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G. Warren
Moderator of
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ORAL 08 - Smoking Cessation, Tobacco Control and Lung Cancer (ID 94)
- Event: WCLC 2015
- Type: Oral Session
- Track: Prevention and Tobacco Control
- Presentations: 8
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ORAL08.01 - The History of Tobacco Litigation in the United States (ID 795)
10:45 - 10:56 | Author(s): K.M. Cummings, A. Brown, R. Goldstein
- Abstract
- Presentation
Background:
This presentation reviews the history of tobacco litigation in the United States.
Methods:
Data for this study comes from industry business records available online through the UCSF Legacy Tobacco Documents Library, transcripts of court proceedings, and news and stock analyst reports on tobacco litigation.
Results:
Litigation against the tobacco industry began in 1954, corresponding to the emerging evidence linking smoking and disease. A total of 109 lawsuits were filed between 1954 and 1970, but only eight were tried and all ended in defense verdicts. Another 150 cases were filed between 1970 and 1985, but none went to trial. There was a second wave of cases filed during the mid-1980s that led to jury trials, but only one, Cipollone v. Liggett Group, was a plaintiff verdict. Cipollone was later overturned on appeal. A third wave of litigation followed in the early 1990s, with several plaintiffs’ verdicts. By 1999, juries were awarding punitive damages against the defendants. The state Attorney General cases against cigarette manufacturers resulted in the Master Settlement Agreement in 1998, which, among other things, required that the cigarette companies release millions of pages of business records. These documents have played a key role in fueling subsequent litigation and winning cases. The Engle v. Liggett Group class action verdict on behalf of injured smokers in Florida in the late 1990s helped to change the industry’s long held position that smoking was unproven as a cause of disease and that nicotine was not addictive. Decertification of the Engle class action lawsuit spawned several thousand individual lawsuits against the cigarette industry in Florida, which have resulted in dozens of verdicts favoring plaintiffs since 2009. Additional litigation against the tobacco industry continues nationwide on the “light” cigarettes fraud and on individual personal injury cases that have resulted in notable verdicts against the tobacco industry.
Conclusion:
In the United States, litigation against the cigarette industry began in 1954 and has accelerated over the past 60 years with a growing number of verdicts favoring plaintiffs since the mid-1990s. Litigation has proven to be a powerful tool for tobacco control efforts helping to change public sentiment about the industry and its products, increasing the costs of cigarettes, and forcing the industry to accept responsibility, in front of a jury, for its deceptive practices.
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ORAL08.02 - Interest in Smoking Cessation Treatment among Patients in a Community-Based Multidisciplinary Thoracic Oncology Program (ID 2886)
10:56 - 11:07 | Author(s): K.D. Ward, S. Kedia, N. Faris, F.E. Rugless, M. Sheean, C. Foust, K.S. Roark, L. McHugh, C. Fehnel, R.U. Osarogiagbon
- Abstract
- Presentation
Background:
Cigarette smoking is the major cause of lung cancer. Many adults smoke at the time of a lung cancer diagnosis and continue to smoke during treatment although doing so adversely affects treatment response, quality of life, and survival time. While authoritative bodies recommend that tobacco use be addressed in lung cancer care, few patients receive effective treatment. The coordinated multidisciplinary model of care delivery, in which patients, their caregivers, and key specialists concurrently develop evidence-based care, offers an ideal setting to integrate high quality cessation treatment. To assess the need for and acceptability of cessation services, we surveyed patients about their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program.
Methods:
The study was conducted in the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN. One-hundred eight consecutive new patients, seen between 7/31/13 and 9/24/14, completed a social history questionnaire. From this history, we extracted data related to sociodemographic characteristics (age, gender, race, marital status), smoking status, age of smoking initiation, and tobacco dependence (using the Heaviness of Smoking Index, consisting of cigarettes smoked per day and time of first cigarette of the day). Current smokers reported their level of interest in quitting, and how likely they would be to participate in a cessation program (‘I would not participate’; ‘I might participate but am not sure’; ‘I would participate’). Chi square tests were used to compare characteristics of those who would participate in the stop-smoking program vs. those who would not or were unsure whether they would participate.
