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Esteve Fernandez

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    ES13 - Global Political, Legal, and Financial Strategies For Tobacco Control (ID 16)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track: Prevention and Tobacco Control
    • Presentations: 5
    • Now Available
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      ES13.01 - Tobacco Cessation and Cancer Patients (Now Available) (ID 3224)

      15:15 - 16:45  |  Presenting Author(s): Esteve Fernandez  |  Author(s): Cristina Martínez

      • Abstract
      • Presentation
      • Slides

      Abstract

      Smoking among cancer patients reduces the effectiveness of treatment, increases the risk of recurrence, and reduces survival time. One third of cancer patients continue smoking after diagnosis or during their treatment. Smoking is also common in patients with a cancer for which there is limited evidence for carcinogenicity of tobacco smoking. Cancer patients who smoke have greater risks, not only of the well known tobacco-related health problems, such as cardiovascular and respiratory diseases and further cancers, but also unfavourable cancer treatment outcomes. There is sufficient evidence to infer a causal relationship between cigarette smoking and adverse health outcomes, including all-cause mortality, cancer-specific mortality and further primary tobacco-related cancers among cancer patients. Poorer cancer treatment outcomes linked to tobacco use by cancer patients re related to altered cancer biology, altered drug metabolism, increased treatment-related complications, and increased tobacco-related comorbidity.

      Although smoking cessation is associated with better outcomes, this key and cost-effective preventive strategy is rarely addressed in health care services. Barriers to incorporating tobacco cessation interventions into hospitals include lack of knowledge, expertise, time, and organizational constraints. In addition, many cancer patients show higher rates of nicotine dependence, low self-efficacy, and higher levels of depression.

      The existing data support the conclusion that continued smoking negatively affects cancer treatment outcomes including survival, recurrence and quality of life and that, by quitting smoking, patients with cancer have the potential to improve their cancer treatment outcomes. At the population-level, there is a need to establish a basic infrastructure to provide tobacco cessation services to cancer patients who smoke, sustainable funding should be identified and allocated to dedicated tobacco cessation services (e.g. quitlines, available treatment for tobacco cessation) as well as tobacco treatment training programmes for health-care providers. At the individual-level, motivational interventions addressed to recognize the cancer-specific risks of smoking do increase patients’ self-efficacy in quitting. Morover, cessation using the "5 A’s model" provides good abstinence rates, and about 80% of smokers could be reached using this approach.

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      ES13.02 - Pursuing Criminal Charges Against Big Tobacco (Now Available) (ID 3225)

      15:15 - 16:45  |  Presenting Author(s): Wanda De Kanter

      • Abstract
      • Presentation
      • Slides

      Abstract

      Abstract 1

      Court of appeal rejects charges made against tobacco industry-

      The Court of Appeal in The Hague has declined to instruct the Netherlands Public Prosecution Service to bring criminal charges against cigarette manufacturers. The court concluded that it is up to the government, not the judiciary, to tackle the rigging of cigarettes. In other words, it’s the government’s move.

      On December 6th, 2018 the Court of Appeal in The Hague delivered its verdict in the proceedings brought by criminal lawyer Bénédicte Ficq on behalf of various individual complainants and a large number of legal entities who previously lodged complaints against cigarette manufacturers. Last February the Public Prosecution Service (OM) decided not to instigate legal proceedings, prompting the complainants to instigate an Article 12 procedure in an effort to force the OM to prosecute.

      In its verdict, the court writes that “the products of cigarette manufacturers are made and tested in accordance with stringent Dutch and European legislation and regulations. As long as the cigarette manufacturers respect these European and national rules, the member states must respect these rules and cannot prohibit the sale of cigarettes. Radical measures against cigarette manufacturers can only be taken by the European regulator.”

      In her reaction, lawyer Bénédicte Ficq draw attention to the significance of the court’s comment, in its detailed motivation, that cigarette manufacturers deliberately market a deadly and harmful product with the sole objective of making money.

