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6. Women and smoking: A report of the Surgeon General. MMWR Morb Mortal Wkly Rep. 2002; 51(RR12):1-30. 7. John Engberg et al. Evaluation of the Arkan- sas Tobacco Settlement program: Progress through 2011 – summary. 2012; RAND Corpo- ration:1-10. 8. Bureau of Legislative Research. Arkansas leg- islative tax handbook. Little Rock, AR: Office of Economic and Tax Policy; 2016. Source: 1970-1978, ICD-8 lung cancer code 162.1; 1979-1998 ICD-9 lung cancer codes 162.2-162.5, 162.8-162.9; 1999-2016 ICD-10 lung cancer code C34 group from the CDC Wonder Compressed Mortality File https://wonder.cdc.gov/ per individual is declining, the risk of developing lung cancer and dying from the disease has in- creased over the last 50 years. 3 Sadly, a female in Arkansas was more likely to die of lung cancer in 2015 than in 1970. In general, the rise in lung cancer incidence in women is troubling. Lung cancer incidence in women increased after targeted-marketing cam- paigns that began in the 1960s and 1970s. 3,12 While the risk of lung cancer has increased in women, lung cancer incidence among men has steadily declined since 1997. This is associated with the fact that women began smoking in large numbers about 25 years after men were smoking heavily. 6 In Arkansas, female adult smoking prevalence peaked in 2013 – an indication that lung cancer incidence and mortality rates have yet to peak in women and will continue to rise. Recent mortality trends, 1999 to 2015, show that lung cancer deaths are decreasing in men, but not yet in women. Conclusion Smoking is the leading preventable cause of lung cancer, and while great strides have been made to reduce tobacco use in Arkansas, lung cancer remains the leading cause of can- cer death in both men and women. 1 Even when heavy smokers quit smoking, the risk of devel- oping the disease remains threefold higher than those who have never smoked cigarettes. 2 If Ar- kansans had the same smoking rate as the U.S., we could save 403 lives per year from lung can- cer and save approximately $26 million per year in direct cancer treatment costs. 9-11 Thus, the challenge continues to reduce the use of tobacco products, including novel electronic devices that deliver nicotine by inha- lation. Cessation programs should target wom- en since their risk of developing lung cancer continues to increase. The most effective public policy to reduce cigarette consumption would Volume 116 • Number 9 be to increase the excise tax on tobacco. The federal and Arkansas taxes on tobacco have not increased since 2009. References 1. Arkansas Department of Health. Arkansas Can- cer Facts and Figures. https://www.healthy.ar- kansas.gov/images/uploads/publications/AR- CancerFacts2017.pdf. Accessed April 4, 2019. 2. Tindle HA, Stevenson Duncan M, Greevy RA, et al. Lifetime smoking history and risk of lung can- cer: Results from the Framingham Heart Study. J Natl Cancer Inst. 2018;110(11):1201-1207. 3. U.S. Department of Health and Human Ser- vices. The health conse- quences of smoking: 50 years of progress. A report of the Surgeon General. Print- ed with corrections ed. At- lanta, GA: U.S. Department of Health and Human Ser- vices, Centers for Disease Control and Prevention, National Center for Chron- ic Disease Prevention and Health Promotion, Office on Smoking and Health; January 2014. 9. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: Arkansas results. http://www.cdc.gov/brfss/ brfssprevalence/index.html. Accessed April 14, 2019. 10. Delongchamp R, Holt A, Faramawi MF, et al. Differences between Arkansas and the Unit- ed States in prevalence of risk factors explain variations in ischemic heart disease mortality rates among pre-Medicare (45-64) and Medi- care (65-84) age groups. European Journal of Environment and Public Health. 2019; in press. 11. Cipriano LE, Romanus D, Earle CC, et al. Lung cancer treatment costs, including patient responsibility, by disease stage and treat- ment modality, 1992 to 2003. Value Health. 2011;14(1):41-52. 12. Pierce JP, Lee L, Gilpin EA. Smoking initiation by adolescent girls, 1944 through 1988. An association with targeted advertising. JAMA. 1994;271(8):608-611. 4. Joseph A, Muggli M, Pearson K, Lando H. The cigarette manufacturers’ efforts to promote tobacco to the U.S. military. Mil Med. 2005;170(10):874-880. 5. Toll BA, Ling PM. The Vir- ginia Slims identity crisis: An inside look at tobac- co industry marketing to women. Tob Control. 2005;14(3):172-180. MARCH 2020 • 211