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William Kenneth Evans
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MS 09 - Global Perspectives in Eliminating the Major Cause of Lung Cancer (ID 531)
- Event: WCLC 2017
- Type: Mini Symposium
- Track: Epidemiology/Primary Prevention/Tobacco Control and Cessation
- Presentations: 7
- Moderators:Carolyn Dresler, William Kenneth Evans
- Coordinates: 10/16/2017, 15:45 - 17:30, Room 315
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MS 09.01 - Global Tobacco Control (ID 7682)
15:45 - 16:00 | Presenting Author(s): Emily Stone
- Abstract
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Abstract:
The history of global tobacco control starts at the beginning of the twentieth century with early data linking the smoking of tobacco with the risk of lung cancer, a previously rare disease. The build up of scientific evidence for the link gained pace toward the middle of century when landmark publications brought more widespread recognition of the phenomenon[1][,][2]. The pivotal US Surgeon General Report from 1964 gave a clear message that tobacco smoking was unequivocally associated with an increased risk of developing lung cancer[3]. Over the following decades the paradigm of tobacco control recognizable today culminated in the development the first global public health treaty, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), which came into force in 2005 and currently lists 181 countries as Parties to the Convention[4]. In 2008, the FCTC launched the MPOWER measures (Table 1.), six steps proven to lead to reduction in tobacco use around the world[5] and that provide the ability to benchmark the effects of tobacco control strategies between countries[6]. In countries with robust implementation, these measures have achieved what may have once been unthinkable, the saving of millions of lives[6] and the reduction in smoking rates to historic post-WWII lows[6]. There have been enormous benefits, with a reduction in cigarette consumption, altered rates of disease and a reduction in smoking uptake. But the inconsistencies in regulation and in MPOWER implementation around the world have led to problems with the shifting of tobacco industry efforts to the developing world[7], the targeting of vulnerable groups for new market share[7] and the entrenchment, in some countries, of the tobacco industry in the halls of government. New threats to global tobacco control are starting to appear from the impacts of globalization of trade[7], newer products whether “low-harm” or otherwise and from focused, covert attacks by the tobacco industry itself. This presentation aims to review the development and impact of current tobacco control policy, to examine emerging threats to tobacco control, to focus on evasive manoeuvres of the globalizing tobacco industry and to discuss possible future tobacco control strategies that these developments will require. Over the last half century the tobacco industry in the developed world has become globalized. Four companies have come to dominate the global tobacco trade, Philip Morris International, British American Tobacco, Japan Tobacco International and Imperial Tobacco[8]. This has given companies such as PMI the economic clout to oppose, delay and threaten tobacco control strategies such as plain packaging and smoking bans[9]. The tobacco industry in Asia, a region of the world with very high smoking rates, is heading towards globalization. Companies such as Korean Tobacco and Ginseng (KT&G) and the China National Tobacco Corporation (CNTC) have developed foreign exports with government support[8] and have strengthened their domestic operations with consolidation and restructuring[8]. New global tobacco players have the potential to generate new competition, innovation and price reduction, all with detrimental impacts on public health[8]. The development of “low-harm” products such as electronic nicotine delivery systems (ENDS), including e-cigarettes, has opened new frontiers in regulatory control with concerns that such products may open new developed world markets for tobacco companies that otherwise continue to sell tobacco cigarettes in low and middle-income countries[7]. Tobacco companies use international trade relations to oppose the implementation of tobacco control measures; in the fight against plain packaging in Australia, the tobacco industry invoked trade treaties and the possibility of unfair trade restrictions. The tobacco industry holds to a culture of political sabotage that includes infiltration of government by lobbyists and open recognition of the value of political skills in undermining public health initiatives in tobacco control All of these developments call for a modernization of the tobacco control paradigm. This may include financial pressures such as disinvestment in the tobacco industry by pension funds[10], staunch regulatory approaches to ENDS and perhaps the development of finely honed political skills to match or surpass those of the tobacco industry. Even creative approaches to the dissemination of data, such as maps showing countries moving towards plain packaging or graphical presentation of the country-by-country distribution of tobacco factories may help inform the community and subvert the newer “low-harm” messages of the large tobacco companies. Many successes over many years can be attributed to traditional tobacco control, the emphasis on the science and the FCTC and MPOWER measures. However, the tobacco industry has very strong drive for survival with multiple strategies for evasion of control. The scientific arguments are irrefutable but are not enough to overcome an industry prepared to either deny the science, to ignore it while developing market share where regulations are weak or to espouse overt evasion techniques in company documents. MPOWER is no longer enough as the opposition does not play by the rules. Effective long-term global tobacco control will need to draw upon many resources including scientific evidence, economic pressure, the ability to avoid distractions and delaying tactics, resolute evaluation and regulation of ENDS and, ultimately, political dexterity in dealing with an industry prepared to do just about anything to maintain profit.Table 1. MPOWER Measures
