The Journal of the Arkansas Medical Society Med Journal March 2020 Final 2

ed 403 Arkansas lives could be saved from lung cancer each year. This decline in deaths would lead to approximately $26 million per year in sav- ings in direct lung cancer treatment costs. 9,11 Discussion Respondents who report having smoked 100 cigarettes in their lifetime and currently smoke every day or some days. In 2011 BRFSS had substantial methodological changes; 2011 and subsequent years are not comparable to years prior to 2011. Source: Behavioral Risk Factor Surveillance System (BRFSS) Lives saved from lung cancer were calculated using methods from Delongchamp et. al. 3,10 Lung cancer treatment costs were calculated using Sur- veillance, Epidemiology, and End Results (SEER)/ Medicare analysis results from Cipriano et. al. 11 The annual number of cigarette packs sold in Arkansas was calculated from 1972 to 2017 using data obtained from the Arkansas Legislative Tax Handbooks. 8 Per capita consumption rates were calculated by dividing the number of cigarette packs sold each year by the number of adult Ar- kansans age 18 and over for the corresponding year; population estimates were obtained from the National Cancer Institute, SEER Program. Results Trends in Tobacco Packs Sold It is important to note that as the state and federal tax rate increased during years 1993, 2003, and 2009; the number of cigarette packs sold decreased during corresponding years. As shown in Figure 1, approximately 284 million packs were sold during the peak consumption time period in 1986 compared to 144 million in 2017, the period when the lowest number of cig- arette packs were sold. This decrease means the number of packs of cigarettes sold per-adult per- year declined from approximately 167 per-adult in 1986 to 62 in 2017. began collecting population-based cancer data, is set out in Figure 3. Incidence trends closely parallel mortality, only 7% survive more than ten-years following diagnosis. 4 Rates in males are roughly double that of females. From 1997 to 2015, the age-adjusted lung cancer incidence rates declined in men (1.45 fewer cases per 100,000 per year, p < 0.0001) and increased in women (0.27 more cases per 100,000 per year, p = 0.018) (Figure 3). Lung cancer mortality increased in Arkansas from 1970 until 1992 and then began a slow de- crease through 2015 (Figure 4). This decline is en- tirely due to decreasing rates among males. Lung cancer mortality rates in females have increased since 1970 and show no evidence of a decreasing trend (Figure 4). Lives Saved from Lung Cancer Deaths In 2017, Arkansas’s smoking prevalence was the fifth highest in the nation and 23% higher than the U.S prevalence. 9 If the state-smoking prevalence was the same as the U.S., an estimat- In 1986, cigarette packs sold per-adult per- year peaked in Arkansas at 167 packs, and sales steadily decreased to reach 62 packs in 2017. The decline in the number of cigarette packs sold an- nually is an indicator that Arkansas smokers, as a group, are smoking fewer cigarettes per year. Although any number of cigarettes smoked will increase disease risk and the Arkansas smok- ing prevalence is in need of improvement, some of the successes since 2000 can be attributed to continual increases in the tobacco excise tax and the Clean Indoor Air Act of 2006 as well as reforms made possible by the Tobacco Settlement Pro- ceeds Act of 2000. 7 During the recent 2019 legis- lative session, the Arkansas Legislature approved an Act that will raise the minimum age to pur- chase tobacco products from 18 to 21 over time. The bill will also remove border excise tax exemp- tions, which will raise the excise tax for cities lo- cated on or near the Arkansas border. These areas will collect the current excise tax, $1.15 per pack. Removing border zone taxes will increase excise taxes in Arkansas cities that border Louisiana, Mis- souri, and Tennessee. Additionally, the bill limits local cities and municipalities from enacting to- bacco regulations that are more restrictive than state laws or rules regarding the manufacturing, sale, storage, or distribution of tobacco products. According to the 2014 U.S. Surgeon General’s report, smokers are more likely to develop cancer because of changes in the levels of carcinogens in cigarettes and the use of ventilated filter ciga- rettes that cause smokers to inhale more deeply, drawing more carcinogens into the lungs. 3 Al- though the number of cigarette packs consumed Trends in Smoking Prevalence In 2017, 22.8% of men and 21.6% of wom- en in Arkansas smoked tobacco (Figure 2). The percent of men who smoked tobacco peaked in 1965, and the percent of women smokers peaked 25 years later in the 1990s. 6 This lag time of peak tobacco use among women explains their contin- ued increasing risk of lung cancer. Lung Cancer Incidence and Mortality Lung cancer incidence and mortality since 1997, when the Arkansas Department of Health 210 • The Journal of the Arkansas Medical Society Source: Incidence from the Arkansas Central Cancer Registry, ICD-O-3, C34 group, 1997-2015 and mortality from the CDC Wonder Compressed Mortality File, ICD-10, C-34 group, https://wonder.cdc.gov/ www.ArkMed.org

The Journal of the Arkansas Medical Society Med Journal March 2020 Final 2 | Page 18