Sarah Miller, RN, Cancer Prevention and Treatment Fund
For years, doctors and medical researchers have been puzzled by the fact that African-Americans are more likely to die from lung cancer than people of any other race or ethnicity, although they are not more likely to smoke. How could this be? Is it because they don’t get diagnosed and treated in time, is it genetic, or is there something else going on? Research indicates that a combination of factors may be responsible for the unequal rates of death from lung cancer.
African-Americans are disproportionately affected by lung cancer. The percentage of African-American men diagnosed with lung cancer each year is at least 30% higher than among white men, even though they have similar rates of smoking as white men. In fact, African-American men tend to smoke fewer cigarettes per day than white male smokers. While African-American women are less likely to smoke than white women, they are about as likely to develop lung cancer and die from lung cancer as white women. African-Americans also tend to be diagnosed with lung cancer at a younger age. Research has examined many possible explanations for these differences.
Is it Genetic?
Scientists have recently identified several genes that are linked to lung cancer. People who have these genes and smoke are more likely to develop lung cancer than other smokers. They have also found genes that cause a person to metabolize nicotine differently, which could be a factor in whether a person develops lung cancer.6 Some of these genes have been found to be more common in people with African ancestry. This suggests that genetics may have a role in the higher rates of lung cancer among African-Americans.
Genetics are only a part of the equation, though. There are many other factors that contribute to differences in lung cancer rates and in death from lung cancer.
Does the Type of Cigarettes Matter?
Tobacco companies have a long history of targeting the African-American community with advertisements for menthol cigarettes. As a result, about 80% of African-American smokers smoke menthol cigarettes, compared with only 20% of white American smokers.
Many researchers have tried to find a link between lung cancer and menthol cigarettes. Some have theorized that the “cooling” effect of menthol cigarettes allows menthol smokers to inhale the smoke more deeply, which could cause more damage to their lungs. Others have speculated that menthol cigarettes might be more addictive than regular cigarettes.
While studies have shown that smokers of menthol cigarettes may have a more difficult time quitting, and are more likely to smoke their first cigarette sooner after waking in the morning than people who smoke regular cigarettes, researchers have not been able to find any chemical properties of menthol cigarettes that make them more addictive.
Smokers of menthol cigarettes do not, on average, smoke any more cigarettes in their lifetime than regular cigarette smokers, and research so far has failed to show that menthol cigarettes cause more cases of cancer than other kinds of cigarettes.
The one obvious problem with menthol cigarettes is that the menthol makes cigarette smoke less harsh for first-time smokers. Because, of this, many young teens smoke them. In fact, while smoking is declining among adults and adolescents, menthol cigarettes are becoming increasingly popular among both adults and kids ages 12-17. Since we know that people who begin smoking at younger ages are more likely to become regular smokers, it is troubling that there is a product available that helps teens to start smoking. Although African-American teens start smoking later than white teens, they disproportionately smoke menthol cigarettes.
Does the Environment Affect Lung Cancer Disparities?
Industries that produce heavier air pollution (for example, factories, oil refineries, and chemical plants) are often located in African-American communities. Exposure to pollution from working in or living near these industries can increase a person’s risk for lung cancer.,
A person who smokes and is exposed to air pollution is at higher risk for lung cancer than a smoker who is not exposed to air pollution. People who are exposed to air pollution on the job are at especially high risk. The fact that these polluting industries are frequently located in African American communities and employ members of that community may also help to explain why African-Americans are disproportionately affected by lung cancer.
Is it Because of Differences in Treatment?
While differences in diagnosis and treatment don’t explain why more African-Americans develop lung cancer, it may help to explain the higher death rate from lung cancer among blacks.
One study of all the lung cancer patients in the Florida Cancer Registry found that the survival time for African-American patients diagnosed for lung cancer was shorter than that of white patients. The researchers also found that the entire difference in survival time between African-Americans and whites could be attributed to the fact that white patients tended to get more timely and appropriate treatment.
They concluded that if African-American patients could begin treatment as early as white patients, and were provided the best treatment for their condition, then their survival time would catch up with that of white patients.
Another study found that many patients with a certain type of lung cancer, for which surgical removal of part of the lung offers the best chance for a cure, did not get the proper surgery. Shockingly, only 62% of all patients who would have a good chance of the surgery helping them had the surgery. When the researchers separated the results out by race, 66% of white patients who were appropriate candidates had the surgery while only 55% of African-American patients who were appropriate candidates had the surgery. While this is bad news for all patients with this type of lung cancer, it is worse news for African-Americans since they were substantially less likely than white patients to get the surgery.
Why Don’t African-American Patients Receive the Proper Treatment?
One reason that African American patients are less likely to receive the proper treatment than white Americans may be that they are less likely to have health insurance. While about 13% of white American adults under the age of 65 are uninsured, 21% of African American adults in the same age group are without health insurance. Uninsured patients may decide against treatment because they can’t afford it, or may have a difficult time finding a hospital that is willing to provide the treatment to uninsured patients.
Another reason that African American patients do not always receive the most appropriate care is that there seem to be communication problems between providers and patients.
Studies have found that the type of communication a patient has with a doctor or health care provider has an impact on his or her decision-making about treatments. In the long-term, this has a huge impact on the state of a person’s health.
Health care providers are increasingly pressured to fit more patient visits into shorter time periods. Because of this, providers have less time to spend getting to know each patient. In this type of situation, people tend to make snap judgments.
Providers make a judgment based on their first impression of a person (what they think of that person after glancing at his or her chart and based on personal appearance). This judgment influences the provider’s judgment about what medical information the patient wants or doesn’t want, what type of treatment the patient is likely to find acceptable, and how reliable the person will be with his or her follow-up care.
Patients, too, know that they have only a short time for an appointment. They also may judge a provider based on his or her appearance and make assumptions. They may assume that the provider is very knowledgeable and that they should just do what the provider says. Patients may also assume, based on a snap judgment, that the provider will not respond well to being asked questions, that the provider does not care about the patient, or that the provider is not going to be helpful.
Research has shown that when the provider is of a different race or culture than the patient, these breakdowns in communication are more severe and have more negative results in terms of the quality of care a patient receives.
What is Being Done to Reduce Disparities in Lung Cancer Survival?
While healthcare providers and lawmakers recognize that this is a serious problem, they also recognize that there is no quick fix.
One step that is being taken by medical schools is to try and attract more African-American students. Currently, African-Americans are under-represented in the medical profession. The assumption is that African-American physicians be able to communicate more effectively with African-American patients, and that they will be able to educate their colleagues to do so as well.
Many people are also trying to limit advertising of menthol cigarettes, especially ads that target African-American teens.
Some public health advocates are urging the FDA to ban menthol in cigarettes. Other flavored cigarettes (“bidis”) have already been banned on the principle that they attract teens to smoking and make cigarettes more tolerable. Since we know that menthol also makes smoking more desirable for teens, and since it is a flavoring for cigarettes, it makes sense that it should be banned along with the other flavors. Banning menthol cigarettes would likely reduce the number of African-American teens that smoke, and might help reduce lung cancer deaths among African-American men and women.
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