References 1. Wynder EL, Graham EA. . Bull World Health Organ 2005;83(2):146–53. 2. Doll R, Hill AB. Bull World Health Organ 1999;77(1):84–93. 3. Health USSGAC on S and, General USPHSO of the S. Smoking and Health. http://profiles.nlm.nih.gov/NN/B/B/M/Q/ 4. United Nations Treaty Collection https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&clang=_en 5. WHO | MPOWER [Internet]. WHO. [cited 2015 Jun 1];: http://www.who.int/tobacco/mpower/en/ 6. Levy DT, Yuan Z, Luo Y, Mays D. Tob Control 2016;tobaccocontrol-2016-053381. 7. Gilmore AB, Fooks G, Drope J, Bialous SA, Jackson RR. Lancet Lond Engl 2015;385(9972):1029–43. 8. Lee K, Eckhardt J. Glob Public Health 2017;12(3):367–79. 9. Peeters S, Costa H, Stuckler D, McKee M, Gilmore AB. Tob Control 2016;25(1):108–17. 10. Tobacco Free Portfolios http://www.tobaccofreeportfolios.org/MPOWER Measures Monitoring tobacco use and prevention policies Protecting people from tobacco smoke Offering help to quite tobacco use Warning about the dangers of tobacco Enforcing bans on tobacco advertising, promotion and sponsorship Raising tobacco taxes
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MS 09.02 - FCTC Implementation around the World (ID 7683)
16:00 - 16:15 | Presenting Author(s): Geoffrey Fong
- Abstract
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Tobacco use has been recognized by the World Health Organization as the number one preventable cause of premature death and disability. In the 21st Century, hundreds of millions of people will die because of tobacco use, with 70% of the toll occurring in low and middle-income countries. To magnify the horror of these projections, the tobacco epidemic, unlike other threats to global health, is a direct result of the activities of the most profitable industry in history. In recognition of this current and future epidemic, countries of the world negotiated and adopted in 2003 the WHO Framework Convention on Tobacco Control, the first-ever treaty of the WHO. The WHO FCTC has been ratified by 180 countries and the European Union, is an example of the promise of international health governance and highlights the central role of scientific evidence in tackling the global tobacco epidemic. A decision adopted by the FCTC Conference of the Parties at its 6th Session (Moscow, Nov 2014) called for an independent expert group to conduct an impact assessment of the treaty in its first decade. The expert group used three sources of evidence. The first source was a global evidence review of the scientific research on the impact of the FCTC across 17 of its articles; this review was conducted by the ITC Project. The second source was two reports prepared by global experts, of which one was prepared by the MacCabe Centre for Law and Cancer that reviewed the impact of the FCTC in legislative action taken by governments in tobacco control and in the use of the FCTC by governments in defense of legal challenges, and the second was prepared by Dr. Stella Bialous on the actions of the tobacco industry to weaken the FCTC. The third source was from evidence gathered by the expert group on country missions to 12 FCTC Parties, two from each of the six WHO Regions, and 3 from each of the four World Bank income levels. The main findings of the Impact Assessment Expert Group were the following: • FCTC has played an instrumental role as catalyst and framework for action— foundation for legislation and in defense against legal challenges. • FCTC has promoted tobacco control action in countries where little had been done, and has helped to strengthen action in countries where it was in place before ratification. • FCTC has broadened tobacco control across government and administration. And it has had impact on a range of international and global institutions and agendas. • FCTC has strengthened the role of civil society in tobacco control • FCTC has contributed to reductions in prevalence among Parties that have implemented FCTC policies at high levels, thus contributing to reductions in tobacco-related mortality and morbidity. • Tobacco industry continues to be the greatest threat to the implementation of the WHO FCTC. The expert group also cited the findings of a seminal study conducted by Gravely et al. on the impact of the FCTC on reductions in smoking prevalence. In an analysis of 126 countries, Gravely et al., found that over the first decade of the treaty, those countries that had implemented a greater number of key demand-reduction FCTC policies at the highest level (i.e., implementing those policies at sufficient strength to meet the standards of the FCTC Guidelines adopted for each of those policy domains: tax (Article 6), smoke-free (Article 8), labelling/warnings (Article 11), banning tobacco advertising, promotion, and sponsorship (Article 13), and cessation (Article 14)) experienced substantially greater decreases in smoking prevalence. On average, each additional policy implemented at the highest level was associated with a decrease in smoking prevalence of 1.57 percentage points (equivalent to a relative decrease of 7.09%). The Gravely et al. article, published in Lancet Public Health, demonstrates the power and potential of the FCTC