.10 (0.91-1.32) 0.98 (0.83-1.16) 1.03 (0.85-1.24)
. 1.78 m 0.97 (0.89-1.06) 0.97 (0.88-1.07) 1.05 (0.89-1.52) 1.07 (0.88-1.29) 0.85 (0.56-1.33) 0.72 (0.44-4.18)
Missing 0.94 (0.87-1.02) 1.55 (1.42-1.70) 1.02 (0.86-1.23) 1.80 (1.48-2.18) 0.93 (0.84-1.03) 1.38 (1.22-1.57)

Copyright 2017. Elsevier Inc. All rights reserved.

a ORs by smoking quantity adjusted for height; ORs for height adjusted for smoking quantity.
b Excludes records within 6 mo of cancer or index date.

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Original Research
 control subjects. In the overall population, and when
stratied by sex, the ORs for lung cancer were not
signicantly different between the rst (shortest) and
any other height quintiles (Table 2). There were no
differences in smoking quantity according to height
quintile for men or women (data not shown). The inter-
action for the effect of smoking quantity in men and
women remained after adjusting for height (P , .0001).
Discussion
The results suggest that women are more suscep-
tible to cigarette smoke than men. Women who have
ever smoked moderately or heavily have a higher
risk of lung cancer than men who smoked the same
amount. We did not nd any association between
height and risk of lung cancer to support our original
hypothesis that this difference is due to women having
a higher dose of carcinogen per unit lung volume.
Strengths and Weaknesses
To our knowledge, this is the largest study to address
this issue in an unselected population and the rst
in the United Kingdom. We have previously shown
lung cancer incidence in THIN to be representative
of the UK lung cancer population through compar-
ison with data from the National Cancer Registry.14
Exposure data were recorded prospectively, which min-
imizes recall bias. However, THIN relies on patients
consulting their general practitioner and input of
data in general practice, thus, some data are incom-
plete. It is possible that men are less accurate than
women when reporting smoking quantity and that
random misclassication could partly explain the
present results. It is also known that women visit
their general practitioner more often than men, and
from this we could extrapolate that men would be
more likely to have missing data. In this study, the
proportion of men with no data on smoking was
similar to that of women, but 25% of men compared
with only 16% of women were known smokers with
unknown quantity. All ORs for lung cancer in this
category were, however, very similar, suggesting that
a difference in missing data is unlikely to explain the
present results. A higher baseline risk of lung cancer
in men could contribute to the differences observed
in the study, but when we calculated the prevalence
of lung cancer in never smokers of both sexes, it was
virtually the same (men, 6.3%; women, 6.4%).
We dened quantity of cigarettes smoked as the
highest quantity ever reported. We appreciate that
this method will not comprehensively represent
the variation in patients lifetime smoking patterns;
however, it allowed us to obtain a smoking history
for . 90% of a general population-based sample.
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There have been changes in patterns of smoking over
time, and more recently, it appears that women are
less likely to smoke heavily but also less likely to stop
smoking.15 Although we were not able to calculate
the total number of years smoked or years since quit-
ting, as this is often not recorded in general practice
data, we did attempt to assess the potential impact of
lower quit rates in women within the limits of the
data. We estimated ORs for lung cancer based on last
reported smoking quantity and status (current or ex)
prior to index date and still found signicant differ-
ences in risk of lung cancer between male and female
moderate and heavy smokers. Unfortunately, as in
most other studies, we did not have comprehensive
information on passive smoking.
Other Studies
Previous research into the difference in effect of
smoking quantity on development of lung cancer in
men and women includes a case-control study using
US cancer registry data in which 14,596 patients
with lung cancer were compared with 36,438 control
subjects, who were patients with other types of can-
cer diagnosed during the same time period.12 The
risk of lung cancer was found to be higher in women
at each level of smoking. A further US study by
Zang and Wynder8 of 1,889 patients (781 of whom
were women) reported that female smokers had a
1.2- to 1.7-fold increase in odds of lung cancer com-
pared with male smokers for all histologic subtypes.
Bain et al11 studied the effect of smoking quantity
on lung cancer by comparing two separate, large,
previously established US cohorts. One of these stud-
ies was the (female) Nurses Health Study, which
began in 1976, and the second was the 1986 (male)
Health Professionals Follow-up Study. Both studies
used mailed questionnaires to obtain exposure infor-
mation and follow-up questionnaires every 2 years
to provide updated smoking data and information
on newly diagnosed diseases. On combining these
two cohorts, Bain et al11 found 1,266 incident cases
of lung cancer in smokers, having excluded never
