Robert A. Winn

Supplementary Figure S2 shows the observed/expected ratio of multiple primary cancers increases with county-level smoking prevalence among survivors of both smoking-related cancers and non-smoking-related cancers.

Supplementary Table S1 shows the sample size, person-years of follow-up, and numeric values of increasing observed/expected ratio of multiple primary cancers with county-level smoking prevalence.

Supplementary Table S2 shows the sample size, person-years of follow-up, and numeric values of increasing observed/expected ratio of multiple primary cancers with county-level smoking prevalence by age groups.

Supplementary Table S3 shows the sample size, person-years of follow-up, and numeric values of increasing observed/expected ratio of multiple primary cancers with county-level smoking prevalence by racial/ethnic groups.

Figure S3. Observed/Expected Ratio of the Occurrence of Multiple Primary Cancers by County-Level Smoking Prevalence and Poverty Levels among Males and Females.

Figure S4. Observed/Expected Ratio of the Occurrence of Multiple Primary Cancers by County-Level Smoking Prevalence by Age Groups and Race/Ethnicity among Males and Females.

Supplementary Figure S1 shows the observed/expected ratio of multiple primary cancers increases with county-level smoking prevalence using 2000-2003 and 2014-2016 smoking prevalence.

Background:As the number of cancer survivors in the United States grows, multiple primary cancer (MPC) has become an increasing public health concern. Understanding geographic variation in MPC incidence can inform targeted public health strategies. In this study, we aimed to examine associations between MPC incidence and county-level cigarette smoking (smoking) prevalence.Methods:We conducted a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results 17 registries, representing 26.5% of the U.S. population. The cohort included 6,364,027 individuals diagnosed with an initial primary cancer between 2000 and 2021, followed through December 2021. County-level smoking prevalence was the primary exposure. The main outcome was MPC incidence, assessed using observed-to-expected ratios across strata of smoking prevalence. Analyses were stratified by sex, age, and race/ethnicity.Results:Observed-to-expected ratios of MPC increased with higher county-level smoking prevalence, from 1.02 (95% CI, 1.01–1.03) among males and 1.24 (95% CI, 1.22–1.25) in females in low-prevalence counties to 1.34 (95% CI, 1.31–1.38) and 1.53 (95% CI, 1.49–1.58), respectively, in high-prevalence counties. Robust relationships were observed among individuals diagnosed with their initial cancer at ages 45 to 64.Conclusion:County-level smoking prevalence is positively associated with MPC incidence. These findings support the need for targeted, community-level tobacco control interventions to reduce MPC risk.Impact:By linking county-level smoking prevalence to MPC risk, this study highlights the potential utility of community-level data in identifying high-risk populations and guiding tobacco control and survivorship interventions.

Lung cancer, once considered a clinical rarity, is now the leading cause of cancer-related mortality among both men and women in the United States (US) and remains the deadliest cancer worldwide. Early investigations focused on a broad range of environmental and occupational exposures as putative factors. However, the emergence of robust epidemiologic evidence in the mid-twentieth century established tobacco use, particularly cigarette smoking, as the dominant driver of lung cancer incidence. These discoveries fundamentally shaped US tobacco control policies, cancer prevention strategies, and subsequent scientific advances in thoracic oncology. Over the past three decades, innovations in screening, staging, molecular characterization, and treatment have transformed the landscape of lung cancer care and created unprecedented opportunities to improve outcomes for populations at greatest risk. Yet, the benefits in these advancements have not been equally realized. Persistent disparities in access to screening, prevention, timely diagnosis, and evidence-based care continue to disproportionately burden at-risk groups, including individuals with lower socioeconomic status and those in rural areas. Addressing these inequities requires multifaceted, cross-sector strategies that extend beyond the clinic to the social and structural determinants of health. This review aims to provide a brief history of lung cancer research, reflect on advancements in lung cancer treatment from 1990 - 2025, and highlight efforts toward continued progress in truly equitable lung cancer screening, treatment, care, and policy.

Background: Cancer survivors are increasingly living beyond 5 years post‐diagnosis and are projected to exceed 26,000,000 in the United States (US) by 2040. Research is needed on racial and ethnic differences in long‐term survival. Methods: In this retrospective cohort study of 10,895,183 individuals diagnosed with cancer from the US population‐based Surveillance Epidemiology and End Result (SEER) data (2000–2021), we compared survival outcomes up to 15 years post‐diagnosis across 6 mutually exclusive racial/ethnic groups: Hispanics, and non‐Hispanic White, Black, Asian, American Indian/Alaska Native (AI/AN), and Native Hawaiian and other Pacific Islander (NHPI). Results: Overall, Hispanic and non‐Hispanic Black, Asian, AI/AN, and NHPI cancer survivors had persistently poorer survival outcomes compared to non‐Hispanic White cancer survivors. AI/AN men and women, NHPI men, and Black women experienced the poorest outcomes. Survival gaps widened over time. By year 15, male AI/AN and NHPI and female AI/AN and Blacks were more than 25% more likely to die compared to their White counterparts. These disparities were most pronounced among individuals with advanced‐stage cancers and persisted across counties with various income levels. Racial/ethnic differences varied by cancer site. Conclusions: Long‐term survival disparities by race and ethnicity persist and widen beyond 5 years post‐diagnosis, particularly among non‐Hispanic AI/AN individuals, NHPI men, and Black women. These trends are not solely explained by income or cancer stage, highlighting the need for long‐term, risk‐based and tailored survivorship care to reduce racial and ethnic differences in cancer outcomes.