      The court writes: “The fact that smoking is harmful to your health, is a serious health risk, can cause serious illness and even death, and is moreover highly addictive, can in the opinion of the court be considered general knowledge and is not disputed by the defendants. The defendants supply cigarettes that they know are or can be addictive and harmful to the health of active and passive smokers. The court assumes that the defendants act with the aim of making a profit
      Here the lawyers note the similarities with verdicts reached against cocaine and heroin dealers. Ficq: “The court could have avoided making these remarks, but has instead chosen to make clear that there is a social evil that the court is powerless to address. In other words, the ball is in the government’s court.”

      Legislator must intervene

      In its conclusion the court expresses it very clearly once again: “Complainants have chosen to address a social problem concerning public health within a criminal framework. However, the court agrees with the Public Prosecution Service that criminal law offers no solution. Radical measures such as banning the production and sale of tobacco, which is produced in accordance with the legal directives, can only be taken by the legislator. The ultimate goal of the complainants, to ban cigarettes cannot be achieved through criminal law. It will instead have to involve an appeal to the European legislator.”

      Conclusion: . “The court recognizes the scale of the social problem and the fact that cigarettes are extremely addictive and deadly, and should actually be banned, but it’s up to the government to take action. That strengthens us in our demand that the Netherlands Food and Consumer Product Safety Authority and the government must take measures to tackle the phenomenon of ‘rigged cigarettes’

      We feel as if we have ended up in a Kafkaesque situation in which it is patently obvious that cigarettes with holes in their filters release more toxic substances than legally allowed. But the legally prescribed smoking machines measure different levels, so cigarettes in their present form are permitted. Those responsible for passing legislation must now change this situation, especially since we’ve know that ‘rigged cigarettes’ cause more lung cancer. Time for government action!”

      ABSTRACT 2

      Tobacco Industry: first we fix the law, then we abide by it

      A little-known issue is the way that the tobacco industry has succeeded, over the years, in bending the implementation of anti-smoking laws to its own will. After all, in violation of all international laws, it exerts a strong influence on how the State determines emission values for cigarette smoke. As a result of that interference, the margins for enforcing the law are far too wide.

      According to Dutch law, every three years cigarette manufacturers must show the government how much tar, nicotine and carbon monoxide (TNCO) their cigarettes contain. These levels are controlled by the National Institute for Public Health and the Environment (RIVM). The RIVM then sends the results to the Dutch Food and Consumer Product Safety Authority (NVWA). If the legally set limits are exceeded, the NVWA must act. It must enforce the law.
      Those legal norms are unequivocally determined in the Law on Tobacco and Smoking Products. A cigarette may emit a maximum of 10 mg tar, 1 mg nicotine and 10 mg carbon monoxide. A smoker may not inhale more poison than that. The law also determines how levels are measured and the margins within which the legal norms must be met.

      However, the margins determined by law are very wide: 20% for tar and nicotine and 25% for carbon monoxide. This means that a cigarette with 12 mg tar (instead of 10), 1.2 mg nicotine (instead of 1) and 12.5 mg carbon monoxide (instead of 10) is still permissible. The NVWA will only intervene above those levels. The literature tells us that maximum margins of 10% are more than enough to conceal variations in measured levels.

      In developing and determining the measurements, the government has — following the example of the European lawmaker — used the services of two private organizations: the Netherlands Normalization Institute (NEN) and the International Organization for Standardization (ISO). These organizations consist entirely of representatives from the cigarette industry. The chairperson himself comes from Philip Morris.

      If you examine the explanation that accompanies the legal article, it turns out that the legal emission margins are statistically baseless. “The conclusions within the report are based on practical experience of verifying these measurements in a number of different marketplaces underpinned by a theoretical consideration of the sources of statistical variation.” (NEN-ISO 8243.2013, IDT)

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      ES13.03 - Foundation for a Smoke Free Future: Funding Opportunities or Smoke Screen for the Tobacco Industry? (Now Available) (ID 3226)

