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Factors Influencing Lung Cancer Rates in Turkey and United States Mengwei Ni

April 26, 2013

Created for Global Urban Lab Rice University: School of Social Sciences & Kinder Institute for Urban Research


Table of Contents

Executive Summary....................................................................................................................................... 2 Report ........................................................................................................................................................... 3 I.

Issue .................................................................................................................................................. 3

II.

Research ............................................................................................................................................ 4

III.

Findings ......................................................................................................................................... 4

Lung Cancer Rates ................................................................................................................................. 4 Tobacco Usage ...................................................................................................................................... 5 Tobacco Production and Policy ......................................................................................................... 8 Tobacco Taxation .............................................................................................................................. 9 Additional Lung Cancer Risk Factors ................................................................................................. 9 IV.

Implications ................................................................................................................................... 9

Discussion.............................................................................................................................................. 9 Future Research .................................................................................................................................. 11 Conclusion ........................................................................................................................................... 11 Acknowledgements..................................................................................................................................... 12 Bibliography ................................................................................................................................................ 13

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Executive Summary Cancer rates have increased around the world, making it a leading cause of death. Specifically, lung cancer has the highest incidence and mortality rates in Turkey and United States. Risk factors for lung cancer include tobacco use, secondhand smoke, exposure to carcinogens, and family history. This study examines the factors affecting lung cancer incidence and mortality in Turkey and the United States, including gender, tobacco usage, and government tobacco policies. Overall, lung cancer incidence and mortality rates are higher in the United States when compared to Turkey, despite the higher percentage of cigarette smokers in Turkey. Additionally, a large gender discrepancy exists in Turkey where a much larger percentage of males, compared to females, use tobacco and are diagnosed with lung cancer. Both countries have similar age distributions of cigarette smokers with a large proportion of young smokers. However, in Turkey, tobacco usage increases with education, while the opposite trend is observed in the U.S.

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Report I.

Issue

The expression “Smoke like a Turk” has its origins in the large role tobacco production and consumption plays in the economy and culture of Turkey. In the 17th century, the tobacco plant was introduced to the Ottoman Empire by British and Venetian sailors (Bilir et al.). Since then, it has yielded great agricultural revenue for the economy. Currently, Turkey is one of the world’s ten largest producers of cigarettes and a lead exporter in oriental tobacco leaf (Yürekli et al.). When I traveled to Turkey, I observed the differences between cultures and lifestyles of people in Istanbul and in Houston, Texas. One of the notable differences I observed was the prevalence of smoking in Istanbul, which confirmed the saying “Smoke like a Turk.” While walking in Istanbul, I encountered people smoking at nearly every corner while such is not the case in Houston. Because smoking is a major health hazard, I investigate here the occurrence of diseases, specifically lung cancer, caused by smoking in the United States and Turkey. Cancer incidence rates have increased around the world, making cancer the leading cause of death (“Cancer”). In 2008, 12.7 million new cancer cases and 7.6 million cancer deaths occurred worldwide with lung cancer being the most common cause of death at 1.38 million (18.2% of the total) (Ferlay et al.). With the high prevalence of cancer worldwide, it is necessary to examine the lifestyles, government policies, and other factors that influence the rising cancer rates. In this report, I compare factors influencing lung cancer rates in the United States and Turkey to provide insight into methods to address this health issue. Lung cancer had the highest incidence and fatality rates among all cancers in both countries. Risk factors for lung cancer include tobacco use, secondhand smoke, exposures at home or work to carcinogens, and family history. In particular, cigarette smoking is the greatest risk factor for lung cancer and caused 90% of cases in the U.S. (“Risk Factors”) and 77% of cases in Turkey (Yürekli et al.). Additionally, high lung cancer incidence rates place a great health burden on the economy and government. Changes in government policies regarding health care and tobacco taxation affect changes in lung cancer rates in both countries. The purpose of this study is to examine how factors such as gender, tobacco usage, and government tobacco control policies affect lung cancer incidence and mortality rates in Turkey and United States. Because tobacco use is the greatest risk factor for lung cancer, it can be hypothesized that if tobacco usage is greater in Turkey, then lung cancer incidence rates in Turkey will be greater than that of the U.S.

