Association Between Socioeconomic Position and Lung Cancer Incidence in 16 Countries: A Prospective Cohort Consortium Study Publisher



Onwuka JU¹ ; Zahed H¹ ; Feng X¹ ; Alcala K¹ ; Erhunmwunsee L² ; Williams RM³ ; Aldrich MC⁴ ; Ahluwalia JS⁵ ; Albanes D⁶ ; Arslan AA⁷ ; Bassett JK^{8, 9} ; Brennan P¹ ; Cai Q¹⁰ ; Chen C¹¹ Show All Authors Show Affiliations
Source: eClinicalMedicine Published:2025

Abstract

Background: Studies have reported higher lung cancer incidence among groups with lower socioeconomic position (SEP). However, it is not known how this difference in lung cancer incidence between SEP groups varies across different geographical settings. Furthermore, most prior studies that assessed the association between SEP and lung cancer incidence were conducted without detailed adjustment for smoking. Therefore, we aimed to assess this relationship across world regions. Methods: In this international prospective cohort consortium study, we used data from the Lung Cancer Cohort Consortium (LC3), which includes 20 prospective population cohorts from 16 countries in North America, Europe, Asia, and Australia. Participants were enrolled between 1985 and 2010 and followed for cancer outcomes using registry linkages and/or active follow-up. We estimated hazard ratios (HRs) for the association between educational level (our primary measure of SEP, in 4 categories) and incident lung cancer using Cox proportional hazards models separately for participants with and without a smoking history. The models were adjusted for age, sex, cohort (when multiple cohorts were included), smoking duration, cigarettes per day, and time since cessation. Findings: Among 2,487,511 participants, 53,830 developed lung cancer during a 13.5-year median follow-up (IQR = 6.5–15.0 years). Among participants with a smoking history, higher education was associated with decreased lung cancer incidence in nearly every cohort after detailed smoking adjustment. By world region, this association was observed in North America (HR per one-category increase in education [HRtrend] = 0.88, 95% CI = 0.87–0.89), Europe (HRtrend = 0.89, 95% CI = 0.88–0.91), and Asia (HRtrend = 0.91, 95% CI = 0.86–0.96), but not in the Australian study (HRtrend = 1.02, 95% CI = 0.95–1.09). By histological subtype, education associated most strongly with squamous cell carcinoma and more weakly with adenocarcinoma (p-heterogeneity < 0.0001). Among participants who never smoked, there was no association between education and lung cancer incidence in any cohort (all p-trend > 0.05), except the USA Southern Community Cohort Study (HRtrend = 0.75, 95% CI = 0.62–0.90). Interpretation: Based on longitudinal data from 2.5 million participants from 16 countries, our findings suggest that higher educational attainment was associated with lower lung cancer risk among participants with a smoking history, but not among participants who never smoked. Limitations of our study include that cohort participants cannot fully represent the general populations of the geographical regions included, and education was the only measure of SEP consistently available across our consortium. Funding: This study was supported in part by theNational Cancer Institute (NCI), theLung Cancer Research Foundation (LCRF), and theWorld Cancer Research Fund (WCRF). © 2025 World Health Organization