to achieve its ultimate objectives. However, the article also presented findings on the current gap between the potential and the reality: that there have been very slow progress in the implementation of just these high-priority policies, consistent with the ITC Project’s global evidence review of the rate of implementation as well as the WHO’s assessment, which showed that by 2014, only 18% of the world’s population were living in countries with comprehensive smoke-free policies, and only 20% of the world’s population were living in countries with large pictorial warnings on tobacco product packaging. Why has implementation of the FCTC been so slow and in many cases at levels below the standards set by the FCTC Guidelines? All of the evidence gathered by the Expert Group points to one cause: the tobacco industry. Through their political influence, both explicit and covert, the tobacco industry has been quite effective in defeating efforts in many countries to implement the FCTC in accordance with their obligations under the treaty. It is necessary for all parties to engage in strong and vigilant implementation of Article 5.3, which forbids industry involvement in the process of formulating tobacco control policies, to advance the treaty and to more fully achieve its demonstrated potential to combat the global tobacco epidemic. The conclusions and take-home messages are: 1. FCTC Impact Assessment has demonstrated that the FCTC has great potential in reducing the number one preventable cause of death and cancer (esp. lung cancer) 2. BUT: FCTC implementation has been slow and in many cases is not at levels called for by the FCTC Article Guidelines. 3. Number of deaths and DALYs attributable to tobacco has increased since 1990. 4. Must SIGNIFICANTLY accelerate and strengthen FCTC implementation, especially in fully implementing Article 5.3. 5. Must expand implementation to other Articles (e.g., illicit trade, alternative livelihoods) 6. Research on evaluating FCTC implementation is essential for fighting industry attempts to weaken and slow the treaty.
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MS 09.03 - Cost Effectiveness of Smoking Cessation (ID 7684)
16:15 - 16:30 | Presenting Author(s): Hong Gwan Seo
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WHO estimates that tobacco kills more than 7 million people each year. More than 6 million of these deaths are the result of direct tobacco use while around 890,000 deaths are the result of non-smokers being exposed to second-hand smoke. Around 60-70% of smokers want to quit smoking. However, the success rate for quitting smoking is quite low without a systematic approach. Counselling and medication can help increase the success rate. Only 24 countries provide national comprehensive cessation services with full or partial cost-coverage to assist tobacco users to quit. This represents merely 15% of the world's population. FCTC article 14 concerns the provision of support for reducing tobacco dependence and cessation, including counselling, psychological support, nicotine replacement, and education programs. Parties are required to develop and disseminate national guidelines on tobacco cessation and are encouraged to establish sustainable infrastructure for such services. Tobacco use treatment are not only clinically effective, but are cost-effective as well. Tobacco use treatments, ranging from clinician advice to medication to specialist-delivered intensive programs, are cost-effective in relation to other medical interventions such as treatment of hypertension, hyperlipidemia and to other preventive interventions such as periodic mammography. Even though a single application of any effective treatment for tobacco dependence may produce sustained abstinence in only a minority of smokers, tobacco use treatment remains highly cost effective. For example, Fiore and colleagues estimate the cost per life-year saved of tobacco dependence treatment to be $3,539. These estimates compare favorably with other health interventions in the U.S. like statins (which costs $50,000 per life-year saved), and diabetes treatment ($34,000 per life-year saved). Most effective way for more clinicians to intervene is to provide them with information regarding multiple effective treatment options and to ensure that they have ample institutional support to use these options. Clinicians, administrators, insurers, and purchasers can cooperate to encourage a culture in which intervention for smokers is an essential part of standard care. Korea is one such successful example. Eighty percent increase of price for a pack of cigarette since 1[st] of Jan, 2015 provided the momentum for other kinds of tobacco control activities. Even though only a small portion of increased tobacco tax was distributed to tobacco control activity, the tobacco control budget in 2015 has jumped by 13 times compared to previous year. 1. 246 Smoking Cessation Clinic in Health centers : All the health centers in Korea have smoking cessation clinic and gives counselling and NRTs for free. 2. Quitline : Nationwide quitline service is located in National Cancer Center. It gives counselling over the phone with proactive service for free. 3. Hospital based smoking cessation service : If a smoker visits hospital and gets counselling and medication(NRTs, bupropion, and varenicline) the fees for counselling and medication is actually free. National Health Insurance Foundation supports this program. 4. Community Smoking Cessation Center: There are 18 community smoking cessation centers in Korea. They provide three different services. 