You only need lungs to get lung cancer
Exploring the rhetoric of lung cancer as a “smoking disease” and what we can do to change that
By Nell Bevan, MSc Science Communication Student at The University of Manchester
“Smoking causes lung cancer” is a phrase disseminated widely in the UK: repeated by healthcare professionals, printed across cigarette packets, quoted in cancer campaigns and often referenced in conversation. It is no secret that smoking tobacco increases your chance of developing lung cancer substantially, but smokers aren’t the sole population at risk of developing the disease. At present, 14% of those diagnosed with lung cancer are ”never-smokers”. In other words, they have smoked fewer than 100 cigarettes in their life. The proportion of never-smokers with lung cancer is increasing, as more people give up smoking and more screenings are done at an earlier stage. This is a huge problem: if lung cancer in never-smokers was considered its own disease, it would be the 8th most deadly cancer in the UK. So clearly, although smoking causes lung cancer, it is not responsible for all lung cancers.
There are a myriad of other carcinogens that can give rise to lung cancer. Aside from smoking; air pollution, family history and exposure to second-hand smoke may all increase the likelihood of a person developing lung cancer. Results from a study on lung cancer undertaken by a network of experts across the country, TRACERx, told us that rates of adenocarcinoma are higher in polluted areas. Adenocarcinoma is a type of non-small cell lung cancer that commonly arises in never-smokers. If there are clearly a variety of causes, how is it that we’ve come to assume that smoking alone causes lung cancer?
A scan of a pair of lungs
Lung cancer: “ A smoking disease”?
Since the 1940s, when smoking was first recognised as carcinogenic, countless campaigns have appeared to dissuade people from smoking. Of course, smoking causes many different diseases including at least 15 different cancers, but its direct impact on lung function has made it synonymous with lung cancer in particular. Probably the most familiar messaging is the warning signs splashed across cigarette packets. These and other similar initiatives have done wonders in reducing smoking levels, and remain imperative in improving general public health. However, they have also birthed some unintended consequences. In particular, the transformation of lung cancer into just a “smoking disease”.
As a result of the implication that lung cancer is caused by smoking, those with a diagnosis may feel blamed for contracting the disease, regardless of whether they smoke or not. Additionally, never-smokers with lung cancer often feel obliged to tell people they’ve never smoked when explaining their diagnosis out of fear of judgement. These worries are an unfair addition to the already large emotional burden that comes with diagnosis. As mentioned, smoking causes a range of diseases, and in fact is increasingly being seen as a disease in itself, so its stigmatisation can be counterproductive to care.
However, this stigma doesn’t just exist socially. It also has implications for clinical practice, where studies have shown that smokers and never-smokers have completely different experiences, even if they display similar symptoms.
Medically speaking, the tie between smoking and lung cancer has been shown to affect both patient and practitioner action. From the perspective of the patient, never-smokers are much less likely to seek medical attention even when symptoms arise. The main symptoms of lung cancer include a continuous cough, repeated chest infections, breathlessness, coughing up blood and weight loss, with never-smokers tending to display mild symptoms. The tendency is that never-smokers dismiss risks of lung cancer instead believing they have a common cold or hayfever.
This issue was particularly prevalent during the COVID-19 pandemic when the public was advised to avoid GP appointments if they were only suffering from a continuous cough (as many never-smokers might). More broadly, a lack of education and resources around lung cancer in never-smokers means that individuals may not believe they are at risk of developing lung cancer in the first place. When these factors don’t dissuade an individual from seeking medical advice, they may then face clinical obstacles too.
The smoking history of an individual heavily influences the decisions of a doctor during an appointment. Even with multiple symptoms present, such as feeling tired, and experiencing constant chest pain, the seemingly lacking educational and government resources for never-smokers has meant that some healthcare professionals are unlikely to assert that the presenting patient has lung cancer. Clinicians may be more likely to assume there is some other issue, such as pneumonia or a chest infection. As a result, a never-smoker will probably not be referred for a low-dose CT scan, despite smokers with the same symptoms being provided with one. Unfortunately, this means that never-smokers are often diagnosed at a stage too late in the disease’s progression for meaningful intervention.
Lung cancer is often diagnosed late, as serious symptoms tend to present themselves at a later stage. Almost two-thirds of UK lung cancer patients are diagnosed at stage three or four. Even at stage three, only 15% of patients diagnosed will survive for more than five years, compared to over 60% at stage one. Therefore, not detecting cancer early does patients a disservice, as it massively reduces their chance of successful intervention. Though this is true of all lung cancer patients, detection is disproportionately delayed in regards to never-smokers.
Making meaningful change
To make meaningful change, there is a need to increase the knowledge and understanding of lung cancer among never-smokers. Already, there is more research being carried out on never-smoker-specific biomarkers, and new investigations into the demographic that gets lung cancer (such as, why is it that more never-smokers who get lung cancer are women?). What’s needed is a communicative link between the research community and practitioners and the public.
Luckily, there are some amazing initiatives that do just that. Gateway C is a resource funded and hosted by The Christie NHS Foundation Trust, here in Manchester. It provides courses for healthcare professionals on early diagnosis in cancer. Their lung cancer-related material includes recommendations on how to approach the never-smoker issue.
The Ruth Strauss Foundation is dedicated to raising public and medical awareness around lung cancer in never-smokers. In 2021, the foundation unveiled a campaign in collaboration with British photographer Rankin titled “See Through The Symptoms” which features a series of photographs displaying the range of never-smokers who can get lung cancer. It aimed to urge “GPs and primary healthcare professionals to act on the symptoms of lung cancer, regardless of the smoking history or age of the patient” (Ruth Strauss Foundation, 2021).
Finally, some amazing communicative resources exist for individuals across many fields, such as Manchester’s own: One in Two: A Manchester Cancer research podcast, whose second season is dedicated to exploring lung cancer from different perspectives.
Beyond increasing awareness, the perception that lung cancer is a “smoking disease” needs to be shifted in order to reduce stigma around the disease socially. Anti-smoking campaigns need to become more effective in acknowledging risk whilst also emphasising non-judgment. By untangling lung cancer from its strict association with smoking, both smokers and never-smokers alike might reap benefits in medical and social contexts. Catching lung cancer early is imperative to survival, and practitioners and patients must become more aware of the symptoms and scope of who’s susceptible, regardless of smoking history. After all, you only need a pair of lungs to get lung cancer.