Are associations between psychosocial stressors and incident lung cancer attributable to smoking?

PURPOSE: To learn whether reported associations between major psychosocial stressors and lung cancer are independent of smoking history. METHODS: Subjects were at least 25 years old and without lung cancer at enrollment in the United States Census Bureau’s National Longitudinal Mortality Survey in 1995–2008. Follow-up via Surveillance Epidemiology and End Results and National Death Index continued until lung cancer diagnosis, death, or December 2011. Involuntary unemployment, widowhood, and divorce, stratified by sex, were tested for association with subsequent lung cancer using proportional hazards regression for competing risks. Smoking status, years smoked, cigarettes per day, and years since quitting were imputed when missing. RESULTS: At enrollment, subjects (n = 100,733, 47.4% male, age 49.1(±15.8) years) included 17.6% current smokers, 23.5% former smokers. Of men and women, respectively, 11.3% and 15.0% were divorced/separated, 2.9% and 11.8% were widowed, and 2.9% and 2.3% were involuntarily unemployed. Ultimately, 667 subjects developed lung cancer; another 10,071 died without lung cancer. Adjusted for age, education, and ancestry, lung cancer was associated with unemployment, widowhood, and divorce/separation in men but not women. Further adjusted for years smoked, cigarettes per day, and years since quitting, none of these associations was significant in either sex. CONCLUSIONS: Once smoking is accounted for, psychosocial stressors in adulthood do not independently promote lung cancer. Given their increased smoking behavior, persons experiencing stressors should be referred to effective alternatives to smoking and to support for smoking cessation.