Policy Update Aims to Advance Tobacco Cessation and Control Worldwide

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In response to scientific advances and the evolving regulatory and policy environment, ASCO recently released an update to its 2003 policy statement on tobacco cessation and control. The statement reviews advancements that have been made since 2003 and outlines a refined set of recommendations based on current challenges and opportunities, including a strong call for oncology professionals to lead by example in combating the tobacco epidemic.

Overall, ASCO’s tobacco control efforts, led by a subcommittee of the Cancer Prevention Committee, aim to help the oncology workforce effectively integrate tobacco cessation and control into their practices, collaborate with other organizations and professional societies to reduce tobacco use and eliminate tobacco-caused disease worldwide, and encourage oncology providers to advocate for tobacco policy change.

Significant Public Health Concern

Commenting on the state of tobacco control 10 years after ASCO’s last policy statement on the subject, Carolyn Dresler, MD, MPA, Chair of ASCO’s Tobacco Control Subcommittee and Associate Director for Medical and Health Science at the FDA Center for Tobacco Products, noted that “there are still too many tobacco-related cancer deaths.”

“Smoking rates in the developing world are escalating,” said James L. Mulshine, MD, of Rush University Medical Center and coauthor of the policy update. He added, “Every time a child begins smoking, the potential for adverse health effects are profound, lasting, expensive, debilitating, and tragic.”

In addition to its role as the largest preventable cause of overall death and disability in developed countries, tobacco use is responsible for 30% of all cancer deaths and 80% of lung cancer deaths. It is also associated with an increased risk for at least 17 types of cancer. Moreover, studies have shown that continued tobacco use after cancer diagnosis compromises the effectiveness of treatment by increasing the risk of treatment-related complications and a second primary cancer.

Despite the associated risks, tobacco use remains pervasive. Although cigarette use has declined in the United States, the use of tobacco products in general is increasing, particularly in developing countries. Alarmingly, the rate of reduction of youth tobacco use is no longer rapidly decreasing. In the United States and around the world, the epidemic of tobacco-related disease and death is a growing concern.

In light of these statistics, the policy update calls upon oncologists to take ownership of the issue, recognizing the essential role oncology professionals have in preventing tobacco-related cancers and death, while increasing the effectiveness of cancer treatments. 

An Achievable Goal

A growing body of evidence shows that tobacco prevention and cessation programs deliver a great return on investment and can reduce rates of smoking and lung cancer.

The California Tobacco Control Program provides an innovative example of how states can implement tobacco control and cessation programs that have a real impact on smoking rates. California’s program, which could serve as a model to other states and the federal government, uses a variety of methods to address tobacco cessation, including a mass media campaign to encourage smokers to quit, a telephone quitline and counseling services, and subsidized nicotine replacement therapy.

Additionally, the Tobacco Control Program encourages the implementation of smoking restrictions in worksites and public places, funds cessation programs at the local level, and encourages physicians and other health-care professionals to advise their patients to quit smoking and to provide referrals to cessation services. Ten years after its inception, the California program produced significant results: Per capita cigarette consumption fell by 57% in California compared to only 27% in the rest of the United States. The evidence indicates that these efforts have had a significant impact on tobacco use prevalence.

The results of California’s tobacco control efforts provide a glimpse of the possibility for success. Although Dr. Dresler noted that the state still has “a ways to go” in improving tobacco control, the California program “significantly altered the trajectory of lung cancer incidence, compared to the rest of the United States,” she said. “It showed that it can be done faster than people in oncology and public health thought was possible.”

ASCO Recommendations

Recognizing the complexity of tobacco cessation and control, the recommendations in ASCO’s policy update are multifaceted, covering a broad range of tactics. At the cornerstone of ASCO’s recommendation is an emphasis on educating providers, patients, survivors, and their families on the negative effect tobacco use can have on not just cancer incidence, but cancer treatment outcomes as well. Another key recommendation is focused on improving patient and family access to access evidence-based tobacco cessation therapies and counseling through health plan coverage and appropriate reimbursement. Research has shown access to these types of services can greatly improve rates of tobacco cessation.

In addition, solidifying tobacco cessation as a component of high quality cancer care through the assessment and potential expansion of current measures, such as ASCO’s Quality Oncology Practice Initiative (QOPI®) measures remain an important component of overall patient care.

To help strengthen the tobacco cessation and control evidence base, ASCO’s statement advocates for a robust tobacco control research agenda through increased funding and the inclusion of tobacco use status as a core data element in oncology clinical trials.

In order to achieve these goals in the area of tobacco control, ASCO continues to advocate for policies that enhance federal, state, and local regulation of tobacco products.

Finally, the policy update asks the oncology community to make a renewed commitment to serve as responsible members of the global society, advocating for coordination of tobacco cessation and control efforts worldwide.

Oncology Professionals Must Lead by Example

The policy update challenges all oncology providers to lead by example by avoiding use of any tobacco and nicotine delivery products, treating tobacco dependence as aggressively as cancer, advocating for the wide availability of cessation services, supporting tobacco-free environments, and refusing to collaborate with or accept support from the tobacco industry.

Reiterating that a significant proportion of all cancer death is tobacco related, Nasser H. Hanna, MD, of Indiana University Health Simon Cancer Center, coauthor of the policy update, said, “I think that we, as oncologists, have a unique responsibility to be highly engaged in helping to prevent tobacco use.”

Integrating Tobacco Cessation into Oncology Practices

To help oncology providers integrate tobacco cessation counseling services into their practices, ASCO has developed a comprehensive toolkit that includes a provider guide, a patient guide, assessment and counseling tools, information about reimbursement, and links to additional resources (including the Quitline, 1-800-QUIT-NOW).

The online resource, available at, “provides all the tools that the clinicians need to educate themselves and educate their patients on the necessity of stopping smoking,” Dr. Hanna said. Moreover, the toolkit provides a way to quickly assess a patient’s level of addiction to tobacco and outlines a cessation plan, based on the results of that assessment.

While acknowledging that oncologists have an important role in engaging patients in the dialogue about tobacco cessation, Dr. Mulshine noted that they have significant limitations on their time. This may require “a new model of care in which oncologists coordinate tobacco cessation,” working with other health-care specialists “to ensure the tobacco control message is delivered consistently and in a high-quality, impactful way,” he said. For example, oncology practices may find it helpful to offer patients access to more comprehensive tobacco cessation counseling provided by specially trained nurses or other health-care professionals, with financial support through current initiatives promoting tobacco cessation services that stem from the Affordable Care Act.

Oncologists’ Role in Advocating for Health Policy Change

According to Dr. Hanna, an oncologist’s responsibility does not stop at the practice level.  He noted, “As those in a position to influence health policy, we must be proactive in our practices, our communities, and at a state, national, and international health policy level.” An oncologist’s voice in the tobacco control policy realm is “unimaginably strong” and valuable, said Dresler, adding that she hopes a realization of that power will encourage many oncologists to take an active role in shaping the future through advocacy efforts. ■

© 2013. American Society of Clinical Oncology. All rights reserved.