Social inequalities and smoking-associated breast cancer - Results from a prospective cohort study

•Active smoking and breast cancer was stratified by level of education and birth cohort in 302,865 Norwegian women•We find increasing risk with increasing smoking exposure in most categories, most consistent in women with low education.•Smoking before first childbirth was consistently associated with increasing breast cancer risk in all levels of education

ObjectiveThe association between smoking and breast cancer has been found in most recent, large cohort studies. We wanted to investigate how smoking-associated breast cancer varies by level of education, a well-established measure of socioeconomic status.MethodsWe included 302,865 women with 7490 breast cancer cases. Participants were assigned to low, moderate or high level of education and analyzed by smoking status (ever/never), and stratified by birth cohorts (≤ 1950 >). We used Cox proportional hazard to estimate hazard ratios (HRs) and confidence intervals (CIs), adjusting for age, number of children, age at first childbirth, BMI, age at enrollment and physical activity.ResultsWomen born ≤ 1950 with low and moderate levels of education had a 40% increase in smoking-associated breast cancer risk (HR = 1.40, 95% CI 1.25-1.57 and HR = 1.14, 95% CI 1.05-1.24, respectively). Women in the same age group with high level of education did not have an increase in risk. No increased breast cancer risk was found among women born after 1950 for any level of education, when analyzed by smoking status. Longer duration of smoking before first childbirth was consistently associated with increasing risk of breast cancer in all three categories of education (all p for trends < 0.01).ConclusionSmoking for several years before first childbirth increases the risk of breast cancer, regardless of educational level.