Reducing Tobacco-Related Cancer Incidence and Mortality Workshop Summary (2013) / Chapter Skim
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Workshop Summary
Workshop Summary
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. Smoking accounts for at least 30 percent of all cancer deaths, and 80 percent of lung cancer deaths (ACS, 2012)
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convened a public workshop, Reducing Tobacco-Related Cancer Incidence and Mortality, June 11–12, 2012, in Washington, DC.2 In opening remarks to the workshop participants, planning committee chair Roy Herbst, professor of medicine and of pharmacology and chief of medical oncology at Yale Cancer Center and Smilow Cancer Hospital, described the goals of the workshop, which were to examine the current obstacles to tobacco control and to discuss potential policy, outreach, and treatment strategies that could overcome these obstacles and reduce tobacco-related cancer incidence and mortality. Experts explored a number of topics, including • he changing demographics of tobacco users and the changing pat t terns of tobacco product use; • he influence of tobacco use on cancer incidence and cancer treat t ment outcomes; • tobacco dependence and cessation programs; • federal- and state-level laws and regulations to curtail tobacco use; • tobacco control education, messaging, and advocacy; • financial and legal challenges to tobacco control efforts; and • esearch and infrastructure needs to support tobacco control strate r gies, reduce tobacco-related cancer incidence, and improve cancer patient outcomes.
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Cancer care could be improved by • ccurately identifying tobacco use in cancer patients during A and following cancer treatment using structured tobacco assessments and/or biochemical confirmation methods. • ncorporating the treatment of tobacco dependence into the I standard of care for all cancer patients who use tobacco products, to improve treatment outcomes and reduce treat ment complications and toxicity.
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• nsuring all insurance plans provide coverage for evidence E based tobacco cessation therapy. • tandardizing electronic medical record fields to document S tobacco use status, cessation referrals, and cessation therapy.
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CHANGING DEMOGRAPHICS OF TOBACCO USE Several speakers noted that the average person who smokes today tends to have a different educational and economic background from the typical person who smoked decades ago, when cigarette smoking was more popular, with fewer known risks. People who smoke now tend to have a lower economic and educational status than those who do not smoke, according to Kenneth Warner, the Avedis Donabedian Distinguished University Professor of Public Health at the University of Michigan School of Public Health.
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However, others disagree with the premise that people who smoke today are more hard core, noting that many people who currently smoke consume fewer cigarettes and smoke far less regularly. Jamie Ostroff, attending psychologist, director of the Tobacco Cessation Program for Memorial Hospital, and chief of the Behavioral Sciences Service at the Memorial Sloan-Kettering Cancer Center, emphasized recent studies suggest that evidence-based approaches to tobacco cessation are also safe and effective for people with mental illness or substance abuse disorders (Fiore et al., 2008; Williams and Ziedonis, 2004)
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Terry Pechacek, associate director for science in the Office on Smoking and Health at CDC, pointed out that after years of sustained progress in reducing smoking in youth, the decline in smoking appears to be slowing for cigarette use, and is at a standstill for smokeless tobacco, since about 2003 (HHS, 2012)
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, so the progress in stemming overall use of tobacco products may be overestimated. "The [tobacco industry]
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There has also been a slowing of progress in reducing the use of tobacco products in older adults, Pechacek noted. He pointed out that the projected prevalence of smoking for 2020, based on current smoking patterns, will be around 17 percent (CDC, 2011d)
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These products include cigars, a type of smokeless tobacco called snus, spit tobacco, dissolv able tobacco products, and the e-cigarette, which is a device that resembles a cigarette and converts a nicotine-laden liquid into vapor. Often noncombustible tobacco products are viewed as being less hazardous to health than combustible ones, but that thinking may be mis guided, according to Pechacek.
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"We are not saying that noncombustible sources don't have a role, but watch out because noncombustible tobacco products are adding on to, rather than replacing, cigarette smoking." Pechacek noted that cigar smoking is assumed to be less dangerous than cigarette smoking because it is often not inhaled, but this may not be the case for current or former cigarette smokers who do inhale cigar smoke. Studies have shown that former cigarette smokers who switched to cigars had potentially higher levels of exposure to toxic chemicals and risk of disease than people who smoke cigarettes (NCI, 2012a)
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Although individual risk for the health consequences of tobacco use may be reduced if individuals replace combustible tobacco products with smokeless tobacco products, the potential for harm at the level of population health may be significant. "A product like snus or even an e-cigarette could potentially cause harm because they introduce kids to a tobacco product that they [might be able to]
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I am living and breathing proof of that." He noted that state governments tend to focus on raising taxes on cigarettes, but not on spit tobacco. Benjamin Toll, assistant professor of psychiatry at the Yale University School of Medicine, member of Yale Cancer Center, and program director of the Smoking Cessation Service for Smilow Cancer Hospital at Yale-New Haven, concurred that much of the research is focused on smoking and how to curb it, and there is a need to study use of all tobacco products.
