Download Educational Slide Set for Physicians on Tobacco Control

IASLC Live Learning
Tobacco Control and
Smoking Cessation
Live Learning Seminars
Chicago: October 14, 2016
Philadelphia: October 21, 2016
San Francisco: November 4, 2016
Disclosures:
•
Contributors to the slide deck are members of the IASLC
Tobacco Control and Smoking Cessation Committee 2016.
•
Slides were contributed by: Graham Warren, Michael
Cummings, Carolyn Dresler, Emily Stone, Matthew Steliga
and reviewed by the Committee.
•
Dr. Cummings has received grant funding from the Pfizer,
Inc, to study the impact of a hospital-based tobacco
cessation intervention, and has received funding as an
expert witness in litigation filed against the tobacco
industry. No other conflicts of interest are declared.
Learning Objectives
•
Demonstrate understanding of:
•
The global impact of tobacco on health and lung cancer
•
Different forms of tobacco control policies
•
The importance of cessation practices and benefits of quitting
•
How to assess tobacco use and nicotine dependence
•
Tailoring evidence based cessation for individual patients
•
Implementing systems to ensure delivery of services
•
Addressing smoking relapse
•
Perspectives on Electronic Nicotine Delivery Systems (e-cigarettes)
Deaths due to cancer type: US 2012
http://globocan.iarc.fr
Deaths due to cancer type: World 2012
http://globocan.iarc.fr
Tobacco and cancer deaths
•
Lung cancer is the most common cause of cancer
mortality in the world and in the US.
•
>80% of cases attributable to tobacco
•
What’s shocking is not merely the millions of deaths
and billions of dollars in cost of this epidemic, but
the fact that much if it is preventable…
Tobacco Control is complex, dynamic, multifactorial
interaction between industry, society, and government
Legislation
Social norm
Tobacco industry
www.tobaccoatlas.org accessed 2.8.15
US Tobacco Control: Policies impact tobacco use.
1964 surgeon general report
US
Per capita
Cigarettes
smoked per
year
1900
1960
2012
Samet JM, Ann Am Thorac Soc 2014;11(2):141-8.
Examples of tobacco control
•
Taxation
•
Limitations on marketing and advertising including
packaging, point of purchase display
•
Age restrictions for purchase
•
Smoking bans in public places
•
Public announcements / information
•
Cessation resources
Why should we as
oncologists care about
cessation?
Isn't it too late?
Does it matter?
What difference can it
really make?
Why is cessation important?
The 2014 Surgeon General’s Report:
• Statistics:
–
–
–
–
Evidence for studies between 1990-2012
Studies with 100+ patients
~400 studies reporting on over 500,000 patients
Effects of smoking on:
1.
2.
3.
4.
5.
Overall mortality/survival
Cancer-specific mortality/survival
Risk of second primary cancers
Cancer recurrence/response to treatment
Toxicity
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking
and Health, 2014.
Why is cessation important?
The 2014 Surgeon General’s Report:
• Conclusions:
– In cancer patients and survivors, the evidence is
sufficient to infer a causal relationship between
cigarette smoking and adverse health outcomes.
Quitting smoking improves the prognosis of cancer
patients.
– In cancer patients and survivors, the evidence is
sufficient to infer a causal relationship between
cigarette smoking and increased all-cause mortality
and cancer-specific mortality.
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking
and Health, 2014.
Why is cessation important?
The 2014 Surgeon General’s Report:
• Conclusions:
– In cancer patients and survivors, the evidence is
sufficient to infer a causal relationship between
cigarette smoking and increased risk for second
primary cancers known to be caused by cigarette
smoking, such as lung cancer.
– In cancer patients and survivors, the evidence is
suggestive but not sufficient to infer a causal
relationship between cigarette smoking and the risk of
recurrence, poorer response to treatment, and
increased treatment-related toxicity.
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking
and Health, 2014.
The 2014 SGR: Outcome Estimates
Effect
Studies
Overall Mortality
159
Associations
(Significant)
87% (62%)
Overall Survival
62
77% (42%)
Cancer Related Mortality
58
79% (59%)
Second Primary
26
100% (100%)
Recurrence
51
82% (53%)
Response
16
72%
Toxicity
82
94% (80%)
RR Magnitude
(median)
Current: 1.51
Former: 1.22
Current: 1.61
Former: 1.03
Current:1.42
Former:1.15
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking
and Health, 2014.
Specific examples:
Impact of tobacco on treatment
• 101 head & neck
cancer patients actively
5 year OS
smoking
• 101 matched controls
who quit
Locoregional
– age, stage, Karnofsky,
tumor location, packyears, chemotherapy,
radiation dose, etc.