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II.

Research

In order to compare lung cancer rates in the U.S. and Turkey, I obtained statistics from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and other published material. Lung cancer incidence and mortality rates were compared by gender in the two countries. Because tobacco use is one of the biggest risk factors for lung cancer, I conducted research to determine tobacco usage, production, and taxation policies in Turkey and United States. To compare tobacco usage, statistics were obtained from CDC, WHO, and other published material. Demographics of tobacco users were compared based on gender, age, and education level. Although tobacco products encompass cigars, shisha, etc., this study focuses on cigarette smoking in order to gather comparable data between the two countries.

III.

Findings

Lung Cancer Rates Table 1. Lung cancer incidence rates of U.S. in 2009 (“Lung Cancer Statistics”) and Turkey in 2008 (“GLOBOCAN 2008”). Lung cancer mortality rates of U.S. in 2009 (“Lung Cancer Statistics”) and Turkey in 2008 (“GLOBOCAN 2008”).

United States

Turkey

205,974

16,451

(0.067% of population)

(0.020% of population)

Men

110,190

14,667

Women

95,784

1,784

Death from lung cancer

158,081

15,101

(0.051% of population)

(0.019% of population)

Diagnosed with lung cancer

Table 1 compares the lung cancer incidence and mortality rates between genders for both U.S. and Turkey. In the United States in 2009, 205,974 people out of a total population of 307 million (“Population Estimates”) were diagnosed with lung cancer. That same year, 158,081 deaths resulted from the disease (“Lung Cancer Statistics”). In Turkey in 2008, 16,451 people out of a total population of 80 million (“Turkey”) were diagnosed with lung cancer. That same year, 15,101 deaths resulted from the disease (“GLOBOCAN 2008”). 0.067% of the U.S. population was diagnosed with lung cancer, while 0.020% of the Turkish population was diagnosed with lung cancer. The percentage of the American population who were diagnosed with lung cancer was more than triple the percentage of the Turkish population. Moreover, the discrepancy between the percentage of the population diagnosed and those who died from lung cancer is greater in the United States, perhaps indicate a greater access to facilities and treatments in the U.S. that allow patients to survive longer after diagnosis. 4|Page


Figure 1. Comparison of lung cancer incidence rates by gender in U.S. in 2009 (“Lung Cancer Statistics”) and Turkey in 2008 (“GLOBOCAN 2008”).

Additionally, a large discrepancy can be observed between male and female lung cancer incidence rates for Turkey, in which males have incidence rates nine times greater than females. The discrepancy between male and female rates in the U.S. is very small compared to Turkey, even though males have a slightly higher incidence rate than females (Figure 1). The gap between the gender incidence rates in Turkey may be due to the large disparity in tobacco usage between the genders or other lifestyle differences. Tobacco Usage

United States

Turkey

Cigarette Smoking

45.3 million (19.3%)

17.3 million (31.3%)

Men

21.50%

47.9%

Women

17.30%

15.2%

Table 2. Percentage of cigarette smokers in U.S. in 2010 (“Adult Cigarette Smoking”) and Turkey in 2008 (Yürekli et al.).

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Cigarette smoking is much greater in Turkey with 31.3% of the population smoking as opposed to 19.3% of the U.S. population (Table 2). Contrary to the hypothesis, even though the percentage of the Turkish population that smoke is more than 1.5 times that of the United States, lung cancer incidence and mortality rates are greater in the U.S.

Figure 2. Comparison of cigarette smoking by gender in U.S. in 2010 (“Adult Cigarette Smoking”) and Turkey in 2008 (Yürekli et al.).