      15:15 - 16:45  |  Presenting Author(s): Emily Stone

      • Abstract
      • Presentation
      • Slides

      Abstract

      The tobacco industry has long sought interactions with the health and medical communities that will enhance its legitimacy and augment profits. In the early 20thcentury, advertising involved the medical community emphasizing doctors who recommended cigarette smoking. From the mid 20thcentury, as scientific evidence developed, the tobacco industry contested restrictions vigorously as tobacco regulation intensified. The advent of ENDS products opened a new phase in marketing which stretched the limits of conventional tobacco control. The PMI Foundation, launched in 2017, targets the health and medical communities, promising research funding, the “Smoke-Free” aim and its interactions with high profile researchers. In the first few decades of the 20thcentury, tobacco companies involved physicians in advertising campaigns to promote health benefits and minimisation strategies for particular brands. Analysis of 1930s and 40s tobacco advertising in medical journals identified a number of strategies employed to involve doctors in promoting cigarettes including flattery, tobacco ‘science’, the advisory role to patients, less “irritating” brands and promotion of specific brands1. Analysis of tobacco advertising from the 1920s to the 1950s identified a focus on throat irritation, strategies to protect from harmful symptoms and portrayal of otorhinolaryngologists as promoters of cigarette-related benefits2. The “More Doctors smoke Camels” campaign3launched in the late 1940s by RJ Reynolds made a number of zealous health benefit claims, although landmark publications linking tobacco cigarettes to lung cancer led to scepticism from the health community and eventual banning of cigarette advertising and promotion in medical journals and at medical conventions3.

      From the mid-1960s, the paradigm for tobacco regulation shifted as evidence accumulated for the harmful effects. Additional key papers include a 1912 monograph, one of the first publications to link lung cancer with tobacco, early writings on lung cancer surgery and the 1964 US Surgeon General Report on Smoking and Health. Legislative efforts to control tobacco accelerated with, in the United States, the pivotal 1998 Master Settlement Agreement by which tobacco companies were obliged to pay compensation to 46 states to offset costs of smoking-induced illnesses4. In the early 21stcentury the WHO FCTC came in to force in 2005 with the launch of the MPOWER measures in 2008, setting up the tobacco framework that has characterised the last decade and a half and to which 181 countries are signatories. The emergence of e-cigarettes and other ENDS products has shifted tobacco control outside the current purview of the FCTC and opened up new areas of controversy as these products evade conventional regulation. E-cigarettes first appeared in the 20thcentury including designs from the 1960s from BAT and from the 1990s from PMI with the contemporary model attributed to an individual inventor5. The early designs were abandoned at least in part due to concerns about commercial viability­6­,7and it was not until the last decade or so that e-cigarettes have reached prominence. The emergence of highly appealing and commercially successful ENDS products such as the Juul device has stimulated concern at the level of the FDA and review of e-cigarette regulation. Companies such as Juul Labs (now owned by a tobacco corporation) and PMI advocate harm-minimization through their ENDS products while parent companies continue to sell conventional tobacco cigarettes in less tightly regulated markets.

      The Phillip Morris Foundation for a Smoke-Free World8was launched in 2017 and immediately prompted controversy. The stated aims of the Foundation include the funding of research, a focus on smoking cessation and harm reduction and the search for solutions to “unique challenges”8. Its launch prompted immediate debate and discussion, including a Lancet Viewpoint by the Foundation’s director, advocating the benefits of reduced-harm products and expressing concern that full implementation of the FCTC would take many years. An editorial in the same Lancet issue raised strong concerns about involving the tobacco industry in tobacco control while acknowledging that (at the time of writing) the Foundation had yet to begin work9. An accompanying commentary piece questions the credibility of the Foundation and points out that the funding of research is used by the tobacco industry as a deliberate strategy that in fact acts as a “public relations” exercise while PMI, in this instance, continues to sell cigarettes as its core product10. More recently, a review of the published tax returns from the Foundation suggest that it is having trouble both raising and spending funds, perhaps indicating some trouble engaging with the research community and multiple publications raise questions about its ethical robustness, the risks of long-term nicotine dependence and its commercial integrity. While the stated aims of the Foundation may appeal, concerns remain about engaging with the tobacco industry, about persistent global cigarette sales, about the use of the Foundation to divert attention from PMI’s efforts to build its market for ENDs products and about the prioritisation of harm-minimisation (with accompanying profits) over genuine efforts to make the world free from tobacco.

