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Lung cancer risk factors

The key risk factors for lung cancer are discussed on this page. Lung cancer risk is also strongly linked with age and sex.

Around 89% of lung cancers in the UK are linked to lifestyle: 91% in males and 87% in females.1 The majority of these cases were caused by smoking.1

Meta-analyses and systematic reviews are cited where available, as they provide the best overview of all available research and often take study quality into account. Individual case-control and cohort studies are reported where such aggregated data are lacking.

Lung cancer risk factors overview

The International Agency for Research on Cancer (IARC) evaluates evidence on the carcinogenic risk to humans of a number of exposures including tobacco, alcohol, infections, radiation, occupational exposures, and medications.2 The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) evaluates evidence for other exposures including diet, overweight and obesity, and physical exercise.84 IARC and WCRF/AICR evaluations are the gold standard in cancer epidemiology. Their conclusions about lung cancer risk factors are shown in Table 4.1.

Table 4.1: IARC and WCRF/AICR Evaluations of Lung Cancer Risk Factors

Increases risk ('sufficient' or 'convincing' evidence) May increase risk ('limited' or 'probable' evidence) Decreases risk ('sufficient' or 'convincing' evidence) May decrease risk ('limited' or 'probable' evidence)
  • Production of aluminum, iron and steel
  • Arsenic and inorganic arsenic compoundsa
  • Asbestos (all forms)
  • Beryllium (and compounds)
  • Bis(chloromethyl)ether; chloromethyl methyl ether (technical grade)
  • Cadmium (and compounds)
  • Chromium (VI) compounds
  • Household coal combustion emissions
  • Production of coal/coke
  • Coal-tar pitch
  • Diesel engine exhaust
  • Hematite mining
  • MOPP (vincristine-prednisone-nitrogen mustard-procarbazine mixture)
  • Nickel compounds
  • Outdoor air pollution (and particulate matter within)
  • Painting
  • Plutonium
  • Radon-222 and its decay products
  • Production of rubber
  • Crystalline silica dust
  • Soot
  • Sulphur mustard
  • Environmental tobacco smoke
  • Tobacco smoking
  • X-radiation, gamma-radiation
  • Beta-carotene supplements (high dose, in smokers)
  • Strong inorganic acid mists
  • Production of art glass, glass containers and pressed ware
  • Household biomass fuel (primarily wood), combustion emissions
  • Working as a roofer (due to oxidized bitumens exposure)
  • Working with mastic asphalt (due to hard bitumens exposure)
  • Manufacture of carbon electrodes
  • alpha-Chlorinated toluenes with benzoyl chloride
  • Cobalt metal with tungsten carbide
  • Creosotes
  • Emissions from high-temperature frying
  • Working as a non-arsenical insecticides sprayer
  • Printing processes
  • 2,3,7,8-Tetrachlorodibenzopara-dioxin
  • Welding fumes
-
  • Fruits (not salted or pickled)
  • Dietary carotenoids

a WCRF/AICR classifies arsenic in drinking water as a cause of lung cancer.

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Tobacco

Tobacco smoking and environmental tobacco smoke are classified by IARC as causes of lung cancer (Table 4.1).2 An estimated 86% of lung cancers in the UK are linked to tobacco smoking - 83% due to active smoking, and 3% due to environmental tobacco smoke exposure in non-smokers.3 An estimated 86% of lung cancer deaths in the UK are causes by tobacco smoking.104

Around 1 in 5 UK adults currently smoke cigarettes.

