Cut down on cigarettes, and you cut down on cancer deaths. That's the good-news trend that's been taking shape in California since the late 1980s, according to "Reducing Smoking and Cancer in California: A Success Story," a report presented at the Centers for Disease Control and Prevention 2001 Cancer Conference held in Atlanta.

Between 1988 and 1998 in California, the death rate for four specific cancers — lung, pancreatic, bladder, and oropharyngeal (including tonsils, soft palate, central pharynx, and base of tongue) — dropped significantly, says Bruce Leistikow, MD, principal investigator of the California study and adjunct associate professor at the University of California's School of Medicine in Davis.

California's overall cancer death rate dropped 12% in that same period, while the cancer death rate in 47 other states dropped only 4%. (Massachusetts and Arizona were excluded from the numbers contrasting the California cancer death rates with the nation because those two states are also home to aggressive anti-smoking campaigns.)

Marlboro Man started to fall from his saddle in 1989, when California increased the cigarette surtax. The state devoted the extra 25-cents-per-pack tax to a multi-faceted campaign to reduce smoking. The Centers for Disease Control and Prevention (CDC) calls such efforts "comprehensive tobacco control programs." Their goals, the CDC says, are to reduce disease, disability, and death related to tobacco use.

The numbers that Leistikow presented in Atlanta make a case that the campaign is working. His study marks the first time that death statistics on all major cancers were examined as a whole, he says.

"I was very pleasantly surprised to see how promptly and greatly the all-sites cancer mortality had come down in California," Leistikow says, "and unpleasantly surprised to see how much the rest of the US is lagging behind."

Leistikow's study found that the reductions in cancer mortality rates amounted to 4,000 California cancer deaths prevented in 1998 alone. The 10-year study also found a mortality gap with the rest of the nation: about 200,000 additional cancer deaths in the rest of the US during the study decade — deaths that would have been prevented had the nation's cancer rates matched California's.

"Leistikow's study is both innovative and utilitarian," says Dileep G. Bal, MD, MS, MPH, national president of the American Cancer Society (ACS). "He is a man of immense talent who has mined this data at considerable length."

Bal says the analysis represents good news as well as bad.

"To begin with the bad news, one cannot unequivocally assert that the lung, pancreatic, bladder, and oropharyngeal cancer declines in the decade from 1988 to 1998 are directly attributable to California's tobacco control program," Bal says.

The unprecedented declines in tobacco prevalence and consumption, he says, took place at the same time as the significant lung cancer declines.

A decline in the cancer death rate occurs one, two, or three decades after a behavioral change — in this case, tobacco use — so, one could argue that the study's drop in cancer deaths are actually due to the tobacco use declines from the '60s, '70s, and '80s and not the steeper declines of the '90s, says Bal, who studied chronic disease epidemiology at the Harvard School of Public Health.

"This," Bal says, "brings me to the good news, and is it ever good news. If you buy this hypothesis, then the mortality of tobacco-related cancers will have accelerating declines as more and more of this tobacco-use behavioral change shows up at the other end of the pipeline in mortality declines."

As California cancer rates declined, so did the amount of cigarette smoke filling Golden State air and lungs. According to the Tobacco Control Section of the California Department of Health Services, between 1988 and 1998:

• The percentage of California adult smokers dropped from 22.8% to 18.4%. (The rate continues to fall, hitting 17.1% in 2000.)
• Per-adult cigarette consumption in California dropped from nearly 127 packs per year in 1987-1988 to 69 packs in 1997-1998, a 45% decline. At the same time, the national annual consumption rate dropped from nearly 155 packs to 116, a 25% decline. (Again, average consumption continues to fall: 53 packs per California adult in 1999-2000; 103 packs nationally.)

Bal, the ACS president, believes the entire nation, "in all probability," will reach the American Cancer Society's 2015 goals of a 25% incidence decline and a 50% mortality rate decline. Because California's tobacco use has declined even more dramatically than the rest of the nation's, that state will "most certainly" meet the 2015 goals, he says.

"How do we move the rest of the nation from probably meeting the ACS 2015 goals to definitely doing so? The answer is simple," Bal says. "The rest of the country needs to adopt an aggressive, comprehensive tobacco control program with, most importantly, adequate funding that meets the CDC's recommended per capita funding levels."