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Cancer deaths attributable to cigarette smoking in 152 U.S. metropolitan or micropolitan statistical areas, 2013–2017

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There are limited data on the burden of cancer attributable to cigarette smoking by metropolitan areas to inform local tobacco control policies in the USA. We estimated the proportion of cancer deaths attributable to cigarette smoking (or population attributable fraction [PAF]) in 152 U.S. metropolitan or micropolitan statistical areas (MMSAs).


Smoking-related PAFs for cancer mortality in ages ≥ 30 years in 2013–2017 were estimated using cross-sectional age-, sex-, and MMSA-specific cigarette smoking prevalence and cancer mortality data obtained from the Behavioral Risk Factor Surveillance System and the U.S. Cancer Statistics Database, respectively.


Overall smoking-related PAFs of cancer ranged from 8.8% (95% CI, 6.3–11.9%) to 35.7% (33.3–37.9%); MMSAs with the highest PAFs were in the South region and Appalachia. PAFs also substantially varied across MMSAs within regions or states. In the Northeast, for example, the PAF ranged from 24.2% (23.7–24.7%) to 33.7% (31.3–36.2%).


The proportion of cancer deaths attributable to cigarette smoking is considerable in each MMSA, with as many as 4 in 10 cancer deaths attributable to smoking in the South region and Appalachia. Broad and equitable implementation and enforcement of proven tobacco control interventions at all government levels could avert many cancer deaths across the USA.

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Fig. 1

Data availability

The data that support the findings of this study are available from the Behavioral Risk Factor Surveillance System (reference number 10) and U.S. Cancer Statistics Public Use database (reference number 11).


  1. Islami F, Goding Sauer A, Miller KD, Siegel RL, Fedewa SA, Jacobs EJ et al (2018) Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin 68(1):31–54

    Article  PubMed  Google Scholar 

  2. Lortet-Tieulent J, Goding Sauer A, Siegel RL, Miller KD, Islami F, Fedewa SA et al (2016) State-level cancer mortality attributable to cigarette smoking in the United States. JAMA Intern Med 176(12):1792–1798

    Article  PubMed  Google Scholar 

  3. American Nonsmokers’ Rights Association. Bridging the gap: status of smokefree air in the United States. Executive summary. Accessed 7 July 2020

  4. Mojtabai R, Riehm KE, Cohen JE, Alexander GC, Rutkow L (2019) Clean indoor air laws, cigarette excise taxes, and smoking: results from the current population survey-tobacco use supplement, 2003–2011. Prev Med 126:105744

    Article  PubMed  PubMed Central  Google Scholar 

  5. Campaign for Tobacco-Free Kids. Top combined state-local cigarette tax rates (state plus county plus city). Updated: June 15, 2020. Accessed 9 Dec 2020

  6. Centers for Disease Control and Prevention (2001) Cigarette smoking in 99 metropolitan areas—United States, 2000. MMWR Morb Mortal Wkly Rep 50(49):1107–1113

    Google Scholar 

  7. Secretan B, Straif K, Baan R, Grosse Y, El Ghissassi F, Bouvard V et al (2009) A review of human carcinogens—Part E: tobacco, areca nut, alcohol, coal smoke, and salted fish. Lancet Oncol 10(11):1033–1034

    Article  PubMed  Google Scholar 

  8. Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE et al (2015) Smoking and mortality—beyond established causes. N Engl J Med 372(7):631–640

    Article  CAS  PubMed  Google Scholar 

  9. Roura E, Castellsague X, Pawlita M, Travier N, Waterboer T, Margall N et al (2014) Smoking as a major risk factor for cervical cancer and pre-cancer: results from the EPIC cohort. Int J Cancer 135(2):453–466

    Article  CAS  PubMed  Google Scholar 

  10. Selected Metropolitan/Micropolitan Area Risk Trends (SMART): BRFSS city and county data and documentation. Accessed 17 June 2020

  11. Surveillance, Epidemiology, and End Results (SEER) Program ( SEER*Stat Database: Mortality—All COD, Aggregated With County, Total U.S. (1969–2017) <Katrina/Rita Population Adjustment>—Linked To County Attributes—Total U.S., 1969–2018 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, released December 2019. Underlying mortality data provided by NCHS (