Smoking

Lung cancer death risk is around 15 times higher in current smokers compared with never-smokers, a cohort study of British males showed.4

Lung cancer risk increases with both smoking duration and amount,4 but duration has the most effect on risk: smoking one pack of cigarettes a day for 40 years is more hazardous than smoking two packs a day for 20 years.5-7 Lung cancer risk in smokers is higher in those who start smoking at a younger age.8-10 Lung cancer death risk is 37% higher per five years younger at smoking initiation, a cohort study of women showed.11

Lung cancer risk is around 26 times higher in men who smoke 15-24 cigarettes per day, compared with never-smokers, a cohort study showed.14 Lung cancer death risk is around 5 times higher in smokers of 1-4 cigarettes per day,12 around 12 times higher in smokers of 8-12 cigarettes per day; at least 24 times higher in smokers of 25+ cigarettes per day;4,13 and 39 times higher in smokers of 42+ cigarettes per day,13 all compared with never-smokers, cohort studies (some including only women or middle-aged people) have shown.

Smoking is more strongly linked with risk of small cell lung cancer and squamous cell carcinoma (SCC) than other lung cancer types, meta- and pooled analyses have shown.115,116

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Stopping smoking

Smoking cessation has very significant health benefits, including improved life expectancy, compared with continued smokers - even for long-term smokers, older smokers,9,10,15 and smokers who quit after lung cancer diagnosis.20

Giving up smoking in middle age avoids most of the subsequent risk of lung cancer, cohort studies from around the world show.9,17-19 In men, 15.9% of those who smoke all their lives die from lung cancer by age 75, compared with 9.9% of those who stop smoking by age 60, 6% of those who stop by age 50, 3% of those who stop by age 40, and 1.7% of those who stop by age 30.9 In women, 9.5% of those who smoke all their lives die from lung cancer by age 75, compared with 5.3% of those who stop smoking by age 60, and 2.2% of those who stop by age 50.9

Reducing cigarette intake rather than stopping may not be as beneficial: lung cancer risk is similar in heavy smokers (around 16-18 cigarettes per day) who halve their intake, compared with sustained heavy smokers.16

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Environmental tobacco smoke

Environmental tobacco smoke (ETS, also called second-hand smoke) is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 15% of lung cancer cases in never-smokers in the UK are linked to ETS.3

Lung cancer risk in non-smokers is around a quarter higher in those exposed to ETS at home or at work, compared with those not exposed to ETS, meta-analyses have shown.21,22 Lung cancer risk in non-smokers is doubled in those with the highest workplace ETS exposure levels, versus those not exposed to ETS, a meta-analysis showed.22

Small cell lung cancer risk in never-smokers is tripled in those exposed to ETS, compared with those not exposed to ETS, a pooled analysis showed; non-small cell lung cancer risk is increased to a lesser degree (28%).25

Lung cancer risk is probably not associated with ETS exposure in childhood, a meta-analysis and large cohort study have shown.23,24

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Cannabis use

Lung cancer risk in males is around doubled in heavy cannabis use (more than 50 times use in lifetime) compared with never-users, even after adjusting for tobacco use, a cohort study showed.108

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Ionising radiation

Residential radon

Radon is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 0.5% of lung cancers in the UK are linked to radon (home rather than occupational exposure) alone, though 3% of lung cancers in the UK are linked to radon and smoking in combination.28 An estimated 9% of lung cancer deaths in Europe are linked to indoor radon exposure.14

Lung cancer risk is 16% higher per 100 becquerel/cubic metre (Bq/m3) increment in usual home radon level, a pooled analysis showed.14 The average UK home usually contains 20 Bq/m3.25 Radon-associated lung cancer risk is similar for smokers and non-smokers (though overall lung cancer risk is much higher in smokers because of their smoking).14

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Other sources of ionising radiation

X radiation and gamma radiation are classified by IARC as causes of lung cancer (Table 4.1).2 An estimated 0.8% of lung cancers in the UK are linked to radiotherapy, 0.3% to diagnostic radiation, and 0.2% to natural background radiation.28

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Occupational exposures

A number of occupational exposures are classified by IARC as causes of lung cancer (Table 4.1).2 An estimated 21% of lung cancers in men in the UK, and 4-5% in women in the UK, are linked to occupational exposures.2,29

Asbestos

Asbestos exposure is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 6-8% of lung cancer deaths in the UK each year are linked to asbestos exposure.27,33