smokers from the study. No signicant differences in
hazard ratios for lung cancer between women and
men were found when smokers of , 25 cigarettes/d
were compared with smokers of . 25 cigarettes/d
who started smoking before and after age 20 years.
A more recent prospective cohort study conducted
by Freedman et al10 also failed to demonstrate a dif-
ference between the sexes in the association between
lung cancer risk and quantity of cigarettes smoked.
This study used participant-reported smoking data,
which were collected by mailed questionnaire on
entry to the AARP Diet and Health Study. Of the
3.5 million people to whom the questionnaire was
CHEST / 143 / 1 / JANUARY 2013 127
on 01/03/2013
 originally sent, only 17.6% responded; however, the
questionnaire did include a detailed smoking his-
tory, which allowed the authors to account for the
effects of changes in smoking patterns over time.
A major difference between the present study and
those described here is the study populations and
selection of participants. Freedman et al10 excluded
people who did not provide a complete smoking his-
tory and showed an approximate 5% higher preva-
lence of never smokers in both men and women
compared with the present study. This may reect
selection bias in their study or a difference in smok-
ing patterns between the United States and the
United Kingdom. The importance of assessing the
association in a UK population study is supported
by evidence from an analysis of 31 studies that sug-
gests that effects of smoking on risk of lung cancer
may differ according to country of residence as well
as to sex.16
Explaining the Difference
We used height as a surrogate for lung volume
because this is the predominant determinant of total
lung capacity17 and found no difference in lung can-
cer risk across the quintiles. An alternative expla-
nation for the ndings is related to evidence that
men and women have different breathing, and thus
smoking, patterns. Perhaps carcinogens are depos-
ited in female lungs at a higher concentration because
of the way they smoke, but studies specically investi-
gating this18,19 found that women tend to have smaller
puff volumes with longer time between puffs, result-
ing in a lower nicotine exposure; thus, alternative
explanations should be sought. As suggested by pre-
vious authors, hormonal effects on the metabolism
of carcinogens and on tumor development may play
a role.8 We were unable to break our results down
by histologic subtype, and given the differences in
the incidence and biologic activity of adenocarci-
noma and squamous cell carcinomas of the lung in
men and women and in smokers and never smokers,20
this should be a consideration for future studies.
Clinical Relevance
In the United Kingdom, smoking prevalence in
women increased from around 1945, and although
it never reached the same peak as in men, it did not
start to decline until the mid-1970s. Lung cancer
incidence in women continues to climb gradually,
and unlike in men, it has not yet peaked.21 We have
shown that women appear to be more susceptible to
cigarette smoke, raising the possibility that we may
not see the same smoking cessation-related decline
in lung cancer incidence and mortality in women that
we have seen in men. The difference is not explained
128
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by the fact that women have smaller lungs than men,
but regardless of the explanation, extrapolating cur-
rent data and disease estimates in male populations
to women may underestimate the impact of smoking
in women.
Acknowledgments
Author contributions: Dr Powell had full access to all of the
data in the study and takes responsibility for the integrity of the
data and the accuracy of the data analysis.
Dr Powell: contributed to the majority of the data organization,
all analyses, and writing of the majority of the manuscript.
Dr Iyen-Omofoman: contributed to the initial stages of data orga-
nization and the study concept and design, assisted with writing
the Materials and Methods section, and proofread and approved
the full manuscript prior to submission.
Dr Hubbard: contributed to the study hypothesis and design, data
interpretation and analysis, and revision of the manuscript prior to
submission.
Dr Baldwin: contributed to the study hypothesis and design, data
interpretation and analysis, and revision of the manuscript prior to
submission.
Dr Tata: contributed to the study hypothesis and design, data
interpretation and analysis, and revision of the manuscript prior to
submission.
Financial/nonnancial disclosures: The authors have reported
to CHEST the following conicts of interest: Dr Hubbard has
worked with GlaxoSmithKline plc as a consultant. Dr Baldwin has
sat on an advisory board for Hoffmann-La Roche Inc. Drs Powell,
Iyen-Omofoman, and Tata have reported that no potential con-
icts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Role of sponsors: The sponsor had no role in the design of the
study, the collection and analysis of the data, or in the preparation
of the manuscript.
Other contributions: We thank Tricia McKeever, PhD (University
of Nottingham) for her assistance with the data processing.
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