A surprising result is the large gap between percentage of male and female smokers in Turkey. From Figure 2, it can be observed that males in Turkey are three times more likely to engage in cigarette smoking than females. In the U.S., there is a small discrepancy between the percentage of male and female smokers. Historically, it was considered unacceptable for women in Turkey to smoke, which may be a possible explanation for the large gender disparity in cigarette smoking. However, from 1997-2009, the smoking prevalence rate of women has increased from 10.9 % to 15.2%, demonstrating an increasing trend in female cigarette smokers (Yürekli et al.). The large gap in male and female smokers can be used to provide a possible explanation for the large gender disparity in lung cancer rates in Turkey.

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Figure 3. Comparison of cigarette smoking by age in U.S. in 2010 (“Adult Cigarette Smoking”) and Turkey in 2008 (Yürekli et al.).

The smoking distribution by age between the two countries is similar; younger people more likely to engage in cigarette smoking (Figure 3). There is a downward trend in smoking as age increases. The data for Turkey includes illegal smoking by minors, which is a big concern for Turkey. Over 8% of those between 13 and 17 years old and 40% of those 25-44 years old are smokers (Yürekli et al.). Because almost half of the population is under 25 years old, a great health and economic burden may be placed on the Turkish government as the young population ages (Bilir et al.).

Figure 4. Comparison of cigarette smoking by education level in U.S. in 2010 (“Adult Cigarette Smoking”) and Turkey in 2008 (Yürekli et al.).

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In addition to gender differences in tobacco usage in Turkey, the more educated is likely to have greater tobacco usage, while the opposite trend is observed in the U.S (Figure 4). The pattern in Turkey is contrary to what is observed in most developed countries as the more educated tend to smoke less (Bilir et al.). Also, the rate of smoking is high in “role model” occupations with 43.9% of physicians, 50.8% of teachers, and 27.1% of parliamentarians smoking (Yürekli et al.). The large percentage of smokers in these occupations may adversely influence the general population and youth. Tobacco Production and Policy The differences observed in tobacco usage between the two countries could be influenced by tobacco production and government control policies. Both the U.S. and Turkey are among the world’s top 10 tobacco consuming countries based on number of smokers. However, Turkey has a much larger proportion of smokers based on its population compared to the U.S. In Turkey, cigarettes are the most common tobacco product with 108.7 billion cigarettes produced and 107.9 billion consumed in 2006. Cigar and pipe tobacco use consisted of only 2.5% of total tobacco product consumption (Bilir et al.). The tobacco plant was introduced to the Ottoman Empire in the 17th century. By 1678, Ottoman officials began to tax and earn revenue from tobacco. Later in 1862, the government set up a monopoly on tobacco production and taxation. Turkey is currently one of the world’s ten largest cigarette producing countries and 26th largest exporter of manufactured tobacco products. Additionally, it is a world leader in oriental tobacco leaf production, which is a type of mild, aromatic, small-leafed tobacco (Yürekli et al., Goodman). Even though U.S. tobacco production has decreased significantly since the 1950s, it is currently still a leading world producer of tobacco leaves. The U.S. combined with China, Brazil, and India to produce more than two-thirds of the world’s tobacco in 2009. Additionally, tobacco companies spend a large amount of money advertising and marketing their products, leading to costs of $10.5 billion in 2008 (“Economic Facts”). Because tobacco usage is a high risk factor for many health concerns, U.S. and Turkish governments have implemented policies to curb tobacco usage. In the U.S., the Public Health Cigarette Smoking Act of 1969 required label warnings on cigarette packages and prohibited cigarette advertising on radio and television. Smoking bans are not regulated by the federal government and remains in the jurisdiction of each state, but the Family Smoking Prevention and Tobacco Control Act of 2009 allows the Food and Drug Administration (FDA) to regulate tobacco products (“Legislation”). Tobacco control legislation has been adopted more recently in Turkey than in the U.S. Prior to 1981, the only major control policy banned cigarette advertising on television, radio, and billboards. Beginning in September 1981, cigarette packages were required to carry warning labels. On November 26, 1996, law number 4207 banned cigarette smoking in some public spaces, expanded cigarette advertising ban, and prohibited sale of cigarettes to minors. Even though the law was comprehensive, it did not designate an agency to enforce the policies, which limited its implementation and effectiveness. In the last decade, Turkey has become more dedicated to limiting tobacco use in the country. It signed the WHO’s Framework Convention on Tobacco Control in April 2004, which calls on governments to adopt policies that reduce tobacco product use and production in the country. Following the signing of the treaty, Turkey became a 8|Page