Lung cancer mortality is 77% higher in asbestos-exposed workers, compared with the general population, a meta-analysis showed.33 Lung cancer mortality is 19-26 times higher in asbestos-exposed current smokers, compared with asbestos-exposed never-smokers, a cohort study showed.34-37

This reflects the higher risk of lung cancer death in current smokers compared with never-smokers, but indicates that smoking and asbestos have a synergistic (combination effect stronger than sum of independent effects) effect on lung cancer development.34-37 Age at asbestos exposure may modify the risk, but evidence is unclear, a systematic review showed.122

Asbestos exposure in the UK (typically in construction and shipyard workers31) peaked around 1963 and decreased rapidly thereafter, it is estimated.32 Asbestos is thought to cause as many lung cancer cases as mesothelioma cases, because lung cancer is much more common than mesothelioma.27,33

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Silica

Silica dust exposure is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 0.02% of lung cancers in Britain are linked to silica (typically in glass manufacture).27

Lung cancer risk is higher in people exposed to silica probably because it causes silicosis: it is not probably not associated with lung cancer risk in people without silicosis.38,39

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Diesel engine exhaust

Diesel engine exhaust exposure is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 0.02% of lung cancers in Britain are linked to occupational exposure to diesel engine exhaust.27

Lung cancer risk is 19-47% higher in professional drivers compared with the general population, meta-analyses have shown;41,42 however, the evidence does not allow a dose-response relationship to be established.121 Lung cancer risk associated with diesel exhaust exposure varies markedly by occupation group; most evidence comes from highly-exposed workers including drivers and mechanics.27,40,41

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Working as a painter 

Working as a painter is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 0.01% of lung cancers in Britain are linked to working as a painter.27

Lung cancer risk is 22-57% higher in painters compared with the general population, meta-analyses have shown.43-45 This may be linked with solvent exposure.

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TCDD (2,3,7,8-tetrachlorodibenzo-para-dioxin)

TCDD is classified by IARC as a probable cause of lung cancer, based on limited evidence (Table 4.1).2 An estimated 0.01% of lung cancers in Britain are linked to TCDD (typically in metal and pesticide production).27

Lung cancer death risk is 22% higher in pesticide production workers compared with the general population, a meta-analysis showed.46

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Occupational radon

Radon is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 0.01% of lung cancers in Britain are linked to working in sites of naturally-occurring high radon.27

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Mineral oils

Exposure to mineral oils is not classified as a cause of lung cancer by IARC,2 but an estimated 0.01% of lung cancers in Britain are linked to mineral oil exposure (typically in metalworkers and printworkers).27

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Arsenic and inorganic arsenic compounds

Working with arsenic and inorganic arsenic compounds is classified by IARC as a cause of lung cancer (Table 4.1).2 An estimated 0.003% of lung cancers in Britain are linked to arsenic and inorganic arsenic compounds (typically in metal production, pesticide production/use, wood preservation).27

Arsenic exposure increases lung cancer risk more in smokers than in non-smokers.35,48,49

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Working as a welder

Welding fumes are classified by IARC as a probable cause of lung cancer, based on limited evidence (Table 4.1).2 An estimated 0.001% of lung cancers in Britain are linked to working as a welder.27

Lung cancer risk is 26% higher in welders compared with the general population, a meta-analysis showed.47

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Other occupational exposures

A number of other occupational exposures are classified by IARC as causes or probable causes of lung cancer (Table 4.1).2 Most of these exposures are thought to affect few workers in Britain.27

Lung cancer risk may be higher in rock wool and glass wool production workers (though not end-users), a meta-analysis found;50 however residual confounding by smoking and asbestos exposure is likely.50

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Air pollution

Outdoor air pollution

Outdoor air pollution (and the particulate matter within it) is classified by IARC as a cause of lung cancer (Table 4.1).2