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Nicotine and activation of systemic nicotinic acetylcholine receptors by various products in tobacco can trigger cell survival pathways that prevent the death of mutated cells. Warren noted several studies demonstrating that nicotine can increase cancer proliferation, angiogenesis, migration, and invasion, and decrease the effectiveness of conventional cancer treatments such as chemotherapy and/or radiotherapy (Warren et al., 2008, 2012c)
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There is insufficient evidence that modifying tobacco products can reduce cancer risk, the report clearly stated. Impact of Smoking on Cancer Incidence and Treatment Outcomes The impact of smoking on cancer is substantial.
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Warren stressed that encouraging cancer patients to quit smoking may have a marked effect on their survival, as some studies have indicated for head, neck, and lung cancers (Browman et al., 1993; Herbst et al., 2005; Thatcher et al., 2005)
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TOBACCO DEPENDENCE What makes tobacco use especially difficult to combat is its addictive nature due to nicotine and other compounds and additives that tobacco products contain. "Nicotine addiction is not just a habit," said Cheryl Healton, founding president and chief executive officer of Legacy.
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"You wouldn't say to someone with schizophrenia ‘you can't take your meds for more than three months because we don't want you to get addicted to them,'" Abrams said. Warner noted that the tobacco company Philip Morris purchased rights to a patent for a nicotine inhaler that might be an alternative to tobacco products for those already addicted to nicotine (Felberbaum, 2011)
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Gritz, professor and chair of the department of behavioral science and Olla S Stribling Distinguished Chair for Cancer Research at the University of Texas MD Anderson Cancer Center, noted that surveys find that cancer patients, especially lung cancer patients, who have a history of smoking have increased levels of guilt and shame compared those who did not smoke.
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They also publicly denied that secondhand smoke is hazardous to 4 United States of America, Plaintiff, and Tobacco-Free Kids Action Fund, American Cancer Society, American Heart Association, American Lung Association, Americans for Nonsmoker Rights, and National African American Tobacco Prevention Network, Intervenors, v. Philip Morris USA, Inc.
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Overview of Tobacco Cessation Therapy The recent tobacco cessation treatment guideline notes that tobacco dependence treatments are effective across a wide range of populations (Fiore et al., 2008)
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Carolyn Dresler, medical director for the Tobacco Prevention and TABLE 1 Tailoring Pharmacotherapy for Tobacco Cessation Therapy Long-Acting Options Short-Acting Options Pick 1 or 2: Add 1 or 2 from here: Nicotine patch Nicotine gum Bupropion Nicotine inhaler Varenicline Nicotine lozenge Nicotine nasal spray SOURCE: Hurt presentation (June 11, 2012)
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Given that tobacco cessation therapy is effective, and even highly
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will help expand coverage of tobacco cessation therapy (see section on Antismoking Laws and Regulations)
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Abrams noted that the pharmacotherapy for tobacco cessation should be akin to the step-up care approach taken to treat asthma, with higher doses, multiple medications, or different medications given until the patient is comfortable, and that physicians avoid the same treatment that has failed in the past. He suggested modifying the tobacco dependence treatment guideline so it has more of a step-up sequential approach that indicates the next option if the previous treatment option fails.
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Lawrence Deyton, director of FDA's Center for Tobacco Products, added that when he worked as a physician at the VA, the EMR there would remind him to make a referral to a tobacco cessation program once he noted
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. She added that helping patients with tobacco cessation is within a nurse's scope of practice, and that nurses are the largest health care workforce so they should be leveraged more in tobacco cessation efforts.
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and patients were highly receptive to interventions offered by trained cessation personnel, he said. Others have explored whether lung cancer screening prompts more people to seek smoking cessation therapy.
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Tobacco Cessation Therapy for Cancer Patients Warren stressed that because tobacco use increases the relapse and treatment complication rate and decreases survival for a number of cancers, tobacco cessation therapy for cancer patients could have a major impact. "This is a single treatment that could potentially benefit 500,000 cancer patients a year and it is something cancer patients can do themselves to improve their outcomes.