1) Residential 5 days smoking cessation program : intensive program which gives counselling, medication, etc. for free. 2) Residential 2 days smoking cessation program : short-term education program for free 3) Visiting program : Some underprivileged smokers, such as female smokers or adolescents who does not go to school, disabled smokers, or college students tend to not use smoking cessation programs due to various reasons. So community smoking cessation centers visit those special underprivileged populations. This service gives counselling and NRTs for free. References Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA. 1997; 278: 1759-1766. Guerriero C, Cairns J, Roberts I, Rodgers A, Whittaker R, Free C. The cost-effectiveness of smoking cessation support delivered by mobile phone text messaging: Txt2stop. Eur J Health Econ. 2013; 14: 789-797. Krumholz HM, Weintraub WS, Bradford WD, Heidenreich PA, Mark DB, Paltiel AD. Task force #2--the cost of prevention: can we afford it? Can we afford not to do it? 33rd Bethesda Conference. J Am Coll Cardiol. 2002; 40(4): 603-615. Stapleton JA, Lowin A, Russell MAH. Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness. Lancet. 1999; 354: 210-215. Tengs TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC, Graham JD. Five hundred life saving interventions and their cost effectiveness. Risk Analysis. 1995; 15: 369-390. Linda Bauld, Ph.D., Kathleen A. Boyd, MSc., Andrew H. Briggs, D.Phil., John Chesterman, Ph.D., Janet Ferguson, MPH., Ken Judge, Ph.D., Rosemary Hiscock, Ph.D.; One-Year Outcomes and a Cost-Effectiveness Analysis for Smokers Accessing Group-Based and Pharmacy-Led Cessation Services, Nicotine & Tobacco Research, Volume 13, Issue 2, 1 February 2011, Pages 135–145, Parrott S, Godfrey C, Raw M, et al. Guidance for commissioners on the cost-effectiveness of smoking cessation interventions. Thorax. 1998;53:S1-38.
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MS 09.04 - Nicotine Dependence and Cessation in Lung Cancer Patients (ID 7685)
16:30 - 16:45 | Presenting Author(s): Matthew A Steliga
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Tobacco use is well known as a carcinogen linked to many malignacies and also linked to non-oncologic diseases such as cardiovascular disease, chronic lung disease, and respiratory infections. The majority of lung cancer patients do have a history of smoking; often many are actvely smoking at the time of diagnosis and many struggle with cessation during treatment and through survivorship. Patients may have a perception of futility and lack of perceived benefit regarding cessation, and some clinicians may view tobacco cessation with a pessimistic perspective in that "the damage is already done." One of the first steps toward cessation in lung cancer patients is to make patients, families, and physicians aware of the continued harms of smoking, the negative impact on efficacy of treatment, and for those who may be treated with curative intent, the potential for development of malignacy in the future. As the potential benefits range widely and may apply differently to different patients, the ability to individualize a message regarding relevant positive impacts of cessation is crucial. For cancer patients overall, there is survival advantage in those who are able to quit, compared to continued smoking. Nicotine and its metabolic products can promote tumor growth through increased proliferation, angiogenesis, and other pathways. Furthermore, nicotine can decrease the biologic effectiveness of conventional cancer treatments such as chemotherapy and radiotherapy. For patients undergoing surgery, smoother recovery and avoidance of perioperative complications such as respiratory infection, wound complications, and perioperative cardiovascular events is critical. For those treated with curative intent, continued smoking can clearly be a significant risk factor for metachronous lung cancer, or development of different primary tumors. Even in those with incurable disease, overall survival benefit of cessation has been demonstrated. In addition, many patients with lung cancer and a smoking history have significant burden of respiratory symptoms, including dyspnea, wheezing, exercise intolerance, cough, pneumonia, etc. From a palliative standpoint, cessation can ameliorate some of the respiratory symptoms, and improve quality of life. Physician advice is a powerful tool and should be part of every encounter. Ask-Advise-Refer is a simple standard strategy which can be integrated into even the busiest of workflows. This involves asking every patient about tobacco use, advising cessation and referral to a tobacco treatment resource. That resource may be a Certified Tobacco Treatment Specialist, a telephone counseling service (such as a 'quitline'), a group counseling setting or other specialist. A more indepth cessation strategy involves the "5 As": Ask, Advise, Assess, Assist, Arrange. In addition to asking every patient about use and advising them to stop, a physician should Assess their use, prior quit attempts, and willingness to make a quit attempt. Then a provider should Assist the patient with their quit attempt with counseling and pharmacotherapy. Motivational interviewing is a standard counseling strategy in which a process of questioning and interviewing which strengthens and engages intrinsic motivation within the patient in order to change behavior. Pharmacotherapy consists of nicotine replacement therapy, varenicline, and/or buproprion. Previous concerns regarding severe psychiatric side effects such as suicidal ideation with varenicline have made some patients and physicians wary to use it; however, a recent trial shows varenicline to be very safe with no higher incidence of psychiatric side effects than placebo. Nicotine replacement therapy (NRT) can be delivered in a slow continuous format via a