Lung cancer risk is 22% higher per 10 micrograms per cubic metre (µg/m3) of PM10 air pollution, a pooled analysis looking at long-term exposure showed.52 This may be limited to lung adenocarcinomas (not squamous cell carcinomas), which are less closely linked with smoking. Lung cancer death risk is 15-21% higher per 10 µg/m3 increase in airborne particulate matter a meta-analysis showed.53

Lung cancer death risk is higher in people living near major roads, a meta-analysis showed.53 Though most evidence linking lung cancer risk with diesel exhaust emissions comes from studies of highly-exposed workers, IARC states diesel exhaust may increase lung cancer risk in the general public.40

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Indoor air pollution

Emissions from household coal combustion are classified by IARC as a cause of lung cancer; emissions from household biomass fuel (primarily wood) combustion or high-temperature frying are classified as probable causes, based on limited evidence (Table 4.1).2

Lung cancer risk is around doubled in people who use coal in the home for cooking or heating, meta-analyses (primarily from China and Taiwan, where coals may be more harmful than those used in the UK) have shown.54,55 Lung cancer risk is not associated with domestic coal use, a European case-control study showed.56

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Family history

Lung cancer risk is 82% higher in people whose sibling has/had lung cancer, and 25-37% higher in people whose parent has/had the disease, a meta-analysis showed.57 The association is independent of smoking.57

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Previous cancer

Lung cancer risk may be increased in breast cancer survivors who had radiotherapy for their primary cancer, however modern radiotherapy techniques may not have the same effect.59 The association may vary by breast cancer type and smoking status, perhaps indicating the link is not solely due to radiotherapy.6

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Lung cancer risk is 5 times higher in Hodgkin lymphoma survivors compared with the general population, a meta-analysis showed.105 Again, radiotherapy treatment for the primary cancer is implicated in this association, as is smoking status.105

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Lung cancer risk is also increased in survivors of non-Hodgkin lymphoma;.67,68,123 testicular cancer;69 uterine sarcomas;70 head and neck cancers;123,124 lip, oesophagus, bladder cancers, and chronic lymphocytic leukaemia (males); and liver, cervix, uterus, and kidney cancers (females),123 cohort studies have shown.

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Previous lung disease

Pneumonia

Lung cancer risk is 43-57% higher in people with a history of pneumonia, with slightly smaller risk increase (35-36%) in never-smokers, a meta-analysis and pooled analysis of case-control studies have shown.75,105 Lung cancer risk is increased in pneumococcal and community-acquired pneumonia.76,117

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Tuberculosis

Lung cancer risk is 48-72% higher in people with a history of tuberculosis (TB), including never-smokers (50-90% higher risk), meta-analyses and a pooled analysis have shown.75,79,106 The risk increase may persist for 20+ years after TB diagnosis, and may be limited to lung adenocarcinoma.79

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Silicosis

Lung cancer risk is around doubled in people with silicosis (caused by silica exposure) meta-analyses have shown.38,39

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Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a collection of smoking-related lung diseases including emphysema, chronic bronchitis, and chronic obstructive airways disease.

Lung cancer risk is 104-144% higher in people with a history of emphysema, though there may be no association for never-smokers, meta- and pooled analyses have shown.75,106

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Lung cancer risk is 47-52% higher in ever-smokers with a history of chronic bronchitis; there is no association for never-smokers, meta- and pooled analyses have shown.75,106

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Infections

Human immunodeficiency virus (HIV)

Lung cancer risk is almost three times higher in people with HIV or AIDS, meta-analyses have shown.71,72 The association is independent of smoking, and is slightly stronger in AIDS than HIV, and in women than men.72,73 

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Immune system

Organ transplant

Lung cancer risk is around doubled in organ transplant recipients, a meta-analysis and large cohort study have shown.71,74

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Autoimmune conditions

Lung cancer risk is up to doubled in people with systemic lupus erythematosus, compared with the general population, meta-analyses have shown.77,78,120

Lung cancer risk is higher in rheumatoid arthritis patients compared with the general population, a systematic review showed.78

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Medical conditions and treatments

Diabetes

Lung cancer risk may be higher in diabetics, particularly diabetic women, a meta-analysis showed.107 

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Diet

Associations between lung cancer risk and diet may be confounded by smoking, as smokers and non-smokers may have different dietary habits; the evidence in this area is generally not strong.