smoke-free country after the Tobacco Control and Prevention of Hazards Caused by Tobacco Products Law was adopted in January 2008. It extended the ban on smoking in public spaces including public buildings, public transportation, sport facilities, and hospitality sector. The Ministry of Health and Turkish regulatory agency for cigarettes and alcoholic beverages (TAPDK) are cooperating to implement and enforce the smoke-free law (Yürekli et al.). Tobacco Taxation Taxes on tobacco products have been shown to decrease tobacco consumption. Taxes and increased cigarette prices can encourage current smokers to quit and prevent young people from initiating (Yürekli et al.). In order to gain revenue and curb tobacco consumption, both governments have exercised taxes. Currently, the U.S. federal cigarette tax is $1.01 per pack, and the average state cigarette tax is $1.49 per pack (“Tobacco Taxes”). In Turkey in 2010, the specific tax was 2.65 Turkish Lira per pack and ad valorem tax of 63% of retail price (Yürekli et al.). Additional Lung Cancer Risk Factors While tobacco usage is the greatest risk factor of lung cancer, other factors include exposure to secondhand smoke, carcinogens, and family history. Radon is a chemically inert, naturally occurring radioactive gas that can be found in rocks and soil. However, it can easily escape from the ground into air, where it can damage cells lining the airways when inhaled. It is the second greatest cause of lung cancer, and is estimated to cause between 3-14% of all lung cancers depending on the radon level in the specific country (“Radon and Cancer”). In the United States, radon causes about 20,000 lung cancer cases each year (“Risk Factors”). Additionally, secondhand smoke exposure has a large negative impact on health. Secondhand smoke may include smoke from a burning cigarette, cigar, or pipe or smoke that has been exhaled by someone smoking. Lung cancer risk increases by 20-30% for nonsmokers who are exposed to secondhand smoke. In the United States, secondhand smoke exposure is responsible for 3,400 lung cancer deaths annually among adult nonsmokers (“Secondhand Smoke”). In Turkey, the National Household Survey conducted in 2003 revealed that 52.4% of respondents were exposed to secondhand smoke (Bilir et al.). Other risk factors may account for the high lung cancer rates in the U.S.

IV.

Implications

Discussion The study examines how factors such as gender, cigarette smoking, and government tobacco policies affect lung cancer incidence and mortality rates in Turkey and United States. A comparison of lung cancer incidence and mortality rates demonstrate that rates are higher in the U.S. than Turkey. Because tobacco usage is the greatest risk factor in lung cancer, I analyzed tobacco smoking based on gender, age, and education level in the two countries. Cigarettes are the most common form of tobacco product used in both countries, so data analysis focused on cigarette smoking. A larger percentage of the U.S. population is diagnosed with lung cancer than that of the Turkish population. However, a large disparity exists between the percentage of males and females who are diagnosed with lung cancer in Turkey, with males consisting of 89% of lung cancer cases. Possible explanations for the large discrepancy could be due to the large percentage of males who smoke compared to females. The percentage of males who smoke in 9|Page