nicotine patch, and/or via short acting NRT such as gum, lozenges, nasal spray, or prescription inhaler. Often times a long acting modality (nicotine patch) can be used in combination with a short acting NRT as combination therapy. Overall pharmacotherapy increases success of quit attempts, and should be integrated as a part of the patient's overall healthcare plan. Often times the choice of pharmacotherapy is guided by what has or has not worked for that patient in the past. Electronic Nicotine Delivery Systems (ENDS) or e-cigarettes have recently become widespread and commonly available in many countries. The nicotine content is widely variable, and other componenets of the vaporised liquid make comparison and quantification much more difficult than that for approved pharmacotherapy where dosing is consistent and predictable. It is true that ENDS may not contain the same level of carcinogens as cigarettes, but in reality many users of ENDS are not able to quit conventional cigarettes, but use ENDS when not able to smoke and then use conventional cigarettes when they can smoke. At current, data is lacking and does not support e-cigarettes above approved pharmacotherapy. For those patients who are using e-cigarettes, the primary goal to complete cessation of conventional cigarettes. Patients who are using e-cigarettes and unable to quit smoking should be steered toward approved pharmacotherapy. Multiple different strategies exist to support patients during cessation attempts. There is no universally applicable single way to approach cessation. Counseling and pharmacotherapy are mainstays of cessation support and best outcomes result from using them together. A concerted, consistent message combined with appropriate pharmacotherapy and counseling may help many patients with lung cancer to quit smoking and gain the benefits of cessation.
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MS 09.05 - Holding the Tobacco Industry Accountable in the Era of Novel Tobacco Products (ID 7686)
16:45 - 17:00 | Presenting Author(s): Yumiko Mochizuki
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Abstract not provided
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MS 09.06 - Tobacco Industry Interference in Low and Middle Income Countries (ID 7687)
17:00 - 17:15 | Presenting Author(s): Nise Yamaguchi
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Abstract:
The 2016 FCTC Report of the Conference of Parties (COP 2016) alerts that tobacco is the only legal non-prescription product that can kill between 33% and 50% of consumers when used as recommended by the tobacco industry [[1]]. The tobacco industry is also the only industry that, due to the potential lethality of its products and their impact on public health, has elicited a legally-binding intergovernmental treaty for protecting public health policies from the interference by the industry and by those who act to protect their interests. Besides the heavy political lobbying for blocking, delaying or weakening public health policies on tobacco control, the industry frequently resorts to legal disputes on the basis of international free trade agreements and bilateral agreements to revert governmental policies1. During the 6th COP, in 2014, the FCTC adhering State Parties have declared that the tobacco industry interference in public health policy for tobacco control continues to represent the main hindrance for full implementation of FCTC articles [[2,3]]. According to the WHO’s global report on tobacco industry interference of 2012, the most common tactics used by the industry are [[4]]: • maneuvering to hijack the political and legislative process; • exaggerating the economic importance of the industry; • manipulating public opinion to gain the appearance of respectability; • fabricating support through front groups; • discrediting proven science; • intimidating governments with litigation or the threat of litigation. Despite the tobacco industry claiming otherwise, the Director-General of the World Trade Organization (WTO) has declared that there is no inherent conflict between FCTC implementation by the ratifying countries and the WTO rules [[5]]. He enlightens that there are two WTO principles that should be respected: the non-discrimination and the necessity principles. The first one implies that the implemented tobacco-control policy does not treat an imported product differently than its domestic equivalent; whereas the necessity principle states that such measure, law or provision “must be necessary for complying with the proposed health goal and that it should not be more restrictive than necessary on trade in order to achieve this goal”[[6]]. Furthermore, according to the WTO, a “Member States have the right to determine the level of health protection that they wish to promote…” and, “when considering the less restrictive alternatives, these must meet the regulatory goal and be reasonably available, as well as genuinely alternative and not complementary measures”[[6]]. As far as bilateral agreements are concerned, the industry has used them in some countries to revert or impede the FCTC provision on cigarette packaging and labeling, by claiming that it breaches bilateral trade provisions that protect trademark and property rights [[6]]. Therefore, legislators should consider four basic principles when implementing tobacco control regulations: 1), to make sure that the law “only restricts property rights to the extent of achieving a public health objective”; 2), to avoid raising expectations of tobacco-industry investors that they will not be subjected to the regulation in question; 3), to ensure legislation’s compliance with the principles of due process and natural justice; and 4), to make sure that