      References

      1. Jackler RK, Ayoub NF. “Addressed to you not as a smoker… but as a doctor”: doctor-targeted cigarette advertisements in JAMA. Addict Abingdon Engl. 2018 Jul;113(7):1345–63.

      2. Samji HA, Jackler RK. “Not one single case of throat irritation”: misuse of the image of the otolaryngologist in cigarette advertising. The Laryngoscope. 2008 Mar;118(3):415–27.

      3. Gardner MN, Brandt AM. “The doctors’’ choice is America’s choice": the physician in US cigarette advertisements, 1930-1953.” Am J Public Health. 2006 Feb;96(2):222–32.

      4. Schroeder SA. Tobacco control in the wake of the 1998 master settlement agreement. N Engl J Med. 2004 Jan 15;350(3):293–301.

      5. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 May 13;129(19):1972–86.

      6. Risi S. On the Origins of the Electronic Cigarette: British American Tobacco’s Project Ariel (1962-1967). Am J Public Health. 2017;107(7):1060–7.

      7. Dutra LM, Grana R, Glantz SA. Philip Morris research on precursors to the modern e-cigarette since 1990. Tob Control. 2017;26(e2):e97–105.

      8. Foundation for a Smoke-Free World [Internet]. [cited 2019 Mar 2]. Available from: https://www.smokefreeworld.org/

      9. Lancet T. Tobacco control: a Foundation too far? The Lancet. 2017 Oct 14;390(10104):1715.

      10. Daube M, Moodie R, McKee M. Towards a smoke-free world? Philip Morris International’s new Foundation is not credible. The Lancet. 2017 Oct 14;390(10104):1722–4.

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      ES13.04 - Comparing ENDS to NRT for Smoking Cessation (Now Available) (ID 3227)

      15:15 - 16:45  |  Presenting Author(s): Hayden McRobbie

      • Abstract
      • Presentation
      • Slides

      Abstract

      Comparing ENDS to NRT for smoking cessation

      For people who smoke, quitting completely is associated with numerous benefits for current and future health. There are a range of effective stop smoking medicines that can increase long-term abstinence rates, compared with unassisted quitting. However, these rates remain low (eg. < 25%), with most people relapsing within 3-6 months. Over the past decade electronic nicotine delivery systems (ENDS), more commonly known as e-cigarettes or vaporisers, have become increasing popular among smokers, and in some countries are now the most commonly used tool to aid smoking cessation.

      Until recently the evidence for the effectiveness of ENDS in helping people stop smoking has been limited, with only two published randomised controlled trials (RCTs). There are now four RCTs; three show the superiority of nicotine containing ENDS, compared to those without nicotine, in helping smokers quit for at least six months and one found vaping to be associated with higher 12-month quit rates than nicotine replacement therapy (NRT; 18% vs. 10%; RR=1.83; 95% CI: 1.30-2.58). The difference in quit rates may have been due to ENDS providing greater withdrawal relief, providing better subjective effects, and smokers being able to self-titrate their nicotine intake. Among 12-month ex-smokers, rates of ongoing ENDS use were significantly higher than ongoing NRT use. This could raise concern if long-term ENDS use is associated with health risk. Alternatively, this could be beneficial if it prevents relapse and so risk-benefit analysis is required.

      Health professionals are often asked by their patients if ENDS can help aid quitting smoking and if they are safe. There are data to show that ENDS are an effective smoking cessation aid, and some evidence to support their superiority over NRT. Current data suggest that health risks associated with ENDS use are substantially less, overall, than risks associated with smoking tobacco. However, the health risks associated with long-term ENDS use remain unknown, and long-term cohort studies, especially regarding lung health in vapers, are needed. To mitigate concern over unknown health risks associated with long-term vaping ex-smokers can be advices to stop vaping as soon as they feel they are safe from relapse to smoking.