  12. Darrow LA, Steenland NK (2011) Confounding and bias in the attributable fraction. Epidemiology 22(1):53–58

    Article  PubMed  Google Scholar 

  13. Greenland S (2004) Interval estimation by simulation as an alternative to and extension of confidence intervals. Int J Epidemiol 33(6):1389–1397

    Article  PubMed  Google Scholar 

  14. Benichou J (2001) A review of adjusted estimators of attributable risk. Stat Methods Med Res 10(3):195–216

    Article  CAS  PubMed  Google Scholar 

  15. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs—2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014

  16. Campaign for Tobacco-Free Kids. State cigarette excise tax rates and randkings. Updated: June 29, 2020. Accessed 9 Dec 2020

  17. Coady MH, Chan CA, Sacks R, Mbamalu IG, Kansagra SM (2013) The impact of cigarette excise tax increases on purchasing behaviors among New York City smokers. Am J Public Health 103(6):e54-60

    Article  PubMed  PubMed Central  Google Scholar 

  18. Hu TW, Sung HY, Keeler TE (1995) Reducing cigarette consumption in California: tobacco taxes vs an anti-smoking media campaign. Am J Public Health 85(9):1218–1222

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. American Lung Association. State tobacco cessation coverage database. Accessed 7 July 2020. 2020

  20. American Cancer Society Cancer Action Network (2019) How do you measure up? A progress report on state legislative activity to reduce cancer incidence and mortality, 17th edn. Accessed 7 July 2020

  21. American Nonsmokers’ Rights Association. Arkansans deserve to breathe easier in the natural state. Accessed 7 Dec 2020

  22. American Nonsmokers’ Rights Association. Oklahoma: preemption keeps the sooner state unhealthy. Accessed 7 Dec 2020

  23. U.S. Census Bureau (2012) 2010 Census Special Reports. Patterns of Metropolitan and micropolitan population change: 2000 to 2010, C2010SR-01. Washington, DC: U.S. Government Printing Office

  24. Jamal A, Phillips E, Gentzke AS, Homa DM, Babb SD, King BA et al (2018) Current cigarette smoking among adults—United States, 2016. MMWR Morb Mortal Wkly Rep 67(2):53–59

    Article  PubMed  PubMed Central  Google Scholar 

  25. Islami F, Ward EM, Jacobs EJ, Ma J, Goding Sauer A, Lortet-Tieulent J et al (2015) Potentially preventable premature lung cancer deaths in the USA if overall population rates were reduced to those of educated whites in lower-risk states. Cancer Causes Control 26(3):409–418

    Article  PubMed  Google Scholar 

  26. Drope J, Liber AC, Cahn Z, Stoklosa M, Kennedy R, Douglas CE et al (2018) Who’s still smoking? disparities in adult cigarette smoking prevalence in the United States. CA Cancer J Clin 68(2):106–115

    Article  PubMed  Google Scholar 

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This work was supported by the Intramural Research Department of the American Cancer Society (no grant numbers apply).

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Authors and Affiliations



JI: Study concept and design, BI: Acquisition of data, Islami: Statistical analysis and drafting of the manuscript, Sahar: Map compilation, All authors: Interpretation of data and critical revision of the manuscript for important intellectual content.

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Correspondence to Farhad Islami.

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Conflict of interest

All authors were employed by the American Cancer Society while this work was conducted. The American Cancer Society receives grants from private and corporate foundations, including foundations associated with companies in the health care sector for research outside of the submitted work. The authors were not funded by any of these grants and their salaries were solely funded through American Cancer Society funds. All authors have nothing else to declare.

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This study was based on government-issued, deidentified, public use data and did not require institutional review board approval.

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Islami, F., Bandi, P., Sahar, L. et al. Cancer deaths attributable to cigarette smoking in 152 U.S. metropolitan or micropolitan statistical areas, 2013–2017. Cancer Causes Control 32, 311–316 (2021).

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