the new regulation will not be discriminatory. The careful application of these principles in the legislation wording and form will not only reduce international litigation but also protect the FCTC-ratifying Party from having to pay the tobacco industry compensation for damages [[6]]. In 2014, the COP participants unanimously decided to accelerate the full implementation in all public administration sectors and diplomatic missions of Article 5.3 and its guidelines [[3]]. Article 5.3 of the Framework Convention for Tobacco Control (FCTC) offers essential guidelines that were unanimously approved by the FCTC-ratifying countries in 2008. Article 5.3 thereby obligates ratifying countries to protect their health policies from tobacco manufacturers’ interference and to recognize that the tobacco industry bears fundamental and irreconcilable conflict of interests with public health and the FCTC implementation. In fact, Article 5.3 guidelines are the backbone of the FCTC treaty and help to prevent and reduce litigations aiming at reversing or halting the implementation of further anti-tobacco policies [[1]]. According to Article 5.3, countries should refuse to treat tobacco companies as “collaborators” in public health policy making; should not invest in the tobacco industry; should not receive contributions or grants from the tobacco industry; should not partner with tobacco industry either for health or other purposes – including their so-called social responsibility programs; should not celebrate non-binding or non-enforceable agreements; nor admit tobacco industry representatives on FCTC delegations or on other tobacco-control administrative agencies. Another relevant provision of Article 5.3 concerns transparency[[7]] in the interactions between government agencies and the tobacco industry by promoting afore public notices and free public access to reports, records, and documents about such interactions, besides promoting public hearings about the meetings. Moreover, it recommends the disclosure or registration of tobacco-affiliated organizations, advocacy groups and lobbyists; legal penalties on tobacco business for disseminating false or misleading information or propaganda; disclosure of tobacco industry business, such as market share, revenues, production, manufacture, relationship with tobacco farmers, investments in marketing, analysis of tobacco products chemical contents, and “social responsibility” actions and related activities; obligatory disclosure of current or past work with tobacco industry by applicants to jobs in governmental bodies involved in health policy-making, policy execution or surveillance[[7]]. The 2016 PAHO Report for the Region of Americas alerts that there are more than one billion smokers in the world and that 11.4% of them live in the Region of the Americas, which represents a population of 127 million smokers in our continent [[1]]. Prevalence shows that 21.2% of adults or teenagers older than 15 are smokers [[1]], which poses a heavy burden on public health, especially because it is among the youth and the lower income segments that the prevalence is higher. However far we had already progressed in fighting smoking and the consumption of other tobacco products, we are still very far from eradicating this addiction that responds for the vast majority of lung cancer cases, not to mention Head & Neck tumors and cardiovascular diseases. The implementation by all ratifying Parties of the FCTC six provisions that comprise the MPOWER package may drastically reduce in the coming two decades the morbidity and mortality associated with tobacco consumption. Our struggle is just beginning. References Pan American Health Organization. WHO FCTC. Report on Tobacco Control for the Region of the Americas. Who Framework Convention on Tobacco Control: 10 Years Later. Washington DC: PAHO, 2016. World Health Organization. FCTC/COP6/16, Implementation of Art. 5.3 of the WHO Framework Convention on Tobacco Control: questions related to tobacco industry interference. Report of the Secretariat of the Convention. Conference of the Parties in the WHO Framework Convention on Tobacco Control, 6th Meeting; 13-18 October; Moscow, Russian Federation. Geneva: WHO; 2014. Available at: . Accessed on June 10, 2017.
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MS 09.07 - Implementation of Smoking Cessation Strategies (ID 7688)
17:15 - 17:30 | Presenting Author(s): Patsy Yates
- Abstract
- Presentation
Abstract not provided
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MA 18 - Global Tobacco Control and Epidemiology II (ID 676)
- Event: WCLC 2017
- Type: Mini Oral
- Track: Epidemiology/Primary Prevention/Tobacco Control and Cessation
- Presentations: 1
- Moderators:H. Kawai, Christian Klaus Manegold
- Coordinates: 10/17/2017, 15:45 - 17:30, Room 511 + 512
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MA 18.01 - Driving Improvements in Cancer Care Ontario's Smoking Cessation Initiative for Cancer Patients in Ontario, Canada (ID 10401)
15:45 - 15:50 | Author(s): William Kenneth Evans
- Abstract
- Presentation
Background:
Substantial evidence exists that quitting smoking after a cancer diagnosis can result in improved treatment efficacy and safety, decreased risk of recurrence and second primary cancers, and lower mortality. Based on this evidence, Cancer Care Ontario (CCO) implemented a smoking cessation program for new ambulatory cancer patients in Ontario’s 14 Regional Cancer Centres (RCCs) in 2014. Implementation is monitored centrally by CCO using performance indicators and monthly discussions with regional champions. Significant variation in implementation processes and performance metrics amongst RCCs highlighted a need for quality improvements.
