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Current cigarette smokers have a higher risk of bladder cancer than previously reported, and the risk for women is now comparable with that of men, according to a scientific study from the National Cancer Institute (NCI).[1] This latest study uses data from over 450,000 participants in the NIH-AARP Diet and Health Study, a questionnaire-based study that was initiated in 1995, with follow-up through the end of 2006.

While previous studies showed that only 20% to 30% of female bladder cancer cases were caused by smoking, the new data from the NIH-AARP study indicate smoking is responsible for actually about 50% of the cases—similar to the proportion found in men in current and previous studies. The increase in the proportion of smoking-attributable bladder cancer cases among women may be a result of the increased prevalence of female smokers in the United States.

In the current study, former smokers were twice as likely, and current smokers were four times more likely, to develop bladder cancer as those who have never smoked. As with many other smoking-related cancers, smoking cessation was associated with reduced risk of bladder cancer. Participants who had been smoke-free for at least 10 years had a lower incidence of bladder cancer compared with those who quit for shorter periods of time or still smoked.

Although smoking carries the same risk for men and women, men are still about four times more likely to be diagnosed with bladder cancer. These results, as well as those from previous studies, suggest that differences in smoking rates explain only part of the higher incidence rates in American men. Researchers suggest that occupational exposures, as well as physiologic differences, may contribute to the gender disparity.

In 2011, approximately 69,250 people will be diagnosed with bladder cancer in the United States, and 14,990 will die from the disease.[1] According to a new report published in the Annals of Internal Medicine, the only sure way to prevent bladder cancer is to stop smoking.[2] Despite the almost 15,000 people who will die of bladder cancer this year, the U.S. Preventive Services Task Force (USPSTF) has determined that there is insufficient evidence to recommend screening among asymptomatic adults at average risk. In 2004, the USPSTF recommended against screening because harms outweighed the benefits; this time, the Task Force has concluded there is insufficient evidence to recommend for or against screening or that screening leads to improved disease-specific or overall morbidity or mortality.

It is also unclear that any routine screening benefits would outweigh the risks, which include false-positive results that lead to needless invasive testing, costs, and anxiety. Another issue is that screening for bladder cancer may pick up “trivial lesions” that are not likely to produce harm. Treating or removing those tumors can cause side effects such as bladder perforation or internal bleeding.

Neither the American Cancer Society (ACS) nor the European Association of Urology recommends routine screening for bladder cancer. Both organizations recommend that attention to bladder symptoms is the best approach for finding bladder cancer at its earliest, most treatable stages in people with no known risk factors—and that the best approach to primary prevention is to eliminate active and passive smoking.[3,4]

While Americans may be smoking fewer cigarettes, the use of smokeless tobacco is increasing at a rate of 6% per year.[5] While the cancer risks of smokeless tobacco, or snuff, are the subject of much debate, a new published article suggests a relationship between smokeless tobacco and heart failure. A team of Swedish researchers analyzed two cohorts of men who never smoked: a community-based group of older men and a large group of construction workers.[5] After adjusting for past and present smoking exposure among the older men, the use of smokeless tobacco was associated with twice the risk of nonischemic heart failure compared with non use. Compared with construction workers who had never smoked cigarettes, men who used snuff currently were 28% more likely to suffer heart failure. There was no relationship between the amount of snuff used daily and the risk of heart failure.

According to an American Heart Association policy statement,[6] smokeless tobacco products should not be used as an alternative to cigarettes or for smoking cessation due to the risk of addiction and return to smoking. According to the AHA, no tobacco product, including dry and moist snuff and chewing tobacco, is safe to consume. Smokeless tobacco products are harmful and addictive—that does not translate to a better alternative.[6]

The statement also addresses a controversy over whether smokeless tobacco product use is a “safer” alternative to smoking. The idea that smokeless tobacco products are preferable to cigarettes is based in part on the Swedish experience showing a significant decrease in smoking among Swedish men between 1976 and 2002 which corresponded to an increase in the use of smokeless tobacco.[7,8] However, the opposite was true in a U.S. study that found no reduction in smoking rates among people using smokeless tobacco products.[9]

For people trying to quit smoking, nicotine replacement therapy (nicotine gum or a nicotine-releasing patch placed on the skin) is a safer alternative compared with using smokeless tobacco products. Clinical studies have found no increased risk of heart attack or stroke with either type of nicotine replacement therapy.

Of course, the best smoking cessation strategy is not to start at all. As the AHA states, “Clinicians should continue to discourage use of all tobacco products and emphasize the prevention of smoking initiation and smoking cessation as primary goals for tobacco control.”[6]

Jill Shuman, MS, ELS
Published on August 30, 2011


  1. Freedman ND, Silverman DT, Hollenbeck AR, et al. Association between smoking and risk of bladder cancer among men and women. JAMA. 2011;306(7):737-745.
  2. Moyer VA; on behalf of the U.S. Preventive Services Task Force. Screening for bladder cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2011;155(4):246-251.
  3. Stenzl A, Cowan NC, De Santis M, et al. The updated EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Utol. 2009;55:815-825.
  4. Bladder Cancer. American Cancer Society Website. . Updated July 15, 2011. Accessed. August 26, 2011.
  5. Arefalk G, Hergens MP, Ingelsson E, et al. Smokeless tobacco (snus) and risk of heart failure: results from two Swedish cohorts [published online ahead of print August 8, 2011]. Eur J Cardiovasc Prev Rehabil. doi: 10.1177/1741826711420003.
  6. Piano MR, Benowitz NL, Fitzgerald GA, et al. Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association. Circulation. 2010;122(15):1520-1544.
  7. Luo J, Ye W, Zendehdel K, et al. Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet. 2007;369(9578):2015-2020.
  8. Foulds J, Ramstrom L, Burke M, Fagerström K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control. 2003;12(4):349-359.
  9. Severson HH, Forrester KK, Biglan A. Use of smokeless tobacco is a risk factor for cigarette smoking. Nicotine Tob Res. 2007;9(12):1331-1337.