Tobacco smoking is widely recognized as the main cause of premature death from lung cancer worldwide [
26‐
28]. The causal relationship of lung cancer and smoking was established in the 1950’s [
26]. Since then, a large number of studies in the literature have revealed the impact of tobacco smoking on lung cancer [
27‐
31]. In particular, the highest risk for lung cancer mortality in ever smokers has been found to be approximately 9 times higher than in never smokers [
32]; much higher than the identified risk in the current study. Similarly to our study, Tammemagi et al., have stressed that smoking is an important independent predictor of short-term lung cancer survival [
27]. Furthermore, age was found to be a significant risk factor in the current study. Larger proportions of lung cancer incidence were observed among patients of age 55 and over. This finding is in accordance with the literature especially among ever smokers of this age group [
32,
33].
In addition, place of residence seems to be a core component of lung cancer incidence and mortality trends, as highlighted by the current and other studies [
34,
35]. It is obvious that a wide range of factors, such as demographic, occupational and environmental, are linked with rurality. These factors may have hidden effects on lung cancer epidemics; such effects are more severe in geographical regions where prevalence of smoking is higher (e.g., urban or semi-urban municipalities) [
35]. Geographical inequalities in lung cancer incidence distribution may be observed due to the different smoking habits between rural and urban regions. Marked differences in tobacco smoking patterns have been found in Greece, among different geographical regions (rural vs urban) and within age groups and genders [
36]. Furthermore, the vast majority of Cretans consider smoking a part of their culture which is strongly linked with social activities of men, especially while socializing in traditional “kafeneia” or modern cafes during the day [
37]. This habit increases both active and passive smoking in public and private working spaces, as well as inside the house, especially in urban, densely populated regions. Moreover, even though most of the municipalities in Crete are characterized as rural or semi-urban, their residents still have a diverse demographic profile; this leads to inequalities even between rural regions of the same county [
15]. Smoking prevalence in these regions may have affected the lung cancer incidence rates, since, as mentioned in the literature, individuals over 70 present significantly lower smoking rates, or die from other causes due to the lag period between tobacco exposure and disease onset [
38]. Apart from smoking, other occupational and environmental risk factors may have an additional effect on the increased lung cancer burden in certain rural municipalities that presented high lung cancer incidence and mortality. Greenhouse intense farming is among the most common agricultural practices in some rural and semi-urban municipalities (codes: 8; 9; 22). Studies has already shown the increased risk of lung cancer mortality and lower survival among individuals exposed to pesticides at work, especially among female greenhouse workers [
39,
40]. Previous studies have documented the association of pesticides/greenhouse farming and the development of chronic disease [
41]. The projected lower survival rates in the current study raise concern towards this direction. Nevertheless, further research and additional field studies on the joint effect of smoking and other risk factors (e.g. environmental exposures, lifestyle habits etc.) are required in order to clearly demonstrate the existence of such association in Crete.
YPLL due to lung cancer are higher in male ever-smokers in most studies, while they present constantly increasing temporal trends (1952: 6.6; 2012: 11.3) [
42]. Nevertheless, the proportion of increase during the last decades is higher in Cretan and Greek female ever-smokers, indicating an urgent need for comprehensive smoking policies that focus on women [
43]. Public health policies for tobacco control should consider the time lag in the tobacco epidemic among women compared to men, the differences in lifestyle and the local particularities and needs per geographical region [
43].