Going up or coming down? The changing phases of the lung cancer epidemic from 1967 to 1999 in the 15 European Union countries

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Abstract

Lung cancer, the most common cause of cancer death in the European Union (EU), continues to have an enormous impact on the health experience of the men and women living in the constituent countries. Information on the course of the lung cancer epidemic is essential in order to formulate an effective cancer control policy. This paper examines recent trends in lung cancer mortality rates in men and women in each of the 15 countries, comparing cross-sectional rates of death in younger (aged 30–64 years) and older populations (aged 65 years or over), and the age, period of death, and birth cohort influences in the younger age group. The latter analysis establishes the importance of year of birth, related to modifications in the tobacco habit among recently born generations. The stage of evolution of the lung cancer epidemic varies markedly by sex and country in terms of the direction, magnitude, and phase of development of national trends. In males, there is some consistency in the direction of the trends between EU countries, declines are apparent in most countries, at least in younger men, with rates in older men either reaching a plateau, or also falling. In younger persons, a decreasing risk of lung cancer death reflects changes in successive birth cohorts, due to modifications in the smoking habit from generation to generation, although these developments are in very different phases across countries. Portugal is the exception to the male trends; there are increases in mortality in both age groups, with little sign of a slowing down by birth cohort. In women, there are unambiguous upsurges in rates seen in younger and older women in almost all EU countries in recent decades, and little sign that the epidemic has or will soon reach a peak. The exceptions are the United Kingdom (UK) and Ireland, where lung cancer death rates are now declining in younger women and stabilising in older women, reflecting a declining risk in women born since about 1950. It is too early to say whether the observed plateau or decline in rates in women born very recently in several countries is real or random. To ascertain whether recent trends in lung cancer mortality will continue, trends in cigarette consumption should also be evaluated. Where data are available by country, the proportion of adult male smokers has, by and large, fallen steadily in the last five decades. In women, recent smoking trends are downwards in Belgium, Denmark, Sweden and the Netherlands, although in Austria and Spain, large increases in smoking prevalence amongst adults are emerging. Unambiguous public health messages must be effectively conveyed to the inhabitants of the EU if the lung cancer epidemic is to be controlled. It is imperative that antitobacco strategies urgently target women living in the EU, in order to halt their rapidly increasing risk of lung cancer, and prevent unnecessary, premature deaths among future generations of women.

Introduction

Lung cancer is the most common cause of death from cancer in the European Union (EU). Over 180 000 deaths were estimated in 1997 [1], representing nearly one-third of the total cancer mortality experienced in the 15 constituent countries. Over three-quarters of these deaths were in men. Tobacco smoking has long been established as the principal cause of lung cancer 2, 3, 4, 5, and in 1995, was estimated to account for 90% of lung cancer deaths among men, and around 60% in women, although a great deal of variation was present between countries [6].

The lung cancer epidemic continues to have an enormous impact on the health experience of the men and women living in the EU countries. The public health resources required to meet these needs are correspondingly large. Information on the evolution of the lung cancer epidemic is therefore essential to formulate effective cancer control policies. Previous studies have revealed the divergent trends in lung cancer mortality rates across EU countries 7, 8, 9. The variation is related primarily to the prevalence and intensity of cigarette smoking in different countries, the main form of tobacco consumed in the EU.

This paper describes the key characteristics of the current lung cancer epidemic in each of the 15 countries in the EU, using an analysis of time trends in national mortality between 1967 and 1999. The independent effects of age, period of death and generation of birth (cohort) on the evolution of trends are evaluated in men and women aged between 30 and 64 years at the time of death. The emphasis on the evolution of death rates in younger populations highlights the change in risk between recent generations, related to changes in tobacco consumption patterns. As Muir and colleagues [10] rationalise, such trends are “uncomplicated by the effect of changes in the prevalence of carcinogenic agents in the distant past, which may have a major effect on the trends in the old”. This overview provides an indication of the overall effectiveness of national and regional prevention strategies within the EU. On the basis of these and recent trends in the prevalence of smoking, the potential future development of the disease burden in the EU is discussed.

Section snippets

Data sources

Mortality from malignant neoplasms of the trachea, bronchus and lung were extracted from the World Health Organization (WHO) Mortality Databank for each EU country, by 5-year age group and sex, using the rubric 162 according to the ICD-8 and ICD-9 revisions. Data were available covering a 30-year span for the following countries: Austria (1970–1999), Denmark (1967–1996), Finland (1969–1998), France (1968–1997), Greece (1969–1998), Ireland (1968–1997), Italy (1968–1997), The Netherlands

Results

In the text that follows the terms ‘younger’ and ‘under 65 years’ are used as synonyms for persons aged from 30 to 64 years; and ‘older’, for persons aged 65 years or above.

Discussion

This paper brings together the most recent trends in lung cancer mortality rates in the 15 countries of the EU. The focus is on a systematic analysis of the cross-sectional trends by age in men and women, and, subsequently, how the joint effects of age, period and cohort influence lung cancer mortality trends in persons (aged under 65 years). The objectives of such a synthesis were to identify the major changes in trends, highlighting the successes and failures of lung cancer prevention efforts

Acknowledgements

The Comprehensive Cancer Monitoring Programme in Europe (CaMon) project is funded by the European Commission, Agreement No. Sl2.327599 (2001CVG3-512).

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