      This presentation will summarise the evidence of effectiveness of ENDS for smoking cessation, and provide an overview of possible health risks, to enable health professionals to better advise their patients who ask about using ENDS.

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      ES13.05 - Stigma and Impact of Tobacco Control Policy (Now Available) (ID 3228)

      15:15 - 16:45  |  Presenting Author(s): Andrea Borondy Kitts

      • Abstract
      • Presentation
      • Slides

      Abstract

      figure1bcandlcpeople.jpg

      A simple quick google search on breast cancer people and lung cancer people is enough to show the impact of stigmatizing smoking on people with lung cancer (Figure 1). Breast cancer people are perceived as pink, young, healthy, cheerful, supportive and happy although that is not an accurate depiction of the breast cancer journey. In contrast, lung cancer people are seen as diseased and dying, sad, concerned, bleak, and alone with little support.

      The stigma associated with smoking stops people from going to the doctor because they are afraid the doctor will think they are stupid for continuing to smoke, it stops people from getting screened for lung cancer because they blame themselves for smoking and feel they deserve the disease or because they are afraid their loved ones will blame them for getting sick. The stigma reduces the funding available for lung cancer research. In the US, federal funding for lung cancer research per lung cancer death is only 15% of the funding amount for breast cancer per breast cancer death.

      People with lung cancer, regardless of their smoking status, encounter stigma on a regular basis.(1) Often after disclosing a lung cancer diagnosis for themselves or for a loved one the first comment is not, I’m so sorry you have this awful disease. The first comment is invariably “I didn’t know you smoked” or “Was he a smoker” or “He smoked a lot. It’s not surprising he got lung cancer” or “It’s to be expected since you are a smoker” In a Global Lung Cancer Coalition survey, one in five people (21%) agreed with the statement that they have less sympathy for people with lung cancer than for people with other types of cancer.

      Studies have shown that the stigma encountered by people with lung cancer reduces quality of life, increases depression and negatively impacts outcomes.(2)

      Probably most disturbing is that stigmatization of smokers has the greatest impact on the socioeconomically deprived, the disadvantaged populations.(3) These populations have the highest prevalence of smokers and encounter the stigma of their race or disadvantage (poverty, disability, sexual preference, behavioral health etc.) in addition to the stigma associated with smoking.(4)

      One could argue that tobacco control (tobacco denormalization efforts) may be tolerable if they resulted in short term stigma but increase tobacco cessation for these disadvantaged populations resulting in an overall public health benefit. Unfortunately, studies show that tobacco control efforts have the least impact on socioeconomically deprived populations thus actually increasing the health inequity (and stigma) for this already marginalized population. Smoking related stigma may actually help reinforce smoking in this population by being perceived as resistance to the norms of society. In other words, tobacco control efforts may not work and may actually have the opposite effect.(5,6,7)

      This stigmatization leads people who smoke to be less likely to seek medical care when they have symptoms, more likely to lie about their smoking, more likely to be refused access to care including curative surgery for early stage lung cancer unless they quit smoking, less likely to be offered smoking cessation help if they are uncomfortable disclosing their smoking status due to stigma and bias from their healthcare professional.(5,6)

      Tobacco control and stigmatization of smokers has resulted in stigmatizing all people with lung cancer regardless of smoking history or socioeconomic status. It’s time to stop stigmatizing people who smoke and people with lung cancer but rather to promote and implement policies that have been shown to work in deterring tobacco use and helping people quit.(8) These include increased age limits for tobacco purchase and use, increased taxes on tobacco sales, free access to tobacco cessation counseling, nicotine replacement products and prescription smoking cessation medications.

      1. Hamann HA, Howell LA, McDonald JL. “You did this to yourself”: causal attributions and attitudes toward lung cancer patients. J Appl Soc Psychol. 2013;43:E37–E45. doi:10.1111/jasp12053.