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. Gritz suggested tailoring tobacco cessation therapy to cancer patients by educating them about the links between cancer outcomes and smoking, by being sensitive to certain physical limitations imposed by the disease, the treatment, and medical contraindications.
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. Given the lack of focus on tobacco assessment and cessation therapy at cancer centers, Gritz emphasized that "we need more resources and topdown leadership and commitment, and we need funding and personnel." There are no standards for cancer centers requiring tobacco cessation programs, Cummings pointed out (Morgan et al., 2011)
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, ASCO is planning a tobacco cessation guide for oncology clinicians.7 The Rx for Change curriculum,8 hosted by the University of California, San Francisco, School of Pharmacy, contains a module on tobacco cessation therapy tailored to patients with cancer. In addition, there are online resources to support clinician interventions, including Helping Smokers Quit: A Guide for Clinicians (HHS, 2008)
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Tobacco control policy options outlined by Warner include informing and educating the public and health practitioners; instituting laws, regulations, taxes, and other disincentives; and promoting or supporting tobacco cessation programs. Tobacco control policy is interactive at both the federal and state levels, as well as more locally, and includes planning, infrastructure, and financial resources.
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• egulating the manufacture, marketing, and distribution of R tobacco products. The 2009 Family Smoking Prevention and
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For Medicaid, the Patient Protec tion and Affordable Care Act (ACA) provided coverage for tobacco cessation therapy, without cost sharing, for pregnant women.
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He said FDA has conducted over 60,000 retail inspections and issued nearly 2,600 warning letters and 140 fines to retailers. Koh noted that HHS is coordinating tobacco control efforts at CDC with those at CMS, which recently expanded its coverage of tobacco cessation therapy to all its Medicare beneficiaries (CMS, 2012)
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that it funds. These quitlines offer evidence-based tobacco cessation counseling, supported by a combination of state, CDC, and NCI funding.
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132 131 133 136 136 133 132 131 131 131 134 131 127 127 128 129 124 125 124 122 119 FIGURE 5 Long-term impact of comprehensive tobacco control in California. With a 15-year investment of $1.8 billion in tobacco control, lung Figure 5.eps and bronchus cancer incidence rates declined faster in California compared to the rest of the United States from 1988 to 2009 (Lightwood et al., 2008)
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The Tobacco Control Act retailer provisions aim to stem youth smoking by restricting cigarette and smokeless tobacco retail sales to individuals younger than 18 years old and requiring proof of age to purchase tobacco products. FDA has invested in local enforcement of such retail restrictions, creating a tobacco retail inspection program with contracts in 37 states and the District of Columbia.
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The law specified that these labels must take up half of the tops of both the front and back panels of cigarette packages, 30 percent of the two principal display panels of smokeless tobacco products, and 20 percent of advertising for both types of products (see the Cigarette Packaging Warning Labels section [page 59]
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The Tobacco Control Act also gives FDA authority to require tobacco companies to report the levels of the harmful or potentially harmful constituents in their products, and the agency plans to educate the public about this information, Deyton said. In addition, FDA plans to conduct or support media campaigns directed at educating youth about the dangers of tobacco products to help prevent tobacco product use initiation and encourage cessation.
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Koh noted that HHS has put forward a bulletin that give states flexibility in selecting a benchmark plan to determine the essential health benefits package (CMS, 2011) , and added that the Federal Employee Health Benefits Plan, which covers comprehensive tobacco cessation therapy, could serve as such a benchmark.
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. Although every state forbids sale of tobacco products to minors, most of these laws do not seem to affect smoking in that population unless they are severely enforced, Warner noted.
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Stevens showed how tobacco control efforts such as smoke-free laws saved more than 1 million lives14 with reductions in tobacco-related diseases and $86 billion in health care savings (Lightwood et al., 2008)
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. 2 bitmaps Tobacco Taxes Since 1996, the total average state and federal taxes on cigarettes have increased from 57 cents to $2.50 per pack, according to McGoldrick.
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McGoldrick reported that though state tobacco tax and settlement revenues in 2012 are estimated at $25.6 billion, only $457 million was spent on tobacco control, which is far less than the $3.7 billion recommended by the CDC and $10.5 billion spent on advertising by the tobacco industry (Campaign for Tobacco-Free Kids, 2012b,d; CDC, 2007d)
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McGoldrick noted some innovative restrictions on tobacco products that New York City tried to institute, but these are currently being challenged in court by tobacco companies. These restrictions include warning signs at the point of sale and bans on all flavored tobacco products, to complement the federal ban on flavored cigarettes.