Red and processed meat

Red and processed meats are classified by WCRF/AICR as possible causes of lung cancer.84

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Beta-carotene supplements

Beta-carotene supplements (in smokers only) are classified by WCRF/AICR as possible causes of lung cancer.84

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Other dietary factors

Total fat, butter, and retinol supplements (in smokers only) are classified by WCRF/AICR as possible causes of lung cancer.84

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Overweight and obesity

Low body fatness is classified by WCRF/AICR as a possible cause of lung cancer.84

Lung cancer risk may be lower in current and former smokers with a higher body mass index (BMI) a meta-analysis showed.112 Confounding by smoking and reverse causality (weight loss caused by undiagnosed lung cancer) are possible.

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Factors shown to decrease or have no effect on lung cancer risk

Decrease risk

Fruits and foods containing carotenoids are classified by WCRF/AICR as probably protective against lung cancer (though beta-carotene supplements are classified as a cause of lung cancer in smokers).84 An estimated 9% of lung cancers in the UK are linked to people eating less than 2-3 portions of fruit each day.85

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Non-starchy vegetables, dietary or supplementary selenium, and dietary quercetin are classified by WCRF/AICR as possibly protective against lung cancer, based on limited evidence.84

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Physical activity is classified by WCRF/AICR as possibly protective against lung cancer, based on limited evidence.84

Lung cancer risk is lower in people with moderate or high physical activity levels versus those with low levels, meta-analyses have shown.92,94,110,111 Confounding by smoking is likely,92 and vigorous activity may be required to obtain benefit.93

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Lung cancer risk may be lower in people with multiple sclerosis (MS), a meta-analysis showed.95 Smoking is implicated in both MS and lung cancer development.95

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Lung cancer risk may be slightly lower in women with older age at menarche (first menstrual period), a meta-analysis showed.114

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Lung cancer risk is 28-38% lower in cotton textile industry and agriculture workers, a meta-analysis showed; this is probably due to endotoxins exposure.102

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No effect

WCRF/AICR make no judgment on the association between lung cancer risk and intake of cereals (grains) and their products; starchy tubers; dietary fibre; pulses (legumes); poultry; fish; eggs; milk and dairy products; total fat; animal fats; plant oils; soft drinks; coffee; tea; alcohol; preservation, processing, and preparation; carbohydrate; protein; vitamin A; thiamin; riboflavin; niacin; vitamin B6; folate; vitamin C; vitamin E; multivitamins; calcium; copper; iron; zinc; pro-vitamin A carotenoids; lycopene; flavonoids; culturally-defined diets; body size, shape, and composition (except low body fatness); or energy intake, due to limited evidence.84

Lung cancer risk is not associated with the following factors, meta- and pooled analyses or systematic reviews have shown:

  • Folate (including folic acid supplementation,86,87 and overall folate126) (some evidence of variation by sex126).
  • Circulating vitamin B6 and methionine levels.88
  • Foods containing soy.89
  • Cruciferous vegetables.109
  • Alcohol.90,91
  • Asthma96 (increased risk shortly after asthma diagnosis probably misdiagnosis of early lung cancer symptoms as asthma96).
  • Statins.118,119
  • Aspirin (some evidence of risk decrease but limited to case-control studies,97,98 lower-quality studies,98 users of 7+ aspirin tablets per week,99 and men.100)
  • Non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs).99,100
  • Parity101
  • Hormone replacement therapy (HRT) use81 (also mixed evidence of risk decrease81 and risk increase82).
  • Oral contraceptives (some evidence of risk decrease).127
  • Fish (some evidence of risk decrease).128

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References for lung cancer risk factors

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Updated: 18 June 2014