Chen AM- Int J Rad Onc 2011
control
Active Quit
Smokin Smokin
g
g
23% 55%
58% 69%
Disease-free
survival
42% 65%
Complication
s Grade 3
49% 31%
Specific examples:
Impact of tobacco on developing future primary tumor
• Retrospective review
Swedish cancer registry
• Breast cancer treatment
with breast conservation
+ radiation
• RR of 2.04: for developing
LUNG cancer in smokers
with ipsilateral radiation
up to 10 years later.
Prochazka M. JCO 2005
Specific examples:
Impact of tobacco on outcomes SCLC
• Small cell lung cancer
• metaanalysis revealed
increased mortality,
second primary and
recurrence for continued
smoking.
Parsons A, et al BMJ. 2010
Specific examples:
Impact of tobacco on survival NSCLC
• Telephone survey of lung
cancer patients who
smoked
• Controlled for age, pack
year history, stage, PS, etc.
• Current tobacco use
associated with increase in
death (HR 1.79)
• Median survival 20.0 vs 29.0
months.
Dobson-Amato KA, J Thoracic Onc 2015.
Ok…
Cessation is important.
How can it be done?
I don’t have enough time.
Patients aren’t going to quit
anyway…
Tobacco Cessation in
Clinical Practice
•
ASK every patient about former and current tobacco use.
•
ADVISE all patients to quit with a personalized message
and discuss benefits of cessation
•
ASSESS dependence on tobacco and willingness to quit
•
ASSIST with behavioral counseling, pharmacotherapy
•
ARRANGE follow up plan (in person, or if not possibleby telephone)
Implementing Cessation into Practice
• The 5 A’s Model
• Ask
• Advise
• Assess
• Assist
• Arrange
• Implementing cessation into
clinical care should consider new
and follow-up approaches
Warren et al. DeVita Principles and
Practice of Oncology
10th ed. 2014
Tobacco Assessment by Oncologists
(Always/Most of the time)
Parameter
IASLC
ASCO
(n=1507)
(n=1197)
Ask if use tobacco
90.2%
89.5%
Ask if will quit
78.9%
80.2%
Advise to quit
80.6%
82.4%
Discuss medications
40.2%
44.3%
Actively treat
38.8%
38.6%
Warren GW et al. J Thorac Oncol 2013 8:543-548
Warren GW et al. J Oncol Pract 2013 9(5): 258-262
Automated Screening and Treatment
Warren GW et al., Cancer 2014
PHARMACOLOGIC THERAPY
Three general classes of FDA-approved drugs for
smoking cessation:
 Nicotine replacement therapy
Nicotine patch, gum, lozenge, nasal spray, inhaler
Can use patch (long acting) with another short acting form
of NRT
 Psychotropics
Sustained-release bupropion
 Partial nicotinic receptor agonist
Varenicline
Explore what has / has not worked for that patient previously.
Most patients have quit or at least had quit attempts in the past
Tobacco Cessation in Clinical Practice
(abbreviated strategy)
•
ASK every patient about former and current tobacco
use.
•
ADVISE all patients to quit and discuss benefits of
cessation
•
REFER patients to evidence based cessation
resources: Tobacco Cessation Specialist, Group
Counseling, Phone Counseling (1-800-QUIT-NOW)
NCCN Guidelines
www.nccn.org (v1, 2015)
www.nccn.org (v1, 2015)
www.nccn.org (v1, 2015)
www.nccn.org (v1, 2015)
What about e-cigarettes?
•
“Hot” topic
•
Advise patients to try FDA
approved pharmacotherapy and
counseling
•
Electronic cigarettes are
variable in the inhaled
components which include
flavorings, additives such as
propylene glycol, etc which may
change when heated.
•
If they are using electronic
cigarettes, discuss tapering and
cessation, or switching to NRT
such as patch + gum etc.
Summary
•
Most lung cancer and many
other cancers are linked to
tobacco use.
•
Most patients DO want to quit,
(and often have tried multiple
times).
•
Physicians should be aware of
and support tobacco control
policies which save lives
•
Cessation impacts outcomes,
even after diagnosis.
•
Cessation can and should be
integrated into clinical practice
Resources
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NCCN Clinical Practice Guidelines
•
•
Treating Tobacco Use and Dependence
•
•
www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/clinicians/update/index.html
CDC
•
•
www.nccn.org
http://www.cdc.gov/primarycare/materials/smokingcessation/
docs/smoking_cessation_additional_resources_508.pdf
IASLC
•
https://www.iaslc.org/patient-resources/tobacco-cessation-0