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New York State and New York City The state and city of New York have passed laws mandating smoke-free workplaces and public places and increased funding for tobacco prevention and cessation programs, including a media campaign to help people quit. These initiatives led to dramatic declines in smoking among youth, McGoldrick reported.
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More recently, Massachusetts dramatically decreased tobacco use among Medicaid (MassHealth) participants by providing tobacco cessation therapy benefits to all its Medicaid beneficiaries and publicizing that benefit.
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According to Land, this publicity boosted consumer awareness of the benefit from 31 percent when the campaign began to 75 percent 18 months later. By May 2009, 37 percent of MassHealth smokers utilized the tobacco cessation therapy benefit, and Land added that currently use is up to 55 percent (Land et al., 2010b)
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According to Land, Atrius Health is demonstrating the usefulness of integrated electronic systems in delivering tobacco cessation therapy. Atrius is a multisite primary care provider in the suburban Boston area.
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. "California used to have a higher lung cancer incidence, [but]
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Warner noted that such reports can have powerful effects, as indicated by the 1964 Surgeon General's report linking smoking to lung cancer. This report prompted a 15 percent drop in cigarette consumption within just three months of release, although recidivism pushed consumption levels back up somewhat (Warner and Mendez, 2010)
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is the flagship tobacco control educational project that Prokhorov developed. It is aimed at smoking prevention and cessation among middle and high school students.
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. Prokhorov noted that only 2 percent of all consumer health cell phone apps are focused on smoking cessation, and a review of those available found most did not adhere to current cessation therapy guidelines (Abroms et al., 2011)
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Using advances in technology and adapting to social media used by youth is a potentially powerful method to prevent future tobacco use. YouTube is another widespread medium that could be used to provide education about tobacco products and cessation, but one study found that although there is information on smoking cessation on YouTube, much of that information is not evidence-based (Richardson et al., 2011)
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Comprehensive restriction of ads for tobacco products can also be effective. One study found that elimination of all forms of advertising and promotion of tobacco products could reduce smoking by about 7 percent, whereas partial bans do not demonstrate this effect (Saffer and Chaloupka, 16 The Fairness Doctrine required broadcasters to ensure fair and balanced coverage of controversial matters, and stations that aired cigarette commercials were required to donate airtime to antismoking messaging (CDC, 2010)
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The campaign featured a number of individuals who experienced smoking-related diseases at a relatively young age, some of whom were diagnosed before they were 40 years old. The campaign also features three former smokers who provide tips on how they successfully quit.
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. Legacy truth® Campaign Launched in February 2000, the truth® campaign is a national youth smoking prevention campaign that exposes the tactics of the tobacco industry, the truth about addiction, and the health effects and social consequences of smoking to enable teens to make informed choices about tobacco use.
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FDA developed graphic warning labels for cigarettes that, unlike previous warning labels, would take up a sizable portion of the package and visually display the hazards of smoking. However, a federal appeals court ruled that the warnings as promulgated were unconstitutional,17and FDA said that it will revise the warnings (see section on the Family Smoking Prevention and Tobacco Control Act, page 39)
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Instead you see lung cancer or emphysema," Hammond said. Message Content, Framing, and Placement The content of tobacco control messaging is an important factor in its effectiveness, several speakers stressed.
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Because most people already recognize that smoking is harmful to their health, Cummings suggested devising new messages to use in media campaigns. These messages could focus on the wrongdoing of the tobacco industry, such as their manipulation of tobacco products to increase the likelihood that people will become addicted to them, he said.
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. Another study involving tobacco control messaging in conjunction with tobacco cessation medicine found approximately a 12 percent greater sustained quitting rate in those given gain-framed messages, which was significant compared to those given lossframed messages (Toll et al., 2007)
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"It is important for us to be able to speak to multiple audiences using mass media channels, so for something like warning labels, there should be something for everybody in there." Ostroff added that the ads for tobacco cessation medications tend to be "feel-good" ads that are hopeful and gain-framed. She suggested more research could be conducted on framing messages about how easy or hard it is to quit to assess the best approach.