      2. Cataldo, JK, & Brodsky, JL. Lung cancer stigma, anxiety, depression and symptom severity. Oncology (Switzerland). 2013;85(1):33-40. http://dx.doi.org/10.1159/000350834

      3. Bell K, Salmon A, Bowers M, Bell J, McCullough L. Smoking, stigma and tobacco ‘denormalization’: Further reflections on the use of stigma as a public health tool. A commentary on Social Science & Medicine's Stigma, Prejudice, Discrimination and Health Special Issue (67: 3). Social Science & Medicine. 2010;70(6):795-799. https://doi.org/10.1016/j.socscimed.2009.09.060

      4. Borondy Kitts AK. The patient perspective on lung cancer screening and health disparities. J Amer Coll Rad. 2019;16(4):601-606. https://doi.org/10.1016/j.jacr.2018.12.028.

      5. Evans-Polce RL, Castaldelli-Maia JM, Schomerus G, Evans-Lacko SE. The downside of tobacco control? Smoking and self-stigma: A systematic review. Social Science & Medicine. 2015;145:26-34. https://doi.org/10.1016/j.socscimed.2015.09.026

      6. Kirsten Bell K, Salmon A, Bowers M, Bell J, McCullough L. Smoking, stigma and tobacco ‘denormalization’: Further reflections on the use of stigma as a public health tool. A commentary on Social Science & Medicine's Stigma, Prejudice, Discrimination and Health Special Issue (67: 3). Social Science & Medicine. 2010; 70(6):795-799. https://doi.org/10.1016/j.socscimed.2009.09.060.

      7. Lozano P, Thrasher JF, Forthofer M, Hardin J, Reynales Shigematsu LM, Santillán EA, Fleischer NL. Smoking-related stigma: A public health tool or a damaging force?, Nicotine & Tobacco Research, , nty151, https://doi.org/10.1093/ntr/nty151

      8. Hill S, Amos A, Clifford D, et al. Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tobacco Control. 2014;23:e89-e97.

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Author of

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    ES13 - Global Political, Legal, and Financial Strategies For Tobacco Control (ID 16)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track: Prevention and Tobacco Control
    • Presentations: 1
    • Now Available
    • +

      ES13.01 - Tobacco Cessation and Cancer Patients (Now Available) (ID 3224)

      15:15 - 16:45  |  Presenting Author(s): Esteve Fernandez

      • Abstract
      • Presentation
      • Slides

      Abstract

      Smoking among cancer patients reduces the effectiveness of treatment, increases the risk of recurrence, and reduces survival time. One third of cancer patients continue smoking after diagnosis or during their treatment. Smoking is also common in patients with a cancer for which there is limited evidence for carcinogenicity of tobacco smoking. Cancer patients who smoke have greater risks, not only of the well known tobacco-related health problems, such as cardiovascular and respiratory diseases and further cancers, but also unfavourable cancer treatment outcomes. There is sufficient evidence to infer a causal relationship between cigarette smoking and adverse health outcomes, including all-cause mortality, cancer-specific mortality and further primary tobacco-related cancers among cancer patients. Poorer cancer treatment outcomes linked to tobacco use by cancer patients re related to altered cancer biology, altered drug metabolism, increased treatment-related complications, and increased tobacco-related comorbidity.

      Although smoking cessation is associated with better outcomes, this key and cost-effective preventive strategy is rarely addressed in health care services. Barriers to incorporating tobacco cessation interventions into hospitals include lack of knowledge, expertise, time, and organizational constraints. In addition, many cancer patients show higher rates of nicotine dependence, low self-efficacy, and higher levels of depression.

      The existing data support the conclusion that continued smoking negatively affects cancer treatment outcomes including survival, recurrence and quality of life and that, by quitting smoking, patients with cancer have the potential to improve their cancer treatment outcomes. At the population-level, there is a need to establish a basic infrastructure to provide tobacco cessation services to cancer patients who smoke, sustainable funding should be identified and allocated to dedicated tobacco cessation services (e.g. quitlines, available treatment for tobacco cessation) as well as tobacco treatment training programmes for health-care providers. At the individual-level, motivational interventions addressed to recognize the cancer-specific risks of smoking do increase patients’ self-efficacy in quitting. Morover, cessation using the "5 A’s model" provides good abstinence rates, and about 80% of smokers could be reached using this approach.

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