The 50th anniversary of the first US Surgeon General’s Report on Smoking and Health provides an opportunity for the oncology community to take stock of whether meaningful progress has been made in tobacco prevention and control. Knowing what we know about the devastation of tobacco use, the leading cause of both preventable death and cancer death, what more can we do to confront this scourge? I would like to suggest three ways that oncology healthcare professionals can make a difference: first, help patients quit tobacco use as part of day-to-day oncology practice; second, take an increased presence in tobacco control efforts; and third, embrace tobacco-free environments.
A number of factors have contributed to the oncology community’s limited involvement in tobacco control. When the Surgeon General’s Report was published in 1964, there was no recognized specialty of oncology to respond. Although the British Doctor’s Study provided some evidence of the role of quitting smoking in improving health outcomes, there were no approved guidelines for how to assist smokers in quitting. It was not until 1988 that a US Surgeon General Report clearly identified nicotine as the addictive component of cigarettes. The role of tobacco use in cancer has been included in curricula for health professionals, but adequate content on evidence-based strategies for supporting the quit efforts of smokers is too often lacking as part of basic preparation. Further, the treatment of tobacco dependence has not been a required component of care for National Cancer Institute–designated Cancer Centers. Information about smoking status is not routinely collected in cancer clinical trials nor included in Surveillance, Epidemiology, and End Report (SEER) databases, limiting data that could be used to examine the impact of continued tobacco use on cancer outcomes.
Treating Tobacco Use in Oncology Care
Since the publication of the first guideline for treatment of tobacco dependence in 1996, two additional guidelines have been published, in 2000 and 2008. The “gold standard” for treatment of tobacco dependence, as recommended in the “Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update,” includes provision of social support and use of approved pharmacotherapy to diminish withdrawal symptoms and improve the likelihood of staying tobacco-free. Although evidence is available about the beneficial impact of quitting on cancer survival and morbidity, translation of the Guideline into clinical practice is lacking. Recognizing this, the American Society of Clinical Oncology (ASCO) created a tool kit of materials to help providers address tobacco in oncology practice. Another evidence-based and free resource that can provide social support and guide smokers through a quit attempt is the national telephone quitline (1-800-QUIT-NOW). Smoking cessation even matters at the end of life, when patients may suffer withdrawal symptoms in a smoke-free hospital or hospice environment. For smokers who have compromised mental status, safety becomes an issue—especially with the presence of oxygen therapy equipment.
US Surgeon General’s Report 50th Anniversary: Perspectives on Smoking & Health
January 14, 2014 marks the 50th anniversary of the landmark publication Smoking and Health: Report of the Advisory Committee to the Surgeon General of the United States. ONCOLOGY is commemorating this anniversary with an expert perspective mini-series on progress, challenges, and new directions in tobacco awareness and control, lung cancer prevention, and patient care.
In the first perspective, which begins on this page, Dr. Linda Sarna of the UCLA School of Nursing discusses meaningful ways in which oncology professionals can advance tobacco control.
In the second perspective, Dr. Jim Mulshine of Rush University Medical Center and Dr. Cheryl Healton of NYU’s Global Institute of Public Health discuss tight integration of tobacco cessation strategies with lung cancer screening in at-risk patients, to enhance screening benefit and advocacy for proactive tobacco control.
In the third perspective, Dr. Alan Blum of the University of Alabama Center for the Study of Tobacco and Society explores missed opportunities in tobacco prevention efforts, and the need for stronger leadership and clearer direction.
One of the barriers to interventions with patients is smoking among healthcare professionals. Although smoking prevalence is low among physicians, further efforts are needed to support smoking cessation among all healthcare providers. Through the Tobacco Free Nurses (TFN) initiative (www.tobaccofreenurses.org), which began in 2003, we focused our efforts on smoking by nurses, who in the mid 1970s had a higher smoking prevalence than women in the general public. TFN was the first national program focused not only on helping nurses stop smoking but also on providing all nurses with essential education and resources to help their patients quit. It is important for all oncology healthcare providers to treat tobacco use and dependence in all of their patients.