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Other ads say ‘we are here to help.'" ANTISMOKING ADVOCACY Several workshop participants stressed the important roles that clinicians, clinician organizations, and patients can play in advocating for antismoking policy. Herbst, an oncologist who treats lung cancer patients, stressed, "The best way I can help a patient is for them to never get lung cancer.
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Many physicians focus their tobacco control efforts on trying to prevent teens from smoking, and Sneegas noted, "If they really want to prevent youth initiation of cigarette smoking or other tobacco product use, then they need to focus on raising the prices of tobacco products, making school campuses tobacco free, ensuring their community is smoke free, and restricting the sale and advertising of tobacco products to children. And of course there's nothing better to help a kid not to start smoking than to help their family quit smoking." She also recommended that everyone monitor tobacco industry promotion and marketing of their products in their local communities.
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Warren further suggested that inclusion of tobacco assessment and cessation therapy in clinical practice guidelines such as those of the National Comprehensive Cancer Network (NCCN) would facilitate rapid uptake by clinical oncology providers.
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Even though states have increased excise taxes on tobacco products, they have allocated the tobacco product tax revenue to balance their budgets. Khuri concurred, adding, "Most states have used their tobacco settlement money to pay off other debts and are shutting down prevention and scientific programs." Even states that earmarked a portion of the money gained from cigarette taxes for tobacco control efforts are finding the funds insufficient.
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We have to do everything in our power to reinvigorate the advocacy infrastructure if we are going to keep making progress on tobacco control policy levers that we know work," he said. McAfee noted that the tobacco industry spends 23 times more on tobacco promotion than states do on tobacco control programs -- $10.5 billion spent by the industry in 2008 compared to less than $500 million spent at the state level, despite the fact that states collect $25 billion a year from the taxes on tobacco products and the Master Settlement Agreement State Tobacco Revenue 30 (taxes and settlement funds)
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for their employees with no copays," he argued. Given their reimbursement difficulties, Hurt's institution, Mayo Clinic, established a charitable fund for tobacco cessation therapy that is composed of money donated by grateful patients for others who cannot afford the treatment.
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code, 301.5. Toll noted that the Yale Cancer Center provides psychotherapy or psychiatric codes for tobacco cessation therapy, and is reimbursed accordingly.
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Matthew Myers, president of the Campaign for Tobacco-Free Kids, and Stevens suggested trying to pass only tobacco control laws in those communities that have access to the resources to defend them, because if the lawsuits prevail, they set legal precedents that can impede other communities from adopting similar laws. RESEARCH AND INFRASTRUCTURE NEEDS Several speakers stressed research and infrastructure needs related to reducing tobacco-related cancer incidence and mortality, including a rapid research capability to assess the use and health effects of new tobacco products, more funding for research on lung cancer and on tobacco cessation therapy, more systems integration, and coordination of tobacco assessment in clinical trials of pharmaceutical products and disease processes.
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Ostroff suggested that research could help determine how to best incorporate CT screening interventions with tobacco cessation therapy. Several speakers pointed out the need to verify self-reports in studies of tobacco use.
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; reprinted with permission from the National Lung Cancer Partnership. tobacco products, while another regulates nicotine replacement treatments, and the degree of regulation is not equal between the two Centers.
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He also stressed that the cancer research and clinician communities are not engaged as fully as they should be in tobacco control advocacy, as well as in assessing tobacco use in their patients and offering tobacco cessation therapy. "If we don't engage then it is not the tobacco industry we have to blame, but rather ourselves," he said.
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2007. Bladder cancer incidence and risk factors in men with prostate cancer: Results from Cancer of the Prostate Strategic Urologic Research Endeavor.
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2012. Deadly alliance: How big tobacco and convenience stores partner to market tobacco products and fight life-saving policies.
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2012. Smoking & tobacco use cessation (counseling to stop smoking or using tobacco products)
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2003. Lung cancer mortality in relation to age, duration of smoking, and daily cigarette consumption: Results from Cancer Prevention Study II.
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2011. Health warning messages on tobacco products: A review.
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Bladder cancer incidence and risk factors in men with prostate cancer: results from Cancer of the Prostate Strategic Urologic Research Endeavor. Journal of Urology 177(3)
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2012b. Smoking cessation and continued risk in cancer patients (PDQ®)
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2012. The return on investment of a Medicaid tobacco cessation program in Massachusetts.
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1993. p53 mutations in lung cancers from non-smoking atomic-bomb survivors.
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2012a. Smoking at diagnosis and survival in cancer patients.
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