Results:
Average age of patients was 65 years (range: 29-91), 41% were men, 58% were white, 39% black, and 15% had graduated college. Patients’ cancer stage broke down to stage I (16%), stage II (9%), stage III (18%), stage IV (28%), and undetermined (29%). 84% of patients had ever smoked cigarettes, 35% currently smoked, and 11% had quit smoking within the past year. Among current smokers, 71% (n=27) were “very interested” in quitting smoking in the next month and of these, 74% reported that they would be willing to participate in a smoking cessation program in the clinic. Willingness to participate in a cessation program was associated with greater interest in quitting (χ[2][1]= 13.3, p=.0003), but was not associated with sociodemographic characteristics, cancer stage, or smoking-related characteristics (amount smoked, age at smoking initiation, or dependence).
Conclusion:
Nearly half (46%) of patients in a community-based multidisciplinary thoracic oncology program were current cigarette smokers or had quit within the previous year, indicating a considerable need for cessation and relapse-prevention support. Encouragingly, a majority of current smokers were highly motivated to make a quit attempt in the next month, and most indicated that they would take advantage of a clinic-based cessation program. Willingness to participate in a cessation program was similar across a broad range of sociodemographic, cancer stage, and nicotine dependence levels. There is considerable need for, and interest in, smoking cessation services in the setting of community-based multidisciplinary lung cancer care.
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ORAL08.03 - Smoking Cessation Before the Initiation of Chemotherapy in Metastatic NSCLC: Impact on Overall Survival (ID 1746)
11:07 - 11:18 | Author(s): S. Chiasson, M. Lelièvre, B. Fortin, J. Dionne
- Abstract
- Presentation
Background:
It is well documented that active smoking affects the overall mortality in lung cancer. Smoking cessation has been associated with better prognostic outcomes in patients with early stage non-small cell lung carcinoma (NSCLC) and limited stage small cell lung carcinoma (SCLC). Smoking cessation impact in advanced stage NSCLC is less well characterized. We studied the benefit of smoking cessation, before the initiation of chemotherapy, on overall survival (OS) in advanced NSCLC.
Methods:
We retrospectively reviewed the clinical data of 306 patients with stage IV SCLC and NSCLC between 2008 and 2014 in our centre. The 237 NSCLC patients treated with at least one cycle of chemotherapy are the subjects of this study. Smoking status and smoking cessation duration at the chemotherapy initiation time, number of packs/years, comorbidities, histology, sites of metastases, type and number of cycles of chemotherapy were all collected. Never-smokers were defined by a smoking history of < 100 cigarettes during their entire lifetime. Survival curves were calculated by the Kaplan-Meier method and compared using log-rank test. Cox proportional hazard models were used for multivariable analyses.
Results:
Smoking cessation before the initiation of chemotherapy is associated with a better median overall survival of 16 vs 10 months (p=0.007). This is even seen in heavy smokers of > 30 pq/year, with a median OS of 15 vs 8 months (p=0.008). The multivariable analysis confirms that active smoking is an independent negative factor on survival (51% increase in the risk of death) after adjustment for gender, heart or vascular disease, diabetes, high blood pressure, ECOG performance status, histology, site of metastases (brain, liver, adrenals, lungs and bones). Figure 1
Conclusion:
Smoking cessation, before the initiation of chemotherapy, is associated with a better overall survival in chemotherapy treated stage IV NSCLC patients, even in previously heavy smokers and after adjustments for comorbidities. This retrospective analysis demonstrates the possible magnitude of the effect of smoking cessation on treatment efficacy with a potential gain of 6 months in median overall survival. Efforts to encourage smoking cessation are likely beneficial even among this population of patients.
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ORAL08.04 - Discussant for ORAL08.01, ORAL08.02, ORAL08.03 (ID 3316)
11:18 - 11:28 | Author(s): J. Ostroff
- Abstract
- Presentation
Abstract not provided
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ORAL08.05 - Impact of an Inpatient Tobacco Cessation Service (ID 1557)
11:39 - 11:50 | Author(s): K.M. Cummings, G. El Nahhas, V. Talbot, D. Wilson, D. Woodard, K. Cartmell, G.W. Warren, B. Toll
- Abstract
- Presentation
Background:
Cigarette smoking is responsible for 85% of all lung cancers and about 1/3rd of all cancer deaths. Quitting smoking reduces the risk of getting lung cancer and other serious health problems. In 2012, the Joint Commission (JC) which sets quality standards for hospitals in the United States recommended that all current smokers identified upon hospitalization receive tobacco cessation services as an inpatient and be followed up after hospital discharge. However, few hospitals implement JC standards due to extra costs, the voluntary nature of the standards, and the lack of evidence demonstrating financial benefits to the hospital and insurers. In 2014, the Medical University of South Carolina (MUSC), a major tertiary care hospital in South Carolina, implemented an automated in-hospital smoking cessation program using interactive voice recognition (IVR) technology to follow-up with patients after discharge consistent with JC standards. This study reports on the results of the program over the first 12 months of operation between February 17, 2014 and January 31, 2015.