Involvement in Tobacco Control Policy
Another way that oncology professionals can accelerate change in tobacco control is through involvement and leadership in policy efforts to promote a tobacco-free world. ASCO has updated its 10-year-old tobacco-control policy, which provides a roadmap for oncology action in supporting US tobacco regulation. The Oncology Nursing Society also has a longstanding policy about global and national tobacco control efforts, which has been endorsed by the American Nurses Association. The oncology community should confront a major factor in the tobacco use epidemic: the tactics of the tobacco industry. November 23, 2013 marked the 15th anniversary of the Master Settlement Agreement between 46 Attorneys General and the 5 largest tobacco companies in the United States, which resulted in the changing of standards for and restrictions on the marketing of cigarettes. The Agreement also led to the creation of the Legacy foundation (www.legacyforhealth.org), which has mounted national educational campaigns and advocated for federal tobacco control legislation. Legacy also supports a documents library at the University of California, San Francisco, that houses more than 14 million internal tobacco industry documents, including advertisements using healthcare professionals to promote tobacco use.
Because the tobacco epidemic is a global problem, and with lung cancer continuing as the leading cause of cancer death worldwide, international advocacy efforts by oncology healthcare professionals are needed. In 2003, the United Nations (UN) World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first international health treaty, was adopted. The FCTC provides opportunities to comprehensively address tobacco control, including expanding the capacity of healthcare providers in the delivery of cessation interventions. Expanding capacity among nurses has been the focus of our efforts in the United States, China, and Eastern Europe, in collaboration with the International Society of Nurses in Cancer Care. Additionally, in 2011 the UN recognized the global burden of noncommunicable diseases (NCDs; cancer, cardiovascular disease, respiratory disease, and diabetes) in causing premature deaths and suffering that negatively impact social and economic progress, especially in developing countries. Four major risk factors (tobacco use, unhealthy eating, harmful use of alcohol, and physical inactivity) are targets for the global plan of action. ASCO is a member of the NCD Alliance (www.ncdalliance.org), whose stated mission is “putting noncommunicable diseases on the global agenda.” Because involvement of the 19 million nurses and midwives worldwide could make a big difference in reducing key NCD risk factors, especially tobacco use, we developed a publication for the WHO to describe how nurses could affect policy, advocacy, research, and education, at individual and organizational levels. We in the oncology community must continue to add our voices to policy efforts in tobacco control through the submission of comments in public hearings and communications with the media.
Finally, the oncology community needs to provide support for adoption of standards of care in hospital settings for the treatment of tobacco dependence. The Joint Commission’s new performance measures for assessment and treatment of tobacco cessation, supported by ASCO, should be embraced by all who care for cancer patients struggling with tobacco dependence. I challenge any organization that rates hospitals as having “best” care to include in their criteria an evaluation of how well hospitals address the needs of patients faced with the challenge of nicotine addiction.
Supporting Smoke-Free Environments
The national downward trend in smoking since the 1964 Surgeon General’s Report on Smoking and Health can be accelerated by the “denormalization” of tobacco use. Smoking and exposure to secondhand smoke are no longer “normal” parts of everyday life. Advocacy efforts to extend smoke-free environments in public housing and public places are increasing. Hospitals went smoke-free in the mid 1990s, but now we see expansion to entire healthcare campuses. Smoke-free environments not only protect nonsmokers from secondhand smoke, but they also facilitate quitting by making smoking more challenging and by providing a supportive smokeless environment.
More than 1,000 college campuses now have smoke-free or tobacco-free policies. The entire University of California, all 10 campuses, will have gone tobacco-free as of January 1, 2014. My institution, the University of California at Los Angeles (UCLA), became tobacco-free on April 22, 2013, Earth Day, to emphasize the negative consequences of tobacco litter on the environment (see http://healthy.ucla.edu/pod/breathe_well). An essential part of our plan included support for smokers who want to quit, through provision of approved pharmacotherapy and increased use of the telephone quitline.
This policy change gave us the opportunity to educate the entire University community about the negative health impact of tobacco use, including exposure to secondhand smoke, as well as the benefits of quitting. The oncology community at UCLA played a pivotal role in the implementation of this change, as they spoke out eloquently about the devastating consequences of a lifetime of tobacco use, through a prism of their own clinical experiences, thus providing support for the tobacco-free policy when it was under fire. These are but three examples of opportunities for the oncology community to ensure that the next generation is free of a life-long addiction to tobacco, and the associated misery.
Financial Disclosure: The author has no financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
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