Turkey is more than three times that of the percentage of females who smoke. This discrepancy could be due to cultural limitations where historically, it was improper for women to smoke. On the other hand, the percentages of men and women who smoke in the United States are similar, so a large discrepancy between male and female lung cancer incidence rates is not apparent. However, a slightly larger percentage of men smoke than women, which also corresponds to a higher lung cancer incidence rate in men. Additionally, in both countries, the younger population is more likely to smoke, which will cause a greater health burden on the government as the population ages. It is especially troubling in Turkey as a large percentage of minors engage in smoking behavior and almost half of the population is under 25 years old. From analyzing the data trends, it is also surprising that the percentage of smokers increases with increasing education in Turkey, which is the opposite trend to what is observed in most other developed countries. The large percentage of smokers in “role model� occupations such as physicians, teachers, and parliamentarians may influence the increasing percentage of young smokers. Another interesting point to note is the discrepancy between the percentage of the population diagnosed and those who died from lung cancer is greater in the United States. For the purpose of our analysis, if we assume that the percentage of people who die from lung cancer were also diagnosed that same year, then 76.7% of those diagnosed died from the disease in the U.S. and 91.8% in Turkey. Even though the deaths from lung cancer were not all from those who were diagnosed in that same year, the hypothetical analysis demonstrates that Turkey had a higher mortality rate. A possible explanation is that the U.S. has greater access to facilities and treatment for cancer, which would allow patients to survive longer after lung cancer diagnosis. In conjunction with lung cancer and tobacco usage statistics, it is also important to consider government policies related to tobacco production and control. Both countries are world leaders in tobacco production, but the governments have aimed to curb tobacco consumption due to health risks associated with tobacco use. In the U.S., smoking bans are regulated by each state, so a nationwide smoking ban does not exist. In recent years, the Turkish government has adopted and enforced stringent tobacco control laws including the banning of smoking in public spaces in 2008. Because taxes on tobacco products are a source of revenue for the government and also aid in the efforts to curb tobacco consumption, both governments have increased taxes in recent years. The seemingly direct correlation found between smoking and lung cancer in the U.S. may not be universal. Despite tobacco use seemingly not having as direct correlation with lung cancer in Turkey compared to the U.S., the large discrepancy between the gender incidence rates in Turkey may still in part be due to males being three times more likely to use tobacco than females. Overall, contrary to the hypothesis, lung cancer incidence and mortality rates were higher in the United States then Turkey, despite the much higher percentage of cigarette smoking in Turkey. Possible explanations include differences in lifestyles or other risk factors in the two countries that would decrease chances of lung cancer in Turkey.

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Future Research It remains unclear why lung cancer incidence and mortality rates are higher in the U.S. than in Turkey despite the lower rate of tobacco usage. For future research, a study can be conducted to examine differences in life style or other risk factors that would influence lung cancer rates. Another area of study could look into the effects of different tobacco products other than cigarettes that are consumed in the two countries. Additionally, interesting trends such as the rise in tobacco usage with greater education in Turkey requires further research. Because the effects of government tobacco control policies require time for the impact on tobacco usage and health to become visible, future studies can look into the same areas that were compared in this study to examine long term effects and trends. In addition to investigating government tobacco control policies, differences between health care systems of the two countries could also be compared to further address questions on discrepancy between lung cancer incidence and mortality rates. Because the lung cancer survival rate is lower for Turkey, it would be interesting to examine differences in lung cancer treatment and facilities in the two countries. While in Istanbul, I toured the American Hospital, which has a new collaboration with M.D. Anderson Cancer Center in Houston. The M.D. Anderson Radiation Treatment Center in Istanbul at American Hospital brings top-notch cancer treatment care to Turkey (“American Hospital”). Collaborations like this bring greater facilities and expertise into Turkey, which may have a positive impact on future lung cancer rates. Conclusion As scientists around the world work to find a cure to cancer and other diseases, individuals continue to be impacted by these debilitating illnesses. While cures and treatments are essential after an individual develops a disease, lifestyles play a major role in the prevention of disease and maintenance of a healthy individual. Even though smoking is a high risk factor for many illnesses, individuals still choose to engage in tobacco product use. Cancer rates have increased significantly, making it the leading cause of death worldwide. Specifically, lung cancer has the highest incidence and fatality rates among all cancers. The focus of this study was to examine how factors such as gender, tobacco usage, and government policies affect lung cancer incidence and mortality rates in Turkey and United States. Since tobacco usage has a positive correlation with lung cancer incidence rates, I had originally hypothesized that lung cancer incidence rates in Turkey will be greater than that of the U.S. because of higher tobacco consumption in Turkey. Overall, contrary to my hypothesis, lung cancer incidence and mortality rates were higher in the United States when compared to Turkey, despite the much higher percentage of cigarette smoking in Turkey. While tobacco usage was not an adequate predictor of lung cancer rates in the two countries as a whole, there did appear to be a correlation lung cancer and tobacco usage data categorized by gender was examined. The expression “Smoke like a Turk” may be a thing of the past as the Turkish government implements policies that limit tobacco usage.