Method:
Funding received from the Canadian Partnership Against Cancer enabled CCO to undertake a series of initiatives to enhance provider and patient education and to standardize processes. Based on program learnings and emerging evidence, the program model was revised from 5As (Ask, Advise, Assess, Assist, Arrange) to 3As (Ask, Advise, Act), and site-specific recommendations were provided to support consistency in implementation. Patient-facing materials, an on-line learning module, scripts and videos were developed to educate healthcare providers and patients on the health benefits of smoking cessation in order to improve rates of screening and referrals to cessation services. Importantly, two performance indicators have been included on CCO’s Regional Scorecard, which measures performance against targets and determines an RCC’s overall performance ranking within the province.
Result:
Performance on the Tobacco Use Screening indicator (proportion of new cancer patients screened for tobacco use) was 42.0% across Ontario in April 2015 when first included on the Scorecard. By March 2017, performance had improved to 62.7%, with significant improvements seen among the lowest-performing RCCs. The Accepted a Cessation Referral indicator (proportion of tobacco users who accepted referral to cessation services) improved only modestly from 19.7% in Q1 of 2016/17 to 23.4% in Q4. This indicator will be added to the Regional Scorecard starting in 2017/18. Both indicators are discussed at the quarterly performance reviews with the Regional Vice-Presidents responsible for cancer services. In 2016/17, lung cancer patients accounted for the largest percentage of current users of tobacco by tumour site (21.9%); in addition, almost a quarter of all patients accepting a referral (24.3%) were lung cancer patients.
Conclusion:
The CCO performance Scorecard is a strong driver of quality improvement. CCO is encouraged by regional enthusiasm to adopt the refined 3As model, and anticipates further improvements in the performance metrics, especially in the number of tobacco users who accept referral to cessation services.
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OA 06 - Global Tobacco Control and Epidemiology I (ID 662)
- Event: WCLC 2017
- Type: Oral
- Track: Epidemiology/Primary Prevention/Tobacco Control and Cessation
- Presentations: 1
- Moderators:G. Kovács, Yun Fan
- Coordinates: 10/16/2017, 15:45 - 17:30, Room 511 + 512
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OA 06.01 - Costs and Cost-Effectiveness of Smoking Cessation Within an Organized CT Lung Cancer (LC) Screening Program (ID 9642)
15:45 - 15:55 | Presenting Author(s): William Kenneth Evans
- Abstract
- Presentation
Background:
Low-dose CT (LDCT) screening of smokers at high risk of developing lung cancer has been shown to reduce LC-specific and overall mortality. A retrospective analysis of the National Lung Screening Trial (NLST) data suggests that smoking cessation contributed to the mortality reduction. Pilot LDCT screening programs are being implemented in Ontario with smoking cessation integrated. The Canadian Partnership Against Cancer with Statistics Canada have developed a microsimulation model (OncoSim-LC, version 2.5) that projects the impact of cancer control measures on LC incidence, mortality and cost. Assuming that each annual visit for LDCT is a teachable moment to promote smoking cessation, we have modelled the potential cost and cost-effectiveness of integrating cessation into an organized screening program.
Method:
OncoSim-LC incorporates Canadian demographic characteristics, risk factors, cancer management approaches and outcomes and resource utilization to assess clinical, economic and healthcare system impacts. We compare a base case of organized screening with no cessation to various scenarios of screening with cessation. Modelling assumptions included: annual screening of 55-74 year olds with 30+ pack year smoking history, target participation rate reached over 10 years; one cessation intervention (nicotine replacement therapy + varenicline + 12 weeks of counselling) costs $490; up to 10 cessation attempts per eligible individual dependent on screening encounters; a permanent quit rate of 5% per cessation attempt. Cost-effectiveness was estimated with a lifetime horizon, health system perspective and 1.5% discount rate. Costs are in 2016 CAD.
Result:
Cessation within a screening program with 60% recruitment and 70% rescreening (adherence) would cost approximately $76 million (undiscounted) per year for 2017-2036 or 8% of the total cost of screening, treatment and cessation. Compared to screening with no cessation, approximately 110 fewer incident cases and 50 fewer lung cancer deaths would occur on average per year for 2017-2036 and cost $14,000/QALY (lifetime horizon). 90% recruitment and 80% rescreening would result in 260 fewer deaths and cost of $24,000/QALY. At a doubled permanent quit rate of 10%, screening with cessation would cost $6,000/QALY. A 50% increase in the cost of the cessation intervention would decrease cost-effectiveness to $22,000/QALY.
Conclusion:
Based on the OncoSim-LC model, a cessation program within an organized LDCT screening program would cost well under $50,000/QALY even over multiple quit attempts. Integrating robust smoking cession initiatives within a LDCT screening program could save lives and be relatively cost-effective.