Methods:
Descriptive statistics are used to report on the number of patients screened, number of tobacco using patients seen by a bedside tobacco counselor while hospitalized, the number of tobacco using patients followed-up 3, 14, and 30 days after discharge, and the rate of unplanned hospital readmissions within a month of discharge.
Results:
A total of 30,846 patients aged 18 and older were screened for tobacco on hospital admission and 18% were identified current smokers. Of the 5,546 identified smokers, 2008 (36%) were approached by a single bedside counselor while hospitalized; 29% were unavailable for counseling for various reasons (e.g., discharged, too sick, not in room, deceased), 11% refused counseling, and 3% reported to the bedside counselor that they were non-tobacco users. A total of 4,197 tobacco using patients were enrolled into the automated telephone follow-up to assess smoking status and offer triage to the state quitline for those who wanted help. A total of 1,378 (33%) responded to at least one of the follow-up calls by one month, with 31% reporting that they were not smoking (10% classified as not smoking if non-responders are counted as smoking). The one month nonsmoking rate was 44% (19% based on intent to treat) in those seen by the bedside counselor compared to 24% (7% based on intent to treat) in those merely followed by phone. Unplanned 30-day hospital readmission rates were 9.1% for patients seen by the bedside counselor as compared with 15.7% for patients who did not receive bedside counseling based on the first 6 months of the program.
Conclusion:
An opt-out inpatient tobacco cessation service is feasible, can reduce relapse back to using tobacco after hospital discharge, and may reduce unplanned hospital readmissions.
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ORAL08.06 - Introducing Smoking Cessation Across Ontario's Cancer Treatment System: Early Successes and Continuing Challenges (ID 537)
11:28 - 11:39 | Author(s): W.K. Evans, R. Presutti, M. Haque, R. Truscott, M. Bassier-Paltoo, A. Peter, L. Rabeneck
- Abstract
- Presentation
Background:
Smoking cessation (SC) has rarely been recommended by oncologists in Ontario’s cancer centres. Many believe it is too late to matter or perceive that patients will not be receptive to SC. However, a growing body of literature has identified substantial health benefits from SC in cancer patients including improved general health, improved all-cause and cancer-specific mortality, reduced toxicity, greater response to treatment and decreased risk of disease recurrence and second primaries. Based on this evidence, Cancer Care Ontario (CCO) undertook an initiative to support SC for new ambulatory cancer patients in its Regional Cancer Programs (RCPs) in 2013.
Methods:
A steering committee of experts recommended a framework for SC in 2012 based on the Ottawa Model for Smoking Cessation. The CCO executive leadership and Regional Vice-Presidents supported the initiative which was then piloted in all 14 health regions in Ontario in 2014. Regional SC “champions” participated in monthly web meetings, data calls and in-person meetings led by a secretariat at CCO. Presentations on the health benefits of SC were made to physicians and other health care providers (HCPs) at regional cancer treatment centres and through the Ontario Telehealth Network. Presentations emphasized short, repeated oncologist scripts on the benefits of SC with referral to other HCPs for in-depth SC advice. New ambulatory cancer patients are screened, advised and referred to internal or external SC services dependent on regional resources. A minimum data set of standardized performance metrics is captured by CCO with patient-level data aggregated at the RCP level, presented as a provincial average, and reviewed with the RCPs in quarterly performance management sessions.
Results:
During Q1-Q3 of the 2014/15 fiscal year, 52.9% of all new ambulatory cancer cases were screened for smoking status. Of those screened, 21.3% were current or recent (within the last 6 months) tobacco users. Approximately three-quarters of these individuals were advised of the benefits of SC; a referral for cessation services was recommended in nearly 50%; of these patients, 66.7% accepted the referral to SC services. Of those accepting a referral, 50.4% chose referrals internal to the cancer treatment facility, 32.3% chose external referrals and the remainder (17.2%) used a combination of both referral resources. As part of this initiative a standardized cancer patient resource on SC in a print-ready format has been recently developed in both French and English and will be adapted for Ontario’s Aboriginal population.