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Acknowledgements I would like to thank Rice University, Global Urban Lab, School of Social Sciences, and Kinder Institute for Urban Research for the opportunity to enjoy the vibrant city of Istanbul, experience the culture and hospitality of the Turkish people, and conduct research on an important health issue. Additionally, I would like to extend my sincere gratitude to the organizations and individuals who welcomed us during our trip to Istanbul and provided us with an unforgettable learning experience. Last but not least, I would like to express my upmost gratitude to Associate Dean Ipek Martinez for the large amount of time and effort she invested in coordinating a wonderful trip, Dr. Michael Emerson for his guidance on my research project, and Abbey Godley for accompanying us on our trip.

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Bibliography "Adult Cigarette Smoking in the United States: Current Estimate." Centers for Disease Control and Prevention, 14 Mar. 2012. Web. "American Hospital Brings Top-Ranked Cancer Services to Turkey With M. D. Anderson Collaboration." The University of Texas MD Anderson Cancer Center, 28 Jan. 2010. Web. Bilir, Nazmi, Banu Çakır, Elif Daglı, Toker Ergüder, and Zeynep Önder. "Tobacco Control in Turkey." World Health Organization, 2009. Web. "Cancer." World Health Organization. N.p., Jan. 2013. Web. "Economic Facts About U.S. Tobacco Production and Use." Centers for Disease Control and Prevention, 15 Nov. 2012. Web. Ferlay, Jacques, Hai-Rim Shin, Freddie Bray, David Forman, Colin Mathers, and Donald Maxwell Parkin. "Estimates of Worldwide Burden of Cancer in 2008: GLOBOCAN 2008." International Journal of Cancer 127.12 (2010): 2893-917. Print. "GLOBOCAN 2008." International Agency for Research on Cancer. World Health Organization, 2008. Web. Goodman, Jordan. Tobacco in History and Culture: An Encyclopedia. Vol. 2. Detroit: Thomson Gale, 2005. 644. Print. "Legislation." Centers for Disease Control and Prevention, 15 Nov. 2012. Web. "Lung Cancer Statistics." Centers for Disease Control and Prevention, 20 Dec. 2012. Web. "Population Estimates." United States Census Bureau, 2010. Web. "Radon and Cancer." World Health Organization, Sept. 2009. Web. "Risk Factors." Centers for Disease Control and Prevention, 05 Feb. 2013. Web. "Secondhand Smoke (SHS) Facts." Centers for Disease Control and Prevention, 01 Mar. 2012. Web. "Tobacco Taxes." State Tobacco Cessation Coverage. American Lung Association, 2012. Web. "Turkey." The World Factbook. Central Intelligence Agency, 12 Apr. 2013. Web.

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Yürekli A, Önder Z, Elibol M, Erk N, Cabuk A, Fisunoglu M, Erk SF, Chaloupka FJ. The Economics of Tobacco and Tobacco Taxation in Turkey. Paris: International Union Against Tuberculosis and Lung Disease; 2010.

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Lung cancer rates comparison