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OA 14 - New Paradigms in Clinical Trials (ID 681)
- Event: WCLC 2017
- Type: Oral
- Track: Clinical Design, Statistics and Clinical Trials
- Presentations: 1
- Moderators:Alex Adjei, Eun Kyung Cho
- Coordinates: 10/18/2017, 11:00 - 12:30, Room 311 + 312
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OA 14.03 - Ontario's Bundled Payment System for Systemic Therapy Supports Lung Cancer Trials (ID 9636)
11:20 - 11:30 | Presenting Author(s): William Kenneth Evans
- Abstract
- Presentation
Background:
Clinical trials (CTs) are recognized as a key component of a quality cancer care system. When funding for systemic therapy (ST) services in Ontario transitioned in 2014/15 from a one-time payment for new cases to bundled payments for specific evidence-informed regimens, stakeholders expressed concern that the funding model could exclude patients from participation in CTs as treatment facilities would only receive funding when evidence-informed regimens were used.
Method:
A CT policy was implemented to enable public funding through the ST funding model for older and inexpensive drugs and their administration within randomized CTs at the level of the standard of care. Non-randomized CTs were to be funded at the level of best supportive care or other appropriate funding level. New and expensive drugs in a CT could be funded through a separate provincial drug reimbursement program if used according to public funding criteria with administration costs covered by the ST funding model. Each new CT is now assessed to determine the level of public funding possible. The funding model can now capture data on phase of trial, disease type, treatment regimen, trial purpose (adjuvant, palliative) and patient accrual by treatment facility
Result:
During 2015/16 and 2016/17, 43 and 44 lung CTs, respectively, were assessed and activated in Ontario. Trial accrual increased by 33% (from 311 to 413 patients) over the two years since the introduction of the funding model. Accrual varied by facility. In 2016/17, it ranged from a low of 0.25% to 37.5% of the new lung cancer (LC) patients seen at individual facilities. For the five largest cancer centres in Ontario, the percentage of patients recruited ranged from 5% to 18.3% and total accruals from these centres (n=257) comprised 63% of provincial LC trial recruitment. Five immuno-oncology trials accrued 183 patients and made up 44% of total LC trial accruals. Public funding through the ST funding model amounted to $415,000 in 2015/16 and increased to $815,000 in 2016/17.
Conclusion:
The new bundled payment system for ST and the CT policy have enabled public funding to support lung CTs. The ST funding model has facilitated the capture of CT data and trends not previously available for LC and other tumours. The new provincial CT policy and payment system do not appear to have negatively impacted participation in lung cancer CTs. The variance in trial accrual between centres warrants further study.
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OA 15 - Diagnostic Radiology, Staging and Screening for Lung Cancer II (ID 684)
- Event: WCLC 2017
- Type: Oral
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:Y. Satoh, Jin Mo Goo
- Coordinates: 10/18/2017, 14:30 - 16:15, Room 303 + 304
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OA 15.01 - Lung Cancer Screening: Participant Selection by Risk Model – the Pan-Canadian Study (ID 8466)
14:30 - 14:40 | Author(s): William Kenneth Evans
- Abstract
- Presentation
Background:
Retrospective studies indicate that selecting individuals for low dose computed tomography (LDCT) lung cancer screening based on a highly predictive risk model is superior to applying National Lung Screening Trial (NLST)-like criteria, which use only categorized age, pack-year and smoking quit-time information. The Pan-Canadian Early Detection of Lung Cancer Study (PanCan Study) was designed to prospectively evaluate whether individuals at high risk for lung cancer could be identified for screening using a risk prediction model. This paper describes the study design and results.
Method:
2537 individuals were recruited through 8 centers across Canada based on a ≥2% of lung cancer risk estimated by the PanCan model, a precursor to the validated PLCOm2012 model. Individuals were screened at baseline and 1 and 4 years post-baseline.
Result:
At a median 5.5 years of follow-up, 164 individuals (6.5%) were diagnosed with 172 lung cancers. This was a significantly greater percentage of persons diagnosed with lung cancers than was observed in the NLST(4.0%)(p<0·001). Compared to 57% observed in the NLST, 77% of lung cancers in the PanCan Study were early stage (I or II) (p<0.001) and to 25% in a comparable population, age 50-75 during 2007-2009 in Ontario, Canada’s largest province, (p<0·001).
Conclusion:
Enrolling high-risk individuals into a LDCT screening study or program using a highly predictive risk model, is efficient in identifying individuals who will be diagnosed with lung cancer and is compatible with a strong stage shift – identifying a high proportion at early, potentially curable stage. Funding This study was funded by the Terry Fox Research Institute and Canadian Partnership Against Cancer. ClinicalTrials.gov number, NCT00751660
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