Conclusion:
CCO’s centralized yet collaborative approach has led to province-wide implementation of a standardized intervention in a relatively short timeframe with limited financial resources. Ongoing barriers to implementation and sustainability experienced by RCPs include financial constraint, limited SC training resources, reluctant physician buy-in, strained staff and system capacity, and suboptimal inter-departmental communication. Nonetheless, there has been substantial progress. Framing SC as a quality of care issue has been critical to the success to date. Sustainability of the initiative will be dependent on continued committed leadership, buy-in from front-line staff, funding for dedicated SC counselors and other resources, and evidence of program cost-effectiveness.
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ORAL08.07 - Primary Prevention of Lung Cancer in Poland - Successes and Challenges (ID 2398)
11:50 - 12:01 | Author(s): J. Jassem, K. Przewoźniak, W. Zatonski
- Abstract
- Presentation
Background:
In the 1990s Poland was among countries with the highest tobacco exposure and catastrophically high lung cancer mortality. Within the past two decades this situation has dramatically improved as a result of comprehensive national tobacco-control programs. We present the current tobacco exposure and
Methods:
Data on trends in cigarette consumption, smoking rates and lung cancer mortality were analyzed using the per capita sale of manufactured cigarettes, results of nation-wide questionnaire surveys conducted in adult (15+) population, and standardized mortality rates from lung cancer, respectively.
Results:
Between 1995 and 2013 annual cigarette sales in Poland decreased from 101 billion to 47 billion. The proportion of smokers among men dropped from 65% in 1980 to 28% in 2013, and among women from 32% to 18%, respectively. If this trend continues, the cigarette consumption per capita in Poland in 2040 will fall to the level of the 1920s. The age-standardized mortality rates per 100,000 from lung cancer in men declined from 71.1 in 1990 to 56.2 in 2010. The pattern of changes in lung cancer mortality among young Polish men became similar to that observed two decades earlier in the Unites States (Figure). However, Poland is still facing several challenges. Between 2003 and 2012 tobacco production in Poland increased by 90%, of which around two-thirds is exported. There is a persistently high proportion of smoking women, with almost a gender parity in the 35-44 age bracket (34% and 32% in women and men, respectively). Polish middle-aged women belong to the most common smokers in the European Union. The mortality rates from lung cancer among women are still on the rise. Since 2010 lung cancer has become the leading cause of death among women in Poland. Today, differences in smoking rates and lung cancer mortality are mainly generated by education and financial status, and not by gender. Figure 1
Conclusion:
There is an apparent need for further tobacco control efforts in Poland, including enforcement of the effective legislative measures (pictorial health warnings, plain cigarette packages, banning the sale of aromatic and ‘slim’ cigarettes) and implementation of tailored population-based preventive programs for women and socially unprivileged populations.
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ORAL08.08 - Discussant for ORAL08.05, ORAL08.06, ORAL08.07 (ID 3329)
12:01 - 12:11 | Author(s): E. Stone
- Abstract
- Presentation
Abstract not provided
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Author of
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PLEN 01 - Lung Cancer Prevention and Screening (ID 50)
- Event: WCLC 2015
- Type: Plenary
- Track: Plenary
- Presentations: 1
- Moderators:C. Dresler, H.I. Pass
- Coordinates: 9/07/2015, 08:15 - 09:45, Plenary Hall (Bellco Theatre)
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PLEN01.03 - Smoking by Lung Cancer Patients: Clinical, Biologic and Behavioral Considerations (ID 2040)
09:20 - 09:50 | Author(s): G. Warren
- Abstract
- Presentation
Abstract:
Smoking is the largest preventable risk factor for the development of lung cancer. Continued smoking by cancer patients and survivors causes adverse outcomes including an increase in overall mortality, cancer specific mortality, risk for second primary cancer, and associated increases in cancer treatment toxicity. Significant evidence demonstrates the biologic mechanisms of cancer initiation and progression caused by cigarette smoke, but relatively few studies have evaluated the effects of smoking on cancer biology and therapeutic response to cytotoxic agents. Most oncologists believe smoking causes adverse outcomes and that smoking cessation treatment should be a standard part of cancer care. However, most oncologists do not regularly provide cessation support to cancer patients. Moreover, tobacco assessments and cessation support are not regularly incorporated into clinical trials design or analysis. Recently released guidelines from several national and international organizations advocate for addressing tobacco use by cancer patients. This session will discuss the clinical and biologic effects of smoking on cancer, present the current state of tobacco assessments and cessation in clinical practice and research, and discuss methods to improve access to cessation support for cancer patients. Discussion will further detail deficits in the current understanding of the effects of smoking on cancer treatment outcomes and highlight areas of needed improvement.
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