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Background Lung cancer is one of the most common forms of cancer and the leading cause of cancer death worldwide, with tobacco smoking as the main cause [1]. In Norway, as in other western countries, smoking was more prevalent among men and in the highest social classes six to seven decades ago [2]. The proportion of male smokers increased until the 1960s, when it was around 65%. Among women, the peak (35%) occurred in the late 70’s [2]. From 1930 until the turn of the century, men have consumed more than 70% of the cigarettes smoked in Norway [3]. The decline in smoking prevalence occurred first and proceeded fastest among those with long education [4]. In Norway, lung cancer mortality for men has been declining since 2011, whereas as of 2013 it is still increasing for women [5]. Due to the lag period between start of smoking and lung cancer death, current mortality rates reflect smoking trends two to three decades earlier [6]. Neither the most recent World Cancer Report [1] nor the United States Surgeon General Report [7] discuss a possible sex difference in the risk of smoking associated lung cancer mortality. In 2001, Tverdal reported that among Norwegians under 50 years of age, lung cancer mortality was higher in women than in men [8]. Later Jha et al. reported from a US cohort, that among current compared with never smokers, women had a higher lung cancer mortality compared with men [9]. Since men and women have entered the stages of the smoking epidemic at different calendar times [10], a possible sex difference for smoking and lung cancer mortality may just have started to emerge. Education, an indicator of socioeconomic status is inversely associated with cancer mortality [11, 12]. Studies from Europe have reported an increased risk of lung cancer in participants of low socioeconomic status despite accounting for smoking habits [13, 14]. To our knowledge, no other prospective cohort studies have examined lung cancer mortality by sex and education. The objectives of the study were to explore a potential heterogeneity in smoking associated lung cancer mortality by sex and education.

Smoking related lung cancer mortality by education and sex in Norway