1. IASLC Live Learning Tobacco Control and Smoking Cessation Live Learning Seminars Chicago: October 14, 2016 Philadelphia: October 21, 2016 San Francisco: November 4, 2016

2. 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.

3. 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)

4. Deaths due to cancer type: US 2012 http://globocan.iarc.fr

5. Deaths due to cancer type: World 2012 http://globocan.iarc.fr

6. 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…

8. Tobacco Control is complex, dynamic, multifactorial interaction between industry, society, and government Legislation www.tobaccoatlas.orgwww.tobaccoatlas.org accessed 2.8.15 Social norm Tobacco industry

9. US Tobacco Control: Policies impact tobacco use. Samet JM, Ann Am Thorac Soc 2014;11(2):141-8. 1964 surgeon general report 190019602012 US Per capita Cigarettes smoked per year

10. 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

11. Why should we as oncologists care about cessation? Isn't it too late? Does it matter? What difference can it really make?

12. 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.Overall mortality/survival 2.Cancer-specific mortality/survival 3.Risk of second primary cancers 4.Cancer recurrence/response to treatment 5.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.

13. 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.

14. 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.

15. The 2014 SGR: Outcome Estimates 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. EffectStudiesAssociations (Significant) RR Magnitude (median) Overall Mortality15987% (62%)Current: 1.51 Former: 1.22 Overall Survival6277% (42%) Cancer Related Mortality5879% (59%)Current: 1.61 Former: 1.03 Second Primary26100% (100%) Recurrence5182% (53%)Current:1.42 Former:1.15 Response1672% Toxicity8294% (80%)

16. Specific examples: Impact of tobacco on treatment 101 head & neck cancer patients actively smoking 101 matched controls who quit –age, stage, Karnofsky, tumor location, pack- years, chemotherapy, radiation dose, etc. Active Smokin g Quit Smokin g 5 year OS 23%55% Locoregional control 58%69% Disease-free survival 42%65% Complication s Grade 3 49%31% Chen AM- Int J Rad Onc 2011

17. 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 developing future primary tumor

18. 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 outcomes SCLC

19. 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. Specific examples: Impact of tobacco on survival NSCLC

20. Ok… Cessation is important. How can it be done? I don’t have enough time. Patients aren’t going to quit anyway…

21. 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 possible- by telephone) Tobacco Cessation in Clinical Practice

22. 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 10 th ed. 2014

23. Tobacco Assessment by Oncologists (Always/Most of the time) ParameterIASLC (n=1507) ASCO (n=1197) Ask if use tobacco90.2%89.5% Ask if will quit78.9%80.2% Advise to quit80.6%82.4% Discuss medications40.2% 44.3% Actively treat38.8% 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

24. Automated Screening and Treatment Warren GW et al., Cancer 2014

25. 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

26. 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)

27. NCCN Guidelines www.nccn.orgwww.nccn.org (v1, 2015)

28. www.nccn.orgwww.nccn.org (v1, 2015)

29. www.nccn.orgwww.nccn.org (v1, 2015)

30. www.nccn.orgwww.nccn.org (v1, 2015)

31. 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.

32. 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

33. Resources NCCN Clinical Practice Guidelines www.nccn.org Treating Tobacco Use and Dependence www.ahrq.gov/professionals/clinicians-providers/guidelines- recommendations/tobacco/clinicians/update/index.html www.ahrq.gov/professionals/clinicians-providers/guidelines- recommendations/tobacco/clinicians/update/index.html CDC http://www.cdc.gov/primarycare/materials/smokingcessation/ docs/smoking_cessation_additional_resources_508.pdf http://www.cdc.gov/primarycare/materials/smokingcessation/ docs/smoking_cessation_additional_resources_508.pdf IASLC https://www.iaslc.org/patient-resources/tobacco-cessation-0